Biographic Data

Name: Mrs. X Age: 65 years old

Address: Caloocan Religious Affiliation: Roman Catholic

Gender: Female

Marital Status: Married

Room and Bed #: CCU5

Chief Complaint: Convulsion

Provisional Diagnosis: Seizure Disorder

Attending Physician: Dr. R. Reyes

Nursing History

A. Past Health History

According to the relative, the client did not have problems regarding her health except for cough and colds
during the past years. The relative also said that the patient had given immunizations but she did not know when
exactly the patient had it. The client had known allergy to Aspirin. Whenever she is sick, she self medicate by taking
paracetamol particularly Biogesic. The client also used herbal preparations for treating her simple illness. The client
has no foreign travel. She had no any history of accidents, trauma and injuries.

The client has hypertension and diabetes mellitus for five years. She takes medication such as
Trimetadizine HCL, Felodipine and Amplodipine as her maintenance medication for hypertension. On the other
hand, the client takes Metformin for her diabetis.

B. History of Present Illness

The present illness started three days prior to admission when the patient experienced pain in the left arm
and eventually accompanied by rigidity of the left hand with involuntary movement. No other signs and symptoms
noted such as fever and headache. No medications taken and no consult done.

One day prior to admission, her symptom occurred and accompanied by headache. There were no
associated fever and vomiting. There were still no medications taken and no consult done.

Four hours prior to admission, the patient still experienced headache and then accompanied by sudden
unrolling of eyeball, tonic and clonic drooling of saliva. The client was brought then to Dodados.ECG was done to
the patient and was advised admission. The family preferred to transfer the patient to FEU Hospital hence was
subsequently admitted.

C. Family History
 Regarding with the client family history of illness, the relative of the patient stated that there were no
history of heredofamilial diseases such as heart and kidney diseases, cancer, asthma and pulmonary tuberculosis
except that there is a history of diabetes and hypertension in their family. However, the relative said that she cannot
recall who among the member in the client’s family have a hypertension or diabetes.

Patterns of Functioning

A. Psychological Pattern

1. Coping Pattern

Prior to hospitalization, the relative of the patient verbalized that whenever the patient has problem she faces and
finds way to solve it. The relative added that sometimes the patient spend time alone to give herself a time to think and to
relax. She also prays to God so that she will be able to think clearly on how to solve problems that comes her way. Regarding
with the client usual problem, the relative said that the patient common problem is about financial yet it was resolved through
the help of the client’s children.

Interpretation:

The client copes with her problem by courageously facing it. Her usual problem is resolved through her children
presence.

Analysis:

In psychosocial theory, older adults usually withdraw from usual roles and they become more introspective and
self-focus as compared to young adult and middle age adult. Withdrawal was theorized as intrinsic and inevitable which is
necessary for successful aging. (Fundamentals of Nursing by Taylor, pg.416).

2. Interaction Pattern

The relative verbalized that the client is very close with her family. She also said that the client has good personal
relationship with her children, grandchildren and siblings. Although misunderstanding is sometimes present in the family, the
relative of the client said that they immediately solve it. “Masayahin naman si Lola kaya nagkakasundo- sundo sila, minsan
nagkakaproblema pero naayos din agad” as relative verbalized. “Pero kung minsan makulit na din si lola kasi matanda na
kaya di maiwasan ang pagkakaroon ng hindi pagkakaintindihan”, as relative added.

. Regarding with her relationship with her neighbors, the relative said that she has open communication with
them. The client isn’t involved in any organization in their community. And in relation to other, she expresses her feelings
and thoughts directly to the person who is involved in the situation.

Interpretation:
 The client has open communication with her family and neighbors. She has close and healthy interaction with them.

Analysis:

Communication is the foundation of the society and the most primary aspect of a nurse patient interaction. Without
communication and could be impossible to share family experiences, gain knowledge, established and maintained
governmental agencies, and enhance entertainment. By nature, human are social beings, and human needs are met in
collaboration with other humans. (Fundamentals of Nursing by Taylor, pg.443)

With an aging population, social organizations for older adults are not as numerous compared to young adults.
Affiliation with others of the same age allows them to share experience and concerns among their companion. It should not
be assumed, however, that older adults still want to associate with others. (Fundamentals of Nursing by Taylor, 5th edition,
page 416).

3. Cognitive Pattern

Before hospitalization, the relative verbalized that the client is cooperative and she is able to respond to the
questions appropriately. She can talk and speak clearly. The relative also said that they noticed changes in the client’s
memory.”Medyo makakalimutin na din si lola matanda na din kasi” as verbalized by the relative. The client does not have
any problem with her senses. Her relative added that the patient is good in communicating with other people and good in
making decisions.

Interpretation:

The client has no problem in terms of her cooperation, manner and responsiveness. However, change in memory
occur as a person ages.

