CHAPTER IV

NURSING ASSESSMENT

Upon assessment, Patient T was lying down on the bed with O2 support

of 2 liters per minute via nasal cannula, no pulse oximeter attached to his finger,

no catheter inserted, and is not wearing diaper. Vital signs were taken;

Respiratory Rate: 21 cpm, Pulse Rate: 55 bpm, Temperature: 36.2 Celsius,

Blood pressure: 130/80 mmHg: O2 sat 99 %.

A. Gordon’s Assessment

Date/Time of assessment: October 04, 2023, at 1:30 pm.

1. HEALTH PERCEPTION-HEALTH MANAGEMENT

Patient T said that his health status right now is not the same as before

when he was so active. He also claimed that his health and body are not that

functional as he usually experiencing like he is catching his breath everytime he

do something that consumes his energy such as walking, and his activities of his

daily living and he easily gets tired which he believes that it is due to his problem

with his heart, as everything he needs to do now is limited. “Luya na akong lawas

karon, wala nay kusog ug dali rako punga’on” as he verbalized. Before, he said,

“Lagsik kaayo ko dati, di ko masakiton pero sukad tong nabal’an na naa koy

problem sa heart nag sunod sunod na akong mga gibati such as ubo, lagnat mga

ana gud”.
 Furthermore, patient T has medicine maintenance such as Entresto,

Vitamin B complex, and Warfarin (2.5 mg) that he needs to take at 8 a.m. In the

afternoon, the medicines that he needs to take are aspirin and dapagliflozin, and

at night, the medicines are atorvastatin and bisoprolol. His stroke medications

were Citifar, Trimetazidine, Carvedilol, and Ramipril, which were also

discontinued after their follow-up checkup, as the doctor, Dra. Amato, said he

had already recovered. He stated that due to financial problems they cannot buy

everything, and he said, “Gilaktawan nako akong tambal, daghan man gud kaayo

ug ana sad akong ate kay kanang tatlo lang daw dira ang paliton kanang mga

importante lang daw na tambal kanang warfarin, dapagliflozin ug atorvastatin.

Gitanggal niya ang Entresto na mao diay tong isa sa mga importante na tambal

mao siguro ang hinungdan nganong naglala ang problema sakong kasingkasing.

Di man nako gusto na dili kompletuhon pero kay lagi kay naa may financial

problems”.

During the assessment, he said that the thing he does now to keep

himself healthy is to follow the doctor’s orders. “Dati tong wala pani akong

ginabati, exercise jud akong ginabuhat kanang mag basketball ug gulay gulay

akong ginakaon, pero karon kay naa naman ni dapat e follow jud ang order sa

doctor ug iwasan na ang mga bawal”. He also said that he learned from his

mistakes in not following the doctor’s orders. He is now taking all the prescribed

medicines he needs to take and is following doctors' orders as he wants to live

long enough to serve the people in the Philippines who are in need. Moreover,

the patient has no allergies and was using herbal medicines such as dahoon ng
bila bila, Gmelina leaves, topical turmeric ointments, and superscent oil. The

patient shared that he just drinks alcohol occasionally, especially on birthdays or

other occasions. He does not smoke and has no other vices.

CUES NURSING PRIORITY RATIONALE

DIAGNOSIS

Subjective cues:

- Pt said that the  Readiness  Priority 9  It is a 9th

thing he does now for priority since

to keep himself enhanced the patient is

healthy is to follow health and determined to

the doctor’s lifestyle follow the

orders. ““Dati tong doctor's

management
wala pani akong orders. He is
related to
ginabati, exercise now
patient
jud akong considering
expressing
ginabuhat kanang embracing a
desire to
mag basketball ug healthy
follow the
gulay gulay akong
doctor’s lifestyle in order
ginakaon, pero
order. to avoid any
karon kay naa
complications
 naman ni dapat e which is good

follow jud ang for the patient.

order sa doctor ug This is a low

iwasan na ang priority since

mga bawal”. He the patient is

also said that he motivated to do

learned from his the right things

mistakes in not for his health so

following the that he can live

doctor’s orders. longer and

serve a lot of
- Pt said that he
people.
learned from his

mistakes in not

following the

doctor’s orders.

