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XI.

APPENDICES
28

NAME: Liza Manangkila NAME: Cecelia Manangkila

PAST MEDICAL HISTORY PAST MEDICAL HISTORY


General health status: General health status:

Untidy appearance, able to answer Untidy appearance, noted poor hygiene and
questions appropriately, noted poor hygiene grooming, able to answer question
and grooming. appropriately with moderate paced and
clear tone.

Past medical problems: Admitted due to


labor pains. Past medical problems: None

Hospitalization and surgery: During her Hospitalization and surgery: None


pregnancy. No past medical surgeries.

Immunizations: Complete
Immunizations: Complete
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General survey General survey


Physical appearance (height and weight Physical appearance (height and weight
appropriate for body build, grooming, and appropriate for body build, grooming, hygiene):
hygiene): Noted poor hygiene and grooming. Untidy in appearance, poor hygiene and
Height and weight appropriate for age. grooming.
Appeared calm and alert during assessment.

Mental status (affect, mood, orientation, recall):


Mental status (affect, mood, orientation, recall): Calm, conscious and coherent during
Calm, conscious and coherent during assessment.
assessment.

Mobility (gait ease of movement, agility): Able to


Mobility (gait ease of movement, agility): Able to perform full range of motion.
perform full range of motion.

REMARKS AND VERBALIZATION FROM THE


CLIENT:

REMARKS AND VERBALIZATION FROM THE


CLIENT:
NAME: JR Manangkila NAME: Adrian Manangkila 30

PAST MEDICAL HISTORY PAST MEDICAL HISTORY


General health status: Visible poor hygiene
and grooming noted. General health status: Visible poor hygiene
and grooming noted
Past medical problems: Cough fever and
colds Past medical problems: Cough fever and
colds
Hospitalization and surgery: None.
Hospitalization and surgery: None
Immunizations: Incomplete
Immunizations: Incomplete
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General survey General survey


Physical appearance (height and weight Physical appearance (height and weight
appropriate for body build, grooming, hygiene): appropriate for body build, grooming, hygiene):
Poor hygiene, dirty nails, scaly skin, dry hair Poor hygiene, dirty nails, wounds on his lower
with dandruff noted. extremities, and scaly skin

Mental status (affect, mood, orientation, recall): Mental status (affect, mood, orientation, recall):
Able to answer some questions. Shy and Shy type, doesnt answer questions and able to
sometimes doesnt answer to questions. Flat follow instructions.
affect noted.

Mobility (gait ease of movement, agility): No


Mobility (gait ease of movement, agility): No limitation of movement, and able to perform full
limitation of movement, able to walk and run in range of motion.
long distance and able to help in households
chores specially cooking.

REMARKS AND VERBALIZATION FROM THE REMARKS AND VERBALIZATION FROM THE
CLIENT: CLIENT:
32
NAME: Gerlie Manangkila NAME: Jecel Mae Santiago

PAST MEDICAL HISTORY PAST MEDICAL HISTORY

General health status: Noted lesions on his General health status: Poor hygiene and
hair, poor hygiene and grooming noted. grooming. Untidy in appearance.
Suffers from colds during assessment.

Past medical problems: None


Past medical problems: None

Hospitalization and surgery: None


Hospitalization and surgery: None

Immunizations: Complete
Immunizations: Complete
33

General survey General survey

Physical appearance (height and weight


Physical appearance (height and weight
appropriate for body build, grooming, hygiene):
appropriate for body build, grooming,
Appropriate weight and height for age, untidy,
hygiene): Dirty long nails, unclean ears, poor
dirty long nails, hair with dandruff, scaly lower
oral hygiene, untidy in appearance, skin
extremities and skin lesions noted.
lesion on her lower extremities noted.

Mental status (affect, mood, orientation, recall):


Mental status (affect, mood, orientation, Oriented to time and current events but
recall): Able to answer question appropriately, sometimes when asked questions she answers
smiling and follows simple instructions. inappropriate.

Mobility (gait ease of movement, agility): Ease


Mobility ( gait ease of movement, agility): Ease of movement, can do light households chores
of movement. like sweeping the floor and washing the
diseases.

REMARKS AND VERBALIZATION FROM THE REMARKS AND VERBALIZATION FROM THE
CLIENT: sakit akong tiyan kay gigutom ko, CLIENT:
gahapon pame nakakaon as verbalized by
gerlie.
34

NAME: Charity Santiago NAME: Jonald Santiago

PAST MEDICAL HISTORY PAST MEDICAL HISTORY

General health status: Visibly poor hygiene General health status: A premature baby.
and grooming, able to help in doing Practiced mixed feeding and has a low birth
households chores appeared untidy, alert weight.
and friendly.

Past medical problems: None


Past medical problems: None

Hospitalization and surgery: None


Hospitalization and surgery: None

Immunizations: On-going immunization.


Immunizations: Complete
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General survey General survey


Physical appearance (height and weight
appropriate for body build, grooming, hygiene): Physical appearance (height and weight
Inappropriate weight and height for age, untidy, appropriate for body build, grooming, hygiene):
dirty long nails and dirty hair with dandruff Weight is not appropriate for age.
note.

Mental status ( affect, mood, orientation, recall):


Mental status ( affect, mood, orientation, recall):
Sleeps soundly at his grandmothers arm.
Smiling, not able to recall recent memory like
what was their breakfast in the morning.

