Cabaluna, Krizzia Franz L.

BSN 1A
BIOGRAPHICAL DATA

Name: Hermes L. Antipaso

Address: North Poblacion, La Libertad Negros Oriental

Sex: Female

Birthdate: December 25, 1972

Age: 56 years old

Place of Birth: Dumaguete City, Negros Oriental

Nationality: Filipino

Marital Status: Married

Religion: Roman Catholic

Educational Attainment: High School Graduate

Occupation: Housewife

Vital Signs:

Height: 162 cm

Weight: 89 kg.

Temp: 37.9 C

PR: 89 bpm

RR; 19 cpm

Admitting Diagnosis: Cirrhosis of the liver

Definition: Is a late-stage liver disease in which healthy liver tissue is replaced with scar tissue and the
liver is permanently damaged. Scar tissue keeps your liver from working properly.

Date of Admission: February 15, 2021 1:00 pm

Source of Information:

Patient — 60%

Significant Others — 10%

Patient’s Chart — 30%

——————————-

100%

Health History

Chief Complaint

“Kutas man gud kayo ma’am, nya sige pa gyud ko suka, wala ko kasabot sa akoa
pamati” – as verbalized by the patient

History of Present Illness

3 weeks before the admission, the patient complained of easy fatiguability when doing simple
Activities of Daily Living. 5 days before she was admitted, she experienced dyspnea which interfered her
ADL’s and was accompanied by skin redness/irritation. According to her guardian, 3 days before
admission, the patient was irritable and there were sudden changes of mood. An hour before she went
to the hospital, the patient vomited fresh whole blood.

Past Health History

Childhood

Patient said she never had any major childhood illnesses and has not experienced
hospitalizations during these years. Occasionally gets cough & colds but treats them with over-the-
counter medications and

Adulthood

Patient started to drink alcoholic beverages at the age of 23. In addition to this, she occasionally
smokes.

Medical History

Patient has no known allergies but has been hospitalized on the year 2012 due to Hepatitis and
Hypertension, on 2015 due to Liver Abscess, on 2017 due Pneumonia. By the year 2019 she has been
hospitalized due to cirrhosis of the liver, then by March due to SOB, Gastrointestinal bleeding and in
August due to Cholecystitis. She has drug maintenance of Livolin 2 capsules Two times a day, Propanolol
1 tab once a day, Tagamet 1 tab once a day.
 Family History by Genogram

Paternal Maternal

75 80 (BA)
81 (DM) 72 (CA)
(SMKR)

69 (TB) 77 (STR)

75
(SMKR)
Sm

56 (ESRD –

DM)

Male (deceased)
Relating to this diagram, it shows that on her paternal side
Female (deceased)
there was someone who died of type 2 diabetes. ESRD can
Female (alive and
be predisposed by a liver disease. people with a family
well)
history of liver disease or autoimmune disease are at an
increased risk of developing these diseases themselves, and

SMKR= smoker possibly cirrhosis (U.S. National Library of Medicine, 2020)

DM= Diabetes Mellitus

TB= Tuberculosis

ESRD= End-stage renal

disease

STR= Stroke

CA= Cancer

BA= Bronchial Asthma

FUNCTIONAL HEALTH PATTERNS (Gordon’s Functional Pattern)

A. Health Perception/Health Management Pattern

Prior to Admission

Patient views her health as being able to do everyday activities and work in the house and
function optimally.

During Admission

Patient is aware of her condition as evidenced by her prior hospitalizations. She sees the
significance of having correct medical support by going to the hospital to be monitored and
medicated accordingly.

B. Nutrition and Metabolism

Prior to Admission

Patient usually eats sources such vegetables with dried fish or canned sardines. She admits she
does not eat on time and usually drinks alcoholic beverages. Has no known food allergies.

During Admission
Patient eats regularly. Diet consists of low protein, low salt, high caloric diet in small frequent
meals (6x/day). Fluids are limited.

C. Elimination

Prior to Admission

Patient usually moves bowel once a day early dawn when she wakes up and prepare for
household chores.

During Admission

Patient Feels incontinent and has incomplete bladder emptying. Patient has an indwelling
catheter inserted and was prescribed Furosemide. Patient has no pain upon urination. Urinary
output is only 200ml. She has no problems with bowel movement.
D. Activity/Exercise
Prior to Admission

Patient has been a mother of 3 kids and she helps them out in daily activities.

During Admission

Patient has difficulty in movement and breathing because of her distended abdomen and
increased weight. She has poor gait

E. Cognitive/Perceptual

Prior to Admission

Patient is responsive. She is oriented to person, place, time, and event. She doesn't have any
vision, hearing, taste and smelling problems. Speech is normal and audible.

During Admission

Patient has a decreased level of alertness and irritable. Thought process is normal and still able
to recall things or events in her life. She does not have any difficulties with her senses.

F. Sexuality/Reproductive

Happy and contented with sexual life. No history of sexually transmitted diseases or any disease
affecting her reproductive system.

G. Roles/Relationship

Prior to Admission

Has a happy relationship with family members and friends.

During Admission

Well-supported by family but has less time with friends due to her condition,

H. Self-Perception/Self-Concept
 Happy-go lucky person who believes everything has a purpose and perfect time.

I. Coping/Stress

Prior to Admission

Copes with stress by being with my friends and relatives drinking sessions and get to talk out
about their frustrations and, in a way, lighten up how they feel.

During Admission

Bed rest, and medication compliance.

J. Sleep/Rest

Prior to Admission

Patient claimed to have been sleeping for 5-6 hours a day and wakes up early in the morning
around 4am.

During Admission

Tries to have a normal sleeping pattern however, sometimes interrupted due to pain and
ineffective breathing pattern

K. Values/Beliefs
Prior to Admission

Patient is Roman Catholic and goes to church every Sunday.

During Admission

Grateful to God that even with the number of times she was hospitalized, still she was able to
recover.
 General Survey

Upon receiving, the patient was conscious and responsive to questions and was willing to take
an IV.

NURSING DIAGNOSIS:

Activity Intolerance related to imbalance of oxygen supply and demand as evidenced by fatigue,
lack of energy, and altered respiratory function secondary to ascites.

Definition:

Insufficient physiological or psychological energy to endure or complete required or desired

activities due to immobility and imbalance between oxygen supply and demand.