He is now taking

all the prescribed

medicines he

needs to take and

is following

doctors' orders as

he wants to live

long enough to
serve the people

in the Philippines

who are in need

 2. NUTRITIONAL- METABOLIC PATTERN

Patient T is a 55-year-old male who weighs about 75 kilograms and

stands 5’6 tall with a body mass index of 25.95, or 26. During the assessment, he

stated that his typical food intake is red rice, which he can consume 2 cups. He

shared that he loves to eat meats such as beef and pork, and they eat meat

twice or three times a week. Also, vegetables such as kalabasa, sitaw, talong,

okra, etc. He also said that he likes to eat fish, especially kinilaw. In fact, the

patient was admitted due to stomach pain, diarrhea, and increased gastric acid

because he frequently ate fish kinilaw in June 2022. He said that it was not every

day, but in one month, fish kinilaw was the food that they were eating. After that,

he was told to keep from consuming coffee, sweets, and sour foods like

pineapple, apples, and bananas. The only recommended fruits were papaya and

avocado. Patient T eventually returns to his previous means of life, drinking

coffee every day and taking Omeprazole and Kremil S to relieve discomfort if he

experiences strange symptoms. Additionally, he loves to eat candies, cakes, and

cupcakes.

The patient shared that he has been taking a vitamin B complex since

2022. His typical snacks are biscuits and soft drinks such as Coke, which he can

consume in 1-2 cups. He said that if they have money, they drink 1 liter of Coke

every day. Moreover, he also said that he is always drinking coffee everyday

(Nescafe Coffee Stick), of which he can consume 1 cup per day. Furthermore, he

shared that his weight before was 94 kg, but after he was diagnosed with heart
problems, he experienced weight loss; his weight now is 75kg. Patient T said he

has no appetite now; he is just eating soft food such as "lugaw," from which he

can consume one small bowl of porridge. His diet now is a low-fat, low-salt diet.

The doctor ordered him to restrict his fluid intake to less than 1500 liters per day.

He can consume 1 liter of water a day. The patient has no dental problems or

difficulty swallowing. He has no food allergies. When he had wounds, he went

through a wound-healing process.

CUES NURSING PRIORITY RATIONALE

DIAGNOSIS

Subjective Cues: .

 Priority 7  The ideal

 Overweight body weight

 Pt stated that his
related to for men with a
typical food intake
food intake height of 5’6
is red rice, which
that exceeds is 128–
he can consume in
body needs.
2 cups. He shared 156 lbs, or

that he loves to eat

58—70 kg
meats such as beef
(Banner
and pork, and they
Health, 2017).
 eat meat twice or The patient

three times a week. weighs 75 kg

Also, vegetables and is

such as kalabasa,
overweight.
sitaw, talong, okra,
Being
etc. He also said
overweight
that he likes to eat
can lead
fish, especially
to
kinilaw.
obesity which

 Pt typical snack can increase

were biscuits, the risk of

Coke, and coffee. several

diseases such
 Pt loves to eat
diabetes and
sweets such as
heart
candies, cake, and
problems.
cupcakes.

Since the

patient has
Objectives:

already a
Weight: 75 kg
heart problem
(Overweight)
it contributes
Height: 5’6 or 170cm more to his

BMI: 25.95 or 26 condition if

it is left

unattended.

This is priority

7, as it needs

long-term

intervention.

