CLIENT’S PROFILE

Demographic Data

Patient X is a 69 year old, female, married, Seventh Day Adventist, presently

residing at Alubihid, Misamis Oriental. Dialect spoken is Visayan and Tagalog only. He

is 180 cm tall. Date of admission was on September, 20 2010 at NMMC Female

Medical Ward with the medical diagnosis of Cardiovascular Disease Infarct left.

Vital signs

BP: 130/80 (lying)

TEMP: 36.9 oC

RR: 20 cpm

PR: 68 bpm

History of Present Illness

Morning prior to admission, Onset of slurring of speech with noted right sided

weakness. On afternoon 5:10pm September 20, 2010 the patient was admitted at

NMMC Female Medical Ward.

- Negative vimiting

- Negative trauma

Previous Hospitalization/Surgeries

Patient X had previous hospitalization because of stroke last 2009 in Bohol

Hospital.

Nutritional Metabolic Pattern

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 Patient’s diet , soft diet. She has a good appetite

Activity Tolerance and Exercise Pattern

Patient can perform different activities such as watching TV, walking exercises.
Much of his leisure activities are working slightly and watching TV. But she can’t speak
well.

Activities of Daily Living (ADL) During Confinement

Patient can feed, bathe, groom, and dress herself. She can move independently

but dependent to her significant other for things that she cannot do due to complaints of

body weakness. Patient X has fatigue and sometimes she is irretable. She has an IV

hooked at his left arm which also interfere the patient’s activity and function.

Sleep-Rest Pattern

Patient X can sleep well 9 – 10 hours of sleep.

Cognitive Perceptual Pattern

Patient X can hear voice tones audibly and can smell fine. She can taste and
feel touch fine.

Patient can speak and understand the dialect Visayan. She has a good memory
and answers appropriately and she is oriented to time, person, and place. He is able to
explain things and has the capacity to make decisions. She copes with it by rest, sleep,
and by drinking medicines.

Self-Perception and Self-Concept Pattern

Patient X is worried about his condition because his condition is a hindrance to

his work which is his source of living(farming). His significant other is very supportive to

her and caters her needs.

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Role-Relationship Pattern

Patient X is married, she has a 3 sons, 1 daugther and is living with his family.
Patient X is a welder and gets some of his financial support at his relatives.

Coping-Stress Tolerance Pattern

Patient X is worried about his current condition since this can be a hindrance to

his work which is his source of living.

Values-Belief Pattern

Patient X is a Roman Catholic, he is also praying to God for his faster recovery.