Nursing Process Application

Data Base and History

Chox Tonton Pinyada(not real name), 20 years of age living in Mn braness st. highway ibabao mandaue city was admitted to VGH last January 27, 2012 at around 8:05am with a chief complain of fever, cough and sinusitis 3 days PTA. He was accompanied by his aunt Dr. Ursal who is currently working in VGH as a physician and at the same time his attending physician. They arrived in VGH through Dr. Ursals car and he was placed in a wheelchair upon admission. His vital signs are: Temp: 38.2C Weight: 43kg Pr: 92bpm Bp: 110/80mmhg RR: 20 cpm He claimed to have no allergies on any food and drugs and have not undergo on any blood transfusion procedures. He took supplements such as Centrum and Sodium ascorbate PTA.

Nursing Assesment

Mr. Chox Tonton Pinyada(not real name) 20 years of age, male, a roman catholic, living in Mn braness st. Highway ibabao, Mandaue cebu city, was admitted to VGH last January 27, 2012 at exactly 8:05am. His chief complaint was fever cough and sinusitis 3 days PTA.

PERSONAL AND SOCIAL HISTORY: A. His father died because of malaria and his mother is currently working as a landlady in their 5 room boarding house. He is 4th in rank among 5 siblings and currently studying Medical technology in Velez College. Their other source of income is their boarding house.

LIVING CONDITIONS: B He rented a boarding house in T. padilla and he live there alone. He goes home every weekend in their house in mandaue city. Their house in mandaue is semi concrete with 2 rooms and 3 people living.

NUTRITION: C. He takes his breakfast every 6:30 in the morning lunch at 12:00 noon and dinner at 7. He takes snacks whenever he is hungry. He likes chicken (specifically legs) in any kind of cooking, potato fries and also dislikes ampalaya. He drinks about 750 1000 ml of water each day and around 2 to 3 glass of juice in any kind.

NUTRITION: C. He takes his breakfast every 6:30 in the morning lunch at 12:00 noon and dinner at 7. He takes snacks whenever he is hungry. He likes chicken (specifically legs) in any kind of cooking, potato fries and also dislikes ampalaya. He drinks about 750 1000 ml of water each day and around 2 to 3 glass of juice in any kind.

SLEEPING PATTERNS: D. He sleeps around 10pm and takes naps around 3pm and usually awakes at dawn around 4am 6am but is able to sleep again. He is more comfortable sleeping in a modified sims position.

ELIMINATION PATTERNS: E. Mr. Chox (not real name) defecates every other day morning or evening with brownish in color. He claimed to defecate allot because he doesnt defecates everyday and usually urinates 3 5 times per day about 100ml of urine with yellowish color and aromatic in odor.

PHYSICAL HYGIENE F. He takes a bath once a day and shampoos his hair every day and is not choosy on soap or shampoo that he will be using. He washes his hands before and after meals and brushes his teeth every day morning and before sleeping. He frequently apply alcohol on his hands.

ENVIRONMENTAL SANITATION: G. Their water source in their house in mandaue is from MCWD and also in his rented boarding house. They store their water by pail and use mineral water for drinking purposes. Their way of disposing human waste is by flush and their garbage disposal is by trash can and collected every Tuesday Thursday and Saturday.

SOCIAL ACTIVITY: H. Mr. Chox is not engaged in any sports since childhood, his hobbies are watching television and surfing the net. he occasionally drinks alcohol, doesnt smoke and gamble.

MEDICAL HISTORY: HEREDOFAMILIAL DISEASE A. His heredofamilial disease background is diabetes mellitus and hypertension.

COMMUNICABLE DISEASES OCCURING IN THE FAMILY:B They have no communicable diseases occurring in the family.

PREVIOUS ILLNESS / SURGERY D. He had no previous surgery and it was his firs time being admitted to a hospital.

