Assessment

(Female Medical Ward)

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Patient EE, admitted February 27, 2012 because of asthma with a chief complain
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of difficulty of breathing. There is a history of asthma on his family. Alert and oriented to person, day, time and situation; no pain or distress. Responds Appropriately to verbal stimuli; no slurring of speech. Vital signs are all normal, no presence of difficulty of breathing and SOB. Peripheral pulses palpable in all extremities. Can move all extremities. Has a IV Fluids of D5W 500cc with 2mg amoxicillin site is free from redness and swelling. Without catheter.

Patient Ms. AKF, admitted in the hospital February 04, 2012 for a Dengue with a chief complain of High grade fever for 3 days, severe dizziness and vomit after every meal. and oriented no to pain person, or day, time situation; distress. Alert and

Responds

Appropriately to verbal stimuli; no slurring of speech. Vital signs are all normal, no presence of high grade fever, vomiting and dizziness. Skin are normal, not dry and no presence of petichae. refill in Abdomen all are soft and not pulses distended. Pink nail beds with normal capillary extremities. Peripheral palpable in all extremities. Can move all extremities. Has a IVF (150cc remaining) , site is free from redness and swelling. No skin breakdown noted. To be go home.

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Patient DB admitted February 24 2012 with the chief complain of body malaise and loss of appetite. Alert and oriented to person, day, time and situation; pain on the right arms near on the insertion site of IVF. Responds Appropriately to verbal stimuli; no slurring of speech. Vital signs are all normal. Can now move all the extremities. Right arm has a limited mobility due to pain. Left leg was amputated since November 2011 due to necrosis of left leg secondary to diabetes. Has a IV Fluids. Site has presence of redness and swelling. With catheter but removed by 11am. Patient complain of fullness bladder and unable to urinate, thats why she is inserted again a catheter around 2pm.

Patient Mr. JS, 37 y/o, admitted because of Diabetic and has a chief complain of distended abdomen and pain on it. Has a history of Diabetes in the family. Alert and oriented to person, day, time and situation; no pain or distress. Responds Appropriately to verbal stimuli; no slurring of speech. Vital signs are all normal. Skin on the body are normal, there are some black spots on his face, neck and arms. Lessened abdominal distention and no pain at all. Nail beds are color white on all extremities. Peripheral pulses palpable in all extremities. There is edema on both feet. Can move all the extremities. No IV fluids, with heplock , No catheter.

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My experience in 3 days duty (March 1, 2, 3)

Our clinical instructor Mr. Gil assigned us on 3 wards, Male medical ward, Female medical ward and surgical ward. We are rotated there everyday because Sr. Gil group us into 3, 4 students each group and assigned us a functional nursing, one for the assessment, one for the vital sign, one for the IV fluids and one for the medication. I really learn a lot there because I encountered different cases especially on surgical ward like wound cleaning and dressing, and proper removal and insertion of catheter, changing IVF, regulating IVF, giving different medication, drug study, bed side conference, health teaching, and assessing patients. Though our everyday was very tiring but its really worthy of your efforts. We also applied there what we learned in school and exercise therapeutic communication to them. Its really a great experience and I wont forget this duty. It adds a lot to my knowledge,

Patient WL 65y/o admitted February 24, 2012 for a diabetes with a chief complain of edema in whole body for 1 week and dizziness. Not Alert on day, time and situation. The patient experiencing headache, they cannot able to buy to buy a medicine thats why no medicine was given. Vital signs are all all normal, no Can patient presence move still of all has dizziness. Peripheral pulses palpable in extremities. The extremities.

edema on his feet. Has a IV Fluid, site is free from redness and swelling. No skin breakdown noted No catheter.

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Our Clinical Instructor

Our clinical instructor is Mr. Gil, It is my second time that Ive been his student, I remember before we do the same thing to him. We do practical nursing and we also do case study before where there I learn how to do case study. He teach us so many things first thing was how to be presentable to others, though on the first day he got mad us because we are not all properly presentable, But I understand him that he just want us to be in better and thats what I appreciate the most because he is like a father to us. He also teach us how to be independent since we are already graduating he let us do things in our own after he teach us how. He also give us advice because most of us fail in the CA2, he cheer us up and motivate us to still have faith, dont give up and dont stop here.

Patient GM admitted February 21, 2012 for a pleural effusion with a chief started complain of difficulty 2012. of breathing, severe productive cough December Responds Appropriately to verbal stimuli; no slurring of speech. Vital signs are all normal, there is still presence of cough. Skin are normal, not dry. Peripheral pulses palpable in all extremities. Can move all extremities. Has a IVF, site is free from redness and swelling. No skin breakdown noted. No catheter.

Ospital of Sapang Palay,

Ospital of Sapang Palay is located on Sapang Palay, San Jose Del Monte Bulacan, we are assigned there under the supervision of Mr. Gil in the area of Medical-Surgical ward. Its my third time to duty there, first is in OB and pedia second in MS ward and recently in MS ward again.

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Patient AA admitted February 26, 2012, 35 y/o for a High Blood (150/100) with a chief complain of dizziness. Alert and oriented to person, day, time and situation; no headache, presence of dizziness nausea and vomiting. and Responds

Appropriately to verbal stimuli; no slurring of speech. Temperature, Respiratory Rate and Pulse Rate are normal, BP is 150/100. Skin are normal, not dry. Pink nailbeds with normal capillary refill in all extremities. Peripheral pulses palpable in all extremities. Can move all extremities. No IV Fluids. With a heplock. catheter. To be go home. No

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Patient JR admitted February 28, 2012 with a chief complain of Stomachache and bulging of the stomach. Responds Appropriately to verbal stimuli; there is slight slurring of speech. Vital signs are all normal. Skin are normal, not dry. Peripheral pulses palpable in all extremities. Can move all extremities. Hand grasp is not that strong. Has a IVF LRS 1000cc, site is free from redness and swelling. No skin breakdown noted. No catheter.

Patient FH, 64y/o admitted February 28, 2012 for CVA. Patient has been a history of stroke. Has been admitted before (January 5, 2011) in the same hospital with a same complain. Patient is unconscious cannot respond to the verbal stimuli, cannot talk, limited mobility of right arm. At risk for aspiration related to unable to swallow, feed by Nasogastric tube. There is a presence of productive cough for 4 days. Abdomen are soft and not distended. Peripheral pulses palpable in all extremities. Cannot the body , lower extremities and left upper extremity. Has a IVF 500 PNSS with a side drip of Mannitol, site is free from redness and swelling. No skin breakdown noted. Has catheter and urine output of 1100 cc in the whole shift (7am-3pm).

Patient Conference
My patient is Mrs. GM, female, 59 years old, married. Admitted on February 27, 2012 for a Pleural Effusion with a chief complain of difficulty of breathing, shortening of breath and severe cough that was started since December 2011. Patient has undergo different types of procedures such as Hematology, Urinalysis and etc.. Patient is under the physician of Dr. Lim. I receive patient conscious and coherent and she responds appropriately to verbal stimuli; no slurring of speech. Theres still a presence of cough but not severe and productive. Has a intravenous fluid of Plain NSS (0.9 NaCl) 700cc remaining. The site is free from redness and swelling. No noted skin breakdown.