Mobility ( gait ease of movement, agility): Noted


Mobility (gait ease of movement, agility): Able to palmar grasp reflex and startle reflex
perform full range of motion.

REMARKS AND VERBALIZATION FROM THE REMARKS AND VERBALIZATION FROM THE
CLIENT: CLIENT:
36
NAME: Jerry Santiago NAME: Radeza Manangkila

PAST MEDICAL HISTORY PAST MEDICAL HISTORY


General health status: Untidy in
appearance, noted poor hygiene and General health status: Untidy appearance,
grooming. noted poor hygiene and grooming, able to
answer questions.

Past medical problems: Cough, cold and


fever Past medical problems: Admitted due to
labor pains.

Hospitalization and surgery: None Hospitalization and surgery: During her


pregnancy. No past medical surgeries.

Immunizations: Complete
Immunizations: Incomplete
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General survey General survey


Physical appearance (height and weight
appropriate for body build, grooming, Physical appearance (height and weight
hygiene): Not on proper hygiene and appropriate for body build, grooming,
grooming. Appeared calm and relax during hygiene): Poor hygiene and grooming
assessment.

Mental status (affect, mood, orientation,


Mental status (affect, mood, orientation, recall): Able to answer question
recall): Oriented with the time and current appropriately and oriented with current
event event.

Mobility (gait ease of movement, agility): Mobility (gait ease of movement, agility):
Able to perform full range of motion. perform full range of motion.

REMARKS AND VERBALIZATION FROM REMARKS AND VERBALIZATION FROM


THE CLIENT: THE CLIENT:

N
38

NUTRITIONAL ASSESSMENT (especially for vulnerable or at-risk members)


Name of Anthropometric data Quantity Eating/feedin
the family & quality g practices
Heigh Weigh Circumference
member of food
t (cm) t (kg)
Ches Abdome Lower Upper intake/da
t n (cm) extremitie extremitie y
(cm) s (cm) s (cm)
Liza 162 41 34 30 20 10 Cooked Usually once
Manangkil vegetable, a day
a salt, dried
fish,
uyap,
ginamos
Cecilia 164 51 28 27 16 9 Cooked Usually once
Manangkil vegetable, a day
a salt, dried
fish,
uyap,
ginamos
JR 142 35 73 69 40 21 Cooked Usually once
Manangkil vegetable, a day
a salt, dried
fish,
uyap,
ginamos
Adrian 120 21 53 56 30 17 Cooked Usually once
Manangkil vegetable, a day
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a salt, dried
fish,
uyap,
ginamos
Gerlie 111 16 56 49 2 16 Cooked Usually once
Manangkil vegetable, a day
a salt, dried
fish,
uyap,
Usually
once a
day
ginamos
Jecel Mae 100 12.5 51 50 11 15 Cooked Usually once
Santiago vegetable, a day
salt, dried
fish,
uyap,
ginamos
Charity 93 9.8 50 45 25 16 Cooked Usually once
Santiago vegetable, a day
salt, dried
fish,
uyap,
ginamos
Jonald 59 2.16 36 35 16 13 Formula Two to three
Santiago milk and times a day
breast
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milk

Jerry 159 46 78 65 42 22 Cooked Usually once


Santiago vegetable, day
salt, dried
fish,
uyap,
ginamos
Radeza 155 41 83 78 37 21 Cooked Two to three
Manangkil vegetable, times a day
a salt, dried
fish,
uyap,
ginamos
41

Name: Liza Manangkila Name: Cecilia Manangkila


Weight: 41kg Weight: 51kg
Weight gain: no noticeable weight gain Weight gain: no noticeable weight gain
Appetite description: Appetite description:
Good ( /) Good ( /)
Fair ( ) Fair ( )
Poor ( ) Poor ( )
Food intolerance: none Food intolerance: none
Dietary restriction: none Dietary restriction: none
Usual food intake: corn rice, salt, sugar, noodles, Usual food intake: corn rice, salt, sugar,
ginamos, vegetable and dried fish noodles, ginamos, vegetable and dried fish
Fluid intake: water Fluid intake: water
Food dislike: durian Food dislike: frog
Problems: Problems:
Nausea: none Nausea: none
Vomiting: none Vomiting: none
Swallowing: none Swallowing: none
Chewing: none Chewing: none
Digestion: none Digestion: none

REMARKS AND VERBALIZATION FROM REMARKS AND VERBALIZATION FROM


THECLIENT: THECLIENT:
42

Name: JR Manangkila Name: Adrian Manangkila


Weight: 35kg Weight: 21kg
Weight gain: no noticeable weight gain Weight gain: no noticeable weight gain
Appetite description: Appetite description:
Good ( ) Good ( /)
Fair ( ) Fair ( )
Poor ( /) Poor ( )
Food intolerance: none Food intolerance: none
Dietary restriction: none Dietary restriction: none
Usual food intake: corn rice, salt, sugar, noodles, Usual food intake: corn rice, salt, sugar,
ginamos, vegetable and dried fish noodles, ginamos, vegetable and dried fish
Fluid intake: water Fluid intake: water
Food dislike: durian Food dislike: durian
Problems: Problems:
Nausea: none Nausea: none
Vomiting: none Vomiting: none
Swallowing: none Swallowing: none
Chewing: none Chewing: none
Digestion: none Digestion: none

