NURSING ASSESSMENT

NURSING SYSTEM REVIEW CHART Date: 8-24-11 Name: Mrs R.E Vital Signs: Pulse: 72bpm BP: 140/100mmhg Temp: 36.6C Height: 55 EENT: impaired vision blind pain reddened drainage gums hard of hearing deaf burning edema lesion teeth Asses eyes, ears, nose throat for abnormality no problem RESP asymmetric tachypnea apnea rales cough barrel chest bradypnea shallow rhonchi sputum diminished dyspnea orthopnea labored wheezing pain cyanotic Asses resp, rate, rhythm, depth, pattern, breath sounds, comfort no problem CARDIO VASCULAR arrhythmia tachycardia numbness diminished pulses edema fatigue irregular bradycardia murmur tingling absent pulses pain Asses heart sounds, rate rhythm, pulse, blood pressure, clrc., fluid retention, comfort no problem GASTRO INTESTINAL TRACT obese distention mass dysphagia rigidly pain Asses abdomen, bowel habits, swallowing, bowel sounds, comfort no problem GENITO-URINARY and GYNE pain urine color vaginal bleeding hermaturia discharge nocturia Asses urine freq., color, control, odor, comfort/ Gyn-bleeding, discharge no problem NEURO paralysis stuporous unsteady seizures lethartic comatose vertigo tremors confused vision grip Asses motor function, sensation, LOC, strength, Grip, gait, coordination, orientation, speech, no problem MUSCULOSKELETAL and SKIN appliance stiffness itching petechiae hot drainage prosthesis swelling lesion poor turgor cool deformity wound rash skin color flushed atrophy pain ecchymosis diaphoretic moist Asses mobility, motion. Gait, alignment, joint function /skin color, texture, turgor, integrity no problem

Weight: 72 kg __dizziness_______ ____________________ O2 inhalation via nasal cannula _@ 2L per min. _____________________ NGT _____________________ ___BP: 140/100mmhg___ _____________________ _____________________ __restlessness __weak __fatigue _____________________ catheter attached to urobag _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _cough _wheezing sounds both lungs _dyspnea_____ _24cpm__________ _respiratory distress__ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _left sided paralysis_ _limited ROM____ _____________________ _____________________ __numbness of extremities _____________________ _____________________

_ _

NURSING ASSESSMENT II
SUBJECTIVE COMMUNICATION: Comments: Hearing Loss Wala man koy problema sa visual changes akong pandungog ang ako denied lang panan-aw medyo halap
as verbalized by the patient.

OBJECTIVE glasses languages contact lens hearing aide R L speech difficulties Pupil size 2-3mm Reaction: Pupil Equally Round and Reactive to Light and Accommodation

OXYGENATION: dyspnea smoking history ____none_____ cough sputum denied CIRCULATION back pain leg pain numbness of extremities denied NUTRITION Diet _Liquid Diet N V Character recent change in weight, appetite swallowing difficulty denied ELIMINATION: Usual bowel pattern once a day constipation remedy Date of last BM 08-23-11

Comments: Gi-ubo man ko ug nay plema, as verbalized by the patient. Resp. regular irregular Description: RR is within normal range R Normal and symmetrical chest expansion L Normal and symmetrical chest expansion

Comments: Medyo hawoy akong lawas as verbalized by the patient.

Heart Rhythm regular irregular Ankle edema _____NONE_______________ Car Rad DP Fem Pulse R___________+_____+_______+___ L_______+____+_______________ Comments: all pulse sites were palpable. if applicable dentures Full Upper Lower none Partial With Patient

Comments: maglisod ko ug kaon ug sakit itulon. as verbalized by the patient.

Comments: Patient s bowel is formed stool and brown in color.

urinary frequency 700cc a day urgency dysuria hematuria Incontinence

Bowel sounds No bowel sounds Present yes no

Urine* (color, consistency, Odor) Yellowish in color, aromatic in odor Briefly describe the patients ability to follow treatments ( diet, meds, etc.) for chronic health problems (if present) The pt. is cooperative and can follow treatments what is given to her.

polyuria diarrhea foly in place character denied ________________ MGT. OF HEALTH & ILLNESS: alcohol denied Dili ko gainom ug ilimnon nga makahubog. SBE Last Pap Smear: none LMP : Menopausal

NURSING ASSESSMENT II

SUBJECTIVE SKIN INTEGRITY Dry Itching Other Denied Wala koy gibati nga katol2x sa panit as verbalized by the patient.

