The nursing process document summarizes a patient admission that includes assessment of medical history, clinical inspection, and psychosocial evaluation. It records the patient's vital signs, physical exam findings, patterns of daily living, and mental status. The admission is for a female patient in her 50s presenting with a chief complaint of difficulty breathing who underwent an unspecified surgical procedure.
The nursing process document summarizes a patient admission that includes assessment of medical history, clinical inspection, and psychosocial evaluation. It records the patient's vital signs, physical exam findings, patterns of daily living, and mental status. The admission is for a female patient in her 50s presenting with a chief complaint of difficulty breathing who underwent an unspecified surgical procedure.
The nursing process document summarizes a patient admission that includes assessment of medical history, clinical inspection, and psychosocial evaluation. It records the patient's vital signs, physical exam findings, patterns of daily living, and mental status. The admission is for a female patient in her 50s presenting with a chief complaint of difficulty breathing who underwent an unspecified surgical procedure.
The nursing process document summarizes a patient admission that includes assessment of medical history, clinical inspection, and psychosocial evaluation. It records the patient's vital signs, physical exam findings, patterns of daily living, and mental status. The admission is for a female patient in her 50s presenting with a chief complaint of difficulty breathing who underwent an unspecified surgical procedure.
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West Visayas State University
COLLEGE OF NURSING La Paz, Iloilo City
NURSING PROCESS I. VITAL INFORMATION Name:
Date of Interview: July
6, 2012 Age: Sex:
Informant: J.C. and J.A.L.
Relation to Client: Patient
herself Address: Civil Status: Date and Time Admitted: Chief Complaint: Ward: Ward Bed No: Religious Affiliation: Physicians Initials: Impression/Diagnosis Pre-op Diagnosis: Post-op Diagnosis: Surgical operation performed: Days Post-op: II. CLINICAL ASSESMENT II.A: NURSING HISTORY 1. History of Present Illness a) Usual Health Status
b)
Chronologic Story
c) Relevant Family History
d) Disability Assessment
2. Past Health Problems
a. Childhood Illness b. Immunization c. Allergies
d. Accidents and injury
e. Hospitalization for Serious Illness f. Medications 3. Family History of Illness
4. Patients Expectations A. What patient expects to occur during the hospitalization
B. What patient expects regarding nursing care
5. Patterns of Functioning a. Breathing patterns Respiratory problems: Difficulty in breathing Usual remedy: Galakat-lakat lang ko kag mag ginhaginhawa asta mag mag-an akon pamatyagan, as verbalized. Manner of breathing: deep inhalation and deep expiration. b. Circulation Usual Blood Pressure: 120/80 140/90 Any history of chest pains, palpitations, coldness of extremities, etc.: None as claimed. c. Sleeping patterns Usual Bedtime: 9:00-9:00 P.M. Bed time rituals: Gapanibin ko danay kag gapangadi antis ko magtulog, as verbalized. Problems regarding sleep: Wala man ko problema sa pagtulog, as verbalized. Usual remedy: N/A
d. Drinking patterns Total Fluid intake/day: TYPE OF LIQUID Water Coffee
Food dislikes: None as verbalized. f. Elimination patterns 1. Bowel Movement Frequency: 1-2 times a day. Problems or difficulties: None as claimed. Usual remedy: N/A 2.
Urination Frequency: 4-5 times a day. Problems: None as claimed. Usual remedy: N/A
g. Exercise Daw wala gid ko ga exercise, makalakat lakat lang ko kis a kung aga palibot sa patyo nga lapit sa amon balay, as verbalized.
h. Personal Hygiene 1. Bath Type: Full bath and Half bath Frequency: Once or twice a day. Time of day: 7:00 A.M. 7:30 A.M.; 7:30 P.M. 8:00 P.M. 2.
Oral Care Frequency: Three times a day. Care of dentures: N/A
3.
Shaving Frequency: None as claimed.
4.
Use of Cosmetics None as claimed.
i. Recreation Listening to the radio. j. Health Supervision Patient usually use over-the-counter medicines whenever she feels sick, such as paracetamol for fever. And, she only seeks medical help when her husband insisted her to do so. III. A. CLINICAL INSPECTION 1. Vital Signs T= PR= BP= RR= 2. Height: 3. Weight: 4. Physical Assesment General Appearance:
A. Integumentary System
B. Neurologic System Eyes:
Date and Time Taken:
Ears:
Nose:
Throat:
Cranial Nerve
How Elicited
Normal Response
CN 1 Olfactory
Hold scent under
one nostril with the other nostril occluded while the patient closes his eyes. Repeat with the other nostril. Near vision: Ask the client to read a newspaper or magazine paragraph. Far vision: Use a Snellens chart and check distance vision. Six cardinal fields of vision: Ask client to follow object as it moves in the six cardinal fields. Response to light and accommodation: Ask client to look straight ahead and shine light obliquely toward facial midline. Cover uncover test:
Identify scent correctly with each nostril
CN 2- Optic
CN 3,4,5oculomotor,Trochle ar, Abducens
Near vision: client
reads print 14 inches without difficulty. Far vision:20/20 visual acuity for right and left eyes. Both eyes move in a smooth, coordinated manner in all direct directions. Pupils equally round and reactive to light and accommodation. Uncovered eye does not wander or move as opposite eye is covered. Covered eye does
Actual Observation
CN V- Trigeminal
CN 7- Facial
CN 8- Acoustic
CN 9glossopharyngeal
Ask client to look
straight ahead, covering one eye with a covering card, and observing uncovered eye for movement. Motor: Ask patientto open his mouth while palpating temperomandibul ar joint. Sensory: Stroke patients face lightly with a cotton and instruct patient to nod each time he feels the cotton touching his face. Touch the forehead, cheeks and chin on both sides of the face. Motor: Ask patient to smile, frown and wrinkle the forehead, bare teeth, puff out cheeks, purse lips and raise eyebrows. Sensory: Touch the anterior twothirds of the tongue with cotton applicator dipped in sugar. The eyes of the patient should be closed and ask him to identify the taste. Ask patient to repeat whispered word from a distance of 1 foot. Observe the patient if gag reflex is present during suctioning. Ask the patient to
not move as cover is removed.
Motor: Eyes should blink simultaneously bilaterally. Patient should chew and move temporomandibul ar joints. Sensory: Should be able to identify light touch.
Motor: Able to smile, frown, bare teeth, puff out cheeks, raise, and lower eyebrows, and close eyes tightly. All movements should be symmetrically done, free from tenderness. Sensory: Should dentify taste.
Patient should repeat whispered word from a distance of one foot. Gag reflex must be intact. Tongue without tremors upon sticking out and should move
CN 10- Vagus
CN XI- Spinal Accessory
CN XIIHypoglossal
move tongue side
to side and his tongue out Observe the patient if gag reflex is present. Ask the patient to move tongue side to side and stick his tongue out. Ask the patient too turn head against resistance. Ask the patient to shrug shoulders against resistance. Ask the patient to protrude tongue, move it to each side against resistance of tongue depressor.
C. Respiratory System
D. Cardiovascular System
E. Gastrointestinal System
F. Genito-urinary System
freely. Should be able to swallow. Gag reflex intact. Uvula and soft palate should symmetrically rise Should be able to move head freely and shrug shoulders against resistance.
Tongue should move symmetrical with smooth tongue movement and bilateral strength.
