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Saint Paul University Philippines

Tuguegarao City, Cagayan 3500


Bachelor of Science in Nursing Level II

Airon Vince P. Calica

James Anthonee G. Palattao
Stephanie Mickey V. Advincula
Grezza Joi J. Leano
Resureccion L. Luyun
Katryn Ann B. Pascual
Abigail L. Villasin

PBL Team: Angel Jhudiel

Mr. Nonito C. Mora Jr., RN, MSN

Clinical Instructor

Biographical Data
• Name: DAD

• Age: 27 years old

• Gender: Female

• Birthdate: November 24, 1987

• Address: Dumangas, Iloilo City

• Height: 5”

• Weight: 63 kg

• BMI: 27.12 (Overweight)

• Ethnic Origin: Ilonggo

• Education: Grade one

• Religious Preference: Roman Catholic

• Nationality: Filipino

• Civil Status : Married



• Subjective data: Guideline Questions:

The client sad that she was good. She rated 8 as her rating to her health. She describe her
health in a good condition right now. “Kung nagkakasakit ako, talagang nahihirapan ako” she
said. Furthermore, after her childbirth she felt weakness, blurred vision, high blood pressure, and
experienced haemorrhage. She also said that she experienced difficulty in caring her children
because she received 2 bags of type A blood from a donor at Red Cross in replace for her blood
before she was discharged from the hospital. “Noong pagkatapos kong manganak, at noong
lalabas na ako, bigla akong nakaramdam na naiihi ako. Pagkabangon ko, nakita ko na maraming
dugo sa kama ko” she said

• Health Management and Habits

She doesn’t feel anything g bad about her body. The client said that she always went
to the doctor when she felt different. In addition, she had her Pap smear last August and she
stated that the result was normal. ( she said that she goes to this screening because she is
conscious about her health and “mahirap na kung may sakit ka” as verbalized by the patient-
tingnan mo airon kung okay to. Dagdagan mo or bawasan mo kung gusto mo). She also narrated
that foods here in tuegegarao makes her weak and become obese, ( diko alam kung anong
ilalagay ko ditto na parte) because not all foods were fresh that was why we’re just eating meat
dishes often. She mentioned that her last immunization was last July 5, 2014 after giving birth to
her 3rd child. She neither drink alcohol nor smoke nor take drugs. She was not always exposed
to pollutions and toxins. She always comply to take her prescribed medications often because she
doesn’t want to become sick or unhealthy. “Mahal magkasakit, kaya sinusunod ko nalang lahat
ng prescribed na gamot sa akin, mahirap na. Nung nanganak ako tinusukan ako ng Tetanus
Toxoid, tinatawag din nilang TT, yung mga folic acid, mga ferrous sulfate yung iba hindi ko na
maalala basta marami” she said.2.


She eats 3 times a day with meat as a preference because of the availability of fresh meats
in Tuguegarao. “Puro karne ang kinakain ko dahil yung ang fresh ditto, mga isda hindi, pero
paminsan-minsan kumakain ako ng isda, ngayon lang ito noong nagtrabaho yung asawa ko dito
sa Tuguegarao. Ang gulay niyo ditto hindi matamis, hindi katulad sa Iloilo kahit half cooked
lang ay malasa at matamis na ang sabaw dito walang lasa” she said. Her preferred snacks were
always tinapay and soft drinks for beverage. She usually eat her meals in breakfast at 6:30 am,
lunch 12 noon, dinner 8 pm. Drinking 6 cups of water is her usually drink. She’s not
experiencing sore throat, sore tongue or sore gums, nausea, vomiting and abdominal pains. Dad’s
weight is 63 kg; she never had any recent weight gain or loses.


“None, because I have a normal bowel movements” as she described her bowel
movement and if there any changes. She usually defecate every morning, twice a day which is
normal because the normal is 1-3 times every three days. She has brown oval- shaped stools as
said by the client. She experiences good bowel movements that was why she doesn’t need to take
laxatives, enemas, and suppositories. She was comfortable every time she defecates. She never
feels any discomfort with her bowel movements and she never had bowel surgeries. Dad’s
urinary habits are normal, she frequently do urinate when she drinks a lot. Yellowish as she
describes the color of her urine and the amount is 1 cup or 210 cc in the hospital as the client


Walking is her daily living activities, eating is her activity on a normal day and she is very
satisfied when she’s eating. The client walks reasonable distances during her time when she
brought in her children and fetch them later on. She doesn’t have difficulty with her self-care
According to her she never had difficulty with any of the self-care activity because she’s
good. She doesn’t have any special devices to help her in her activities. Dyspnea, shortness of
breath, palpation, chest pain, stiffness and weakness base from her answer these have nothing to
do to affect her activities.

• Leisure Activities

She enjoys watching tv or reading articles and plays Sudoku, her health is not
affecting her ability to enjoy her leisure. She has a time for her leisure activities and her hobby is
eating, surfing and sleeping. Furthermore, she designs and prints graduation pictures at North
Central Elementary School, Tuguegarao City for her leisure time. She also has ‘mini tindahan’ at
their place.

• Exercise Routine

According to her she believe that walking give her exercise, she walk everyday
and her health never interfered with her exercise routine.

• Occupational Activities

The patient is a housewife and there’s no anything can affect her health. “No,
because I don’t have any problem’ she answer when I ask her if health affect her ability to work
as a housewife. She described her weekly pattern of activity and leisure in a good condition. She
doesn’t have any disease that can affect her cardio-respiratory system or muscle skeletal system.


