RLE 001

Cebu Normal University

College of Nursing Cebu City
Mission-Vision: Care Using Knowledge and Compassion Theory-based (Betty Neuman)

ASSESSMENT FORM
Name of Student: Jayza Mae R. Nacua Ward 5 Name of Clinical Instructor: Ms. Lovelyn Garcia 2014 I. Area of Assignment: VSMMCInclusive Dates: January 6-9,

CLIENTS PROFILE & CENTRAL CORE

Clients Initials: D.S.O Age : 21 years old Gender: Male Religion: Roman Catholic Civil Status: Single Allergies: no known allergies Diet: diet as tolerated Height: 52 Weight: 50kg Date & time of Admission: January 2, 2014 (10:28AM) Mode of Admission: via ambulance Impression/Diagnosis: Gunshot wound point of entry paravertebral T7-T8 right, point of exit midaxillary line right T9 with pneumothorax Reason for seeking health care: gunshot wound Vital Signs: T: 36.3 degrees celsius PR: 72 bpm RR: 22 cpm BP: 120/80 mmHg Pain score: 8/10 General Physical Description: Client appears tidy; without IVF; with CTT insertion at right chest/lung; hair is unkempt; fingernails and toenails are long and appears to be dirty; wears slightly dirty but appropriate clothing; appears to be older in terms of chronological age; has dark complexion; appears to be asthenic. General Behavior exhibited: Client establishes good eye contact; alert and oriented; speech is clear and appropriate; follows through with train of thought; facial expressions symmetric and correlate with mood and topic discussed. Physician in-charge: Dr. Rodolfo Jose Abalos, Jr Nurse-on-Duty:
II.

STRESSORS & REACTIONS TO STRESSORS A. Clients Complaints Upon Admission Gikalit ra gyud mig pusil kami sa akong kauban sa trabaho. Wa mi kaila atong namusil namo. Gitabangan kos mga standby nga nakakita kay nagdugo naman ug mayo akong dughan. Nakuyawan kog maayo ato abi nako mahubsan nakog dugo, as verbalized by the patient. Stressors as perceived by the client and SOs: Nakuyawan sad mi para sa akong anak kay unexpected man kaayo to nga pngahitabo. Wa gud nay atraso akong anak unya pusilon lag kalit. Nag-guol ko kay naa raba siyay anak nga 6months ug iyang pares nga gimingaw nasad niya , as verbalized by patients mother.

B. Identification and Reactions to Stressors by person variables/subsystems: 1. Intrapersonal a. Physiological (Head to Toe) Past medical history:
Illnesses: no previous illnesses Surgery: no previous surgeries History of chronic disease: no history of chronic disease Immunization History: (specify the number of doses received) __1___ BCG __3___ DPT __3___ OPV __1___ AMV _____ MMR __3_ HepB ___2__ TT _____ HiB _____ MMV _____ Rubella Vaccine _____ Others(specify) Smoking: patient is not into smoking ___N/A__ pcks/day ___N/A__ pck/year Alcoholic Beverages: _______beer_Type ________1-2 glasses Amount __ocassionaly_Frequency of Use __January 1, 2014__ Date of Last Drink Illicit drugs: patient does not use illicit drugs _____N/A_____Type __N/A___Amount _____N/A____ Frequency of Use __N/A__ Date of Last Use Medication (prescription/OTC) Medicine Dose Cefuroxime 500mg 1tab PO Etoricoxib 120mg 1tab PO Vitamin C 1tab PO Frequency BID OD OD Last Dose 500mg 1tab PO 120mg 1tab PO 1tab PO Indication antibacterial Pain reliever Vitamin C supplementation and to strengthen the immune system ______________ Drugs _____ poor

Allergies: ______________ Foods Perception of health: _____ good Dietary Preferences: egg, vegetables, pork

__/___ fair

Physical Assessment: Central Nervous System

Level of Consciousness: ___/__alert _____lethargic _____drowsy _____Obtunded _____Stupurous _____Comatose Mood (subjective): ___/__ pleasant _____irritable __/___calm _____happy _____euphoric _____ anxious _____ fearful _____ others(specify) Affect (objective): _____surprise _____anger _____sadness _____joy _____disgust _____fear _____flat _____blunted __/___full Orientation Level: __/___person __/___place __/___time Memory: __/___ recent __/___Intermediate __/___Remote Pupils: Right Left __3mm_size _PERRLA__Reaction _3mm__size __PERRLA_Reaction Reflexes:

