PATIENTS PROFILE

Name: K.K.T.L.
Age: 7 years old
Gender: Female
Address: San Pablo, Isabela
Date of Birth: June 13, 2010
Provider of History: Father
Place of Birth: San Pablo, Isabela
Primary & Secondary Languages: Itawes and Tagalog
Race/Ethnic Background: Filipino
Status: Single
Religion: Born Again Christian
Educational level: Grade 2
Significant others:
Date of Admission: September 27, 2017
Attending Physician: Dra. Malillin
Chief Complaint: Fever and loss of appetite

REASONS FOR SEEKING HEALTH CARE

4 days prior to admission, (+) intermittent fever was slightly relieved by intake of Paracetamol.
Consultation was done and was diagnosed to have ATP (Adenosine Triphosphate) and
medications were given.

2 days prior to admission, the patient still have fever and with decreased appetite thus prompting
for the consultation in the Saint Paul Hospital.

PAST HEALTH HISTORY

According to the father, patient K.K.T.L. was never been hospitalized but stated that, Minsan
sinisipon siya at inuubo kapag malamig ang panahon. Kapag nilalagnat naman siya eh
nagkakaroon ng pantal sa katawan pero hindi namin siya dinadala kaagad, observation muna.
Kung mahina na siya kumain at tingin ko nanghihina na saka namin dinadala. In addition, the
father said that the patient completed her immunizations: BCG, DPT, OPV, Hepa B and MR and
has no known allergies.

PRESENT HEALTH HISTORY

Prior to patient K.K.T.L. admission, Saturday (September 23, 2017) Nagsuka siya ng tatlong
beses noon na may kasamang lagnat tapos pantal sa katawan. Inobserbahan muna namin siya
tapos pinainom ng Paracetamol para sa lagnat niya. as verbalized by the father. Sunday
(September 24, 2017) patient K.K.T.L. was brought to the Divine Mercy Wellness Center for
consultation and was diagnosed that she has tonsilitis. K.K.T.L. even underwent complete blood
count (CBC) and the result was 271. The Paracetamol was continued due to her fever. Few days
after, Wednesday (September 27, 2017), the father stated that, Dinala na namin siya sa hospital
kasi on and off naman na yung lagnat niya at ayaw nang kumain. Nakikita ko na rin mahina na
talaga siya tapos sumuka pa ng dalawang beses. On that same day, patient K.K.T.L. was
admitted to St. Paul Hospital. Moreover, CBC with Platelet count was performed as ordered by
the physician.

FAMILY HEALTH HISTORY

The maternal side of the patient had a history of lung cancer which caused the death of her
brother at the age of 57 and cancer in the bone marrow which also caused the death of her
another brother at the age of 20. In addition, the rest of the family members in the maternal side
of the patient claimed to be healthy and have no illness. On the other hand, the paternal side of
the patient had a history of pneumonia which caused the death of his father at the age of 68. The
rest of the members are claimed to be healthy and have no illness.

GORDONS 11 FUNCTIONAL PATTERN

Health Perception- Health Management Pattern

Before hospitalization, the patient perceives health in a way that shes is not suffering from any
diseases and having a good hygiene. She is not taking any vitamins, Kapag mag-vitamins ako
eh baka po tatangkad. as stated by the patient. In addition, the patient is afraid in taking
medicines.

During hospitalization, the patient feels unhealthy and according to her, Hindi ko po gusto yung
mga pagkain kuya. On the otherhand, she is obedient in taking her medications without being
afraid of it and cooperative in all the nurses interventions.

Nutritional and Metabolic Pattern

Before hospitalization, the patient takes her meal three times a day without any restrictions.
According to his father, Paborito niya yung mga pagkain na may sabaw tapos yung mga
nilagang baboy at manok pati na rin yung tinola. She has no difficulty in swallowingand she
eats junk foods during snack time which cause a delay in eating lunch or dinner. The patient
drinks a 5-8 glasses of water a day.

During hospitalization, her fluid intake increased about 10-15 glasses a day to prevent her from
dehydraton, and her appetite loss due to the food she is taking in the hospital. She even
verbalized that, Hindi ko po kasi gusto yung mga pagkain dito, kuya. In addition, the patients
diet is DAT (Diet as tolerated),

Elimination Pattern

Before hospitaliazation, the patient defacates once every other day in every morning before
going to school with a formed stool in consistency and brownish in color. She urinates 5 times a
day with an amber color.

During hospitalization, the patients did not defacate since she was admitted in the hospital. She
urinates 8-9 times because of the increased in fluid intake with an amber color.

Activity- Exercise Pattern

Before hospitalization, during the weekend the patient plays outdoor games like tagu-taguan
and habul-habulan together with her cousins or friends. Her favorite sport game is badminton.

During hospitalization, most of the patients time was spent for resting and sleeping, and
sometimes playing Zombie Catcher and watching Mr. Bean on the phone.

Sleep-Rest Pattern

Before hospitalization, she sleeps at 9 pm after watching Probinsiyano which is one of her
favorites to watch and wakes up at 6 am to prepare herself in going to school. At times, she
sleeps late whenever she slept at the afternoon.

During hospitalization, the patient slepeps at 9 pm and has sleep disturbances whenever the nurse
takes her vital signs or administering medications. She wakes up at a usual time of 7 am.
Cognitive- Perceptual Pattern

Before hospitalization, the patient is normal in terms of his cognitive abilitis. She also added that
she has no problem with her senses.

During hospitalization, she relates to me actively by responding to my questions enthusiastically.

She also shared some of her school activities like reading.

Self- Perception Self Concept Pattern

According to patient K.K.T.L., Mabait po ako at matulungin, ako po yung naghuhugas ng mga
pinggan at tumutulong kay mama sa paglaba po.

Role-relationship Pattern

The patient has a close relationship with her family, but she is closer to her mother if it is time of
sleeping and to her father if they will go outdoor. She is the eldest and she loves taking care of
her sibling. Her younger sister is 4 year olds that is why she plays the role as an older sister.

Sexuality- Reproductive Pattern

Prior to her age, the patient is not yet oriented with any sexual matters. According to her father,
she has not yet experienced menstruation.

Coping Stress Tolerance Pattern

The patient K.K.T.L., stated that, Natutulog na lang po ako kapag malungkot ako tapos kapag
may problema eh sinasabi ko kila mommy at daddy.

Value-belief Pattern

The patients religion is Born Again Christian. They attend mass regularly as a family. She
verablized that, Takot po ako gumawa ng masama kasi magagalit si papa God. The father of
the patient stated that there are no cultural, spiritual or religious practices that affect her
daughters health care.