The patient

has other

problems that

need

immediate

attention, and

the patient’s

weight has

slightly

increased,

which we can

solve through

health

education.
3. ELIMINATION PATTERN

Patient T does not have any problems when urinating or defecating and

does not have trouble holding urine. During hospitalization, he urinates 3-4 times

or 400-850 ml a day, and he defecates every morning once a day. But before he

shared that he could pass stool 2 times a day. Prior to admission, patient T

stated that his urinary elimination pattern is usually 5-7 times a day. During the

assessment, patient T said that the doctor ordered him Lactulose so that he

could pass stool easily Valsalva maneuver will not be done by him.

Upon Assessment in the hospital, Patient D verbalized "Kung mag-ihi ko

karon wala man koy problema, pero mao lang to medyo need pa nako ug

assistant mag lakaw padulong cr kay ana man ang doctor na di kaayo ko dapat

mag lihok lihok”. (When I urinate now, I have no problem, but I still need

assistance since the doctor refrained me from moving excessively.) Patient T

shared that on his first and second days of hospitalization, the doctor had

advised him not to use the bathroom in order to prevent Valsalva maneuver,

however, now the doctor had advised him to mobilize slowly, and he can now

tolerate going to the bathroom. He also stated that the color of his stools

depends on the foods he eats; sometimes they are green, brown, or yellow, and

the color of her urine is yellow. Upon assessment, he said that he does not

experience excessive sweating as their room is airconditioned.

CUES NURSING PRIORITY RATIONALE

DIAGNOSIS

Subjective Cues:  No  No  No identified

identified identified problem.

 During
problem. problem.
hospitalization, he

urinates 3-4 times

or 400-850 ml a

day, and he

defecates every

morning once a

day.

 Patient T said that

the doctor ordered

him Lactulose so

that he could pass

stool easily and

Valsalva maneuver

will not be done by

 him.

 Patient still needs

assistance in

urinating since he

was permitted not

to move

excessively.

Objectives:

Urine color: Yellow

Stool color: Brown,

green and yellow.

4. ACTIVITY EXERCISE PATTERN

Patient T is a 55-year-old male, who clearly stated that he was exercising before until he was

diagnosed with a heart problem. He was playing basketball twice or thrice a month which served as his
exercise he said. Also, patient T is a missionary pastor who headed the church’s missions’ program and

assisted in providing outreach, assistance, and support during difficult times through charitable and

evangelistic activities which they traveled to different places here in the Philippines every week and took it as

his opportunity to walk as he believes that it is one of his works out. Patient T’s wife helped him during his

hospital stay with tasks including appropriate grooming, feeding, and urinating because he was not permitted

to move properly due to his condition. Furthermore, patient T said that he would still be able to normally move

a week prior to admission but he experienced shortness of breath and chest pain but he just ignored it.

Upon assessment, patient T said that he was weak and lethargic as he was just staying on his

bed the whole time, he was encouraged to mobilize slowly but still, he believes that due to his condition, he

was unable to move just like before as he easily experienced chest pain and shortness of breath. Additionally,

the patient was advised to avoid Valsalva maneuver and strenuous exercises. Moreover, according to him he

still needs assistance and he said, “Wala man pud sad ko ginapalihok kaayo jud kay akong kasing-kasing lagi

hina na dali lang ko pungahon”, (I was not permitted to move as my heart is already weak).

Further, as observed during the assessment, the patient has O2 support of 2 liters per minute via nasal

cannula and still manifests shortness of breath when talking and pauses every 2–3 sentences to compensate

for air. He said that “dako jud ug tabang ang oxygen kay kung wala ni, magalisod ko ug ginhawa.
CUES NURSING PRIORITY RATIONALE

DIAGNOSIS

Subjective Cues:

