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Client Profile with hypertension

Client Profile with hypertension

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Published by: plokatz on Mar 30, 2010
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05/18/2012

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Remedios Trinidad Romualdez Medical FoundationCollege of Nursing
OB-Ward Duty RequirementsAbuyog district hospital
Patient’s Profile 
Laboratory Results 
Physical Examination 
Pharmacology Sheets 
Nursing Care Plans 
Journal Readings 
 
Submitted by:
Dichoso, Lowrence Precious C.Group GBSN II-B
Submitted to:
Ms. Joreena AlvaranClinical Instructor
 
March 29, 2010
 
Patient’s Profile
Interview and Assessment Date:
March 29, 2010
Setting: Female Ward Abuyog Hospital Name: Salanap, FlorianaAge: 50Date of Birth: December 17, 1959Birthplace: Abuyog, LeyteSex: FemaleCivil Status: MarriedOccupation: HousewifeSpouse: Salanap, NoelOccupation:CarpenteAddress: Buntay, Abuyog, LeyteReligion: CatholicRace/Nationality: Asian/FilipinoAttending Physician: Dr. BautistaSource of Information: Client, and her daughter 
 
CHIEF COMPLAINT 
“Highblood ako, maiha na inin mga lima ka.tuig na. Tigda nla naglipong an ak uloasya guinpaadmit ak ky dere na ngane ak nakakatukdaw. 
HISTORY OF PRESENT ILLNESS
The client was admitted last March 26, 2010 at around 8:30 in the morning. Admittedto the female ward per wheelchair – dizziness noted.Admission Diagnosis: HCVDFinal Diagnosis: Hypertensive cardiovascular Disease, Diabetes Mellitus, type 2
 
Symptoms started: 45 years oldOnset of symptoms: GradualOften the problem occurs: During afternoonExact Location of distress: HeadCharacter of the complaint: intensity of pain (8 in the scale of 1-10 as the highest is 10)Activity in which the client was involved when the problem occurred:Doing household chores and walkingPhenomena or symptoms associated with the chief complaint: dizzinessFactors that aggravate the problem: foods with ginataan and oily foodsFactors that alleviate the problem: leaves of yabana, tanglad, daily exercise
 
PAST HISTORY 
CHILDHOOD ILLNESSES:The client have had: chickenpox, mumps and measlesCHILDHOOD IMMUNIZATIONS:Date of last tetanus shot: 1976ALLERGIES:No allergies to any drugs, animals’ /insects and to any environmental agentsType of reaction that occurs: none Reaction treated by: noneACCIDENTS AND INJURIES:NoneHOSPITALIZATION FOR SERIOUS ILLNESS:Reason: HypertensionDates: 2006, 2009Course of recovery: 2 weeks or depending if blood pressure is still elevatedSurgery performed: noneMEDICATIONS:Currently used prescription: Amlodipene, captoprilOver-the-counter medications: none 
FAMILY HISTORY OF ILLNES
Parents: Sanchez, Guillerma at homeSanchez, Crisanto – cause of death is a illness in the head due tothe nature of the work: carpenter Grandparents: no data gatheredThere is Family history of hypertension and Asthma. 
LIFESTYLE
PERSONAL HABITS:Drinks COLA occasionally, the Amount is 1 bottle of 8 oz once a month.DIET:The typical diet is 1 cup rice/meal, vegetables, banana, gabi. Client eats three timesa day and have an afternoon snack of usually bread or kakanin. Mrs. Salanap herself Cooks and shop for food. They don’t have ethnically distinct food patterns and noAllergies noted.SLEEP/REST PATTERN:Daily sleep: 9:00 PM – 5:00 AM having 8 hrs of sleep everydayDifficulty sleeping: SometimesRemedies used for difficulties: Get ample sleep on the next dayACTIVITIES OF DAILY LIVING (ADLS):There are no difficulties experienced in the basic activities of eating, grooming,elimination, and locomotion. Except during when her head becames painful.

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