Kareen Mae C. Sanchez N2F NURSING PROCESS I. DEMOGRAPHIC PROFILE: Name: M.L.R.

Age: 29 Gender: Female Address: Quezon City Religion: Roman Catholic Date of Birth: August 6, 1979 Place of Birth: Quezon City Civil Status: Single Nationality: Filipino II. CHIEF COMPLAINT “Nagpunta ako dito sa hospital para sa chemotheraphy ko pero medyo masakit din ang ulo ko.” III. HISTORYOF PRESENT ILLNESS Two days prior to admission, the patient experienced headache before going to sleep, she took analgesic and the pain was relieved but she was not able to sleep well because she still felt a little pain. One day prior to admission, the headache didn’t persist so she was able to rest well during that day. Before admission, the patient complained about her headache and since it was the scheduled date for her chemotherapy, the mother brought her to the hospital. Upon admission, the patient’s vital signs were obtained and the respiratory rate was 18 breaths per minute, pulse rate was 82 beats per minute, temperature was 36.6°C, and blood pressure was 120/80. She rated the pain 4 over 10, 10 being the most painful. IV. PAST MEDICAL HISTORY In the year 2008, patient was rushed to the hospital due to severe headache and nausea which later on was diagnosed to have a tumor in the brain (Asthrocytoma) during her hospitalization. Patient had undergone series of chemotherapy which was done every three weeks. Patient had chickenpox when she was 10 yrs. old. Patient has been vaccinated with 1 dose of BCG, 3 doses of DPT, 3 doses of OPV and 3 doses of Hepatitis B except for the vaccine for Measles.

She helps her mother in . buses and tricycles. school. PSYCHOSOCIAL HISTORY The patient lives with her family. ACTIVITIES OF DAILY LIVING The patient likes to rice and viand for breakfast. The patient has an effective relationship with the other members of the family and there are no known conflicts between them. are readily available near their house. VII. It will take five to ten minutes of walking for the patient to reach their baranggay health center. As for the kind of neighborhood. Within the last six months. FAMILY HISTORY + DM + + HP N + DM + HP N HP N HPN + P x LEGEND: Female Male Px – Patient DM – Diabetes Melitus HPN – Hypertension + . The patient didn’t drink alcoholic beverages nor smoke cigarettes nor try taking illegal drugs. she loves to have banana cue for snack or other street foods.died VI. The patient has an excellent social relationship with the neighbors because they are her friends. market and transportation such as jeepnies. The patient is open. the patient observes a balanced diet by eating rice for carbohydrates. They can always count on her whenever there is a problem. Oftentimes. The patient stays at home everyday and sometimes goes to the mall with her family. the patient grew up in their concrete two-storey house in the urban area. The patient has no vices. the patient had traveled to Pampanga for vacation. fish or meat for proteins and fruits and vegetables for vitamins and minerals. church. in terms of the emotional and social aspects with her family. the patient eats snacks in the afternoon. The patient is not that active in their community because she seldom participates in baranggay’s projects. Malls.V. During lunch and dinner time.