Analysis:

Older adults maintain intelligence, problem solving, judgment, creativity and other well practiced cognitive skills. In
this stage, retrieval of information from long term memory can be slower, especially if the information is not frequently used.
Older adults tend to forget the recent past. The older people need additional time for learning, largely because of the problem
of retrieving information. Her learning is enhanced through educational and life experiences. Young adults can able to
respond or react well as compared to middle-aged adult which take longer. In this stage of development, young adult have
long-term memory. They have no changes in their senses at this stage. (Fundamentals of Nursing by Taylor, 5th ed., pg.418-
419)

4. Self-Concept Pattern

According to the relative, the client is a happy person. She added that the client is contented with her life and for
what she has.”Masayahin talaga si lola, lagi nga yan tumatawa pagnagjojoke ako. Kuntento na naman sya sa buhay na meron
sya ngayon”as verbalized by the relative. And before hospitalization, the relative said that the client feels worried about her
health condition and about the expenses especially when it regards to her medications. However, the relative stated that the
client’s children were there to support and provide her needs.

Interpretation:

The client is a jolly person and she is happy with herself. She is worried about her health and their expenses yet she
is secured through her children moral support.

Analysis:

A person’s self concept results from a variety of past experiences, interpersonal interactions, physical and cultural
influences, and education. It includes a person’s perceptions of his/ her own strengths and weaknesses. Illness can alter a
person’s self- concept as it affects roles, independence, and relationship with important other. (Fundamentals of Nursing by
Taylor, 5th edition, page 67)

5. Emotional Pattern

As stated by the relative, there are times that the client encounters problem and the usual problem is about the
financial expenses in their home. She feels sad whenever she think about it. However, her children support relieves her
 sadness. “Ang mga anak nya tumutulong sa kanya sa kanilang gastusin”, as verbalized by the relative. The relative of the
client also said that she is naturally a happy person and is very loving to her family. She is also sweet to her grandchildren.

Interpretation:

The client feels sad whenever she thinks about her problem but it relieves through her children support. The client is
naturally a happy person. She loves her family so much and she is sweet to her grandchildren.

Analysis:

Later life is a long and varied stage of the life cycle. Older people may face many different emotional and physical
experiences and may have vastly different psychological, social and physical resources available for coping. The interactions
between a person’s physical, social and psychological resources are complex. However, in contrast to physical and social
resources, a person’s psychological coping/resources may be more implicit and difficult to identify. Fundamentals of Nursing
by Taylor, 5th Ed. pg.576)

The interactions between a person’s physical, social and psychological resources are complex. However, in contrast to
physical and social resources, a person’s psychological coping/resources may be more implicit and difficult to identify.
(Fundamentals of Nursing by Taylor, 5th Ed. pg.576)

6. Sexuality Pattern

According to the relative, the client has no problem with her sexuality. She added that the client is happy and
contented for what she is. She expresses her sexuality by wearing clothes that are appropriate for her gender such as wearing
daster.

Interpretation:

The client has no problem when it comes to her sexuality. She expresses herself by being a woman through wearing
clothes that is suitable for herself.

Analysis:

As time passes, gradual internal and external physiologic changes occur. These are not pathologic changes but there
are also normal changes as a person gets older.

Women and men have the capacity for sexual desire and sexual activity throughout their lives—there is no reason
why one cannot express one’s sexuality well beyond the “reproductive years” (the ages during which men and women are
fertile). In fact, women and men who have been sexually active throughout their adult lives seem to be more sexually
responsive in old age than those who have not. (Fundamentals of Nursing by Taylor, 5th Ed. pg.420,724)

7. Family Coping Pattern

According to the relative, the client is currently living together with her husband. She stated that the client have an
open communication and harmonious relationships with her family. Though there are times that they encounter small
problem within the family, the relative said that they talk about it and just help each other.

Interpretation:

The client has an open communication with her family and when they encounter problems, they solve it together.

Analysis:

Effective managing of adaptive tasks by family member involves with client’s health challenge, who now exhibits
desire and readiness for enhanced health and growth in regard to self and in relation to the client. (NANDA, p.240)

B. Socio-Cultural Health

1. Cultural Pattern
 The client religion is Roman Catholic. “Lagi naman nagsisimba si lola pag linggo”as relative verbalized. The
relative said that the client abides practices, beliefs and values of their religion such as the celebration of Holy Week. The
client believed that eating meat is prohibited every good Friday, as the relative added. She also stated that the client buys
OTC drugs such as Biogesic as seen on Television ads for simple headache and fever. “Sa awa naman ng Diyos eh nawawala
din yung’ sakit ng ulo tska lagnat siguro paglipas ng mga isa o dalawang araw kaya hindi na nagpapacheck-up”as verbalized
by the relative. “Pero kapag hindi nawala yung sakit kahit na uminom ng gamot ng mga dalawang araw eh dun na
pinapachekup si lola. Moreover, the relative also said that the client also use herbal preparation as means of treating her
simple illness

Interpretation:

The client abides the most important religious practices that they have. She takes OTC drugs and herbal medication
in treating her simple illnesses.

