Professional Documents
Culture Documents
Case Study Format
Case Study Format
I. Biographic Data
Address: # 56 Roosevelt Park Subdivisions, San Pablo, Dinalupihan Bataan Age: 32 Gender: Male Marital Status: Single Room and Bed #: N/A Chief Complaint: N/A Provisional Diagnosis: N/A Attending Physician: N/A Religious Affiliation: Roman Catholic Occupation: student
syempre naman nilagnat na ako. May allegy rin ako sa alikabok. Nakumpleto ko yung mga baku-bakuna na iyan sabi sa akin ng nanay ko. May allergy ako sa malalansang pagkain, tulad ng itlog, sa seafoods, especially yang hipon. Allergic din ako sa alikabok, madalas ako bumabahing kapag pumasok sa ilong ko yang alikabok nayan. Nung limang taon ako, sabi sa akin ng nanay ko na nalaglag ako sa tricycle at nabagok daw ako tapos maraming dugo ang lumabas sa ulo ko kwento sa akin ng nanay ko. Dahil masyadong maraming dugo ang lumalabas at hindi humihinto, kinailangan na tahiin , kaya nga natahi tong ulo ko eh, dito sa may bandang noo ko. Madalas pag may nararamdaman akong masakit iniinoman ko na lang ng paracetamol o kaya naman pas masakit ang mga kasukasuan ko tulad ng muscle pain o kaya headache ibuprofen ang iniinom ko.
namatay na. Ang Mama ko normal hypertensive o kaya naman diabetic, ang Papa ko lang ang Hypertensive wala naming sakit ang mga kapatid ko.
B.
Nutritional-Metabolic Pattern
Ang kaen ko, anu almusal, tanghale, hapunan tapos siyempre may mga miryenda na rin kasama, madalas kasabay ko yung family ko, pero pag may pasok,kasabay ko mga classmates ko, lutong ulam n lang kam. Makatubig akong tao,kadalasan, nakaka 3-4 akong baso ng tubig sa isang kainan pero minsan depende padin yun sa kinakaen ko tsaka mas gusto ko kasi yung pantay lang, di masyadong karne siyempre gulay din,ganun
Interpretation: The client is considered to have a glance diet because he meets the adequate nutrients needed by the body accordingly to the clients BMI and consumes adequate food/fluid. Analysis: Nutrient intake is sufficient for meeting metabolic needs. Demonstrate behaviors to attain/maintain appropriate weight at a satisfactory level for height, weight, body build, age and gender (Nurses Pocket Guide ed. 11 by Doenges, Moorhouse, Murr p.488)
C. Elimination Pattern
7-10 times a day ako umihi,kadalasan yellow or clear yung color niya. Tapos pag tuwing umaga, regular yung bowel ko, brown siya tsaka malambot-lambot siyempre mabaho din pero minsan depende din sa kinakain ko kung magiging matigas o anong kulay
Interpretation: The client has normal elimination pattern and no difficulty in eliminating and excretion of urine, the appearance of the clients stool depends on what he eats. Analysis: Establish/maintain regular pattern of bowel functioning possible (Nurses Pocket Guide ed. 11 by Doenges, Moorhouse, Murr p.488)
D. Activity-Exercise Pattern
510; 72 kg. (muscle tone) FAIR
Tuwing umaga, pagpapasok, mula sa bahay,naglalakad na lang ako hanggang sakayan mga 2mins na paglalakad ,parang exercise na din tapos nag-lalaro kami ng mga classmates ko ng basetball para naman mabanat-banat yung buto
Interpretation: the client has a good activity-exercise pattern. He tries to maintain an active body by the regular exercise, sport engagement and other recreational activities to have an appropriate body build for his weight, height and age and he has no difficulties in activities he engages in.
Analysis: clients form of exercise is regular and light just to maintain currnet body build appropriate for height and weight. ( Nurses Pocket Guide ed. 11 by Doengenes, Moorhouse, Murr p.70-73)
E. Sleep-rest Pattern
Hirap ako matulog kaya 5 oras lang ang tulog ko palagi tapos humihilik ako, tapos maaga pa nagigising dahil layo ng bahay ko eh, kaya pag-dating sa school panay ang hikab ko pero di naman apektado yung activities ko sa school, tsaka energetic padin naman, nakakapagkulitan pa ko sa mga classmates ko
Interpretation: The client has poor sleep and rest pattern because of difficulty in sleeping and insufficient sleep taken a day or every night shown by the clients frequent yawning but has enough energy to sustain his everyday activities. He does not do any interventions to cope with his difficulties in sleeping. Analysis: The client has disrupted sleeping patterns. Difficulty falling asleep; waking up too early; dissatisfaction with sleep ( Nurses Pocket Guide ed. 11 by Doengenes, Moorhouse, Murr p.422 and p. 429)
F. Cognitive/Perceptual Pattern
Tapos na ko ng BSManagement, bale 2nd course ko na ito, anu, ok naman, walang problema, di ako nahihirapan kasi parang may background na ko sa college kahit na magkaiba yung course ko, wala din naman problema kunyari sa oras kasi sarili ko naman yung oras ko, di ako nagtratrabaho, focus lang sa studies.
