University of the Philippines Manila

The Health Sciences Center

COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
CHED Center of Excellence
Julita V. Sotejo Hall, Pedro Gil St., Ermita, Manila

Nursing 105: Nursing Interventions I

Assessment Database

Client’s Profile

The client is Mrs. Nena Girado. She is 68 years of age, born on June 12, 1950. She lives
in Building 4, 106 Safari St., San Andres Bukid, Manila with her son and 2 of her grandchildren. She has
an eatery in front of her house that sells food from morning until the afternoon.

Client has chronic hypertension detected last 2008 when she experienced severe nausea. She was
brought to the Ospital ng Maynila and upon initial assessment, she found out her blood pressure then was
250/150. She was admitted for one day and was diagnosed to have hypertension right after. She started
taking maintenance medicine immediately after discharge. She takes Losartan and Amlodipine once a day
every day after lunch.

The client has deficient knowledge on managing hypertension especially on giving proper
nutrition to the hypertensive client which could lead to inability to provide nursing care to the sick
member of the family due to inadequate knowledge of the nature and extent of nursing care needed. Mr.
George Girado, her son, is at risk of developing hypertension because of familial history of hypertension
and dietary factors.

I. Family Structure, Characteristics and Dynamics

Head of the Family: Nena Girado

Address: Building 4, 106 Safari St., San Andres Bukid, Manila
Member of Households:

Family
Relation Highest Occupation Remarks:
Member Marital
to the Sex Birthday Educational Date
Status
Head Completed Entered
Name Type of Work Place

College
Nena Girado Head F O6/12/1950 Widowed Pivate Secretary Sta. Ana, Manila 10/02/2017
Undergraduate

College San Andres

George Girado Son M 10/04/1977 Married Mechanic -
Undegraduate Bukid, Manila

Figure 1. Surral Family

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 Mrs. Nena Girado acts as the head of the household. She lives with her son, George
Girado, 40 years old, and his two children aged 22 years old and 16 years old. The family is a
matriarchal family as Mrs. Nena makes the decisions for majority of the things inside the house.
They are an extended family. Mrs. Nena reported that her relationship with her son and
grandchildren are harmonious and peaceful. They live in Building 4, 106 Safari St., San Andres
Bukid, Manila. The house and lot is owned by their family.

II. Socioeconomic and Cultural Characteristics

Mrs. Girado is a retired private secretary of an agency. With the help of her son, she now
owns an eatery in front of her house selling breakfast and lunch which is the main source of
income of their family. In a day, she makes 500 pesos of profit. Aside from this, Mrs. Girado
receives money from her children abroad every month. She reported that she gets a total of 200
US Dollars every month. In a month, they have an approximate of P25,000 pesos. The client
reported that sometimes, she gets some spare money to be added to the expenses for the next
month but she doesn’t have savings.

Gross Monthly Income Approx. P25,000 per month

Monthly Expenses Allotted Budget

Electricity P2000

Water Supply (Drinking and Non- P1800

drinking water)

Food P7000

Personal necessities (shampoo, soap, P1,000

toothpaste, toothbrush)

Health P8,000

Transportation P700

Education Allowance P4500

Total P25,000

Monthly Savings P0

Table 1. The Monthly Income of Family

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 The family’s monthly income is approximately twenty five thousand pesos a month. 32%
of this were spent to health such as maintenance medications, multivitamins, clinic consultations
and laboratory tests. They think that they have enough enough income or budget a month. Their
savings are usually spent whenever they wanted to go to mall and watch movies.

Mrs. Nena and Mr. George watch television, read the newsapaper and listen to the radio
to be updated with the current news and situation. They do not own a private vehicle. They
usually ride the jeepney when they go to other places like the hospital and mall. The usual
problem of the family is financial when there are unexpected expenses that arise. Mrs. Nena said
that she asks for help from his youngest son who lives in Makati when their family faces financial
problems.

The family is a Catholic family. They attend the church every Sunday. Mrs. Nena’s
oldest grandchild, ________, is currently the SK Secretary of their barangay. They actively attend
meetings and helps with the programs of their community whenever there is one. The biggest
problem that they think the community faces is that their barangay officials are not organized.
Mrs. Nena also said “Wala nga kaming barangay hall eh kaya hindi mo alam kung saan ka
pupunta kapag may emergency.” According to her, the barangay should find a solution to this
problem for better living conditions of the members of the community.

