I.

Health history

A. Demographic profile

Name: R.G
Gender: Male
Age: 41 years old
Birth date: September 23, 1967
Birth place: Pasig , Metro Manila
Marital status: Married
Nationality: Filipino
Religion: Born Again- Christian
Address: Brgy. Pantihan 3, Maragondon, Cavite
Educational background: High school graduate
Occupation: Factory worker in Monterey
Usual source of medical care: Doctor/Healthcare Professional

B. Source and reliability of information

The patient R.G is the primary source of information. He is conscious and

coherent, able to speak Tagalog fluently. His wife is also considered as source of
information regarding patient status and condition.

C. Reasons for seeking care or chief complaint (Top 3)

1st – insufficient sleep at night

2nd – loss of his weight
3rd – scaly of skin

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D. History of present illness

Patient R.G was handled during our duty at Brgy. Pantihan 3, Maragondon,,Cavite
with the chief complaint of insufficient sleep at night, loss of his weight and scaly of
skin. The laboratory test and special treatment for the patient are not applicable
because this case is base on community setting.

E. PAST MEDICAL HISTORY OR PAST HEALTH

• Pediatric/childhood

-Incomplete immunization- (-) serious illness on this stage

• Injuries or accidents

-1992, right leg accident due to mishandling of machine

• Serious or chronic illness

-December 2003, Diabetes Mellitus diagnosed clinically

-2x FBS result 300mg/dl

-2006 Pulmonary Tuberculosis, diagnosed clinically

-Chest X-ray and sputum AFB examination

-2007 Urinary Tract Infections

-Urinalysis (pyuria)

• Hospitalization

-1992, Water Rose General Hospital

Admitting diagnosis: Right leg machine accident

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 -December 2003, Rizal Medical Center, Pasig City, Metro Manila

Admitting diagnosis: Diabetes Mellitus Type 2

• Operation

-not applicable

• Obstetric History

-not applicable

• Immunizations

-incomplete immunization (unrecalled)

• Allergies

-No known allergies to food and medication

• Medication

-Metformin 500mg/tab

1 tab TID p.c.

-Gliclezide 80mg/tab

1 tab OD a.c.

-Vitamin B Complex tablet

1 tab OD

-Alaxan 500mg/tab (Paracetamol + Ibuprofen)

1 tab PRN for fever and pain

• Last Examination Date

-July 2007 (OPD case), Philippine General Hospital, Taft Avenue, Manila

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 F. FAMILY HISTORY

(+)
DM

55 y/o 83 y/o
(+) (+)
HPN CVA

39 38
y/o y/o 37
y/o

41
y/o LEGEND:
37y/o
(+) DM

Female

Male

Patient

16 15 9 y/o Deceased
1 1 2
y/o y/o 3 1 y/
y/ y/ o

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G. SOCIO-ECONOMIC STATUS

Mr. R.G. lives in their own house at Pantihan 3, Maragondon, Cavite. His wife is
selling and making barbeque sticks as the source of their income while his 16 years old
son works as a vendor in a wet market at Dasmarinas, Cavite as additional source of
income. They also received financial support from their relatives in Pasig. They can be
measured up as to poor class family. The patient has no history of drinking alcohol and
cigarette smoking.

H. DEVELOPMENTAL HISTORY
A person may experience midlife crisis between the ages of 35-45 years old, the
“deadline decade”. This occurs when the individual recognizes that he has reached the
halfway mark of life and according to Erik Erikson, the developmental task of the
middle-aged adult is Generativity vs. Stagnation.
As to our patient, who belongs to a middle age group and is suffering from a life-
threatening condition, he had experienced this developmental crisis, which led him to be
non-productive.
Being non-productive led him to be stagnant after the occurrence and diagnosis of
his disease which made him to be dependent with his family, he can’t attend, function and
be able to accomplish his responsibilities as a father, a husband and as part of the
community.

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I. REVIEW OF SYSTEMS AND PHYSICAL EXAMINATION

Subjective Objective

General

“Ito nangangayat na dahil sa Weight: 35 kg. (July 10, 2009)

sakit ko” as verbalized by the 87 kg. (December 2003)
patient.
(+) wt. loss 48kg.
(+) numbness at times(lower
extremities)
(+)excessive sweats, axilla
(+)weakness
(-)malaise
(-)chills
(-)fever
BP- 130/80 Temp. – 36.5 °C

Integument

Skin:
“Hindi makati sa binti, pero ang (+)itchiness (upper extremities)
braso, nangangati” as verbalized (+)scaly skin
by the patient. (-)history of skin disease

Hair:
“Dati malago ang buhok ko” as Thinning of hair, evenly distributed
verbalized by the patient. (+)itchy scalp (scratching)
(+)Oily hair

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Nails:
“Ito matigas na ang kuko ko (+)clubbing of nails (long nails)
kumpara dati” as verbalized by (+)Yellowish nail beds
the patient.

