Professional Documents
Culture Documents
> Stress is a disruptive condition that occurs in response to adverse influences from the
internal/ external environments. It is a state produced by a change in the environment that
is perceived as challenging/ threathening.
The community is not congested. The people are very friendly. They are all happy
people and live peacefully.
A. Family structure, characteristics and dynamics
Mr. Marcelo is the hand of their family, provider and for decision making in the family
especially in financial and health. Mrs. Malveda is responsible for household chores and
take care of her children. Lane, graduated as teacher of Polytechnic University of the
Philipphine and successfully earn reputation but unfortunately she died due to delivery of
her first daughter. Mr. Marko was the older brother in the family, he graduated as
engineer in Adamson University an dcurrently working at Italy and was married to a
nurse. The youngest brother was Mr. John Malveda graduated as an engineer at PUP. He
is currently working in Norway. The type of the family was extended family there was no
readily observable conflict between members of the family. The children monitors their
mama and papa regarding matters in health care and maintenance of medicines.
B. House Plan
The family of Malveda have good shelter to sleep with 3 bedrooms 1 kitchen 3 comfort
rooms. They are comfortable in their house
They has adequate living space for living. The Mother and her grand daughters are
sleeping at bedroom 1 while the head of the family sleeps at bedroom 3. Bedroom 2 is a
guest room.
C. Kind of neighborhood
According to the patient their environment is conclusive and safe. She verbalized that the
people in the community are friendly and willing to help.
Chapter 2.
A. Biographical Information
Mrs. Rosita Malveda currently living at San Fernando, Sto. Thomas Batangas, a Filipino,
roman Catholic and was born at Batangas on December 13 1944. The source of
reliability of information is directly to the patient and was interviewed on June 30 2011
B. Chief Complaint/s
“Masaki yong paa ko at pasumpong sumpong ito, tska namamanhid ilang araw na” as
verbalized by the patient.
C Present Illness
According to the patient her left lower leg experienced pain and numb but can tolerate the
pain.
D. Past History
a. According to the patient she has no major injuries during childhood such as fever,
colds, mumps etc. She undergone 3 surgical procedure the thyroidectomy, CS section,
and appendectomy. The patient had no allergies to food, environment and drugs. She
completed her vaccines during her childhood. She doesn’t drink alcoholic beverage and
not smoking. According to her she usually maintain her anti-hypertensive drug and also
her vitamins
E. Family History
The client’s grand parents are already dead. Her father is deceased he has asthma. The
client have hypertension as well as her sister
Asthma
HPN HPN
64 60
Client indicator
Female
Male
F. Review of system
General Appearance
Client has a medium body frame, an upright posture and smooth rhythmic gait.
He is appropriately dressed, no body odor and obviously she has no physical deformity.
He is 5’6 in height and and a weight of 54kg.
V/S
blood pressure is 180/60mmHg, respiratory rate is 21 cpm, and pulse rate of 63 bpm,
temperature of 35.7 ‘C.
Skin
Normal in racial tone between light to medium brown, warm to touch and dry.
Skin is elastic and mobile. No lesions in upper extremity, and has burn at the left
dorsum of left foot. Hair is evenly distributed, no bruises or birth marks. Noted
scar on thyroid area
• Hair
Hair is black and evenly distributed there are presence of white hair due to aging. The
scalp has no lesions, masses and nodules palpated. There are no any infestations.
Head is appropriate to his body size. The hair is evenly distributed. Head contour
is smooth with uniform constituency and symmetrical facial movements and features.
• Eyes
The eyes are straight and normal, eyebrows and eyelashes are evenly distributed.
Eyelids have an effective closure. Eyeballs are symmetric, conjunctiva is pink in color,
sclera is white, pupils are equal and reactive to light and accommodation, sinuses non
tender. Has a normal visual field and respond to six ocular movements.
• Ear
Ear is within normal racial tone. It is symmetric in size and position. Pinna recoils
when folded and some cerumen found at external canal. Client difficulty of responding to
a normal whisper at 6ft.
• Nose
Nose is normal in racial tone, the septum is at the midline. Air moves freely
through the nares as the client breathe. Mucosa is pink and clear without any lesions.
Sinuses are not palpable.
• Mouth
Lips are pink and mucosa is moist. Tongue is at the midline. Teeth are incomplete
but has presence of dentures. Gums is pink and the soft and hard palate as well. Both
palate are palpable. Frenulum is at the midline. No presence of breath odor.
• Pharynx
Uvula is at the midline, mucosa is pink in color. Tonsils are not inflamed.
Posterior pharynx is congested. Gag reflex is present when elicited.
• Neck
Neck muscles are equal in size, muscle strength is good presence of scar at
thyroid area. Lymph nodes are not palpable. The trachea is in the midline. Thyroid gland
is not palpable.
Patient refused to assess her breast. But according to her breast are symmetrical
and there is no presence of nodules or discharges.
Chest shape is AP lateral ratio 1:2. Lung expansion on posterior and anterior are
both symmetrical. Tactile fremitus are symmetrical. Broncho vesicular is his breath
sound. Apical pulse is present. Has a normal heart sounds in pulmonic, tricuspid, aortic
and mitral valve.
• Abdomen
Motor strength on both upper and lower extremities are both good with the grade
of 5.
No obvious physical deformities but with burn site at left dorsum foot, peripheral pulses
are palpable.
• Genitalia
Psychological
She is happy with her husband even though there children is far from them. She stated
that her family and children of her sons and daughter, relatives are most significant
people in her life. She has good relationship with her neighbors and people in barangay.
She stated that she undergone CS section, according to her she has no any sexual
deformities. She is in the stage of menopause.
She had no hearing difficulty. In our assessment she has hard time of responding in a
whispered voice
She was able to cope up by engaging herself to recreational activities like watching
television everytime
Elimination
She usually defecates every other day and urinates everyday without difficulty
Client sleeps at around 10pm and wakes up at around 4am in the morning, she loves to
sleep every afternoon
Safe environment
Oxygenation
Nutrition
Anthropometry
Developmental Theories
According to Erickson generativity is defined as concern for establishing and guiding the
next generation. There is concern of providing for humankind that is equal to concern of
providing for self.
Analysis:
According to her, she is satisfied with her life, her family. She is happy of having
grandchildren
Analysis:
According to Jean Piaget memory and problem solving are maintained. Learning
continues and can be enhanced by increased motivation at this time of life
Analysis:
Client is cooperative and likes to share her past experiences when she was interviewed
Kohlberg defined middle adulthood as preconventional level which takes step to support
others right
Analysis:
She is friendlywith her companion. When she is right, she support and defend it but if it
is wrong she condemn it.
Analysis:
She stated that she prays everyday and goes to church every Sunday.
Collaborative
Administer to relieved pain
analgesics as
prescribed by the
physician