I.

PATIENTS ASSESSMENT DATA BASE

A. GENERAL DATA
1. Patient’s Name: C.M.
2. Address: Vargas Sta Ignacio Tarlac
3. Age 46y/o
4. Sex: F
5. Birth Date: 09/23/63
6. Rank in the family: 3rd in the family
7. Nationality: Filipino
8. Civil Status:married: Married
9. Date of Admission: 08/25/09
10.Order of Admission: N/A
11. Attending Physician: Dr. Roedel Dizon
B. CHIEF COMPLAINT: Chest pain, difficulty of breathing, nausea and vomiting, BP of 160/ 100

C. HISTORY OF PRESENT ILLNESS: Few hours PTA,the clients feels so dizzy,having chest pain,and n/v.She doesn’t take any drugs for
maintaining.

D. PAST HEALTH HISTORY/ STATUS

• Identify the clues that may aid in diagnosing the present illness
1. Childhood Illnesses: The patient has no history of childhood illnesses although she has experienced colds and cough.
2. Immunization: the patient has completed her immunization. 1 BCG, 3DPT, 3OPV, 3Hepa B, 1 Measles
3. Major Illnesses: The patient was hospitalized because of hypertension type 2,1 year ago
4. Current Medication: no maintainance.
5. Allergies: no allergies noted

E. FAMILY ASSESSMENT

NAME RELATION AGE SEX OCCUPATION EDUC’L ATTAINMENT

 Johny Condez Husband 47 M farmer high School

F. SYSTEMS REVIEW - (Gordon’s 11 Functional Health Patterns Assessment, more patient’s more than 3 y/o)

1. HEALTH PERCEPTION – HEALTH MANAGEMENT PATTERN

Subjective: According to patient, health must be first to recognize. Having HPN type 2,can disturbed her daily living.
2. NUTRITIONAL – METABOLIC PATTERN
• Subjective: dietary and fluid intake
 Appetite: According to the client she has a good appetite.She eat 3 times a day.
 Usual Daily Menu
• Food - meats, vegetables, egg, rice and fruits
• Water - 8 glasses/ day
• Beverages - juices and sometimes soft drinks

3. ELIMINATION PATTERN
• Bowel habits: she’s defecates 1x a day and doesn’t have any alteration upon urination. According to her mother,
bowel is usually yellow cylindrical and soft.
• Color: brown
• Odor: pungent, affected by food type
• Consistency: solid form
• Laxative use if any: none

 Bladder: She has no problem in urination. Patient usually urinate 4-6x a day
• Color: yellowish
• Odor: aromatic
• Alterations if any: none
4. ACTIVITY – EXERCISE PATTERN
• Purpose: to determine the clients activities of daily living, including routines of exercise, leisure and recreation.
This includes activities necessary for personal hygiene, cooking, shopping, eating, maintaining the home and
working.
• Subjective:
 Self – care ability
_II__Feeding _II__Dressing _II__Grooming
_II__Bathing _II__Toileting _II_ Cooking
_II__Bed mobility _II__Home maintenance ___others

Legend
0 – full care
I – requires use of equipment
II – requires assistance or supervision from others
II – requires assistance or supervision from another, and equipment and a device
IV – dependent; doesn’t participate

5. COGNITIVE – PERCEPTUAL PATTERN

• Purpose: to determine the functioning status of the five senses, vision, hearing, touch (including pain perception),
Taste and smell. Devices and methods used to assist the client with deficits in any of these five senses are
assessed.
• Subjective:
 Hearing: no abnormalities noted
 Vision: no abnormalities noted
 Sensory perception: Good response
 Learning styles: Watching and observing others in order to learn and understand
6. SLEEP – REST PATTERN
• Purpose: to determine the clients perception of the quality of his or her sleep, relaxation and energy levels.
Method used to promote relaxation and sleeps are also assessed.
 • Subjective: Usually she sleeps at night by 10 o’clock and she’s awake at 6 o’clock in the morning

7. SELF-PERCEPTION AND SELF-CONCEPT PATTERN

• Subjective: The patient feels not to worry about hr current state,she identifies her self as a healthy
person,she’s not thinking anathing that will result to trigger her HPN.
8. ROLE RELATIONSHIP PATTERN
Subjective: The patient has good relationship with his family and doing all her responsibilities as a
mother of her children and a good wife to her husband.
9. SEXUALITY-REPRODUCTIVE PATTERN
• Subjective: not active in sexual intercourse
 Physical and psychological effect of the clients current health status on sexual expression
 For female clients include:
• Menstrual history
o Age of onset of menarche: 12 y/o
o Number of menstrual days: 5days
o Number of pads every menstruation: 5pads
o Presence of PMS, dysmenorrheal and other menstrual problems: none
• Obstetric history:
o TPAL
o Operations: none

 For both sexes

Contraception: none
Sexual activities: none
Special health reproductive problems: none
History of sex abuse: none
 10.COPING-STRESS TOLERANCE PATTERN
• She believes that laughter is the best medicine.Subjective: The patient coped with her disease by sleeping
most of the time
11.VALUE-BELIEF PATTERN
• Subjective: According to the patient, she only believes that there is only one God but there’s no salvation.
G. HEREDO-FAMILIAL ILLNESS

