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˜ Consult Health facility in times of health crisis.
˜ Diagnosed with PTB last 2008 and had undergone a
series of treatment and the medications prescribed to
him are INH, rifampin, ethambutol and pyrazinamide
daily for 8 weeks and continuing for up to 6 to 7 months
but after three months he stopped taking these
medications without consulting his physician.
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˜
edications like over-the-counter drugs.

˜ During admission patient complies with the

medicines needed.
˜Does not take any food supplement or
vitamins.
˜Patient has no allergies to food, and drug.
˜Do not practice regular exercise.
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˜eight: 72 kg
˜Height: 5͛6 ft
˜Vital signs: ( July 31,2010 12pm)
BP- 120/70
PR- 73 bpm
RR- 21 cpm
T- 36.4üC
˜PTA, the patient eats 3 times a day with a serving of 1-
2 cup of rice, viand and a glass of water
˜Patient experience acute pain in the right upper chest.
˜Presence of stabbed wound at the upper right portion
of his back.
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˜Post operative incision at the upper right portion of

his chest.

˜IVF D5 LR 1000cc x 10 hours hooked at right

metacarpal vein regulated at 10 gtts per minute.

˜Occasional drinker, drinks alcohol atmost 2-3

times/week but drinks in lager amounts.

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˜ Prior to admission, the patient has a bowel
habit of 1-2 times a day
˜ During the admission, the patient able to
urinate 2-3 times a day and a bowel movement
of 3 times within 5 days of hospitalization.
˜ no observed blood during urination.
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˜During the admission patient needs assistance in ADL.
˜Patient has slowed and cautious movement due to
CTT attached
˜Able to ambulate with limited movement on left arm
due to IV infusion and upper right extremities due to
the CTT attached ranging from the chest to the hands
left arm due to IV infusion.
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D  






˜
ale, married, 5 children
˜Reported no use of contraceptives both artificial and
natural methods.
˜The patient has been married for 20 years, currently
staying with his children but is away from his wife for almost
a year due to work assignments.
˜Patient does not have questions or concerns about how
his illness will affect the sexual aspect of his life.
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˜No sensory deficits.
˜PERRLA
˜Oriented to time, place and person.
˜Responds appropriately to verbal and physical stimuli.
˜Recent and remote memory intact.
˜Patient states pain on the right upper chest with pain scale
of 7 out of 10, 10 as the highest.
˜Patient verbalized ͞Okay naman ang akong samad, kining
tubo lang medyo sakit malisdan ko mag lihok maong
kelangan jyud nay mag tabang͟
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˜No hearing, visual and memory difficulties noted.
˜Patient does not have difficulty understanding,
answering questions and following directions.
˜Patient has clear and appropriate responses to
questions.
˜Patient talks in ͞Bisaya͟
˜Patient is able to participate in decision making for his
health.
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˜ëtates good relationship with family but always in
trouble and argument when he is intoxicated with
alcohol.
˜The patient͛s parents are still alive.
˜Family is supportive financially and emotionally.
˜Patient verbalized ͞
aayo man among relasyon sa
among balay, okay pud mi sa akong asawa, pirmi man
siya naga tawag sa amua.
akakita lang man ko og
away didto sa amu kanaang naka inom na lage, unya
magkainitan, magkabiklanay dira jud͟
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˜Client works as a tricycle driver.

˜Positive interaction with watchers/significant others

observed.

˜Does not have difficulty in relating to staff and nurses;

complies with the instructions provided by the health

care givers.
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˜ Patient expresses understanding and recognition of
his present condition and does not verbalize signs of
hopelessness; ͞Okay naman ko, pwede naman gani
mudagan.͟
˜Patient talks with eye to eye contact with clear voice.
˜Patient manages to smile and conversant with others.
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˜Patient is properly groomed: Clean fingernails,

toenails and hair is well commed.

˜Patient expresses concern with his illness and work

͞Basig madugayan ko diri sa hospital,obserbahan pa

man gud daw ko ingon sa doctor unsaon nalang ang

mga bayarin kelangan jud mag trabaho͟.

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˜Patient is Roman Catholic by faith.

˜Attend mass whenever possible.

˜Prays by himself.

˜Values family relationships.

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˜Family members are supportive to patient͛s needs.
˜Patient verbalized ͞
aau gani naa akong asawa, sige
gani to padala og kwarta kay hurot na jud akong kwarta
diri naga bisita man pud akong mga parente diri, nag
llisod pud lage to sila maong maulaw pud ta mangayo
og tabang͟.
˜ëleeps, listening to music, playing of cards and
drinking of alcoholic beverages as a form of relaxation.
˜He asks questions about his vital signs.
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áá  




˜ sually the patient sleeps at around 8:00-9:00 in the
evening and wakes up at 5:00 in the morning.
˜During hospitalization, he experiences discomfort due
to the CTT attached to him. He tries to take a nap of
about two hours in the afternoon.
˜Patient does not have any sleeping routines or
sleeping aids.
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˜Takes pain relievers and OTC drugs for common illnesses.
˜Patient verbalized ͞Gapalit nalang kog tambal sa botika,
mga over-the-counter, para mayo dayun ang akong mga
sakit, sama sa ubo, sip-on o hilanat͟
˜No stated childhood illness.
˜Unreported presence of allergies as stated by patient
͞ala man koy allergies͟.
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˜Diagnosed with PTB last 2008 and had undergone a

series of treatment and the medications prescribed to

him are INH, rifampin, ethambutol and pyrazinamide

daily for 8 weeks and continuing for up to 6 to 7 months

but after three months he stopped taking these

medications without consulting his physician.

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edicines:
1. Ampicillin 100 gm IVTT q 6hours PRN
2. Ketorolac 30 mg IVTT q 8hours, ANëT
3. Cefuroxime 500 mg 1tab PO, TID
4. Cefuroxime 750 mg IVTT q 8hours
5. Ambroxol 75 mg 1tab PO, TID
6.
yrin-P 3 tabs 30 minutes before breakfast