G.

NURSING HEALTH HISTORY

A.Nursing assessment
Name: VK
Age: 45
Occupation: Field/ sale supervisor
Race: Filipino
Birthday: Feb 27, 1986
Place of Birth: Calumpit, Bulacan
Religion: Protestant
Educational attainment: College Graduate
Health care finance: Wifes job
Date of admission: Nov 24, 2013
Date of Discharge: Nov 28, 2013

B.Reason for Visit/ Chief complaint:

Epigastric pain

C.Nursing health history

Patient was diagnosed of Lung Ca Stage IV Last December 2012

F. GORDONs 11 FUNCTIONAL PATTERN

Time: 11:25
Date: November 27, 2013
Location: BMC

1. HEALTH PERCEPTION/ HEALTH MANAGEMENT PATTERN

Prior to Hospitalization

During Hospitalization

When asked about his health prior to hospitalization,

the patient stated satinginkonaman okay ako date,
hndinamanakosakitin. Malakaspa kosakalabaw. He
rated his health (10 as the highest number) 8 out of
10, when asked why he rated himself 8, he stated Eh
hindinamantayoperpekto. Napapagod at tinatablan
din ngsakitminsan. He believes that eating nutritious
food, having enough hours of sleep, a little exercise
and staying away from cigarettes and alcohol are the
important factors of having a healthy life. When asked
about taking un-prescribed over-the counter drugs, he
stated pagsimplenglagnat, ubo, sakitngulo at
katawanlang, umiinomakonggamottuladngbiogesic,
robittusin. Ganun. He also said that he immediately
takes a rest and doesnt force himself in doing tasks
he cant when hes not feelng well.
He doesnt believe in faith healers and asks medical

Before being admitted to BMC, the client was first diagnosed of Lung
Cancer stage IV at The Lung center of the Philippines last December 12,
2013.
When asked about his illness and how he finds his health during
hospitalization, he stated Lagenalangakongnakahiga,
anghirapgumalawkaseanghinangkatawankosakapasumpongsumpongyung
sakitngdibdibko. he rates his health as 3 out of 10 now. He said that this
illness took a lot from him. From his energy, to his body and character.

practitioners for help. When asked about smoking, he

stated Hindi akonagyoyosi, bibihiralang din kung
uminom. Kumbagapag may
importantengokasyonlangtuladng birthday.
2. NUTRITIONAL METABOLIC PATTERN
Prior to Hospitalization

During Hospitalization

Prior to admission, the patients usual food preferences are

vegetables, fish and chicken, He mention that he has good
appetite and can eat anything edible because he doesnt have
any allergy. He eats three times a day and sometimes take
snacks in between meals. He usually eats bread and a cup of
coffee in the mornind and a cup or rice or two accompanied
with viand during lunch and dinner. He also mentioned that he
eats breakfast and dinner together with his family at home and
lunch together with his workmates. He also drinks 8-10 (around
2000-2400ml) glasses of purchased mineral water a day.

During hospitalization, he said that the usual food he consumes

is soup and anything that isnt that heavy. He doesnt eat the
daily delivered food from the hospital because he doesnt like
how it tastes. He doesnt have appetite and is too lazy to eat
even if his wife assists him every meal. He can only finish half
of a bowl of soup and can only take a cup of water every meal.
He also said that he doesnt like to eat rice.
Due to his poor appetite, the doctor prescribed Appetitite Plus
as a supplement.
His usual fluid intake is around 3-4 (around 720-960ml) glasses
of mineral water a day.
3 day dietary recall

Breakfast

Nov 25, 2013

bowl of
soup
1 glass of

Nov 26, 2013

bowl of oat
meal
1 glass of

Nov 27, 2013

1 piece of ube
cake (small
serving)

water (240ml) water

(240ml)
Lunch

Dinner

bowl of
soup
1 glass of
water (240ml)
bowl of oat
meal
1 glass of
water
(240ml)

1 glass of
milk

bowl of
soup
1 glass of
water (240ml)

1 glass of
water
(240ml)
bowl of
soup
1 glass of
water (240ml)
1 glass of
milk

3. ELIMINATION PATTERN

Prior to Hospitalization

During Hospitalization

When asked about how many times he urinates and defecates He said he is experiencing constipation and has difficulties of
a day, he stated that Mga 3 hangang 4
defecating. He also urinates 2-3 times a day or per shift and
nabesesakongumihisaisangaraw. Dependena din sanainom
didnt report on any difficulties.
kung tubigsakasainit, kaseminsananglakaskongmagpawis.
Araw-arawnamanakongdumudumi, may arawnahindi,
FECES
COLOR
perokaraniwanoo. He also stated that he tries to defecate
ODOR
every morning before going to work. When asked about the
FREQUENCY
characteristics of his urine and stool he said, manilaFORMATION
nilawyungihiko. Yung dumikonaman eh buo. He also said that
DIFFICULTY
he doesnt have any difficulties in urinating and defecating.
URINE

According to him, he perspires depending on the heat and the

amount of work hes doing.
FECES
Light brown
Foul odor
5-6 times a week
formed
none
URINE
COLOR
Amber
ODOR
Foul odor
FREQUENCY 3-4 times a day
AMOUNT
Estimated 600-800
ml a day

COLOR
ODOR
FREQUENCY
AMOUNT

Amber
Foul odor
2-3 times a day
400-600
ml(estimated)

COLOR
ODOR
FREQUENCY
FORMATION
DIFFICULTY

4. ACTIVITY/EXERCISE PATTERN
Prior to Hospitalization
The patient considers his work as a sales/field supervisor as
his form of exercise. He said going to work every day is
enough. araw-arawnamanyungpasokniya,
luneshangangbiyernes. Paguwipagodna den. As stated by his
wife. He helps in household chores like cleaning the house and
washing dishes when he is available.
He doesnt experience any difficulty in ambulating and
moving. According to him, bathing and grooming himself is an

During Hospitalization
He can sit, feed and lay on the bed by himself. But has
difficulties in ambulating and using the bathroom by himself
due to over all weakness and pain in his chest area. He cant
groom and dress himself without the aid of one of her
relatives.

easy task and can be achieved alone.

