BIOPHYSICAL DATA

NAME: “Client X”

ADDRESS: SAV.1 Lower Brgy. Sucat, P'que City

AGE : 60 y/o

GENDER: Female

OCCUPATION: Vendor

MOTHER'S NAME : (DECEASED)

FATHER'S NAME : (DECEASED)

RELIGION: Catholic

ACTUAL FINDINGS NORMAL FINDINGS INTERPRETATION

BP 120-90 mmHg 120-80mmHg NORMAL
RR 17BPM 16-20BPM NORMAL
PR 80BPM 60-100BPM NORMAL
BMI 30 15.5-24.9 NORMAL

HEALTH PERCEPTION /HEALTH PATTERN

“ Malusog ako kung titignan, pero sa tingin ko hindi”.She is a vendor. Every morning they go to market with her daugther. She has
eleven siblings (11).The youngest is 18 y/o and the eldest is 32y/o .In their house she do small household chores like washing the dishes
or sweeping the floor.She has a diabetes at the age of 40 until now , so she lessen eat food rich in carbohydrates . She avoid to eat fatty
foods and less work to avoid the attack of hypertension.

NUTRITIONAL AND METABOLIC PATTERN

“Wala po akong ganang kumain, at madaling mauhaw ; hindi ko nakakain ang mga pagkain na gusto ko”

.In her breakfast she usual eat cereal/oats or bread with (non fat)milk . 1 cup of rice in the afternoon with fish or vegetables . In dinner is
almost the same but sometime when she felt bad(very weak, feeling head/backache) she only eat fruits (apple, banana. Etc..) as a subsitute
. In AM, PM and midnight snack she eat bread or fruits. She always take her maintenance ( enalapril,metformin)for diabetes and
hypertension ( TID).

SKIN: Good skin turgor ; Mucous membrane pink; Pale

Allergies : NONE

3 DAYS FOOD RECALL 1ST DAY 2ND DAY 3RD DAY

BREAKFAST CEREAL/BREAD+ MILK CEREAL/BREAD+ MILK CEREAL/BREAD+ MILK

AM SNACK NONE BREAD BREAD

LUNCH 1 CUP RICE/FISH 1CUP RICE/VEGETABLE 1 CUP RICE/FISH/MEAT

PM SNACK BREAD “BANANA CUE” BREAD

DINNER FRUITS 1 CUP OF RICE /VEGETABLE 1CUP OF RICE/FISH

MIDNIGHT SNACK CEREAL/BREAD+ MILK CEREAL/BREAD+ MILK CEREAL/BREAD+ MILK

ELIMINATION PATTERN

BOWEL:“Maganda at maayos naman”

She has a normal BM(bowel movement) . Her last BM was lately.She have her BM (TID)
COLOR:YELLOW
ODOR:AROMATIC
SHAPE:FORMED

URINARY:“Maganda at maayos naman”

Denies any changes in urinary elimination pattern; no difficulty initiating; Since she has a diabetes, she drink water more than 8 glasses
(15 glasses per day) . She urinates 8 times a day -states “it has normal large amount”

COLOR:AMBER YELLOW
ODOR:AROMATIC
RBC:NONE

ACTIVITY-EXERCISE PATTERN

“Madali akong mapagod at mauhaw”.No daily exercise program only walking and doing household chores.Her usual activities are,doing
household chores(sweeping the floor,washing dishes,cooking and babysits her grandchildren) She always have a bottled water when
leaving at home to increase fluid intake and to suppresed tiredness and thirsty.

SLEEP AND REST PATTERN

“Madali akong makatulog”. Her normal sleep was 6 -8 hours ; Denies use of sleeping medication . Drinking only milk to relax her body
before going to bed. She have her nap for atleast 30 min. “Nakakaidlip ako pag nakaupo ; pag pagod”

COGNITIVE-PERCEPTUAL PATTERN
SENSES : “Medyo hindi na ako makabasa, malabo na yata ang mata ko dahil sa Diabetes” . Denies speech problem ; -States she
probably needs glasses but she cannot used because of her diabetes- States “sumasakit ang ulo ko pag gumagamit ng salamin”

SELF-PERCEPTION
Reports , She doesn't afraid of dying ,”Kaya ko pa, umiinom naman ako ng ganot at inaalagaan ng mga anak ko”. She has a 11 sibling ,
the 7 are married , and the remaining 4 was lived with her.

ROLE RELATIONSHIP PATTERN

Lives only with her 4 siblings and occasionally babysits his grandchildrens.

SEXUALITY-REPRODUCTIVE PATTERN

1 Year of being a widow ; menopaused at the age of 55 ;reports no problem with sexual part of her life; “Hindi ko na kailangang mag-
alala sa ganyang bagay, matanda narin ako at masaya sa buhay ko”

COPING STRESS TOLERANCE PATTERN

“ Madali akong magalit , doon ko lang nalalabas ang saloobin ko, tyaka gumagaan ang pakiramdam ko”
Her way to cope in stress is to watch television anf babysits her grandchildren

VALUE-BELIEF PATTERN
CATHOLIC, attends to church every week; Her relationship in God is good; reading bible night and day .
”My faith in Him is the most important”

ASSIGNMENT
 IN
NCM (100)

SORIANO, ALLAN JR. O SIR. ROSEBERT “RB”VALDEZ AGURILLA

CPN-1PN12

DATA ASSESMENT NURSING DIAGNOSIS GOAL AND INTERVENTION RATIONALE EVALUATION

OBJECTIVES
 INDEPENDENT

OBJECTIVES: IMBALANCE GOAL : - Review usual -May reveal GOAL MET

NUTRITION After 3 hrs. of activities /obssesive nature
“Wala po akong (less than body nursing exercise program of weight Is the client attain
ganang kumain, at requirements ) intervention the noting repetitive his normal
madaling mauhaw ; related to : LOSS client will know activities / in balance
hindi ko nakakain OF WEIGHT appropriate
the sol'n for her nutrition?
ang mga pagkain WITH AN exercise
na gusto ko”
imbalance - to reveal
ADEQUATE nutrition. changes that
FOOD INTAKE ; - Note total should be made in
WEAKNESS OF daily ,maintain
MUSCLES FOR
OBJECTIVES: client's dietary
SUBJECTIVES: diary of calorie in intake.
DAILY REQ'D
ACTIVITIES. As - Review usual take, patterns and
HEIGHT: 4'5 manifested by: activities / times of eating
“Wala po akong exercise program -to monitor
WEIGHT : 80 ganang kumain, at noting repetitive - weigh weekly effectiveness or
pounds madaling mauhaw ; activities / in and document dietary plan.
hindi ko nakakain appropriate results.
SKIN: pale ang mga pagkain
exercise
na gusto ko” DEPENDENT
-LOSS OF
WEIGHT WITH - Note total
AN ADEQUATE daily ,maintain
FOOD INTAKE diary of calorie in
take, patterns and
-WEAKNESS OF
MUSCLES FOR
times of eating INTERDEPENDENT
DAILY REQ'D
ACTIVITIES. - weigh weekly
and document
results.