Light Stoke Ncp

University of the East Ramon Magsaysay Memorial Medical Center College of Nursing Aurora Blvd., Quezon City I. Clients Profile Name: Ms. A.G. Age: 44 years old Birthday: Feb. 16, 1963 Sex: Female Status: Single Address: Samal, Bataan Education: College Graduate Occupation: Broker Religion: Roman Catholic Chief Complain: Numb Right Extremities x1 for almost a day before the admission Date and time admitted: Nov. 9, 2007 at 7 PM Attending Physician: Dr. II. Client Health Status History of Present Illness Chief Complain: “Namamanhid ang kanang bahagi ng aking katawan at masakit ang aking ulo.” Three days prior to admission, the patient stayed at her office for the whole day to do her job. After doing her job, she went straight home and slept for more than 10 hrs. Two days prior to admission, she went visiting some business partners in the afternoon wherein they ate typical Filipino foods which includes seafood. Activities included the day before the admission are social drinking with some of her friends, smoked 2 cigarette packets for the whole day, attending feast wherein she was able to eat a lot of lechon baboy and doing some office works. Before she was admitted at the nearest hospital in their place, she went to her office to do her job. The problem occurred slowly and it happened in the morning of Nov. 6, 2007 around 10:00 while she was reading some papers. The patient verbalized, “Namanhid and kanang bahagi ng aking katawan. Parang dahan dahang nawala ang pakiramdam nito.” The numbness said to come with headache and it aggravates whenever she tried to move. The patient verbalized, “Sobrang sakit sa ulo. Pinakamalala sa lahat ng sakit sa ulo naranasan ko.” She was rushed at the nearest hospital by her best friend right after seeing Ms. A.G. crying for help. During that time, she said that she was quite distressed with her office works. She was attended by a neurologist and was diagnosed to have blood clot in her brain. She was admitted to that hospital for 1 and a half days. Reports were increased blood pressure from 110/80 to 180/130 and headache. Gradual numbness acutely occurred during the admission. On the 2nd day of admission (Dec. 12), the patient was transferred at UERM Hospital for further diagnosis. Tests were performed by neurologists and it was reported

that the clot in her brain didn’t change since her admission from the previous hospital. The right side of her body was then paralyzed. On the 1st day of admission at UERM hospital, he was diagnosed to have light stroke caused by the clot in her brain after going through tests. Other reports were hypertension, increased bad cholesterol level, increased uric acid, and hypertension. She was then administered medications by her attending doctor to treat her paralyzed condition. On her 2nd day at UERM hospital, she underwent rehabilitative measures. Reports said that her brain was now in a good condition without any complications or deviations of the normal state of her brain. Blood pressure was slowly restored and head ache was still present which was rated by the patient as 2/10. On her 3rd day at UERM hospital, her BP was 128/80 (taken11:30 AM) with TPR of 36, 60, 20. On that day, she was then discharged. History of Past Illness The patient had been diagnosed to have hypertension. She only takes medications for her hypertension only of she feels that she’s sick. She was never hospitalized due to hypertension. She was never hospitalized before nor underwent surgeries. There were no medications taken by the patient before she was admitted except Centrum. Regarding her vaccination status, she said that she doesn’t know whether she had completed the required vaccinations. She never had acquired communicable diseases except for colds and flu. She had chicken pox when she was 8 years old. Mumps and measles when she 12 years old. She has no allergies. She was never involved in an accident and was never severely injured. Growth and development Travel Development and social history III. Family history diagram IV. Gordon’s Functional Health Patterns A. Health Perception and Health Management Pattern Subjective The patient verbalized, “sa tingin ko, okay lang naman ang aking pangangatawan. Minsan lang naman ako magkasakit. Bumigay na ‘rin siguro sa dami ng mga ginagawaka ko. Mukang kelangan ko atang iimprove ang paraan ng pagpapanatili ng kalusugan ko.” “ Ngayon lang naman ako nagkasakit ng ganito. Siyempre, tumatanda na rin ako. Sabagay, minsan lang din talaga ako uminom ng vitamins ko. Pag gusto ko lang. Lagi ko kasing nakakalimutan.” “Sa kondisyon ko

