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MANILA DOCTORS COLLEGE

President Diosdado Macapagal Blvd., Metropolitan Park, Pasay City

NURSING PROCESS

I. ASSESSMENT
A. GENERAL DATA
Patient’s Initials: J.E.M Numbers of days in the Hospital: 3
Address: Bacoor City Date of Admission: August
15, 2010
Age: 53 y/o Order of Admission: Ambulatory
Sex: Female Informant: Self
Date of birth: July 12. 1957 Date of History Taking:
August 17, 2010
Place of birth: Janiuay Iloilo Occupation: Housewife
Civil Status: Single

B. CHIEF COMPLAINTS

C. HISTORY OF PRESENT ILLNESS

2 weeks prior to admission, the patient felt pain at LLQ that


causes her not able to perform much activities. She decided to consult a
doctor in Manila Medical Center and she was advised to have a laboratory
test and KUB UTZ and was diagnosed having Nephrolithiasis Left staghorn
calculus, and was advised to take potassium citrate 10 meq tablet 2x a
day and sambong 1 tablet 2x a day .She was then referred to Manila
Doctors Hospital for further medical intervention and for removable of
these stones.
She said that she had discomfort in urinating and it is tea
colored urine. Also, she complains of on and off flank and lower abdomen
pain rated as 6/10, from a scale of 0-10, 10 being the highest. The pain is
usually stimulated when she’s doing householdchores.
D. PAST HISTORY

1. Childhood illness/es :
None
2. Adult illness/es:
Hypertension
3. Immunization:
None
4. Previous Hospitalization:
Gave Birth (1987,1994)
Raspa (1992, 1996)

5. Operation/s:
Raspa (1992, 1996)
6. Injuries:
None

7. Medications taken prior to confinement:


Potassium citrate 10 meq tablet 2x a day
Sambong 1 tablet 2x a day
Calcium Poten Cee 500mg OD
Coversil 1 tab OD
8. Allergies
None

E. SYSTEM REVIEW

A. Health Perception Pattern

Prior to confinement, the client feels good about herself although


sometimes she is not conscious or particular in maintaining her health
healthy. She did not experience any severe illnesses or pain on her body
before except when she’s having fever or flu. She denies that she don’t take
drugs, alcohol or cigarettes. For her the best thing to do, to keep her body
healthy are having a balance diet, drinking 8 glasses of water, proper
hygiene and exercising every day although sometimes she drink only 6
glasses of water a day and sometimes eating too much salty foods.

During the confinement, the client feels bored because she cannot do
the usual activities that she always do like doing household chores, going to
the market and playing badminton. But still she also feels a little bit good
because she can relax in the hospital. She listens and cooperates to the
advices and instructions given by her physician and nurses. She believes
that complying on medication and proper interventions is important to
have a successful and uncomplicated recovery.

B. Nutritional metabolic pattern

BREAKFAST LUNCH DINNER SNACK


Pandesal Sinigang Sinigang Break with
Hotdog (Pork,Fish) (Pork,Fish) Butter/ Peanut
Fried Egg Tinola (Fish) Tinola (Fish) Butter
Rice Beef Steak Beef Steak Hotdog
Meatloaf Fried Fish Fried Fish Meatloaf
(bangus, Tilapia) (bangus, Tilapia)
Fried Chicken Fried Chicken
Chapsuey Chapsuey
Rice Rice
Banana / Mango Banana / Mango

Beverages:
Beverages: Beverages: Beverages:
Water, Orange
juice, Coffee Water, Coke, Water, Coke, Water, Coke,
Sprite, Sprite, Sprite,
Orange/Mango Orange/Mango Orange/Mango
juice juice
juice

In a day she can drink at least 6-8 glasses. If she is playing badminton
she can drink 10 glasses of water and softdrinks. She has a weight of 61 kg
and she has a lot and thick strands of hair. She can eat any food because she
has a good appetite she doesn’t choose on the food that she is going to eat,
that’s why sometimes she forget the proper diet that she should have. When
there is a wound it heals well and it does not stay long. She has a smooth
skin, there were no any lesions but sometimes if it is cold her skin becomes
dry but the lotion is the best way for her to put so that it will moisten the
skin. She have 30 permanent teeth and there were no presence of dental
cavities because she visits her dentist once a year to have a checkup.
During hospitalization, she said that even she is in the hospital, she
still have a good appetite. On the first day she was advised to have an NPO
because she will undergo surgery for the 2nd day so on the 2nd day she was
advised that she can eat food like crackers until she is fully recovered with
the surgery and the following day she was advised to have a Full diet and
she ate bread with butter in the morning and in lunch she ate Kare-Kare with
rice also papaya. She drink only 4-6 glasses a day.

