DE LOS SANTOS STI COLLEGE

201 E. Rodriguez Sr., Quezon City

COLLEGE OF NURSING
Nursing Process
I. Assessment
A. General Data
Patients Initial! A.G.F. In"ormant! The Clients pri!ry "!regi#er $or
t%o &2' ye!rs !nd the "lient (r.
A.G.F.
A##ress! Quezon City Date o" A#mission! )e"e*er 0+, 2011
Age! ,- ye!rs old Or#er o" A#mission! .i! Stret"her
Se$! (!le No. o" #a%s in t&e &os'ital! /00 d!ys to present
Date o" (irt&! August 2+, 1-12 Data o" )istor% Ta*ing! Septe*er 1, 3 1+, 2011
Place o" (irt&! 4ue#! .iz"!y!
Ci+il Status! (!rried
Occu'ation! Forer Re!l St!te 5%ner6Tr!"tor )ri#er67!"iendero
(. C&ie" Com'laint! ,(!t!g!l ng !y u*o si d!ddy g! t!long &1' t!on n!- !s #er*!lized
*y the "lients "!regi#er.
C. )istor% o" Present Illness
The "lient h!s e8perien"ed ild stro9e 5ne &1' ye!r prior to !dission, he %!s
!ditted in the :ntensi#e C!re ;nit &:C;' in (!ri9in! .!lley 7ospit!l $or t%o &2' %ee9s,
!nd %!s dis"h!rged. <e"!use o$ the illness, he "!n no longer resue his nor!l !"ti#ities
%ithout support sin"e he h!s !lre!dy le$t sided *ody %e!9ness. A$ter ! $e% onths, the
p!tient h!d !spir!tion pneuoni! hen"e he %!s !ditted !g!in to (!ri9in! .!lley
7ospit!l, then he h!d undergone into, ! tepor!ry tr!"heostoy &$enestr!ted' to pre#ent
$urther "opli"!tion, *ut these restri"ts in his $eeding through outh !nd !n endos"opi"
edi"!l pro"edure "!lled =er"ut!neous Endos"opi" G!strostoy &=EG', %herein ! tu*e
%!s p!ssed into the p!tients sto!"h through !*doin!l %!ll, it %ill pro#ide ! e!ns o$
$eeding %hen or!l int!9e %!s not !de>u!te.
?ith the s!id "ondition o$ the "lient, he %!s then re$erred to ! long ter $ull tie "!re
$!"ility &hoe"!re' %herein they pro#ide !dult d!y"!re ser#i"es $or seniors %ho need
post@hospit!l or post@oper!ti#e edi"!l !ttention !t St. C!illus (edh!#en *y her
physi"i!n )r!. A. Cruz. 7en"e, le!ding to his !dission.
D. Past )istor%
.. C&il#&oo# Illness/es! Chi"9en po8 !t the !ge o$ - ye!rs old
0. A#ult Illness/es! )i!*etes (ellitus type :: sin"e 10 ye!rs old, (ild Stro9e one &1'
ye!r prior to !dission.
1. Immuni2ation! The "lient "!nnot re"!ll his iuniz!tion re"ords.
3. Pre+ious )os'itali2ation! )ue to ! (ild stro9e
4. O'eration/s! The "lient h!d ! tepor!ry tr!"heostoy &$enestr!ted' !nd
=er"ut!neous Endos"opi" G!strostoy &=EG' lo"!ted !t
Ae$t ;pper Qu!dr!nt6Epig!stri" Region.
5. In6uries! 4one
7. 8e#ications ta*en 'rior to con"inement 9For 5 8ont&s:! &C!r*o"isteine Solu8'
(u"olyti" $or produ"ti#e "ough, &(etroprolol' !nti B hypertensi#e edi"!tions to
lo%er his <lood =ressure !nd &Apidr!' :nsulin to lo%er his sug!r le#el.
;. Allergies! 4one
E. S%stem Re+ie<s
)ealt& Perce'tion = )ealt& 8anagement Pattern
=rior to "on$ineent, the "lient is ,, ye!rs old. The "lients "!regi#er st!ted th!t,
he h!d !n unhe!lthy li$estyle $or he h!s *een so9ing $or $i$ty eight &0+' ye!rs !nd Cust
stopped in 200+. 7e so9es 1 p!"9 o$ =hilip (orris ! d!y !nd drin9s !l"oholi" *e#er!ge
o$ 1 B 2 *ottles o$ *eer in ! %ee9. The "lients "!regi#er st!ted th!t during his younger
ye!rs, he !">uired dise!ses li9e "hi"9enpo8. The "lient "!nnot re"!ll his iuniz!tion
re"ords during his "hildhood ye!rs. 7e h!s no 9no%n !llergy. 7e h!s )i!*etes (ellitus
type ::, sin"e %hen he %!s thirty $i#e &10' ye!rs old !nd h!d ! ild stro9e one &1' ye!r
prior to "on$ineent !t St. C!illus (edh!#en, (!ri9in! City
)uring "on$ineent, the "lientDs "!regi#er reported th!t the "lient "!n no longer
do the things th!t he used to do *e$ore. The "lientDs !"tion is ore liited !nd %ith ore
pre"!utions. The "lient *e"!e ore !%!re !*out his he!lth, espe"i!lly the things th!t he
needs to !#oid li9e drin9ing !l"oholi" *e#er!ges !nd so9ing "ig!rettes. ?ith his "urrent
"ondition, he e!gerly "oplies %ith the do"tors order !nd other edi"!l st!$$ $or the
*etterent o$ his he!lth !nd $or his $!ily.
Anal%sis! ?ith the "lients "ondition, he h!d e8pressed his e!gerness to stop
so9ing !nd drin9ing !l"ohol *e"!use he h!d per"ei#ed th!t *oth !re the !Cor $!"tors
!$$e"ting his illness. <e"!use o$ his "urrent "ondition, the "lient $eels th!t his illness %ill
e#entu!lly *e"oe se#ere, i$ he %ill not *e "opli!nt %ith his edi"!tion !nd to the
do"tors !d#i"e. 7e holds tot!l responsi*ility, !nd re!dy to $!"e !nd de!l the
"onse>uen"es o$ his !"tions.
Nutritional an# 8eta>olic Process
=rior to "on$ineent, the "lients "!regi#er reported, th!t the "lients !ppetite %!s
good. 7e used to e!t &1' three to &2' $our ties ! d!y th!t in"ludes his sn!"9 in the
!$ternoon, or in the e#ening *e$ore he sleeps. 7e e!ts !lost e#erything *ut r!rely e!t
#eget!*les. A""ording to the "lients "!regi#er, "lient %eighs /0 B ,0 9ilogr!s.
)uring "on$ineent, the "lients "!regi#er s!id, th!t the "lient is restri"ted to so$t
diet only. The "lient h!s no teeth !nd he h!s ! tepor!ry tr!"heostoy &$enestr!ted'. The
"lient is no% on =er"ut!neous Endos"opi" G!strostoy &=EG' sin"e l!st ye!r o$ 2012,
%here osteorized $ood &5F' is gi#en e#ery +E00 !, 12E00 noon, 2E00 p !nd +E00 p.
7e "onsues 110"" osteorized $ood e!"h e!l %hi"h is ! tot!l o$ 1,120"" o$ osteorized
$ood in ! d!y. App!rently !s o$ the onth o$ Septe*er 2011, the "lient %eights 00 B /0
9ilogr!s %ith ! *ody !ss inde8 o$ 1+.1 !nd height o$ 010F.
Anal%sis! ?eight loss h!s *een noted in the l!st / onths $ro /0 @,0 9ilogr!s
to 0+ 9ilogr! !s o$ this onth o$ Septe*er 2011. Sin"e the "lient h!s "hroni"
*ron"hitis ! ye!r !go, this sho%s th!t the o8ygen!tion in his *ody is ip!ired. The
o8ygen needed $or respir!tion is in!de>u!te to supply enough nourishent to the "ells
!$$e"ting the *ody tissues. ?ith this "ondition, the priority is $o"used on the "lients
respir!tion to !int!in !de>u!te g!s e8"h!nge %ithin the *ody th!n the "lients nutrition.
Th!t is %hy the "lient h!s us"le %!sting !nd %eight loss.