OBJECTIVE Dry Cold Pale Flushed Warm Moist Cyanotic * Rashes, ulcers, decubitus (describe size, location, drainage) Patient has no skin rashes,has dry skin.

ACTIVITY/SAFETY convulsion Comments: dizziness Kinahanglan ko limited motion alalayan kay diko of joints kabakod kung ako ra Limitation in as verbalized by the ability to patient. ambulate bathe self other denied COMFORT/SLEEP/AWAKE: pain Comments: (location, Maayo man hinuon ang frequency akong pagkatulog , as remedies) verbalized by the nocturia patient. sleep difficulties denied COPING: Occupation: unemployed Members of household: 6 members Most supportive person: All family members

LOC and orientation : The patient was oriented to place, time and person.. Gait: Walker Cane Other steady unsteady __________________ sensory and motor losses in face or extremities ______numbness of extremities_____ ROM limitations patient cannot sit but with assistance.

facial grimaces guarding other signs of pain no other signs of pain side rail release form signed ( 60 + years) __with side rails__________________

Observed non-verbal behavior : The patient was conscious and coherent The person and his phone number that can be Reached any time : No Oppurtunity

SPECIAL PATIENT INFORMATION ( USE LEAD PENCIL) _____PT/OT ___ Daily weight 140/80BP q shift ____ Irradiation ___ Neuro vs _____ Urine Test ___CVP/SG. Reading _____ 24 hours Urine Collection Date Ordered 08-20-11 08-20-11 07-20-11 Diagnostic Exams CBC Urinalysis Creatinine, BUN Date Done 08-20-11 08-20-11 08-20-11 Date Ordered 08-20-11 08-20-11 I.V Fluids / Blood PNSS 1L @ 20 gtts/min. Manitol fast drip DateDisc.

ACTUAL NURSING MANAGEMENT

S Lain kayo akong paminaw dili ko kasabot as verbalize by the patient

  

Headache Anxiety Dizziness

High Risk for Discomfort related to Headache caused by increased arterial vascular pressure and Dizziness caused by hypotensive state related to drug therapy
Short Term: At the end of 30-45 minutes of nursing intervention, patient will appear comfortable. Long Term: At the end of 1 week of nursing intervention, patient will be able to verbalize self care measures to reduce/avoid discomfort. Independent:

1. Minimize environmental stimuli.  Stress & anxiety can increase perception of pain & discomfort 2. Elevate head of bed 30 degrees  To minimize changes in position that can trigger dizziness or lightheadedness 3. Instruct to change position slowly, sit before standing up from a lying position  To allow the body to adapt to redistribution of blood 4. Encourage relaxation techniques (deep breathing exercise, imagery, etc.)  To relieve discomfort and promote rest Dependent: Administer analgesics as prescribed by the physician  Drug used to reduce stress and discomfort.

At the end of 30-45 minutes of nursing intervention, patient was feeling comfortable.

Wala koy mabatian sa tuo nga bahin sakong lawas as verbalized by the patient.

  

Limited ROM Numbness of the side of the body Anxiety

Impaired physical mobility related to neuromuscular impairment A Short Term: At the end of 30-45 minutes of nursing intervention, patient will be able to perform passive or active physical activity independently or with assistive devices as needed. Long Term: At the end of 3 weeks of nursing intervention, patient will be free of complications of immobility. Independent: 1. Encourage and facilitate early ambulation and other ADL when possible

 To focus attention into wellness therapy 2. Turn and position every 2 hours or as needed  To optimize circulation to all tissues and to relieve pressure 3. Perform passive/active assistive ROM exercises to all extremities  To promote increased venous return , prevent stiffness, and maintain muscle strength and endurance 4. Turn patient to prone or semiprone position once daily unless contraindicated

 To drain bronchial tree 5. Keep side rails up and bed in low position  To promote safe environment
Dependent: Consult rehabilitation medicine personnel as appropriate  For further care and management

At the end of 30-45 minutes of nursing intervention, patient was able to perform passive or active physical activity independently or with assistive devices as needed.

