Biographic Data

The name of the client is Adelina Aquinog (Bed #34, FSW), house
wife, was born in March 3, 1948, 62 years of age, lives in Ligas, Bacoor
Cavite with a chief complaint of fall. According to her daughter, her
mother fell into the floor from the 4th step of the stairs. It was her niece
who called and told her that the client fell down. She also said that she
went to 4 hospitals. The daughter verbalized, “Kagabi nga nilalagnat yan e
nung sinugod ko dito. Siguro dahil din na rin kinaya ng katawan ni nanay.”
The client’s daughter didn’t tell me the reason why she brought her
mother in to 4 hospitals. When assessed, the client’s vital signs were
T= 38.2 °C, PR= 86 bpm, RR= 36 bpm, BP= 170/70. The client’s
temperature and blood pressure elevated and was repeated after a
few hours. The client’s temperature and blood pressure during second
assessment were T= 38.0 °C and BP= 170/80. Still elevated and on
going care of the nurse is being rendered.

Past Health History

When asked about the past health history of the client, the
daughter said, “Nagkaroon na ng mga sakit si nanay noon. Ung tigdas
nga, nagkaroon na siya nung buhay na ako.” The daughter implied that
her mother/the client got the disease at her middle aged years. When
asked about if the client was fully immunized, she doesn’t know about
her mother’s immunization status. When also asked about the client’s
reproductive health, the daughter answered, “Menopause na si nanay.
Nung 45 years old pa lang siya.”

Present Health History

At present, the client is strong according to the daughter. Before

the accident, her mother was still functioning well in their home. The
daughter verbalized, “Malakas pa yan si nanay. Malikot nga minsan eh,
kaya ayan, nalaglag sa hagdanan. Masipag yan si nanay. Hindi mo
mapapatulog yan, kapag walang ginagawa, ayun. Doon lang tulog ng
tulog.” When asked about the client’s present health situation, the
daughter answered, “Minsan nag-aalala na ko dito kay nanay kasi
minsan high blood yan e. May iniinom siyang gamot pang-maintenance
lang. Nalimutan ko na kung anong pangalan nung gamot.” “Matakaw
din yang si nanay. Malakas sa ulam yan, pero mahina sa kanin.
Gustong gusto niyan ung saging, tsaka manok.”, the daughter added.
When asked about the medication that the client is taking, if there are
any, the daughter said “Ayun nga ung pang-maintenance lang nung
high blood. Hindi siya nag-vvitamins din pala.” With regards to the
client’s injury, when asked about the pain of the client, the daughter
said “Minsan nagsasabi sya na may masakit sa kaniya, pero okay okay
naman daw siya. Malakas pa nga eh.” After a few a hours, the
daughter told me, “Kanina pala, natanggal yung tapal sa sugat niya sa
ulo. Yung pinalitan kanina nung teacher niyo. Nag-alala lang ako kasi
bakit natanggal bigla.”

GENOGRAM

- Mother
- Deceased

- Father

- Client

- Hypertension

- Diabetes Mellitus

Jose Aurora
Aquinog Rivera-
Aquino
g

Adelin
a
Aquino
g, 62
y/o

In this genogram, the client’s parents have both hypertension

that’s why she also has it. Both parents died several years ago. The
father died because of Heart attack, while the mother died because of
ulcer, according to the daughter of the client. When asked about the
age of both parents, she said that she can’t remember the age of both
parents of the client when they died.