COLLEGE OF NURSING
HEALTH ASSESSMENT
Putalan, Tammy Rose BSN-1E
Client Information
The patient is a 21-year-old single woman who is a Roman Catholic living in Pajac, Lapu-Lapu City, Pacific Villa
1, subdivision, block 8, lot 2 and 4 dama de Noche street, and was admitted once to Mactan Doctor’s Hospital
in the year 2018. Her admission was due to asthma, and she was attended by Dr. M. D.
History Present Illness
The patient reported that she is frequently having a hard time breathing these past few days. This has been
ongoing for a week. The symptoms that she has observed are heavy breathing and random cough, which are
triggered when she inhales the smoke, particularly secondhand smoke. She uses an inhaler to relieve the
symptoms. She did not try to do any self-medication. Instead, she went to Mactan Doctor's Hospital and did a
consultation last year with Dr. M. G, and was diagnosed as asthmatic as well as advised to use an inhaler. It
was her parents who urged her to seek medical help in the hospital.
Past Health History
The patient is not diabetic or hypertensive, and she doesn't smoke. Occasionally, she drinks alcohol since the
age of 18. She has no allergies when it comes to food and drugs. Her heredo-familial diseases (HFDs) include
asthma on both maternal and paternal sides.
Previous Hospitalization
The patient was hospitalized once in the year 2018 at Mactan Doctor's Hospital due to high fever and asthma.
She stayed for 2 days in the said hospital and was attended by Dr. M. G. She was discharged in improved
condition and was given an inhaler and medications, which she cannot recall the specific name.
Environmental History
The patient is currently living in Pajac, Lapu-Lapu City, Pacific Villa 1, subdivision, block 8, lot 2 and 4 dama de
Noche Street for almost 5 years. She lives in a one-story house which contains 5 bedrooms and 10 windows.
She lives with her 6 family members along with 1 Siamese cat and 1 Pomeranian dog. Their water is Supplied
by MCWD while electricity is supplied by MECO. Trash collection in their place happens every Wednesday. The
nearest hospital is the Mactan Doctor's Hospital, which is less than 6 km from their house. Drinking water is
bought from a local water-refilling station. Their food is usually obtained from the Gaisano Grand Mall
Mactan, which is a 15-minute car ride from their place. The subdivision where the patient lives currently have
3 security guards roaming 24/7, which makes her feel safe. That being said, the patient is quite uncomfortable
with her neighbors as they tend to be noisy at night.
GORDON’S FUNCTIONAL HEALTH PATTERN:
Health Perception Health Management
The patient stated that one must prioritize health above all. On a scale wherein 10 is the highest and 1 is the
lowest, she rates her health as 6/10 due to her asthma. She only sees a doctor if the symptoms persist for 3
consecutive days and if her family tells her to do so. She is fully aware of her asthmatic condition and is always
bringing an inhaler with her in case it is triggered. She is fully vaccinated with the AstraZeneca vaccine and is
also constantly taking vitamin C. Patient is not familiar with BSE. The client uses OTC drugs such as
Paracetamol (Biogesic) for fever and Phenylpropanolamine (Neozep) for colds. She is also very fond of drinking
warm green tea to relieve her colds and fever symptoms.
Nutritional Metabolic Pattern
The patient is 5'2 in height and weighs 42kg. She eats 3 times a day with her family, and her usual meals are
oats and fruit for breakfast, meat, and rice for lunch, and soup and rice for dinner. The patient is very fond of
eating fruits, particularly avocado and banana. She consults a dentist once a year, and so far, no dental
problem is noted. The patient takes vitamin C twice and drinks an average of 5 glasses of water a day. She
hasn't observed recent weight loss.
Elimination Pattern:
The patient has a problem with defecating. She only defecates thrice or 4 times a week, usually in the
morning. Her stool is usually brown or yellow in color, firm in texture, and easy to pass. To help her eliminate
stool, she drinks a probiotic beverage (Yakult). She has no problem with her urination. She voids usually after
an hour when drinking lots of water at once. On average, she voids 4 times a day.
Activity Exercise Pattern:
The patient is currently a BSN student at UCLM. She usually reports to school at 7:00 am during a face-to-face
setting, which usually occurs on Fridays. On other weekdays, she attends online classes from 7:30 a.m. in the
morning until 1:30 p.m. . Upon waking up, the patient immediately takes a bath. Before going to bed, the
patient does her night routine, which consists of brushing her teeth, taking a half bath, and doing her
nighttime skin care. After meals, she usually sits down and watches T.V. if there are no online classes after
meals. She usually exercises at least 2 times a week, usually during weekends. She doesn't have constant
recreational activity, but on her leisure days, she often spends it with her cat.
Sleep and Rest Pattern
The patient usually sleeps from 11-12 pm and wakes up at a fixed time, which is 7:20 in the morning. She
doesn't use any sleeping aids or drugs as she doesn't have any trouble sleeping comfortably. She uses two
pillows one on her head and one around her arms. The number of hours of sleep she gets is often 7 hours.
Aside from that, she takes naps in the afternoon around 3:00 pm.
Cognitive Perceptual Pattern:
The patient is oriented with regard to time, places, and people. She has still a good sensory status and can
successfully recall past events, as well as important basic information like her full name and birthdate.
Self-Perception and Self Concept Pattern
There are times when the patient negatively sees herself, especially if she is dealing with a problem. She finds
herself as someone who is still improving and is learning, but whenever she is unsatisfied with something, she
feels lacking. Despite working to be a better person, she has achievements, such as being a consistent honor
student in junior high school and a varsity volleyball player. She finds her current life as the life of a normal
young adult who is building her future through working on completing college. She stated that she is currently
satisfied with the flow of things right now, despite being stressed from time to time due to her being grade-
conscious and her attitude of constantly overthinking about her future. Nevertheless, she tries to maintain a
positive mindset.
Role Relationship Pattern
The patient is the second child and the first daughter of her mother. She has 3 siblings, one is her eldest
brother, and the two are her younger sisters. She has a good relationship with her family, particularly with her
eldest brother which she can relate to as he is a nurse. She also has friends, but she prefers to discuss her
problem with her family. Her family is aware of her asthmatic condition and is also helping in monitoring her
condition.
Sexually Reproductive Pattern:
Her puberty started when she was 13 years old, which is the age when she noticed her pubic hair is growing
and her breast, hips, and but are developing more. Her menarche also happened at the said age, as well. She
never had any sexual contact so far, and currently doesn't have a partner.
Coping Stress Tolerance Pattern
The patient takes stress in a positive way. She sees it as something that fuels her to be productive. She is
currently not stressed right now, but whenever she is stressed, her coping mechanism is eating spicy food and
getting a lot of sleep. Her short-term stressor is her younger siblings, as they tend to be needy. Her long-term
stressor is her schoolwork. She believes that she is stressed whenever she distanced herself from other people
and constantly overthinks something.
Value Belief Pattern
The patient is Roman Catholic, and her religion influences her values. She strives to do good and follow the 10
commandments, which are stated in the bible. Due to the pandemic, she and her family have not attended
mass for a while. Despite that, they still practice their praying the rosary every night. She sees herself as
FAIRLYreligious, and she usually prays when she is about to eat, facing a problem, and is about to sleep.
