West Visayas State University COLLEGE OF NURSING La Paz, Iloilo City

Adult Nursing Process

I. VITAL INFORMATION Name: J.C. Date of Interview: 07-11-12 8:00 am Age: 75 years old Informant: JC and J.L Sex: Female Relationship to Patient: patient herself; daughter Address: Zone 4, BRGY. Don Esteban Lapuz, Iloilo City Civil Status: Widowed Date and Time Admitted: 7-05-12 1:10 am Chief Complaint: Gulpi lang nagsakit ang dughan ko kag nabudlayan mag-ginhawa. Ward: FMSW Bed No.: Bed No. 1 Allergies: No known drug, food, animals, or dust and other environmental allergies. Religious Affiliation: Roman Catholic Physicians Initial: Dr. L and Dr. A Impression/Diagnosis: Left ventricular dysfunction, Pulmonary edema, acute coronary syndrome, non-ST elevation myocardial infarction Killip III ; Diabetes Mellitus 2 Pre-op Diagnosis: NA Post-op Diagnosis: NA Surgical Operation Performed: NA Days of Post-op: NA

II. CLINICAL ASSESSMENT II. A.: NURSING HISTORY 1.History of Present Illness a. Usual Health Status J.C. was diagnosed to have Diabetes Mellitus 15 years ago by Dr. L, a private doctor. She was prescribed with Debtan 10mg/tab, 1 tablet once a day and Metformin 10mg/tab, 1 tab thrice a day. She regularly takes her maintenance drugs. She was unable to regularly check her blood glucose level because according to them, they will not consult a doctor unless there is something wrong with her. She also takes herbal medications like KOI herbal capsule 1 tablet once a day for 2 years and Dr. PINOY for a year once a day because she was convinced by the advertisement that by doing so it will help lower her blood glucose. She stopped taking these herbal medications when she was admitted while her medications for her DM were replaced by new prescribed medications at the hospital. Aside from DM, JC and her family knew nothing about other condition she has. b. Chronologic Story In the year 1997, J.C. mentioned that she experienced excessive thirst almost all the time that is why she always drinks water approximately 500ml hourly. In so, she has this urgency and frequency in urinating every now and then

ranging 20-25 times a day, amount of urine unrecalled. She also gets tired and sometimes has blurred vision. That year, she decided to have a medical check up. She was diagnosed by Dr. L, a private physician, of having Diabetes Mellitus II. She was prescribed with Debtan 10mg/tab, 1 tablet once a day and Metformin 10mg/tab, 1 tab thrice a day. She is noncompliant to drug regimen. She doesnt bother to check her blood glucose level since she has not felt anything wrong. In year 2004, she was diagnosed with cataract and was submitted to have cataract extraction. However, due to elevated blood sugar level, J.C. was denied to undergo the extraction. Physician and institution unrecalled. In 2007, she went completely blind. Seven months PTC, January 2012, date unrecalled. J.C. suddenly woke up at around 12 midnight with dyspnea and chest pain graded 4/10 accompanied by dizziness, nausea and difficulty of opening her mouth. As a remedy, her daughter placed another pillow on her back for relief. For her mouth problem, her daughter soaked towel in warm water and massage the cheeks and mandibular area until J.C. slept. The next day, J.C. reported that she was relieved of the abovementioned symptoms; therefore she thought that she was already well. After a week, date unrecalled, J.C. noticed that she developed DOB whenever she is in supine position. As a remedy, she added another pillow under her back and found it effective. Since then, she sleeps or lies down having 2 pillows with her. Two hours PTC, July 4, 2012, 11:00 pm, while sitting, she experienced a sudden difficulty of breathing, accompanied by nausea and dizziness with sharp stabbing pain in the epigastric area radiating to chest graded as 5/10. They decided to go to WVSU Medical Center. Thus, this admission.

