PATIENT’S PROFILE

NURSING HEALTH HISTORY

Patient name: Mrs. K

Sex: Female

Birthdate: April 10, 1951

Age: 67 years old

Birthplace: Biliran, Biliran

Permanent Address: Brgy. Julita, Biliran, Biliran

Nationality: Filipino

Religion: Roman Catholic

Occupation: Housewife

Health Care Financing: Phil Health

Source of Medical Care: Naval Hospital, Eastern Visayas Regional Medical Centter

HISTORY OF PRESENT ILLNESS:

The patient is known to have a case of Congestive Heart Failure III. Four weeks before
admission to Eastern Visayas Regional Medical Center, she was admitted to a hospital in Naval,
Biliran for three days as she experienced dyspnea and easy fatiguability. She was then
discharged and advised to seek consultance at EVRMC. She was given medications such as
Cefuroxime, Doxofylline, Spironolactone, Clopidogrel, Atorvastatin and Farvosin.

As verbalized “ Madali ak kapuyun bisan guti la tak ginhihimo ha balay, danay ngan bisan
naukoy la ako- nakukurian ak paghinga.”.

Because of their home being far away from the hospital, it took two weeks before she
able to go to EVRMC. After that she then went to EVRMC for consultation and was diagnosed
with Hospital Acquired Pneumonia , Ischemic Heart Disease and Congestive Heart Failure III.
The patient admits that she does not seek medical attention unless she feels that home
remedies and rest could not alleviate her symptoms, resulting her to have not known the
severity of her illness. She opted for admission as she still experienced dyspnea and easy
fatiguability upon consultation. After two days of admission in the hospital, she was then
discharged. When she was heading back to her house, they met an accident resulting Mrs. K to
go back to the hospital with the same symptoms and a few bruises hence- admission.

PAST MEDICAL HISTORY:

Childhood: Common cough, Colds, Fever

Previous hospitalization: Naval Hospital

FAMILY HISTORY:

Paternal: Hypertension

Maternal: Diabetes Mellitus type-II, Hypertension

LIFESTYLE

DIET:

Before being diagnosed with condition, patient had a regular diet, taking meals sometimes
thrice when budget permits or twice a day. She eats a small amount for each meal. Her diet is
composed of vegetables such as: ganas, kangkong, and kamote occasionally. For breakfast, she
eats bread- sometimes partnered to milk. She started not to eat fish by the age of sixty and still
goes on without eating them until now. She prefers to eat Tocino rather than fish as she is fond
of them. Nararasahan ko an langsa han isda amo diri na gud ako nakaon hin isda.

Now:

As she is confined, she gets to eat three times a day but is not able to finish one meal given by
the hospital. “Yana guti la gihap tak kakaon pero nakakaon ako tulo ka beses kada adlaw.” She
gets to eat different varieties of food but still does not eat her fish if present in her meal. She
also eats small portions of meat and is able to finish half of her rice.
ELIMINATION

BEFORE: She has no difficulties in urination and excretion of wastes. She defecates at least one
a day or six to seven times in a week and urinates three or four times a day. She admits that she
barely drinks water and estimates her urine to about 300-500mL.

NOW:

She now is urinating 6-7 times a day with no discomfort. The patient experiences frequent
urination as she is prescribed diuretic medications. Her urine output is estimated to be 600-
800mL in twelve hours.

SLEEP AND REST

Before: Timprano ako nakaturog, mga alas nuybe- amo tak oras pagkaturog. Timprano liwat ak
nagmamata, alas kwatro di ngan alas singko- nagmamata na ako.

Now: “Nakaturog ako mga alas nuybe, pero namamata ako kay may beses na ginkukurian ak
paghinga. Diri ako nakakakaturog hin maupay pa.” She sleeps in the afternoon after her meal
but is awoken by the same symptoms oftentimes.

ACTIVITY OF DAILY LIVING

Before: Patient considered walking as her form of exercise. She walks minimally as she gets
tired easily. She does a few household chores at home together with her husband as she just
stays at home.

Now: “Yana, ginaalalayan ak nak asawa pag magamit ak CR, para makaput hiya nak gamit” as
verbalized. She cannot walk by herself in which she is assisted by her husband in all things from
positioning herself, eating and accompanying her to the comfort room.

SOCIAL DATA

Patient is living with her husband. Her two daughters are in Manila as they are the ones who
goes there to visit them.

EDUCATIONAL HISTORY

The patient is an elementary graduate.

ECONOMIC STATUS

Patient is unemployed, her husband supports them with his vegetables being sold. She also
receives financial support of two thousand to three thousand monthly from her daughters and
from Senior Citizen Funds.

NEIGHBORHOOD

Patient is living in Brgy. Julita, Biliran, Biliran

COPING AND STRESS TOLERANCE

“Nakigsturya la ako tak asawa, kami man la it aada. Kun mayda man iba nasangkay na napakada
balay- nakigsturya la liwat ako. Waray man ak bisyo, inom ngan sigarilyo diri man ak hiton. as
verbalized.

VALUES AND BELIEF

Patient is a roman catholic and practices her faith by praying. She sometimes go to Church
when she feels well.

PATTERNS OF HEALTH CARE: Health Insurance provided by Phil Health