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Kareen Mae C.


Name: M.L.R.
Age: 29
Gender: Female
Address: Quezon City
Religion: Roman Catholic
Date of Birth: August 6, 1979
Place of Birth: Quezon City
Civil Status: Single
Nationality: Filipino


“Nagpunta ako dito sa hospital para sa chemotheraphy ko pero medyo masakit din ang ulo ko.”


Two days prior to admission, the patient experienced headache before going to sleep, she took analgesic
and the pain was relieved but she was not able to sleep well because she still felt a little pain. One day prior to
admission, the headache didn’t persist so she was able to rest well during that day.
Before admission, the patient complained about her headache and since it was the scheduled date for her
chemotherapy, the mother brought her to the hospital.
Upon admission, the patient’s vital signs were obtained and the respiratory rate was 18 breaths per minute,
pulse rate was 82 beats per minute, temperature was 36.6°C, and blood pressure was 120/80. She rated the pain 4
over 10, 10 being the most painful.


In the year 2008, patient was rushed to the hospital due to severe headache and nausea which later on was
diagnosed to have a tumor in the brain (Asthrocytoma) during her hospitalization. Patient had undergone series of
chemotherapy which was done every three weeks. Patient had chickenpox when she was 10 yrs. old. Patient has
been vaccinated with 1 dose of BCG, 3 doses of DPT, 3 doses of OPV and 3 doses of Hepatitis B except for the
vaccine for Measles.

+ HP
DM +
+ +

N +



Female Male Px – Patient DM – Diabetes Melitus HPN – Hypertension + - died


The patient lives with her family. The patient has an effective relationship with the other members of the
family and there are no known conflicts between them. The patient is open, in terms of the emotional and social
aspects with her family. As for the kind of neighborhood, the patient grew up in their concrete two-storey house in
the urban area. The patient has an excellent social relationship with the neighbors because they are her friends. They
can always count on her whenever there is a problem. The patient is not that active in their community because she
seldom participates in baranggay’s projects.
It will take five to ten minutes of walking for the patient to reach their baranggay health center. Malls,
church, school, market and transportation such as jeepnies, buses and tricycles, are readily available near their
house. The patient has no vices. The patient didn’t drink alcoholic beverages nor smoke cigarettes nor try taking
illegal drugs.
Within the last six months, the patient had traveled to Pampanga for vacation.


The patient likes to rice and viand for breakfast. During lunch and dinner time, the patient observes a
balanced diet by eating rice for carbohydrates, fish or meat for proteins and fruits and vegetables for vitamins and
minerals. Oftentimes, the patient eats snacks in the afternoon; she loves to have banana cue for snack or other street
foods. The patient stays at home everyday and sometimes goes to the mall with her family. She helps her mother in
doing the house chores in the morning and rests and watches television shows during free time. She sleeps in the
afternoon after eating lunch and during the night.


1. Health Perception - Health Management Pattern
S: Patient verbalized, “Hindi ako madalas na magkasit noon hanggang sa naospital ako noong March 2008 at
nalaman ko na may tumor ako sa utak. Dati kasi hindi naman ako nagpapachech-up sa doctor kapag hindi naman
masyado malala ang nararamdaman ko. Hindi rin ako umiinom ng vitamins. Simula lang noong nagkasit ako,
nagsimula akong uminom ng vitamins. Tingin ko dati hindi rin ako ganon ka-healthy kasi mataba na din ako dati pa
eh pero nung magkasakit ako lalo na akong nag-ingat sa kalusugan ko para hindi na lumala pa yung sakit ko. Simula
nung nalaman kong may sakit ako lagi na ako nagpapatingin sa doktor kahit hindi malala yung nararamdaman ko,
para syempre maagapan. Iniinom ko din yung mga nireresetang gamut ng doktor sa akin. Katulong ko si mama at
ang mga kapatid ko sa paglaban sa sakit ko, kung ako lang kasi sa palagay ko hindi ko kakatanin.

O: The patient is wearing a shirt and pants. She is properly groomed and doesn’t have any body odor. Her
height is 5’1 and her weight is 132lbs. (BMI: 23.4). Her vital signs are: BP- 120/80mmHg, PR- 82bpm, RR- 18bpm
and temperature- 36.6°C.