Feeding=0
grooming=0
Bathing=0
mobility=0

Feeding=0
Bathing=2
mobility=0

toileting=0
dressing=0

bed

LEGEND:
1- Full self-care
2- Requires use of equipment or device
3- Requires assistance or supervision from other person
4- Requires assistance and supervision from other
person/device
5- Dependent and does not participate

toileting=2 grooming=2
dressing=2

bed

LEGEND:
1- Full self-care
2- Requires use of equipment or device
3- Requires assistance or supervision from other person
4- Requires assistance and supervision from other
person/device
5- Dependent and does not participate

5. SLEEP/REST PATTERN
Prior to Hospitalization
According to him, he sleeps 8-10 hours a day. He usually
sleeps at around 10 and wakes up at 7 in the morning to fix
and groom himself for his work. The patient is satisfied with
his sleep and feels refreshed when he wakes up. His sleeping
environment is good and quiet. He sleeps after watching
teleseryes at night or sometimes after dinner. He said that he
doesnt have any difficulties in falling asleep.
On weekends, he takes a nap in the afternoon or whenever he
can. He relaxes by watching tv or listening to the radio.

During Hospitalization
When asked about his sleeping pattern at the hospital, he said,
hindiakomakatulogngmahimbing, paputolputollangnamaikli.
Kahitnanghihinaako, di akopinapatulogngsakitngdibdibko.
He reports difficulty in sleeping and was prescribed
zolpidem(stilnox) 10mg at bedtime by the doctor to help him
fall asleep, in which he said helped a lot because he sometime
take small naps.

Nov 25, 2013

Nov 26, 2013

Nov 27, 2013

Time of sleep
Time of
awakening
Total no. of
sleep
Quality

12:00 mn
3:00am

11:00pm
4:00am

12:00mn
3:00am

3 hours

5 hours

3hours

6. COGNITIVE PERCEPTUAL PATTERN

Prior to Hospitalization
He can read, write and comprehend. His eyesight and hearing
abilities are not altered. He can easily understand and follow
directions but have some difficulty in recalling some events
that happened in the past.

During Hospitalization
His senses are the same as before hospitalization. During the
interview, he was able to analyze the question and answer it
logically. He was able to apply and learn information that hes
been taught.

7. SELF PERCEPTION PATTERN

Prior to Hospitalization

During Hospitalization

He describes himself as jolly and very approachable. He is very

much happy and contented with who he is and how his life has
been. He wouldnt change anything about himself. He also
mention that he like his body built. He is usually in a good
mood and cant be easily irritated. He considers himself calm
and full of patience.

When asked about what she feels about himself, the client said
Anglakina g pinagbagoko. Payatpayatkona. Di nakokatuladng
date namasigla.
He also sees himself as a burden to the family. He said that his
sickness is the biggest trial his ever experienced in his
existence. He said that he is not the same person as before.
He is not that bright and is more irritable to even the small
stuff. He believes that his sickness changed a lot of his
characteristics.

8. ROLE RELATIONSHIP PATTERN

Prior to Hospitalization
He lives with his family. He mostly decides for the whole family
though he also seeks for their advice and opinions. He also
said that their family is full of harmony. He said that his family
has an open relationship; they are responsible and helps each
other. He also mentioned being good friends with his
neighbors and sometimes chat and bond with them.

During Hospitalization
His family takes care of him and never abondons him during
the course of his illness. Their close family relationship is still
intact and everyone is treating him the same and not as
burden.

9. SEXUALITY/REPRODUCTIVE PATTERN
Prior to Hospitalization
He was married at the age of 21 and got his first child at the
age of 27. He has 3 children with the age of 20, 17
respectively. Both of his child are females. He said that he and
his wife try to have sex at least 2 times a week. He said that
they never used contraceptives and supports the natural
method of spacing their children.

During Hospitalization
He is not sexually active.

10. COPING STRESS TOLERANCE PATTERN

Prior to Hospitalization
He said he releases stress by watching tv and talking ti his

During Hospitalization
His hospitalization and diagnosis of cancer caused him a lot of

family. He sometimes go out and talk with his friends around

the neighborhood. He confides with his wife about almost
everything because he believes that honesty is the key to a
successful relationship.

stress. He worries a lot on how will they settle hospital bills

and if he is going to be cured. He alleviates stress by talking to
his family and focusing on how to get better. He frequently
prays because he knows that at times like this, God is the one
to ask for help.

11. VALUES/BELIEF PATTERN

Prior to Hospitalization
He and his family are members of the Methodist church. They
attend the mass every Sunday and are really active members
of the church. He was also a chairman of their church and
participates to the churchs mission.

During Hospitalization
He continues to believe in his religion and is strongly praying
that he will one day be cured due to Gods help. Though his
illness is a really big trial, he still firmly believes and has put
his faith to God.
Ever since his diagnosis of lung ca, he seldom goes to church
because of feelings weak and pain.