“Hindi ako madalas na magkasit noon hanggang sa naospital ako noong March 2008 at nalaman ko na may tumor ako sa utak. Madalas kong pinapaluto yun tuwing Linggo. Kahapon ng umaga. No lesions found. para syempre maagapan. 2. Tingin ko dati hindi rin ako ganon ka-healthy kasi mataba na din ako dati pa eh pero nung magkasakit ako lalo na akong nag-ingat sa kalusugan ko para hindi na lumala pa yung sakit ko. Kumakain din ako minsan ng street foods. Nasal orbit appears wet. the center has lesser number of hairs than the surrounding part. Noong nagkasakit ako. Dati kasi hindi naman ako nagpapachech-up sa doctor kapag hindi naman masyado malala ang nararamdaman ko. Noong tanghalian naman kanin at nilagang baka ang ulam. kumain ako sa mga fast food restaurant.” O: Patient’s hair is unevenly distributed. warm and moist.18bpm and temperature. Skin is slightly pale.6°C. Bago ako matulog ay uminom din ako ng gatas. kumakain rin ako ng snacks. nakakaubos ako ng mahigit walong basong mineral water. Wala naman akong allergy sa mga pagkain. Pero mahilig din naman akong kumain ng mga gulay at prutas. Sa loob ng isang araw. nagsimula akong uminom ng vitamins.4. No dandruff was noticed. and it is dry and thin. dinagdagan ko lang yung pagkain ng mga masustansiyang pagkain. VIII. Tapos nung hapunan nag-uwi ng hipon yung kapatid ko kaya iyon ang ulam namin. Minsan rin. Hindi rin ako umiinom ng vitamins. Simula lang noong nagkasit ako. RR. (BMI: 23. She sleeps in the afternoon after eating lunch and during the night. S: Health Perception .4). Her height is 5’1 and her weight is 132lbs and the BMI is 23. S: Nutritional . GORDON’S FUNCTIONAL HEALTH PATTERN: 1.120/80mmHg.36. PR. Katulong ko si mama at ang mga kapatid ko sa paglaban sa sakit ko.doing the house chores in the morning and rests and watches television shows during free time.82bpm. kung ako lang kasi sa palagay ko hindi ko kakatanin. Iniinom ko din yung mga nireresetang gamut ng doktor sa akin. kumain lang ako ng kanin at ulam ko ay pritong isda. O: The patient is wearing a shirt and pants. Her height is 5’1 and her weight is 132lbs.Metabolic Pattern Patient verbalized. “Paborito kong kainin yung lutong kaldereta ni mama.Health Management Pattern Patient verbalized. She is properly groomed and doesn’t have any body odor. No suspicious rashes. Oral mucosa appears wet. Her vital signs are: BP. A: Readiness for enhanced health management. Tatlong beses akong kumain sa isang araw. A: Readiness for enhanced nutrition. lagi na ako nagpapaluto ng gulay kay mama tapos nagkakakain din ako madals ng mga prutas kasi madalas bumili yung mga kapatid ko. Simula nung nalaman kong may sakit ako lagi na ako nagpapatingin sa doktor kahit hindi malala yung nararamdaman ko. Madalas. . The abdominal bowel sound is normal high-pitched gurgles heard at 5-20 seconds interval.

dullness over spleen and liver. naming subject yun na yung maituturing kong exercise ko.18bpm and temperature. Patient’s urine output per day is 840cc. The urine is light yellow in color and is faint aromatic. Wala naman akong nararamdamang sakit at di naman ako nahihirapan. Mahilig akong pumunta sa mall kasama ang mga kapatid ko at hindi ako mahilig sa sports. Her muscle strength is rated 75% which is normal full movement against gravity and against minimal resistance. There was no tenderness in the abdomen. The bowel is cylindrical in shape and brown in color. 4. Ang dumi ko kadalasan ay pahabang pabilog at color brown. Wala din naman akong napapansing dugo o kakaibang kulay sa aking dumi. Estudyante ako kaya kailangan kong gumising ng umaga. Ngayon. A: Activity intolerance r\t generalized weakness.” O: The bladder is not distended and the abdomen is symmetrical. Madalas pa rin ako tumulong sa gawaing bahay ngunit hindi na ako madalas lumabas at wala din akong exercise kasi madalas nanghihina ang pakiramdam ko kaya pinipili ko na lang na magpahinga. Her vital signs are: BP. Wala naman akong problema pagdating sa pagdumi.6°C.The patient is able to walk but is not standing erect. kinailangan kong tumigil sa pag-aaral ko. O: The patient appears to be weak and skin is pale in color . The liver and bladder are not palpable. The bowel output is once a day.36. bago pa ako magkasakit nag-aaral ako sa UM at isa akong HRM student. A: Readiness for enhanced elimination pattern. “Dati.3. RR. PR82bpm. “Normal naman ang pag-ihi ko kahit may sakit ako. Tumutulong din ako sa mga gawaing bahay tuwing weekends at pag wala masyadong ginagawa. The muscle tonicity is in the normal condition of tension/tone of a muscle at rest. Sa isang araw mga limang beses akong umiihi at mga apat na baso ang dami kung tatantyahin ko yung iniihi ko sa isang araw. siguro yung P. Pero nung magkasakit na ako.E. “Before. Araw-araw ay nakakadumi naman ako nang walang nararamdamang masakit o kaya naman hirap sa pagdumi.120/80mmHg. Tympanitic sound was heard over the area of the stomach. There are no hemorrhoids found inside the anus. S: Elimination Pattern Patient verbalized. nagcocommute lang ako papuntang school tapos hindi ako madals na mag-exercise. She can do active range of motion on light activities and an increased respiratory rate and shortness of breath in moderate and heavy activities. siguro mga 9 pm tulog na ako at 5 am naman ang gising ko. 5. The extremities are warm and has capillary refill of less than 3 seconds. mga 8 hours ang tulog ko. madalas din paputol-putol yung tulog . S: Sleep – Rest Pattern Patient verbalized. mga 5-6 hours na lang dahil madalas ay sumasakit yung ulo ko kapag gabi kaya hindi ako nakakatulog ng maayos. There are no audible bowel sounds.Exercise Pattern Patient verbalized. S: Activity .