Subjective: Communication:

Objective: Pupil size R 3cm L 3cm

Reaction: both eyes are equally round Wala koy problima sa akong pananreactive to light accommodation he aw ug pandungog as verbalized by the was able to read my name plate when I patient. asked him to do so . Pt. was able to answer the questions well when interviewed. Pt can identify diff. colors well.

Subjective Oxygenation: Gi ubo ko atong ni aging adlaw, pero karun wala na as verbalize by the patient.

Objective Respiration: The patient has regular respiration and heard crackling sound when auscultated . It is an indication that there is presence of mucus in the airway

Subjective: Circulation Sa karun, wa na mag sakit akong dughan as verbalized by the patient.

Objective Heart rhythm Patients heart rhythm is normal without the presence of chest pains and discomforts. V/S: BP:110/80 RR: 20 cpm PR: 92 There is absence of pitting edema. Urinalysis had a result of: Glucose (-) Protein (-)

Subjective: Nutrition wala pkoy gana mo kaon as verbalized by the patient.

Objective

Patient was not able to finish his meal during noon time but eats in between meals.

Subjective: Eliminaton Urinary frequency: 9 times per day 6am to 3:20pm Last BM: Jan. 30 12 noon.

Objective 9 times per day with yellowish colored urine and aromatic in odor. of urine per urination

Defecates once every other day, either morning or evening with a brownish colored stool.
daghan-daghan jd akong tae kay dili man ko everyday malibang as stated by the patient.

Subjective: MGT. OF HEALTH & ILLNESS mo inom ko occasionally as verbalized by the patient.

Objective The patient claimed to have no vices such as gambling, smoking and drugs. But drinks alcohol occasionally.

patient is eager to get well because he is following treatments accordingly.

Subjective: SKIN INTEGRITY sakit ang gi kwaan ug dugo as verbalized by the patient.

Objective has poor skin turgor due to skin hematoma from frequent blood sampling. Pt .has pimples and flushed and dry skin due to fever.

Subjective: ACTIVITY/SAFETY

Objective

The patient is oriented to time and g kapoi akong lawas as stated by the space. pt. The patient can ambulate but experiencing fatigue.

Subjective:

Objective:

COMFORT/SLEEP/AWAKE maka mata ko ug alas tres sa kadlawon as stated by the patient.

claimed to have pain in the left arm and awakens at night to urinate and patient is able to sleep again after.

Date Ordered

Diagnostic/Laboratory Examination

No.

Result

Significance

01-27, 28, 29,30-12

CBC

1st

RBC - 0.38 Platelets 160

Decreasing Increasing

2nd

RBC- 0.41 Platelets - 160

Increasing

3rd

RBC 0.44 Platelets - 151

Increasing Decreasing

4th

RBC 0.40 Platelets - 102

Decreasing Decreasing

Urinalysis

Glucose (-) Protein (-)

Subjective:

Objective:

Na balaka lge ko kay wala ko nka There was no sign of non-verbal sulod sa akong klase pila na ka adlaw behavior when conducting interview as verbalized by the patient. with the patient. Patients most supportive person is his mother.

Assesment
Cephalocaudal

HEAD Hair is equally distributed among the scalp; the pt. has black long hair and a round head. There are no deformities found on the pts head. Facial muscles are functioning well. Patient can close his eyes tightly, smile, show his teeth, raise his eyebrows and puff his cheeks. His sensations are all normal and there is presence of pimples on his face and a flush face due to hyperthermia. Patient can identify or sense which part of the face is being touched. Patients temporal artery is not palpable, elastic and non tender which is a normal sign that there are no problems present.

EYE The patients eye lashes are present which prevent foreign object from entering the eye. The eyelids have no abnormalities and the overall position of the eye is normal. Patients PERRLA is normal with 3mm when introduced to light, and the constriction was fast. Pupils accommodation was normal, patients pupil constricted when asked to focus on far side to the near side. The eye movements are also normal when performed the 6 cardinal of gaze.