Amount of sun exposure: Exposure to sunlight every morning

Head:
“Sumasakit ang ulo ko na parang (+)frequent headache
tinutusok” as verbalized by the (+)dizziness
patient. (-) lumps

Eyes:
“Malabo na ang paningin ko” as (+)blurry vision
verbalized by the patient. (+)PERRLA
(+)Anicteric sclera
(+)Pale conjunctiva
(+)itchiness
(-)discharge

Ears:
“Malinaw pa naman ang Both ears hears well when the examiner
pandinig ko, pero may sumasakit is 3 feet away
minsan” as verbalized by the (-)cerumen
patient. (-)discharge

Mouth and Throat:

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 “Medyo hirap akong lumunok” (+)difficulty in swallowing
as verbalized by the patient. (+)lesions on tongue
(+)dental carries
(+)hoarseness of voice
Pink tonsils
(-)bleeding gums
(+) gag reflex

Neck:
“Wala naming problema sa leeg (-)stiffness
ko” as verbalized by the patient. (-)pain
(+)palpable bilateral lymphs

Breasts and Axillae:

“Pawisin ang kilikili ko” as (+)excessive sweating, axilla

verbalized by the patient. (-)lump
(-)pain
(-)rash
(-)nipple discharge

Respiratory:
“Medyo nahihirapan akong RR – 28 bpm
huminga” as verbalized by the (+)difficulty of breathing
patient. (+)wheezes on both lungs
(+)barrel chest
Productive cough
(+)green sputum
History of lung disease: pneumonia,
PTB, 2006
Last chest x-ray: 2007

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Cardiovascular
Central:

“Paminsan- minsan sumasakit (+)chest pain

ang dibdib ko” as verbalized by (+)dyspnea on exertion (bed to chair)
the patient. (+)nocturia

Peripheral:

(+)coldness(general)
(+)pallor in hands
(+)clubbing of nails
(+)tingling (sole of feet)
(-)numbness
(-)varicose veins
(-)ulcers
0-1 second, capillary refill

Gastrointestinal:

“Eto madalas magan ako (+)good appetite

kumain” as verbalized by the
patient.
Food intake tolerated
(+)minimal dysphagia
(-)hematemesis
Frequency of BM: 3x a week
Characteristic of stool: yellowish-
brown in color, formed in consistency
(+)constipation (arch and formed stool)
(-)hemorrhoids

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Urinary:

“Ihi ako ng ihi” as verbalized by (+)polyuria

the patient. (+)dysuria
(+)nocturia
Dark Yellow in color
History of urinary disease: UTI(2006)

Genitalia:
Refused
Musculoskeletal:

“Kumikirot ang kasukasuan at (+)minimal pain, knee area and ankle

buto-buto ko” as verbalized by (+)pain, calf area
the patient. (+)lower back pain, radiating
(+)weakness, leg muscles

Neurologic:

“Alam ko pa naman ang mga (-)history of seizure, stroke, fainting

sinasabi ko ngayon” as
verbalized by the patient. Mental:
(-)nervousness
(+)depression
Self-pity and crying

Motor function:
(-)tremors
(-)paralysis

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 Sensory function:
Oriented to time, person and place

Hematologic:

“Pagkakaalam ko,wala naman (-)bruises

akong sakit sa dugo” as (+)palpable lymph nodes
verbalized by the patient. (+)bleeding tendency of skin (scaly
skin)
(-)history of Blood Transfusion

Endocrine:

“Sa pamilya naming may (+)DM, type II

Diabetes, kaya ako merong (+)polydypsia
Diabetes” as verbalized by the (+)polyuria
patient. (+)polyphagia
(+)weight loss
(+)change in skin texture, scaly skin
(+)excessive sweating, axilla
(-)nervousness
(-)tremors

J. FUNCTIONAL ASSESSMENT

I. Health Perception/Health Management Pattern

Mr. R.G. is a 41 yrs old, male and seriously ill person. Once he felt something wrong
about his condition, he seeks for medical advice. Occasionally, he also had colds in the past. Last

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December 2003, after a consultation from a physician and with accompanying lab result of blood
sugar level (2x done, result is increased 300mg/dl) he was diagnosed of DM type 2. The client
believes that he acquired his illness from his grandfather who also had Diabetes Mellitus.
According to Mr. R.G., eating nutritious food, exercise and religiously taking of prescribed
medication or what nurse’s and Doctor’s advise/suggest will keep him healthy. Due to financial
incapacity, this regimen was not taken into consideration.

II. Self Esteem, Self Concept/Self Perception Pattern

Before he was diagnosed with DM type 2, Mr. R.G. is a responsible husband and father to
his wife and kids. He was able to provide the needs of his family. The client possessed a jolly and
fun loving type of personality.
Since his illness started, most of the time, he felt self-pity and worthless. He is always
irritable and angry when he thinks that he was ignored. Because of his condition he became more
depress and the only thing that gave him hope and strength is through prayer.

