Area Initial Pattern Ongoing assessment

Usual Pattern (February 25, 2020) (March 1, 2020)

Health Perception – Health

Management Pattern
 Client claimed that
 Client claimed that he is okay
 Client claims that he feels okay as his
but the edema on both legs
general health has been legs feels kind of
made him unable to walk due
good for the past years. comfortable than
to pain during mobility.
 Client claims that he before.
 No known food allergies and
had colds in the past years  Client claimed that
medication.
but tends to work unless she he must be compliant
 Chief complaint: bilateral
becomes very ill. till recovery.
edema grade II, Anorexia,
 Client claims that  Client claimed that
dyspnea.
she walks around to keep he slowly able can
 Client verbalized “Wala
himself healthy and clean eat small portions but
naman ko gana ikaon”
their home’s surroundings. not like before.
 Client verbalized “sakit
She doesn’t smoke or drinks  No facial grimace
naman ilakaw”
alcohol. noted.
 Client verbalized “gikutas
 Client claims he has  Client verbalized
pud ko ato.”
been hospitalized the past “dili rako kaayo mu
 Pain scale= 7/10
year due to anorexia. lihok para dili mo
 Diagnosis: PTB-BC; EP-TB;
 Client claims that it sakit.”
Malnutrition
was easy for him to follow  Client claims that he
 Facial grimace upon
at first. They were told to can breathe easily.
movement.
have a follow-up check-up,  Pain scale= 3/10
Height: 5ft 4inches (1.626m)
but they thought he’s  Weight: 34kg
already fine so check-up  Weight 33kg  Vital signs:
was disregarded.
 BMI=12.5 kg/m2 T= 35.6 C
 Vital signs: P=119bpm, regular,

T= 36.7 °C strong
BP=100/70mmHg
P= 131bpm, regular, strong
RR=21cpm, regular
BP= 80/60 mmHg without effort
 R= 25cpm, regular, with minimal use O2 saturation: 97%
of accessory muscles

O2 saturation: 93%

Stat medication:

Meropenem 1gm IVTT q8hrs

HRZE 2 tabs OD before breakfast

KCl 1 tab TID

Omeprazole 40mg IVTT OD before

breakfast

Paracetamol 500mg 1 tab Q4hrs PRN

for T> 38 °C

Dopamine drip @ 30cc/hr

Nutritional-Metabolic  Diet: OF 500 kcal in 500cc water  Diet: soft diet c SAP
Pattern in 6 divided doses.  + 3egg whites/day
 Client claims “gamay ra ko ug  Has good appetite as
 Client claims that
kaon.” claimed
her typical food intake
 No difficulty in swallowing.  No difficulty in
during breakfast, lunch and
 With D5LR 1L @ 10cc/hr swallowing
dinner may be similar either
 Dopamine drip @ 30cc/hr  With D5LR 500cc
salted dried fish, meat, fish
running at 10cc/min
and some vegetables.
 Significant other
verbalized “gamay ra kayo
na syag kaon and usahay
wlay gana.
 Significant other
verbalized “mutumar na
siyag vitamins pero dili pud
sige.”
 Client claims that he
drink milk in the morning
and water for every meal
approximately 2 glasses.
 Client claims to lose
weight
 Client claims “mura
man kog dili ma linsan.”
 Client claims no
food restriction since then
when she thought he doing
fine.
 Client claims no
discomfort in swallowing.
 Claims that wounds
heal well
 Client has no skin
problems and dryness.

Elimination Pattern  Bowel elimination: twice a day;  Bowel elimination: once;

brown; wet brown; formed
 Client claims that he
 Urinary elimination frequency:  Urinary elimination: with
defecates once every day
every 2 hours. Amount: about a foley catheter; character:
and its formed. No
glass (240ml) as claimed: yellow yellow in color;
discomfort unless
in color; Discomfort: none; discomfort: none
constipated. No use of
 Problem in control: None Problem in control: none
laxatives.
 Does sponge bath daily or every  Took a sponge bathe this
 Client claims to urinate
other day. morning
frequently like every 2 to
3 hours. Slightly
yellowish in color. No
problem in controlling.
 No odor problems. Not a
heavy perspirant
Activity-Exercise Pattern
 Client verbalized “magsige rako
 Client works as a  Sitting on bed
higda dri hospital.”
construction worker  Client verbalized that
 She feels mild pain and discomfort
 Client claims to have “maglihok rko
 Client verbalized “gikutas pud koa
energy to do desired pakilid napud para
to.”
activities. dili kaayo mangatol.”
 Client’s daughter is there to assist
 Claims walking daily as  Client claimed that
him to move but cannot walk due
her form of exercise. he can breathe easily.
to the edema on both feet.
 Client sleeps during his  Client participated in
 Perceived ability for:
leisure time. treatment regimens.
o Feeding: 0
 Perceived ability for:  Client verbalized
o Dressing: 0
o Feeding: 0 “dili naman kaayo
o Cooking: N/A
o Dressing: 0 sakit ako tiil, madala-
o Bathing: 2
o Cooking: 0 dala raman.”
o grooming: 2  Client claimed that
o Bathing: 0
o shopping: N/A he can walk heading
o grooming: 0
o toileting: 2 to the toilet with
o shopping: 0
o general mobility: 2 assistance.
o toileting: 0
o bed mobility: 2  Perceived ability for:
o general mobility:
o home maintenance: N/A Feeding: 0
0
o bed mobility: 0 Dressing: 0
o home
Cooking: N/A
maintenance: 0
Bathing: 2

