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Case Analysis

(Ncm 104A)

Submitted by:
Anuddin, Sha-Ina M.
Submitted to:

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I. Client’s Profile

Name: Panilaga, Aida Occupatiion: Housewife

Address: Curuan, Zamboanga City Educational Attainmennt: Elem. Graduate

Age: 47 Dialect/Language spoken: Chavacano

Gender: Female Religion: Roman Catholic

Marital Status: Married

Medical Impression: Open Fracture Distal Third Tibia (R)

A.Past Health

-No previous hospitalization, no known allergies to food and drugs

-HPN

-DM

B. Family History

-HPN

-Asthma

-DM

II. Gordon’s Functional Health Pattern

Health-Perception/ Health Management Pattern

The patient is almost generally the same as how every Filipino seeks health assistance. Without
any problem regarding her health, she would not approach health workers not unless it is life-
threatening. Although she was not hospitalized prior to her current illness, the patient has the
proper perception whether she is being treated correctly as with the management done to her
at the hospital in ZCMC.

Nutritional/ Metabolic Pattern

The patient eats three times a day. She says that she eats a balanced diet. Although she is not
fond of eating fish, he loves to eat vegetables such as okra and is fond of munching fruits like
bananas and catmon. She usually drinks coffee every morning. She prefers to drink water than
carbonated beverages. During her hospital stay, she is instructed with diet as tolerated.

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Elimination Pattern

According to the patient, when she is at home she usually defecates for at least once a day,
same as with her stay in the hospital. She urinates more frequently (average of 4 times daily)
during his stay at the hospital than the time prior to his admission.

Activity/ Exercise Pattern

She stated that she always do household chores such as cleaning their house and do their
laundry, as housewife she always do such things.

Sleep-rest Pattern

The patient sleeps for an average of 8 hours per day before her confinement. During her
hospital stay, she usually sleeps for 4 hours and takes nap in the afternoon. She had a difficulty
of moving around the bed due to the external fixator attached to her leg.

Cognitive/ Perceptual Pattern

From her point of view, she has a good memory. She says that she can still remember things of
great importance especially with regards to her family and loved ones. Her hearing ability is also
in normal condition and so does her sense of sight.

Self Perception/ Self-Concept Pattern

The patient says that she is very much comfortable with her body image prior to her injury.
Even if her left leg is injured, she still feels optimistic about regaining her old functionality and
image.

Role/ Relationship Pattern

She lives with her family and performs her obligations as a mother. The patiemt stated that
they handle their problem with her husband by privately talking. They lived as a nuclear family.
Her husband is the breadwinner in their family. And there's no problem in regards with the
relationship to their children

Sexuality & Reproductive Pattern

She started her menstruation whem she was 15 years old, no abnormality on her
menstruation/regular menstruation

Coping/ Stress-tolerance Pattern

The patient copes up with stress by relaxing like watching tv, nap, taking snacks. When they
have a problem in family they resolved it by means of talking to each other.

Value/ Belief Pattern

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The patient is a Roman Catholic, she seldom go to church with her family, but never forget to
pray. When she got to church she brings with her their children and sometimes only her
husband.

III. Comprehensive Analysis

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