1 Da%s Diet Recall
?e %!nted to h!#e ! 1 d!ys diet re"!ll ho%e#er "lient is on osteorized $ood sin"e l!st ye!r o$
2012. 5steorized $ood %!s "oputed *!sed on the "lients *ody !ss inde8 &<(:' %hi"h is 1+.1,
height o$ 010F, %eight o$ 0+ 9g. Tu*e $eeding o$ 2000 G"!l, 00 H C754, 00H C75 !nd 20H
F!ts. Feeding r!te6#olue o$ 110 "" e#ery $our &2' hours, $eeding $lush o$ /0 "". Forul! is
"oposed o$ /00 l. Glu"ern! %hi"h "ont!ins #it!in suppleents, "hroiu pi"olin!te !nd
phytosterols. Se#en &,' s"oops o$ =oly"ose %hi"h "ont!ins "!r*ohydr!tes, iner!ls,
phosphorous, "!l"iu, "hloride !nd sodiu !nd one &1' s"oop o$ :p!"t %hey %hi"h "ont!ins
%hey protein %hi"h is ! i8ture o$ *et!@l!"toglo*ulin, !lph!@l!"t!l*uin, *o#ine seru !l*uin.
Elimination Pattern
=rior to "on$ineent, the "lients "!regi#er reported th!t he #oids 1 B 2 ties !
d!y, his urine "olor %!s yello%, there %!s no *urning sens!tion $elt during urin!tion. 7e
usu!lly o#es his *o%el e#ery orning %ith *ro%n !nd $ored stools.
)uring "on$ineent, the "lients "!regi#er reported th!t she "h!nges his di!per
t%o &2' ties ! d!yI his urine is *right yello% %ith no p!in or *urning sens!tion during
urin!tion. The "lient h!s episodes o$ "onstip!tion th!t r!nges $or 1 B 2 d!ys. 4o
edi"!tions is gi#en, *ut the "!regi#er reported th!t she gi#es <!rley $or 10"" e#eryd!y
!t 10E00 !, !s ordered $or prophyl!8is in order to pre#ent the signs !nd syptos o$
"onstip!tion. ?hen the "lient de$e"!tes, the stool is $ored in !ppe!r!n"e, d!r9 *ro%n in
"olor !nd no presen"e o$ *lood.
Anal%sis! There %!s no o*#ious pro*le on the "lients eliin!tion p!ttern prior
to "on$ineent. The pro*le on de$e"!tion o""urs during "on$ineent, %herein the "lient
h!s episodes o$ "onstip!tion due to io*ility *e"!use o$ the "lients *ody %e!9ness. :n
!ddition to th!t the "lient h!s lesser $luid !nd $i*er int!9e.
Acti+it%= E$ercise Pattern
=rior to "on$ineent, !""ording to the "lients "!regi#er he pre$erred to sleep %ith
one &1' to t%o &2' pillo% on his he!d. The "lient "!n %!l9 !round their *!"9y!rd e#ery
orning $or 10 B 10 inutes, !nd the "lient %!s !lre!dy e8perien"ing $!tig!*ility !nd
shortness o$ *re!th. The "lient h!d his person!l !ssist!nt !round the house, !ssisting the
"lient on doing his !"ti#ities o$ d!ily li#ing. 7is Co* %!s ! tr!"tor dri#er !nd re!l est!te
o%ner. The "lient li9es to %!t"h sho%s !nd o#ies on his tele#ision !nd resting. 5n
%ee9ends, soeties the "lient li9es to pl!y !t the "!sino $or $un !nd h!#e ! drin9 !t the
*!r.
)uring "on$ineent, !""ording to the "lients "!regi#er, he "!n still l!y do%n on
*ed %ith one &1' to t%o &2' pillo% on his he!d %hile lying on sei B $o%lers on *ed. 7e
does h!#e ! physi"!l ther!py e#ery Tuesd!y !nd Frid!y $ro -E00 ! to 11E00 !. The
"lient does %!l9ing %ith !ssist!n"e $ro the physi"!l ther!pist o$ St. C!illus !nd his
"!regi#er, !""op!nied %ith the use o$ %!l9er, he %!l9s $or se#en &,' ties *!"9 !nd
$orth &/, steps, *!"9 !nd $orth', "ir"ling his le$t !nd right !r $or 10 inutes !nd "y"ling
$or 20 inutes %ith %eights o$ t%o &2' 9ilos $or e!"h $oot to enh!n"e the "lients us"le
strength !nd *uild us"le tone in the upper !nd lo%er e8treities. 7e is !*le to o#e his
*ody slightly in his *ed. The "lient usu!lly e8perien"ed e!sy $!tig!*ility %hile doing his
ther!py &%!l9ing' %ith ! respir!tory r!te o$ 20 *re!ths per inute !nd ! pulse r!te o$ 110
*e!ts per inute !s o$ Septe*er 1,, 2011. 7e h!s liited r!nge o$ !"ti#itiesI he !lso
needs !ssist!n"e &"!regi#er' on his siple !"ti#ities o$ d!ily li#ing.
Anal%sis! The "lient is se#enty nine &,-' ye!rs old, sin"e the "lient is !t his old
!ge, the physiologi"!l "h!nges on his pulon!ry *rought !*out *y !ging in"ludes
redu"ed *re!thing "!p!"ity, redu"ed #it!l "!p!"ity, in"re!sed residu!l #olue, de"re!se
"ough re$le8 !nd de"re!se "ili!ry !"ti#ity. Sin"e the "lient h!s "hroni" *ron"hitis, the
"lient h!s "hroni" !ir$lo% liit!tion. This is *e"!use the *ron"hi!l tu*es !re in$l!ed
%hi"h n!rro%s the !ir%!y !nd the "!pill!ry pere!*ility on the "lients lungs is high, so
there is ! hyperse"retion o$ u"us th!t ip!irs !ir$lo%. Th!t is %hy the ip!ired lungs o$
the "lient "!n !9e *re!thing di$$i"ult !nd liit !"ti#ity. :$ there %ill *e !n in"re!se
%or9lo!d !"ti#ity, the "lients *ody %ill "opens!te *y in"re!sing his respir!tion !nd
pulse r!te.
Slee' Rest Pattern
=rior to "on$ineent, the "lients "!regi#er reported th!t, %hen the "lient %!s still
residing !t their house in Cu*!o, Quezon City, he reported th!t his "hroni" "oughing
re!lly *others his rest in the !$ternoon !nd espe"i!lly his sleep !t night. Coughing
persistently %!s !n e8h!usting e8perien"e. A""ording to the "lient, ost o$ the tie he
only sleeps $or si8 hours or less !nd %!9es up in *et%een !nd h!#e thirty inutes to one
hour !$ternoon n!ps. 7e pre$ers sleeping %ith one to t%o pillo%s on his he!d !nd l!ying
do%n on his side is the ost "o$ort!*le position. ;su!lly %!t"hing tele#ision rel!8es
hi.
)uring "on$ineent, the "lients "!regi#er reported th!t, sin"e the "lient "!e to
this institution St. C!illus (edh!#en, his sleep !nd rest got *etter. The "!re !nd
guid!n"e th!t the institution !nd the person!l "!re h!#e pro#ided %ere re!lly ! gre!t
"ontri*ution, !nd in$luen"e to the ipro#eent o$ the "lients sleep !nd rest p!ttern. This
is not only *e"!use o$ the edi"!tion !nd ther!py th!t he h!d t!9en $or his "ough, *ut
!lso the "onsistent independent nursing "!re. 7is "!regi#er s!id th!t, the "lient sleeps $or
eight &+' hours ! d!y %herein he st!rts to sleep !t se#en &,' in the e#ening, %!9es up !t
ele#en &11' in the e#ening !nd sleeps !g!in !t one &1' in the orning !nd $in!lly %!9es up
!t $our &2' in the orning. :n !ddition to th!t, the "lient sleeps $or t%o &2' hours $or his
!$ternoon n!p e!"h d!y. Although, the "lient still h!s produ"ti#e "ough %ith %hitish
phleg, the "!regi#er e8pl!ined th!t his sleeping !nd resting p!ttern h!#e gre!tly
ipro#ed. A""ording to the "!regi#er, his "lient is re!lly loo9ing $or%!rd to h!#e ! *etter
he!lth st!tus.
Anal%sis! Sleep !nd rest !re essenti!l to physi"!l he!lth !nd eotion!l %ell@*eing.
