Biographic Data

Name: Lola JDC

Age: 59 years old

Address: K-5th St. Kamuning, Quezon City

Gender: Female

Date of Birth: March 24, 1951

Place of Birth: Sta. Mesa, Manila

Ethnic Group: None

Primary Language Spoken: Tagalog

Marital Status: Widowed

Educational Attainment: High School Graduate

Occcupation: None (Housewife)

Religious orientation: Roman Catholic

Healthcare Financing Aid: none

Date Admitted: July 4, 2010

Chief Complaint: Black Tarry Stool

Diagnosis: Hemorrhagic Gastritis, Bleeding Peptic Ulcer, Anemia

Past Health History

According to the client, she had measles and chicken pox when she was a child but she could not
recall when. She said that she just remembered being brought to San Lazaro General Hospital. She
cannot remember the drugs she took but she recalled that she was ordered to have a CBC during her
hospitalization in San Lazaro. According to the client, this is the only instance of her being
hospitalized prior to being admitted in FEU hospital.

When asked about her vaccines, the client said that her mother told her she was only vaccinated with
BCG when she was a child. She said, “Hindi pa naman daw kasi uso yung mga bakuna na ganyan
noon.”

The client said “mabilis akong sipunin lalo na pag nauulanan kaya ang ginagawa ko para mawala yun
eh yung Vicks, inaamoy ko, gumiginhawa naman pakiramdam ko noon”.

Last 1st week of June(she cannot remember the exact date), the client had flu for 2 days and she took
Biogesic as a medicine.

The client has no recent travel outside the city or outside the country.

Present Health History

 The patient has obvious scoliosis checked upon conduction of physical examination. She claims
to experience back ache, mostly on the lower portion of the spine. “Nananakit nga itong likod ko lalo
na pag naglilinis ako ng bahay, pag nagwawalis ng matagal syempre nakabend ka di ba, pero hindi
ko naman ito masyadong iniinda kasi kayang kaya pa naman tiisin” the client explained. There was no
test or examination done yet to check her unaligned spine and no treatment or preventions done.

One week prior to admission, the client experienced epigastric pain for a week( june 27-july4),
gnawing in character associated with nausea. She took Zantac 150mg/tab which afforded temporarily
relief. It was self-prescribed and she knew the drug from asking the saleslady from the drugstore.
Three days prior to admission, the patient admitted to have a black tarry stool. She was
admitted July 4. The patient was prescribed to take the following medicines upon being confined at
FEU hospital, Omeprazole, Ciprofloxasin, Mucosta (Rebamipide), Mg. Nitrate, and Dulcolax. (Drugs
further explained in drug study)

Family Health History

The client has a history of scoliosis, arthritis and rheumatic heart disease. Her mother died
because of pneumonia and her father died because of arthritis according to her. Her second daughter
died because of rheumatic disease when she was 27 years old. She can remember that her Lola had
a Scoliosis. No other disease was mentioned by the client.

A. Health Perception and Health Management

When the client was asked to rate her general health, rating it from 1-10(10 as the highest
and 1 as the lowest) she would claim that her general health would be 8. The client generally
describes herself as healthy. When we asked her to define healthy, she said “Healthy pag wala kang
nararamdaman, maayos ka at maganda ang pakiramdam mo at sa ngayon naman okay naman na
ang pakiramdam ko.” she does not have a routine exercise, “yung paglalakad ko araw-araw pagpunta
at paguwi mula sa eskwelahan ng mga apo ko, yun na siguro ang ehersisyo ko.” She explained. The
client performs breast-self examination everyday “kinakapa kapa ko din kung may bukol o masakit. “
No one teaches her about it. The patient claims she does not believe in primitive practices and
superstitions. The client has no regular medical check-up or even dental check-up.”pag may
nararamdaman na akong hindi na talaga maganda at hindi na kayang tiisin saka ako
nagpapakunsulta sa doctor” she claims.

