St.

Paul University Philippines

Tuguegarao City, Cagayan 3500
SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES
COLLEGE OF NURSING
1ST SEMESTER, AY 2020-2021
BACHELOR OF SCIENCE IN NURSING – LEVEL II

HEALTH ASSESSMENT
Part 1. Health History
A. Biographic Data
Client J.U., is a 44 year old Filipino-Chinese male client who is currently residing at Zone 1,
Maguilling, Piat, Cagayan with his mother, wife, and 2 children. He was born on May 12, 1976
in Maguilling, Piat, Cagayan. He speaks Tagalog and Itawes. He is a BS Agriculture graduate,
now self-employed and manages his own farm. He is a househusband, and spends most of his
time in gardening and raising chickens. His religion is Roman Catholic.
B. Chief complaint/Present health concern
According to the client, his major concern is his gouty arthritis which was diagnosed last
2018. Recently, it began to exacerbate, prompting him to visit his doctor last December 10, 2020.
C. History of present health concern
When asked to recall how his present concern began, the client verbalized, “Noong 2018,
left side ng paa ko ang nagsweswell. Ngayon, nawala na yung mga tophi ko sa left pero lumipat
naman sila sa right. Akala ko noon nalamigan lang o kaya ito na yung epekto ng mga
pagkasprain ko noong nagbabasketball ako nung kabataan ko kaya pinahilot ko. Nalaman ko
lang nung nagpacheckup ako na gout pala siya kaya di na ako nagpahilot.” He added that he
adhered to his diet and took the medicines given to him religiously for 6 months. When his
symptoms subsided, he did not go back for a follow-up checkup. 2 years later, the client
experienced excessive inflammation in the right side of his body prompting him to visit his
doctor again.
When he is at the peak of inflammation, the client rated pain to be 10/10 because even with
the slightest touch, it would already feel like he’s been fractured. He said that the pain would be
felt all day long but peaks at night. At present, he would rate it as 2/10. The client described the
pain to come from joints where tophi has developed like the client’s hallux, wrist, elbow, knee,
and phalanges. He is aware of the food that should be avoided. He said, “Sunod sunod kasi ang
mga handaan noong November dito at napadalas ako kumain ng pansit. Naparami ako sa karne
ng kalabaw at liver kaya biglaang natrigger itong gout ko.” When triggered, the client said that it
will take no less than 2 weeks for him to recover. “Mahirap kasi mapababa at maflush sa
katawan yung uric acid lalo na kung walang gamot ang kung panay ang pagkain ng bawal. Kaya
ngayon, kahit mahirap, tinitiis ko nalang na sundin yung diet kasi yun ang nagpapagaling sakin.”
The client could not independently perform his activities of daily living when he experiences
 St. Paul University Philippines
Tuguegarao City, Cagayan 3500
SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES
COLLEGE OF NURSING
1ST SEMESTER, AY 2020-2021
BACHELOR OF SCIENCE IN NURSING – LEVEL II

gout attacks. “Hindi ako makalakad kahit papunta lang ng banyo o kusina. Maski ang umupo
lang sa higaan masakit na.”

D. Past Medical History

The client claimed that he barely gets admitted to the hospital. His last confinement and
surgery was when he was a child because of burn and accident. He said that he had chickenpox,
measles and mumps when he was young. He was vaccinated before but was not able to recall the
vaccine/s administered to him. He also received deworming during his elementary years. Since
December, he takes Celecoxib 200mg/cap 2x a day (pain reliever & anti-inflammatory),
Colchicine 500microgram/tab 1x a day (block the effect of high uric acid) and Febuxostat 80mg
per tab at 1/2 tablet per day (lower down blood uric acid level) as prescribed by his doctor. He
applies Aescin Diethylamine salicylate on swollen areas when necessary. He denies any allergy
from the medications he take. The client has tried home remedies which he found on the internet
such as vitaplus supplements, King’s herbal supplement, honey with apple cider vinegar, and
honey with lime. He deems his medicines and home remedies effective but according to him, all
of these would be futile if he will not adhere to his diet.
E. Family Health History
 St. Paul University Philippines
Tuguegarao City, Cagayan 3500
SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES
COLLEGE OF NURSING
1ST SEMESTER, AY 2020-2021
BACHELOR OF SCIENCE IN NURSING – LEVEL II

F. Review of Systems
Skin, Hair and Nails: Brown complexion, warm to touch, presence of burn scars. Denies
excessive sweating, lesions, balding, and dandruff. Experienced rashes lately with an unknown
cause. Reports white hair; Denies problems with nails.

Head and Neck: Denies headaches, swelling, stiffness of neck; denies difficulty in
swallowing, sore throat, enlarged lymph nodes.

Eyes: Denies any problem with vision. Doesn’t wear glasses. Denies any eye infection,
redness, excessive tearing, halos around lights, blurring, loss of side vision, moving black spots,
flashing lights, double vision, and eye pain.