c. Relevant Family History Paternal Diabetes Mellitus (+), Father Uncle suspected DM Maternal Hypertension (+), Mother

d. Disability Assessment Ever since J.C was blind her activities of daily living which includes doing of household chores was impeded. Her maintenance medication takes up a percentage on their allowance, does resulting to J.C noncompliance to drugs. Due to her blindness and being easily gets tired brought effects on her relationship with her grandchildren. She was not able to play with them unlike what she usually does before. 2. Past Health Problems/Status a. Childhood Illness (+) flu (+) cough (+) common colds (+) measles (+) mumps (+) chicken pox

b.Immunizations Immunizations and dates are unrecalled by patient. c. Allergies No allergies to food, drugs, animals, dust or any other environmental factors d. Accidents and Injuries In year 1995, J.C. was hit by a piston on her left side of forehead. e. Hospitalizations for serious illnesses NONE according to J.C. d. Medications Metformin (Nu-Metformin) 10mg, 1 tab ,TID Debtan 10mg , 1tab, OD 3. Family History of Illness Diabetes Mellitus (+), Father Hypertension (+), Mother 2 brothers- suspected died of HPN

4. Patients Expectations a. What does he/she expect to occur during hospitalization? Nga mabuligan ko nga mag-ayo eh, nga madula ang akong nga balatian. b. What does he/she expect regarding nursing care? Nga padayunon nila ang ila nga ginaubra, ubrahon nila ang tanan kag dapat nga ubrahon para sakon nga pag-ayo. 5. Patterns of Functioning a. Breathing Patterns Respiratory Problems: Difficulty in breathing when in supine position Usual Remedy: Elevation of back and head by placing 2 pillows beneath the head. Manner of Breathing: Deep inspiration and shallow expiration.

b. Circulation Usual Blood Pressure: 120/80 mmHg 140/90 mmHg Any history of chest pain, palpitations, coldness of extremities, etc.; (+) Chest pain - January 2012 ,date unrecalled

c. Sleep Patterns Usual bedtime: 1am-2am Number of pillows: 4 (28x16x3 inches: 2 on the head, 2 on the left side) Bedtime Rituals: Listening to radio and taking sponge bath Problems regarding sleep: Daw malumos sya kung maghigda. verbalized by J.L. Usual remedy: Ginadugangan namon isa ka ulonan para makaidag-idag sya. verbalized by J.L.

d. Drinking Patterns Kinds in Fluid in 24 hours/ Amount in mL or Number of Bottles: Kind of Fluid Water Coffee Softdrinks Total Amount 1000-1500 ml/day 1-2 cup/day (240 ml) 1 bottle per day (325ml) 1565-2305 ml/ day

e. Eating Patterns Usual Food Taken (quantify) 1 sachet of quaker oatmeal (33 g) , 1 medium sized pandesal, 1 small bowl of miswa Time (range)

Breakfast

6:30am-7:30am

Lunch

1 medium sized chicken drumstick, 3-4 tablespoon steamed rice, 3 pieces pork siomai

11:00am-12:00nn

Dinner

3-4 tablespoon of beef broth, 3-4 tablespoon steamed rice

6:00pm-7:00pm

Snacks

2-3 pieces of Fita crackers, 8-10 pieces of fish balls, 1 cup (240ml) lugaw

2:00pm-3:00pm

Food Likes: Chicken (any kind of preparation), pork siomai Food Dislikes: Vegetables f. Elimination Patterns 1.Bowel Movement Frequency: Once a week Problems or Difficulties: Constipation Usual Remedy: Takes Dulcolax 15mg/tab, PRN

2.Urination Frequency: 20-25 times /day Problems: none Usual Remedy: N/A g. Exercise: None as claimed h. Personal Hygiene 1.Bath Type: shower bath and sponge bath Frequency: twice a day Time of Day: 4am and 8 pm 2.Oral Care Frequency: 2 times a day Care of Dentures: N/A 3.Shaving: None Frequency: N/A 4.Use of Cosmetics: Lipstick

i. Recreation: Listening to radio was her form of recreation or she often stays outside their house to talk with her neighbours.

j. Health Supervision: Whenever J.C. isnt feeling well she first visit the barangay health center. She only visits the dentist if she has dental problems.