The client’s past illnesses were fever, colds, and cough. Client uses Vicks whenever she has
colds or cough and Paracetamol whenever she has a fever.

The client takes a bath twice a day. She brushes her teeth regularly every after meal. She washes her
hand before eating. Her finger nails were clean and properly trimmed.

The client proudly says that she does not smoke, drink liquor or even tried prohibited drugs.
The client believes that the environment affects one person’s health. The patient lives in Quezon City.
Their place has good ventilation. They do not have any pet at home. Disposing of garbage is by the
use of trashcan with garbage bag. The garbage truck is roaming around every morning every day.
There is also continuous supply of water. Their house was kept clean by her daughters and sons.
“Bihira ang daga at ipis samin, lagi naman kasing malinis ang bahay at kung meron man para sa daga
naglalagay kami ng pandikit sa ipis naman baygon” .They were buying distilled drinking water and left-
over foods were kept In the refrigerator.

B. Nutritional and Metabolic Pattern

The patient consumes any kind of food three times a day. “Hindi naman ako mapili sa
pagkain.” The client also loves to drink coffee, softdrinks and eat sour foods like green mangoes. The
client drinks 3-4 glasses of water a day. But according to her she also consumes 3-4 cups of coffee a
day. One cup n the morning, one cup after lunch, one cup as a merienda and one cup at night.

According to the client, she oftentimes skips her meals because of the household chores. She
said, “Sinasabihan na nga nila ako sa bahay nagpapalipas daw ako ng pagkain, gusto ko kasi
matapos yung gawain ko agad.”

She prefers eating at home rather than eating anywhere outside to attain comfort. “Mas
masarap kumain kapag nasa sariling bahay kasama mo yung mga mahal mo sa buhay, mga
kapamilya mo.” she verbalized. She also said that she would choose an eating place that has no foul
smell and right lighting and ventilation. She usually eats with her family. “Ang sarap kasi sa
pakiramdam kapag sabay-sabay kayo kumakain ng pamilya mo, ako na din kasi nagluluto pero
minsan yung mga anak ko din.” she stated. The client usually cooks fried, sinigang, nilaga,
eskabetche, paksiw and ginisa. The patient spends most of their money in food. “Ang mahal ba
naman ng mga bilihin ngayon.” she said. The client stated that eating right kind food, at the right time,
and right amount is the meaning of good nutrition for her.

The patient asserted that she never loses his appetite even when she is stressed and angry.
“mahina lang talaga ako kumain, isang platito lang yata nakakain ko pag nasa bahay “ The client have
problem with dentitions but it does not affect her eating habits.

This 3 Day Diet recall shows her meal pattern when she was in the hospital. The
Doctor advised her for a soft diet.

3 Day Diet Recall

Day 1 Day 2 Day 3

BREAKFAST BREAKFAST BREAKFAST

240 ml of water 240 ml of water 240 ml of water

2pcs of medium sized pandesal 2pcs of medium sized pandesal 2pcs of medium sized pandesal

4 match box sized of Meatloaf

Half cup of sautéed Upo

LUNCH LUNCH LUNCH

480 ml of water 480 ml of water 480 ml of water

1 cup rice 1 cup rice 1 cup of Lugaw

1 medium sized paksiw na tilapia 1 medium sized Steamed 1 medium sized Inihaw na tilapia
w/ 1 cup soup (paksiw) galunggong fish

DINNER DINNER DINNER

240 ml of water 240 ml of water 480 ml of water

1 cup of rice 1 cup of rice 1 cup of Lugaw

 1 cup of sautéed Upo with soup 1 medium sized sinigang na 1 medium sized fried tilapia
tilapia w/ 1 cup soup
Half cup of sautéed Upo
1 cup Abitswelas

Patient claimed that she does not have any eating disorders and does not have any skin
problems due to food allergy.

C. Elimination Pattern

Before the client experienced black tarry stool, her usual stool was brown or greenish in
color,semi-solid and pungent in odor.