III. Home and Environment

The family lives in a two-storey house. On the first floor, there is the living room, the
kichen and the bathroom. In the second floor, there are two rooms where the family sleeps on. In
front of the house, there is a table set up for Mrs. Nena’s eatery. This is where mostly the
interaction of the student nurse and the client happened. The family also has a dog that stays
inside the house. It is kept on a leash and tied on the gate for most of the day. The kitchen is clean
and the pots and pans used for cooking are stored properly on a rack. They have a refrigerator
where they store their leftover food. They use LPG gas for cooking their food.
As for waste disposal, the family doesn’t practice segregation of wastes. They just put
everything in a plastic bag and at the end of the day, they leave it outside their house for the
garbage truck to collect. The garbage truck passes by in front of their house every day late at
night or early in the morning.

Figure 2. Interior House of the family

The house has two bedrooms on the second floor. The first room is shared by Mrs. Nena
and her eldest grandchild while the other is shared by Mr. George and the other grandchild. The
student nurse was not able to see the interior of both of the rooms as per the client’s request.

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 The house consist of 5 lights. One at the living and dining area, kitchen area, bathroom,
and one for each bedroom. They do not use candle or gas as a light source. They have their own
water supply and their service provider is Maynilad. They buy mineral water from the water
station nearby because Mrs. Nena thinks that the water from the faucet is not safe for drinking.
They do have rice cooker, electric and gas stove. Most of the time they use electric stove to cook.
The pots and pans are placed in the cabinet. The student nurse did not saw presence of insects.
Utensils are stored in the cabinet.

According to the client, there are cockroaches, mosquito and rats inside their house. They
are using insecticides to kill vectors. Mrs. Nena reported that there are also termites in the walls
so they pay for termite control services once a year. They also have a pet dog named Sia. Sia is
always on a leash. For most of the day, he is tied on the gate of the house where his food and
water is. Sometimes, Mrs. Nena takes her outside for a walk.

The street where the couple lives is not a slum, congested nor a squatter’s area. The
nearest basketball court in the area is the one near the Pedro Gil Health Center. Furthermore, the
client said that the health facilities needed are very accessible because the Health Center is very
near to them. However, Mrs. Nena still prefers going to the Ospital ng Maynila for her checkups
because she knows a doctor there. They only go to the health center when they need immediate
checkups and for immunizations. They are contented on the services that the health center is
offering to them.

IV. Health Status of Each member of the Family

Mr. Nena Girado
The primary client is Mrs. Nena Girado. She is 68 years old born on June 12, 1950. She is
a Roman Catholic and her highest educational attainment was 2nd Year College. She has
Philhealth and SSS for her Health Care financing. She is a Chronic Hypertension patient
diagnosed in 2008. She usually goes to the Ospital ng Maynila for her consultations and
checkups. Her maintenance medications for hypertension are Losartan and Amlodipine. She also
drinks multivitamins, Vitamin B complex and Lysine.
The client reported that she has had chickenpox and measles in her childhood. She also
had complete vaccinations ever since she was a child. She has no known allergies to drugs and
food. Her most recent visit to the hospital was a month ago for her regular checkup as part of her
management of hypertension. She has familial history of hypertension on her mother side and
diabetes on her father’s side. She also mentioned that out of her 10 siblings, 5 has passed away
and 3 of them had hypertension.
The client thinks that she is a healthy person despite her health condition because she said
that she can still do the things that she normally does. She said that since she takes her
medications everyday, she is going to be fine. When asked what she does to keep herself healthy,

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 she said that she eats a lot. She doesn’t have a diet plan that she follows and just eats what’s
available. She doesn’t smoke nor drink alcoholic drinks. She thinks that her familial history of
hypertension plays a huge part of her acquiring the condition.
The client tries to eat a balanced diet everyday. Her meals always has go, grow and glow
foods. She reported that she tries to stay away from fatty foods. During the food recall, however,
most of the food she reported are fried. She drinks 2 liters of water every day. There are no
changes in her appetite lately. She also did not experience sudden weight loss or weight gain. She
does not have any problem in excretion or voiding. When asked about her physical activity, she
said that moving around the house, cleaning, cooking, going to the market are all enough for her
physical activity. She doesn’t exercise because she said that it is too time-consuming and that she
cannot find the time and energy for it anymore. The client has a BMI of 27.6 which is
overweight. She also has android obesity as her fats go to the visceral area.
The client sleeps from 9pm to 5am every day. She naps in the afternoon after she closes
her eatery for an additional 30 minutes of sleep. Mrs. Nena claimed that she falls asleep easily
and that she doesn’t srink any medications to help her fall asleep. She wears reading glasses but
she claims that she still can see clearly without it. She does not have any hearing difficulties.