A: Readiness for enhanced health management.

2. Nutritional - Metabolic Pattern

S: Patient verbalized, “Paborito kong kainin yung lutong kaldereta ni mama. Madalas kong pinapaluto yun
tuwing Linggo. Pero mahilig din naman akong kumain ng mga gulay at prutas. Tatlong beses akong kumain sa isang
araw. Madalas, kumakain rin ako ng snacks. Minsan rin, kumain ako sa mga fast food restaurant. Sa loob ng isang
araw, nakakaubos ako ng mahigit walong basong mineral water. Wala naman akong allergy sa mga pagkain.
Kumakain din ako minsan ng street foods. Noong nagkasakit ako, dinagdagan ko lang yung pagkain ng mga
masustansiyang pagkain, lagi na ako nagpapaluto ng gulay kay mama tapos nagkakakain din ako madals ng mga
prutas kasi madalas bumili yung mga kapatid ko. Kahapon ng umaga, kumain lang ako ng kanin at ulam ko ay
pritong isda. Noong tanghalian naman kanin at nilagang baka ang ulam. Tapos nung hapunan nag-uwi ng hipon
yung kapatid ko kaya iyon ang ulam namin. Bago ako matulog ay uminom din ako ng gatas.”

O: Patient’s hair is unevenly distributed, the center has lesser number of hairs than the surrounding part, and it
is dry and thin. No dandruff was noticed. Skin is slightly pale, warm and moist. No suspicious rashes. No lesions
found. Nasal orbit appears wet. Oral mucosa appears wet. Her height is 5’1 and her weight is 132lbs and the BMI
is 23.4. The abdominal bowel sound is normal high-pitched gurgles heard at 5-20 seconds interval.

A: Readiness for enhanced nutrition.

3. Elimination Pattern
S: Patient verbalized, “Normal naman ang pag-ihi ko kahit may sakit ako. Wala naman akong nararamdamang
sakit at di naman ako nahihirapan. Sa isang araw mga limang beses akong umiihi at mga apat na baso ang dami
kung tatantyahin ko yung iniihi ko sa isang araw. Wala naman akong problema pagdating sa pagdumi. Araw-araw
ay nakakadumi naman ako nang walang nararamdamang masakit o kaya naman hirap sa pagdumi. Wala din naman
akong napapansing dugo o kakaibang kulay sa aking dumi. Ang dumi ko kadalasan ay pahabang pabilog at color

O: The bladder is not distended and the abdomen is symmetrical. There are no audible bowel sounds.
Tympanitic sound was heard over the area of the stomach; dullness over spleen and liver. There was no tenderness
in the abdomen. The liver and bladder are not palpable. There are no hemorrhoids found inside the anus. Patient’s
urine output per day is 840cc. The urine is light yellow in color and is faint aromatic. The bowel output is once a
day. The bowel is cylindrical in shape and brown in color.

A: Readiness for enhanced elimination pattern.

4. Activity - Exercise Pattern

S: Patient verbalized, “Dati, bago pa ako magkasakit nag-aaral ako sa UM at isa akong HRM student,
nagcocommute lang ako papuntang school tapos hindi ako madals na mag-exercise, siguro yung P.E. naming subject
yun na yung maituturing kong exercise ko. Tumutulong din ako sa mga gawaing bahay tuwing weekends at pag
wala masyadong ginagawa. Mahilig akong pumunta sa mall kasama ang mga kapatid ko at hindi ako mahilig sa
sports. Pero nung magkasakit na ako, kinailangan kong tumigil sa pag-aaral ko. Madalas pa rin ako tumulong sa
gawaing bahay ngunit hindi na ako madalas lumabas at wala din akong exercise kasi madalas nanghihina ang
pakiramdam ko kaya pinipili ko na lang na magpahinga.

O: The patient appears to be weak and skin is pale in color .The patient is able to walk but is not standing erect. Her
muscle strength is rated 75% which is normal full movement against gravity and against minimal resistance. She can
do active range of motion on light activities and an increased respiratory rate and shortness of breath in moderate
and heavy activities. The muscle tonicity is in the normal condition of tension/tone of a muscle at rest. The
extremities are warm and has capillary refill of less than 3 seconds. Her vital signs are: BP- 120/80mmHg, PR-
82bpm, RR- 18bpm and temperature- 36.6°C.