C. Elimination pattern

Prior to confinement, she defecates every morning the character of it is


light brown and it has a soft form. She doesn’t feel any discomfort whenever
she defecate also she doesn’t take any laxatives for eliminating. In her
urinary elimination it depends on the amount of liquid that she take, usually
it’s 4-5 times a day which is amber-yellow color and sometimes tea colored
urine and sometimes she feels discomfort when urinating and her lower
abdomen became painful. In controlling, she can handle properly. The client
perspire depends on the activity that she is doing, mostly she doesn’t
perspire that much but if the activity requires a lot of effort like badminton,
that’s the time she experience much perspiration. Good for her that the
perspiration is not that bad odor because she observes proper hygiene.
During hospitalization, she did not defecate for 2 days but on the 3rd
day she already defecate which the character of it is light brown and it has a
soft form. Also when defecating she doesn’t feel any discomfort and doesn’t
even take laxatives. Her urine is amber-yellowish in color and usually she
urinates at least 3-4 times a day.

D. Activity-rest pattern
Prior to confinement, the client states that she have sufficient energy
whenever she have to do a certain activity. For her the source of her exercise is
playing badminton that takes for her a whole day to play and it is usually 3-5 times
a week and she claims that she doesn’t feel tired easily. The daily activities that she
do at home are cleaning, washing clothes, cooking and buying goods in the market.
There are times that she is experiencing flank pain so she cannot perform activities.

During hospitalization, the client is just lying down on her bed and sometimes
she is in a semi fowler position or she sits on her bed, she felt some discomfort after
the surgery but she can tolerate it. The client has the ability to do anything like
feeding, bathing, toileting, bed mobility, dressing, grooming, general mobility which
is in the Level #0 which is a full self care.

The client has a full self care because she can perform any task by her own self. In
her gait and posture she can balance her body when sitting. During the assessment
she stands at that time. She has a tight grip because she can pick up her cellphone
or objects that fits her hand and when she picks it up it doesn’t fall easily.

Pulse Rate: 72 Temperature: 36.8 C

Respirations: 20 Breath sounds: no sounds

Blood Pressure: 130/90

The client has a good hygiene because she is clean in her body, smells good,
and wears clothes that fit.

E. Sleep-rest pattern

Prior to confinement, client takes 6-7 hours of sleep if it is she’s not


busy because there are times that she is playing computer puzzle games
and she tries to finish it so this is the reason sometimes she doesn’t sleep
early or she went home late because of badminton. She sleeps at 10:00 pm
and wakes up around 4:00 am to prepare breakfast for her children. She’s
having a nap for 1 hour in the afternoon if she’s not doing anything.
Whenever she sleeps she don’t experience too much dreams and she
doesn’t wake up in the middle of the night. Her energy is enough for her to
perform her daily activities.
During hospitalization, she can also sleep well. She sleeps at 10:00 pm
to 6:00 am which is an 8 hour of sleep but she is experiencing dreams
sometimes. Still she doesn’t wake up in the middle of the night. Also she’s
having a nap in the afternoon for 1hour. She also have enough energy for
light activities.

F. Cognitive-perception pattern
Prior to confinement, the client doesn’t have any hearing difficulties so she
can hear clearly. There is a problem with her eyes because both eyes are
experiencing astigmatism. She uses eye glasses with unrecalled grade. She doesn’t
anymore recall when she visited her ophthalmologist. In decision making, she can
decide by herself and sometimes with the help of her husband especially if it is a
serious matter. For her the best way to understand things is through discussion and
demonstration. At this moment she doesn’t feel discomfort in fact she is happy
because she was advised to go home.

During hospitalization, the client is not experiencing any hearing


difficulties but still there is a problem with her eyes which is both
astigmatism. She still she uses eye glasses with unrecalled grade. During the
stay in the hospital her daughter, niece and nephew were there to take care
of her and give all her needs.

The client can hear whispered words, can read newsprints easily also
she can grasp ideas and questions both abstract and concrete. The client’s
vocabulary is normal it’s not that wide but she knows a lot of words to say
that has sense. She has a long attention span because she really
concentrates on the interview. She doesn’t feel bored about it because she
enjoys answering the questions.

