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She resides at Fairlaine subdivision Tarlac City together with her maid. Her husband is formerly government employee worked in tarlac city hall for 38 years but died 1yr ago due to colon cancer. They have two daughters and one son and are all college graduates. Her eldest daughter is a registered nurse working in US and the other two siblings lived in manila with their own family but sometimes visit their mother in times of need. Mrs. V’s medical expenses and other financial needs are supported by her siblings. Due to present illness her lifestyle is affected. Before she had this disease patients was socially active, but at present she was not able to mingle with her neighbors, go to other places where she wants to go, and cannot serve to the church where she used to do it during her younger years. Mrs. V also stated that she do not smoke and drink alcohol. Norms: Social status includes family relationships/friendships that state the patient’s support system in time of stress and in time of need. It meets a fundamental human need for social ties, making life less stressful and social support buffers the negative effects of stress, thus indicating indirectly contributing to good health outcomes. (Friedman and Smith 1988) Analysis: Based on the above statements Mrs. V’s social status is affected by her condition. Though she has a close family relationship and a very active social life before, her condition forces her to restrain from interactions outside home.
II. Mental Status Mrs. V is oriented to time, place and person. She can identify things or names being asked. She can recall recent and remote memories she experienced. She is able to read and write and can speak in English, Tagalog and Kapampangan. She is responsive and answers to the questions being asked. Norms: The content of the patient message should make sense. The ability to read and write should match the patient’s educational level. The patient should be able to correctly respond to questions and to identify all the objects as requested. The patient should be able to evaluate and act appropriately in situations requiring judgment. (Health assessment and physical examination 3rd edition by Mary Ellen Zator Estes) Analysis: Being responsive and being able to answer questions accordingly are the major determinants which indicate patient’s mental capabilities are still functioning well.
III. Emotional Status Mrs. V is cooperative and relaxed while performing the interview. She stated that she does not feel any fear regarding her condition. She accepted it and stated that every individual has an end. She believes that everything has a reason and said that everything is in God’s plan. Mrs. V just prayed that she will not suffer too much pain from her condition. Norms: The old adult is in the stage where an issue of ego integrity vs. despair arises. Integrity manifests with wisdom and feelings of satisfaction with one’s life while despair arises from remorse about what could have been. The presence of despair causes life to be viewed as meaningless. (Source: Nursing CEU.com: The process of human development) Analysis: The fact that the patient shows acceptance regarding her current health condition shows that she is emotionally stable and reacts accordingly. She believes that her life is part of God’s will and everything that happens to her has a reason.
IV. Sensory Perception She is using reading glasses due to blurring of vision. Her hearing ability is normal using whisper test with distance of two feet. Her sense of smell is normal and she can distinguish foul and fresh odor. Her lips are light brown in color. Her tongue is slightly pink and she can taste whatever food she eats. During bed bath Mrs. V complains of pain when the towel is pressed on her lower extremities. Norms: Each of the five senses becomes less efficient in older adult hood. Changes result in loss of visual acuity, less power of adaptation to darkness and dim light, decreased in accommodation to near and far objects. The loss of hearing ability related to aging affects people over age 65. Gradual loss of hearing is more common among man than women, perhaps because men are more frequently in noisy work environments. Older people have a poorer sense of taste and smell and are less stimulated by food than the young. Loss of skin receptors takes place gradually, producing an increased threshold for sensations of pain, touch, and temperature. (Fundamental of Nursing 7th edition Barbara Kozier) Analysis: Mrs. V’s blurring of her vision is due to aging process. The sense of smell, taste and hearing can perceive stimuli accordingly. Pain felt on extremities is due to presence of edema.
V. Motor Stability Mrs. V’s gait is slight staggering with weakness on legs so she needs support when standing up and walking. She is not comfortable with her condition. She finds walking, sitting, or changing positions difficult. Mrs. V tries to perform things alone if she can but admitted that she needs the help or assistance of another person often. Norms: Late adulthood is in the stage where neuron loss continues with associated decrease in cerebral flow. Reaction times slow due to decreased levels of neurotransmitter. Gait and balance are affected with decreased proprioception. (Focus on Pathophysiology by Bullock and Henze). The patient with ascites maybe short of breath and uncomfortable from enlarge abdomen. (Brunner and Suddarth’s Textbook of Medical-Surgical Nursing) Analysis: Due to her present condition and also due to old age, the patient has difficulty in coordinating movements as well as performing ADLs.
VI. Body Temperature The table below shows the temperature of Mrs. V during the shift:
Norms: Normal axillary temperature is within 36.4ºC to 37.4ºC. (Health assessment and physical examination 3rd edition by Mary Ellen Zator Estes)
VII. Respiratory status Respirations were normal in pattern but in terms of depth shallow respirations noted. Table below shows the respiratory rate of the patient.