 “Dako jud ug  Impaired  Priority 1  This is a top

tabang ang oxygen Gas priority as

kay kung wala ni, Exchang gas

maglisod ko ug e related exchange

ginhawa” as he to plays a role

verbalized. decreas in the nursing

ed care plan for

 Patient T’s wife
oxygena patients with
helped him during
tion and heart failure
his hospital stay
fluid (CHF) as it
with tasks
accumul directly
including
ation in impacts
appropriate
the oxygenation.
grooming, feeding,
alveoli Ensuring
and urinating
seconda oxygenation
 because he was ry to is vital

not permitted to heart because it

move properly due problem. can lead to

to his condition. complication

Patient T said that s and even

he still be able to be a life

normally move a threatening.

week prior to Moreover,

admission but he aside from

experienced the fact that

shortness of the patient

breath and chest has CHF, he

pain, but he just also

ignored it. cardiomegaly

that
 Upon assessment,
contributes to
patient T said that
poor
he was weak and
oxygenation.
lethargic as he
In patients
was just staying
with CHF,
on his bed the
the heart is
whole time, he was
unable to
encouraged to
adequately
mobilize slowly but
 still, he believes pump blood,

that due to his resulting in a

condition, he was reduction

unable to move in cardiac

just like before output. This

as he easily can lead to

experienced chest insufficient

pain and shortness oxygenation

of breath. of tissues

and poor
 Additionally, the
carbon
patient was
dioxide
advised to avoid
elimination.
Valsalva
As a result,
maneuver
the patient
and strenuous
may
exercises.
experience
Moreover,
symptoms
according to him
such as
he still needs
shortness of
assistance
breath, fast
and he said,
breathing,
“Wala man pud
and low
sad ko
 ginapalihok oxygen

kaayo jud kay saturation

akong kasing- levels, which

kasing lagi hina will worsen

na dali lang ko the patient's

pungahon”, (I condition

since the
was not
body is not
permitted
receiving
to move as
enough
my heart is
oxygen.
already weak).
 Priority 2

 It is a top 2
Objective cues:
priority as

 Observed during cardiac output

the assessment, plays a role in

the patient ensuring that

manifests tissues receive

shortness of blood flow,

breath when allowing cells to

talking and pauses carry out their

every 2–3 metabolic

functions
 effectively.
sentences to
Neglecting this
compensate for
can result in
air.
impaired

pumping of

blood by

the heart,

leading to

 Decreas ischemia

ed (lacking blood

Cardiac flow) in tissues

output and organs,

related which can

to have health
hypertr implications.
ophy.
 Priority 3

 Ineffective

tissue

perfusion

means that

organs and

tissues are
 not receiving

an adequate

supply of

oxygen and

nutrients.

This can lead

to serious

complications

and even be

life-

threatening if

not

addressed

promptly. It

is a top

priority, as

proper blood

flow is

essential for

the

functioning of
 Ineffecti
our body
ve
tissues and
Tissue
Perfusi organs. It

on ensures that

related cells receive

to the oxygen

decreas and nutrients

ed they need to

cardiac carry out their

output. metabolic

processes

effectively. In

nursing

care,

ensuring

adequate

tissue

perfusion is

a priority as

it directly

affects the

patient's well-

being,

symptom

management
 , and

prognosis. It

serves as a

foundation

for

interventions

and plays a

significant

role in

supportingthe

patient's

recovery

journey

towards an

 Priority 6 improved

quality of life.

 It is a 6th

priority as the

patient often

faces

difficulties in
carrying out

their day-to-

day

activities.

They may feel

tired easily.

This has

an impact on

their well-being

and

independence.

Moreover, it

can worsen the

underlying

problem. Make

it more difficult

for patients to

regain their

physical

abilities.
 Activity

Intolera

nce

related

to

reduce
d

cardiac

output

and

fatigue.
5. SLEEP- REST PATTERN

Prior to admission, Patient T stated that he usually sleeps at around 10 p.m. and

often wakes up around 5 a.m. or 6 a.m. During his hospitalization, Patient T verbalized

"Sakto man akong tulog diri pero mao lang to every time maka feel ko nga gasakit

akong dughan makamata ko ug mag ingon mani sila sa nurse station, hatagan lang

dayon ko ug tambal maong makatulog sad ko balik,”, (My sleep here is good, but every

time I feel pain in my chest, and I can wake up. My watchers here will report it to the

nurse station, and they will give me pain medication, and after that I can sleep again).

