Health Assessment Lab

Health History

Submitted by:

Guevarra, Angelica Paula P.

BSN 1-6

November 2018
I.PATIENT’S BIOGRAPHICAL INFORMATION

Name: Basilisa Judaya

Address:Tanza Cavite
Age:49
Gender:Female
Race:Filipino
Marital Status:Single
Occupation:School Janitress
Religious Affiliation:Born Again Christian
Health Care Financing:Daughter’s Income

II. CHIEF COMPLAINT

Easily gets tired and pain in the neck area (Thyroid).
\
III. PRESENT ILLNESS
The client was diagnosed with high blood pressure on 2005, after giving birth to her
fourth child. Since then, the patient started medication for her high blood this includes
Lorazepam and Atorvastatin. On 2015, the client felt pain in her lower neck. It was checked
during a medical mission and an ultrasound of the client’s neck was made. The results of the
results of the ultrasound revealed that the client has hypothyroidism.

IV. PAST ILLNESS

Other than pre-natal check up when she was pregnant, the client has no medical history.
The only procedure that the client experiencedis dilation and curettage procedure after suffering
from miscarriage on 2009. There is also no reported accidents and injuries. The Client is
complete of immunization. Last shot was for anti-tetano in 2002. There is no known food or drug
allergy in the patient.

V. FAMILY HISTORY
Client’s mother side has a history of hypothyroidism which was the known primary cause
of her grandmother’s death in 2005. On the father’s side, there is a history of high blood, which
his late grandfather and father have. Children of the client has no reported history of genetic
diseases.
VI. PSYCHOSOCIAL HISTORY
The client has no history of smoking, drink alcoholic beverages as well taking drugs.
Leisure activities of the client includes cleaning the house, watching television or listening to
radio. The client describe her workplace as stressful due to heavy workloads, and most time she
needs to deal with importunate students and parents as well as co-workers. Another factor that
contributes to her stress is the late monthly salary. Because of this, the client’s family is not
financially stable but her eldest daughter who is a domestic helper and her significant other who
is a driver help her in financial needs. Client has a good relationship with her siblings as they
contact each other time to time. As for the neighborhood the client stated that she does not have a
good nor bad relationship with her neighbors. She spent most of her time at work and house so
she doesn’t have much time to socialize with her neighbors.