6. Narririnig ko ng malinaw ang sinasabi ng kausap ko. CNVIII – Vestibulocochlear: Weber (-). Client answers the question without difficulty. Nakikita ko ng malinaw ang mga bagay at hindi rin ako gumagamit ng salamin sa pag-babasa. The cranial nerve assessment: CNI – Olfactory: The patient was able to smell the vinegar and the coffee. She has a poor posture and frequent yawning. A: Disturbed sleep pattern r/t pain and discomfort. isa yakap-yakap ko at isa naman sa pagitan sa legs ko. Ayos naman ang panlasa ko. CNVII – Facial: The client was able to determine the taste the lemon and sugar correctly. Wala rin akong problema maging sa pandinig at pang-amoy ko. T-shirt at shorts o kaya pajama lang ang suot ko kapag natutulog. and she speaks in a soft voice. Client is able to express well what she wants to say. place and event. CNV – Trigeminal: The client was able to clench her jaw. Madalas nakatagilid ako matulog. “29 years old na ako. Malinaw ang aking paningin. : Blink reflex. : Proprioception: client was able to determine the position of the arm while eyes closed. Hindi rin ako hirap kumain o ngumuya ngunit paminsan ay wala akong ganang kumain. O: Client is well-oriented to time. Wala rin akong nararamdamang sakit sa paligid ng mata ko. nagtutoothbrush muna ako at naghihilamos o kaya naman minsan kumakain pa ng midnight snack.ko. Kinesthesia: client was able to determine the movements of the arm while her eyes closed. Kung minsan din nakakaidlip ako sa hapon ng mga isang oras. Bago ako matulog. Medyo pagod at nanghihina yung pakiramdam dahil na rin siguro sa sakit ko. Nandito ako sa hospital ngayong umaga para sa scheduled chemotherapy ko. CNII – Optic: The client has 20/20 vision. The patient seems restless and tired. : Sterognosis: client was able to determine the objects while eyes closed. Nakakapagdesisyon ako para sa sarili ko dahil nasa tamang edad na naman ako. her pattern of speech is coherent. Isang unan sa ulo.” O: The patient has a visible dark spot under the eye. Client does not have difficulty recalling past situation. nagpapahinga lan ako sagayon dahil kinailangan kong tumigil sa pag-aaral ko dahil nga sa karamdaman ko. Rinne AC > BC A: Readiness for enhanced knowledge . S: Sensory – Cognitive – Perceptual Pattern The patient verbalized.