S O A P

Wala ko magdahum na ma ingon ani ko as verbalize by the patient.  Failure to recognize the impact of the health problem.  Inaccurate follow through of instructions.  Anxiety Knowledge deficit related to unfamiliarity of the disease treatment, prevention and prognosis secondary to lack of information. Short term: at the end of 45 minutes, we will be able to explain to the daughter of the patient to what is the relevance and importance of knowing the disease of her mother. Long term: at the end of 3 hrs, the daughter of the patient will be able to understand the disease process and recognize the relevance of the disease condition.

Independent 1.) Provided information relevant to the situation focusing on disease process. 2.) Discussed the mode of transmission of the disease. 3.) Discussed on what the importance of the medication of her mother is taking. 4.) Informed the significant others on the availability of community health resources. Dependent

5.) Involved the family members in the planning of care to the patient.

At the end of 3 hrs, the daughter of the pt. was able to express, understand of the disease condition in its level as evidenced by restating relevant information discussed and verbalized willingness to comply with medication.

S O

Gi-ubo ko ug naay plema . As verbalize by the patient. > (+) wheezing  (+) crackles > ineffective coughing  increase bronchial secretions

A P

Ineffective Airway clearance r/t increase bronchial secretions Short Term: After 8 hours of nursing intervention the patient s significant others will understand about airway clearance and how to maintain effective airway. Long Term: After 2 weeks of nursing intervention the patient s secretions are mobilized and airway is free of excessive secretions as evidenced by clear lung sounds.

Independent 1. Elevated the head of the patient in a 30-40 for better lung expansion and Improved gas exchange. 2. Turned to side patient and use back tapping if not contraindicated. 3. Used of mechanical ventilation if anticipated for breathing pattern and loosen Secretions for easy removal. 4. Used suction and medications as needed. Dependent

5. administer the ff: a.) Salbutamol + ipratropium neb every 6 b.) neb + 2cc NSS every 8 & as needed.

After 3 days of nursing intervention, patient s progress are not slightly met because there are still some secretions and needs longer intervention.

S O

The patient cannot talk because the mechanical ventilator was attached. >Activity intolerance >Prolonged bed rest 24/7 >Limited strength, cannot ambulate self >attached nasogastric tube

A P

Impaired physical mobility r/t nasogastric tube. Short Term: At the end of 4 hours of nursing intervention, the patient will do passive ROM exercises w/ support from the nurse and significant others. Long Term: At the end of 3 days of nursing intervention, the patient will be able to tolerate ROM exercises.

Independent 1.) Turn to sides the patient every 2 hours to promote blood circulation. 2.) Keep side rails up always to secure safety. 3.) Perform passive assistive ROM exercises to all extremities to promote venous return and prevent stiffness 4.) Maintain limbs in functional alignment. Support feet in dorsiflexed

position to maintain proper alignment of extremities and prevents Contractures. Dependent 5.) Instruct the significant others regarding hazards of immobility. Emphasize importance of measures such as position change, ROM

After 3 days of nursing intervention, the patient have slightly met to tolerate ROM exercises limited to her and needs assistance as always.

S O

Galisod ko ug ginhawa . As verbalize by the patient

-RR: 24cpm -retained secretions -restlessness

A P

Impaired gas exchange related to fluid filled alveoli Short term: At the end of 2 hours of nursing intervention, patient shows progress in breathing. Long term: At the end of 5 days nursing intervention, patient shows optimal gas exchange as evidence by normal ABGs.

Independent 1. Elevated the head of bed 30-40. 2. Suctioned if needed. 3. Oxygen therapy applied and regulated as ordered.

Dependent 1. Administer the ff: a.) Salbutamol + ipratropium neb every 6. b.) neb + 2cc NSS every 8 & as needed.

2. Oxygen therapy applied and regulated as ordered.

At the end of 5 hours the patient was not able to comply the intervention that we done because of her weight.