0 | Page MANILA TYTANA COLLEGEFORMERLY MANILA DOCTORS COLLEGE OF NURSING Pres. Diosdado Macapagal Blvd., Metropolitan Park, Pasay City Nursing ProcessManila Doctors Hospital, Manila BSN III-A05 (RLE103) Submitted to: Jennifer T. Navarro, R.N., MAN Submitted by: Group 1 Amacio, Ivy Frances Canlas, Monique Ferrer, Danille Lutrinia, Gloraine Joanne Date Submitted: January 18, 2012
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MANILA TYTANA COLLEGE
FORMERLY MANILA DOCTORS COLLEGE OF NURSING
Pres. Diosdado Macapagal Blvd., Metropolitan Park, Pasay City
Nursing Process Manila Doctors Hospital, Manila
BSN III-A05 (RLE103)
Submitted to:
Jennifer T. Navarro, R.N., MAN
Submitted by:
Group 1
Amacio, Ivy Frances
Canlas, Monique
Ferrer, Danille
Lutrinia, Gloraine Joanne
Date Submitted:January 18, 2012
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MANILA TYTANA COLLEGE
MANILA DOCTORS COLLEGE OF NURSING
Pres. Diosdado Macapagal Blvd., Metropolitan park, Pasay City
NURSING PROCESS
I. ASSESSMENT
A. General Data
Patient’s Initial: C.A.O
Address: Bangalon Daraga, Albay Date of Admission: 01/07/2012
Age: 48y 11m 28d No. of days in this Hospital: 5 days
Sex: Female
Date of Birth: 01/10/1963
Place of Birth: Guionobatan
Civil Status: Married
Occupation: N/A
B. Chief Complaints
Anterior neck mass
C. History of Present Illness
One year prior to admission, patient noted weight loss with associated episodes of
palpitations and easy fatigability. This prompted consult in a local clinic in Bicol where
she was also noted to have anterior neck mass on physical examination. She was givenoral medications (unrecalled) which gave relief of symptoms.
Patient was apparently well until..
One month prior to admission when the patient noted easy fatigability with episodes of
shortness of breath. She also noted increasing size of her abdomen and both lower
extremities. Consult done in a hospital where she was given medications. Patient
decided to seek consult in Manila hence, this admission.
D. History of Past Illness
Childhood Illness/es: N/A
Adult Illness/es:
(+) Hypertension x 8 years (no maintenance of meds given)
(-) DM
(+) Bronchial Asthma: Last attack 2004; no maintenance of meds.
Immunization: Unrecalled
Previous Hospitalization:
Operation/s: S/P EL for Ectopic pregnancy (1989)
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Injuries: N/A
Medication taken prior to confinement (for 6 months): Unrecalled
E. System Reviews
1. Health Perception-Health Management Pattern
The patient rated her health 7 out of 10 (10 being the highest). She does
not have routine physical examination and she does not perform self-breast
examination. The patient stated that “siguro my mga magbabago pagkatapos ko
ma-operahan”. She drinks alcohol occasional but she does not smoke. She does
not have any idea what is the cause of her illness but when she felt something is
wrong, she consulted a physician and medications were given.
2. Nutritional-Metabolic Health Pattern
3-Day Diet RecallSunday Monday Tuesday
Breakfast Scramble egg, 1 cup
of Rice, 1 glass of
water
Hotdog, 1 cup of
Rice, 1 glass of
water
Scamble egg, 1 cup
of Rice, 1 glass of
water
Lunch Fried fish, 1 cup of
Rice, 1 glass of
water
Sinigang na isda, 1
cup of Rice, 1 glass
of water
Tinola, 1 cup of
Rice, 1 glass of
water
Dinner Munggo, 1 cup of Rice, 1 glass of
water
Cream of mushroom, 1 cup of
Rice, 1 glass of
water
Pinakbet, 1 cup of Rice, 1 glass of
water
The patient typical daily food intake is meat and her snack is junk foods.
Her typical fluid intake is soft drinks but drinks also water. According to her, she
lost some weight and she eats but when she swallows the food there is pain.
Before she does not have any kind of diet but now her diet is low salt low fat diet.
3. Elimination Pattern
The patient is not experiencing any discomforts during bowel eliminationand urinary elimination. Her usual stool is brown and hard. She urinates 2-3 times
a day. The color of her urine is yellow and there is no odor. The patient does not
have any body cavity drainage.
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4. Activity-Exercise Pattern
The usual activity of the patient is when she wakes up she takes a bath
then brushes her teeth. She cooks food for the family. During her spare time, she
is sleeping, eating, watching television or reading some magazines. Before the
patient experience shortness of breathe and easily gets tired.
The patient usually sleeps for 8-9 hours and she is satisfied with that.
There are no disturbances when she is sleeping. She does not have a bed routine
and she allows herself to relax if there is time. She experience difficulty of sleeping before she was admitted.
6. Cognitive-Perception Pattern
The patient is able to read and write. Her hearing and vision is good. She
does not experiencing difficulty in her memory. When it comes to decisionmaking she consults her husband for her to decide easily. For her, the easiest way
to learn things is visualization and verbalization.
7. Self - Perception Pattern
According to the client she described herself as “pumanget” and
“pumayat”, she even stated that her skin got darker. Sometimes the patient feels
she just wanted to die because of her condition. She doesn’t easily get irritated butshe did stated that “kapag lang paulit-ulit, nakakainis na.”