The patient claims that before she was admitted to the hospital she defecates two times a
day. She describes her stool as black in color. “Pagkatapos kong dumumi nanghihina ako, nahihilo at
pinagpapawisan. Mabilis din tibok ng puso ko at parang nanlalabo ang paningin.” The patient
experienced this for three days. “Nag-alala na ang anak ko kaya dinala na niya ako sa ospital.” The
patient stated.

According to the patient, she has a frequent urination. “Wala naman problema sa pag-ihi ko.
Maayos naman”, the client verbalized. She urinates at least six times a day and the color is usually
yellowish. The client said that her urine does not have odour. The client goes immediately to the toilet
to urinate.

The patient perspires depending on the weather. And she claimed that she does not have any
odor problem because she uses anti-perspirant or deodorant to prevent body-odor.

D. Activity-Exercise Pattern

The patient said that her usual activity is cleaning their house. She always clean their house
and like to maintain orderliness and cleanliness by putting things at their proper places. She also
takes care of her grandchildren. “Nasa trabaho kasi ang mga anak ko kaya ako na ang nag-aalaga”
the client stated. She takes care of them by helping them prepare for school. She wakes up five-thirty
in the morning and does her routines. “Maaga akong gumigising para makapaghanda sa mga apo ko
sa pagpasok nila”, the client added. She is also the one who takes them to school. “Para sa ‘kin
exercise ko na yung paglalakad ko sa kanila mula sa bahay hanggang sa school” she verbalized.
According to the client, she walks her grandchildren to school and back home for approximately 15
minutes. She said that sometimes she skips her meals because she wants her works to be done.
“Sinasabihan na nga nila ako sa bahay nagpapalipas daw ako ng pagkain, gusto ko kasi matapos
yung gawain ko agad”. She said that she doesn’t get tired easily and restores her energy by watching
TV. The list of his activities in one day is clearly tabulated below.

Time Activity

5:30 am - 6:00 am Wakes up and prepares for her Grandchildren to

go to school

6:00 am – 6:30 am Takes her Grandchildren to school then back

6:30 am – 7:00 am Takes a bath

 7:00 am – 9:00 am Cleans the house

9:00 am – 9:30 am Eats breakfast

Brush teeth

9:30 am – 10:30 am Watches TV

10:30 am – 12:30 pm cooks for lunch and cleans the house

12:30pm – 1:00 pm picks up her grandchildren from school

1:00 pm – 2:00 pm eats lunch

brush teeth

2:00 pm – 6:00 pm washes the Dishes and spends time with her
grandchildren

6:00 pm – 6:30 pm prepares dinner

6:30 pm – 7:30 pm eats dinner

7:30 pm – 8:30 pm washes the dishes and watches TV

8:30 pm – 9:00pm prepares to sleep

brush teeth take a bath
9:00pm – 5:30 am sleep

E. Sleep and Rest Pattern

The client duration of sleep is 8 hours. She usually sleeps at night at 9pm and awakens at
5:30 am. The client wakes up early to help prepare her grandchildren to go to school. The client feels
satisfied with her sleep when she wakes up.

The client has a routine before she sleeps. She said, “nanonood ako ng TV para antukin ako.”
The client also said that she has no problem in sleeping even when she was not able to watch
television shows and also does not use any medication to fall asleep. When she feels sleepy, she
brushes her teeth, takes a bath and then she prays. Watching TV is also her form of rest after
cleaning their house.

The patient doesn’t have any problem regarding her environment. According to her, their
environment is quiet and peaceful. “Wala kaming problema sa mga kapitbahay namin kapag gabi na,
lahat kami natutulog na wala naman maingay kaya masarap ang tulog ko”. The patient verbalized.