<!sed on the report st!ted *y the "lients "!regi#er, it sho%s th!t the "lients sleeping !nd
resting p!ttern h!s *een !$$e"ted *y three &1' $!"tors %hi"h !re the $ollo%ingE "lients
sleeping p!ttern "h!nges *rought !*out *y nor!l !ging pro"ess, "hroni" "ig!rette use,
!nd "oughing. Sin"e "lient is !lre!dy se#enty nine ye!rs old, it is nor!l th!t sleeping
hours *e"oe less due to old !ge %herein it is nor!l $or elderly to sleep lightly,
interittently !nd %!9es up $re>uently. The "lient !s *eing ! "hroni" so9er sin"e his
teen !ge li$e, !nd %ho h!d re"ently stopped $e% ye!rs !go is ! 9ind o$ li$estyle %here it is
"oon to h!#e di$$i"ulty o$ sleeping due to the stiul!ting e$$e"ts o$ ni"otine $ro
"ig!rettes. A""ording the C7EST (!g!zine@Fe*ru!ry 200+ :ssue, the peer@re#ie%ed
Courn!l o$ the Aeri"!n College o$ Chest =hysi"i!ns &ACC=' e8pl!ins th!t so9ers
usu!lly h!#e less deep sleep !nd ore on light sleep %hi"h e8pl!ins the e8perien"e o$
ni"otine %ithdr!%!l e!"h d!y th!t ser#es !s ! "ontri*utor to sleep distur*!n"e
&s"ien"ed!ily."o'. Another "!use is the "lients persistent "ough %hi"h *others hi
"!using e8h!ustion to the "lient. <ut e#en so, sin"e "lients st!yed !t St. C!illus,
sleeping !nd resting p!ttern h!d gre!tly ipro#ed due to "!regi#ers inter#entions !nd
edi"!tions !s ordered.
Cogniti+e Perce'tual Pattern
=rior to his "on$ineent, the "lients thin9ing "!p!"ity !nd underst!nding is
logi"!l !nd inn!te, !nd there !re no signs o$ !ltered ent!l st!tus. 7is de"ision !9ing
s9ills %ere not tr!nsp!rent, sin"e the p!tient is ! stri"t type o$ person !nd thus this e!ns
th!t the p!tient is not !%!re o$ his "ondition.
)uring "on$ineent, the "lients de"ision !9ing !*ility still re!in int!"t.
A""ording the "lients "!regi#er, the "lient is !*le to underst!nd the gi#en instru"tions, !s
%ell !s the iport!n"e o$ the inter#ention per$ored *y his "!regi#er. ?ith this, the "lient
is !*le to "ooper!te %ith the nursing "!re !nd soe%h!t "ould respond $reely to e8press
hisel$, !ns%er the >uestion, or !s9 ! $!#or. There !re ties th!t he is stu**orn, !s per his
"!regi#er, *ut he 9no%s ho% to listen !nd !""ept reinders.
Anal%sis! Su!rizing the "ogniti#e !spe"t o$ the "lient, his "urrent "ondition
did not !$$e"t his de"ision !9ing s9ills, he is still !rti"ul!te %ith %h!t he %!nts to s!y.
7is Cudgent s9ills is still good $or he listens to his "!regi#er !nd underst!nds the
iport!n"e o$ instru"tions, %hi"h helps hi to h!#e *etter progress o$ his he!lth
ipro#eent.
Sel" Perce'tion an# Sel"Conce't Pattern
=rior to "on$ineent, the Clients "!regi#er st!ted th!t, he %!s ! re!l st!te "o"onut
$!r o%ner, ! h!rd %or9er !nd ! lo#ing $!ther. 7e %!s stri"t in !n!ging his $!r, $or he
%!nted to !tt!in its su""ess, produ"ti#ity, !nd !int!in st!*ility. 7e is %ise in !9ing
di$$i"ult de"ision, espe"i!lly e>uipped to o#e under pressure. 7e is !lso s!rt in
!n!ging his e8penditures. 7e r!ised his $!ily %ell !nd %!s re!lly ! gre!t pro#ider to
his $!ily.
)uring "on$ineent, the "lients "!regi#er st!ted th!t, initi!lly there !re p!rtly
soe "h!nges in his *eh!#ior due to his ip!ired he!lth st!tus, *e"!use !ll the things he
used to do *e$ore, he "!nt do it !nyore due to his "hroni" illnesses. 7is %eight got
lo%er th!n *e$ore, !s per his "!regi#er. There !re ties th!t he thin9s he is useless,
*e"!use he "!nt e#en do the *!si" hygieni" e!sures $or hisel$. Although, initi!lly he
$elt this %!y $or hisel$, the "!regi#er reported th!t he e#entu!lly !""epted his o%n st!te
!nd Cust le!rned to $o"us on ho% to ipro#e hisel$ $or the *etterent o$ his he!lth *y
*eing optiisti", inste!d o$ *eing pessiisti".
Anal%sis! =rior to "on$ineent, the "lients sel$@estee h!d de"re!sed due to his
"hroni" illnesses. )uring "on$ineent the "lient understood th!t he needs !ssist!n"e $or
his d!ily !"ti#ities !nd h!d !""epted th!t he needs to ipro#e hisel$ !nd his he!lth
"ondition *y "oplying %ith his "!regi#er, do"tor !nd nurses. :n this %!y, it "!n pre#ent
in"re!se %or9lo!d !nd in"re!se o8ygen de!nd.
Se$ualit%=Re'ro#ucti+e Pattern
=rior to "on$ineent, the "lients "!regi#er reported th!t, his "lient is no longer
se8u!lly !"ti#e. A""ording to the "!regi#er, his %i$e !nd his $!ily per!nently resides
in the ;nited St!tes o$ Aeri"! $or ore th!n 20 ye!rs !nd usu!lly his %i$e Cust #isits
=hilippines to see her hus*!nd $or ! "ert!in period o$ tie, then go *!"9 to the ;nited
St!tes o$ Aeri"! !g!in. She !lso !dded th!t she h!snt seen the "lient $or !ny !ttepts or
inst!n"e o$ !stur*!tion !nd Cust $o"uses on his he!lth. Reg!rding the "lients
reprodu"ti#e !spe"t, there %!s no noted history o$ reprodu"ti#e pro*les or se8u!lly
tr!nsitted in$e"tion. )uring the "lients %ell st!te %hen he is ore physi"!lly "!p!*le to
*e se8u!lly !"ti#e, he h!s eight &+' "hildren. 4o history o$ !ny $or o$ !le
"ontr!"eption th!t %!s used.
)uring "on$ineent, the "lients "!regi#er st!ted th!t, his %i$e is in the
=hilippines $or $our onths sin"e August 2011 Cust to "ele*r!te his *irthd!y !nd %ill *e
going *!"9 to the ;SA *y 4o#e*er 2011. <!sed on the "!regi#ers report, his %i$e is
s%eet to his hus*!nd. E8pression o$ !$$e"tion is ore on %ordings, holding h!nds, !nd
through hugs !nd 9isses. The "!regi#er $eels th!t, the "lient is not "!p!*le o$ eng!ging on
se8u!l !"ti#ities due to his present st!te o$ e!sy $!tig!*ility on his !*ul!tion !nd other
o#eents th!t is %hy it re>uires "!regi#er !ssist!n"e.
Anal%sis! Se8u!lity !nd reprodu"tion p!ttern "!n *e s!id to *e he!lthy $or the
"lient %herein he %!s !*le to reprodu"e eight &+' "hildren %ithout !ny !*nor!lities or
"!used !ny reprodu"ti#e pro*les. The "lients penis is in good "ondition %ith nor!l
"h!nges *rought !*out *y !ging. <!sed on re"ent studies !nd loo9ing !t the "lients
li$estyle, so9ing "!n de"re!se the >u!lity o$ seen, !nd distur*s horon!l *!l!n"e th!t
!y *oth !$$e"t $ertility &n"*i.nl.nih.go#'.
Role Relations&i' Pattern
=rior to "on$ineent, the "lients "!regi#er st!ted th!t, he is ,- ye!rs old !nd he is
2
th
"hild in his $!ily. 7e is !rried !nd h!s eight &+' "hildren. 7e is ! lo#ing hus*!nd, !
good $!ther !nd ! role odel $or the. The "lient h!s *een !%!y $ro his $!ily, %ho !re
!ll residing in the ;nited St!tes o$ Aeri"! $or ore th!n 20 ye!rs. For the "lient, this is
Cust $ine $or hi *e"!use he is Cust *eing pr!"ti"!l %ith the situ!tion. As long !s there is
"ouni"!tion, he is "ontented.