VITAL SIGNS PHARYNX

Temp: 36.2/axillary Uvula in midline, pinkish mucosa

PR: 90 bpm (-) inflamed tonsils

RR: 20 breaths per minute NECK

HR: 92 bpm Normal ROM

BP: 120/70 mmHg Trachea in midline

GENERAL SURVEY: Non- palpable thyroids

Conscious, coherent, calm (-) Neck enlargement, NVE

Oriented to time, person and place CHEST AND LUNGS

Coordinated Gait Symmetrical, I/E ratio: 1:1

(-) Signs of distress (-) ICS Retractions

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(-) Fatigue (-) use of accessory muscles

SKIN (-) rales, wheezes

(-) pallor, (-) jaundice, (-) cyanosis (-) rhonchi at left lung field

Smooth texture, cold and clammy APL ratio: 1:2

temperature

Poor skin turgor Equal chest expansion

(-) pedal edema Symmetrical tactile fremitus

HEAD Vesicular breath sounds over entire lung field

Normocephalic, symmetrical HEART

Evenly distributed hair, clean scalp Pericardial area flat, normodynamic

Fine texture of hair No prominent pulsations

(-) Alopecia, masses, lesions, tenderness (-) heaves, thrills, tenderness

EYES PMI at 5th ICS LMCL

(-) swelling, lesions S1>S2 at apex, S2>S1 at base

Pale conjunctiva, anicteric sclera (-) murmurs, extra heart sounds

Smooth, clear cornea BREAST AND AXILLA

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PERRLA, 4mm (-) masses, redness

(+) Arcus Senilis Symmetrical, equal breasts

NOSE ABDOMEN

Symmetrical, septum in midline Symmetrical, flat

Pinkish mucosa, patent nares (-) striae, (-) masses

(-) alar flaring, perforation Normoactive bowel sounds 10/min RLQ

(-) discharge, sinus tenderness Present at all quadrants

MOUTH (-) bruit, rebound tenderness

Intact speech (-) muscle guarding

Pinkish mucosa BACK AND EXTREMITIES

(-) pallor of lips (-) CVA tenderness

(-)dryness, (-)lesions Symmetrical peripheral (radial) pulses

(+) missing teeth (all) Pink nail beds

(+) wears dentures

EARS Capillary refill (1 sec)

Normoset, symmetrical Full ROM of upper/ lower extremities

Symmetrical gross hearing (-) clubbing

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 (-) edema, joint swelling, tenderness

Muscle tone normal

(-) muscle weakness, tremors

GENITOURINARY

*not assessed*

Nutritional Assessment and Analysis

Mr. Miguel’s height is 160 centimeter and his current weight is 56 kilogram. His current Body
mass index is 21.875 which is normal level. As computed, His desirable body weight is 54
kilograms whereas in consideration of his weight, he does not meet his desirable body weight.
His total energy allowance is 1620 calories.
As for his 24 hour food recall because Mr. Miguel does not remember his 72 or 48 hours food
recall, His breakfast was one serving of suman, two slices of gardenia bread, two servings of
breast chicken adobo and a cup of rice. His lunch was half cup of rice, one serving of omelet with
onion and tomato and one serving of saluyot and kangkong. His dinner was once cup of rice and
one serving of sotanghon with sayote.

Figure 4. Nutritional Analysis of Mr. Miguel Surral

According to the FNRI, the nutritional analysis on figure 4 as based on the computation of age 70
years old and above. Mr. Surral has an increased amount of intake of niacin. According to studies,
Niacin can boost levels of good HDL cholesterol and lower triglycerides. Niacin modestly lowers
bad LDL cholesterol. However, niacin is only effective as cholesterol treatment at high doses.

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 These doses could pose risks, such as liver damage, gastrointestinal problems and glucose
intolerance. It also helps reduce atherosclerosis or hardening of arteries.
Client has lack of intake in Vitamin C levels. Vitamins C is used for growth and repair of tissues
in all parts of the body. It helps body to make collagen, an important protein used to make skin,
cartilage, tendons, ligaments and blood vessels. Low levels of vitamin c have been associated
with a number of condition including high blood pressure, stroke, atherosclerosis and the build-up
of plaque in blood vessels that can lead to heart attack and stroke. Furthermore, according to
studies, Vitamin C does not lower cholesterol levels or reduce overall risk of heart attack but
evidence suggests it may help protect arteries against damage. To conclude, Client should
increase the amount of intake of vitamin C.
Vitamin B1, also called thiamine or thiami, is one of 8 B vitamins. B vitamins help the body
convert food into fuel, which the body uses to provide energy. Thiamine is sometimes called an
"anti-stress" vitamin because it may strengthen the immune system and improve the body's ability
to withstand stressful conditions. Some of the symptoms of thiamine deficiency are headache,
nausea, Fatigue, irritability, depression and abdominal discomfort. Client does not experience any
of these symptoms but according to Mr. Miguel sometimes he experiences abdominal discomfort.