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Time of 9:00pm 9:00pm 9:15pm 9:10pm 8:30pm 9:30pm 9:00pm

sleep

Wake up 5:30am 5:30am 5:30am 5:30am 5:35am 7:00am 7:00am

 Time

Naps none none none none none none none

Total 8 hours 8 hours 8 hours and 8 hours 9 hours 10 hours 10 hours

number of and 30 and 30 15 mins. and 20 and 5
sleep mins. mins. mins. mins. 30 mins.

Feeling refreshed refreshed refreshed refreshed refreshed refreshed refreshed

after sleep

F. Cognitive-Perceptual Pattern

The client is a highschool graduate. She doesn’t have any difficulties in speaking, writing and
hearing but she claims that she has a difficulty in reading nowadays. ”Lumalabo na nga yung mata ko
eh, di ko na mabasa yung mga nakasulat sa dyaryo” she added. She did not go to an optometrist or
ophthalmologist yet to have a check on her eyes. She pronounces the words correctly. When it
comes to hearing, even though he is already 59 years old she doesn’t have any problem regarding
hearing. The patient’s memory is still good. “minsan lang may mga nakakalimutan din pero mga
simpleng bagay lang tulad ng eksakton petsa, mga ganun”. According to her she’s not yet
experiencing second childhood which she is proud of. “Pakiramdam ko batang-bata pa rin ako, wala
akong problema sa memorya at hindi pa ako ulyanin” patient said. The patient answers are all
appropriate for my questions and she is very attentive.

The patient doesn’t have problem in smelling and tasting but she admitted that sometimes it is
being affected by the weather or her sickness.

When asked about pain, she said that the most painful experience she had was because of
her epigastric pain, which occurred for a week, she rated it as 7 whenever on its peak (1 being the
most tolerated and 10 being the most painful), she took Zantac 150mg/tab whenever pain is felt and
the drug afforded temporarily relief.

G. Self Concept- Self Pattern

The client feels good about herself. She rated her self 9 out of 10. “Diyos ang gumawa sa
akin kaya nararapat lang na mahalin ko ang sarili ko, hindi nga lang 10 kasi di naman ako perpekto
may mga kamalian din ako sa buhay” she verbalized. She is very proud and confident about herself.
”may edad na ko pero kaya ko pa ding gawin lahat ng bagay at naniniwala akong nagagawa ko ang
obligasyon ko sa aking mga anak,” she added. She sees herself as a unique individual who loves
people who loves her. “Mabait ako kung mabait ka sa akin, wala akong kaaway kaya masaya ako”.
According to her, “pakikisama or camaraderie” is the key to a good relationship with others. She never
question God about her physical appearance or anything bad about her. “Kuntento ako sa binigay ng
Panginoon sa akin, bakit ako magrereklamo kung ito ang gusto niya at maraming nagmamahal sa
akin bilang ako kaya bakit ako magbabago” patient said. She never consider other people as a rival,
she considers everybody as a friend and companion in life.

“Sa edad kong ito kuntento na ako sa buhay na may mga anak at mga makukulit na apo na
laging nandyan sa tabi ko,” patient verbalized. Client has no more plans in life, she only hopes that
her daughters and sons and grandchildren will have a good future. “Ang gusto ko na lang sa buhay
maging masaya kaming lahat at walang maging problema sa pera syempre.” patient said.

H. Role-Relationship Pattern

The client lives with her 80 year old mother and her 2 children and their families. “Halos hindi
nagkakaroon ng problema sa bahay. Kung meron man yung tungkol sa mga apo ko lang pag binilhan
ang isa dapat bilhan din ang isa para walang selosan,” the client stated. The client said that she
enjoys their bonding moment by watching TV and pakikipagkulitan with her grandchildren. The client
has a good relationship with all his children because they never let the problem of the family worsen
and be heard outside the four corners of their house

She also has good relationship with her friends. “Yung mga kaibigan ko yung mga kapitbahay
namin. Minsan lang naman ako lumabas ng bahay kapag wala akong magawa, ayun, dun kami
nagkakausap-usap.” the client stated. The client said that she does not encounter problems with her
friends. She has no enemies and never fights with others.