EARS The ears, Pts ear needs further cleaning because of the presence of ear wax and have no lesions or any tenderness and both are symmetrical to each other.

NOSE The nose, the patient is having sinusitis 3 days PTA and feel tenderness when sinuses are palpated. Currently there are no difficulties on breathing. The mouth had no sign of any lesions and no dentures but he was having retainers and there is absence of bleeding gums.

NECK The neck is perfectly symmetrical; there are no lesions, no mass presences, and neck flexion is normal. The arm has presence of hematoma due to the frequent blood test done to the patient. Flexions of the left arm is limited due to the dextrose attached, hands and fingers are normal.

POSTERIOR THORAX The posterior thorax, had no indication of any mass, tenderness, lesions; shape and size are both normal; symmetrical. The respiratory expansion is normal. While doing the percussion and auscultation, there is no sign of any abnormalities during the procedure.

SKIN The skin has poor skin turgor because of the presence of hematoma on the skin due to frequent blood sampling. And dryness of skin was identified during the interview

MUSCULOSKELETAL Patient claimed to have no experience on sprain and muscle spasms but experienced muscle cramps due to plantar flexion.

Outline of Nursing Management

Nursing Diagnosis

Fever related to ongoing infection

Nursing Goal:

After 4 hours of nursing interventions the patients fever will be in normal range.

Nursing interventions:
Identify underlying cause. Monitor core temperature. Monitor blood pressure and invasive hemodynamic parameters if available Monitor heart rate and rhythm. Monitor respiration.

Monitor and record all sources of fluid loss such as urine and diarrhea; wounds, fistulas; and insensible losses which can potentiate fluid and electrolyte losses Note presence or absence of sweating as body atempts to increase heat loss by evaporation, conduction, and diffusion. Monitor laboratory studies such as ABGs, electrolytes, cardiac and liver enzymes, glucose; urinalysis and coagulation profile.

Nursing Diagnosis

Anxiety related to unknown cause of infection

Nursing Goal

After 4 hours of nursing intervention the patient will cope with the current medical situation without demonstrating severe signs of anxiety.

Nursing Intervention
Spend 10 minutes with patient twice per shift. Convey a willingness to listen. Offer verbal reassurance; for example, I know youre frightened. Ill stay with you. Listen attentively; allow patient to express feelings verbally. Give patient clear, concise explanations of anything about to occur. Avoid information

Make no demands on patient. Identify and reduce as many environmental stressors (including people) as possible. Teach patient relaxation techniques to be performed at least every hour, such as guided imagery, progressive muscle relaxation, and meditation. Have patient state what kinds of activities promote feelings of comfort, and encourage patient to perform them.

Nursing Diagnosis
Knowledge Deficit related to unknown cause of infection

Nursing Goal

After 4 hours of intervention, the patient will be able to verbalize understanding of condition, disease process, and treatment.

Nursing Intervention
Ascertain level of knowledge, including anticipatory needs. Determine client's ability, readiness, and barriers to learning. Individual may not be physically, emotionally, or mentally capable at this time. Be alert to signs of avoidance. Client may need to suffer consequences of lack of knowledge before he or she is ready to accept information

Identify support persons/SO requiring information. Assess the level of the clients capabilities and the possibilities of the situation. May need to help So(s) and/or caregivers to learn. Provide positive reinforcement. Can encourage continuation of efforts.

Discharge planning
Medications -Follow doctors prescription accordingly -Take medication at home as ordered Exercise -Practice deep breathing exercise every morning upon waking up. -Encouraged to do things that he can tolerate Avoid dangerous activities. Outpatient Advice the pt. to approach to the nearest HC for follow up check up Health Teaching -Discuss the importance of medication -Do hand washing and personal hygiene -Instruct patient to have frequent oral care Diet -Eat green leafy vegetables, sea weeds and take iron supplement. - Increase fluid intake. Spiritual -Have faith in the supreme being in every health crisis that you`ll encounter.