VI. GORDON’S 11 TYPOLOGY

Pattern Before During Analysis Interpretatio
n
Health Notaware that her Having diagnosed of Became health Health
Perception– disease maybe high blood and aware not only perceptions also
Health genetic.Can do hypothyroidism, the for herself but predicted
Management any heavy loads of client now become for her family perceived control
and use of
Pattern activities daily. more aware of herself, also.
control-
her health and as well enhancing
the health of the family. strategies
Sheeducate her family indealing with
members about her age-related
health and help them to challenges, as
prevent the disease to assessed in 1995
occur in them. Have (Menec, 1999)
difficulty to finish
heavy load work in one
go.
Nutritional– The client eat Diet became restricted
Drastic change The study
Metabolic Pattern whatever food is after the diagnosis of
was made in the showed that the
served. She cannot hypothyroidism.Intake
diet. Consume proportion of
let her day pass of rice is reduced, and
food in deaths associated
with suboptimal
without eating often makes banana a
moderation
diet varied across
rice. Has a high substitute for rice. Less
unlike before demographic
intake of caffeine intake of coffee, and
that she eats groups. For
– every morning, only black coffee with
whatever is instance, the
afternnoons, small amount of sugar
served. proportion was
sometimes at is consumed every higher among
night. The client morning. Daily water men than women
seldom drink intake is more than 8- (Hicklin, 2017).
sweetened drinks, 10 cups.
more intake of
water.
Elimination Used to take Take bowels every Bowel Exhaustion,
Pattern eliminate vowels morning. If she hadn't movements are weakness, feeling
 regulaly every eaten vegetables or regular every run down,
morning without fruits stool is slighthly morning sluggish,
difficulty. The hard to eliminate. The however, the overtired, or just
consistency and urge to urinate is client is plain pooped
color of stool is experienced from time experiencing out—fatigue is a
normal. to time because of too difficulty in common
There is no much water intake. excreting stool. symptom of
reported difficulty thyroid disease
in urination. (Shomon, 2018)
Cognitive Pattern Able to remember Understands well her Can understand Several studies
well. Activities disease and tries to well. But have examined
that helps her manage it. Mainly sometimes associations
learn more is because of age, the become more between
hypothyroidism
through reading client become forgetful forgetful that
and cognitive
newspaper or for example she forgets when she was problems in the
watching where is her eyeglasses younger. elderly with
television. even its on her head mixed results.
and such. Difficulty in Symptoms of
decision making is not hypothyroidism
experienced. She has in adults can
her significant other include cognitive
and children to make problems such as
decisions with.She decreased
memory,
more focused on work
depressed mood
and earning money so and a general
time for reading or mental slowing
watching is lessen. (Papaleontiou)
Activity-Exercise Before having The only means of Less physical Overt
Pattern children or family physical activity is her activity was hypothyroidism
of her own, she daily work as a school made that may is associated with
has plenty time for janitress. Most of her also contributed modest weight
gain, but there is
herself and can go daily activities includes to weight gain.
a lack of clarity
out for exercise. cleaning snd looking regarding
She jogged every for children in the subclinical
morning around school she works. hypothyroidism.
the neighborhood There are times when Novel view
without easily she worked too much indicates that
getting tired. she gets dizzy and changes in
disoriented. Admist of thyroid-
the difficulty in her stimulating
work she learnt to be hormone (TSH)
could well be
satisfied with it.
secondary to
obesity. The
increasing
prevalence of
obesity further
confounds
definition of
normal TSH
range in
population
 studies. (Samyal,
2016)
Sleep-Rest Pattern Since she does not Due to the demands of Rest and sleep Some people
work before and her work, the client's deprived. with
only works inside rest time is the time hypothyroidism
her house, she can where she gets to sleep. and sleep apnea
will experience
control her time Typically she would go
insomnia. Due to
and therefore has to bed around 11 to 12 the poor quality
ample time to rest. am then wakes up at 3 of the sleep, the
or 4 am. She snores time in bed may
most of the time and be extended.
sometimes have Going to bed
difficulty falling asleep. early, or staying
in bed too late,
may lead to
problems falling
asleep at the
beginning of the
night. (Peters,
2018)
Self-Perception– She described Only her physical state Still optimistic Optimism and
Self-Concept herself an changed, she's still for herself and health appear to
Pattern optimistic and optimistic because she for the family. be at least
happy person. know there is a support moderately
correlated.
system that helps her.
Optimism has
been shown to
explain between
5–10% of the
variation in the
likelihood of
developing health
conditions, such
as heart disease,
stroke, and
depression.
Furthermore,
optimists may
respond better to
stress.
Role-Relationship She and her She worked and Relationship Families—
Pattern partner is not because of some work- with her sibling especially those
married but they relared circumstances became stronger. who
with their children her partner was not Since busy with communicate
in the same house. living in their house but work, the role of openly—may be
His partner is the still supports the family taking care of strengthened by
main decision financially. She and her the house was experiences
maker and the eldest daughter became then turned as a associated with
breadwinner. The breadwinners. With her role for the managing their
client was just a current health situation, second eldest child's health
typical house wife. the family is coping up daughter. condition or
well since she disability. In
explained thoroughly to many cases, the
family's
 her children her management of a
condition. Her children child's chronic
is trying not to increase condition may
stress. Her coworkers provide them
with a sense of
are also supportive in
cohesiveness,
terms of health aspects. mission, mastery,
They help her to finish and pride which
her work. builds the
Since the clientis busy, resiliency of the
she immediately goes family. (2015)
straight home after
work so she does not
much have interaction
with the neighbors.
Sexuality- The first Uses birth control pills Client now is in The biggest
Reproductive menstruation was after giving birth to the menopausal potential for
Pattern on December 1983 fifth child. Since she stage. There are mischief in the
when she was 13 and her partner was not also changes in whole thyroid
field is in the
and in 2nd year of living in the same the mood
highschool. The house, there is no brought by this arena of women’s
duration of her sexual activities. On stage. Gets health and
menstrual cycle is august 2018 is the last irritated easily. menopause.
one week. She got record of period. Everything from
minor vaginal
pregnant five Becomes easily
irritations to
times but the fifth irritated specially when repeated
pregnacy led to a her children didn't miscarriages have
miscarriage. The listen to her. been shown to be
gap between her thyroid-related in
children from a certain
eldest to youngest percentage of
is: 6 years, 2 years sufferers
and 4 years. (Shomon, 2108)
Coping-Stress Major stress that As of now there is no Has created The personal
tolerance Pattern was experienced is major stress coping attitude towards
when she thought experienced aside from mechanism and disease and the
that her eldest work stress and have learnt how corresponding
coping
daughter will financial difficulties. to deal with
mechanisms go
marry in early age. She manage these kind stress in her beyond
She managed it by of stress by praying and everyday life. biomedical
praying and talking to her very factors to
seeked the advice close youngest sibling. influence the
of a pastor. course of the
disease.
(Schussler, 1992)
Value-Belief She was never Actively goes to church Became more Religion serves at
Pattern religious before every Sunday. religious and least three
but believed in Sometimes goes to cell spiritual. functions for the
God. She goes to groups or prayer Relationship sick or dying
patient. Religion
church frequently meetings. For her, God with
provides such
and only prays is the main source of churchmates has practical
when needed. strength which enables improved.
Her goal in life is her to go on with resources for
to make her life.The pastor as well coping with
children finish her brothers and sisters sickness,
their studies. in Christ are also suffering, and
mortality as
source of support.
prayer, social
She hopes that her support, and
children finish their ritual actions
studies and grew up aimed at
well without forgiveness,
experiencing the same transcendence,
disease that she have. and healing. It
gives hope in the
face of inevitable
death. The
particular clinical
benefits of
religion, both
physical and
psychologic, as
well as its
possible
distortions, are
known
anecdotally.
(Sevensky, 1981)