grooming: 2

shopping: N/A

toileting: 2

general mobility: 2

bed mobility: 2
 home maintenance: N/A

Sleep-Rest Pattern  Took intermittent naps.  Client claimed he still

 Does not feel rested for days. took naps in between.
 Client claims she
 Sleeps for 2hrs then wakes up.  Client claims he feel
generally rested and
rested than the first day
ready for activities after
he was admitted.
sleep
 Client claims that he can
 Claims no sleep onset
sleep about 3-4 hours
problems though he
then wake up.
wakes up in between to
urinate.
 Usually sleeps during
leisure time
 Usual onset of sleep=
9pm
 Usual waking up= 5am
 Doesn’t experience
nightmares or bad
dreams

Cognitive-Perceptual Pattern  Has difficulty in hearing. Whisper  Has difficulty in hearing

test= Unsatisfactory  Easily supply answer
 Client has hearing
 No eyeglasses used when he can hear the
difficulty but she has no
 Can easily answer if he can hear question clearly during
hearing aids.
well the questions during the interviews
 No glasses and can’t
interview  Uses Visayan dialect to
determine last time he
 No change in memory lately communicate
got it checked.
 Uses Visayan dialect to  Rate pain as 2/10. With
 No change in memory
communicate just slight discomfort
lately
 Complains of pain in his back and
 Important decision are
lower extremities Rated pain scale
easy to make, if not his
7/10 (where 10 is the most painful;
wife usually does it
and 0 as no pain)
 Uses Visayan dialect to
 communicate  Facial grimace noted.
 Easiest way is through  Client verbalized “sakit ilihok ako
visual aids. tiil”

 Client verbalized that “ sakit ako

likod.”

Self-Perception – Self-  Claims to be happy. What  Claims that he is still

Concept Pattern really is bothering him is the pain on happy despite being in
both extremities. the hospital because of
 Client describe
 Client claims easily get the possibility to get well
himself as a happy
annoyed and frustrated due to the  Client feels that he has
individual no matter what
condition. recovered but still wants
and he feels good about
to be sure
himself.
 Client claims that he has
 Client claims he can
to adapt to things to
do anything on his own,
prevent himself from
have time for himself until
being a patient and
there was pain on the legs.
considers himself as a
 Client claims he
vulnerable individual
doesn’t get angry or
because of the nature of
annoyed easily. Only if his
his work.
kids don’t listen.
 Client claimed that he
 He is hopeful that
must be compliant till
he’ll be fine.
recovery.
 When he gets
frustrated, he usually walks
and cool off himself.
Role Relationship Pattern  It was the client who told the wife  Client was visited by his
that he must sought admission. daughter
 Client lives with his wife
 Client’s wife is always with him  Client’s daughter and
and kids.
catering his needs wife alternately takes
 Client claims that there’s
 Client relies everything to the care of him.
no family problems he
 had difficulty in doctor and nurses
handling.
 Family depends on him
too.
 Client’s family is
worried about her health
status.
 Client doesn’t feel lonely
since they are together in
one home.
 Client feels comfortable
walking and talking to
neighbors since his
neighbors are close by.

Sexuality-Reproductive  No pain and difficulty  No pain and difficulty

 Satisfied with sexual

relationship
 No changes lately and no
problem
Coping-Stress Tolerance  Client’s anxiety makes her  Client is still anxious
stressful about his condition
 There is a significant
 Kind of worried about expenses,  Client hopes to be fully
change for him in his life
since he is the breadwinner of the recovered soon.
since the admission last
family.  Client is worried that
year, that’s where losing
 Client trusts his wife that she will how he can help his
weight started and
sort it out for her. family and work because
having not enough
 Client claim that he has no idea of the condition.
energy.
why it happened to him but he is  Client claims that what
 Client’s wife helps him
still waiting for the diagnosis. might others think having
hand in hand in time of
 Client claimed that its stress from this kind of condition.
problems.
work that started all this.
 Client claims that his
neighbor is helpful.
 Client claims that he is
relax most of the time.
 If ever problems arise in
his life, he talk it out
with his wife.
 So far talking it out has
been successful for him.
Value-Belief Pattern  Client values the presence of the  Values his health by
nurse researcher who is around. allowing doctors and
 Client just want to have a
 Client told the nurse he usually nurses to manage his
happy life.
believes that big hospital requires condition.
 Client doesn’t go to
down payments in order to sought  Client claimed that he
church but believes that
admission. must be compliant till
everything happens for a
 Client values his health and is recovery.
reason.
worried he will not be able to do  Expresses gratitude to the
 Client claims that
his role in the family so he sought nurse researcher
religion is important in
admission when everything  Client hope that the final
his life and helps them
doesn’t seem right. diagnosis will be just a
during difficulties.
 Family is important for him and so manageable one and
 Client claims he prays a
is God. wouldn’t affect his future
lot and has a strong bond
well-being so that he can
to God.
go back to work for his
 Religion can’t interfere
family.
in any way.