G. Self-perception pattern

Prior to confinement, she feels good and proud to herself because she
is contented on her physical appearance and she’s contented of everything
she owns. She is a productive person that’s why she always does something.
If she has problems, she doesn’t think of it very much because she knows
that she can easily resolve it. Despite of that she doesn’t easily lose hope
because she said that she is a strong person.

During hospitalization, she feels bored because she wants to stay at


home and play again badminton and she feels not good because she cannot
do what she wants like going to the market and playing her favorite sport
which is badminton but then she didn’t think that she lost weight. Even she
is bored her family were there to support and be with her, in that case she
felt very much loved by her family.

While having the interview the client really had her attention on the
interview because she is focus on the things that we were talking about. She
really looks through the eyes on the one that she is talking to. While having
the conversation the voice of the client is not that too soft or loud it is in a
normal volume and there were no problem in her speech and she is in a
relaxing position, she is just in sitting position. The client feel relaxed during
the conversation.

H. Roles-relationship pattern

Prior to confinement, the patient is the mother of the family. She lives
with 6 other family member. They don’t have any serious family problem
because they are all open with each other so they can immediately fix small
problems. Her role is to take care of her children and fulfilling all the duties
as a mother. When she is brought to the hospital her family felt sad because
they don’t really want anyone in their family to be brought in a hospital so
for them the best way to do is to support JEM by fulfilling all the needs. She
emphasized that they have a happy and strong family so they don’t feel any
problem with the other member of the family. She joined the Badminton
Golden Girls wherein they always play badminton also her friends felt
worried about her confinement. For her she has a sufficient allowance for her
every day needs.

During hospitalization, her family felt sad and worried about her
condition, instead of just feeling sad and worried they make her happy by
taking care of her and being with her all the time. Her friends are all
checking her and asking how does she feels by calling her through mobile
phone.

During the assessment the client shows that she is really happy with
her family and friends because they are the one who’s managing what are
the things that is needed to do in the hospital.

I. Sexuality-reproductive pattern

The patient claims that even her husband is not always at home they
are still sexually active and doesn’t anymore use any contraceptives because
she is already menopause since 47 y/o.

J. Coping stress tolerance pattern

During hospitalization, she felt stressed because she cannot do a lot of


activities. To be able to be not worried she used to listen music in her radio
in the hospital to serve as destruction in her stress also she asked her
daughter to do her duties that was left in the house. There were no
medications given to her to relieve her stress. In her case she can handle it
with the support of her children.
K. Value-beliefs pattern

Prior to confinement, her plans for the future are to finish studying and to be
a successful entrepreneur wherein she knew that it will come true. She is a Roman
Catholic and according to her, religion is important to her and her family. She is
active in her religious organization which is held every Saturday. They always hear
mass and they really believe to God.

During hospitalization, although she can’t go to church, she still


personally prays for her family and for the guidance and blessings that God
had given to them. Her religion doesn’t affect her stay in the hospital
because there were no restrictions in taking medications or interventions.
Although she was brought to the hospital her faith to God is still the same as
before.

F. Family Assessment

NAME RELATION AGE SEX OCCUPATI EDUCATION


ON AL
ATTAINTME
NT
M.A.M Husband 57 M Seaman College
Graduate
J.E.M Daughter 23 F English- College
Korean Graduate
Interpreter
J.M.E.M Son 16 M Student 4th yr HS
J.E Niece 38 F OFW College
Graduate
C.B Niece 25 F OFW College
Graduate
R.M Nephew 22 M Seaman College
Graduate

G. Heredo
Maternal: Hypertension
Paternal: Hypertension

H. developmental History

I. Physical Examination (date and time)

Height: Actual Weight:


Actual Height: Ideal Body Weight:

Vital Signs
Temperature:
PR:
RR:
BP:
A. Skin
I:
• Tan skin color and same as the rest of the body except the
abdomen, back and thigh which is light brown.
• There is no presence of lesions or any wounds.
• There is no presence of edema

P:
• moist and warm
• smooth skin but some parts are dry like legs and arms
• Has smooth and intact texture
• Skin-fold areas such as the axillae has minimal perspiration
• poor skin turgor
• There are no abnormal masses or distention present.