Upon assessment, when we asked how frequent he experienced chest pain, he

said “Masulayan nako to mga kaduha o tulo kada semana”. He also claimed that he can

go back to sleep within 15-20 minutes after taking medication. He also verbalized,

“Tulog ra pud akong permi ginabuhat, kay after kaon makatulog man pud dayon ko.

Murag nabawi lagi akong mga kulang na tulog dati kay kung maka tulog ko karon like

11 p.m., makamata ko mga alas otso na pud”, (Sleep was the activity that I am always

doing, because after I eat, I can sleep easily. I feel like I have regained my sleep).

Additionally, patient T said that he felt rested when he woke up and does not have any

sleeping aids. He claimed that he was snoring, but not too loud, and it was confirmed by

his wife.

CUES NURSING PRIORITY

RATIONALE

DIAGNOSIS

Subjective cues:  Disturbed   It is a 5th

 Prior to Sleep Pattern Prio priority as

admission, related to rity 5 the patient

Patient T stated chest pain sleep is

that he usually disturbed

sleeps at around due to pain

10 p.m. and often he is

wakes up around experiencin

5 a.m. or 6 a.m. g in his

During his chest due to

hospitalization, his

Patient T condition,

verbalized "Sakto this may

man akong tulog affect his

diri pero mao lang recovering

to every time stage. Also,

maka feel ko nga patient

gasakit akong becomes

dughan dependent

makamata ko ug in nursing

mag ingon mani medication

sila sa nurse which might

station, hatagan be the

lang dayon ko ug reason that

 tambal maong his sleep will

makatulog sad ko continuously

balik,”, (My sleep be disturbed

here is good, but without

every time I feel medication.

pain in my chest, Moreover, it

and I can wake is a 5th

up. My watchers priority as it

here will report it directly

to the nurse impacts the

station, and they patient's

will give me pain ability to

medication, and rest,

after that I can recover, and

sleep again). cope with

 Upon their

assessment, condition.

when we asked

how frequent he

experienced chest

pain, he said

“Masulayan nako

to mga kaduha o
 tulo kada

semana”. He also

claimed that he

can go back to

sleep within 15-20

minutes after

taking medication.

 He also

verbalized, “Tulog

ra pud akong

permi ginabuhat,

kay after kaon

makatulog man

pud dayon ko.

Murag nabawi lagi

akong mga

kulang na tulog

dati kay kung

maka tulog ko

karon like 11

p.m., makamata

ko mga alas otso

na pud”, (Sleep
 was the activity

that I am always

doing, because

after I eat, I can

sleep easily. I feel

like I have

regained my

sleep).

6. COGNITIVE- PERCEPTUAL PATTERN

Patient T is 55 years old, and his highest educational attainment is college. He is

a degree holder with a course in theology. Prior to admission, the patient was wearing

eyeglasses. His eyesight score using the Snellen chart is 20/70; he also said that he did

not use a hearing aid and did not have hearing difficulties.

Upon assessment, the patient is oriented to time, place, person, and

circumstances and can recall past events except the time when he had a stroke in April

2023. The patient experiences short-term amnesia as he cannot remember what

happened to him and does not recognize the people that surround him. He stated that

he does not recall everything that occurred during that time. Further, there is no

significant change in the status and perception of his five senses upon assessment.

Moreover, the patient experienced chest pain upon assessment, with a pain scale of
5/10. He said that he felt like his chest was being stabbed. “Gasakit akong dughan,

mura siyag ginatusok,” as verbalized by the patient.

Moreover, the patient said that, in terms of decision-making, he was the one who

decides in the family, and he can easily decide, just like when it comes to his condition,

every time he felt like his condition was not improving, he would tell his wife to bring him

to the hospital.