)uring "on$ineent, the "lients "!regi#er st!ted th!t, he h!d !""epted !nd no%
"ontented %ith his "urrent st!te. E#en his $!ily li#es iles !%!y $ro hi, he is
th!n9$ul th!t his %i$e !nd "hildren still !9e hi $eel spe"i!l !nd iport!nt in soe
%!ys. 7e is gl!d th!t he r!ised his $!ily %ell, *y gi#ing support !nd lo#e to the. 7e is
gr!te$ul th!t !ll o$ his eight &+' "hildren $inished their studies. This %!s ! gre!t
!"hie#eent $or hi, *e"!use $or the "lient, edu"!tion is the only tre!sure th!t he "!n
gi#e to his "hildren th!t "!nnot *e stolen. 7e is h!ppy *e"!use he %!s !*le to do th!t, $or
his $!ily. And he is proud o$ his "hildrens !""oplishent !nd $or !ll the help th!t
they#e gi#en to hi. As per his "!regi#er, the "lient is #ery th!n9$ul in spite o$ his
"urrent he!lth "ondition, *e"!use he $eels th!t his $!ily "!res $or hi ore in spite o$
their dist!n"e $ro e!"h other.
Anal%sis! The "lient h!s ! good "h!r!"ter !nd h!d per$ored his role !s ! $!ther
!nd ! lo#ing hus*!nd so %ell. The "lient is Cust *eing pr!"ti"!l !s long !s there is "onst!nt
"ouni"!tion, he is "ontented.
Co'ing=Stress Tolerance Pattern
=rior to "on$ineent, "lients "!regi#er st!ted th!t, the ost stress$ul e#ent th!t
the "lient e8perien"ed %!s the tie %hen he %!s di!gnosed to h!#e )i!*etes (ellitus
type :: %hen he %!s 10 ye!rs old !nd ild stro9e one ye!r prior to his !dission. The
"lient %!s irrit!*le !s reported *y his "!regi#er. 7e usu!lly de!ls %ith his stress *y
isol!ting his sel$ $ro people !round hi. :n !ddition, the "lients pri!ry re!son %hy
theres ! need $or this type o$ !dission, %!s no one is !*le to t!9e "!re o$ hi in his
hoe. ?ith this he de"ided to get !ditted in ! long ter $!"ility "!re &hoe "!re' %here
he!lth "!re pro#iders !re present to "losely onitor !nd t!9e "!re o$ hi.
)uring "on$ineent, "lients "!regi#er reported th!t the "lient h!s *een stressed
out due to his illness. 7e "!nnot resue his nor!l !"ti#ities %ithout support. 7e h!d
!lso undergone ! tepor!ry tr!"heostoy &$enestr!ted' !nd l!ter he h!d =er"ut!neous
Endos"opi" G!strostoy &=EG' sin"e or!l int!9e is not !de>u!te. The "!regi#er s!id th!t,
the "lient is #ery e!ger to h!#e his tepor!ry tr!"heostoy &$enestr!ted' reo#ed sin"e
he %!nted to e!t nor!lly. Soeho% the "lient is !*le to "ope@up %ith his present
situ!tion through or!l support $ro his $!ily, "!regi#ers !nd !*o#e !ll his $!ith to God
th!t li$ts his spirit th!t he "!n o#er"oe !ll these tri!ls in his li$e.
Anal%sis! :n the !ging pro"ess, there !re physiologi"!l "h!nges th!t o""ur on e!"h
indi#idu!l. )epending on ho% people "ope %ith it. For the "lients situ!tion th!t is #ery
!"ti#e *e$ore, it %!s ! nor!l re!"tion $or the "lient to $eel irrit!ted, $rustr!ted !nd
stressed out due to un%!nted "h!nges th!t h!ppened in his *ody, th!t "!using ip!irent
on his "!p!*ility to do his !"ti#ities o$ d!ily li#ing. <ut e#entu!lly, the "lient %!s !*le to
le!rn ho% to "ope up %ith the present situ!tion !nd h!d !""epted the things th!t he "!n no
longer do. ?ith this, the "lient is !*le to de!l %ith his he!lth situ!tion !nd h!s the
deterin!tion to ipro#e his he!lth st!tus.

?alue (elie" Pattern
=rior to "on$ineent, the "lients "!regi#er s!id th!t, the "lient deeply *elie#es in
God %hi"h he !d!pted $ro his p!rents. As per his "!regi#er, *e$ore !dission he
!"tu!lly goes to "hur"h t%i"e ! %ee9. 7e h!d di$$erent stress in li$e th!t he en"ountered,
*ut he !l%!ys pr!y to God $or %isdo !nd .
)uring "on$ineent, his "!regi#er st!ted th!t his $!ith in God %ill not "h!nge. 7is
*elie$s re$le"t his roo !tosphere %herein it is $ull o$ religious !teri!ls !nd $igurines
displ!yed. 7is "lients priest #isits hi on"e ! %ee9 !s he pr!ys o#er hi %hile he is
!ditted !t St. C!illus. 7is rel!ti#es #isit hi !s %ell %hen his priest "oes o#er. 7e
h!s ! strong $!ith in God th!t he %ill get *etter !nd %ill *e *!"9 in his ipro#ed st!te.
Anal%sis! 7is #!lues !nd *elie$s !$$e"t his "ondition *e"!use it helps hi to thin9
ore positi#ely !nd strengthens hi to ipro#e hisel$ !nd his he!lth. 7is $!ith !nd trust
in God gi#es hi "our!ge to $eel *etter !nd o#e $or%!rd.
F. Famil% Assessment
Name Relation Age Se$ Occu'ation E#ucational
Attainment
C. F. ?i$e ,0 y6o Fe!le Retired <!n9er College
Gr!du!te
).F. Son /0 y6o (!le <usiness!n College
Gr!du!te
A.G. )!ughter 0+ y6o Fe!le <usiness%o!n College
Gr!du!te
G.R. )!ughter 0, y6o Fe!le <usiness%o!n College
Gr!du!te
C.S. )!ughter 22 y6o Fe!le Re!l St!te College
Gr!du!te
G.F. Son 21 y6o (!le Re!l St!te College
Gr!du!te
(.4. )!ughter 20 y6o Fe!le 7otel (!n!ger College
Gr!du!te
A.T. )!ughter 1, y6o Fe!le <usiness%o!n College
Gr!du!te
<.E. )!ughter 10 y6o Fe!le <usiness%o!n College
Gr!du!te
G. )ere#itar%
@Famil% Illness
8aternal! )i!*etes (ellitus !nd 7ypertension
Paternal! )i!*etes (ellitus !nd 7ypertension
). De+elo'mental )istor%
T&eorist Age Tas* Patient
Descri'tion
Ego Integrit%
Eri"9son ,- Appre"i!tes the p!st, present, !nd the $uture, sel$@
!""ept!n"e o$ o%n "ontri*ution to others, sel$@
%orth !nd sel$@!""ept!n"e o$ "h!nge. JE!st ?est
4ursing Re#ie% Center. Coprehensi#e Re#ie%er
$or the 4urse Ai"ensure E8! &4AE' p.2+2K
The "lients
"!regi#er st!ted
th!t, hes so
gr!te$ul th!t he
!lre!dy
!""oplished
the things th!t he
pl!nned $or his
$!ilys $uture.
As per his
"!regi#er, his
"lient is not yet
re!dy to die !s
$or his !"tion
sho%s
deterin!tion in
$ighting to
ipro#e his
he!lth st!tus
despite o$
e#erything he
h!d e8perien"ed.
Freud ,-
Genital Stage
Se8u!lity is "h!nnelled into rel!tionships %ith
opposite se8. )e#elopent o$ se8u!l identityI
!*ility to lo#e !nd %or9. JE!st ?est 4ursing
Re#ie% Center. Coprehensi#e Re#ie%er $or the
4urse Ai"ensure E8! &4AE' p. 2+1K
The "lients
"!regi#er st!ted
th!t his %i$e
li#es in ;SA.
7is %i$e is in the
=hilippines $or
$our onths
sin"e August
2011 Cust to
"ele*r!te his
*irthd!y !nd %ill
*e going *!"9 to
the ;SA *y
4o#e*er 2011.
<!sed on the
"!regi#ers
report, his %i$e
is s%eet to his
hus*!nd.
E8pression o$
!$$e"tion is ore
on %ordings,
holding h!nds,
!nd through
hugs !nd 9isses.
The "!regi#er
$eels th!t the
"lient is not
"!p!*le o$
eng!ging on
se8u!l !"ti#ities
due to his
present st!te o$
e!sy $!tig!*ility
on his
!*ul!tion !nd
other o#eents
th!t is %hy it
re>uires
"!regi#ers
!ssist!n"e.