III. Activity-Exercise Pattern

Perceived ability for: (Refer to Functional Level Code)

Feeding Level II Grooming Level II

Bathing Level II General Mobility Level II
Toileting Level II Cooking Level IV
Bed Mobility Level II House Maintenance Level IV
Dressing Level II Shopping Level IV
Functional Level Code

Level 0 Full Self Care

Level I Requires Use of Equipment or Device
Level II Requires Assistance or Supervision from Another Person
Level III Requires Assistance or Supervision from Another Person and
device
Level IV Is Dependent and Does Not Participate

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IV. Sleep/Rest Pattern

The patient had altered sleep pattern. Each day he only had a maximum of 2 hours of
sleep and despite of that he still fells god upon waking up. He said sometimes the pain he felt put
him into sleep.

V. Nutritional/ Elimination

The patient usually takes a glass of milk in his breakfast and he takes heavy meals more
frequently but after eating he usually felt stomach ache. He has supplements of vitamin B-
complex. He typically drinks more than an 8 glasses of water per day. Patient stated that prior to
his illness he weighted 87kgs but at present he weighs 39kgs.
We noticed that the patient skin is scaly all over his body. He also have lesion in his
tongue and positive dental carries.
The patient usually had 3x bowel movement per week with a dark yellowish brown color
stool, with hard formed in consistency. On the other hand he noted that he frequently void with
dark yellow in color urine and felt some discomfort when urinating.
During the day patient is experiencing excessive sweating in his armpit.

VI. Sexually- Reproductive Pattern

The patient is inactive in sexual intercourse due to present condition

VII. Interpersonal Relationship / Resources

Patient can speak and understand English and Tagalog. He can clearly express himself.
He has 6 children and they were close to each other.
Before patient is very active and usually socializes with his neighbors.
Patient R.G’s family was very supportive and understanding, now that he is battling with
his disease.
The patient is dependent due to his illness.

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VIII. Coping and Stress Tolerance

Before when patient R.G is anxious he wants to be alone, when he is stressed, he prefers
to drink liquor and involved himself in gambling.
When he was diagnosed of DM Type 2 there have been many changes occurred that made
difficult for him to adjust. He cannot perform the usual activities that he had before. When
patient R.G is stressed, he prefers to cry until he falls asleep. When it comes to problem, he tried
to calm himself through prayers.

IX. Values-Belief Pattern

Patient R.G is a Born Again Christian, before according to the client he always hears
mass every Sunday with his family.
Due to his illness he wasn’t able to go to mass. According to the patient there are many
practices affects his illness.
He wasn’t able to follow therapeutic regimen due to financial problem and a strong faith
to God helps him to get through all the suffering he has.
After what happened, patient R.G is still not seeking for medical assistance due to
financial problem. Religious effort is still a part of patient R.G.’s life.

X. Personal Habits
Before, patient R.G. used to maintain a good personal hygiene and had a diet without
restriction. He used to work as a factory worker 6 days per week and was able to help in doing
household chores when he got home. He had a good sleep pattern of almost 8 hours at night.
Every Sunday he goes to mass with his family and occasionally at his free time he drinks and
smoke with his friends.
At present, due to his illness, patient R.G wasn’t able to perform his usual routine. He had
to stopped from working in able to attend his health needs and become dependent to his family.

II. PROBLEM LIST

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 1. Imbalanced Nutrition Less than body requirements

2. Disturbed Sleep Pattern

3. Impaired Skin Integrity

4. Activity Intolerance

5. Risk for Infection

6. Risk for Falls

7. Risk for Security

III.

A.) ACTUAL OR ACTIVE PROBLEM

Problem No. Problem Date Identified Date Resolved Remarks

Imbalanced July 09, 2009 July 16, 2009 Client appetite was
1 Nutrition Less increase.
than body
requirements
2 Disturbed Sleep July 09, 2009 July 16, 2009 The client can sleep
Pattern now from 4-8 hours
unlike before.
Impaired Skin July 09, 2009 July 16, 2009 The wound is clean
3 Integrity and dry.
Activity July 09, 2009 July 16, 2009 The client able to
4 Intolerance perform some
minimal ADL

B.) High Risk or Potential

Problem No. Problem Date Identified

1 Risk for infection July 09, 2009

2 Risk for Falls July 16, 2009

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 3 Risk for Security July 16, 2009

IV. NURSING CARE PLAN

V. ANATOMY AND PHYSIOLOGY
VI. PATHOPHYSIOLOGY
VII. MEDICAL MANAGEMENT
VIII. PROGRESS NOTES
IX. DISCHARGE HEALTH TEACHING PLANS
X. SUMMARY OF CLIENT STATUS OR CONDITION AS OF LAST DAY OR
CONTACT

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