CUES NURSING PRIORITY

RATIONALE

DIAGNOSIS

Subjective cues:  Acute pain  Priority 4  Acute pain is

- Pt said he felt like related to a distressing

his chest was being tissue experience for

stabbed. “Gasakit ischemia patients.

akong dughan, mura (Coronary Tissue

siyag ginatusok,” as artery ischemia,

verbalized by the occlusion) especially in

patient. the context of

coronary
Objective cues:
artery
 The patient
occlusion, can
experienced
lead to severe
chest pain upon
consequences
assessment,
like
 with a pain scale myocardial

of 5/10. infarction

(heart attack)

if left

untreated.

Prompt pain

management

is crucial for

preventing

further

damage to the

heart muscle.

Addressing

this problem

can elevate

the patient

comforts

which is

helpful for his

fast recovery.

7. SELF-PERCEPTION CONCEPT PATTERN

 Prior to admission, Patient T described himself as an approachable and friendly

type. He said that he is patient and does not like being angry. He also stated that there

are changes in his body, according to him: he has lost weight, his body is not

functioning like before, and he always feels weak and easily gets tired. However,

despite all of these, he also believes that he can recover. Patient verbalized, “Dili na

pareha sa dati akong lawas kay karon wala na kaayo ko kusog ug tungod sa akong

kasingkasing limitado na tanan”, (My body now is not the same as before because I

don’t have the strength to do things that I could do before, and because of my condition,

my actions and movements are limited).

Nevertheless, he feels good when it comes to himself. He said that all of the

things that happened to him did not hinder him from doing his purpose and mission in

this world, and his condition right now will not stop him from serving other people, as he

still has lots of plans for those whose rights were deprived. Moreover, during

hospitalization, according to patient T, he is anxious about his hospital bills but believes

that God will provide.

Furthermore, the patient said that he was not afraid to die. Because dying for him

is the will of God, and he believes that if it is your time, it is really your time. He also said

our lives are not ours; we just borrowed them from the Lord, and we must take good

care of them. He also said that death is just there, and he has been through a lot of

circumstances, but he is still alive, which means he still has a purpose in this world.

Upon assessment, patient T was able to cooperate despite his condition. He can

maintain eye contact, he is focused on answering the question, his voice is not that loud
but clear, and he is relaxed but is catching his breath when talking longer. He

responded positively, just as he was responding to the questions that we were asking

him.

CUES NURSING PRIORITY

RATIONALE

DIAGNOSIS

Subjective Cues:

 Priority 10
 Readiness  Accepting
 Pt said that he is
for one's
patient and does not
Enhanced strengths and
like being angry. He
Self-Concept limitations is
also stated that there
related to a sign of
are changes in his
patient positive self-
body, according to
expressing esteem and a
him: he has lost
acceptance healthy self-
weight, his body is not
of strengths concept. This
functioning like before,
and indicates that
and he always feels
limitations. the patient is
weak and easily gets
in a better
tired. However, despite
mental and
all of these, he also
emotional
believes that he can
state, which
recover.
can have a
  He feels good when it positive

comes to himself. He impact on

said that all of the their overall

things that happened well-being. It

to him did not hinder is a less

him from doing his priority as the

purpose and mission in patient

this world, and his expressed a

condition right now will desire to

not stop him from accept his

serving other people, strengths and

as he still has lots of limitations.

plans for those whose

rights were deprived.

8. ROLE - RELATIONSHIP PATTERN

According to patient T, he lives with her common-law wife. The patient has 11

children, five of whom have their own families, and he now has 7 grandchildren, with 5

boys and 1 girl. His other children are living with their siblings; that is why they are just

two people living in their house. According to him, he raised his child well and has faith

in God. He said that in terms of handling problems, he does not have any difficulties as

he believes that God is with him. In terms of his relationship with his wife, he said that
every time there is a problem between them, he chooses not to say anything and

chooses to be silent, as he does not want to prolong their arguments.