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ngayon, masasabi ko na hindi nga ako health kahit sabihin natin na okay ang pangangatawan ko.” “Bihira lang ako magpunta sa doctor kasi karaniwan lang naman na mga sakit ko ay ubo, sipon, at sakit sa ulo.” “Pah hinahigh blood naman ako, my gamot kay nareremedyohan kaagad.” “Kung dati akala ko ay kakayanin ng katawan ko ang lahat ng mga ginagawa ko, ngayon naisip ko na may limit din pala ito lalo na’t hindi ako ganoon kaconsciuos sa health ko.” Nursing Diagnosis: B. Nutrition – Metabolic Pattern Subjective The patient verbalized, “Mahilig ako kumain! Paborito ko nga ang talangka.” Kumakain ako ng 3x sa isang araw. Hindi pa kasama doon ang mga merienda. Mahilig ako sa mga lutong bahay at bihira lang ako kumain sa mga fast foods.” Sa bahay ako kumakain ng breakfast at dinner samantalang sa labas pag lunch.” The patient said that she buy her buys her lunch at the carinderia near her office. “Masarap yung luto nila dun lalo na yung talangka.” “Si ate madalas maghanda ng pagkain sa bahay. Pag siya ang nagluluto, nakakadalawang tasa ako ng kanin!” “Mabilis din ako magutom lalo na kapag ang daming iniisip o ginagawa.” Regarding the fluid intake, the patient verbalized “malakas din ako uminom ng tubig. Siguro mga 12 glasses a day” “ Pag nag-iinuman kami ng aking mga kaibigan, nakaka-10 bote ako ng beer kapag San Mig Light at 8 naman kapag red horse o di kaya San Mig Dry. Karne ang pinupulutan namin.” “Hindi ako umiinom ng tubig na hindi mineral…” “Nagtatake ako ng Centrum isang beses sa isang araw pero madalang lang din kasi lagi kong nakakalimutan.” “Mahilig ako sa karne pero kumakain din naman ako ng gulay.” Nursing Diagnosis:

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C. Elimination Pattern Subjective The patient verbalized “Hindi ako nagpipigil umihi. Nakakaihi ako ng mga 6 –8 na beses sa isang araw. Mga 6 na baso din naman ang naiihi ko.” Ginagawa kong habit ang pag-dumi araw araw. Huwag lang sa opisina kasi parang hindi ako hiyang dun kaya sa bahay lang ako dumudumi. It’s either umaga bago umalis ng bahay or gabi bago matulog.” “Madalas, brown ang kulay ng dumi ko.” “Hindi naman ako nahihirapan sa pag-ihi or pagdumi. Wala naman akong nararamdaman na sakit o kirot.” “Pag nag-iinuman kami, madali ko lang maiihi ang mga ininom ko. Kung hindi naman, naisusuka ko ito.” “Mabilis akong pagpawisan kahit na nakaupo ako at lalo na kung mainit. Buti na lang at aircon sa opisina ko.” “Nagyoyosi ako pag dumudumi ako. Para kasing mas napapadali eh.”

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Nursing Diagnosis: D. Activity – Exercise Pattern Subjective “Minsan lang ako maglakad-lakad sa malalayo. Dati naglalakad-lakad ako ng mga isang oras sa isang araw. Pero ngayon, hindi na. Bihira na lang. Madalas, nasa opisina lang ako na nakaupo. Sa tingin ko nga, kulang na ako ng exercise.” “My routine ako sa araw-araw. Paggising ko ng umaga, kain kaagad tapos bihis papuntang opisina. Sa opisina, ginagawa ko ang aking trabaho. Nagbabasa ng mga papeles at iba pa. Nagbiyabiyahe din ako sa iba’t ibang lugay. Sa isang linggo, nakakatatlo hanggang lima akong biyahe papunta sa mga lugar na 2-3 oras ang layo. Nagcacar kami papunta. Ako nagdrdrive.” “Minsan, tumutulong ako sa bahay. Naglilinis at nag-aayos ng mga gamit.” Nursing Diagnosis: E. Sleep - Rest Pattern

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Subjective The patient’s sister verbalized “Mantika yan matulog. Sampung oras!!” The patient verbalized “ Masarap ako matulog eh. Kung pupwede, matulog na lang ako maghapon.” She said that she normally goes to sleep 11 in the evening and gets not less than 10 hours of sleep every night. She also sleeps for an hour or two whenever she finds to even between work. “Mabilis akong makatulog pag malambot ang higaan at upuan tapos hindi masyadong mainit. Nakatihaya at nakatagilid ang madalas na posisyon ko sa pagtulog. Gumagamit ako ng 2 unan. Isa sa ulo at isa bilang dantay.” The patient mentioned that whenever she cannot sleep during the night, she listens to music or drink alcoholic beverages with her friends. She added “naliligo ako bago matulog. Sinisigurado kong fresh ako pag matutulog.” “Wala akong katabi sa pagtulog.” “ Importante sa akin na makatulog ng maayos kasi sa tingin ko, ito ang tanging paraan para makabawi ako sa pagod.” “ Sa pagpapahinga naman, sinisigurado kong masaya itong gawin. Sa tinign ko kasi, mas mabilis mapawi ang pagod pag masaya ang ginagfawa mong pagpapapahinga.”