Examination (examples of objective data):The patient was a bit distracted. Her voice is hoarse and tuned down. Closed body
posture, gives the impression of detached and uninterested contact.
8. Roles – Relationship Pattern
According to the client she is now living with her husband. Her 4 children
already had their own work and family. She stated that her children were shocked
hearing her condition, but they have to accept the truth. Her husband is still
working and according to the client, her husband’s income is sufficient for their
daily needs.
9. Sexuality – Reproductive Pattern
According to the client she had her first menstrual period when she was in
2nd
year high school (14 years old). Ever since then, she has had regular
menstruations monthly. As the life with her husband, she states that she is
satisfied, “ngayon kasi, hindi na kami nagsesex, parang mag kapatid nalang ang
turing namin sa isa’t-isa.”. As for their family planning, client says that they don’t
use any contraceptives; either natural or artificial. The client’s LMP was last
December 3, 2011.
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10. Coping – Stress Tolerance Pattern
According to the client she is just relaxed since she doesn’t have any
work. If there is a big decision to make, she first consults her husband before
making a decision. Before, she used to drink alcohol, but not too much.
11. Values – Beliefs Pattern
According to the client, she is a Roman Catholic but goes to church rarely.
F. Family Assessment
Name Relation Sex Occupation Educational Attainment
R.A Husband M Employee College Graduate
C.A Son M Employee College Graduate
S.A Daughter F Employee College Graduate
I.A Daughter F Employee College Graduate
B.A Son M Employee College Graduate
G. Heredo
*Family Illness:
(+) Hypertension-Mother
(-) DM
(-) Thyroid diseases
H. Developmental History
Theorist Age Task Patient Description
Erik Erikson 48 years old Generativity vs
Stagnation
The patient cares
about her
environment andsociety. The patient
loves and cares her
family.
Sigmund Freud 48 years old Genital Stage The patient is living
with her husband.They have children.
The patient loves and
cares her family.
Jean Piaget 48 years old Formal Operational
Stage
The patient has no
difficulty inperceiving things.
The patient usually
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does visualizationand verbalization on
learning. She is not
dependent on to
others on doing suchactivities of her daily
life.
Lawrence Kohlberg 48 years old Conventional: Stage
IV
The patient knows
her role to the
community. Shefaces the
consequences and
does her obligationsto her family.
James Fowler 48 years old Stage V: Conjunctive The patient
developed her ownfaith and belief but
goes to church rarely.
She always looksforward to God when
problems arise. She
prays for her familyand others.
I. Physical Examination (date and time)
Height: 5’1 Actual Weight: 135lbs
Actual Height: 5’2 Ideal Body Weight: 118lbs.
Vital Signs:
Temperature: 36.8˚C
PR: 93 beats per min.
RR: 20 breaths per min.
BP: 160/100 mmHg
A. Skin
Inspection: no lesions
no edema
skin color is light brown
skin color is uniform
Palpation:
skin is moist
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B. NailsInspection:
smooth texture
pink in color
C. Head and Face
Inspection:
the client’s head is normocephalic
symmetric facial features
no edema present
with facial grimace
D. EyesInspection:
eyebrows are evenly distributed
no discharges
no discoloration in eyelids
no edema pupils are equal, round
F. Ears
Inspection:
auricle’s color is same as facial color
symmetrical
no lesions
G. Mouth and Pharynx
Inspection:
outer lip is pink in color soft and has the ability to purse her lips
H. NeckInspection:
muscles of the neck are equal
head is in the center
has coordinated movement
dysphagia
Palpation:
negative lymph nodes
I. Thorax/Lungs
Inspection:
Spine vertically aligned with anteroposterior to transverse diameter of ratio 1:2.
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J. Spine
Inspection:
Spinal column is straight, right and left shoulders and hips are at the same height. There
is bilateral symmetry of vocal fremitus. In terms of breathing pattern there is a quiet, rhythmic
and effortless respiration.
Palpation: chest wall is intact
no tenderness or masses
K. ExtremetiesInspection:
both extremities are equal in size
no involuntary movement
can perform complete range of motion
L. Breast
Inspection:
Rounded in shape, slightly unequal in size, generally symmetric. Skin color is uniform and
same with the color of the abdomen. The areola is round and bilaterally the same. Its color is
dark brown. The Nipples are inverted and color is darker than the areola.
M. Abdomen
Inspection:
Has the same color with the body color but it is lighter because of less exposure to sun.
Symmetric in contour
symmetric in movement caused by respiration
Auscultation:
Audible sounds were heard and there are absence of both arterial bruits and friction rub
Palpation:
There is no evidence of enlargement of liver.
There is no tenderness while palpating the abdomen.
N. Genitals
No opportunity. Client reported of discharges coming out of her vagina, but she seems
agitated. Hence, the examiner did not proceed with the assessment.
1.) The first priority nursing diagnosis is Risk for Imbalanced Nutrition: less than body requirements-
Because the patient needs to take sufficient nutrients to meet the metabolic needs of the body to be able
to consume adequate nourishment needed by the body based to patient’s weight, age and height.
2.) The second priority nursing diagnosis is Fatigue; appropriate nursing interventions are necessary toincrease energy and improved well-being of the patient. Because fatigue is overwhelming, sustained
sense of exhaustion and decreased capacity for physical and mental work at usual level.
3.) The third priority nursing diagnosis is Disturbed Body Image; means confusion in mental picture of
one’s physical self. The patient is manifesting weight loss. That’s why necessary nursing interventions
should be done for the patient to accept the change or loss and change in her lifestyle.