REMARKS AND VERBALIZATION FROM REMARKS AND VERBALIZATION FROM


THECLIENT: THECLIENT:
43

Name: Gerlie Manangkila Name: Jecel Mae Santiago


Weight: 16kg Weight: 12.5kg
Weight gain: no noticeable weight gain Weight gain: no noticeable weight gain
Appetite description: Appetite description:
Good ( /) Good ( /)
Fair ( ) Fair ( )
Poor ( ) Poor ( )
Food intolerance: none Food intolerance: none
Dietary restriction: none Dietary restriction: none
Usual food intake: corn rice, salt, sugar, noodles, Usual food intake: corn rice, salt, sugar,
ginamos, vegetable and dried fish noodles, ginamos, vegetable and dried fish
Fluid intake: water Fluid intake: water
Food dislike: durian Food dislike: durian, santol
Problems: Problems:
Nausea: none Nausea: none
Vomiting: none Vomiting: none
Swallowing: none Swallowing: none
Chewing: none Chewing: none
Digestion: none Digestion: none

REMARKS AND VERBALIZATION FROM REMARKS AND VERBALIZATION FROM


THECLIENT: THECLIENT:
44

Name: Charity Santiago Name: Jonald Santiago


Weight: 9.8kg Weight: 2.16kg
Weight gain: no noticeable weight gain Weight gain: no noticeable weight gain
Appetite description: Appetite description:
Good ( /) Good ( /)
Fair ( ) Fair ( )
Poor ( ) Poor ( )
Food intolerance: none Food intolerance: none
Dietary restriction: none Dietary restriction: none
Usual food intake: corn rice, salt, sugar, noodles, Usual food intake: breast milk and formula milk
ginamos, vegetable and dried fish Fluid intake: breast milk and formula milk
Fluid intake: water Food dislike: none
Food dislike: durian Problems:
Problems: Nausea: none
Nausea: none Vomiting: none
Vomiting: none Swallowing: none
Swallowing: none Chewing: none
Chewing: none Digestion: none
Digestion: none

REMARKS AND VERBALIZATION FROM


REMARKS AND VERBALIZATION FROM THECLIENT:
THECLIENT:
45

Name: Jerry Santiago Name: Radeza Manangkila


Weight: Weight:
Weight gain: no noticeable weight gain Weight gain: no noticeable weight gain
Appetite description: Appetite description:
Good ( ) Good (/)
Fair (/) Fair ( )
Poor ( ) Poor ( )
Food intolerance: none Food intolerance: none
Dietary restriction: none Dietary restriction: none
Usual food intake: vegetables and fish Usual food intake: dried fish and vegetables
Fluid intake: water Fluid intake: water
Food dislike: none Food dislike: none
Problems: Problems:
Nausea: none Nausea: none
Vomiting: none Vomiting: none
Swallowing: none Swallowing: none
Chewing: none Chewing: none
Digestion: none Digestion: none

REMARKS AND VERBALIZATION FROM REMARKS AND VERBALIZATION FROM


THECLIENT: THECLIENT:
46

VALUES, HABITS, PRACTICES ON HEALTH PROMOTION, MAINTENANCE AND DISEASE PREVENTION

NAME IMMUNIZATI HEALTHY REST EXERCIS USE OF STRESS USE OF


ON OF AND E PROTECTI MANAGEME PROMOTIV
LIFESTYL
FAMILY SLEEP ACTIVITI VE NT E-
E
MEMBER ES MEASURE ACTIVITIES PREVENTI
PRACTICE VE
S HELATH
SERVICES
Liza COMPLETE Usually Sleeps at Goes to Uses Chit Use of
Manangk eats 9pm and work by katol as chatting herba;
ila vegetables wakes up walking mosquito with medicines
and dried at 5am killer and neighbors and over
fish uses the
slippers counter
drugs
Cecilia COMPLETE Usually Sleeps at Only Uses Chit Use of
Manangk eats 8pm and takes katol as chatting herba;
ila vegetables wakes up small mosquito with medicines
and dried at 4am distance killer and neighbors and over
fish walks uses the
slippers counter
drugs
Jerry COMPLETE Usually Sleeps at Goes to Uses Drinks Use of
Santiago eats 9pm and work by katol as alcohol herba;
vegetables wakes up walking mosquito medicines
and dried at 5am killer and and over
fish uses the
counter
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slippers drugs
Radeza INCOMPLET Usually Sleeps at Goes to Uses Chit Dependent
Manangk E eats 8pm and work by katol as chatting from
ila vegetables wakes up walking mosquito with parents
and dried at 5am killer and neighbors
fish uses
slippers
Jr INCOMPLET Usually Sleeps at Takes Uses Playing with Dependent
Manangk E eats 9pm and small katol as their from
ila vegetables wakes up distance mosquito neighbors parents
and dried at 5am walk killer and siblings
fish
Adrian INCOMPLET Usually Sleeps at Takes Uses Playing with Dependent
Manangk E eats 9pm and small katol as their from
ila vegetables wakes up distance mosquito neighbors parents
and dried at 5am walk killer and siblings
fish
Gerlie COMPLETE Usually Sleeps at Takes Uses Playing with Dependent
Manangk eats 9pm and small katol as their from
ila vegetables wakes up distance mosquito neighbors parents
and dried at 7am walk killer and siblings
fish
Jecel COMPLETE Usually Sleeps at Takes Uses Playing with Dependent
Mae eats 9pm and small katol as their from
Santiago vegetables wakes up distance mosquito neighbors parents
and dried at 6am walk killer and siblings
fish
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Charity COMPLETE Usually Sleeps at Takes Uses Playing with Dependent