PATERNAL- Bronchial Asthma

Maternal- none
H. DEVELOPMENTAL HISTORY

I. PHYSICAL ASSESSMENT

A. General Survey: 1. Patient has on stages of recovery.

2. Actual height: 5’2 ft. Weight: 65 kg.
B. Vital Signs – T PR RR BP
36.4 91 24 160/100
C. Regional Exam – utilize IPPA technique
Hair, head and face: round shape, evenly distributed, dry, poor hygiene
Inspection: black, long and thick hair
Palpation: round shape head
Percussion:
Auscultation:
Eyes: pupils are equal and round reactive to light and accommodation
Nose: no discharges noted
Ears: symmetrical ears and no discharges noted
Mouth and Throat: pinkish gums, has yellowish teeth.
Neck and Lymph nodes: Symmetry: Symmetrical Growth: none
Skin: brown complexion
Nails: pale, dirty nails
Thorax and Lungs: with wheezing and dyspnea noted
Cardiovascular: tachycardia (heart rate-123bpm)
Breast and Axilla: not assess
Abdomen: round abdomen
Extremities: not assess
Genitals: not assess
Rectum and Anus: not assess
Neurological/ Cranial nerves
• Note: Breast, genitals, rectum and anus are strictly assessed only with CI. (ASK
PARENTAL/PATIENT CONSENT)
• No IE for pregnant women
II. PERSONAL / SOCIAL HISTORY
Habits/vices: none
Caffeine – cups/day: 2cups
Smoking – sticks/packs/day: never smoke
Alcohol – brand/ bottles/day never drink alcohol
Tea – cups/day: none
Drugs – marijuana etc/ OTC drugs: Salbutamol sulfate
Lifestyle: sedentary lifestyle
social affiliation: Go out with friends.
rank in the family: 2nd child in the family
travel (within 6 mos)
educational attainment: High School

III. ENVIRONMENTAL HISTORY

The patient lives in rural area..

IV. PEDIATRIC HISTORY

Maternal and Birth History
  Date of birth: September 23, 68
 Birth weight: cannot remember
 Type of delivery: NSD
 Condition after birth: no abnormalities
 Hospital:Tarlac Provincial Hospital
b. Mother
 Complications of delivery: none
 Anesthesia: local anesthesia
 Exposure to tetranogens: none
c. Neonates
 Neonatal history: there was no abnormalities
 Feeding history
 Type of feeding: breastfeeding

V. INTRODUCTION:

. Hypertension is a chronic medical condition in which the blood pressure is elevated. It is also referred to as high blood pressure or
shortened to HT, HTN or HPN. The word "hypertension", by itself, normally refers to systemic, arterial hypertension.[1]

Hypertension can be classified as either essential (primary) or secondary. Essential or primary hypertension means that no medical
cause can be found to explain the raised blood pressure. It is common. About 90-95% of hypertension is essential hypertension.[2][3][4][5]
Secondary hypertension indicates that the high blood pressure is a result of (i.e., secondary to) another condition, such as kidney disease or
tumours (adrenal adenoma or pheochromocytoma).

Persistent hypertension is one of the risk factors for strokes, heart attacks, heart failure and arterial aneurysm, and is a leading cause of
chronic renal failure.[6] Even moderate elevation of arterial blood pressure leads to shortened life expectancy. At severely high pressures,
defined as mean arterial pressures 50% or more above average, a person can expect to live no more than a few years unless appropriately
treated.[7] Beginning at a systolic pressure (which is peak pressure in the arteries, which occurs near the end of the cardiac cycle when the
ventricles are contracting) of 115 mmHg and diastolic pressure (which is minimum pressure in the arteries, which occurs near the beginning
of the cardiac cycle when the ventricles are filled with blood) of 75 mmHg (commonly written as 115/75 mmHg), cardiovascular disease
(CVD) risk doubles for each increment of 20/10 mmHg.]

VI. ANATOMY AND PHYSIOLOGY

VII. PATHOPHYSIOLOGY

VIII. DRUG STUDY

1) GENERIC NAME: Captopril

BRAND NAME: Capoten

 CLASSIFICATION: Antihypertensive
DOSAGE: 25mg
INDICATION: HPN 2
Mechanism of Action Side effects Contraindication Adverse reaction Nursing
consideration
By inhibiting Hypotension, Contraindicated in CNS: fainting, -Obtain baseline
angiotensin tachycardia patient’s hypersensitive to dizziness assessment of BP
converting enzyme, drugs or any of it’s CV: tachycardia and status and assess
prevents pulmonary components hypotension frequently
conversion of GI: nausea and throughout therapy.
angiotensin 1 and 2 vomiting - Be alert for
adverse reaction
-Asses patient and
family’s of drug
therapy

2) GENERIC NAME: Hydrocortisone

IX. LIST OF IDENTIFIED PROBLEMS ACCORDING TO PRIORITY
1. Activity intolerance r/t imbalance between O2 supply and demand.

X. NURSING CARE PLAN

XI. ONGOING APPRAISAL

Summary of patient’s health status, day to day appraisal
Panpacific University North Philippines
Urdaneta City, Pangasinan
College Of Nursing

Case Study

Asthma

Submitted by: Ian Villoser

BSN IV-A

Submitted to: Ms. Camagay,RN