N S T T U T E O F N U R S N G

AN3 3W4NN

















8 80 0B BM MI IT TT TE ED D B BY Y: :









I 8|ograph|c Data

name C 8
Address Marlklna
Age 30 y/o
Cender lemale 8ellglous AfflllaLlon CaLhollc
MarlLal SLaLus Wldowed CccupaLlon 8uslnesswoman
Chlef ComplalnL (AmpuLaLed leg/ 8l )
ulagnosls
Admlsslon uaLe SepLember 2009
ALLendlng hyslclan ur Zlmbabwe


II -rs|ng n|story

a asL PealLh PlsLory

1he paLlenL sald LhaL hls chlldhood lllnesses only lnclude chlcken pox and
measles Pe had compleLe vacclnaLlons as well She dld noL have any prlor
hosplLallzaLlons oLher Lhan Lhe currenL She has no known allergles She has noL
encounLered any accldenLs She has been ouL of Lhe counLry She has been ln London on
!anuary 2003 and ln lLaly on lebruary 2006 and ln 8arcelona on Aprll 2007 and ln
SanLorlnl on May 2009 and ln 8lo ue !anelro on !uly 2009 She doesn'L have any local
Lravel

b PlsLory of resenL lllness

1he paLlenL was broughL Lo Lhe hosplLal afLer Lhe Lyphoon Cndoy" hlLs
Marlklna

c lamlly PlsLory

1he paLlenL ls marrled and has Lhree chlldren who dled on Lhe day Lhe Lyphoon
Cndoy" hlLs Marlklna Per parenLs were already deceased 1he paLlenL sald Lhelr famlly
do noL have any heredlLary dlsease whaL she only knows ls LhaL her grandparenLs (she
does noL know who ln parLlcular) had a menLal dlsease buL Lhey are boLh deceased now


III Act|v|t|es of Da||y L|v|ng

ADL 8efore
nosp|ta||zat|on
Dr|ng
nosp|ta||zat|on
Interpretat|on and Ana|ys|s
a -tr|t|on 1he paLlenL eaLs flsh
meaL and vegeLables
Lhree Llmes a day
and consumes
approxlmaLely slx
glasses of waLer per
1he paLlenL has noL
eaLen for Lhe pasL Lwo
days
?oung adulLs should conLlnue Lo eaL a
healLhy dleL followlng Lhe
recommended porLlons of Lhe flve food
groups wlLh speclal aLLenLlon Lo proLeln
calclum and llmlLlng cholesLerol and
calorlc lnLake 1wo or Lhree llLers of fluld
day should be lncluded ln Lhe dally dleL
(lundamenLals of nurslng by kozler
pp11801181)

?

||m|nat|on











1he paLlenL
ellmlnaLes everyday
wlLh a formed llghL
Lo dark brown sLool
he urlnaLes 36 Llmes
a day wlLh a llghL
yellow color
1he cllenL hadn'L
defecaLed urlnaLes
23 Llmes a day
lmpalred moblllLy may llmlL Lhe cllenL's
ablllLy Lo respond Lo Lhe urge Lo defecaLe
and Lhe cllenL may experlence
consLlpaLlon Cr a cllenL may experlence
fecal lnconLlnence because of poorly
funcLlonlng anal sphlncLers
(lundamenLals of nurslng by kozler 7
Lh

edlLlon p12271228)

?
c erc|se 1he paLlenL goes Lo
Lhe gym Lhrlce a
week wlLh her
husband
1he paLlenL ls ln a
compleLe bed resL
wlLh 8aLhroom
rlvllege
Lxerclse lnvolves Lhe acLlve conLracLlon
and relaxaLlon of movemenL lndlvlduals
who faced wlLh lnacLlvlLy because of
lllness or ln[ury are aL rlsk for many
problems LhaL can affecL ma[or body
sysLem wheLher lmmoblllLy problems
ofLen depends on Lhe duraLlon of Lhe
lnacLlvlLy Lhe cllenL's healLh sLaLus and
Lhe cllenL's sensory awareness 1he mosL
obvlous slgns of prolonged lmmoblllLy
are ofLen manlfesLed ln Lhe
musculoskeleLal sysLem CllenL's
experlence a slgnlflcanL decrease ln
muscular sLrengLh and aglllLy whenever
Lhey do noL malnLaln a moderaLe
amounL of physlcal acLlvlLy ln addlLlon
lmmoblllLy adversely affecLs Lhe
cardlovascular resplraLory meLabollc
and psycho neurologlc sysLems
(lundamenLals of nurslng by kozler 7
Lh

