I.

BIOGRAPHIC DATA a. Name: b. Address: c. Age: d. Gender: e. Date of Birth: f. Place of Birth: R. H. #47 Panopyo compound, Cubao Q.C 83 years old Male February 11, 1931 Manila City None Tagalog Married Philippine Army (2nd Lieutenant) Roman Catholic Filipino February 23, 2014 (Sunday) 11:55 PM Dyspnea Parkinsons dse Sepsis Seizure ARF sec to HCAP ----ICU Room 163 A ----

g. Ethnic Group: h. Primary Language Spoken: i. j. Civil Status:

Educational Attainment: College Undergraduate (2nd Year College)

k. Occupation: l. Religious Affiliation:

m. Nationality: n. Date of Admission: o. Time of Admission: p. Chief Complaint: q. Admitting Diagnosis: r. Attending Physician: s. Ward: t. Room & Bed:

u. Hospital Number: v. Health Care Financing And Usual Source of Medical Care w. Income

None Php 40,000 (Monthly)

II.

PRESENT HEALTH HISTORY Patient is chronically bedridden due to old infarct. Patient was previously admitted at MICU because of ARF and HCAP. He was intubated and tubed to mechanical ventilator. Patient was eventually improved and was discharged on January, 2014. Few Hours prior to admission, patient had fever and episode of cough, productive but was unable to expectorate. The wife verbalized Madalas ko siyang sinasuction lalo kapag nahihirapan siyang huminga ako kaya kapag medyo inuubo na siya. Patient was then brought to hospital and was subsequently admitted. Patients case was managed as Parkinson Disease Sepsis Seizure ARF. Secondary to HCAP.

III.

PAST HEALTH HISTORY Due to the clients current physical condition and difficulty in speaking, questions were answered by his wife. According to his wife, the patient did not experience any specific diseases or illness during his childhood except for flu, colds and fever. The wife also stated that except for the monthly check-up, the patient is always admitted to the hospital because of Parkinsons disease ;they discovered it since 2007. On September, 2013, the client had a seizure and discovered that. the patient had a stroke. The wife stated that she didnt know if the patient has a complete immunization. The patient doesnt have any allergy on drugs and foods. Patient had a car accident. The last time he was hospitalized is because of a gunshot during the war. Patient does not take any food supplements or any medications before but currently, he maintains taking his oral medications. Patient travelled in LA, California before.

IV.

FAMILY HEALTH HISTORY According to the patients wife, the patient has 3 siblings who already passed away but she doesnt not know the cause of their death . The patients parents also passed away but she doesnt know the cause as well. They have five children ,2 boys and 3 girls. The oldest is Luzviminda 50 years old, Lani 48 years old, Gerry 46 years old, Gessie 44 years old, and the youngest Lorlyn 38 years old. They are all alive and they dont have any specific disease or illness. Hereditary disease in their family include hypertension

GORDONS FUNCTIONAL HEALTH PATTERNS I. HEALTH PERCEPTION PATTERN

In a scale of 1-10, 1 being the lowest and 10 being the highest, the wife stated that she rates health as 5 which is average because of the condition of her husband. Mother verbalized that syempre ang goal ko lang ngayon eh yung gumaling yung asawa ko. They are not following any beliefs and practices. They only go to hospital if a member of the family is not feeling well or sick. Wife stated that since July, last year, the patient has a monthly check-up because everytime the patient stand up suddenly he will fall down. Currently They do not experience financial problem. Personal hygienic practices that he follows are taking a bath every day, hand washing, trimming of nails every end of the month, using deodorant and brushing teeth thrice a day. Patient does not smoke but he used to drink alcohol when there is an occasion. They have good toilet facilities, good water supply and good waste management because their garbage is collected thrice a week. II. NUTRITIONAL AND METABOLIC PATTERN According to the wife, shes the one responsible for food budgeting . As mentioned, kinilaw na isda, inihaw na isda and other fish dishes are the patients usual meal. It was mentioned that clients favorite food is inihaw na isda and he drinks juice a lot . As the wife verbalized madami pinagbago, dati nakakain siya lahat ng gustuhin niya ngayon hindi na kasi binawal na din ng doctor niya lalo na yung mga isdang dagat eh yun pa naman paborito niya.It was verbalized that eating foods such as rice with viand plus fruits and vegetables are essential to be a healthy individual but the patient didnt want to eat fruits. It is also stated that since 2000 the patient stopped taking alcohol . Since the patient is currently in the hospital, the doctor said that he cannot eat fish especially isdang dagat . III. ELIMINATION PATTERN Currently, patients bowel movement is 2-3x a week and the patient is constipated. His stool is semisolid and dark in color especially now that he is taking Ferrous Sulfate. As mentioned, there is pain when defecating but the wife gives the patient yogurt and prune juice to relieve constipation. The patient doesnt experience any problem on urination. IV. ACTIVITY-EXERCISE PATTERN As the wife verbalized dati nung malakas pa siya, siya lagi naglilinis ng kapaligiran tapos naglalakad-lakad siya twice a week. The wife also stated that the patient has a routine push-up every day. On September, 2013, the client had a seizure, since then the client was not able to walk. V. SLEEP-REST PATTERN Patient has usually 8 hours of continuous sleep a day. Usual time of sleep is 8 PM and usual time for waking up is 4 AM. According to the wife the client looks refreshed and in a good

mood upon waking up. His sleeping environment is usually quiet and has adequate ventilation. He has no problems falling asleep. I. COGNITIVE PERCEPTUAL PATTERN The client is able to read, write and speak/understand English language during the course of the interview. There were no significant changes or any difficulties which has been experienced by the patient specifically with the clients senses such as in hearing, tasting and smelling. The patient is far sighted which lead him to seek advice from an eye specialist. Eyeglasses have been worn for almost 2 years already though the exact grade of the lenses was not recalled by the clients wife. She added that most of the time, he is forgetful in a sense that he experiences difficulty in recalling the location of particular things. This occurs most of the time. II. SELF- PERCEPTION PATTERN Due to the clients underlying condition and difficulty in speaking, data were not gathered. III. ROLE- RELATIONSHIP PATTERN According to the wife, patient is a responsible father to their children. They are all happy together. There are times that they quarrel but its not that much of a big dea l for them. They handle their family problem by talking with each other.According to the wife, patient doesnt have problems when it comes to work and his workmates. Their family bonding is going to church. IV. COPING STRESS TOLERANCE PATTERN The patient handles their problems by praying and with the help and support of family. According to the wife he doesnt get angry easily. According to wife, when patient is faced with problems ,he is able to control the situation. He also stated that one way of coping is through resting, eating and talking with his family he feels relaxation. V. VALUE BELIEF PATTERN For the patients wife, what makes a person healthy is having no illness and disease. Health is very important to their family especially that being healthy and fit is one of the requirements for work. Religious practices are important to their family. Since the patient is a preacher, they pray through singing. Some of the religious practices that they follow is not eating meat during the Holy Week specifically during Good Friday. They are a God-fearing family and religion is very important to their family. Religion helps especially when difficulties arise. In relation to society, patient is very sociable. He has a lot of friends in their neighborhood.