A: Activity intolerance r\t generalized weakness.

5. Sleep – Rest Pattern

S: Patient verbalized, “Before, mga 8 hours ang tulog ko, siguro mga 9 pm tulog na ako at 5 am naman ang
gising ko. Estudyante ako kaya kailangan kong gumising ng umaga. Ngayon, mga 5-6 hours na lang dahil madalas
ay sumasakit yung ulo ko kapag gabi kaya hindi ako nakakatulog ng maayos, madalas din paputol-putol yung tulog
ko. Bago ako matulog, nagtutoothbrush muna ako at naghihilamos o kaya naman minsan kumakain pa ng midnight
snack. Madalas nakatagilid ako matulog. Isang unan sa ulo, isa yakap-yakap ko at isa naman sa pagitan sa legs ko.
T-shirt at shorts o kaya pajama lang ang suot ko kapag natutulog. Kung minsan din nakakaidlip ako sa hapon ng
mga isang oras.”

O: The patient has a visible dark spot under the eye. She has a poor posture and frequent yawning. The patient
seems restless and tired.

A: Disturbed sleep pattern r/t pain and discomfort.

6. Sensory – Cognitive – Perceptual Pattern

S: The patient verbalized, “29 years old na ako, nagpapahinga lan ako sagayon dahil kinailangan kong tumigil
sa pag-aaral ko dahil nga sa karamdaman ko. Medyo pagod at nanghihina yung pakiramdam dahil na rin siguro sa
sakit ko. Nandito ako sa hospital ngayong umaga para sa scheduled chemotherapy ko. Nakakapagdesisyon ako para
sa sarili ko dahil nasa tamang edad na naman ako. Malinaw ang aking paningin. Nakikita ko ng malinaw ang mga
bagay at hindi rin ako gumagamit ng salamin sa pag-babasa. Wala rin akong nararamdamang sakit sa paligid ng
mata ko. Wala rin akong problema maging sa pandinig at pang-amoy ko. Narririnig ko ng malinaw ang sinasabi ng
kausap ko. Hindi rin ako hirap kumain o ngumuya ngunit paminsan ay wala akong ganang kumain. Ayos naman ang
panlasa ko.

O: Client is well-oriented to time, place and event. Client answers the question without difficulty, her pattern
of speech is coherent, and she speaks in a soft voice. Client does not have difficulty recalling past situation. Client is
able to express well what she wants to say. The cranial nerve assessment:
CNI – Olfactory: The patient was able to smell the vinegar and the coffee.
CNII – Optic: The client has 20/20 vision.
CNV – Trigeminal: The client was able to clench her jaw.
: Blink reflex, Kinesthesia: client was able to determine
the movements of the arm while her eyes closed.
: Proprioception: client was able to determine the
position of the arm while eyes closed.
: Sterognosis: client was able to determine the objects
while eyes closed.
CNVII – Facial: The client was able to determine the taste the lemon and
sugar correctly.
CNVIII – Vestibulocochlear: Weber (-), Rinne AC > BC

A: Readiness for enhanced knowledge

7. Self-perception – Self-concept Pattern
S: Patient verbalized, “Dati, masaya na ako at kuntento sa buhay ko ngunit simula noong malaman ko ang
sakit ko, sobra akong nag-alala sa kalagayan ko, bawat araw iniisip ko kung gaano na lang katagal ang itatagal ko,
sobrang natatakot akong mamatay at ayoko pang mamatay. Sana ay patagalin pa ng Diyos ang buhay ko dahil
minsan tingin ko sa sarili ko ay wala ng pag-asa pang gumaling pero salamat sa pamilya ko dahil lagi silang
nakasuporta sa akin.”
O: The patient slouches when she sits. Patient’s voice is audible.. She speaks in a soft voice and seems to be
bothered. She also doesn’t maintain an eye-to-eye contact while speaking.

A: Anxiety of death r/t chronic illness or severe condition.