edlLlon p1068)

uue Lo hosplLal sLay paLlenL can no
longer do hls usual acLlvlLles

d nyg|ene 1he paLlenL Lakes a
baLh Lwlce everyday
ln Lhe mornlng and
ln Lhe evenlng
Slnce hosplLal
admlsslon paLlenL dld
noL Lake a baLh
8aLhlng produces sense of wellbelng lL
refreshlng and relaxlng and frequenLly
lmproves morale appearance and self
respecL Some people Lake a mornlng
shower for lLs refreshlng sLlmulaLlng
effecL CLhers prefer an evenlng baLh
because lL ls relaxlng
(lundamenLals of nurslng by kozler 7
Lh

edlLlon p704

?
e |eep and
kest
1he paLlenL sleeps
from 11 ln Lhe
evenlng Llll 7 ln Lhe
mornlng
1he paLlenL sleeps
was noL conLlnuous
lL has been suggesLed LhaL malnLalnlng a
regular sleep wake rhyLhm ls more
lmporLanL Lhan Lhe number of hours
acLually slepL
(lundamenLals of nurslng by kozler 7
Lh

edlLlon p1113)
Mlddle aged adulLs malnLaln Lhe sleep
paLLern esLabllshed aL younger age 1hey
usually sleep 68 hours per nlghL
(lundamenLals of nurslng by kozler 7Lh
edlLlon p1116)



I 9atterns of Inct|on|ng
A 9sycho|og|ca| nea|th

aCop|ng 9atterns

lnterpretotion
4no/ysis

Interact|on 9atterns

lnterpretotion
4no/ysis

cCogn|t|ve 9atterns


lnterpretotion
4no/ysis



dmot|ona| patterns
lnterpretotion
4no/ysis

eea||ty
1he cllenL doesn'L have any sexual lnLeresL slnce her husband dled

lnterpretotion Per sexuallLy ls approprlaLe Lo her developmenLal sLage
4no/ysis Mlddle age adulL ls upon Lhe age of menopausal perlod from ages 30 and
above Sexual lnLeresL may be decreased aL Lhls perlod of Lhelr llfe (uevelopmenL
Lhrough llfe a psychosoclal approach 8arbara m newman hlllp r newman p 423)


fIam||y Cop|ng 9atterns


lnterpretotion
4no/ysis

8 oc|o c|tra| patterns
1 C|tra| patterns
1he cllenL ls a devoLed 8oman CaLhollc She has no oLher splrlLual pracLlces buL she and her
famlly always prays before Lhey eaL

lnterpretotionroper CulLural aLLern
4no/ysis 1he famlly passes on paLLerns of dally llvlng and llfesLyles Lo offsprlng
CulLural rules values and bellefs glve people a sense of belng sLable and able Lo
predlcL oLhers (looJomeotol of Notsloq 7
tb
eJltloo kozlet pq 178)




nv|ronment pattern
lnterpretotion
4no/ysis A safe envlronmenL ls one whlch people can funcLlon safely and one ln
whlch Lhey obLaln a sense of securlLy (looJomeotols of ootsloq 7
tb
eJltloo kozlet
pq 480)


conom|c pattern
1he cllenL ls a 8uslnesswoman 1ogeLher wlLh her husband Lhey help each oLher ln provldlng Lhe
needs of Lhelr famlly

lnterpretotionadequaLe economlc flnances

4no/ysisllnanclal resources lncrease Lhe ablllLy Lo provlde Lhe necessary
commodlLles for healLh and well belng (Notsloq looJomeotols k uoolels pq 855)



