I.

ASSESSMENT A. General Data Patients Initials: R.B. Address: Paraaque Age: 45 y.o. Place of Birth: Antique Nationality: Filipino Date of Admission: 07/20/1966 # of Days in the Hospital: 22 days B. Chief Complaint grabe ang sakit ng ulo ko as verbalized by the patient. C. History of Present Illness Sex: Male Civil Status: Married Order of Admission: Rehabilitation

3 weeks prior to admission, patient noted to have sudden onset of severe headache in occipital area when he is way on board (south Africa). Patient was then bought consult and was given pain medications. CT scan was done revealed infarct and hydrocephalus. Patient underwent VP-shunt on the left parieto-occipital region. Patient was then inducement therapy w/ no noted neurological deficit and was discharged. One day prior to admission, patient diagnosis w/ assorted limitations. No noted loss of consciousness, vomiting, fever, cough or colds. Patient sought consult to their ship doctor. Patient was given ferrous sulfate. Few hours prior to admission, condition still persisted w/c prompted consult in MDH hence the admission. D. Past History 1. 2. 3. 4. 5. 6. 7. 8. Childhood Illness: Measles, Mumps, Adult Illnesses: Hypertension Immunization: BCG (at birth), DPT (childhood), OPV, HEPA B Vaccine Previous Hospitalization: none Operations/s: none Injuries: None Medications taken prior to confinement: Centrum, High Calci-Block Allergies: None

E. Systems Review 1. Health Perception Health Management Prior to confinement, the client's general health was in quite good condition until he felt pain in his head. He rated his pain as 7 out of 10, 1 being the lowest and 10 the highest. He goes to Saudi Arabia for his work as a seaman. He also had his personal hygienic practices like taking a bath twice a day and brushing his teeth thrice a day. He started drinking alcoholic beverages at the age of 19. He usually have his annual check-up to their accredited hospital of their company. He thinks that he felt sick because of his stress working at the ship and for being awake sometimes for almost 22 hours in a day During confinement, the client described his general health more improving as he stays longer at the hospital because he have the more time to rest and reconditioned himself to what happened after he was admitted at the ward. The goal of his health is to recover from his condition and to be able to work again to the ship. While he was is the hospital he still doing his hygienic practices

1.) Pain related to tissue ischemia 2.)Disturbed Sensory Perception related to altered sensory integration 3.) Deficient knowledge related to unfamiliarity with information resources