B. Nails
I:
• transparent, well rounded, convex, with a nail bed angle of
about 160 degrees, without inflammation
• Pinkish in color
• Clean and well trimmed
P:
• capillary refill time of 2 seconds
• smooth to touch and intact

c. Head and Face


I:
• Head is held upright and still.
• head is proportional to the size of the body,
• symmetrical and aligned, oval in shape,
• normocephalic in size, has no deformities or any swelling.
• face is round and proportional to the head and also
symmetrical
• Eyes, nose, ears and mouth are symmetrical to
each other
• Able to perform facial expressions such as smiling and
frowning without any difficulties.
P:
• Absence of any tenderness and lesion
D. Eyes
I:
• No bulging of eyes or eyelids.
•Equally distributed eyes lashes.
•The eyebrows are symmetrical to each other.
• Eyes are symmetrical to each other, pupils are equal and
round.
• Responds well by dilation and contraction.
•Opens, closes, and blinks properly.
• Both eyes are having astigmatism; wears eye glasses with
unrecalled grade
• Absence of redness, edema, inflammation and
lesions
• No excessive tears and dryness
• Cornea is clear and has no presence of lesions
• Sclera is white in color

Reaction to light

• pupil constricts when Illuminated


• Non-illuminated pupil constricts
• Accommodation and convergence
• Pupil constricts when looking at near object
• Pupil dilate when looking at far object
• pupil converge when near object is moved toward nose.

Visual field

• When looking straight ahead, client can see object in the


periphery.

E. Ears
I:
• Parallel
• Proportional and symmetrical to the head and the face.
• Color is the same as the surrounding area, no presence of visible
masses, wounds, deformities and lesions.
• Ear canal is pinkish, few exudates, with fine hairs and scanty
amount of cerumen.
• Both ears can hear whisper words within 2 feet,
• In Rhinne’s test the air conduction is longer than bone
conduction.
P:
 Auricles are smooth in texture
 No tenderness and lesions upon palpation

F. Nose
I:
• Proportional in relation to the face.
• Nasal bridge is straight, pointed and in the midline.
• No nasal flaring and no exudates.
• No nasal discharge
• Has a pinkish, mucous membrane.
• Nasal septum is in the midline.
P:
• Patent nares
• No tenderness in the frontal and maxillary sinuses.
• Absence of tenderness and lesions
• Absence of swelling

G. Mouth and Pharynx


I:
• light pink lips with brown spots
• light pink gums
•No presence of halitosis.
•Lips are moist and symmetrical to each other
• moist buccal mucosa,
• tongue dull red and can move freely
• the uvula is in the midline and it is pinkish in color
•No presence of ulcerations
•Absence of edema

H. Neck
I:
• no lesion
• Absence of scars
• No visible pulsations
• Absence of visible veins
• prominent clavicle
• neck moves freely without discomfort
P:
• non tender
• Trachea is in midline
• no masses

I. Spine
I:
• Spine lies at midline in the anterior-posterior
direction
• Curved in lateral position
• Presence of normal muscle bulk
• Has proper posture and gait
P:
• No tenderness and masses felt
• No swelling; no dislocations

J. Thorax/Lungs
I: RR: 20
• Scapulae are symmetrical and closely attached to the
thoracic wall
• Absence of chest deformities
• Expands and relaxes regularly with equality of movement.
Pa:
• Tactile fremitus is symmetric
• Good lung expansion
Per:
• resonance heard over lung fields

A:
• (-) wheeze

K. Cardiovascular/Heart
I:
• No presence of visible pulsations
Pal:
• No presence of abnormal pulsations in all areas
• Poor skin turgor
• Chest wall is warm to touch

A:
• normal rates with Heart Rate of 72
• regular rhythm
• no murmur

L. Breast
Refused

M. Abdomen
I:
•Abdomen is symmetrical
•Flabby
•umbilicus has no inflammation and no discharges

A:
•Presence of soft gurgling sounds 25 times per minute
•Bowel sounds are audible
Per:
• Dull sound heard over solid masses or internal organs
• Tympanic sound heard over the stomach and intestines
Pal:
• There are no presence of abdominal tenderness and
masses
• There is no presence of discomfort during palpation

N. Extremities
I:
• Proportional to the gross body structure, parallel and
symmetrical
• Can move in full range of motion.
P:
• (-) tremors

• (-)deformities

• (-)tenderness

• (-)swelling

O. Genitals
Refused
P. Rectum
Refused

Q. Neurologic exam
JEM is conscious and oriented with the time and place. She is able
to converse and can follow simple commands.

