PATIENT’S PROFILE

Name: Mr.Yabi X

Age: 64 years old

Sex: Male

Birthday: August 22, 1946

Birth rank: 2nd to the eldest

Number of siblings: 2

Religion: Roman Catholic

Civil Status: Married

Number of children: 2, with 2 living

Nationality: Filipino

Height:

Weight: 70.3 kg

Address: Rosario Pasig

Date Admitted: may 1, 2011

Chief Complaint: Difficulty of breathing and chest heaviness radiates

on upper back and nape area

Final Diagnosis: t/c Acute Coronary Syndrome

Health History

History of Present Illness

According to him 1 week before the admission he experience chest

heaviness that radiates to her upper back and nape but he did not consult
when the chest heaviness with pain scale of 10/10 and DOB persist he finally
decided to consult.

Past Medical History

The patient had a completed the immunization when he is a child. He

has no history of accident. He hospitalized last December 2010 in Medical
City because of stroke. This is the second time he hospitalized

Family History

Father Stoke Mother HPN

Eldest 65 yrs Patient,64 years Youngest, 60

old, HPN old Stoke years old

Wife, 58 years Eldest, 38 Youngest 35

Legend: old years old years old
Deceased

Alive

Pain Scale

The patient experience heaviness at his chest radiating to his upper

back and nape. He said he feels the pain most of the time when he is sitting
or standing. He rated the pain 10 out of 10 at the ER but during my
assessment he rated the pain 8 out of ten.
FUNCTIONAL HEALTH PATTERNS

Health Perception & Health Management Pattern

According to him, he believes that health a very important
aspect in life.also he do consultation. When he knows that he has a DM
he advice his daughter and son to have a proper diet and do
consultation. y when he experience health problems he usually seek
for consultation. He also follow and express his concerns about his
health he also follow what the nurses and doctors say. He is very
cooperative to the management.

Nutrition & Metabolic Pattern

Before the hospitalization he drinks at least 5 times a week and
he eats meats and vegetable. He likes soup. He eats at least 1 ½ cup
of rice every meal. He doesn’t take a snack. He doesn’t love to eat
sweet foods.
During hospital days he eats what food the dietary gave but
sometimes he don’t eat it and wait for the food from her significant
others. Also he drinks 8 to ten glasses of water because of the hot
weather.

Elimination Pattern
Before the admission the patient can go to CR anytime he wants.
He has a bowel once every 2 days. His stool is forms slightly dark
brown. He urinate at least 4x a day. His urine is yellow and clear
appearance. He doesn’t feel any difficulty or pain during urination and
defecation. He doesn’t experience excessive sweating because if he
feels hot he can open the aircon.
During hospital days the patient goes to CR even though it’s not
advisable for him. He urinates at least 4x a day with yellow colored
urine and clear appearance. In the first week of hospitalization he
voids at least twice a week but during the interview he voids at least
once every 2 days. His stool is formed and brownish in color. He also
experience sweating because of the hot weather.
.
Activity & Exercise Pattern

Before hospitalization, the patient do exercise every morning he

doest want to go with other places. He just watching or reading if he
has a vacant time. But now since the doctor order him CBR without
BRP he always in bed he just sleep or reading books when he has a
free time
 Level 0 Full self-care
Level 1 Requires use of equipment or device
Level 2 Requires assistance or supervisions from another
person
Level 3 Requires assistance or supervisions from another
person/device
Level 4 Is dependent and does not participate

Before hospitalization:
Feeding: 0 Bed Mobility: 0 Grooming: 0
Bathing: 0 Dressing: 0
Toileting: 0 General Mobility: 0

During hospitalization:
Feeding: 0 Bed Mobility: 0 Grooming: 0
Bathing: 3 Dressing: 3
Toileting: 3 General Mobility: 3

Sleep & Rest Pattern

Before hospitalization, the client’s sleep pattern was usually 7

hours. His sleeps very well and doesn’t have the need to take any
sleep medications. His sleep is continuous and usually wakes up early.
He always does daytime naps. He always does watching television. But
during the hospitalization his sleep is disturb since every four hours
nurses take his vital signs and sometimes he feels chest pain or DOB

Cognitive-Perceptual Pattern

The patient has no problem in hearing. He uses reading glass for

the past 2years. If he feels pain he tried to manage it by himself and if
he can’t, he asks a help to his family. He can speak clearly. In terms of
decision making since he is the father he always decide for his family
but now since he is in the hospital his wife decides. But still they
consult each other.

Self - perception & Self-concept Pattern

According to him he has a high self esteem. He can

communicate well and express his idea. He has a good eye contact
during the interview. He doesn’t care to show his hands even though it
is slightly edematous and has a mark of many inserted needle because
 of IV insertion. He also calls the nurse if he feels bad and express what
he needs.

Role Relationship Pattern

There are changes on his role relationship pattern, he cant do his

role in their house. Even though his family visits him in the hospital,
he cant do his role. His family is very supportive and there are
financing his hospitalization.

Sexuality - Reproductive Pattern

Before the admission the patient is very satisfied to his sexuality
pattern even though they have a less contact with his wife because
he can show his love to her but during hospital days he is satisfied
because they have no private place for both of them

Coping Stress Tolerance Pattern

According to the patient he always keep his problem to himself

but if he knows that he can’t solve it by himself he always open it to
his wife. During the admission, since many changes happens, new
environment, he just trying to adopt all the changes by himself.

Value – Belief Pattern

The client is a Catholic. According to him, before and during

admission his faith doesn’t change. He always pray specially when he has
a problem. Even though he doesn’t go to church every Sunday he has a
high faith to GOD.