Norms: Normal respiratory rate for adults is 12-20cpm. Average is 18. In terms of pattern, normal respirations must be regular and even in rhythm. The normal depth of respirations is non exaggerated and effortless (Health assessment and physical examination 3rd edition Mary Ellen Zator Estes) Analysis: Mrs. V has normal respiratory status except for her depth which is because of the diaphragm being distended by the peritoneal cavity filled with fluid which limits lung expansion.
VIII. Circulatory status: The circulatory status of the patient as well as blood pressure noted below:
Norms: Normal cardiac rate for an adult is 60-100 beats per minute while the normal blood pressure is 120/80 mmHg. The working capacity of the heart diminishes with aging. The heart rate of older people is slow to respond to stress and slow to return to normal after stress. Reduced arterial elasticity results in diminished blood supply to the parts of the body especially the extremities. (Kozier et. al, 2004)
IX. Nutritional Status Prior to admission Mrs. V meal intake is two to three times a day. The food served is usually vegetables, fish, and sometimes meat. She always eats fruit. During admission, the food served to Mrs. V is low in salt and in fat. She was advised by the AP to eat food rich in protein and decrease her fluid intake. Mrs. V’s body weight is increased due to accumulation of fluid (ascites) in the peritoneal cavity and is not caused by additional nourishment in the body. Norms: Fluid, salt and fat restriction is the diet management for patients with ascites. Brunner and Suddarth’s Textbook of Medical-Surgical Nursing) Analysis: Fluid intake limit prevents the exacerbation of the already increased fluid in the extracellular compartment. Salt restriction prevents water retention in the body while fat restriction prevents complications in fat digestion and absorption as liver function already is impaired and consequently bile production.
X. Elimination status Mrs. V usually defecates one to two times a day. On July 17, 2008 from morning until 2 pm she did not urinate. And on the following day she urinated two times. Norms: An individual usually defecate one to two times a day or every 2 days and urinates 30 cc/hr. (Nutrition by Alex Abelos ) Analysis: The patient has poor elimination status due to irregular urination.
XI. Reproductive status Mrs. V had her first menstrual period at age 12. She got married at age 21. She had her first pregnancy at age 22. Her siblings have 2 to 3 yrs age gap. She had undergone hysterectomy. Norms: Menarche, which is the first menstruation occur at an average age of onset between 9 to 17 years old. Pregnancy may occur from stage of menarche up to cessation of menstrual period. Menopause occurs with age range of 40 to 55. (Maternal and Child Health nursing fourth Edition by Pilliterri) Analysis: As based from the above information, patient has a normal reproductive status.
XII. Sleep-rest pattern She usually sleeps 7 to 8 hours a day. She stated that sometimes her sleep is interrupted when nurse get vital signs early in the morning. She usually watches television at home during rest hours and also during admission. Norms: Sleep refers to altered consciousness with general slowing of physiologic process while rest refers to relaxation and calmness, both mental and physical. A typical sleeper will pass through 7 to 9 hours of sleep and take a rest using some relaxation activities such as reading, telling stories and others. (Nursing Fundamentals by Rick Daniels) Analysis: Mrs. V’s sleep and rest pattern is normal.
XIII. State of skin appendages Mrs. V’s skin is brown in color, wrinkled and dry. She complains of occasional itchiness on her lower extremities and she has a slight edema. Her hair is thin, fine and gray. Her conjunctiva is slightly pale, and sclera is white in color. She has scar on the ® upper quadrant, and ® lower quadrant of her abdomen. With cutdown catheter on the right basilic vein and tenkhoff catheter inserted on the peritoneal cavity. Her nails are long and nail beds are pale in color. Norms: Obvious changes occur in the integumentary system (skin, hair, nails) with age. The skin becomes drier and more fragile, the hair loses color, the finger nails and toe nails become thickened and brittle, and in woman over 60, facial hair increases. These integumentary system changes accompany progressive losses of subcutaneous fat and muscle tissue, muscle atrophy, and loss of elastic fibers. (Fundamental of Nursing 7th edition by Barbara Kozier) The palpebral conjunctiva should appear pink and moist. Normally, the skin is a uniform whitish pink or brown color, depending on the patient’s race. Normally, the nails have a pink cast in light-skinned individuals and are brown in dark-skinned individuals. (Health assessment and physical examination 3rd edition by Mary Ellen Zator Estes) Analysis: Based from the above information the color of her conjunctiva and nail beds are not normal. Presence of cutdown catheter and peritoneal drainage placed patient at high risk for infection.