C p|r|ta| 9attern

1 ke||g|os e||efs and 9ract|ces
1he cllenL ls a devoLed 8oman CaLhollc She always go Lo Lhe church ln AnLlpolo She goes Lo
church every Sunday and helps wlLh Lhe proceedlngs

lnterpretotion normal values and 8ellef paLLern may seem very lndlvlduallsLlc buL
Lhere are sLlll cases LhaL people Lend Lo have splrlLual problem and may need Lo seek
help
4no/ysis CllenLs may have rellglous bellefs LhaL aLLrlbuLe lllness Lo a splrlLual
dlsrupLlon Many elders frqeunLly use and hlghly value rellglous coplng sLraLegles
such as prayer Lvldence shows splrlLual wellbelng Lo be dlrecLly vorelaLed wlLh
menLal healLh and less medlcal lllness among elders (looJomeotols of ootsloq 8
tb

eJltloo kozlet ooJ tbs poqe 10471054)

IV 9hys|ca| Assessment

norms AcLual llndlngs lnLerpreLaLlon and Analysls

Ceneral Appearance
1 osLure/CalL
2 Cbserve body
bulld helghL and
welghL



3 ersonal
Pyglene/
Croomlng











4 verbal/non
verbal behavlor


n/A
8ody bulld
helghL and
welghL are
proporLlonaLe


Clean neaL













Able Lo
communlcaLe
well


n/A
8ody bulld
helghL and
welghL are
proporLlonaLe


unkempL













Was noL Lalklng
much


n/A
normal





ulrLy cloLhes unkempL halr and oLher
sllps ln personal hyglene may be a slgn
of llmlLed energy or ablllLles
SomeLlmes Lhey polnL Lo blgger lssues
such as depresslon hldden healLh
problems or Lhe beglnnlng of
demenLla or cognlLlve decllne
(hLLp//wwwaglngcarecom/leaLured
SLorles/ 94933/ersonalPygleneand
Pandllngually1askshLm)
CllenL's hosplLallzaLlon alLers hlm ln
accompllshlng hls personal hyglene


normal

MeasuremenLs
1 1emperaLure
2 ulse 8aLe
3 8esplraLory 8aLe
4 8lood ressure


363 C373 C
60100 bpm
1620 cpm
SysLollc 110
130

369 C
76
18
110
70

normal
normal
normal
normal


3 WelghL
6 PelghL
ulasLollc 7090




116 lbs
3' 4

8Ml 199


normal
normal

normal

8Ml CaLegorles
normal welghL 183249
CverwelghL 23299
CbeslLy 8Ml of 30 or greaLer



8CD 9Ak1 -CkMAL II-DI- AC1UAL II-DI- A-ALI
I-
Assess



alpaLe


O Skln color ls llghL brown
O Cenerally unlform excepL
ln areas exposed Lo Lhe
sun
O no edema leslons and
abraslons





O resence of molsLure ln
skln skln folds and ln Lhe
axlllae
O 1emperaLure ls unlform
wlLhln normal range

O LlasLlc

O LlghL 8rown skln
O unlform ln color


O no edema buL has some
leslons all over her body
due Lo Lhe dlsasLer she
experlenced



O Skln folds and axlllae are
molsL buL Lhe skln ls dry












O Skln LemperaLure ls noL
unlform Lhe feeL are cold
Lo Louch




O normal










ury skln ls common lL
happens more ofLen ln
Lhe cold alr ouLslde and
heaLed alr lnslde cause
low humldlLy lorced
alr furnaces make skln
even drler1he skln
loses molsLure and may
crack and peel or
become lrrlLaLed and
lnflamed 8aLhlng Loo
frequenLly especlally
wlLh harsh soaps may
conLrlbuLe Lo dry skln
Cold skln ls a sympLom
of a wlde varleLy of
mlld Lo serlous
dlsorders dlseases or
condlLlons Cold feeL
can resulL from poor