II. B.: CLINICAL INSPECTION

II.B.1. Vital Signs: T = 36.6 C/axilla BP = 120/70 mmHg II.B.2 Height: Not assessed II.B.3.Weight: Not assessed

Date and Time taken: 07/11/12; 8:00am PR = 75 bpm RR = 23 breaths/min

II.B.4. PHYSICAL ASSESSMENT GENERAL APPEARANCE Patient lying on bed, awake, in supine position with two pillows on her back talking to her daughter. Oxygen delivered at 2 L/min via nasal prongs; With heplock in place at left metacarpal vein.. Foley catheter in place attached to urobag with approximately 30cc light amber urine. She wore a green sleeveless dress. Hair is slightly dishevelled, face is clean of any impurities. Has an ectomorphic body structure. Foul breath odor noted.

INTEGUMENTARY SYSTEM Skin dark brown, dry, thin, translucent, with poor skin turgor at (pila ka sec) upon assessment at the (site of assessment); skin folds noted on (sites), soggy and elastic; hematomas noted at R antecubital fossa with diameter of 2cm and at R metacarpal vein with diameter of 1cm. Scalp hair evenly distributed, black, smooth, 4-5 inches in length, without dandruff, infection, and infestation; eyebrows thin, evenly distributed, and symmetrical; Eyelashes evenly distributed, symmetrical, and curves outward. Fingernails pale, trimmed but unclean, firmly attached to nail beds, without signs of clubbing; toenails black, gouty.

NEURO-SENSORY SYSTEM

CRANIAL NERVES I. Olfactory Nerve

HOW ELICITED

NORMAL RESPONSE Perception of any odor; identifies scent correctly from one another.

PATIENTS RESPONSE Able to smell scent of citrus.

Hold the scent under one nostril with the occluded nares while the patient closes eyes. Repeat with one other nostril. Ask the patient to read a certain text at 2 feet distance

II. Optics

Visual acuity intact; will be able to read words or letters

Patient unable to read.

III. Occulomotor IV. Trochlear VI. Abducens V. Trigeminal

Ask client to follow SNs finger in Six Cardinal fields of gaze, check for reaction and accommodation using a penlight. Ask patient to open her mouth while palpating temporomandibular joint; ask patient to close eyes and wipe cotton over forehead while eyes closed. Ask client to smile, raise eyebrows Occlude ear intermittently and ask patient to report whispered words at 2 feet distance. Done on both ears. Observe the patient if gag reflex is present with tongue depressor; Ask patient to move tongue side to side and stick his tongue out Allow client to sip water

Able to follow finger to six directions of gaze; pupils equally round and reactive to light.

Not assessed. Patient is blind

Able to move jaw up and down with force applied to each side of face; able to distinguish light touch sensation.

Able to distinguish feel the sensation of cotton wisp touching face with closed eyes.

VII. Facial

Able to demonstrate varied facial expressions Able to repeat the words whispered

Able to smile and raise eyebrows Able to hear and repeat whispered words

VIII. Acoustic

IX. Glossopharyngeal

Gag reflex must be intact, tongue with tremors upon sticking out and should move freely Positive swallowing reflex

Positive gag reflex; tongue was able to move freely

X. Vagus

Able to sip and drink water with no difficulty Able to shrug her shoulders against resistance

XI. Spinal Accessory

Ask patient to turn head against resistance; ask patient to shrug her shoulders against resistance Instruct patients to protrude tongue and move it from side to side

Able to move shoulders in full ROM; move head from side to side against resistance Moves tongue freely

XII. Hypoglossal

Moves tongue freely

RESPIRATORY SYSTEM Nose uniform in color, symmetrical, without discharges, lesions or tenderness; nares patent; nasal mucosa pink, without lesions; with oxygen at 2L/min via nasal cannula. Trachea at midline position. Thorax symmetrical; respiratory rate= 23 breaths per minute, characterized by deep inspiration with use of accessory muscles and shallow expiration; tactile fremitus symmetrical; lung fields at right upper, left upper, left lower, right middle, and right lower lobes clear to auscultation with no adventitious breath sounds.

CARDIOVASCULAR/CIRCULATORY SYSTEM S1 heard loudest at the apex of the heart; S2 heard loudest at the base of the heart; PMI at the 5 inter-costal space, left mid-clavicular line.
th

Jugular veins not distended. Carotid, apical, brachial, and radial pulses graded 2; carotid pulse=76bpm without bruits, apical pulse=77bpm, brachial pulse=26bpm, radial pulse=75bpm; femoral, popliteal, and pedal pulses graded 1.