=i!get ,-
Formal O'erational T&oug&t
A*str!"t thin9ing, Sep!r!tion o$ $!nt!sy $ro $!"t,
Re!lity@oriented, A*le to thin9 !*out ! pro*le
!nd Aogi"!l, dedu"ti#e re!soning J$ro gener!l to
spe"i$i"K. JE!st ?est 4ursing Re#ie% Center.
Coprehensi#e Re#ie%er $or the 4urse Ai"ensure
E8! &4AE' p. 2+0K
As per "lients
"!regi#er, his
"lient !nd his
$!ily !re #ery
generous !nd
#ery help$ul.
E#en though he
is ! type person
%ho is #ery
stri"t, he is
!""ood!ting
!nd sh!res his
%isdo to
younger
gener!tion.
Gohl*erg ,-
Le+el 1 Stage 4 Post Con+entional
So"i!l "ontr!"t, utilit!ri!n l!%@!9ing
perspe"ti#es. Follo%s st!nd!rds o$ so"iety $or the
good o$ !ll people. JE!st ?est 4ursing Re#ie%
Center. Coprehensi#e Re#ie%er $or the 4urse
Ai"ensure E8! &4AE' p. 2/0K
7is "!regi#er
st!ted th!t his
"lient is ! stri"t
person in ters
o$ *eh!#ior !nd
!l%!ys $ollo%s
rules !nd
regul!tionI he
!lso underst!nds
his dise!se
despite o$ his
"ondition !nd
!ge. 7e !lso
st!ted th!t he
re!lly %!nted !ll
to *e in pl!"ed
!s %h!t it is to
*e done.
Fo%ler ,-
Stage 4 Con6uncti+e Fait&
A"9no%ledges p!r!do8 !nd tr!ns"enden"e rel!ting
re!lity *ehind the sy*ols o$ inherited systes.
The indi#idu!l resol#es "on$li"ts $ro pre#ious
st!ges *y ! "ople8 underst!nding o$ !
ultidiension!l, interdependent LtruthL th!t
"!nnot *e e8pl!ined *y !ny p!rti"ul!r st!teent.
Jen.%i9ipedi!.org6%i9i6Fo%lersMst!gesM
o$M$!ithMde#elopentK
The "lients
"!regi#er st!ted
th!t, his "lient is
not yet re!dy to
die !nd still
$ighting despite
th!t he 9no%s
%h!t %ill h!ppen
in the $uture.
I. P&%sical E$amination 9Se'tem>er .7 A .;B 0C.1:
)eig&t! 010F Feet &1,,.+0 "' Deig&t! 0+ 9ilogr! &12, l*s'
Actual )eig&t! 010F Feet &1,,.+0 "' I#eal (o#% Deig&t! /0.0@,0 9ilogr!s
&122@102 l*s' <(:
1+.1&;nder%eight'
?ital Signs!
Tem'erature! 10.2
o
C Res'irator% Rate! 20 *re!ths per inute
Pulse Rate! 102 *e!ts per inute (loo# Pressure! 1106+0 7g
Regional E$amination
ACTUAL
ASSESS8ENT
NOR8AL
ASSESS8ENT
ANALESIS an#
INTERPRETATION
A. S*in Ins'ection
S9in "olor is $!ir
%ith soe !re!s o$
dis"olor!tion.
The =EG "o#ers
the le$t epig!stri"
!re! o$ the "lient,
no s%elling or
lesions noted.
Pal'ation
S9in te8ture is
roughed, %rin9led
!nd s!gged.
)e"re!sed s9in
oisture.
S9in "olor is good,
no *ruising,
erythe! or !re!s
o$ dis"olor!tion,
s9in te8ture loo9s
sooth !nd int!"t.
&S9ill!stersE 1
inute !ssessent,
2
nd
Edition, A.?.?,
200/'
The "lient h!s $!ir
"olored s9in, roughed
in te8ture %ith
noti"e!*le %rin9ling
o$ the s9in *rought
!*out *y nor!l
"h!nges o$ !ging.
(. Nails Ins'ection
4!il *eds !re p!le
in "olor.
4!il *eds !re
slightly "ur#ed.
4!il edges !re
sooth !nd
rounded.
Slight "lu**ing o$
n!ils in *oth upper
!nd lo%er
e8treities.
4!il *eds r!nges
$ro pin9 to *ro%n
depend on the s9in
"olor.
&S9ill!stersE 1
inute !ssessent,
2
nd
Edition, A.?.?,
200/'
A*nor!l $indings !re
p!le n!ils !nd
"lu**ing o$ $ingers.
=!le n!ils !y
indi"!te de"re!sed
o8ygen!tion in the
*lood !nd "lu**ing o$
$ingers !y indi"!te
poor o8ygen!tion in
the e8treities !s %ell
!s "hroni" hypo8i!.
C. )ea# an# Face Ins'ection
7e!d is
noro"eph!li",
syetri"!l in
sh!pe.
7!ir is $ine to
tou"h !nd %ith
!le *!ldness
p!ttern in the he!d.
7e!d ust *e
nor!l in sh!pe !nd
! tr!u!ti", h!ir h!s
!#er!ge te8ture.
&S9ill!stersE 1
inute !ssessent,
2
nd
Edition, A.?.?,
200/'
The h!ir distri*ution
in the he!d o$ the
"lient is $ine %ith
o*#ious !le *!ldness
p!ttern due to !ging.
(ole in the le$t
lo%er "hi"9.
D. E%es Ins'ection!
4o ede! or
lesions present on
the eyelids.
S"ler! is p!le in
"olor !s %ell !s the
"onCun"ti#!.
7!s "loudy
!ppe!r!n"e on the
"entr!l p!rt o$ the
"orne!.
.isu!l !"uity is
diinished 206200
!s #er*!lized *y
the "lients
"!regi#er
.isu!l !"uity is
*il!ter!lly 20620.
=upils "onstri"t !t
2 to 2 in
di!eter %hi"h !re
e>u!lly re!"ti#e to
light. S"ler! is
%hite !nd
"onCun"ti#! is pin9.
&S9ill!stersE 1
inute !ssessent,
2
nd
Edition, A.?.?,
200/'
The #isu!l !"uity !y
diinish due to !ging,
The "loudy
!ppe!r!n"e in the
"orne! !y "on"lude
"!t!r!"t "!used *y
"hroni" di!*etes
ellitus or "ould *e !
senile $or o$ "!t!r!"t
*rought !*out *y
!ging. The "onCun"ti#!
is p!le %hi"h !y
indi"!te !nei!.
E. Ears Ins'ection
4o #isi*le !ss or
!ny dis"h!rge
dr!ining $ro the
e!r "!n!l.
=!tient is !*le to
he!r %hispered
#oi"e or e#en
nor!l #oi"e.
4o !ss or !ny
dis"h!rge dr!ining
$ro the e!rs !nd
%ith good he!ring
!"uity.
&S9ill!stersE 1
inute !ssessent,
2
nd
Edition, A.?.?,
200/'
The p!tient h!s no
pro*le in he!ring.
7e "!n he!r !nything
!nd respond %hen he
is "!lled or !s9ed.
F. Nose Ins'ection
4!s!l u"os! is
pin9I septu is in
idline.
4o #isi*le
dis"h!rge
(u"os! is pin9ish
in "olor. There is
neither septu
de#i!tion nor
#isi*le dis"h!rge.
&S9ill!stersE 1
inute !ssessent,
The "lient h!s no
!*nor!l $indings
noted.
2
nd
Edition, A.?.?,
200/'
G. 8out& an#
P&ar%n$
Ins'ection
5uter Aips !re dry
!nd h!#e dus9y
"olor.
5r!l u"os! !nd
tongue is p!le in
"olor.
Gus h!#e dus9y
"olor.
5r!l u"os! is
pin9. )entition is
good. =h!ryn8 h!s
no e8ud!tes.
&S9ill!stersE 1
inute !ssessent,
2
nd
Edition, A.?.?,
200/'
4o other !*nor!l
$indings e8"ept $or the
lips !nd gus th!t is
dus9y in "olor due to
"ig!rette so9ing $or
0+ ye!rs.
). Nec* Ins'ection
=!tient h!s !
tepor!ry
tr!"heostoy
&$enestr!ted'.
?hitish sputu &0
l B 10 l'
Gurgling sound
during "oughing.
5#er de#eloped
sterno"leido!stoi
d us"les
Pal'ation
4o tenderness,
s%elling !nd !ss
upon p!lp!tion.
Thyroid isthus
p!lp!*le, lo*es not
$elt, no "er#i"!l
lyph node
p!lp!ted.