Moreover, he states that even if their family has problems and difficulties, they

can handle them. He stated that his family and friends are very supportive. Even if he

was in the hospital, his friends would make time to visit him, even if they were in other

places, just like his siblings. Although his siblings are not there physically, he said that

with their love, care, and support for him, he felt like they were just near him.

Additionally, he said that he felt safe in their relationship with his wife, as his wife is with

him through thick and thin. His wife was the one who took good care of him.

Furthermore, the patient belongs to social groups as he is a missionary pastor. In

fact, they have a foundation whose goal is to help other people, especially those who

are in need. Their foundation is the Amihan Foundation, of which he is the founder.

They also have a church that he and his father serve. He said that since their foundation

is still in the process of being launched, they still have financial problems, and he said

that maybe if their foundation’s budget is set, they will not think about the money or

worry about where they will get money for hospitalization.

CUES NURSING PRIORITY

RATIONALE

DIAGNOSIS

Subjective cues:  No  No identified  No identified

 According to him, identified problem problem

he raised his child problem

well and has faith in

God. He said that in

terms of handling

problems, he does

not have any

difficulties as he

believes that God is

with him. In terms

of his relationship

with his wife, he

said that every time

there is a problem

between them, he

chooses not to say

anything and

chooses to be

silent, as he does

not want to prolong

their arguments.

 He states that even

if their family has

problems and

difficulties, they can

9. SEXUALITY REPRODUCTIVE PATTERN

Patient T said that there was no problem in terms of having sex with his wife. He

said that he is satisfied with his sexual relationship with his partner.

The patient stated that there was no misunderstanding between him and his wife

after being assessed. He stated that he has not used any contraceptives, such as

condoms, ever since. However, he said that his condition is not the same, and maybe it

would affect their sexual activity. Moreover, when we asked about the statement of his

wife, she said, “Okay lang man, pero syempre naa na siyay ginabati. Ang problema lang

karon kay minsan mutindog iyang kuan, minsan dili”, (Our sexual activity is fine, but

since he has a health condition, sometimes his penis will erect and sometimes it will

not), as she verbalized while laughing. Nevertheless, she said that “pero wala man gud

nay problema sa babae kay ang babae dali rana siya pero mao lang jud to,” as she

stated.

CUES NURSING PRIORITY

RATIONALE

DIAGNOSIS

Subjective Cues:

 Sexual  Sexual
 Pt said that his  Priority 8
Dysfunction dysfunction
condition is not the
related to can lead to
same, and maybe it
altered feelings of
would affect their cardiac frustration,

sexual activity. function and anxiety,

Moreover, when we physical depression,

asked about the limitations. and reduced

statement of his self-esteem.

wife, she said, “Okay By addressing

lang man, pero this issue,

syempre naa na nurses can

siyay ginabati. Ang help improve

problema lang karon the patient's

kay minsan mental and

mutindog iyang emotional

kuan, minsan dili”, well-being,

(Our sexual activity which can

is fine, but since he have positive

has a health effects on their

condition, overall

sometimes his penis recovery and

will erect and adjustment to

sometimes it will altered cardiac

not), as she function.

verbalized while

laughing.
10. COPING STRESS TOLERANCE

Patient T stated that the most significant change in his life occurred when he was

diagnosed with a heart problem. Despite that, his view of life did not change, and his

faith in the Lord deepened. He does not like to think negatively about his condition, as

he always thinks positively. He said that he would fight until the end.

Upon assessment, patient T stated that he is relaxed and calm most of the time.

Patient verbalized, "Magtinabangay mi sakong asawa pag naay problema ug mag ampo

jud mi kay mao jud na ang solusyon sa tanan" (Me and my wife are helping each other,

and we are always praying as it is the only solution for everything). Moreover, in his

battle, he said that he is not the only one who’s facing it, as he has a lot of people

praying for his fast recovery, and he doesn’t have any reason not to fight for it.