8. Coping – Stress Tolerance Pattern

S: Patient verbalized, “Dati, wala naman masyado nakakastress sa akin kasi masayahin naman akong tao pero
nung nagsimula akong magkasakit lagi ko ng naiisip yung karamdaman ko, kung ano na ang mangyayari sa akin o
kung mamamatay na ba ako pero sa tulong ng aking pamilya at mga kaibigan, pinipilit kong lumaban kasi sobrang
mahal nila ako at ineencourage akong lumaban at may pag-asa pa sa kabila ng mga pag-subok. Kaya
nagpapasalamat ako dahil sa kanila.”

O: The client is cooperative during the interview and there is an organized thought process and clear speech

A: Readiness for enhanced coping.

9. Role – Relationship Pattern

S: Patient verbalized, “Ang mga kasama ko sa bahay ay yung mama at mga kapatid ko. Nandun din yung
dalawa kong nakababatang kapatid pati yung kuya ko na may asawa na. Kapag nagkakaproblema ako o
nagkakasakit, si mama lang ang nilalapitan ko kasi mas close ko siya. Wala pa naman akong trabaho kaya hindi pa
ako nakakapagbigay ng pera sa amin. Yung tita ko sa ibang bansa ang sumusuporta sa amin kasi dalaga naman iyon
at malaki ang kinikita niya sa ibang bansa, yung kuya ko din ay nagtatrabaho na at nagbibigay din ng pang-gastos
kay mama tapos yung sumunod sa akin ay may trabaho na din, yung bunso naman ay graduating na. Mabuti naman
akong anak sa mama ko at kapatid sa mga kapatid ko, sa katunayan ay close talaga kami ng pamilya ko lalo na nung
mamatay ang papa namin. Mabait at matulungin din akong kaibigan.

O: The client is closely bonded and has good communication with her family. The client also communicates to
others effectively. She was with her mother and sister when she got admitted.

A: Readiness for enhanced role and relationship process

10. Sexuality – Reproductive Pattern
S: Patient verbalized, “Babae ako syempre. Nagkaroon ako ng menstruation nung grade 6 ako. Simula noon
napansin ko na ang pagbabago sa’kin. Nagsimulang nagmature ang boses ko, tumangkad ako kahit papano, at saka
napansin kong nagsimula na rin akong tubuan noon ng buhok sa kilikili at sa private part. Hindi ko na priority
ngayon ang pagkakaroon ng boy friend, kuntento na ako sa pamilya at mga kaibigan ko.

O: The client has normal breasts. No cyst in the breasts. The pubic hair is evenly distributed.

A: Readiness for enhanced sexuality-reproductive pattern.

11. Value – Belief Pattern

S: Patient verbalized, “Roman Catholic ako, dati sobrang madasalin ko at nagsisimba pa ko lingo lingo.
Deboto pa nga ko ni sto. Niño pero nung magkasakit ako sinisi ko ang Diyos sa kalagayan ko. Sa dinami-dami ng
tao bakit ako pa yung binigyan niya ng ganitong karamdaman. Napakasakit isipin na malala yung sakit mo eh.
Simula noon, hindi na ako nagsimba o nagdadasal. Ewan ko pero mabigat lang sa pakiramdam pag naiisip kong may
sakit ako. Para bang nabalewala yung pananampalataya ko.

O: Patient became emotional while she was interviewed. The patient is not observed to have religious routines.

A: Spiritual Distress r/t chronic illness.