GASTROINTESTINAL SYSTEM Lips dry and pale; right cuspid and left lateral incisor on the upper gum and 2 first cuspid and 3 cuspid on the lower gum. Total of 9 teeth all with caries. No dentures used; oral mucosa pinkish and moist. Tongue- midline, dark pink, moves freely but with white patches and white dots on it. No tenderness felt. Hard palate and soft palate are free of lesions and tenderness. Uvula- midline and hangs freely and rises symmetrically. Tonsils graded +1. Umbilicusmidline and not everted. Abdominal girth is 80 cm. Bowel sound is at 3-5 cycles/ minute in all quadrants.

GENITO-URINARY SYSTEM Bladder not distended upon palpation; with Foley catheter inserted to the urinary meatus and attached to urobag with amber-colored urine approximately 30cc in amount.

REPRODUCTIVE SYSTEM Breasts symmetrical, sagging, without lesions or masses; areolas dark 2 inches in diameter; nipples everted; pubic hair black but with strands of gray hair; labia majora symmetrical with foul odor noted.

ENDOCRINE SYSTEM No excessive hair growth noted. Thyroid gland not enlarged upon palpation, moves up and down when swallowing.

MUSCULOSKELETAL SYSTEM Upper extremities are weak but moved freely by patient in slow manner; in full passive range of motion. No pain, thickening, nor swelling noted when assessing temporomandibular joint, shoulders, elbows, wrists and knees. Both biceps and triceps graded as 3/5. no polydactyl noted. Lower extremities palpable muscle contraction but no movement. Full passive range of motion Hamstrings and quadriceps graded 2/5. No pain, thickening, nor swelling noted when assessing hip, knee and ankle joints. Neither bone deformities nor swelling noted.

LYMPHATIC SYSTEM Preauricular, postauricular, occipital, retropharyngeal, submaxillary, submental, superficial cervical, deep cervical and supraclavicular lymph nodes are not palpable. Lymph nodes in the axillae not palpable. Spleen not palpable. Inguinal lymph nodes not palpable.

HEMATOPOIETIC SYSTEM Spleen not palpable; hematology result as of 7/09/12 shows decreased Red Blood Cell and hematocrit count. Capillary blood glucose as 7/11/12 is 99mg/dl. Capillary refill at fingernails, greater than 2 seconds. Bulbar and palpebral pale pink. Nail beds pale

II.B.5. PSYCHOSOCIAL NURSING ASSESSMENT 1. Lifestyle information

J.C. is 75 years of age, widowed and a Roman Catholic who used to live in Brgy. Jocson, Lapuz, Iloilo City. Now, she resides in Zone 4, Brgy. Don Esteban, Lapuz, Iloilo City together with her only daughter who is a housewife, son-in-law and 3 grandchildren. She keeps a good relationship with her neighbours. She values God and her family and considers her daughter and grandchildren to be very significant. If she can do it, she goes to church every Sunday together with her daughter. At home, she spends her time listening to the radio and most of the time, she sleeps. She doesnt eat vegetables and fish but only prefer to eat foods rich in carbohydrates such as oatmeal. She drinks soft drinks for two to three times per week and a cup of coffee every day. J.C. is not alcoholic but has history of smoking. She does not also engage in exercise routine. She doesnt have any pensions and gets financial support from her son-in-law and if needed, she seeks aid from her sister. She does not comply with her medications for treatment in DM and buys only when she has money.

2. Normal coping patterns

J.C. stated that if she and her husband have problems, they discuss it together. In addition to, patient verbalized Kis-a gabaisanay kami kag wala gaintindihanay. Tulugan ko na lang na tapos pagka-aga, OK naman kami. When her husband died, she coped with her problems by talking the problem with her daughter.

3. Understanding of present illness

Siyempre bal-an ko man ni nga may sakit ko e. Nga bulag ko. Ti wala naman ako may mahimo. Ginapasa-Diyos ko na lang ni., as verbalized by J.C.

4. Personality Style:
She is the kind of person who likes to play with her grandchildren when she is not asleep. J.C. answers every question asked to her. She is accommodating to health care providers. She is optimistic to get well and get out of the hospital. Sometimes she gets irritable especially if her daughter is not around.

