NURSING PROCESS

I. Assessment:

A. General Data

 Patient’s Initials: Lola get’s

 Address: Mambog Bacoor, Cavite
 Age: 64
 No. of Days in this Hospital: N/A
 Place of Birth: Camiling Tarlac
 Informant: Lola Get’s
 Occupation: Housewife
 Sex: Female
 Civil Status: Marriage
 Date of History: June 4, 2010

B. Chief Complaints:

-Sumasakit ang ulo ko kapag tumatayo. “As verbalized by the patient” and vomiting.

C. History of present illness:

-Known hypertension to drug for so may years and maintain amlodipine 10mg/tab apparently
well around 4 am. Today patient had onset of dizziness meds until around 1 pm sudden of hypogastric
pain asses witch 7 pain scale episode vomits.

D. Past History

 Childhood Illness/s: Chickenpox, Mumps, Asthma.

 Adult Illness/s: scoliosis, hypertension, UTI, Cataract.
 Immunization Date: N/A
 Previous Hospitalization: Many times on hospital for high blood and cataract.
 Operations (include year): N/A
 Injuries(include year): N/A
 Allergies: detergent
 E. Systems Review

 Health perception-Health Management: My patients Lola gets know her limitation for
example drinking alcohol when there is a party she stops immediately when she is not on
her mind but she was risk in infection of inadequate primary defense like change in Ph
secretion, decrease in cillary action also decrease in physical strength and decrease in
mobility.
 Nutritional Metabolic Pattern: Lola gets eat on time. The foods that’s she ate most of the
time are vegetable, sea foods, beef, chickens. Like adobo, tinola, ginataang kalabasa.
 Elimination Pattern: Before she admits n the hospital his elimination pattern is regular but
sometimes it is irregular. On her 2nd day on the hospital she was given buscopan for enema
to eliminate. After the enema her elimination is now regular.
 Activity and Exercise: No exercise, He sad that her exercise is walking only because of
insufficient physiological or psychological energy to endure and also because of insufficient
muscle strength
 Cognitive-Perceptual: When I was interview my patient was conscious about the pain on its
abdomen. She doesn’t know why her abdomen is aching. The nurse sad that they will go to
have ultrasound on the abdomen.
 Sleep and Rest: No problem on her sleeping pattern and she is always at rest but no exercise
 Self –Perception –Self-Concept: stay at home and less activities,
 Role Relationship: Lola gets is just having fun w/ his grand son and her grand daughter and
also she the 7th of the 10 brothers and sisters
 Sexuality-Reproductive: menopause
 Coping/Stress Tolerance: hard to adjust from stress
 Values/Beliefs: Catholic

F. Family assessment:

Name Relation Age Sex Occupation Educational Attainment

Mr. A Husband 62 Male N/A N/A

Miss. B Daughter 24 Female Nurse College Graduate
Miss. C Daughter 19 Female Student College
Mr. D Son 22 Male Student College

G. Heredo- Family Illness:

 Maternal: High Blood

 Paternal: High Blood

H. Development History:
 Theorist Age Task Patient Description

I. Physical Examination (date and time)

 Ultrasound (July 6, 2010/ 9am)

J. Regional Examination

 Skin: (-)
 Nails: (-)
 Head and Face: (-)
 Eyes: (+) cataract
 Ears: (-)
 Nose: (-)
 Mouth and Pharynx: (-)
 Neck: (-)
 Spine: (+) scoliosis
 Thorax and Lungs: (-)
 Cardiovascular/Heart: (-)
 Breast: (-)
 Abdomen:
 Extremities: (-)
 Genitals: (-)
 Rectum and Anus: (-)
 Neurological Exam: (-)

II. Personal/Social History:

 Habits: watching TV
 Vices: N/A
 Lifestyle: At home only
 Social affiliation: N/A
 Rank/order in the Family: 7th eldest of the 10th siblings
 Travel: Guam
 Patients Teaching High school
 Occupation: House wife
III. Environmental History:

IV. Obgyne History:

 Menarche (age):

V. Pediatric History

 Birth Date: September 3, 1954

 Birth Weight: N/A
 Type of delivery: NSD
 Condition After Birth: Healthy
 Hospital: Marie Child Hospital

Mother:
 Complication after delivery: No complications
 Anesthesia drug during labor: N/A
 Exposure of Teratogenic Agents during Pregnancy: N/A

VI. Other Source of Information:

A. Drug study:
 Generic Name: Indication Dosage Action Adverse Nursing Patients
(Brand Name): Effect consideration Teaching
Classification:

-Losartan -Treatment of -50mg/ -Selectively -Dizziness, -Monitor patients - Teach the

-(Cozaar) hypertension in tab blocks the asthenia, BP. patient to avoid
-Anti-hypertensive heart failure and binding of fatigue, -tell the patient sunlight or wear
myocardial angiotensine II headache, to avoid salt sunscreen
infarction, it may to receptor site insomnia, substitutes. because
be using alone or in in many tissue edema -Asses patient photosensitivity
combination w/ especially the chest renal function. may occur.
other hypertensive vascular smooth pain,
agents. muscles and nausea
adrenal glands. abdominal
This prevents pain,
the diarrhea
vasoconstriction

-Amlodipine
-(Norvasc)
-

B. Laboratory Result or Findings

Laboratory Normal Value Result Interpretation/

Significance
1. Urea Nitrogen 1. 11.0 mmol/L
2. Creatinine: 2. 114.9 mmol/L
3. Uric Acid (for 3. 0.15 mmol/L
female): 4. 4.1 mmol/L
4. Potassium: 5. 153 mmol/L
5. Sodium: 6. 0.75
6. Segmenters: 7. 0.25
7. Lymphocytes: 8. 125
8. Hemoglobin: 9. 0.38
9. Hematocrit: 10. 7.3
10. Total WBC:

VII. Nursing Care Plan:

A.

B. Ongoing Appraisal:

C. Discharge Plan:
 Medication
 Exercise
 Treatment
 Health education
 OPD follow-up
 Diet
 Signs and Symptoms