S: Patient verbalized, Activity Insufficient Goal: 1. Determine baseline 1. Provides opportunity to 1. The patient will
“Dati, bago pa ako intolerance r\t physiological or activity level. track changes demonstrate a
magkasakit nag-aaral generalized psychological energy After 48-72 hrs. of decrease in
ako sa UM at isa akong weakness to endure or complete nursing intervention: 2. Assess the level of 2. Helps in knowing the physiological signs
HRM student, evidenced by required or desired mobility and the capability of patient of intolerance.
nagcocommute lang ako patient’s daily activities can be The patient will physical condition of which is needed in setting
papuntang school tapos appearance of caused by a be able to the patient goals. 2. The patient will
hindi ako madalas na weakness and generalized weakness verbalize and participate willingly
mag-exercise, siguro pale skin or pain. When a identify the 3. Adequate energy is in necessary/desired
yung P.E. naming color and by person feels negative factors 3. Assess the needed for activities to be activities.
subject yun na yung daily weakness and pain, it affecting nutritional status of the done.
maituturing kong activities as will result the person activity patient. 3. The patient will
exercise ko. verbalized by to rest instead of tolerance and verbalize techniques
Tumutulong din ako sa the patient. completing desired eliminate or 4. Note presence of 4. To prevent in conserving and
mga gawaing bahay activities. reduce their factors contributing to overexertion. utilizing energy
tuwing weekends at pag effects when fatigue. when doing
wala masyadong possible. activities.
ginagawa. Mahilig 5. Monitor patient’s 5. Sleeping difficulties
akong pumunta sa mall The patient will sleeping pattern and should be taken care of 4. The patient will
kasama ang mga be able to use amount of sleep. before activity should also verbalize
kapatid ko at hindi ako identified start. factors that will
mahilig sa sports. Pero techniques to show signs of
nung magkasakit na enhance activity 6. Observe and 6. Monitoring these will overactivity.
ako, kinailangan kong tolerance. document the response help as a guide for
tumigil sa pag-aaral ko. of patient to the optimal results of the
Madalas pa rin ako activity. activity.
tumulong sa gawaing *Pulse rate
bahay ngunit hindi na *Dyspnea
ako madalas lumabas at Objective: *Fatigue
wala din akong exercise
kasi madalas nanghihina At the end of 2 7. Create guidelines 7. Achieving guidelines
ang pakiramdam ko hours of nursing and goals for the and goals promote
kaya pinipili ko na lang intervention, activity for the patient motivation for the patient.
na magpahinga. patient will: and the nurse.

O: The patient appears Report

to be weak and skin is measurable 8. Create activities 8. To enhance ability to
pale in color .The increase in when the patient has participate in activities.
patient is able to walk activity the most energy.
but is not standing erect. tolerance.
Her muscle strength is 9. Plan care with rest 9. To reduce fatigue. To
rated 75% which is Decrease periods between promote energy
normal full movement physiologic activities. conservation and
against gravity and sign of recovery.
against minimal intolerance.
resistance. She can do 10. Support patient in 10. Exercise sustain
active range of motion Participate doing ROM exercises muscle strength and
on light activities and an willingly in at least 3 times a day. ROM.
increased respiratory desired or
rate and shortness of necessary 11. Educate the patient 11. To promote awareness
breath in moderate and activities. to recognize signs of when to ease activity.
heavy activities. The physical overactivity.
muscle tonicity is in the
normal condition of
tension/tone of a muscle 12. Teach methods to 12. To manage activities
at rest. The extremities utilize and conserve within individual limits
are warm and has energy. and to increase activity
capillary refill of less levels gradually. To
than 3 seconds. Her . reduce oxygen
vital signs are: BP- consumption, permitting
120/80mmHg, PR- more prolonged activity.
82bpm, RR- 18bpm and
temperature- 36.6°C.
S: Patient verbalized, Spiritual .Impaired ability to Goal: 1. Listen to 1. Identifies need 1. The patient will
“Roman Catholic ako, Distress r/t experience and client/SO’s for spiritual verbalize increased
dati sobrang madasalin chronic illness integrate meaning After 48-72 hrs. of reports/expressions of advisor to address sense of
ko at nagsisimba pa ko as evidenced by and purpose in life nursing intervention: anger/concern, client’s belief connectedness and
lingo lingo. Deboto pa the through a person’s alienation from God, system.. hope for future.
nga ko ni sto. Niño pero verbalization of connectedness with Patient will and so forth.
nung magkasakit ako patient. self, others, or a verbalize 2. The Patient will
sinisi ko ang Diyos sa power greater than increased sense of 2. Determine sense of 2. Indicators that demonstrate ability to
kalagayan ko. Sa oneself can be connectedness and futility, feelings of may see no, or help self/participate
dinami-dami ng tao caused by a chronic hope for future. hopelessness and limited, in care.
bakit ako pa yung illness because it helplessness, lack of options/alternative
binigyan niya ng causes anxiety and Patient will motivation to self s or personal 3. The patient will
ganitong karamdaman. fear of death on the demonstrate help. choices available discuss beliefs/values
Napakasakit isipin na part of the patient ability to help and lacks energy about spiritual issues.
malala yung sakit mo which affects their self/participate in to deal with
eh. Simula noon, hindi spiritual being. care. situation.
na ako nagsimba o 4. The patient will
nagdadasal. Ewan ko Objective: 3. Note recent changes 3. Helpful in verbalize acceptance
pero mabigat lang sa in behavior. determining of self as not
pakiramdam pag naiisip At the end of 2 hours severity/duration deserving
kong may sakit ako. nursing intervention, of situation and illness/situation.
Para bang nabalewala patient will: possible need for
yung pananampalataya additional
ko. referrals.
The patient will
O: Patient became discuss 4. Develop therapeutic 4. Promotes trust
emotional while she beliefs/values nurse-client and comfort ,
was interviewed. The about spiritual relationship. encouraging client
patient is not observed issues. to be open about
to have religious sensitive matters.
routines. The patient will
verbalize 5. Involve client in 5. Enhances
acceptance of self refining healthcare commitment to
as not deserving goals and therapeutic plan, optimizing
illness/situation. regimen as outcomes.
6. Provide information 6. Realizing these
that anger with God is feelings are not
a normal part of the unusual can
grieving process. reduce sense of
guilt, encourage
open expression
and facilitate
resolution of