R. Cranial Nerves
I - Can sense smell
II/III - Has astigmatism on both eyes
IV/VI - Extra ocular Movement: Parallel eye movement
V - Able to grind; reacted on light touch sensation
VII - Able to raise both eyebrows, frown, show
teeth, close eyes, blink
VIII - Lateralization on both ears
IX/X - Able to swallow; (+) gag reflex
XI - Can shrug shoulders
XII - Protrudes tongue
Reflexes - Postive Patellar reflex
Biceps can normally flex the elbow.
Triceps has the ability to extend the elbow.
I. PERSONAL / SOCIAL HISTORY

Habits:
She does household chores, always watching television
and reading newspapers every morning.

Vices:
For her taking drugs, smoking and drinking alcohol are bad
so she don’t do that.

Lifestyle:

Social affiliation:
She didn’t joined any social affliation.

Client’s usual day like:


When she wakes up in the morning, she will eat breakfast
and then take a bath, after that she will go to the market
and then she will clean the house. After cleaning she will
eat lunch and in the afternoon she will just take a rest and
take a shower .When it is already night she will prepare
food for her children and they will eat all together. After
eating she will just take a rest while watching tv and then
she will sleep. That is her routine always.

Rank/ order in the family


She is the mother in their family

Travel (for the last 6mos only)


For the last 6 months she didn’t go anywhere she just
stayed in their house

Educational attainment:
She is a college graduate

II. ENVIRONMENTAL HISTORY


The patient lives with 2 other family member at a bungalow and it is
well ventilated. The houses in the neighborhood have an adequate
space which would lessen the risk for fire. They have waste disposal
and is collected everyday usually in the morning. Market, church and
health center are near within their place. They have 1 SUV and
sometimes they use public transportation as their means of
transportation.

IV. OB/GYNE HISTORY


Menarche : 14 y/o
Menopausal age: 35 y/o

Deliveries: G P Operation: Total Hysterectomy


OB Score: T P A L

V. PEDIATRIC HISTORY

VI. PATHOPHYSIOLOGY

VII. LABORATORY
COMPLETE BLOOD COUNT

HEMATOLOG NORMA RESU


Y L LT INTERPRETATION
VALUES
HEMOGLOBIN 123 – 125 NORMAL
153 g/L The blood has the capability to
transport oxygen to tissues and
organs and to deliver the waste
product carbon dioxide to the lungs,
where it is exhaled.
NORMAL
HEMATOCRIT 0.36– The hematocrit of the patient is
0.38
0.45 made up of red blood cells which is a
proportion in the blood
4.10 – NORMAL
RED BLOOD
5.10 x 4.48 There is a normal number of RBC in
CELL
1012L the whole blood
NORMAL
WHITE 4.00 –
The blood has the capability to help
BLOOD CELL 10.50 x 10.30
the body to take action and
109L
eliminate infection
NORMAL
NEUTROPHILS 0.36–
0.57 Has a normal number of neutrophils
(segmenters) 0.66
in a WBC
DECREASED
LYMPHOCYTE
0.24– It cannot produce enough antibodies
S 0.22
0.44 and cannot much recognize foreign
substances.
INCREASED
EOSINOPHILS 0.01 - It is more sensitive in an allergic
0.11
0.04 responses and in resisting some
infections
NORMAL
Has the ability to respond to
MONOCYTES 0.02 - infection and inflammation by
0.10
0.12 releasing certain proteins
(monokines) that can inactivate
bacteria.
BASOPHILS 0.00 - NOT
0.01 DONE
0.02 - NOT
STABS
0.05 DONE
NORMAL
11.50 –
RDW 14.0 There is normal variation of size in
14%
RBC
NORMAL
It has the normal measurement of
MCV 80– 96 85.30
the average size of the RBC of the
patient
MCH 27.50 – 27.90 NORMAL
33.20 pc It has a normal average amount of
oxygen-carrying hemoglobin inside a
RBC
35.40 –
DECREASED
MCHC 35.50 32.7
Decreased when MCV is decreased
g/dL

IX LIST OF PRIORITY PROBLEM

X. NURSING CARE PLAN

XI. ONGOING APPRAISAL

XII. DIACHARGE PLAN

M- medication
E- exercise
T- treatment
H- health education
O- OPD follow-up
D- diet
S- spiritual