NURSING HEALTH HISTORY

BIOGRAPHIC DATA
Name: Eladio Guttierez Age: 77yrs old Address: Sitio Dalampadigan, Pagbilao,Quezon Gender: Male Race: Filipino Birthday: February 18, 1933 Place of birth: Pagbilao, Quezon Religion: Roman Catholic Educational level: Highschool Graduate Occupation: Fisherman Informant: the patient and relatives Attending Physician: Dr. Tiopianco Chief complaint: abdominal pain with difficulty of urination Diagnosis: prostate adenocarsinoma with minimal ptb

REASONS FOR SEEKING HEALTH CARE:

The patient, Eladio Guttierez suffered from abdominal pain with difficulty of urination associated with cough and cold for two days. Although the patient said he did not worry much about his condition because he trust the health care team, He feels bad about his hospitalization and expresses being homesick.

HISTORY OF PRESENT HEALTH CONCERN

C - the patient experience intolerable pain and burning sensation when urinating. O the patient started experiencing abdominal pain and difficulty of urination last Friday, 2 days ago L the patient feels abdominal pain on the hypogastric region. D the patient has experienced this condition for two days S on a scale of 1-10, 10 being the highest, the patient rated it 6 for the severity of the pain he experience P nawawala ang sakit pag pinipispis ko ang tiyan ko hanggang makatulog ako as patient verbalized A the patient experience intolerable pain and burning sensation when urinating accompanied by cough and cold

PAST HEALTH HISTORY

Eladio Guttierez has no problems at birth. He has incomplete immunizations for newborn because the immunization program that time was not yet promoted. Based from the patients chart he has many laboratory examinations, which we do not know whether it was from previous hospitalization or check up because the patient claims that this is his first hospitalization which is quite doubtful for his age. Although he confirmed that last Sunday, Oct. 3, he was diagnosed of having prostate adenocarsinoma with minimal PTB. It was also the patients first time to undergo surgery, last where he had an orchiectomy. He has not had any previous accidents and he has no allergies.

RELEVANT FAMILY HISTORY

According to the patient, they have a history of hypertension on his motherside. His father died due to an accident while his mother died due to her old age. He also said that his family members were all quite healthy and they have no history of other illness such as TB, DM etc.

REVIEW OF SYSTEMS
Skin: the skin is rough and dry with freckles. Has dark complexion. No skin diseases. Hair: evenly distributed with presence of white hair. Head: the patients head is well rounded. No complaints of headache or dizziness. Teeth: incomplete set of teeth, has dentures. Yellowish in color. Eyes: has blurred vision, does not wear glasses. Has cataract. Ears: sometimes have difficulty hearing. No complaints of discharges, infection or ringing in the ears. Nose: no nosebleeds, with colds. Lips: dry, crackled lips.

Mouth and throat: no complaints of sore throat, inflammation and difficulty of swallowing. Cardiovascular System: cardiac rate is normal ( beats per min) Respiratory system: with cough but no complaints of chest pain and difficulty of breathing Gastrointestinal system: with abdominal pain on hypogastric region, no complaints of nausea and vomiting Genitourinary system: with difficulty and pain of burning upon urinating. Neurological system: no seizures or paralysis Musculoskeletal system: no complaints of weakness, numbness or tingling sensation.

LIFESTYLE The patient is 77 years old, married with 4 children. He works as a fisherman and lives close to the sea. He spent most of his life in Bantigue, Pagbilao. According to the patient he doesnt take any vitamins and his work is his main form of exercise. He also said he likes eating vegetables but it is often not available in their area, he doesnt follow any diet and eats the usual Filipino diet of rice with ulam. He also admits that he drinks too much coffee and thats probably why he has difficulty in sleeping at night. He doesnt drink and just recently (3 months ago) stopped smoking.

DEVELOPMENTAL
In Erik Eriksons Psychoanalytic theory, my patient, Eladio Guttierez, falls under the last stage which is Integrity Vs. Despair. In this developmental stage many older adults review their lives with a sense of satisfaction even with their inevitable mistakes, while some see themselves as failures. Based on my interaction with my client, he seems to be satisfied with his life and how it turned out to be. They have a good family relationship. His children have families of their own and stable living. Even if he only lives with his wife and one grandson whos parents work abroad, his other children live close to their neighborhood and he describes home to be entertaining especially because of his grandchildren. He also did not feel depressed with his condition and said he trust the health care team. He seems to have acceptance of death and have found contentment in his life.