Ears: Denies loss of hearing, ringing and buzzing, earache, drainage from ears, dizziness
and exposure of loud noises.

Mouth, throat, nose and sinuses: Denies bleeding of gums or other dental problems;
Denies sore throats and hoarseness; Denies mouth lesions, rhinorrhea, nasal obstruction, frequent
colds, sneezing, and nose bleeds. Reports snoring.

Thorax and lungs: Denies difficulty in breathing, pain, shortness of breath during
routine activity, orthopnea, sputum, hemoptysis, and respiratory infections.

Breast and regional lymphatics: Denies lumps or discharge from nipples; Denies
swollen or tender lymph nodes in axilla.

Heart and neck vessels: Reports last blood pressure of 120/80mmHg; Denies chest pain
or pressure, palpitations and edema.

Peripheral Vascular: Reports unilateral swelling of leg and feet due to formation of
tophi; Reports sores on legs, Denies changes of color or texture changes on the legs or feet.

Abdomen: Reports occasional indigestion and bloating when lying down immediately
after eating. Denies difficulty swallowing, nausea, vomiting, abdominal pain, gas, jaundice, and
hernias.
 St. Paul University Philippines
Tuguegarao City, Cagayan 3500
SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES
COLLEGE OF NURSING
1ST SEMESTER, AY 2020-2021
BACHELOR OF SCIENCE IN NURSING – LEVEL II

Male genitalia: Denies sexual problems and STIs; Urinates approximately every 2 hours.
Circumcised at age 10; Denies difficulty in urinating and voiding problems.

Anus, rectum and prostate: Reports daily bowel movement of soft, yellow brown stool
as a mechanism of his medicine; Denies pain with defecation, hemorrhoids, blood in stool,
constipation and diarrhea.

Musculoskeletal: Reports unilateral swelling of leg, arm, and feet due to formation of
tophi. Reports redness, pain and stiffness of joints; Reports difficulty to perform ADLs
independently due to pain related to gouty arthritis.

Neurologic: Denies depression, anger and suicidal thoughts; Denies headaches, loss of
strength or sensation, lack of coordination; Denies difficulty speaking, memory problems,
strange thoughts and actions, and difficulty in learning.
G. Lifestyle and Health Practices
The client does not have vices on smoking or drinking alcohol, but he is a heavy drinker of
carbonated drinks. On a regular day, before his gout exacerbated, the client would drive his wife
to school, do gardening, feed chickens, and visit the farm. He used to be a member of his
school’s basketball varsity team and he remained active in basketball until 2010. At present,
because of his gout, he would normally just stay in the house with his children and watch movies
online as his main source of entertainment.

Gordon’s Typology of 11 Functional Health Patterns

1. Health Perception – Health Management

Client J.U. described his health to be “improving’. He sees importance in his health
because his roles and functions as a father depend on it. He finds his family as his greatest
motivation in regaining his health particularly because his kids are still young and he wants to
witness them grow and achieve their dreams. As a result of this motivation, he has now become
more compliant in his medication and diet, as well as the advices of his doctor and family who
longs nothing but his immediate recovery. He doesn’t go frequently to the hospital because he
has a sister who works as a nurse that checks on him regularly as she happens to live in the same
compound with him. He realizes the effect of his health on his activities of daily living. “Kapag
may sakit ako, hindi ko nagagawa yung mga usual kong ginagawa tulad ng pagpunta sa farm.”
At present, he rates his health 7 out of 10 because he has not fully eliminated the tophi
 St. Paul University Philippines
Tuguegarao City, Cagayan 3500
SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES
COLLEGE OF NURSING
1ST SEMESTER, AY 2020-2021
BACHELOR OF SCIENCE IN NURSING – LEVEL II

formations in his legs, and because according to him, there’s still a lot to improve on in terms of
his health considering how healthy he was before.

2. Nutritional – Metabolic
Client J.U. admits that his diet used to consist of mostly red meat and other fatty food. At
present, he usually eats 2 cups of rice every meal time, which although above average, would
still be seen by the client as an improvement compared to his old habit of eating 3 cups of it. He
eats mostly fruits and vegetable, and limits meat. “Bihira na akong kumain ng kahit anong
klaseng karne, pati manok.” The client doesn’t skip any meal nor does he eat late. He usually
eats snacks with his children by 3:00 PM. He claims that he drinks about 200 ml of water 8 times
a day and that he has already gotten away from his habit of drinking too much carbonated drinks.
He also drinks Buko Juice whenever available. He didn’t have good appetite during the peak of
his gout because he couldn’t move his hands freely, but now his appetite is returning back to
normal. His daily menu now comprises of rice, sayote, fried egg, sinigang na isda (he eats
various fishes), and other food as long as it is not high in purine. He also takes vitamin C and
other supplements.

3. Elimination

Client J.U. urinates 6-7 times a day which approximately measures 200 mL each output.
He said that his urine was orange during the peak of inflammation as a mechanism of his
medicines. Now, it is yellowish. He moves his bowel once a day, and describes his stool to be
yellow brown in color and soft in consistency. The client denies incontinence and any discomfort
while urinating or defecating. He also denies excessive perspiration.