5. History of Psychiatric Disorder:

J.C. has no history of psychiatric disorder nor has any family member with history or having a psychiatric disorder. She had not taken any psychiatric medications. 6. Recent Life Changes Or Stressors J.C. stated the death of her husband as her recent life change. After her husband died last 2007, all the properties possessed by her husband were taken by her husbands brothers and sisters, including the house and lot which they used to live in. This forced her to move in with her daughter and her family in a single-room boarding house.

7. Major Issues Raised By Current Illness Financial issue was the primary problem of J.C. brought about by her present illness. 8. Mental Status Examination APPEARANCE Neat Clean Disheveled Inappropriate Make-Up Poor Grooming Erect Posture

Good Eye Contact

Others: _________________

Description: Patient appears untidy. She is wearing wrinkled clothes. Hair is uncombed, lips are dry, and nails are trimmed but dirty. BEHAVIOR Calm Appropriate Restless Agitated Compulsions

Unusual Actions

Others: _________________

Description: J.C. is calm and has appropriate reactions during the nurse-patient interaction. Facial expression is appropriate although sometimes appears irritated upon answering some questions. Frets and becomes agitated whenever her daughter leaves for transactions such as paying of bills, buying of medications and passing of specimens for laboratory tests. SPEECH Appropriate Soft Mute Pressured Loose Association Loud

Others: _______________

Description: J.C. speaks in an audible soft tone, understandable and in a moderate pace. MOOD/AFFECT Appropriate Anxious Angry Labile Flat Depressed Worried

Others: _______________

Description: Patients mood is appropriate during the interview of the SNs although sometimes she gets irritable during the absence of her daughter due to necessary hospital transactions. THOUGHTS Appropriate Delusions Low Self-Esteem Phobias Suicidal Intentions Others: ________________ Hallucinations

Description: Patient exhibits thought association and has sense of reality. Most of the time, thought content makes sense.

ABILITY TO ABSTRACT Impaired: YES NO

Description: Mayad man kay damo gold., as stated by J.C. after being asked to interpret the quotation, Time is gold. In the quotation Aanhin mo pa ang damo pag patay na ang kabayo., the patient verbalized, Pabay-an mo lang e.

MEMORY Impaired recent memory: Impaired past memory: YES YES NO NO

Number of objects able to remember after 5 minutes: remembered 2 out of 10 objects namely, chair and blanket Description: For her past memory, patient was able to recall about her husband, their relationship and other significant events that happened to her life. Patient was asked about her past 24 hour intake for her recent memory, she answered ESTIMATED INTELLIGENCE Below Average CONCENTRATION Able to focus Easily distractible Average Above Average

Able to subtract backwards by 7s from 100 correctly until number: unable to subtract 7s from 100. ORIENTATION Person JUDGEMENT Realistic decision making: YES NO Time_x_ Place Situation

Description: Patient was asked if what would she do if ever she found money left by someone she verbalized, di man ko ka kita kay bulag ko. INSIGHT Good Fair Poor

Description: patient has good insight about her situation. She verbalized ginapa sa diyos ko nalang sitwasyon ko.

II.C. NURSING PROGRESS NOTES (On-going Appraisal)

--

nakatulankosabayoko medyonainitanako

--

Unpleasant breath and body odor Unclean clothing and bed linens Unclean nails and uncombed hair

Self-care deficit related to weakness and blindness

P/I

--

Patient will be free of bad breath and body odor Clothes and bed linens will be changed and made tidy Hair will be combed and nails will be trimmed

Provide bed bath/sponge bath Provide oral care Change clothes and bed linen Bed making

Goal met Client is free from unpleasant breath and body odor Malimpyo na pamatyagan ko kag wala na ako nainitan

V. PROBLEM LIST (Identified Nursing Diagnoses numbered according to priority) 1. 2. 3. 4. 5. 6. Impaired Gas Exchange related to Altered Oxygen-carrying capacity of the blood. Constipation related to Gastrointestinal Tract mobility. Ineffective Peripheral Tissue Perfusion related to Immobility. Self-care Deficit related to Weakness. Impaired Physical Mobility related to weakness. Imbalanced Nutrition: Less than body requirements related to inadequate nutrition and fluid intake. 7. Risk for Injury related to Blindness.