&S9ill!stersE 1
inute !ssessent,
2
nd
Edition, A.?.?,
200/'
The p!tient h!s history
o$ !spir!tion
pneuoni! %hi"h
le!ds hi to h!#e !
tr!"heostoy. The
"lient *re!thes through
his tr!"heostoy
&$enestr!ted' !nd upon
"oughingI there is !
l!rge !ount o$
sputu e8pelled $ro
it. )uring the "lients
respir!tory p!ttern
!ssessent, the "lient
uses h!s
o#erde#eloped
sterno"leido!stoid
due to "hroni"
hypo8i!.
I. S'ine Ins'ection
The p!tient is
slightly 9yphoti" in
st!ture %hen
Spine is in idline
%ithout de#i!tion
on the other side.
?hene#er the "lient
does %!l9ing
e8er"ises, the
%!l9ing %ith !n
!ssisti#e de#i"e.
&S9ill!stersE 1
inute !ssessent,
2
nd
Edition, A.?.?,
200/'
"!regi#er !ssists hi
%ith the use o$ !
%!l9er. 7!#ing !
slightly 9yphoti"
st!ture "!n *e *rought
!*out *y !ging
pro"ess.
F. T&ora$/ Lungs Ins'ection
Chest
"on$igur!tion is
syetri"!l on
*oth sides.
Anteroposterior
di!eter o$ 1,"
!nd Tr!ns#erse
di!eter is 20 ".
<!rreled "hest in
!ppe!r!n"e.
The "lients
respir!tion is 20
*re!ths per inute.
7e h!s $!st !nd
sh!llo% *re!thing
%ith o#erde#elop
sterno"liedo!stoi
d us"les.
7!#e "hest
retr!"tions.
=rodu"ti#e "ough
%ith %hitish
sputu.
Percussion
Reson!nt during
per"ussion.
Chest "on$igur!tion
is syetri"!l side
to side. The A=T
di!eter is less
th!n the tr!ns#erse
di!eter or 1E2 in
r!tio. Respir!tions
!re >uiet !nd
l!*ored. Reson!nt
during per"ussion
!nd there is no
!d#entitious sound.
&S9ill!stersE 1
inute !ssessent,
2
nd
Edition, A.?.?,
200/'
A*nor!l $indings
h!#e *een seen in the
"lient %here he h!s !
*!rrel sh!ped "hest
This sho%s th!t !n
!nteroposterior
di!eter o$ 1, !nd !
tr!ns#erse di!eter o$
20 h!s s!ll
di$$eren"e or !lost
e>u!l in e!sureent.
The "lient h!s
%heezing %hi"h %!s
he!rd during
e8pir!tions. Rhon"hi
is ! lo% pit"h sound
he!rd !ll throughout
the "y"le o$ his
respir!tions %hi"h
indi"!tes !ir%!y
o*stru"tion. Reson!nt
upon per"ussion is
present *e"!use o$ the
in"re!sed u"us
produ"tion. 7e h!s
"hest retr!"tions !nd !
produ"ti#e "ough %ith
%hitish sputu %hi"h
is ! sign o$ "hroni"
*ron"hitis. )uring
episodes o$ "oughing,
Auscultation
=!tient h!s
%heezing during
e8pir!tion he!rd
o#er upper thor!"i"
!re!.
7!#e rhon"hi
during e8pir!tion
throughout
respir!tory "y"le.
there is ! $lushing o$
the $!"e due to
hypo8i! "!using
#!sodil!tion to
in"re!se *lood $lo%
$or ore o8ygen!tion
!s ! "opens!tory
e"h!nis during
hypo8i!.
G. Car#io+ascular/
)eart
Auscultation
=ulse r!te is 102
*e!ts per inute.
Regul!r !nd not
*ounding.
7e!rt ururs.
4or!l pulse r!te is
/0@100 *e!ts per
inute, regul!r
*e!ts !nd not
*ounding. ;pon
!us"ult!tion, S1 !nd
S2 he!rt sounds !re
nor!l. S2 he!rt
sound is nor!l $or
elderly.
&S9ill!stersE 1
inute !ssessent,
2
nd
Edition, A.?.?,
200/'
Client %ith "hroni"
*ron"hitis is prone to
right sided he!rt
$!ilure there$ore he
h!s !ni$est!tions
su"h !s he!rt ururs
%hi"h "!n *e ! nor!l
$inding $or !n elderly
person.
L. (reast Ins'ection
<re!st s9in is
nor!l !nd
syetri"!l. 4o
ede! or erythe!
present.
<re!st s9in is
sooth, undipled
!nd s!e "olor !s
the s9in.
&S9ill!stersE 1
inute !ssessent,
2
nd
Edition, A.?.?,
200/'
4or!l $indings in the
*re!st !re o*ser#ed.
8. A>#omen Ins'ection
7!s =EG on the
le$t upper
>u!dr!nt6epig!stri"
region %ith
neg!ti#e residu!l.
Auscultation
7igh pit"hed
gurgling *o%el or
noro!"ti#e *o%el
sound he!rd e#ery
10 se"onds.
A*doen is
protu*er!nt %ith
nor!l *o%el
sounds. :t is so$t
!nd non@tender.
&S9ill!stersE 1
inute !ssessent,
2
nd
Edition, A.?.?,
200/'
The "lient h!s =EG
sin"e he h!d his
tr!"heostoy. 7e h!s
nor!l *o%el sounds.
N. E$tremities Ins'ection
The "lient h!s p!le
p!ls !nd soles.
The "lient h!s
*ody %e!9ness on
the le$t side &due to
ild stro9e'.
C!n o#e
e8treities %ithout
!ny di$$i"ulty.
&S9ill!stersE 1
inute !ssessent,
2
nd
Edition, A.?.?,
200/'
The "lients p!ls !nd
soles !re p!le in "olor
%hi"h !y indi"!te
poor o8ygen!tion.
O. Genitals Ins'ection
Clients genit!li!
h!#e no dis"h!rge
or !ny
dis"olor!tion.
4o s%elling or
!ss o*ser#ed.
Client %e!rs !dult
di!pers.
4o dis"h!rge or
lesions noted, !s
%ell !s !ss !nd
s%elling in the
genit!li!.
&S9ill!stersE 1
inute !ssessent,
2
nd
Edition, A.?.?,
200/'
Client %e!rs di!per
*e"!use he h!s urin!ry
in"ontinen"e. 7e
"h!nges di!per 2 B 1
ties d!ily.
P. Rectum an#
Anus
Ins'ection
The "lient h!#e
de$e"!ted $ored
stools during our
shi$t.
4o dis"h!rge,
lesion, or
heorrhoids noted.
&S9ill!stersE 1
The "lient is using
di!pers due to
in"ontinen"e *rought
!*out *y !ging.
4o heorroids or
s%elling noted.
Client h!s ! he!led
*ed sore on his
*!"9.
inute !ssessent,
2
nd
Edition, A.?.?,
200/'
H. Neurologic
E$am
Ins'ection
The "lient is !lert
!nd "oherent. 7e
h!s pro*les %ith
*!l!n"e due to le$t
sided *ody
%e!9ness.
The "lient "!n
shrug his shoulder,
pupils !re e>u!l,
eyes o#e $reely,
*oth eyes "!n *e
"losed, "!n sell,
"!n identi$y odors,
"!n he!r !
%hispered #oi"e,
no tongue
de#i!tion, !nd
#oi"e is "le!r !nd
strong.
&S9ill!stersE 1
inute
!ssessent, 2
nd

Edition, A.?.?,
200/'
The "lient h!s no
!ltered ent!l st!tus
he underst!nds %h!t
h!s *een s!id to hi.
7e is oriented to d!te
!nd tie e#eryd!y !s
%h!t his "!regi#er
does in the orning.
II. Personal / Social )istor%
)a>its! ?!t"hing tele#ision &espe"i!lly ne%s'
?ices! 1 p!"9 per d!y !nd 1 B 2 *ottles o$ *eer ! %ee9.
Li"est%le! ;nhe!lthy li$estyle $or he h!s *een so9ing 0+ ye!rsI so9es 1 p!"9 o$
=hilip (oris ! d!y !nd drin9s !l"oholi" *e#er!ge o$ 1 B 2 *ottles o$ *eer !
%ee9.
Social A""iliation! E!ting in ! rest!ur!nt %ith $!ily !nd rel!ti#es e#ery %ee9end
!nd going to *!r o""!sion!lly !nd e#ery tie %hen he %!s
in !nil! %ith his $riends.
Clients usual #a% li*e! Going to his 7!"iend!.