__2+___ grade (describe) normoreflexive Grasps: Right Left ___/__Strong __/___Weak __/___Strong __/___Weak Others: _____Numbness _____Tingling _____Restless _____ Mannerism Pain: None: _____ Provoking/Precipitating factors: right lung injury Quality/Location: right lung/chest Radiating or non-radiating: nonradiating Severity/intensity: 6/10 pain score Timing: irregular Visual Acuity: __/___Normal _____glasses _____ contacts _____blind (R/L) _____Prosthesis: (artificial eye) R/L Hearing: __/___Normal _____impaired (R/L) _____deaf(R/L) _____hearing aid _____tinnitus _____drainage from ears Touch: ___/__Normal _____abnormal (specify) Smell: _/____normal _____abnormal Communication: _____ Brocas Aphasia _____ Wernickes Aphasia _____ Global Aphasia

Cardiovascular System
Pulse Rate and Characteristics: __/___regular _____irregular __/___strong _____weak __80bpm___ Right Upper Extremity __80bpm___ Left Upper Extremity __80bpm___ Right Lower Extremity __80bpm___ Left Lower Extremity Heart Sounds: __/___ S1 __/___S2 _____Others (specify) Blood Pressure: _100/60mmHg__ standing __100/60mmHg___lying __100/60mmHg___sitting Extremities: Temperature: Upper Extremities _____cool __/___warm Lower Extremities _____cool __/___warm Capillary Refill Time: __1___ second/s Homan's Sign: __/___ Negative _____Positive Claudication: __/___ Negative _____Positive Nails: __/___Normal _____Thickened _____Clubbing _____Other (specify)

Respiratory System
Chest: Respirations: _____ symmetrical __/___ asymmetrical (specify) right chest expansion due to right lung injury ___24cpm__ rate ___/__ depth (shallow/deep, abdominal/diaphragmatic) __/___ regular _____ irregular (specify) _____ periods of apnea _____ dyspnea at rest _____ orthopnea _____ dyspnea on exertion _____others(specify) ___/__ absent _____ present (specify) _____ dry _____soft

Cough:

_____ Sputum: Breath Sounds: _____ Normal

_____ productive _____ nonproductive _____ whooping _____odor _____color _____consistency

Respiratory devices: __/___ CTT: with CTT at right lung/chest _____ Tracheostomy: _____ ETT: _____Oxygen Therapy:

___/__ Adventitious (specify location) at right lung _____ absent __/___ crackles _____ rhonchi _____ friction rub _____ wheezing

Gastrointestinal System
Prescribed Diet: diet as tolerated Appetite: _____Normal __/___Abnormal (specify) lacks appetite due to fear that his right lung might be affected if he eats too much Gag Reflex: __/___ Present _____ Absent GIT problems: _____ Nausea _____Vomiting _____ Dysphagia _____ Constipation _____ Diarrhea _____Incontinence _____ hemorrhoids _____ Others (specify) Feeding Ability: __/___ Able _____ Unable (specify) Mouth: _____pink _____inflammed _____moist __/___dry _____lesions/ulcerations ___/__ Others(specify) brownish and slightly pale Oral Prosthesis: no oral prosthesis Defecation Pattern: ___solid, moist__ Consistency ___brownish__ Color ___moderate__ Amount ___1-2 times a day__ Frequency Abdomen: __/___symmetry __/___ flat _____rounded _____obese _____Ascites _____Soft __/___Firm _____ Tender _____ Distended Bowel sounds: _____Hypoactive _____ Hyperactive __/___Normoactive _____Absent Bowel Diversions: _____ Ostomies (specify)

Integumentary System
__/__ color: pallor, ashen, pink, jaundice, cyanotic, ruddy _/___ temperature: warm, cool __/__dry, moist, clammy, diaphoretic _/___Skin integrity: intact, impaired (specify) with CTT insertion at right chest/lung _/___turgor: good, poor ____edema:pitting/non-pitting, dependent, bipedal, periorbital, anasarca ____pruritus ____bruises/lesions ____decubitus ulcer (describe)

Urinary System
Bladder Patterns: __yellowish___ color __moderate___ Amount __slightly cloudy___ Turbidity __5-6 times a day___ Frequency Urinary problems: _____Dysuria _____Nocturia _____Urgency _____Hematuria _____Retention _____Burning _____Hesitancy _____ Incontinence Elimination Assistive Devices: _____ catheterization (specify)

Musculoskeletal System
Self-Care Ability: (0=Independent 1=Assistive device 2=Assistance from others 3=Assistance
from person and equipment 4=Dependent/Unable)

Self care Feeding Bathing Dressing Bed Mobility

0 / / / /

Self care Transferring Ambulating Toileting

0 / / /

Problems: _____ tremors Assistive Devices: __/___none _____Walker _____wheelchair Gait: __/___normal Range of Motion: __/___normal Posture: __/___normal _____Lordosis Deformities: ___/__None Amputation: __/___None

_____ atrophy _____ swelling _____crutches _____Commode _____cane _____splint/brace _____others (specify) _____abnormaI (specify) _____limited (specify) _____Kyphosis _____Scoliosis _____Yes (specify) _____ Yes (specify)