O LlasLlc skln reLurns Lo
normal sLaLe when
plnched

clrculaLlon hearL
dlsorders lnfecLlon and
oLher abnormallLles
O normal

-AIL
lnspecL



O Convex CurvaLure

O SmooLh 1exLure
O 8ed color ls hlghly vascular
and plnk ln color
O 1he Llssues surroundlng
Lhe nalls have lnLacL
epldermls

O Convex curvaLure 160
degrees
O SmooLh LexLure
O llngernalls are plnk ln color

O lnLacL epldermls


O normal

O normal
O normal

O normal


nAIk
lnspecL

O 1he scalp ls whlLe and free
from any lnfesLaLlons
O Lvenly dlsLrlbuLlon of halr
growLh over Lhe scalp
O 1hlck halr

O WhlLe scalp and no
lnfesLaLlons
O Lvenly dlsLrlbuLed halr

O 1hlck halr

O normal

O normal

O normal


ULL
IAC
lnspecL






O 1he skull ls rounded
normocephallc and has a
smooLh conLour
O SymmeLrlc faclal feaLures
and nasolablal folds
palpebral flssures are equal
ln slze


O 1he skull ls round
normocephallc

O SymmeLrlc faclal feaLures
and movemenLs


O normal


O normal




lnspecL











O 1he halr of Lhe eyebrows ls
evenly dlsLrlbuLed 1he skln
ls lnLacL
O 1he eyebrows are
symmeLrlcally allgned
O 1he eyelashes are evenly
dlsLrlbuLed and are sllghLly
curled ouLward
O 1he skln of Lhe eyellds ls
lnLacL Lhe eyellds close
symmeLrlcally
O Caplllarles are sllghLly
evldenL ln Lhe bulbar

O 1he halr of Lhe eyebrows ls
evenly dlsLrlbuLed 1he skln
ls lnLacL
O 1he eyebrows are
symmeLrlcally allgned
O 1he eyelashes are evenly
dlsLrlbuLed and are sllghLly
curled ouLward
O 1he skln of Lhe eyellds ls
lnLacL Lhe eyellds close
symmeLrlcally
O Caplllarles are sllghLly
evldenL ln Lhe bulbar

O normal


O normal

O normal


O normal


O normal

con[uncLlva
O 1he lrls ls round and flaL
O 8oLh eyes are coordlnaLed
con[uncLlva
O 1he lrls ls round and flaL
O 8oLh eyes are coordlnaLed

O normal
O normal

Ak
lnspecL

alpaLe




O Color same as Lhe faclal
skln symmeLrlcal
O 1he ear ls moblle flrm and
noL Lender 1he plnna
recolls back afLer lL ls
folded

O Color same as Lhe faclal
skln symmeLrlcal
O 1he ear ls moblle flrm and
noL Lender 1he plnna
recolls back afLer lL ls
folded


O normal

O normal

-C
lnspecL



O SymmeLrlc sLralghL no
dlscharge or flarlng has
unlform color
O nasal sepLum ls lnLacL and
ln mldllne

O SymmeLrlc sLralghL no
dlscharge or flarlng has
unlform color
O nasal sepLum ls lnLacL and
ln mldllne

O normal


O normal


MCU1n
lnspecL





O 1he gums are plnk molsL
and have flrm LexLure
O 1he Longue ls plnk sllghLly
rough has no Lenderness
moves freely

O 1he gums are plnk molsL
and have flrm LexLure
O 1he Longue ls plnk sllghLly
rough has no Lenderness
moves freely

O normal

O normal


-C
lnspecL


O Muscles equal ln slze and
head ls cenLered


O Muscles equal ln slze and
head ls cenLered


O normal

9C1kICk

A-1kICk
1nCkAk
lnspecL





O ChesL wall ls symmeLrlc
O ChesL wall lnLacL no
Lenderness and no masses
O ;uleL and efforLless
breaLhlng



O ChesL wall ls symmeLrlc
O ChesL wall lnLacL no
Lenderness and no masses
O ;uleL and efforLless
breaLhlng




O normal
O normal

O normal



nAk1
lnspecL
resence or
absence of
pulsaLlon on
aorLlc and
pulmonlc
areas


O no pulsaLlon








O no pulsaLlon









O normal