Ran*/Or#er in t&e "amil%! The "lient is 2
th
in $i#e &0' si*lings.
Tra+el 9"or t&e last 5 mont&s onl%:! 4one.
E#ucational Attainment! College Gr!du!te &<!"helor o$ Coer"e'
III. En+ironmental )istor%
=rior to "on$ineent, the "lients "!regi#er st!ted th!t, he %!s li#ing in ! *ig
house $ully "eentedI its li9e ! !nsion !s #er*!lized *y his "!regi#er. As the
"!regi#er des"ri*es it, the "lient h!s $our &2' !ids %hi"h !int!in the "le!nliness o$
his house. 7e is !lso using ! $lushed type o$ toilet, !nd their %!ter supply is supplied
*y their pri#!te %!ter supplier. They *uy iner!l %!ter $or their %!ter to drin9. :n
!ddition, he h!s he"t!res o$ "o"onut $!r th!t ser#es ! sour"e o$ in"oe. 7e used his
tr!"tor !s ! e!n o$ tr!nsport!tion in going to his $!rI %herein e#eryd!y he %!s
e8posed to dust. 7is $!ther h!s *een so9ing "ig!rettes %hen the "lient %!s still
young. And one o$ his *usinesses is %ith "o"onut pl!nt!tion !nd !9ing "opr! &it is
the pro"ess o$ !9ing "o"onut oil *y e!ns o$ drying, ste!ed, !nd pressurized'
%hi"h e!ns he is de!ling %ith en#ironent!l pollut!nts !nd !ir%!y irrit!nts $ro
so9es $ro !"hineries.
)uring "on$ineent, the "lient %!s !ditted !t St. C!illus (edh!#en, (!ri9in!
City. 7e is !ditted in ! suite type o$ roo %ith $ully !ir "onditioned !nd $ully
$urnished roo %ith !ppli!n"es li9e tele#ision !nd re$riger!tor. 7is rel!ti#es "!n #isit
hi t%i"e ! %ee9 or ore. St. C!illus (edh!#en is ! hoe"!re $or elderly th!t
"!ters di$$erent types o$ p!tient li9e psy"hi!tri" !nd edi"!l6surgi"!l "lients %hose
$!ily "!n no longer gi#e !ttention they re>uire.
I?. Pat&o'&%siolog%
?. La>orator% E$am
La>orator%
&Septe*er 1,, 2011'
Normal Range Result Anal%sis/Inter'retation
Com'lete (loo#
Glucose
/E00 ! +0 B 120 g6dl 12/ g6dl :n"re!sed, "on"entr!tion
o$ glu"ose in the *lood 11E00 ! +0 B 120 g6dl 120 g6dl
La>orator%
&August 0, 2011'
Normal Range Result Anal%sis/Inter'retation
Com'lete (loo#
Count <it& Platelet
Count
)emoglo>in 121 @ 101 g6A 120 g6A )e"re!sed, the p!tients
o8ygen "ir"ul!tion in the
*ody de"re!ses so the
heoglo*in "!rrying
"oponent de"re!ses
!lso.
)ematocrit 0.12 @ 0.20 g6dl 0.2+ g6dl )e"re!sed, due to
de"re!sed R<C sin"e
he!to"rit is siply !
e!sure o$ ho% u"h the
*lood #olue is !de up
o$ red *lood "ells.
Re# cell count 1.-1 @ 0.22 8 10N126A 2.+0 8 10N126A )e"re!sed, sin"e this is
the pri!ry e!ns o$
deli#ering o8ygen to the
*ody tissues.
D&ite cell count 2.0 B 10.0 8 10 Ng6A 11.20 8 10 8Ng6A :n"re!sed, *e"!use there
is presen"e o$ in$e"tion.
Neutro'&ils 0.00 B 0.,0 0.+2
La>orator%
&(!y 20, 2011'
Normal Range Result
Arterial (loo# Gas Result
p7 Re!"tion ,.12 @ ,.22 ,.11
=!C52 10 @ 20 7g 2, 7g
7C51 22B2/ E>6A 2, E>6A
Anal%sis! =!rti!lly Copens!ted, Respir!tory A"idosis.
I= Ra% Re'ort &5"to*er 10, 2011'
C)EST
Aung $ields !re seen in grey.
The he!rt is enl!rged.
Aort! is "!l"i$ied.
I8PRESSION
7!ziness in Appe!r!n"e
C!rdioeg!ly.
Athero!tous Aort!.
?I. Drug Stu#%
?II. List o" Priorit% Pro>lem
1. :ne$$e"ti#e !ir%!y "le!r!n"e rel!ted to in"re!sed u"ous se"retions se"ond!ry to
stiul!tion o$ go*let "ells6hyperpl!si! o$ u"us se"reting org!ns pri!ry to
Chroni" <ron"hitis !nd in$l!!tory response.
2. :ne$$e"ti#e *re!thing p!ttern rel!ted to in"re!se u"ous se"retions in the !ir%!y
!s !ni$ested *y Chest retr!"tions, in"re!sed u"ous se"retions $!st *re!thing,
use o$ !""essory us"les, e8ertion!l dyspne! %hen %!l9ing !nd Shortness o$
*re!th.
1. :p!ired g!s e8"h!nge rel!ted to poor "ir"ul!tion o$ the o8ygen se"ond!ry to
*ron"hitis !s !ni$ested *y Shortness o$ *re!th, in"re!sed se"retions in the
!ir%!y, sp!ss o$ the *ron"hus !nd $!st sh!llo% *re!thing.
2. A"ti#ity intoler!n"e rel!ted to i*!l!n"es to o8ygen supply !nd de!nd
se"ond!ry to o*stru"tion in the !ir%!y pri!ry to hyper se"retions o$ the u"ous
se"reting org!ns !s !ni$ested *y e8ertion!l dyspne! %hen %!l9ing, *ody
%e!9ness !nd e!sily $!tigue.
0. :*!l!n"ed nutritionI less th!n *ody re>uireents rel!ted to liited $ood int!9e
se"ond!ry to "hroni" o*stru"tion o$ the !ir%!y.
/. :p!ired s%!llo%ing rel!ted to in!*ility to !sti"!te solid $oods se"ond!ry to
o*stru"tion o$ the !ir%!y !s !ni$ested *y presen"e o$ tepor!ry tr!"heostoy
&$enestr!ted' tu*e, de"re!sed g!g re$le8 !nd in"re!se u"ous se"retions o$ %hitish
phleg.
,. Ris9 $or !spir!tion rel!ted to presen"e o$ tepor!ry tr!"heostoy &$enestr!ted'
tu*e in the !ir%!y se"ond!ry to o*stru"tion o$ the !ir%!y !s !ni$ested *y %hitish
sputu se"retions, presen"e o$ =EG tu*e, !nd in!*ility to s%!llo% o$ the p!tient.
?III. Nursing Care Plan
II. Ongoing A''raisal!
.
st
#a% 9Se'tem>er .7B 0C.1:
?e %ere endorsed to ! "lient n!ed (r. A.G.F %ho is ,- ye!rs old %ith ! "!se o$
C5=) &Chroni" 5*stru"ti#e =ulon!ry )ise!se'E Chroni" <ron"hitis. 7e %!s
!ditted in ! pri#!te isol!tion roo %hi"h is the l!st roo $ro the nurses st!tion.
?e h!#e seen the "lient lying on *ed, %ith he!d ele#!ted to 20 degrees, !nd %ith
tr!"heostoy !nd =er"ut!neous Endos"opi" G!strostoy &=EG'. 4o other
"ontr!ptions hoo9ed to the "lient, *ut h!s su"tion !"hine, o8ygen %ith huidi$ier,
!nd ne*ulizer !t the *edside. Su"tion !nd o8ygen "!n *e used !s needed *y the
p!tient. )uring the $irst d!y o$ rot!tion, the "lient h!d his orning shi$t pri#!te
"!regi#er %ho h!d !lre!dy per$ored the orning "!re $or the "lient. To h!#e ! *etter
underst!nding !*out the "lient !nd his "!se, %e pro"eed to the nurses st!tion to re!d
his "h!rt !nd re!d his edi"!tion sheet.