CUES NURSING PRIORITY RATIONALE

DIAGNOSIS

Subjective Cues:

 Effective It is the least

 Patient T stated that Priority 11
Coping-stress priority as the
the most significant
pattern patient has
 change in his life related to the effective coping

occurred when he was availability of mechanisms.

diagnosed with a heart family and This may

problem. Despite that, friend’s indicate that

his view of life did not support and patient has a

change, and his faith in presence, higher chance

the Lord deepened. He care, love to improved

does not like to think and faith in conditions and

negatively about his God. it directly

condition, as he always impacts the

thinks positively. He patient's

said that he would fight emotional well-

until the end. being,

 Upon assessment, psychological

patient T stated that he health, and

is relaxed and calm ability to

most of the time. effectively

Patient verbalized, navigate and

"Magtinabangay mi cope with

sakong asawa pag stressful

naay problema ug mag situations.

ampo jud mi kay mao

jud na ang solusyon sa

 tanan" (Me and my

wife are helping each

other, and we are

always praying as it is

the only solution for

everything).

 In his battle, he said

that he is not the only

one who’s facing it, as

he has a lot of people

praying for his fast

recovery, and he

doesn’t have any

reason not to fight for it

11. VALUES AND BELIEF PATTERN

Patient T is a born-again. He identified himself and his family as devout followers

of Christ, and he claimed that religion is very important to him and acts as a source of

guidance. He also stated that God would assist them with all of their life's problems. He

added that he is grateful and content in his life, despite all the challenges. Patient T

became a missionary pastor in 1988; at the time, he was well-known for translating for
the foreign missionaries serving in Bohol. Together with his common-law wife, he

embarks on a missionary journey across the Philippines to share the word of God.

His plans for the future are to help and serve people. He is establishing his

foundation so that he can help not just a small number of people but millions. He has

plans to build a hospital to help people who are unable to help themselves financially.

With the help of God, he believes that he can achieve his mission, as God has not taken

his life yet. He believes that if God lets him die, it means that his mission and purpose in

this world are already done, but despite all the health problems he encountered, he is

still alive, which means his mission hasn’t ended yet. He also believes that prayers are

the best medicine.

Moreover, regarding his faith to recover, he believes that following the doctor’s

order will extend his life in this world. He is determined to no longer repeat the previous

mistakes which is him being noncompliant with his maintenance and medications. He

now understands the significance of taking his prescribed medicines and plans to

discuss with his sister the need for him to comply with his treatment. In the past, his

sister had made decisions about his medications, which is an action they now recognize

as potentially detrimental to his condition. With the support of his wife and his family,

they have decided to jointly take charge of their healthcare decisions for the sake of his

well-being with knowledge and willingness to follow the treatment plan.

CUES NURSING PRIORITY

RATIONALE
 DIAGNOSIS

Subjective Cues:  Readiness for  Priority 11  It is a 11th

 Pt said that his enhanced priority

sister was the one emancipated since the

who decides about decision patient is

what medication making. determined

should he take. to follow

 Pt admitted that he the doctor's

is noncompliant orders and

with his is willing to

medications discuss

before. previous

 He believes that problem

following the that could

doctor’s order will aggravate

extend his life in his

this world. He is condition to

determined to no the family

longer repeat the in order to

previous mistakes embrace

which is him being openness

noncompliant with to prevent

his maintenance future

 and medications. problems in

He now health.

understands the
 This is a low
significance of
priority since
taking his
the patient is
prescribed
motivated to
medicines and
do the right
plans to discuss
things for his
with his sister the
health so that
need for him to
he can live
comply with his
longer and
treatment.
serve a lot of
 With the support of
people.
his wife, they have

decided to jointly

take charge of their

healthcare

decisions for the

sake of his well-

being