Santiago eats 9pm and small katol as their from
vegetables wakes up distance mosquito neighbors parents
and dried at 6am walk killer and siblings
fish
Jonald ONGOING On Usually n/a Uses n/a Dependent
Santiago breastfeedi sleeps at bonet, from
ng 8pm but gloves and parents
wakes up socks
at
12midnig
ht or
3am and
continue
s to go
back to
sleep
until
7am
49

GORDONS FUNCTIONAL HEALTH PATTERN

Liza Manangkila
Description Assessment
Health perception and health Perceived level of health and well She doesnt smoke nor drink
management being, and practices for alcoholic beverages, and she said
maintaining health. Habits that shes able to complete her
may be detrimental to health are immunization. Doesnt perform
also evaluated, including smoking regular self breast examination.
and use of alcohol or other drugs.
Nutrition and metabolism Pattern of food and fluid intake No allergies to food, likes to eat
relative to metabolic needs. The meat and dish. No discomfort felt
adequacy of local nutrients during swallowing, chewing or
supplies is evaluated. digestion. Good skin turgor noted
drinks 6-8 glass/day with fair
complexion.
Elimination pattern Excretory pattern (GI, GU and She has no difficulties in urinating
Skin). Incontinence, constipation, and removing her bowel. No usual
diarrhea, and urinary retention pattern in voiding and defecating.
may be identified. Usually void 3-5 times a day, no
blood noted in the stool and uine.
Activity and exercise Activities of Daily Living (ADLs) Goes to work by walking. She
requiring energy expenditure emphasized that she has no time
including self-care activities. for exercise, does daily households
Assess major body system involved chores. No use of any assistive
with the activity and exercise device.
including respiratory,
cardiovascular, and
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musculoskeletal systems.
Cognitive and perception Ability to comprehend and use Achieved elementary level of
information. Assess sensory education. No recent change in
functions. Sensory experience such memory.
as pain and altered sensory input
may be identified and evaluated.
Sleep and rest Sleep, rest and relaxation She is able to sleep uninterrupted
practices. Dysfunctional sleep with no problems in sleeping.
patterns and fatigue may be Sleeps 6-8 hours a day.
identified.
Self-perception and self-concept Attitudes towards self, including Calm and very responsive during
identity, body image, and sense of the interview.
self worth. Level of self-esteem and
response to threats of self-concept.
Roles and relation Roles in the world and other She is living with her family. She
relationships. Satisfaction with goes to work to provide the needs
roles, role strain, or dysfunctional of her family. Problems especially
relationship may be further financially was one of the thing
evaluated. that seen difficult to handle.
Sexuality and reproduction Satisfaction/dissatisfaction with She is satisfied with her sexual
sexual patterns and reproductive partner. No history of vaginal
functions. Concerns with sexuality discharges, bleeding or lesions.
may be identified.
Coping and stress tolerance Perception of stress and coping No stressful or traumatic events in
strategies. Support systems are the past year. Feels relaxed but
evaluated, and symptoms of stress gets anxious when they argue
are noted. Effectiveness of coping
51

strategies in terms of stress about their financial needs.


tolerance may be evaluated.
Values and belief Values, belief, and goals that may She is catholic but doesnt go to
be guide choices or decisions. church regularly.

Cecilia Manangkila
Description Assessment
Health perception and health Perceived level of health and well Usual health status is good. She is
management being, and practices for not taking or using any tobacco,
maintaining health. Habits that alcohol or prohibited drugs.
may be detrimental to health are Doesnt perform regular self-breast
also evaluated, including smoking examination. No recent surgery.
and use of alcohol or other drugs.
Nutrition and metabolism Pattern of food and fluid intake Current weight is 51 kilograms.
relative to metabolic needs. The Usual intake of corn rice and
adequacy of local nutrients vegetables. She is not taking any
supplies is evaluated. supplements/vitamins. Her
appetite is good as she verbalizes
it. no discomfort felt during
swallowing or chewing.
Elimination pattern Excretory pattern (GI, GU and No usual pattern in defecating but
Skin). Incontinence, constipation, usually defecates once a day. Stool
diarrhea, and urinary retention characteristics were soft, variable,
may be identified. and brownish in color. She usually
voids 3-5 times a day. No
discomfort felt during voiding or
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defecating. No blood noted in the


stool and urine.
Activity and exercise Activities of Daily Living (ADLs) She is a widow and takes care of
requiring energy expenditure her grandchildren. Doesnt exercise
including self-care activities. regularly but only takes small
Assess major body system involved distance walks. Her leisure time
with the activity and exercise spends it on resting and doing
including respiratory, household chores. No use of any
cardiovascular, and assistive devices.
musculoskeletal systems.
Cognitive and perception Ability to comprehend and use Elementary level of education.
information. Assess sensory Doesnt wear any hearing aids or
functions. Sensory experience such glasses or any devices.
as pain and altered sensory input
may be identified and evaluated.
Sleep and rest Sleep, rest and relaxation Generally rested and ready for
practices. Dysfunctional sleep daily activities after sleep. Usually
patterns and fatigue may be sleeps 5-8 hours per day. There
identified. were no sleeping problems and
doesnt take any medications to aid
sleep.
Self-perception and self-concept Attitudes towards self, including During assessment she appears
identity, body image, and sense of calm and alert. According to her
self worth. Level of self-esteem and daughter, Mrs Cecilia is very
response to threats of self-concept. patient in taking care of her
grandchildren.
Roles and relation Roles in the world and other She is a widow. Lives together with
53

relationships. Satisfaction with the family of her daughter, Liza


roles, role strain, or dysfunctional Manangkila. Maintains a good
relationship may be further relationship with her family and
evaluated. neighbors. Arguments cant be
denied due to lack of financial
resources
Sexuality and reproduction Satisfaction/dissatisfaction with No history of vaginal discharges,
sexual patterns and reproductive bleeding or lesions. Doesnt have
functions. Concerns with sexuality any recent pap smear examination
may be identified. or mammogram. No pelvic or rectal
problems. Not sexually active
Coping and stress tolerance Perception of stress and coping No stressful or traumatic events in
strategies. Support systems are the past year. Feels relaxed but
evaluated, and symptoms of stress gets anxious when they argue
are noted. Effectiveness of coping about their financial needs.
strategies in terms of stress
tolerance may be evaluated.
Values and belief Values, belief, and goals that may She is a Roman Catholic but she
be guide choices or decisions. doesnt go to church regularly.

Jerry Manangkila
Description Assessment
Health perception and health Perceived level of health and well Mr. Jerry consumes 5-10 sticks of
management being, and practices for cigarettes per day and drinks
maintaining health. Habits that alcohol occasionally.
may be detrimental to health are
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also evaluated, including smoking


and use of alcohol or other drugs.
Nutrition and metabolism Pattern of food and fluid intake Eats once or twice a day and he
relative to metabolic needs. The usually takes vegetables and
adequacy of local nutrients drinks 8-10 glasses of water a day.
supplies is evaluated.
Elimination pattern Excretory pattern (GI, GU and He urinates 4-5 times a day with
Skin). Incontinence, constipation, yellowish in color and defecates
diarrhea, and urinary retention once a day with no regular pattern.
may be identified.
Activity and exercise Activities of Daily Living (ADLs) He works as a laborer with a salary
requiring energy expenditure of 1200 pesos per week. According
including self-care activities. to him daily walking is his exercise
Assess major body system involved and his hobby is watching
with the activity and exercise television.
including respiratory,
cardiovascular, and
musculoskeletal systems.
Cognitive and perception Ability to comprehend and use Coherent, no sensory defects and
information. Assess sensory well oriented to time and place.
functions. Sensory experience such
as pain and altered sensory input
may be identified and evaluated.
Sleep and rest Sleep, rest and relaxation He usually sleeps 8:00-10:00 PM
practices. Dysfunctional sleep and wakes up at 4:00-5:00 AM. He
patterns and fatigue may be doesnt have any sleeping problems
identified. but a noisy environment could
55

interrupt his sleep as verbalized.


Self-perception and self-concept Attitudes towards self, including According to his wife he is a loving
identity, body image, and sense of and caring father o is children.
self worth. Level of self-esteem and
response to threats of self-concept.
Roles and relation Roles in the world and other Maintain a good relationship with
relationships. Satisfaction with his family and neighbors.
roles, role strain, or dysfunctional
relationship may be further
evaluated.
Sexuality and reproduction Satisfaction/dissatisfaction with No rectal or pelvic problems. He is
sexual patterns and reproductive satisfied with her sexual partner.
functions. Concerns with sexuality
may be identified.
Coping and stress tolerance Perception of stress and coping To cope up his stress he usually
strategies. Support systems are watches television and drinks
evaluated, and symptoms of stress alcohol
are noted. Effectiveness of coping
strategies in terms of stress
tolerance may be evaluated.
Values and belief Values, belief, and goals that may He is a Roman Catholic but
be guide choices or decisions. doesnt go to church regularly.
56

Radeza Manangkila
Description Assessment
Health perception and health Perceived level of health and well Her usual health status is good.
management being, and practices for Incomplete immunization and no
maintaining health. Habits that recent surgery. Doesnt perform
may be detrimental to health are self breast examination
also evaluated, including smoking
and use of alcohol or other drugs.
Nutrition and metabolism Pattern of food and fluid intake Good appetite. Her usual food
relative to metabolic needs. The intake is salt, dried fish and
adequacy of local nutrients vegetables. Usual fluid intake is
supplies is evaluated. water with 6- glasses a day and no
problem in swallowing, chewing,
and digestion.
Elimination pattern Excretory pattern (GI, GU and Usually defecates in the morning.
Skin). Incontinence, constipation, Doesnt experience bleeding or
diarrhea, and urinary retention constipation. Color of her stool is
may be identified. yellow and no history of diarrhea.
Void 3-5 times a day.
Activity and exercise Activities of Daily Living (ADLs) Her daily activity is taking care of
requiring energy expenditure her baby and no medical condition
including self-care activities. that limits her activity. No regular
Assess major body system involved exercise noted.
with the activity and exercise
including respiratory,
cardiovascular, and
musculoskeletal systems.
57

Cognitive and perception Ability to comprehend and use Pain felt at perineal area due to
information. Assess sensory pregnancy and a pain scale of
functions. Sensory experience such 5/10. No problem in hearing and
as pain and altered sensory input memory. Achieved elementary level
may be identified and evaluated. of education.
Sleep and rest Sleep, rest and relaxation Usually sleeps 8pm-5am with no
practices. Dysfunctional sleep naps and she feel rested. No
patterns and fatigue may be sleeping problems and when the
identified. baby cries it interrupts her sleep.
Self-perception and self-concept Attitudes towards self, including During assessment she appears
identity, body image, and sense of calm and alert.
self worth. Level of self-esteem and
response to threats of self-concept.
Roles and relation Roles in the world and other She is single mother with one
relationships. Satisfaction with child. Limited social activity and
roles, role strain, or dysfunctional has a good relationship with her
relationship may be further family.
evaluated.
Sexuality and reproduction Satisfaction/dissatisfaction with No history of STD, no pelvic and
sexual patterns and reproductive rectal problems. Type of her
functions. Concerns with sexuality delivery is normal, no history of
may be identified. vaginal discharge, bleeding and
lesions.
Coping and stress tolerance Perception of stress and coping No stressful or traumatic event in
strategies. Support systems are the past year. Her usual handling
evaluated, and symptoms of stress of stress is average.
are noted. Effectiveness of coping
58

strategies in terms of stress


tolerance may be evaluated.
Values and belief Values, belief, and goals that may She is a roman catholic and no
be guide choices or decisions. religious restriction but doesnt go
to church regularly.

Jr Manangkila
Description Assessment
Health perception and health Perceived level of health and well Usual health status is fair,
management being, and practices for incomplete immunization and no
maintaining health. Habits that recent surgery in the past year. Not
may be detrimental to health are taking or using tobacco, alcohol
also evaluated, including smoking with prohibited drugs.
and use of alcohol or other drugs.
Nutrition and metabolism Pattern of food and fluid intake Poor appetite description. Usual
relative to metabolic needs. The food intake is salt, sugar and fish.
adequacy of local nutrients He likes chicken, hotdog and cake.
supplies is evaluated. His usual health fluid intake is
water with 6-8 glasses and no
problems in swallowing, chewing
and digestion.
Elimination pattern Excretory pattern (GI, GU and usually defecates in the morning.
Skin). Incontinence, constipation, Doesnt experience bleeding or
diarrhea, and urinary retention constipation. Characteristics are
may be identified. yellowish in color, variable in
amount and soft in consistency.
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Activity and exercise Activities of Daily Living (ADLs) Daily activity is playing around
requiring energy expenditure together with his siblings and
including self-care activities. neighbors and no medical
Assess major body system involved condition that limits activity.
with the activity and exercise
including respiratory,
cardiovascular, and
musculoskeletal systems.
Cognitive and perception Ability to comprehend and use No pain felt during assessment.
information. Assess sensory Sensory status is normal. Can
functions. Sensory experience such speak in moderate pace and has a
as pain and altered sensory input clear tone.
may be identified and evaluated.
Sleep and rest Sleep, rest and relaxation Usually sleeps for 8 hours and
practices. Dysfunctional sleep feels rested after sleeping. No
patterns and fatigue may be sleeping problems and
identified. interruptions.
Self-perception and self-concept Attitudes towards self, including During assessment appeared calm
identity, body image, and sense of and alert.
self worth. Level of self-esteem and
response to threats of self-concept.
Roles and relation Roles in the world and other Active and has a good relationship
relationships. Satisfaction with with his family.
roles, role strain, or dysfunctional
relationship may be further
evaluated.
Sexuality and reproduction Satisfaction/dissatisfaction with No rectal or pelvic problems. Not
60

sexual patterns and reproductive sexually active.


functions. Concerns with sexuality
may be identified.
Coping and stress tolerance Perception of stress and coping No stressful or traumatic event in
strategies. Support systems are the past year.
evaluated, and symptoms of stress
are noted. Effectiveness of coping
strategies in terms of stress
tolerance may be evaluated.
Values and belief Values, belief, and goals that may He is a roman catholic but doesnt
be guide choices or decisions. go to church regularly.

Adrian Manangkila
Description Assessment
Health perception and health Perceived level of health and well Incomplete immunization without
management being, and practices for any recent surgery. Not taking any
maintaining health. Habits that alcohol, tobacco and prohibited
may be detrimental to health are drugs.
also evaluated, including smoking
and use of alcohol or other drugs.
Nutrition and metabolism Pattern of food and fluid intake He eats once or twice a day with
relative to metabolic needs. The good appetite and he usually eats
adequacy of local nutrients vegetables and take 7-10 glasses of
supplies is evaluated. water a day
Elimination pattern Excretory pattern (GI, GU and Urinates 4-5 times a day with
Skin). Incontinence, constipation, yellowish in color and defecates
61

diarrhea, and urinary retention once a day with no regular pattern.


may be identified.
Activity and exercise Activities of Daily Living (ADLs) Watching television in their
requiring energy expenditure neighborhood and play with his
including self-care activities. siblings and neighbors. No regular
Assess major body system involved exercise.
with the activity and exercise
including respiratory,
cardiovascular, and
musculoskeletal systems.
Cognitive and perception Ability to comprehend and use Able to hear in both ears with good
information. Assess sensory eyesight. Appears calm and
functions. Sensory experience such responsive during assessment.
as pain and altered sensory input
may be identified and evaluated.
Sleep and rest Sleep, rest and relaxation He usually sleeps at 8:00-9:00 PM
practices. Dysfunctional sleep and wakes up at 6:00-7:00 AM
patterns and fatigue may be with no sleeping problems.
identified.
Self-perception and self-concept Attitudes towards self, including During assessment he appears
identity, body image, and sense of calm and responsive. No recent
self worth. Level of self-esteem and change in memory.
response to threats of self-concept.
Roles and relation Roles in the world and other He has 7 siblings and sometimes
relationships. Satisfaction with plays with his brother and sister
roles, role strain, or dysfunctional with no relationship problems
relationship may be further within the family.
62

evaluated.
Sexuality and reproduction Satisfaction/dissatisfaction with No rectal or pelvic problems. Not
sexual patterns and reproductive sexually active
functions. Concerns with sexuality
may be identified.
Coping and stress tolerance Perception of stress and coping To cope up his stress he usually
strategies. Support systems are play games with his siblings and
evaluated, and symptoms of stress neighbors
are noted. Effectiveness of coping
strategies in terms of stress
tolerance may be evaluated.
Values and belief Values, belief, and goals that may He is a roman catholic but doesnt
be guide choices or decisions. go to church regularly.

Gerlie Manangkila
Description Assessment
Health perception and health Perceived level of health and well Complete immunization and no
management being, and practices for recent surgery.
maintaining health. Habits that
may be detrimental to health are
also evaluated, including smoking
and use of alcohol or other drugs.
Nutrition and metabolism Pattern of food and fluid intake Good appetite and he usually eats
relative to metabolic needs. The vegetables and take 7-10 glasses of
adequacy of local nutrients water a day.
63

supplies is evaluated.
Elimination pattern Excretory pattern (GI, GU and Urinates 3-5 times a day with
Skin). Incontinence, constipation, yellowish in color and defecates
diarrhea, and urinary retention once a day with no regular pattern.
may be identified.
Activity and exercise Activities of Daily Living (ADLs) Watching television in their
requiring energy expenditure neighborhood and play with his
including self-care activities. siblings and neighbors.
Assess major body system involved
with the activity and exercise
including respiratory,
cardiovascular, and
musculoskeletal systems.
Cognitive and perception Ability to comprehend and use Able to hear in both ears with good
information. Assess sensory eyesight. Appears calm and
functions. Sensory experience such responsive during assesstment.
as pain and altered sensory input
may be identified and evaluated.
Sleep and rest Sleep, rest and relaxation He usually sleeps at 7:00-8:00 PM
practices. Dysfunctional sleep and wakes up at 7:00-8:00 AM.
patterns and fatigue may be
identified.
Self-perception and self-concept Attitudes towards self, including During assessment he has skin
identity, body image, and sense of lesions in his upper extremities.
self worth. Level of self-esteem and
response to threats of self-concept.
64

Roles and relation Roles in the world and other He has 7 siblings and sometimes
relationships. Satisfaction with plays with his brother and sister.
roles, role strain, or dysfunctional No relationship problems.
relationship may be further
evaluated.
Sexuality and reproduction Satisfaction/dissatisfaction with No rectal or pelvic problems. Not
sexual patterns and reproductive sexually active.
functions. Concerns with sexuality
may be identified.
Coping and stress tolerance Perception of stress and coping To cope up his stress he usually
strategies. Support systems are play games with his siblings and
evaluated, and symptoms of stress neighbors. Eating.
are noted. Effectiveness of coping
strategies in terms of stress
tolerance may be evaluated.
Values and belief Values, belief, and goals that may He is a roman catholic but doesnt
be guide choices or decisions. go to church regularly.

Jecel Mae Manangkila


Description Assessment
Health perception and health Perceived level of health and well Complete immunizations. No
management being, and practices for recent surgery in the past year.
maintaining health. Habits that Doesnt use any prohibited drugs
may be detrimental to health are and alcohol
also evaluated, including smoking
and use of alcohol or other drugs.
65

Nutrition and metabolism Pattern of food and fluid intake Currently weighs 12.5 kilograms.
relative to metabolic needs. The No discomfort felt during eating,
adequacy of local nutrients chewing or swallowing. Usually
supplies is evaluated. eats corn rice and vegetables. She
doesnt like to eat durian and
drinks water 5-7 glasses per day.
Elimination pattern Excretory pattern (GI, GU and Defecates once a day in no usual
Skin). Incontinence, constipation, time. Characteristics are soft,
diarrhea, and urinary retention variable in amount and brownish
may be identified. in color. No blood noted. Voids 5-6
times a day and there were no pain
or discomfort felt
Activity and exercise Activities of Daily Living (ADLs) Playing with friends and helping in
requiring energy expenditure some household chores were her
including self-care activities. usual activities. Likes to play
Assess major body system involved bahay-bahayan with her
with the activity and exercise neighborhood friends.
including respiratory,
cardiovascular, and
musculoskeletal systems.
Cognitive and perception Ability to comprehend and use She doesnt go to school yet. Shes
information. Assess sensory shy at first but gets a little bit
functions. Sensory experience such talkative when she feels
as pain and altered sensory input comfortable to the person shes
may be identified and evaluated. talking to.
Sleep and rest Sleep, rest and relaxation Sleeps for 6-8 hours per day and
practices. Dysfunctional sleep feels rested after sleeping.
patterns and fatigue may be
66

identified.
Self-perception and self-concept Attitudes towards self, including During assessment, she appears
identity, body image, and sense of shy and her grandmother said that
self worth. Level of self-esteem and shes good in helping her doing
response to threats of self-concept. some household chores.
Roles and relation Roles in the world and other No relationship problems
relationships. Satisfaction with
roles, role strain, or dysfunctional
relationship may be further
evaluated.
Sexuality and reproduction Satisfaction/dissatisfaction with Not applicable
sexual patterns and reproductive
functions. Concerns with sexuality
may be identified.
Coping and stress tolerance Perception of stress and coping Not applicable
strategies. Support systems are
evaluated, and symptoms of stress
are noted. Effectiveness of coping
strategies in terms of stress
tolerance may be evaluated.
Values and belief Values, belief, and goals that may Shes a Roman Catholic but
be guide choices or decisions. doesnt go to church regularly
67

Charity Manangkila
Description Assessment
Health perception and health Perceived level of health and well Appears to be active and playful
management being, and practices for during assesstment.
maintaining health. Habits that
may be detrimental to health are
also evaluated, including smoking
and use of alcohol or other drugs.
Nutrition and metabolism Pattern of food and fluid intake Able to eat any foods given to her.
relative to metabolic needs. The And she has no food allergies
adequacy of local nutrients
supplies is evaluated.
Elimination pattern Excretory pattern (GI, GU and Usually voids 3-5 times a day and
Skin). Incontinence, constipation, defecates once a day
diarrhea, and urinary retention
may be identified.
Activity and exercise Activities of Daily Living (ADLs) Has no regular exercise. But tends
requiring energy expenditure to play a lot.
including self-care activities.
Assess major body system involved
with the activity and exercise
including respiratory,
cardiovascular, and
musculoskeletal systems.
Cognitive and perception Ability to comprehend and use She doesnt go to school yet. Shes
information. Assess sensory shy very talkative when she feels
functions. Sensory experience such comfortable to the person shes
68

as pain and altered sensory input talking to and shes very playful.
may be identified and evaluated.
Sleep and rest Sleep, rest and relaxation Able to sleep uninterrupted.
practices. Dysfunctional sleep
patterns and fatigue may be
identified.
Self-perception and self-concept Attitudes towards self, including Calm and responsive during the
identity, body image, and sense of assessment.
self worth. Level of self-esteem and
response to threats of self-concept.
Roles and relation Roles in the world and other Tends to take care of her younger
relationships. Satisfaction with brother which is still an infant.
roles, role strain, or dysfunctional
relationship may be further
evaluated.
Sexuality and reproduction Satisfaction/dissatisfaction with Not applicable.
sexual patterns and reproductive
functions. Concerns with sexuality
may be identified.
Coping and stress tolerance Perception of stress and coping No recent stressful or traumatic
strategies. Support systems are event
evaluated, and symptoms of stress
are noted. Effectiveness of coping
strategies in terms of stress
tolerance may be evaluated.
Values and belief Values, belief, and goals that may Roman Catholic but doesnt go to
69

be guide choices or decisions. church regularly

Jonald Santiago
Description Assessment
Health perception and health Perceived level of health and well N/A
management being, and practices for
maintaining health. Habits that
may be detrimental to health are
also evaluated, including smoking
and use of alcohol or other drugs.
Nutrition and metabolism Pattern of food and fluid intake Client is on breastfeeding
relative to metabolic needs. The
adequacy of local nutrients
supplies is evaluated.
Elimination pattern Excretory pattern (GI, GU and Client has no problem in urinating
Skin). Incontinence, constipation, and removing bowel
diarrhea, and urinary retention
may be identified.
Activity and exercise Activities of Daily Living (ADLs) N/A
requiring energy expenditure
including self-care activities.
Assess major body system involved
with the activity and exercise
including respiratory,
cardiovascular, and
musculoskeletal systems.
70

Cognitive and perception Ability to comprehend and use N/A


information. Assess sensory
functions. Sensory experience such
as pain and altered sensory input
may be identified and evaluated.
Sleep and rest Sleep, rest and relaxation Client is able to sleep
practices. Dysfunctional sleep uninterrupted
patterns and fatigue may be
identified.
Self-perception and self-concept Attitudes towards self, including N/A
identity, body image, and sense of
self worth. Level of self-esteem and
response to threats of self-concept.
Roles and relation Roles in the world and other N/A
relationships. Satisfaction with
roles, role strain, or dysfunctional
relationship may be further
evaluated.
Sexuality and reproduction Satisfaction/dissatisfaction with N/A
sexual patterns and reproductive
functions. Concerns with sexuality
may be identified.
Coping and stress tolerance Perception of stress and coping N/A
strategies. Support systems are
evaluated, and symptoms of stress
are noted. Effectiveness of coping
strategies in terms of stress
71

tolerance may be evaluated.


Values and belief Values, belief, and goals that may N/A
be guide choices or decisions.