Mabait at matulungin din akong kaibigan. bawat araw iniisip ko kung gaano na lang katagal ang itatagal ko. sobrang natatakot akong mamatay at ayoko pang mamatay. 8. Yung tita ko sa ibang bansa ang sumusuporta sa amin kasi dalaga naman iyon at malaki ang kinikita niya sa ibang bansa. si mama lang ang nilalapitan ko kasi mas close ko siya. yung kuya ko din ay nagtatrabaho na at nagbibigay din ng pang-gastos kay mama tapos yung sumunod sa akin ay may trabaho na din. sa katunayan ay close talaga kami ng pamilya ko lalo na nung mamatay ang papa namin. 9. She was with her mother and sister when she got admitted. S: Coping – Stress Tolerance Pattern Patient verbalized. Sana ay patagalin pa ng Diyos ang buhay ko dahil minsan tingin ko sa sarili ko ay wala ng pag-asa pang gumaling pero salamat sa pamilya ko dahil lagi silang nakasuporta sa akin. Mabuti naman akong anak sa mama ko at kapatid sa mga kapatid ko. S: Role – Relationship Pattern Patient verbalized. sobra akong nag-alala sa kalagayan ko. A: Anxiety of death r/t chronic illness or severe condition. She also doesn’t maintain an eye-to-eye contact while speaking. Kaya nagpapasalamat ako dahil sa kanila. Nandun din yung The client is cooperative during the interview and there is an organized thought process and clear speech dalawa kong nakababatang kapatid pati yung kuya ko na may asawa na. “Dati. S: Self-perception – Self-concept Pattern Patient verbalized. She speaks in a soft voice and seems to be bothered. Wala pa naman akong trabaho kaya hindi pa ako nakakapagbigay ng pera sa amin. The client also communicates to others effectively.” O: pattern. wala naman masyado nakakastress sa akin kasi masayahin naman akong tao pero nung nagsimula akong magkasakit lagi ko ng naiisip yung karamdaman ko. O: The client is closely bonded and has good communication with her family. masaya na ako at kuntento sa buhay ko ngunit simula noong malaman ko ang sakit ko. Kapag nagkakaproblema ako o nagkakasakit.” O: The patient slouches when she sits. “Ang mga kasama ko sa bahay ay yung mama at mga kapatid ko. A: Readiness for enhanced coping. “Dati. A: Readiness for enhanced role and relationship process .7. kung ano na ang mangyayari sa akin o kung mamamatay na ba ako pero sa tulong ng aking pamilya at mga kaibigan. Patient’s voice is audible.. pinipilit kong lumaban kasi sobrang mahal nila ako at ineencourage akong lumaban at may pag-asa pa sa kabila ng mga pag-subok. yung bunso naman ay graduating na.

dati sobrang madasalin ko at nagsisimba pa ko lingo lingo. Para bang nabalewala yung pananampalataya ko. tumangkad ako kahit papano. Hindi ko na priority ngayon ang pagkakaroon ng boy friend. 11. Niño pero nung magkasakit ako sinisi ko ang Diyos sa kalagayan ko. Simula noon napansin ko na ang pagbabago sa’kin. A: Spiritual Distress r/t chronic illness. The pubic hair is evenly distributed. Nagsimulang nagmature ang boses ko. Sexuality – Reproductive Pattern S: Patient verbalized. Sa dinami-dami ng tao bakit ako pa yung binigyan niya ng ganitong karamdaman. Deboto pa nga ko ni sto. Napakasakit isipin na malala yung sakit mo eh. hindi na ako nagsimba o nagdadasal. O: The client has normal breasts. Nagkaroon ako ng menstruation nung grade 6 ako. Value – Belief Pattern S: Patient verbalized. A: Readiness for enhanced sexuality-reproductive pattern. at saka napansin kong nagsimula na rin akong tubuan noon ng buhok sa kilikili at sa private part. No cyst in the breasts.10. “Babae ako syempre. Simula noon. “Roman Catholic ako. O: Patient became emotional while she was interviewed. The patient is not observed to have religious routines. Ewan ko pero mabigat lang sa pakiramdam pag naiisip kong may sakit ako. . kuntento na ako sa pamilya at mga kaibigan ko.