A$ter g!thering the d!t!, *!sed on his "lients s"hedule, he is $or Coplete <lood
Glu"ose &C<G' onitoring !t /E00 ! %hi"h %!s t!9en !nd re"orded %ith ! result o$
12/ g6dl. 7e %!s onitored $or his C<G *e"!use he h!s "ontrolled Type :: )i!*etes
(ellitus sin"e he is 10 ye!rs old. A$ter th!t %e g!#e hi his A!ntus &Apidr!' 1+ units
Su*"ut!neous on the 2
th
le$t !re! on his !*doen. :t "ontrols his glu"ose le#el in the
*lood. At ,E10 ! %e h!#e t!9en his #it!l signs !nd re"orded %hi"h !re the $ollo%ingE
! teper!ture o$ 10.2
o
C, ! pulse r!te o$ 102 *e!ts per inute, ! respir!tory r!te o$ 20
*re!ths per inute !nd ! *lood pressure o$ 1106+0 7g. A$ter th!t, %e h!d prep!red
his edi"!tions !nd the osteorized $ood $eeding %hi"h %ill !ll *e !dinistered !t +E00
!. #i! =EG. 7is edi"!tion %ere (ethy"o*!l 1 t!* 000 g !nd %!s diluted to 10
"" o$ hot %!ter, this is indi"!ted $or his .it!in <12 !n!geent, !nother is :*eret
10"" gi#en $or his !nei! !nd Citi"holine 2 "" $or ner#e stiul!tion %hi"h %ere !ll
pl!"ed in one edi"ine "up to *e in"orpor!te to his osteorized $ood o$ 110 "" during
$eeding. There is $lushing o$ 10 "" o$ %!ter *e$ore !nd !$ter $eeding $ollo%ed *y !$ter
"!re. There is neg!ti#e residu!l noted $ro the peg.
At -E00 !, the "lient is s"heduled e#ery Tuesd!ys !nd Frid!ys $or his =hysi"!l
Ther!py Reh!*ilit!tion !nd %e !ssisted hi on his %!y to the =hysi"!l Ther!py
Roo. The "lient %!s hoo9ed into ! TE4S &Tr!ns"ut!neous Ele"tri"!l 4er#e
Stiul!tion' to $urther stiul!te his us"les $or o*ility. ?e !ssisted hi on his
%!l9ing !nd "y"ling o#eent o$ his lo%er !nd upper e8treities %ith !tt!"hed one
pound o$ %eights $or his !rs %hile doing the e8er"ises $or toning !nd strengthening
o$ his us"les. The reh!*ilit!tion ther!py l!sts $or t%o &2' hours !nd then %e !ssisted
hi *!"9 on his %!y to the roo. :n doing his e8er"ises, these !de hi re!lly tiredI
he !ni$ested shortness o$ *re!th !nd re>uested to "oe *!"9 to his roo to rest.
At 10E00 !, he is s"heduled to h!#e his <!rley $lushing o$ 10 "" on"e ! d!y, it is
! prophyl!8is $or his "onstip!tion it !lso "ont!ins $i*er, !nd #it!ins !nd iner!ls.
?e !lso !dinistered .entolin #i! ne*uliz!tion to relie#e *ron"hosp!s !nd li>ue$y
se"retions. A$ter !ll the ne"ess!ry inter#entions %!s "!rried out, th!ts the tie %e
%ere !*le to t!l9 to his pri!ry "!regi#er, !s *eing the ost reli!*le sour"e $or our
g!thering o$ our d!t! *e"!use shes *een ! pri#!te "!regi#er o$ the "lient $or t%o
ye!rs, $!ilies resides outside the "ountry !nd no $!ily e*ers6rel!ti#es th!t
#isited during our shi$t. )uring the "on#ers!tion, %e !s9 her soe in$or!tion !*out
the "lient th!t %e "!nnot $ind or o*t!in $ro his "h!rt. ?e !lso did ! physi"!l
e8!in!tion %hene#er the "lient is in "o$ort!*le disposition. At 12E00 noon, %e h!d
gi#en !g!in his pres"ri*ed !$ternoon edi"!tions &the s!e edi"!tions gi#en in the
orning' !nd osteorized $ood $eedings. ?e h!d !lso t!9en his #it!l signs prior to th!t
!s %ell !s the C<G %ith the result o$ 120 g6dl *e$ore his $eeding in lun"h.
:n su!riz!tion o$ %h!t h!ppened on the $irst d!y o$ "lient "!re, in ters o$ the
"lients o*ility, he "!nnot %!l9 !lone %ithout !ny !ssist!n"e o$ ! %!l9er !nd
guid!n"e $ro his "!regi#er !nd physi"!l ther!pist. 7e !y $!ll do%n %hen no one is
!ssisting hi. The edi"!tions th!t %ere gi#en to the "lient %ere $or his di!*etes
ellitus Type ::, his *ody %e!9ness, $or pre#ention o$ his "onstip!tion, !nd #it!in
<12 !nd :ron !s suppleents to tre!t his !nei!. These !re the edi"!tions th!t %ere
ordered *y his do"tor to !id the "lient on his nutrition!l i*!l!n"e, sin"e he lost ! lot
o$ %eight !$ter he %!s on =EG. The "lients "!regi#er %!s "on"erned *e"!use the
"lient h!d e8pressed his deterin!tion o$ %!nting to go *!"9 to his nor!l $eeding
%ithout =EG !nd e!t regul!r $ood.
0
n#
#a% 9Se'tem>er .;B 0C.1:
At 0E10 !, %e did the orning "!re $or the "lient. ?e "h!nged his di!per, did
tr!"heostoy "!re !nd =EG "!re !nd "h!nged the linens. ?e !lso did ne*uliz!tion on
the "lient !t /E00 !.
At ,E10 !, C<G %!s t!9en !nd re"orded %ith ! result o$ 12, g6dl. Sin"e the
"lients *lood sug!r %!s high he %!s gi#en A!ntus &Apidr!' insulin, 1+ units #i!
su*"ut!neous in his 2
th
right !*doin!l !re!. This %!s gi#en to hi $or his "ontrolled
insulin le#el. .it!l signs %ere t!9en !nd re"orded %ith the $ollo%ing resultsE !
teper!ture o$ 10.0
o
C, ! pulse r!te o$ +- *e!ts per inute, ! respir!tory r!te o$ 20
*re!ths per inute, *lood pressure o$ 1206+0 7g !nd !n o8ygen s!tur!tion o$
-/H. A$ter th!t, %e h!d prep!red his edi"!tions !nd the osteorized $ood $eeding
%hi"h %ill !ll *e !dinistered !t +E00 ! #i! =EG. 7is edi"!tion %ere (ethy"o*!l
1 t!* 000 g !nd %!s diluted to 10"" o$ hot %!ter, this is indi"!ted $or his .it!in
<12 !n!geent, !nother is :*eret 10 "" gi#en $or his !nei! !nd Citi"holine 2 ""
$or ner#e stiul!tion %hi"h %ere !ll pl!"ed in one edi"ine "up to *e in"orpor!te to
his osteorized $ood o$ 110 "" during $eeding. There is $lushing o$ 10 "" o$ %!ter
*e$ore !nd !$ter $eeding $ollo%ed *y !$ter "!re. There is ! neg!ti#e residu!l noted
$ro the =EG.
At 10E00 !, %e h!d gi#en his .entolin #i! ne*uliz!tion. A$ter ne*uliz!tion, the
"lient %!s %ith produ"ti#e "ough !nd produ"es ! lot o$ %hitish sputu !ppro8i!tely
0@10 l per episodes o$ "oughing %hi"h %!s !n!ged *y "hest #i*r!tion %hene#er
he "oughs produ"ti#ely. At 11E00 !, he %!s !g!in s"heduled to t!9e his C<G re!ding
%hi"h resulted to 120 g6dl glu"ose le#el. ?e prep!red !g!in the pres"ri*ed
edi"!tion &the s!e edi"!tions gi#en in the orning' !s %ell !s his osteorized
$ood $eedings. At 12E00 noon %e !lre!dy h!d gi#en hi his $eedings !nd edi"!tions
#i! =EG. And then #it!l signs %ere t!9en !nd re"orded.
)uring our $ree tie, %e "ontinued g!thering d!t! !*out the "lients history !nd
other ne"ess!ry in$or!tion !nd !lso per$ored !ssessents !nd physi"!l
e8!in!tions. ?e !s9ed soe help $ro his pri!ry "!regi#er to gi#e us the needed
in$or!tion *e"!use the "lient h!s !n ip!ired spee"h due to the presen"e o$ his
tr!"heostoyI he ight h!#e ! h!rd tie gi#ing us the in$or!tion %e needed
*e"!use t!l9ing re>uires o8ygen de!nd. ?e h!#e g!thered in$or!tion !*out his
p!st !nd present illnesses, his $!ily history, !nd o*t!in d!t! $or our gordon
!ssessent.
I. Disc&arge Plan! 46A