I. Sexuality-Reproductive Pattern

The client had her menarche when she was 12 years old and she had regular menstrual flow of
3-5 days and using 3-4 napkins per day. She never doubted her gender. The client usually wears
daster “simple lang ako, daster na hindi masyadong maikli nag karaniwan kong sinusuot, at pag may
okasyon naman, binibilhan ako ng mga anak ko ng bestida.”

When the client was asked when did she had her first sexual intercourse she smiled at first and
she answers 19 years old, it was after her marriage, they did not use any contraceptives. They did not
also have a family planning. She was sexually active until her husband died 20 years ago. She admits
that she already had her menopose. “mga 48 yata ako nagmenopose, ang pakiramdam parang
medyo mainit yung katawan tapos ayun, din a nga ako dinatnan pa. Tanggap ko naman ang ganoong
mga pangyayari kasi syempre tumatanda na talaga, wala naman nagbago bukod na lang sa hindi na
ko bumibili pa ng napkin” she added.

By this time the client is smiling to every question being asks, according to her she is not used
to answer questions regarding her sexuality, but she still able to answer the questions. “Wala naman
akong dapat itago”, she added.

J. Coping Stress Tolerance Pattern

The client claims that she does not easily get stress. “Bihira magkaroon ng problema sa amin.
kung meron naman napakaliit na bagay lang tulad ng simpleng tampuhan sa mga apo ko kais gusto
nga nila kung anong meron ang isa, meron din ang isa”, the client verbalized.

When asked about her husband, “syempre may mga oras pa rin na naaalala ko yung asawa
ko kasi 20 years ko ding kapiling yun, mabait yun at ni hindi ako pinaggagawa sa bahay noon, siya
ang naglalaba at nagluluto noon, ang gusto niya lang daw ay mag-alaga ako ng mga anak namin,
mahal na mahal ako nun at mahal na mahal ko din siya pero kung yun talaga ang plano ng Diyos diba
at saka 20 taon na din ang nakakalipas, tanggap ko na un, tinulungan din naman ako ng mga kapatid
ko sa pagpapalaki sa mga anak naming. Yung sa anak ko naman na namatay din, syempre nalungkot
ako ng sobra nung mga panahong yun pero ano bang magagawa ko, pinahiram lang siya sa akin ng
Diyos at naniniwala naman akong nagampanan ko ang pagiging ina ko sa kanya, maligaya na din sila
sa piling ng Diyos ngayon”. The patient said.

She said that sometimes if there were bigger problems she needs to face, it was resolve by
the family alone and she does not tell her friends about it. “Problema ng pamilya, dapat sa pamilya
lang din maresolba” she stated. “sa ngayon ang problema namin ay itong bayad sa hospital pero di rin
naman ako pababayaan ng mga anak at kapatid ko,tulongtulong sila sa pagbabayad dito.” The client
admits that she is not stressed or feeling any discomfort even though she has been staying for a
month now in the hospital.

For the client, a criticism does not affect her at any point. “Binabalewala ko nalang yon para
hindi ako apektuhan.” she added.

K. Values and Belief Pattern

The client is a Roman Catholic. The patient verbalized “tuwing Linggo nagsisimba ako, lagi rin
akong nagdadasal pagkagising ko at bago matulog”. According to the patient she practices the things
that a Catholic usually does. She values her life and the people around her. The religious practice
which is important to her is praying because praying keeps her spiritually, emotionally and
psychologically balanced. “Nagdadasal din ako tuwing may problema para magpasalamat at
humihingi na rin ng tulong sa tuwing nasa kagipitan ako.” The patient likes her religion because she is
used to it and it is already the religion she grew up with. The client also said that she does not believe
in any superstitious beliefs. She verbalized, “di ako naniniwala sa mga pamahiin na yan, ang
importante magdasal ka dahil yun ang mas makapangyarihan.”