VITAL SIGNS  Client use it as a maintenance

JUNE 11, 2024  3 tabs. a day is taken if there is any sakit (ex. Cough,
T: 36.1 arthritis)
P: 85
R: 20 FOOD SUPPLEMENT
BP:180/100
1. CELL MINERAL DROPS (1 glass 7 drops @ PC)
SPO2: 98
 Use for highblood
 Drinks this if naay sakit gibati
JUNE 12, 2024
 The client had also used this in his wound on the
T: 35.9
right legs, once ra niya gi tul an
P: 73
R: 18
BP: 180/ 100
SAKIT NI LOLO
SPO2:
HYPERTENSION

JUNE 13, 2024  60 yrs. old nagsugod bana-bana ni lolo

T: 36.1  Sakit batok
P: 79  Walay lilong maong magsige gihapon adto bukid
R: 20  Last 2018, ni adto clarin pacheck up kay taas bp (200/80)
BP: 160/90  Gi undagan Losartan (May 2024) because nagpa bp sa
SPO2: 98 iyang wife with their digital bp ang kuha kay 120/70
mmHg
 Always drank tuba before maoy reason daw sa sakit pero
MEDICATIONS karun wala na nagdrink

1. LOSARTAN 50mg 1tab PO OD @ AM

ATHRITIS
 Maintenance
 May 2024 last taken, June 12 ni inom balik because  2018 start of arthritis
of the student nurse  Swelling on right toes and knees
2. DRENEX 3mg 1tab PO  Redness in the affected areas
 Taken if naay arthritis  May 2024 last nitukar ang pain because of eating bulinaw
 Maoy gi puli sa sarimax  Naundang iyang pagbike
 May 2024 start of taking this medicine  Cannot walk because of the pain
 If taken, 2-3 hours mawala na ang pain  According to the patient, the pain will start on his right
 Taken 1-3 days nga totally mawala ag pain toes with a prickling sensation then it will go up to his
3. SALBUTAMOL 2mg 1tab PO knees.
 every cough i take  Red and hubag/hupong ang knees & toes
 partneran niya ug tahibo  Magpuli puli ang both right & left knees and feet pero pag
4. SARIMAX May only ang right mi sakit
 Last gitake April 2024, gi undangan kay dugay ang  Gi imnan Drenex only once in that day nga nisakit then
effect. They believe with his wife nga madaot ilang Nawala nadaw ag pain pero ni take ug 3 days nga
kidney kay sige take mao gi stop. nawalajud totally
 3 times a day gi take sauna  As we interviewed the client, he knows nga dapat jud
likayan ang kontra na foods especially seafoods
HERBAL
IMPAIRED HEARING
1. TAHIBO 1capsule PO PC @ AM
 Client use it as a maintenance  ad
 Maroon color and is put in a small plastic cellophane
 Mg. was not indicated in the packaging COUGH BECAUSE OF CIGARETTES?
2. BIO-TROFF 300mg 1tab PO PC @ PM
 ad
 Put in a plastic container
 11 GORDON’S FUNCTIONAL PATTERN reads too much, his vision will get blurry. The client
doesn’t have problems with his sense of smell, taste and
HEALTH PERCEPTION touch.

 According to the client, he considers himself a healthy SLEEP REST

person because he can still go and work on his farm. He
was caught in the rain in May 2024, which caused him to  Upon waking up, the client feels well rested and fresh. He
get a cold. He automatically drank a medication said that he usually goes to sleep at 9pm and wakes up at
(paracetamol) he had taken from their local RHU. His 3am in the morning so he can start his day earlier. He told
last check-up was last year because of his cough. He us that it has become a habit to wake up early to boil some
stayed for about 8 days in the hospital of Clarin. water and also do the rosary. He doesn’t have a problem
sleeping because once he is in bed, he automatically falls
NUTRITIONAL METABOLIC asleep due to the exhaustion of what he did during the
day.
 The client eats three times a day and maintains a healthy
diet. His usual foods to eat are rice, fish, and vegetables. SELF PERCEPTION
When eating a fish, he wants it to be “inun-unan” or in a
soup. He stated that he sometimes eats chicken but mostly  As we interviewed the client, he was confident upon
stays away from meat. “Ganahan sad ko mo higop og answering and was open to himself. He said that he is
sabaw nga daghan kamunggay” as verbalized by the confident in who he is. We asked him if he considers
client, he believes that it has a lot of benefits. The client himself handsome and he said yes, but the only thing he is
also loves to eat fruits like banana, lansones, apple, and insecure about is his height.
orange. Moreover, he drinks almost half a gallon of water
in a day especially when he goes pangahoy. “Panagsa ROLE RELATIONSHIP
rako mo inom softdrinks kana ra mokaon kog baboy nya
 The client lives with his wife and their youngest son. He
panagsa raman sad, di sad ko tigkaon chichirya” as
has a very good relationship with his wife, whom he can
verbalized by the client.
talk to if there are any problems. He helps his wife in
housework and takes care of their pwd son. He doesn’t
ELIMINATION
belong to any social groups, and it’s been a long time
 As stated by the client, he defecates once or twice a day. since he talks with his friends.
He said that it is not difficult when defecating, and it was
smooth. The color of his stool is dark brown and the SEXUALITY REPRODUCTIVE
consistency is not that hard or too soft. He estimated that
 The client have four children. The two of them are female
he could urinate up to three to five times a day. His urine
and the other two are male.
is pale yellow in color. He added that he don’t feel any
pain or issues when urinating.
COPING STRESS
ACTIVITY EXERCISE
 Whenever the client has a problem, he has a wife who he
 Every morning, the client goes to his coconut/banana
can lean on and share his problems with. He also said that
plantation. He said that he rides his bike when going there
sometimes he talks to his child living in Cabulijaan. “If
and it serves as his exercise. Also, he said that he can
naay problema kailangan rajud ta magrelax kay para di ta
cook, clean their house, and do the laundry. In his leisure
maghuna huna ug maot, relax lang jud ta” as verbalized
time, he enjoys taking care of his plants and when he is
by the client when we ask him what he usually do when
bored, he listens to the radio. He also told us that he used
he have problems.
to play volleyball.

VALUE-BELIEF
COGNITIVE PERCEPTUAL
 According to the client, he really values their religion.
 The client was not easily distracted when we interviewed
Nowadays, he isn’t always present on Sundays because he
him. He listened to us attentively and correctly answered
watches his PWD son but that doesn’t stop him from
our questions. He told us that he can’t really hear well in
being a good believer in God. He always prays the rosary
his right ear. He also needs reading glasses because if he
 at 3 am in the morning. If he has a problem, he believes
that God will not neglect him and lead him to a good path.

HEAD TO TOE ASSESSMENT

GENERAL SURVEY

 The client have a high blood pressure on the first time we

came which is 180/100 then on the last

SKIN, HAIR, NAILS

 The clients skin waswarm to touch. You can see some

parts of his skin especially his nose, arms and back that
there was hyperpigmentation although it seems a bit
lighter. His hair on his body is thin except on his legs. The
distribution of the clients hair in the head is not that even
since there are some parts that has a little bit of hair. He
have a thin hair with the color of black and white mixed
together. His scalp was really smooth, moist and does not
have any lesions although you can tell that the his scalp
was thin by touching it. As I touch the clients scalp, he
told us that there wasn’t any pain that he felt.

NOSE, MOUTH

HEAD AND NECK

CHEST, LUNGS, AND ABDOMEN

EXTREMETIES (UPPER & LOWER)

BACK AREA

MOBILITY