IV. ASSESSMENT A. ASSESSMENT TOOL I.

General Information Name: Patient CG Occupation: Retired Informants: Patient CG' neice Admission date: July 6, 2011 Age: 84 years old Civil Status: Married Relation: neice Time: 9:58AM Sex: Male Religion: Roman Catholic Birthday: November 19, 1926

Address: Pongol Libona, Bukidnon, Philippines

Chief Complaints: Loss of consciousness Attending Physician: Dr. A, and Dr. P Diagnosis/ Impression: CVA, infarct, Hypertension stage 2 Final diagnosis: Cerebrovascular disease, acute right basal ganglia hemorrhage, hypertension cardiovascular disease, community acquired pneumonia. History of Present Illness: The patient has a history of hypertension for 20 years- initially on unrecalled prescribed antihypertensives until prescribed lately with infusion antihypertensives by X but claimed no meds for 2 days. Positive Diabetes Milletus 2, asthmatic. In 2010 had ceverbralvascualr disease slurred speech with residual lateral weakness. The patients smokes until today, started when was 15 years old until the present times. Non alcoholic beverage drinker. Positive for: cough, chestpain and easy fatiguability. A day prior to admission the patient was found lying down at the comfort room. Was immediately lifted and brought to bed. Blood pressure was taken and revealed 280?110 mmHg. Medicine was given under the tongue by the midwife. Advised for admission but patient refused. Family noted left sided weakness associated with slurred speech. No meds given. No consultation done. Few hours prior to admission the patient was lying on bed but was noted to be drowsy and aphasic. He was brought to the nearest hospital. And blood pressure was 120/80mmHg. Persistence of drowsiness and aphasia.

Transfered and admitted to another hospital for ICU admission. Vital Signs (on July 14, 2011: assessment day): HR: 95bpm RR: 20cpm Temp: 36C Weight: BP: 170/100 mmHg O2 Sat: 96%

VITAL SIGNS MONITORING (July 14, 2010, 6:00AM-2:00PM Shift) DATE / TIME 714/11 6 7 8 9 10 11 12 1 2 BP 130/80mmHg 160/80mmHg 150/80mmHg 140/80mmHg 140/50mmHg 140/60mmHg 170/90mmHg 150/80mmHg 160/80mmHg PULSE 80bpm 84bpm 82bpm 84bpm 83bpm 85bpm 84bpm 82bpm 85bpm RR 21cpm 20cpm 20cpm 21cpm 20cpm 21cpm 20cpm 20cpm 21cpm TEMP 36.2C 36.0C 36.0C 36.1C 36.0C 36.0C 36.0C 36.3C 36.5C

Patient had high blood pressure ranging from 130/80 to 170/90 throught the shift. . Note: The phrases, words or sentences enclosed with quotation marks were the statements verbalized by the patient during assessment. II. Activity/ Rest Subjective Usual activities/hobbies: sig era man na siya sa balay permi, gakaon, tulog uig gapanigarilyo Leisure time activities: Gatan-aw ug tv, ug sige ragyud ug panigarilyo

Limitations imposed by condition: Dili siya pwede mutrabaho o mag arsa sa mga bugat, nag lisod siya og lihok-lihok dili siya mustorya sa ato. Number of hours of sleep: dali rani siya matulog. Magmata-mata. Mga tulo o upat ka oras lang gyud Naps: dili man ni siya makatulog sa buntag, gapahulay lang. Aids: wala man siyay ginagamit para makatulog siya Difficulty in sleeping:galisod ni siya ug tulog. Kung makatulog man gani kay gamatamata gihapon. Kadali ra kayo iyang tulog permi. Feeling on awakening: kasagara kay galisod ni siyag ginhawa, pagmata niya kay manigarilyo napud Others/ Comments: Patient is too dependent on cigarette smoking and has a disturbed sleeping pattern. Objective Observed response to activity: stable vital signs, still with increased blood pressure Cardiovascular: 95bpm, within normal range Respiratory: 22cpm, slightly increased Mental Status: oriented, conscious and coherent Posture:poor LOM limited level of movement Tremors none noted Others/Comments III. Circulation Subjective History of Hypertension: 20 years