Analysis:

Culture refers to the common lifestyles, languages, behavior patterns, traditions and beliefs that are learned and
passed from one generation to the next culture influences a person’s word view and relationships with the surrounding
environment, religion, time and others. Culture provides each person with specific rules for dealing with the universal events
of life – birth, mating, childrearing, illness, pain and death. (Fundamentals of Nursing by Taylor, page 450)

2. Significant Relationship Pattern

The client has a harmonious relationship with her husband as well as with her children and grandchildren. The
relative verbalized that “Maayos ang samahan sa aming pamilya,mahal na mahal ni lola ang kanyang asawa, mga anak at
apo”. The relative stated that they love and respect each other. They also support each other especially in times of sickness
like with the clients’ present condition, the family are there to support her. They encounter some misunderstandings but
resolve it easily like with the client’s family and relatives. The relative verbalized that “Hindi naman maiiwasan ang konting
tampuhan at problema sa isang pamilya pero naaayos naman kaagad”. In addition, the relative also said that the client’s
family have an open communication and good interaction with each other .

Interpretation:

The client’s relationship with her family is healthy because they have no conflicts. If they have problems, it is
immediately resolved.

Analysis:

When a person gets older, he or she becomes more mature and gives more importance to a long-lasting and
satisfying relationship to be able to love and be loved. He or she focuses more on the things that will make him or her happy
and forget all the other things that seem to be unimportant for the older adults, valuing people plays an important role because
there are times that they feel being ignored whenever they have children or not. (Fundamentals of Nursing by Taylor, 5th
Ed., page 992)

3. Recreational Pattern

Prior to hospitalization, the client loves to watch programs on television such as watching dramas in the evening and
watching entertainment show where it serves as her relaxation time.”Mahilig syang manuod nung mga drama tuwing gabi at
saka manuod ng wowowee kapag tanghali”, as relative verbalized.

The relative said that that the client does not engage in any strenuous activities. She only does light activities in the
home. The relative considers also walking as the form of exercise of the client.

Interpretation:

She is a person who only engages in watching television as her form of relaxation and walking and doing light
activities as her form of exercise.
 Analysis:

As time passes by, when a person gets older, he or she pertains to be busy and spend his or her time for a day to a
particular activity. Older adult s adjusts to slower physical activity as compare to the young and middle age adults. Their
physical strength decreased and they will not able to do heavy activities. Sometimes, having so many work could lead to
stress and fatigue that could contribute the patient to have sickness or to develop a disease but there are times that it just only
serves as a form and part of their relaxation. (Fundamentals of Nursing by Taylor, 5th Ed., page 750)

4. Environment Pattern

In Caloocan where the client resides, the relative said that the client home is well ventilated and has an adequate
lighting facility. Outside to the place where the client lives, the relative added that the environment especially the neighbors
were good. In the hospital, as we observed, her bed is neat and clean, it is well lighted and the ventilation as well as the staff
were good.

Interpretation:

The client home environment is well ventilated and lighted as well as his current environment in the hospital.

Analysis:

A pollution free environment is particularly important for individuals with respiratory problems. Persons with
altered respiratory function should reduce their activities, stay indoors, and use an air conditioner, electric air cleaner or air
filter. (Fundamentals of Nursing by Taylor, 5th edition, page 1392)

C. Spiritual Health

1. Religious Beliefs and Practices Pattern

According to the relative, the client has a great faith in their religion. She abides with the practices, beliefs
and values of their religion. Such as, proper attire and attending worship during Sunday. The relative added that the client
strongly believes in God wherein the client always prays only not for herself but also most for her family.

Interpretation:

The client strongly abides by her religion’s practices. She does pray for herself and most for her family.

Analysis:

Religions directly influence the patient’s response to illness and suffering, self care practices such as diet and
hygiene, birth and death ritual, gender role, spiritual practices, and moral code. (Fundamentals of Nursing by Taylor, 5th Ed,
page 976)

Many elders take their faith and religious practice seriously and display a high level of spirituality. They have
strong religious convictions and continue to attend religious meeting or services. (Fundamentals of Nursing by Taylor, 5th
Ed, page 419)

2. Values Pattern

According to the relative, the client is living with her husband. She values her husband, children and grandchildren
so much as she considered them as the most significant people in her life. “Mapagmahal at maalalahanin si lola lagi nya
inaala ang kapakanan ng bawat isa”, as the relative verbalized. The client is very wisely when it comes in spending money
for she thinks that her children are working hard to support and provide their needs.”Matipid si lola lalo na sa paggastos
dahil umaasa na lang sila sa suporta ng kanyang mga anak, as relative verbalized. As stated by the relative, there are times
that she does not want to go for check up when she’s not feeling well for she doesn’t want to spend much money for her.
Nevertheless, her children does not allow it and they insisted their mother to consult a doctor whenever she is not in good
condition.

Interpretation:
 The client is thrifty when it comes to spending money as she thinks about her children hardship just to help them for
their needs. She values her family very much as she considered them as the most important people in her life.

Analysis:

A person values influence believes about human needs, health, and illness: the practice of health behavior and
human responses to illness. (Fundamentals of Nursing by Taylor 5th Edition Page 91).