Adequate energy is needed for activities to be done. The patient will be able to use identified techniques to enhance activity tolerance. 3. PLAN Goal: After 48-72 hrs. Pero nung magkasakit na ako.E. Determine baseline activity level. Sleeping difficulties should be taken care of before activity should start. it will result the person to rest instead of completing desired activities. 6. Madalas pa rin ako tumulong sa gawaing bahay ngunit hindi na ako madalas lumabas at wala din akong exercise kasi madalas nanghihina ang pakiramdam ko kaya pinipili ko na lang na magpahinga. The patient will demonstrate a decrease in physiological signs of intolerance. naming subject yun na yung maituturing kong exercise ko. When a person feels weakness and pain. RATIONALE 1. 6. EVALUATION 1. 4. Objective: At the end of 2 hours of nursing intervention. Monitor patient’s sleeping pattern and amount of sleep. 4. 3. Tumutulong din ako sa mga gawaing bahay tuwing weekends at pag wala masyadong ginagawa. Mahilig akong pumunta sa mall kasama ang mga kapatid ko at hindi ako mahilig sa sports. Assess the nutritional status of the patient. Monitoring these will help as a guide for optimal results of the activity. bago pa ako magkasakit nag-aaral ako sa UM at isa akong HRM student. 2. siguro yung P. INTERVENTION 1. The patient will also verbalize factors that will show signs of overactivity. Provides opportunity to track changes 2. The patient will verbalize techniques in conserving and utilizing energy when doing activities.ASSESSMENT S: Patient verbalized. of nursing intervention: The patient will be able to verbalize and identify the negative factors affecting activity tolerance and eliminate or reduce their effects when possible. Achieving guidelines and goals promote motivation for the patient. kinailangan kong tumigil sa pag-aaral ko. RATIONALE Insufficient physiological or psychological energy to endure or complete required or desired daily activities can be caused by a generalized weakness or pain. O: The patient appears NSG DX Activity intolerance r\t generalized weakness evidenced by patient’s appearance of weakness and pale skin color and by daily activities as verbalized by the patient. “Dati. The patient will participate willingly in necessary/desired activities. To prevent overexertion. *Pulse rate *Dyspnea *Fatigue 7. nagcocommute lang ako papuntang school tapos hindi ako madalas na mag-exercise. Note presence of factors contributing to fatigue. 2. Observe and document the response of patient to the activity. Create guidelines and goals for the activity for the patient and the nurse. Helps in knowing the capability of patient which is needed in setting goals. . patient will: Report 7. 5. Assess the level of mobility and the physical condition of the patient 3. 4. 5.

12. To manage activities within individual limits and to increase activity levels gradually. The muscle tonicity is in the normal condition of tension/tone of a muscle at rest. She can do active range of motion on light activities and an increased respiratory rate and shortness of breath in moderate and heavy activities. . Participate willingly in desired or necessary activities. Her muscle strength is rated 75% which is normal full movement against gravity and against minimal resistance. To promote energy conservation and recovery. To reduce fatigue. To enhance ability to participate in activities. Exercise sustain muscle strength and ROM. Educate the patient to recognize signs of physical overactivity.The patient is able to walk but is not standing erect.18bpm and temperature. 11. Support patient in doing ROM exercises at least 3 times a day. To promote awareness when to ease activity. 8. permitting more prolonged activity. The extremities are warm and has capillary refill of less than 3 seconds. 8. 9. 11. Plan care with rest periods between activities. 10.36. Her vital signs are: BP120/80mmHg. RR.to be weak and skin is pale in color . Teach methods to utilize and conserve energy. 10. Decrease physiologic sign of intolerance. measurable increase in activity tolerance. PR82bpm. . Create activities when the patient has the most energy.6°C. To reduce oxygen consumption. 12. 9.

Helpful in determining severity/duration of situation and possible need for additional referrals. 3. Objective: At the end of 2 hours nursing intervention. The patient will verbalize increased sense of connectedness and hope for future. encouraging client to be open about sensitive matters. 4. INTERVENTION 1. The patient will discuss beliefs/values about spiritual issues. 5. . The patient is not observed to have religious routines. 5. or limited. patient will: The patient will discuss beliefs/values about spiritual issues.ASSESSMENT S: Patient verbalized. 2. Develop therapeutic nurse-client relationship. 4. 2. alienation from God. Determine sense of futility. O: Patient became emotional while she was interviewed. 3. Napakasakit isipin na malala yung sakit mo eh. The patient will verbalize acceptance of self as not deserving illness/situation. Identifies need for spiritual advisor to address client’s belief system. NSG DX Spiritual Distress r/t chronic illness as evidenced by the verbalization of patient. Note recent changes in behavior. Patient will demonstrate ability to help self/participate in care.. dati sobrang madasalin ko at nagsisimba pa ko lingo lingo. 4. others. “Roman Catholic ako.Impaired ability to experience and integrate meaning and purpose in life through a person’s connectedness with self. of nursing intervention: Patient will verbalize increased sense of connectedness and hope for future. RATIONALE . The Patient will demonstrate ability to help self/participate in care. Involve client in refining healthcare goals and therapeutic regimen as appropriate. optimizing outcomes. or a power greater than oneself can be caused by a chronic illness because it causes anxiety and fear of death on the part of the patient which affects their spiritual being. Simula noon. Ewan ko pero mabigat lang sa pakiramdam pag naiisip kong may sakit ako. Niño pero nung magkasakit ako sinisi ko ang Diyos sa kalagayan ko. RATIONALE 1. PLAN Goal: After 48-72 hrs. Listen to client/SO’s reports/expressions of anger/concern. The patient will verbalize acceptance of self as not deserving illness/situation. lack of motivation to self help. Enhances commitment to plan. Deboto pa nga ko ni sto. 2. Para bang nabalewala yung pananampalataya ko. feelings of hopelessness and helplessness. Indicators that may see no. 3. EVALUATION 1. hindi na ako nagsimba o nagdadasal. Promotes trust and comfort . Sa dinami-dami ng tao bakit ako pa yung binigyan niya ng ganitong karamdaman. and so forth. options/alternative s or personal choices available and lacks energy to deal with situation.