• Ability to Understand

“Good” as she described the doctor told her about her health, she is satisfied in
understanding her illness and prescribed care. The best way to learn according to her is read,
watch at TV and etc.…

• Ability to Communicate

According to the patient her current state of her health is good, she’s not able to
ask questions about her treatments, medications and sometimes she feel difficulty expressing
herself or explaining things to others due to nervousness.

• Ability to Remember

She was not able to remember recent events and events of long ago.


• Sleep Habits
Client says she generally achieve 5-6 hours per night which she thinks provides
her with ample rest and enough to provide her energy for the day. She sleeps at 10 pm but before
sleeping usually took her shower and watches on the TV every night, she take 30 minutes to fall
asleep, when she awaken she take 5 minutes to fall asleep again and “good” as she rate the
quality of her sleep.The patient never experience difficulty in falling asleep, never felt fatigued
after sleep period. Her current health never altered her normal sleep habits and she feel that her
sleeping habits have contributed to her current illness.

• Sleep Aids

She chooses reading, relaxation techniques and listening to music helps her to fall


She described herself physically fit and she has no illness to affect herself. She
considered God and her family to be her strength and fatigue as her weakness. She felt happy to
herself and her family is happy too about her. She feels good about her appearance, she doesn’t
have any illness that can affect her appearance. If she would change her appearance and if she
could she wants to undergo skin medications. She feel pity with those people with disabilities,
we observed there’s nothing unusual about this patient’s appearance, she is comfortable with her
appearance and as we described the patient feeling state is normal.


• Perception of Major Roles and Responsibilities in Family

According to her, her mother has a mild intermittent asthma while her father is healthy.
She is living with her both parents and they get along through family bonding. She’s very happy
and satisfied about her family and her role is being a good mother, her role is very important
because she is a mother of 3 children. Taking care of her children is her major responsibility. She
has a good relationship to her husband. She also stated that her husband and she makes the
decision in their family.

• Perception of Major Roles and Responsibilities at Work

Our patient is a mother, her major role as a mother is to raise her children well. She feels
very happy with her friends and children. For now there’s no any major problem with her family.

• Perception of Major Roles and Responsibilities

For her God is the most important in her life. “Good” as she described her neighborhood
and community. She never participated in any social groups or neighborhood activities. For her
there’s nothing she can contribute to society, corruption that she wants to change about her
community if she could and according to her she described herself as a good mother and her
various role in life is to be good mother and wife to her husband. Relationship to God and family
is important to her.


• Female

During her 12 years of age the client experienced her menarche and she said that
it was always normal. She felt tense and emotional during her menarche. She gained water
weight and feel bloated. She had pain (cramps) in her abdomen that lasted for 3 hours. “
Nagmens ako nung Grade 6 ako, 12 years old ako nun, nung una normal at nung pagdatin ko ng
college nakaranas na ako ng cramps sa tiyan ko” she said.

She had her coitarche when she was 20 years old. She conceived thrice and gave birth thrice
also. All of her children were alive. She said that her OB-Gynecologist was Dra. Palattao at St.
Paul Hospital. She uses “Trust” pill and had her Pap smear last August. Moreover, she said that
the result was negative (normal cervical cells were discovered during Pap smear as seen on the
results). She doesn’t have illnesses that affects her sexual relationship.

She also said that he feel no pain while voiding and there is no unusual odor


According to patient Dad, she doesn’t drink any alcohol beverages, but she takes “Stress
tabs” daily in the evening. She takes Stress tabs daily in the evening to replace the nutrients
she used in her daily activity and to provide her essential vitamins and minerals to help her
body naturally defend against physical change. She usually sleeps, drinks milk, eats and
compensate with food on occasion and prays to relieve her stress and tension. She doesn’t
have illness to affect her when she’s stressed. Moreover, she said that she seeks for her
parents’ advice when she felt under pressure to overcome her problems.


• Values, Goals and Philosophical Beliefs

The most important to her life is GOD, family and friends. She wants to
accomplish is her children to finish their studies and the most major influencing factor that
helps her make decisions is her goals in life. God, both parents, friends is the major source of
her strength in life.

• Religious and Spiritual Beliefs

The patient’s religion is a Roman catholic. She doesn’t have a religious affiliation.
The patient doesn’t have any health practices or restrictions to follow that can affect her during
ill or hospitalized. She wants the hospital chaplain visits her and praying, reading scripture is
important. She goes to mass every Sunday with her family but sometimes they cannot go because
of other circumstances. She always read the Bible. “May maliit ako ng Bible, binili ko rito sa
Tuguegarao palagi ko yung binabasa. Sobrang mahalaga talaga ang religion para sa amin . Alam
mo naman yun. Siya ang tumutulong sa akin sa araw araw at sa mga panahon na naghihirap
kaming pamilya. Sa awa ng Diyos hindi kami palaging nagkakasakit.” In contrary, she is not
very active in church activities but she always pray every night and go to mass as often as she
can. Patient Dad believes also in the superstitious belief like “Kapag nagwawalis ka sa gabi,
tinatakwil mo ang grasya na galing sa Diyos, wala namang mawawala kung maniniwala ka di
ba?” as the patient verbalized. She also explained that God is important to her life because for
her GOD is no. 1. Her parents and family are her source of strength and praying helped her with
her spiritual strength while she’s giving birth with her children in the hospital.

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