Reproductive System
Sexual concerns: no sexual concerns reported (patient is sexually active, about 3 times a week) Female: __N/A___LMP __N/A___GPTPAL Score __N/A___Menopause (specify) Family Planning: __N/A___No __N/A___Yes (type) Vaginal bleeding: __N/A___No __N/A___Yes (describe) History of sexually transmitted disease __N/A___None _N/A____Yes(specify) Last Pap Smear: ___N/A______ Male: Prostate problems _/____No ___Yes (type) Penile discharges: _____No _/_Yes (type) normal- whitish-yellowish in scant amount Last prostate exam:____none___ Congenital Problems: _____hypospadia _____epispadia History of sexually transmitted disease ___/__None _____Yes(specify)

b. Psychological
Overt signs of stress: (crying, wringing of hands, clenched fists)

Coping Strategies: sleeps, talks about the problem and possible solutions Impact of Hospitalization/Illness (financial, self-care, role performance): lisod lagi kaayo ni namo kay wa sad mi kwarta. Nag-guol ko sa akong pares ug akong anak kay mingaw na kaayo ko nila. Naka-undang sad ron ug skuyla akong asawa tungod aning gasto-an sa ospital, as verbalized by the patient. Recent Major loss: no reported recent major losss Living Arrangement: _____ Alone ___/__Nuclear _____ Extended Number of Children: one Occupation: water refilling station maintenance Employment Status: ___/__employed _____ unemployed Social activities: _____active __/___limited _____none

c. Spiritual
_____Protestant _/____Catholic _____Jewish ____Muslim _____Buddhist _____others(specify) Religious Practices/Restrictions: Goes to church every Sunday or at least once a week; prays everyday; active in fiests of religious saints Concerns related to spiritual or religious customs? No concerns reported related to spiritual or religious customs Religion:

d. Developmental Psychosocial tasks: Psychosexual task: Cognitive level: Moral Development: 2. Interpersonal (between persons) and Extrapersonal (within the community) a. Socio-cultural Community participation: Patient is inactive in community activities, but intercats with seldom people in the community including neighbors, friends, relatives Health cultural beliefs: Believes in albularyos and quack doctors in treating mild to severe health conditions Political Affiliations: >votes during elections >no specific political affiliations Stressors as perceived by the nurse: Financial concerns Poorly ventilated and humid environment Pain at right lung Emotional security

NURSING DIAGNOSES (in priority)

Classification Physiological Nursing Problems (at least 5) 1. Acute severe pain related to tissue damage secondary to CTT insertion at right lung 2. Impaired tissue integrity related to invasive surgical incision secondary to CTT insertion at right lung 3. Disturbed sleep pattern related to pain and discomfort 5. Risk for infection related to inadequate primary defenses (traumatized tissue)

Psychological Socio-cultural Spiritual Developmental

4. Deficient knowledge related to unfamiliarity with information

III.

Discharge Planning

Clients Initials: D.S.O Diagnosis: Gunshot wound point of entry paravertebral T7-T8 right, point of exit midaxillary line right T9 with pneumothorax Probable Date: January 11, 2014 Destination: Opao, Mandaue City, Cebu Transportation: public utility vehicle Medications continue prescribed medications and take religiously (no medications ordered as of now, but probably it would be: >antibiotics >pain relievers Environment & -Advise to take adequate rest and sleep Exercise -encourage to have daily exercise such as walking and frequent ambulation, as tolerated -encourage to maintain clean and health-conducive environment Treatments -take the prescribed medications religiously -change wound dressing frequently and maintain it clean and dry -practice deep breathing exercises -practice splinting especially during coughing Hygiene -encourage to take a bath daily and continue hygienic measures (i.e. toothbrushing) -advise to perform frequent hand washing Observable symptoms Advise patient to report or seek medical care if the following observable symptoms occur: -increasing pain at right lung -difficulty breathing -unusual drainage at surgical site (i.e. pus, blood, wet and foul odor) -bleeding at surgical site -signs of infection: hyperthermia, redness, inflammation, swelling Dietary Prescription -advise to eat healthy foods such as green leafy vegetables, fruits, soup -adhere to high protein diet for wound healing -increase fluid intake especially water for hydration Spirituality Encourage to continue spiritual activities and practices such as going to church at least once a week and to pray

everyday

_____________________________ Name/Signature of Student Rating Scale: 5 4 3 2 1 = = = = = when when when when when the the the the the student student student student student gives gives gives gives gives much more than what is expected more than what is expected what is expected less than what is expected much less than what is expected

Summary of Scores
Components Clients Profile Clients Complaints Past Medical History Central Nervous System Cardiovascular System Respiratory System GIT System Integumentary System Urinary System Musculoskeletal System Reproductive System Psychological Spiritual Developmental Socio-Cultural Nursing Diagnoses Discharge Planning TOTAL Highest Possible Score 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 85 Actual Score

__________________________________ Name/ Signature of Clinical Instructor