BLOOD CHEMISTRY AND LIPID PROFILE

FBS 5.45

BUN 7.79 HIGH

CREATININE 94.3

URIC ACID 266.6

Lipid profile is used to evaluate the response of the client to dietary and drug therapy for
hypocholesteremia whereas Mr. Miguel is taking atorvastatin which is used to treat
hyperlipidemia and hypocholesteremia. Client has low LDL levels according to Davis, low levels
of LDL may be affected by drugs such as atorvastatin which is used to lower lipids in the blood.
Hence, it also the same why Mr. Surral has low levels of cholesterol on the results of his lipid
profile.
Blood urea nitrogen is used to assess nutritional support and his renal function. Routine BUN
levels monitoring is done because client is at risk of developing renal disease because of
hypertension whereas client has decreased cardiac output because of increase in afterload which
could result to decrease in renal perfusion. Increased levels of BUN could indicate excessive
protein ingestion prior to the withdrawal of the blood for blood chemistry.

COMPLETE BLOOD COUNT

WBC 7.2

NEUTROPHILS 67.9

LYMPHOCYTES 23.8

MONOCYTES 8.3

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 EOSINOPHILS 0

BASOPHILS 0

RBC 4.06

HGB 13.6

HCT 38.1

MCV 93.9

MCH 33.4

MCHC 35.6

RDW 11.6

PLATELET 173

It is necessary for a patient with Chronic Hypertension to have routine complete blood count
because it would be able to monitor fluid imbalances whereas fluid imbalance could affect the
blood pressure of the client. Furthermore, it is also part of general physical examination. The
results of the complete blood count of the client are in normal levels.

URINALYSIS

COLOR YELLLOW

TRANSPARENCY TURBID

EPITHELIAL CELLS FEW

MUCUS THREAD ABUNDANT

ALBUMIN NEGATIVE

SUGAR NEGATIVE

SPECIFIC GRAVITY 1.020

pH 6.0

WBC 1-2

RBC 2-4

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 Routine Urinalysis is used to provide screening as part of a general physical examination
especially that Mr. Surral has chronic hypertension which might give an effect to the function of
his kidney. The results of the urinalysis of Mr. Surral are in normal range. Abundant mucus
thread is normal for a client whereas it would result to the transparency of the urine of Mr.
Miguel whereas he has turbid urine transparency.

V. Values and Practices on Health

The couple described a person who is healthy and according to them, a healthy person is person
who can converse with them. Furthermore according to Mr. Surral, a person may look healthy
physically but it may have sick but he just did know it. He also said that a healthy person is
beautiful and sexy. Eating right kind of food & at the right time, getting a good sleep and having
daily exercise are the ways of the couple to maintain their health. Furthermore, they also
verbalized, “Kaya naman nagkakasakit yung tao dahil sa mga sobrang bagay. Sobrang pagkain
kaya nataba ng sobra”. They also believe that the environment could also the cause of sickness. A
sick person for Mr. Surral is a person who looks pale, sad, thin and tired.
They said that they consult to the ‘albularyo’ because they would still end up consulting the
doctor. Hence if they consult the ‘albularyo’ they would waste money. Furthermore, they follow
all the doctor is saying to them especially when it comes to medicine. For example, if the doctor
said that they should finish a certain drug for one week, they would finish it for a week despite
the signs and symptoms are gone. Mr. Surral also said that he drinks whatever the doctor has
recommended for him. As much as possible, the couple would seek or visit the doctor if they felt
something different and they also that they have not yet come to the point that they don’t consult
the doctor because of financial problem.
No one drinks nor smoke on the couple but their third child is chronic smoker. They convincing
their son to stop cigarette smoking but according to them they cannot stop their son. Furthermore,
the couple does not remember if they have complete vaccines as verbalized, “Parang nung
panahon naming parang wala pa atang ganyan”. According to the couple, they always have a
good and enough sleep. They perform daily exercise as recommended by the doctor.

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