Interpretation: The client already finished a four year course which his highest educational attainment and is expresses motivation to enhance his cognitive/perceptual pattern and no sign of difficulties, conflicts, emotional changes, mental disorders. Analysis: The client has no cognitive dissonance; memory deficit and no signs of mental impairments (Nurses Pocket Guide ed. 11 by Doenges, Moorhouse, Murr pp.451-454 )
H. Role-Relationship Pattern
Kasama ko sa bahay yung family ko, tsaka yung pamangkin ko, bayaw ko kasi nasa abroad so bale, extended kami,mas marami, mas masaya. Sa neighborhood namin, bago lang kami pero ok naman lahat nakakasundo namig, sa mga classmates ko, ok din,masaya kasi wala ako near akakaaway Tatay ko siyempre yung decision maker sa bahay, tapos hati-hati yung mga gawaing bahay kahit matanda na ko,para din a din mahirapan nanay namin sa gawaing bahay.
Interpretation: The client has a healthy role-relationship pattern. He demonstrates a wide base of socialization with others in his community, family, friends, and classmates. He has satisfying personal relationship and adequate personal resources. He helps in the division of activities in their household Analysis: The client meets physical, social and psychological needs of family members. No signs of altered state of wellness and has accepted social behavior/values. Has the ability to engage in satisfying personal relationships. Participates in activities/ programs in the community and expresses increased self-worth and does not demonstrate any sign of social isolation (Nurses Pocket Guide ed. 11 by Doenges, Moorhouse, Murr pp. 639-640)
Analysis: The client is sexually healthy and no signs of any sexual dysfunctions. The client has no conflicts with orientation and is comfortable with his sex preferences (Nursess Guide Pocket ed. 11 by Doenges, Moorhouse, Murr p.611,p.615)
J. Coping/Stress-tolerance Pattern
Ang mga magulang ko pa rin ang sumusuporta sa akin. Sila rin minsan nakaka-alam kung anong problema pero minsan lang, madalas mga kaibigan ko ang nilalabasan ko ng sama ng loob kasi nasa tamang edad naman na ako diba? Kaya makagagawa na ako ng tamang desisyon para sa sarili ko, pam paalis ng stress, naidadaan ko na lang pag-gagala at pag nagkayayaan, inuman na lang oh kaya yosiyosi sa tabi tabi habang nagkukwentuhan parang dyan ko nailalabas yun bang mawala ang stress sa katawan ko.
Interpretation: The client has a good coping stress mechanism because of his different recreational activities to strengthen or improve his stress levels. Analysis: Meet psychological needs as evidenced by appropriate expression of feelings, identification, of options and use of resources. Verbalizes or demonstrates reduced stress reaction. Has available support systems, family, friends can provide client with ability to handle current stressful events. (Nurses Pocket Guide ed. 9 by Doenges, Moorhouse, Murr p. 183)
K. Value-Belief Pattern
Roman Catholic ako, nagsisimba ako tuwing linggo kasama ko pa nga ang mga magulang ko. Dati nai-involved ako dyan sa mga activities sa church kaso nung magsimula na magcollege na ako nahinto na ako sa pag attend-attend dya kasi siyempre busy na tapos laging gala lang kasama yung tropa. Malakas ang pananalig ko sa Diyos syempre kaya ngayon pag may oras ako, nag-sisimba ako di katulad dati nalilimutan ko na
Interpretation: The client is a Roman Catholic with a strong spiritual belief and social development became a barrier to client practicing religion but shows motivation for change. Analysis: The client has strong values and beliefs which affect the clients worth as a person, object, idea, or actions. The clients values also influence decisions and actions. Expresses desire to strengthen
religious belief patterns/customs that had provided comfort/ religion in the past (Nurses Pocket Guide ed. 11 by Doenges, Moorhouse, Murr pp. 559-562)