Heart Trouble: wala man pud ni siyay problema sa kasing-kasing, aside sa iyang high bblood na pwede makaapekto sa iyang kasing-kasing Ankle/ Leg edema: gapang hupong iyang wala nga kamot. Paralyzed naman na, dili niya malihok Slow Healing: wala man koy napansin Cough/ Hemoptysis: ga-ubo ubo man ni siya pero galisod lang siyag pagawas sa plemas. Extremities Numbness and Tingling: paralyzed man iyang too nga kamot ug tiil. Wala raman pud siya nagproblema ug binhod ug sakit. Change in frequency/ amount of urine:wala man koy napansin

Objective Blood Pressure R Lying: Sitting:Standing: Standing: Pulse Pressure: PMI: at apex Heart rate/ Sounds: S1(lub) and S2 (dub) heard over right of midclavicular line. Rhythm: regular heart rhythm Pulse: Carotid 60 bpm Radial 61 bpm Temporal 60 bpm Vascular Bruit: No sound heard Breath sounds: heard over bilateral lung fields clear Jugular vein distention: None noted Extremities Temp: Color: Capillary Refill: Homans Sign: negative L Lying: Sitting:

Varicosities: none Color of Nail Beds: pale Lips: moist and intact, without lesions Mucous membranes: moist without lesions Sclera: White Others/Comments Extremities are warm IV. Ego Integrity Reports of stress factors:Gaingon man siya sa iya mga problema. Usahay kay dili na siya ganahan sa iyang sakit, gareklamo siya pero gapanigarilyo lang gihapon Ways of handling stress: gapahulay ra siya sa balay Financial concerns:gadawat naman siya ug pension kay retired naman pero gatabang ra gihapon mi Relationship status: namatay naman iyang asawa mga 3 years ago. Mayo raman ang relasyon sa iyang mga anak ug sa amo. Lifestyle: kasagara kay sa balay ragyud ni siya kay wala naman siyay trabaho. Talagsa kay galakaw-lakaw kadjot. Recent changes: karon kay dili nagyud siya katarong ug lihok. Gahigda or galingkod ragyud siya bisag asa Feelings of Helplessnes/Hopelessness/Powerlessness: wala man pud siyay ginareklamo mahitungod ani Others/Comments: Objective

Emotional status: Calm Observed physiologic response: elevated BP Others/Comments: Patient is conscious, coherent and cooperative.

V. Elimination Subjective Usual bowel pattern: ika usa sa usa ka adlaw man na siya malibang Character of stool:usahay tubol, usahay basa-basa Last BM: kagahapon Laxative use:wala man Usual voiding pattern: ikatulo hantod lima man na siya makaihi sa usa ka adlaw Others/Comments: Patient experiences no significant changes regarding elimination. VI. Food/ Fluid Usual diet (type): Meals Breakfast Lunch Dinner Food Gulay, rice Isda, gulay,rice Isda,rice Fluid tubig tubig tubig

Number of meals/day:ika-tulo sa usa ka adlaw Last meal intake: sa NGT ra man siya ginapakaon, kanina paniudto iyang last Loss of appetite: katong wala pa siyay NGT kay gakawalaan na gyud siya ug gana mukaon. Allergies/ Food intolerance: wala man pud siyay allergy sa pagkaon, dili lang gyud siya ipakaon ug sobra ka parat ug mga tambok nga pagkaon tungod sa iyang high blood.

Others/Comments: Client was instructed with low salt, low fat diet and was prescribed with Heraclene to enhance appetite Has had NGT removed recently. Objective Current Weight: 75kgs Height: 58 Body build: large frame Mucous membranes:dry Skin turgor: poor Condition of teeth/ gums: dry, pale Appearance of tongue: moist, pale VII. Hygiene Subjective ADL ( Independent/ Dependent ) Mobility Hygiene D / I D / I Feeding Dressing D / I D / I Toileting D / I

Equipment / Presence of devices required: wala man siyay lain ginagamit, kami lang ang gatabang sa iyang paglihok.

