Professional Documents
Culture Documents
PERSONAL HISTORY
NAME: Patient PRM ADDRESS: Sulivan Baliuag, Bulacan BIRTHDAY: November 24, 1982 AGE: 29 years old GENDER: Male STATUS: Single NATIONALITY: Filipino RELIGION: Jehovas Witness EDUCATIONAL ATTAINMENT: College undergraduate OCCUPATION: None HEALTH CARE FINANCING AND USUAL SOURCE OF MEDICAL CARE: None DATE OF ADMISSION: February 1, 2012 TIME: 3:19 pm CHIEF COMPLAINT: Non healing left foot wound ADMITTING DIAGNOSIS: Peripheral Arterial Occlusive Disease
Mother Side
S.C 70
C.S. 79
R.M 50
E.R 48
M.A 46
E.B 43
R.C 53
L.M 48
E.V 47
R.C 45
R.M 44
C.C 42
LEGEND:
PRM 29
S.M 28
M.M 25
M.C 23
L.M 20
DURING HOSPITALIZATION
Patient was on DAT (diet as tolerated) as of Wednesday since the day of his confinement February 1, 2012, and then the client was ordered to be on NPO (nothing per orem) on the night of February 12, 2012. 72hour diet recall Date February 10, 2012 Breakfast 1glass of water 1cup of coffee Fita crackers 9 pcs 1glass of water 1cup of Coffee mammon Lunch 2glasses of water 1 pc Fried fish 1 cup rice 2glasses of water 1 saucer ginisang togue 1 cup rice Dinner 2glasses of water 1 cup of rice 1 saucer Adobo 2glasses of water 1 bowl of sinigang na bangus 1cup rice NPO
Februar y 1, 2011
3 glasses of water 1 bowl of tinolang manok 1 cup of rice 1/3 small saucer of patis
DURING HOSPITALIZATION
Frequency 1-2 times a day Color/ Consistency Light brown, formed stool Light yellow urine Discomfort No discomfort
Urine 5-6 times a day No discomfort Usually patient PRM defecates at least 1-2 times a day it is formed and brown in color. He urinates 4-5 times a day for approximately with yellowish color urine. The patient defecates once or twice a day with a light brown, formed stool and Normally he doesnt feel any pain while voiding and defecating. urinates 5-6 times a day without any discomfort.
DURING HOSPITALIZATION
During hospitalization, PRM needs help whenever he will go to the toilet room. He is accompanied by his mother through on a wheel chair. He is also helped for changing his clothes. He wasnt able to ambulate freely in the ward due to his left foot, he needs assistance. The only thing he does in the ward is to sit on a chair near his bed and lie down.
DURING HOSPITALIZATION
During hospitalization, he usually has a continuous rest and sleeps. He only get awaken at night when the nurses gives medication and of obtaining vital signs.PRM told us that sleeping in the hospital is not as comfortable as in their house. He takes naps too if theres a chances to. He gets bored during hospital stay for he only just sits and lay down on his bed, his only everyday routine in hospital.
Before hospitalization, the patient sees himself as a jolly and friendly When he found out that he needs to undergo below knee amputation person. He makes friends easily and said that she does not want to make enemies he cant help to feel self pity but then again, he just accepted it since its the with anyone. He makes sure that no one is hurt when he makes decision. PRM does only way for him to become better. He just looks into things in a positive not easily get mad or annoyed with jokes and is always cheerful. He said that being way. with his family is what makes him happy the most.
8. ROLE-RELATIONSHIP PATTERN
PRM is single and not yet married. He stays with his mother house. He has a good, harmonious relationship with his family. They dont have any problem or argument at home. They all communicate with each other. They do things and face struggles with helping hands. His mother is the one who stays with him in the hospital. His father and other sibling already visited him, according to PRM.
9. SEXUALITY-REPRODUCTIVE PATTERN
PRM is single and not yet married. He had his circumcision when he was 12 years old.