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NURSING ASSESSMENT

II

Name of Patient: Corazon B. Siton Age: 63 y/o Sex: Female


Chief Complaints: Inclusive Dates: March 27-30, 2017
Impression/Diagnosis: Subarachnoid hemorrhage secondary to ruptured Allergies: None
aneurysm
Date and time of Admission: March 4, 2017 Diet: Soft Diet
Type of Operation (if any):________________________________

Normal Pattern Before Hospitalization Initial (loading) Clinical Appraisal


(typical pattern)
Day 1 (first day of duty) Day 2 (second day of Day 3 (third day of
duty) duty)
1. Health
PerceptionHealth Pt. receives self as not so Pt. perceives self as not Pt. perceives self as not Pt. perceives self as not Pt. perceives self as not
Management a. healthy as she often feel healthy after knowing of healthy after knowing of healthy after knowing of having healthy after knowing of
Perceived health sick. having tumor in the brain having tumor in the brain tumor in the brain and had having tumor in the brain
status and had undergone and had undergone undergone surgeries. and had undergone
Pt. compensates by eating surgeries. surgeries. surgeries.
b. Perceived health fruits and veggies Pt. follows doctor’s orders
management frequently to manage Pt. follows doctor’s orders Pt. follows doctor’s orders religiously in the hopes of Pt. follows doctor’s orders
health. religiously in the hopes of religiously in the hopes of getting better. religiously in the hopes of
getting better. getting better. getting better.
c. Healthcare
Pt. eats healthy foods and Pt follows doctor’s orders.
Behaviors: health
cleaning the house as part Pt follows doctor’s orders. Pt follows doctor’s orders. Pt follows doctor’s orders.
promotion and
of her daily activity.
illness prevention
activities, medical
treatments,
followup care

Patient’s Name / Room No. | 1


2. Nutrition-Metabolic
a. Daily food and fluid Pt’s usual intake are fruits, Pt is on NGT. No significant changes. No significant changes. No significant changes.
consumption vegetables, rice and 5-7
b. Food preferences glasses of water/day.
c. Use of dietary Pt. has skin lesions on the
supplements Pt prefer meat, rice, fruit in foot.
d. Skin lesions and meal.
ability to heal
e. Integumentary No dietary supplements.
condition
f. Weight, height, Pt’s weight, height, temp is
temperature not taken.

3. Elimination
a. Bowel and urinary Pt urinates 5x/day and Pt urinates 250ml with the Pt urinates 1600ml with the Pt urinates 1000ml with the Pt urinates 1400ml with the
excretion patterns the color is white and color of yellow and not color of yellow and not color of yellow and not color of yellow and not
defecate yet. defecate yet. defecate yet. defecate yet.
yellow.
b. Perceived regularity
or irregularity of Irregular Irregular Irregular Irregular
elimination Pt. usually defecate
once a day.
c. Use of laxatives or
routines No use of laxatives. No use of laxatives No use of laxatives No use of laxatives No use of laxatives
d. Changes in time,
modes. Quality or
quantity of
excretions

e. Use of devices for No device used. No device used. No device used. No device used. No device used.
control

Patient’s Name / Room No. | 2


4. Activity Exercise
a. Patterns of Pt. usually socializes with Pt. is on bed rest.
personally relevant neighborhood.
exercise, activity,
leisure, and No significant changes No significant changes No significant changes
recreation Pt cannot perform ADls due
Pt. was able to perform to her illness.
b. ADLs that require ADLs.
energy
expenditure

c. Factors interfering
with the desired
pattern

5. Sleep – Rest
a. Patterns of sleep
and rest-/relaxation Pt. usually sleeps 8pm and
in a 24-h period wakes up at 4am.
Pt’s SO feels she had an
b. Perception of quality Pt feels she had adequate adequate rest and sleep No significant changes No significant changes No significant changes
and quantity of rest and sleep. due to her illness.
sleep and rest
None
c. Use of sleep aids None
and routines

6. Cognitive – Perceptual
a. Adequacy of vision, Pt. no report of changes in Pt. R eye is not
hearing, taste, vision, hearing, touch and reactive to light.
touch, smell smell. There is a changes No significant changes No significant changes No significant changes
in food preferences.
b. Pain perception and
management

c. Language,
judgment, memory,
decisions

Patient’s Name / Room No. | 3


7. Self-Perception – Self-
Concept Pt has reported positive Pt. R eye cannot response,
a. Attitudes about self attitude toward siblings, not able to talk and L foot
husband and children. has edema.
b. Perceived abilities, No significant changes No significant changes No significant changes
worth, self-image, Pt perceives self as a sick
emotions but not totally dependent.
Has positive outlook on
c. Body posture and self-image.
movement, eye
contact, voice and No changes in posture and
speech patterns slight limitation to
movement.

8. Role-Relationships
a. Perception of major Pt role as a mother to her Pt role as a mother and wife
roles, relationships, four children and a good is good as verbalized by her
and responsibilities wife to her husband. husband.
in current life No significant changes
situation Pt is satisfied to her roles. No significant changes No significant changes
Pt is satisfied to her roles.
b. Satisfaction with or
disturbances in roles
and
relationships

Patient’s Name / Room No. | 4


9. Sexuality-Reproductive
a. Satisfaction with Pt is satisfied to her Pt is satisfied to her
sexuality or sexual sexuality. sexuality.
relationships No significant changes No significant changes No significant changes

b. Reproductive pattern Not taken Not taken

c. Female menstrual Not taken Not taken


and perimenopausal
history

10. Coping – Stress


Tolerance Pt believes that life must
a. Capacity to resist go on despite of all the
challenges to struggles.
selfintegrity No significant changes
Family bonding as outlet Family bonding as outlet for No significant changes No significant changes
b. Methods of handling For stress. stress.
stress
Her support system is her Her support system is her
c. Support systems family members. family members.

Compensates by
d. Perceived ability to practicing a healthy
control and manage lifestyle (exercise, eating
situations nutritious foods, adequate
rest)
11. Value-Belief
a. Values, goals, or Pt believes in GOD as the Pt believes in God as the
beliefs (including divine creator and divine creator and healer of
spirituality) that supreme provider. mankind.
guide choices or No significant changes No significant changes No significant changes
decisions
Pt perceives conflicts ill Perceives conflict will
b. Perceived conflicts resolves by working hard resolve by hard work and
in values, beliefs, or and asking God’s asking God’s assistance
expectations that assistance and blessings and blessings through
are health related through prayer. prayer.

Patient’s Name / Room No. | 5