Objective General Appearance: Appears neat and clean Manner of dress: Clothes are fit and are appropriate Habits: Body odor: Smells pleasant, no foul odor noted Condition of scalp: No scales present, moist and intact scalp VIII. Neurosensory Subjective: Eyes Vision impairment: R ( / ) L ( /) Last exam: Dili na nako mahinumduman, murag dugay nagyud kayo to

Sense of smell: makasimhot ra man na siyag tarong Epistaxis: wala man pud Others/ Comments: Patient wears eyeglasses due to vision impairement. Objective Mental Status: Oriented/ Disoriented: (/ ) Alert ( ) Stuporous Affect Euthymic Memory ( / )Time ( ) Drowsy ( ) Comatose ( x ) Delusions ( / ) Place ( ) Lethargic ( ) Cooperative ( x ) Hallucinations Remote: Good ( / ) Person ( ) Combative

Recent: Good

Speech pattern: unable to speak Pupil Size/Reaction: right and left pupils are equal round and has appropriate reaction to light, Handgrip/ release: R unable to grip Posturing: poor Others/Comments: patient is alert and awake with eyes open, he also responds appropriately by nodding. IX. Pain/Comfort Subjective L weak

Onset: Duration:

Location: Intensity (1-10): Quality: Description of pain: Precipitating Factors: Aggravating factors: How relieved: Objective o Moving very slowly o Lying down during the day o Feelings of tightness o Avoiding physical activity o Requesting help with walking Others/ Comments: X. Respiration Subjective Dyspnea: galisod gyud ni siya ug ginhawa hubakon man pud gud Cough/ sputum: ga ubo man siya pero galisod siya ug pagawas sa plemas niya Use of respiratory aids oxygen lang diri sa hospital Oxygen O2 inhalation via nasal cannula, regulated @2L/min Others/Comments: Patient experiences difficulty in breathing especially upon exertion. Objective RR: 22 cpm Depth: shallow Symmetry: uses respiratory muscles bilaterally and simultaneously Use of accessory muscles: not using

Nasal flaring: none noted Fremitus: Breath Sounds clear, no adventitious breath south heard over bilateral lung fields Cyanosis: not noted Clubbing of fingers: not noted Restlessness: not noted

XI. Safety Subjective Allergies/sensitivity: wala man ni siyay allergy Hx of STD:wala man pud Blood transfusion:wala, una gyud ni niya na admission History of Accidental injuries: wala man Fractureswala Back problems:usahay mureklamo siya Changes in moles:wala Enlarged nodes:wala Ambulatory device:wala Prosthesis:wala Expression of ideation of violence:wala man pud siyay gina-ingon Objective Diaphoresis: none Scars: not noted, Blisters: non present Drainage (note location): no drainage General Strength: weak, needs assistance in doing activities like walking towards CR and sitting on bed Gait: unable to stand at all Paresthesia/paralysis: none Skin integrity: intact Ulcerations:non noted Burns: non present Arthritis:usahay gatukar-tukar

Ecchymosis: Large, irregular macular lesions noted on whole body

XII. Sexuality Sexually active: No Sexual concerns/ difficulties: ( x ) Penile discharge ( / ) Circumcised Last prostate examination: wala pa sukad Penis: not assessed privacy XIII. Social Interactions Marital status: Married Living with: Yrs in relationship: 35 years Testicles: not assessed Others/Comments: condition of genitalia was not assessed because patient wants ( x ) Prostate disorder ( x ) Vasectomy

kauban niya iyang mga anak o kami iyang mga igagaw

Concerns/stresses: gaproblema mi sa iyang sakit, kung kinsay mag-alaga Extended family:gapuyo man mi iyang igagaw pati iyang mga pag-umangkonkauban niya Other support person:iyang mga anak ug mga pag-umangkon gatabang sa iya Role within the family structure: siya man ang gabantayan namo sa balay Report of problems related to illness/ condition: galisod siya ug ginhawa ug lihok gyud. Dili pagyud namo siya masabtan usahay. Others/Comments: Patient is supported by children and cousins. XIV. Teaching/ Learning Dominant language: Bisaya speech Educational level: highschool graduate raman na siya Health beliefs/ practices:gapahilot man mi mao raman pud. Literate: able to talk but has very slurred

Familial risk factors: (+) HPN all siblings of the patient Use of alcohol (amount/frequency):dili man ni siya ga-inom ug mga beer

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