University of The Philippines Manila
University of The Philippines Manila
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.
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
Electricity P2000
Food P7000
Health P8,000
Transportation P700
Total P25,000
Monthly Savings P0
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.
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.
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.
(-) pallor, (-) jaundice, (-) cyanosis (-) rhonchi at left lung field
NOSE ABDOMEN
GENITOURINARY
*not assessed*
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.
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.
FBS 5.45
CREATININE 94.3
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.
WBC 7.2
NEUTROPHILS 67.9
LYMPHOCYTES 23.8
MONOCYTES 8.3
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
ALBUMIN NEGATIVE
SUGAR NEGATIVE
pH 6.0
WBC 1-2
RBC 2-4
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.