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Nursing Diagnosis: F. Coping - Stress - Tolerance Subjective The patient verbalized “this past few days, napagod ako. Ang dami kasing ginagawa.” “Nakakapagod din mag-isip. Dagdagan mo pa ang pagbiyabiyahe ko a week.” She mentioned that she’s a chain smoker. She consumes 2 packets of Marlboro Red cigarettes a day. “ Umiinom din ako ng beer. Kahit papano, nakakalimutan ko ang mga problema ko.” “Nakikipaglaro din ako ng tong-its. Madalas ako manuod ng TV at mag unwind.” “Buti na lang at may best friend akong nagpapawala lahat ng pagod.”

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Nursing Diagnosis: G. Role and Relationship Subjective Her sister verbalized “Mahal siya ng mga tao lalo na nung vice mayor pa siya sa lugar namin. Sobrang responsible siya. Kung may lalampas pa ng 100%, bibigyan ko siya ng 1000%” She added that her sister is brave. The patient lives with her sister. Her parents are separately living with them.” She currently has personal relationship with her best friend.” She verbalized “ Mahal ko ang mga tao sa paligid ko at pagsisilbihan ko sila sa abot ng aking makakaya.” “Nung vice mayor ako, ginagawa ko ng maayos ang aking mga responsibilidad. Tinutulungan ko ang mga tao sa aking bayan. Hindi ko rin naman nakakalimutan ang aking mga magulang. Tinutulungan ko din sila.” “masaya naman ako sa relasyon sa mga tao sa paligid ko. She verbalized “I’m very very satisfied sa relasyon ko.” For her support system, she has PhilHealth and Caritas.

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Nursing Diagnosis: H. Cognitive and Perception Subjective The patient is 44 years old. She verbalized “sa ngayon, parang napapagod ako. Ang dami kasing ginagawang tests sa akin.” She was able to reason regarding the current political status of the Philippines. She sai “ Masyado kasing gahaman ang ibang katauhan sa pulitika kaya ndi umuunlad ang ating bansa.”

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Nursing Diagnosis: I: Self Perception and Self Concept Subjective The patient verbalized “Sa tingin ko, masaya na ako sa buhay ko. Lalo na

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ngayong nalaman ko na marami din palang nagmamahal sakin lalo na ang best friend ko. Ang aking kahinaan? Hanggang ngaun ay hindi ko pa rin natutukoy. Sabihin na lang natin na takot akong magkaroon ng kaaway. Strengths? Friendly ako at matulungin.” “Sa pamamagitan ng pagsasabi ng totoo sa mga tao, nasasabi ko ang saluobin ko. Pero minsan, tinatago ko lang ang kalungkutan sa aking sarili. Tska iniiwasan kong maging malungkot.” “Sa kondisyon ng aking katawan ngayon, sa tingin ko kelangan ko ng maging conscious sa health ko. Mahirap pala. Lalo na’t pinapahalagahan ko ang aking sarili katulad ng aking pagpapahalaga sa aking kapwa.” Her sister verbalized “ Mabilis yan magalit at mabilis din matuwa. Kalog ba.”

Nursing Diagnosis: J. Sexuality and Beliefs Subjective The patient verbalized “ Satisfied ako sa gender ko kahit sabihin nilang hindi ito normal. Minsan nakakainis ang mga tao, napakakitid ng isip. Dahil nga ganito ako, pinapakita kong mahal ko ang isang tao through my actions.” “Kahit naman magkasakit ako, sinisugrado kong maipapakita kong mahal ko ang isang tao sa lahat ng pupwedeng paraan.” “Pamilya? As is girl at boy? Hindi ko alam. Masaya na ako at isa pa, matanda na rin ako.”

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Objective The patient had her first menstruation period when she was 12 years old. She has regular menstruation cycle which last for 5 - 7 days a month. She consumes an average of 15 napkins every time she has period.

Nursing Diagnosis: K. Values and Beliefs Subjective The patient’s religion is Roman Catholic. The patient verbalized “Tinuruan kami ng aming magulang na magpakumbaba at magpasalamat sa Panginoon sa kahit ano mang mangyari sa buhay namin.. Dapat

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laging nagppray. Importante din na magkaroon ng positive outlook sa buhay.” “dapt din na tumulong sa mga tao lalo na sa material na bagay. Bigyan ng pera ang mga nangangailangan at mrami pang iba.” Her sister verbalized “Importanteng hindi iviolate ang 10 Commandments.” They go to church every Sunday at St. Claire. The patient mentioned that she gave offerings to the church and sponsors some events in the church. “Ang goal ko sa buhay ang ang mag-silbi through material things” “Naniniwala ako na kung anong itinulong mo ay masusuklian pa ng mas madami.” Nursing Diagnosis: