NURSING HISTORY 2:00 in the afternoon at Manuel J. Santos Hospital I was assigned to Mr. Emberto Mantilla.

I ask him why hes here and he told me that he feel dizziness due to hypertension that lead to mild stroke. It was hes first time to be admitted because of mild stroke because usually hes being admitted due to LBM and for some operations. Hes a 50yrs old who live at Purok5, San Isidro, San Francisco, Surigao del Norte. I ask him when his birthday is and he directly answered me January 15, 1962 in the morning, then his birthplace was at Placer, Surigao del Norte. He was delivered natural type of giving birth a type that dont need any medication and has no pain. Next am I ask my patient if he had already been immunized and he answer: measles vaccination and cholera vaccination. He has no allergies anyway in medications, food and environment. The only childhood illnesses that he remembers are chickenpox and sore eyes and no major illness. In the past history hospitalization he only remembered that he was admitted in Surigao provincial hospital due to loose bowel movement or LBM. The past operations that he had been are the removal of the intestine during 2000 and sewing the urinary bladder 2009 both during at Davao provincial hospital. Mr. Embertos wife is Mrs.Josephine 49yearsold, they have four children named: (the twins) Kristine Jane and Kris John both 14yearsold, Audrey Ann 10yeearsold and Diana 7yearsold. I ask the patient if this illness has a big impact for his activity daily living and he answered me Yes, especially the business I also ask him hes expectation in the hospital and he told me that I hope I can go home immediately. For his habits Mr. Emberto always drink alcohol most likely 1times a week but then in the present he never drink same for the tobacco and he never smoke at this moment and for the caffeine a big YES 3times a week. The activities of daily living of Mr.Emberto in the morning are walking and sitting, in the afternoon traveling is the most common he does every day as what he told me and in the evening he usually watch TV and he sleeps 8:00pm. Mrs. Josephine is the family decision maker and the patients family crisis is that the children were so worried about their dad. For the check-ups the last visit he remember was last 2010 in Davao Medical Center and hes physician is Dr.Zavala and other one that he remember also is in San Francisco Hospital and hes physician is Dr.Gellion . For the examinations he does the dental last 1998 and it was just fine no implications. For his diet in breakfast the usual food that he ate are egg, hotdog and rice every 8:00am, while in lunch and dinner are vegetables, fish and rice every 12:00noon for the lunch and 7:00pm for the dinner. For the environment they live in a rural area, their culture is Bisaya and they have a business they sell BALOT. The only

medication that he remembers to take is aspirin since he and his wife cant remember what medication hes taking and the reaction of hes body is normal. No exercise pattern was being performed by the patient. The patient dont have any trouble in sleeping and hes duration of sleep in night is 10hours. Hes income came from hes business which is balot. For hes educational attainment he finished elementary at San Isidro Elementary School but he doesnt remember if what year he had graduated. And in high school he graduated in Urios in their place. There is no laboratory test that he has been thorugh for this admition. He cant rememeber what month or age he can sit and walk without support, also able to say the first word. Likewise in Able to control his defecation and urination he cant remember his age. But then for the age of he can write and read well he can remember he was just about 7yearsold. There are no unsual motor skills, language and social in his developmental according to him.

NURSE PATIENT INTERACTION NURSE Maayong hapon Sir. Ako si Kathleen Urquia sir incoming 2ndyear ng FSUU puwede ko mag.interview nimo sir? Kung okay ra nimo sir naa unta koy ipangutana about sa pamilya labi na sa imong panglawasan sir. Unsay pangalan nimo sir? Pila may edad nimo sir? PATIENT Maayong hapon sad. Okay raman. ANALYSIS/INTERPETATIO N The patient is very accommodating and has showed willingness in participation in the interview. The patient shows interest in the topic.

Sige okay ra, unsa may pangutana nimo?

Emberto Mantilla

To identify the client and to know some personal data. To identify the client and to know some personal data. To identify the client and to know some personal data. To identify the client and to know some personal data. To identify the client and to know some personal data. To identify the client and

50

Asa man ka nag-puyo sir? Kanus-a man imong birthday sir? Asa man ka gipanganak sir? Kung kabalo ka unsa

Purok 5, San Isidro, San Francisco, Surigao del Norte. January 15, 1962.

Placer,Surigao del Norte.

Basta kay buntag man

orasa ka gipanganak sir? Unsa man na pagpaanak nimo sir? CS ba or natural ra sir? Walay mga pag-lisod sa pag-panganAk sa imoha sir? Kung kadumdum ka sir unsay mga immunization na humana nimo sir? Wala kay mga allergy sa mga tambal, pagkaon ug sa Tong bata paka sir naa kay nadumduman na mga sakit ug unsa pod tuiga? Unsa may gianhi nimo sir? pta Sauna sir naa kay nadumduman na nahospital ka sir? Unsa to tuiga sir ug nganu na hospital ka? Naa kay mga opera na gi-agihan sir sauna?

to. Natural raman.

to know some personal data. To identify the client and to know some personal data. To identify the client and to know some personal data. To identify what immunization that the patient already taken. To identify if the patient is hypoallergic. To enable to know the past illness of the patient. To enable to identify the patients chief of complains.

Wala man pod.

Sa akong nadumduman kay sa tipdas ug cholera lang. Wala man.

Chickenpox raman akong nadumduman wala sad ko kadumdum unsa to tuiga. Nag-lipong ko kay highblood daw.

Wala ko kadumdum man ug unsa tuiga basta kay gi-LBM ko ato sa Surigao Provincial Hospital ko na admit ato. Tong gitanggal akong tinae kay sa San Fransisco 2000 man to tapos tong gi-tahi akong gallbladder 2009 to siya. Josephine, highblood ra

To know his past health history.

The patient can still remember clearly what operation he had been through & the year also. To know their health condition or usual heath

Puwede mahibaw-an sa pangalan sa imong misis

sir? Naa siyay mga sakit pod sir? Kanang sa mga anak nimo sir puwede mahibaw-an ang mga ngalan ug naa ba sila mga sakit pati pod edad nila sir kung okay ra. Sa nahitabo karon sir na apektohan ba imong pang-adlaw na ginabuhat labi na sa pangginabuhi? Unsa may inyo expectation diri sa hospital sir? Naay nahitabo na mga accidente nimo sir? Puwede mahibaw-an sir if ga-inom ka kag mga alcohol sir ug pila man sa isa kasemana? Ga-yosi ka sir pila man sad sa isa kasemana? Sa kape sir? Kapila sad? Sa pang-adlaw-adlaw nimo sir unsay ginabuhat nimo kada buntag pag-mata nimo? Pila ka oras man ka naga-lakaw sir? Sa hapon sir unsa sad

man iyaha. Kristine Jane ug Kris John kaluha na sila 14, Audrey Ann 10 dayun si Diana 7. Wala man silay mga sakit. O okay di man ko matarbaho.

problems. To identify the members of the family and to know them better.

To enable to know the affect of the illness.

Na unta maayo nako.

The patient wants to be cure. To enable to know the past accidents of the patient. To identify the habits of the patient.

Naa tong gipusilan ko.

Sauna raman karon wala naman. Wala sad ko kadumdum ug kapila. Sauna ra pod. Kada buntag mga ka3 ko sa semana. Ingkoray lang lakawlakaw sad.

To identify the habits of the patient. To identify the habits of the patient. The patient doesnt have healthy activities.

Wala man ko kadumdum kay putol-putol man sad. Ga-byahe man mi permi

The patient cant really remember how long he walks. To enable to identify the

ginabuhat nimo sir? Sa gabie sir unsa man ginabuhat nimo? Unsa orasa man ka naga-tulog sir? Unsay relation nimo sa imong kauban man sir? Kinsa may tigdecide sa inyong pamilya sir? Sa nahitabo sir unsa may apekto sa inyo pamilya? Kadumdum paka sir sa mga checkups nimo sa una sir? Ug kinsay doctor nimo sir? Ug unsa pod toh tuiga?

mao raman kay para sa among business. Tan-aw lang TV. 8:00pm tulog nako ana. Akong asawa. Siya. (pointing to his wife) Akong mga anak kay nabalaka man nako. Akong nadumduman kay sa Davao Medical Center si Dr.Gellion tong 2010 ug sa San Fransisco Hospital si Dr.Zavala wala ko kadumdum unsa toh na tuig.

patients daily living. To enable to identify the patients daily living. The patient has a good hobby in sleeping. The patient can identify the person.

The patient can still remember his physician.

Kadumdum sad ka sa Tong sa dentist lang mga sauna na mga 1998 man to okay ra examinasyon na gibuhat man wala may daot daw. sa inyo sir? Unsa tuiga? Ug unsa sad ingon sa Dr. sir? Unsay mga ginakaon inyo sa buntag sir ug unsa orasa mo mamahaw? Sa udto sir? Ug panihapon sad sir? Rice man mi dayon itlog ug hotdog man kasagaran sud-an dayon 8:00am mi mamahaw. Rice gihapon ug sud-an kay gulay ug isda. Mao ra gihapon rice dayon gulay ug isda. It shows that the patient doesnt eat too much The patient has preservatives in the meal.

meat. Asa man mo ga-puyo sir? Sa syudad ba o sa baranggay? Unsa may culture ninyo sir? Unsa may tarbaho ninyo sir? Unsa sad ginatumar nimo na tambal sir? Kada kanus-a man nimo gina-inom ug unsa sad response sa imong body sir? Ga-exersice pod ka sir? Sa pag-tulog nimo sir okay ra? Di ka maglisod ug tulog? Ug udto sir ga-tulog ka? Puwede ko mangutana sir about imong pagskwela sauna sir? Asa ka nag-Elementary sir ug unsa ka na tuig ni graduate? Asa pod ka naghighschool sir? Sa karon sir nay gibuhat na laboratory examination nimo? Kadumdum paka sir ug pila ka kabulan na Barangay.

Bisaya. Naa ra business. Sako nadumduman aspirin lang. Akong asawa man ga-kuwan sa mga tambal gud. Apekto kay okay ra. Dili man. Okay lang. Dili man. The patient has an idea for the medication hes been taking.

The patient has lack of exercise. The patient has no difficulty in sleeping.

Dili sad. Oo. Kutob highschool raman ko. To know the educational background of the client.

Sa San Isidro Elementary To know the educational School wala nako background of the client. kadumdum unsa tuiga man. Urios sa amo-a. Wala man. To know the educational background of the client. To know the patients present examinations. To enable to know the

Wala jud.

nakaingkod na din a kailangan hawiran sa uban tao? Sa paglakaw sir? Pila pod kabulan naka sir na nakaistorya ka? Unsa pod edad nimo na macontrol na nimo sir imong pagkalibang? Pag-ihi sir? Tong bata paka sir unsa may kasagaran ginadula man nimo? Pilay edad nimo sir na nakasulat nakag maayo? Nakabasa sir? Tong bata paka sir wala kay pag-lisod sa pagsabot, pagistorya ug paginteract sa uban tao? Wala pod. Wala naman ko kadumdum. Wala sad ko kadumdum.

childhood of the patient.

The patient cant remember.

Wala pod. Trompo ug basketball rmay na dumduman nako. 7 7 Wala man sad. The patient was active in his childhood. The patient has late developmental. The patient has late developmental.