S: Patient verbalized, Disturbed Disturbed sleep Goal: 1. Assess the vital signs. 1. To provide 1. The patient will
“Before, mga 8 hours ang sleep pattern pattern is time- baseline data identify individually
tulog ko, siguro mga 9 pm r/t pain and limited disruption After 48-72 hrs. of appropriate
tulog na ako at 5 am naman discomfort and of sleep (natural, nursing intervention: 2. Assess past patterns of 2. Sleep patterns interventions to
ang gising ko. Estudyante abnormal periodic sleep in normal patient’s are unique to each promote sleep.
ako kaya kailangan kong physiological suspension of Patient will environment of patient. person.
gumising ng umaga. status or consciousness) manifest (Amount, bedtime, 2. The patient will
Ngayon, mga 5-6 hours na symptoms as amount and optimal amount rituals, positions, aids increase sense of
lang dahil madalas ay evidenced by quality can be of sleep without and interfering agents) well-being and
sumasakit yung ulo ko visible spot caused by experiencing feeling rested.
kapag gabi kaya hindi ako under the eye physiological adverse effects. 3. Assess factors that 3. Knowing an
nakakatulog ng maayos, of the patient, discomfort or affect the patient’s sleep etiologic factor will 3. The patient will
madalas din paputol-putol poor posture pain. Dark circles are difficulty. guide proper improve in her sleep
yung tulog ko. Bago ako and frequent not visible sleeping patterns. and rest pattern.
matulog, nagtutoothbrush yawning. under eyes.
muna ako at naghihilamos 4. Train the patient to 4. This promotes
o kaya naman minsan perform a daily schedule regulation of the
kumakain pa ng midnight for sleeping and waking. circadian rhythm
snack. Madalas nakatagilid and reduces the
ako matulog. Isang unan sa energy used for
ulo, isa yakap-yakap ko at alteration to
isa naman sa pagitan sa changes.
legs ko. T-shirt at shorts o
kaya pajama lang ang suot 5. Propose the use of 5. Milk contains L-
ko kapag natutulog. Kung soporifics like milk. tryptophan which
minsan din nakakaidlip ako aids in sleeping.
sa hapon ng mga isang Objective:
oras.” 6. Provide quiet 6. To establish
At the end of 2 environment and optimal sleep and
O: The patient has a visible hours nursing comfort measures in rest patterns
dark spot under the eye. intervention, preparation for sleep.
She has a poor posture and patient will: (back rub, washing
frequent yawning. The hands/face, cleaning and
patient seems restless and The patient will straightening sheets)
tired. verbalize the
causative 7. Try to let the patient 7. Research
factors of sleep sleep for sleep cycles for indicated that 60 to
disturbance. a minimum of 90 90 minutes are
minutes. needed to a
The patient will complete a sleep
demonstrate cycle. A complete
optimal balance sleep cycle is
of rest and needed to have
activities optimal sleep.

The patient will 8. Teach effective age- 8. To enhance

express appropriate bedtime client’s ability to
increased ability rituals fall asleep
to sleep.

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