4. Activity - Exercise
On a regular day, client J.U. would do gardening, feed chickens, and take a walk
in the farm, which he considers as his exercise. He also drives his wife to school 2x a week.
When he does not have anything to do, or when his gout is triggered, he just spends his time
lying in bed and watching movies online.

5. Cognitive - Perceptual
The client does not use reading glasses nor does he have difficulty seeing things.
He denies getting dizzy of reading in his phone. He denies impairment in hearing, tasting, and
smelling. He also denies any history of depression or any mental health disorder. He is able to
communicate his thoughts and express his feelings well. In addition, the client can still think
 St. Paul University Philippines
Tuguegarao City, Cagayan 3500
SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES
COLLEGE OF NURSING
1ST SEMESTER, AY 2020-2021
BACHELOR OF SCIENCE IN NURSING – LEVEL II

rationally. He does not have any trouble processing any words or information, does not have
strange or unusual thoughts, and does not have any short-term memory loss.

6. Sleep - Rest
Client J.U. sleeps at 10PM but sometimes stretches it to 11PM when he feels like
watching movies. He wakes up around 6-6:30AM. He, at times, wakes up in the middle of his
sleep to urinate. Nevertheless, the client verbalized that he feels rested when he wakes up. He
takes a nap normally after eating lunch and feeding the dogs. He doesn’t have difficulty inducing
sleep, but he said that he experiences interrupted sleep due to gout attacks. Given the scale of 1-
10 having 10 as the highest, the client rated his quality of sleep as 8 because he has not fully
recovered from gout.

7. Self-perception and self-concept

The client perceived himself as someone with a shallow happiness. His talents and skills
are playing basketball and badminton, gardening, and driving. The client stated that he is
satisfied with his current status in life and what he has achieved for himself and his family.
“Kuntento na ako sa pag manage ng farm basta laging kumakain ng masasarap ang mga anak
ko.” Although he has burn scars all over his body and his face, he never had insecurities about it.
“Pakiramdam ko naman kaya ko siyang idala. Mula naman bata ako meron na siya.” He noticed
that he started to get weaker and to get tired easily even after his condition on gout improved. He
perceives that his condition makes him less of a person. “Kasi sa edad ko dapat productive and
active pa ako eh katulad ng mga batchmates ko. Dati, pag nakikita ko ang mga hindi nakalakad
pakiramdam ko kaawa-awa sila, ngayon ganun din ang nararamdaman ko sa sarili ko.”
8. Role-relationship
The client said that he does not have any problem with his family relationship.
What’s troubling him, however, is his guilt in seeing his child and wife assume his role as a
father. In this regard, he finds in his family the greatest motivation to recover and regain his old
self. When asked about his role in the family, he identifies himself as the pacifier and comedian
who always takes even the most distressing situations lightly. His wife, his sister, and his son
take turns in assisting and taking care of him.
9. Sexuality- reproductive
The client recalls that his last sexual activity was before the recurrence of his
gout. Nevertheless, he feels very intimate with his wife. The client and his wife are in good state
in terms of their sexual- reproductive aspect as evidenced by their 2 offspring. He answered none
 St. Paul University Philippines
Tuguegarao City, Cagayan 3500
SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES
COLLEGE OF NURSING
1ST SEMESTER, AY 2020-2021
BACHELOR OF SCIENCE IN NURSING – LEVEL II

when asked if he has a sexual problem or dysfunction in his reproductive system. Yet, he said
that he quite lost his desire for sexual activities due to pain from gout. The client was
circumcised at the age of 10.

10. Coping stress and coping tolerance

The client identifies his inability to perform his daily activities independently, as well as
his shift in diet, as the biggest changes in his life recently. He normally eats whatever he wants,
but now feels controlled and restricted. He verbalized, “Noong Christmas at New Year hanggang
tingin nalang ako sa mga handa. Pabiro ko nalang inamoy yung mga pagkain na bawal sakin para
parang natikman ko na rin sila.” He said that his condition causes him stress especially when it is
fluctuating. “Minsan, yung mga anak ko rin nagpapastress sakin pag natataasan nila ako ng boses
o di kaya pag mahirap sila utusan”, he added. However, he said that he is able to manage this
stress because of his wife who takes care of him, listens to his sentiments, and attends to his
concerns. In addition, he manages stress by watching movies online. He does not drink alcohol,
use medication or take recreational drugs to relieve stress.

11. Value-belief
The client believes in “family first”. He also said that this is something that he
wish to impart to his children so that wherever they go, they remain family oriented. He
considered health as a priority especially that there are a lot of medical practitioners in their
family. However, he believes that prayer is the most effective medicine. He joins his family in
the praying of holy rosary and also goes to Church every Sunday as long as he is able to walk.

Developmental level
There are changes that occurred to the client physically. He observed that he gets
tired easily, and that his hair became thin and turned gray as part of aging.