PROBLEM IDENTIFICATION Clustered Cues PRESENT HEALTH HISTORY Subjective: -Client verbalized Sa tingin ko ang hina hina ko na kasi

sumasakit yung katawan ko lagi at madali akong mapagod -sore throat for two weeks Objective -Client P.M is experiencing fever for two weeks now. During the interview, her body temperature was 38.5C -RR:33 -with pale and slightly dry lips -with red and swollen tonsils -RR: 33 -Colds -Wheezing on both lungs -Dyspnea -Use of accessory muscles -Nose Flaring Ineffective Airway Clearance Ineffective airway Clearance related to bronchial secretions Inferences Diagnostic Statement

Hyperthermia

Hyperthermia secondary to infection

Client P.M. believed that a person whom exhibiting a big body built and observably fat is a healthy person. He value health as his second priority next to food. He considers his practice of drinking enough water and avoiding alcoholic beverages and cigarette smoking as a way of attaining good nutrition. NUTRITIONAL/ METABOLIC PATTERN Objective -low fat, low salt and high potassium diet

NORMAL

Patient is health-conscious and practices a healthy lifesttyle

NORMAL

Knows the prescribed appropriate diet meal plan

-Client looks thin.

MEASUREMENT BMI= 18.24 (under the ideal rate) ELIMINATION PATTERN -Client is usually urinating thrice a day. He described his urine as yellow in color. He also defecates once a day and his stool was described as brown and semi-solid. He doesnt feel any discomfort or pain whenever he urinates and defecates. ACTIVITY-EXERCISE PATTERN Subjective: -Client verbalized Madali akong mapagod Objective: -Looks tired and weary -Presence of eye bags - Inflammation in the elbows, knees, wrist -Jerky movements -limited ROM -Pulse rate: 120beats/min, irregular, weak, Tachycardia -Blood Pressure: 80/50 mmHg -RR: 33, dyspnea -with pale conjunctiva, nail clubbing and buccal mucosa -Cold and clammy skin -Capillary refill 3-4 secs -heart sounds with murmurs Normal urine and stool. No pain during urination and defecation.

NORMAL

Physical Mobility Impaired

-Physical Mobility, impaired related to pain in the joints with uncontrolled movement

Decreased Cardiac output

Decreased Cardiac output related to valve stenosis

Activity Intolerance

Activity Intolerance related to decreased Cardiac output

SLEEP-REST PATTERN Subjective -Client verbalizedMahirap matulog sa hospital, kaya lagi

Sleep Deprivation

-Sleep Deprivation related to

akong puyat Objective -Client looks restless. -Presence of eye bags. -Usually yawns and felt sleepy always. -He usually sleeps 6 hours every day COGNITIVE-PERCEPTUAL PATTERN -He has no difficulties in learning

fatigue, restless

NORMAL

Can read, write and speak well. No problem in understanding and perceiving information. Anxiety related to financial crisis

SELF-PERCEPTION AND SELF-CONCEPT PATTERN Subjective -Client verbalized Nagaalala ako sa pambayad ko sa hospital baka kulangin ang pera. Objective -Client looks restless. ROLE-RELATIONSHIP PATTERN - He is the second child in the family. He helps in the family financial matters by being a barter in divisoria. SEXUALITYREPRODUCTIVE PATTERN Client P.M still doesnt want to be in a relationship because he perceives that he wouldnt be able to handle it. He also dont have plans of engaging in premarital sex because his priority was his family. COPING-STRESS PATTERN -Client describes a stressful event as having problems in his family and their financial status. He and his family solve their problems by talking about it. He is not

Anxiety

NORMAL

Close relationship with family and healthy social life.

NORMAL

Not engaged in high risk of sexual practice. No sexual dysfunction.

NORMAL

Client deals with his problems with the help of his family.

fond of drinking alcoholic beverages VALUE BELIEF PATTERN Client perceives the value of being respectful to others is important to him so that hell be able to socialize with others. NORMAL Client respects people so that he in return will gain respect