. Realizing these feelings are not unusual can reduce sense of guilt. INTERVENTION 1. 4. PLAN Goal: After 48-72 hrs. (Amount. EVALUATION 1. poor posture and frequent yawning. bedtime. positions. Isang unan sa NSG DX Disturbed sleep pattern r/t pain and discomfort and abnormal physiological status or symptoms as evidenced by visible spot under the eye of the patient. Sleep patterns are unique to each person. madalas din paputol-putol yung tulog ko. mga 8 hours ang tulog ko. rituals. Provide information that anger with God is a normal part of the grieving process. 4. Assess factors that affect the patient’s sleep difficulty. 2. Knowing an etiologic factor will guide proper sleeping patterns. Ngayon. Train the patient to perform a daily schedule for sleeping and waking. periodic suspension of consciousness) amount and quality can be caused by physiological discomfort or pain. The patient will improve in her sleep and rest pattern.6. nagtutoothbrush muna ako at naghihilamos o kaya naman minsan kumakain pa ng midnight snack. This promotes regulation of the circadian rhythm and reduces the energy used for 3. Assess the vital signs. To provide baseline data 2. RATIONALE 1. siguro mga 9 pm tulog na ako at 5 am naman ang gising ko. 6. ASSESSMENT S: Patient verbalized. “Before. Dark circles are not visible under eyes. The patient will increase sense of well-being and feeling rested. Estudyante ako kaya kailangan kong gumising ng umaga. aids and interfering agents) 3. Madalas nakatagilid ako matulog. of nursing intervention: Patient will manifest optimal amount of sleep without experiencing adverse effects. 2. encourage open expression and facilitate resolution of conflict. Bago ako matulog. RATIONALE Disturbed sleep pattern is timelimited disruption of sleep (natural. 3. Assess past patterns of sleep in normal patient’s environment of patient. The patient will identify individually appropriate interventions to promote sleep. mga 5-6 hours na lang dahil madalas ay sumasakit yung ulo ko kapag gabi kaya hindi ako nakakatulog ng maayos.

The patient seems restless and tired. cleaning and straightening sheets) 7. T-shirt at shorts o kaya pajama lang ang suot ko kapag natutulog. (back rub. isa yakap-yakap ko at isa naman sa pagitan sa legs ko. 8. washing hands/face. Kung minsan din nakakaidlip ako sa hapon ng mga isang oras. Provide quiet environment and comfort measures in preparation for sleep. Objective: At the end of 2 hours nursing intervention. 8.” O: The patient has a visible dark spot under the eye. She has a poor posture and frequent yawning. Propose the use of soporifics like milk. The patient will demonstrate optimal balance of rest and activities The patient will express increased ability to sleep. 6. Research indicated that 60 to 90 minutes are needed to a complete a sleep cycle.ulo. A complete sleep cycle is needed to have optimal sleep. 7. To enhance client’s ability to fall asleep . patient will: The patient will verbalize the causative factors of sleep disturbance. To establish optimal sleep and rest patterns 5. alteration to changes. Teach effective ageappropriate bedtime rituals 6. 5. Try to let the patient sleep for sleep cycles for a minimum of 90 minutes. Milk contains Ltryptophan which aids in sleeping.