St.

Anthony’s College
NURSING DEPARTMENT
San Jose, Antique
VISION
St. Anthony’s College is a Catholic Educational Institution committed to holistic human formation through
Spirituality, Academic excellence and Community service.
MISSION
To provide quality, holistic, relevant educational programs, services and experiences for our students and other stakeholders
in Antique and the larger community.

NURSING PROCESS GUIDE

(ADULT)

I. VITAL INFORMATION

Name: S.S.T. Date of Interview: 01/28/2020

Age: 70 Informant:
Address: Igbangcal, Tobias Fornier, Antique Relationship to Patient:
Civil Status: Widow
Date and Time Admitted: 1/23/2020 2:30pm
Chief Complaint: Dizziness

Ward: ICU
Bed No.: 4
Allergies: No known allergies to food and drugs
Religious Affiliation: Roman Catholic
Physician’s Initials: Dr. V.
Impression/Diagnosis:
Pre-op Diagnosis (optional):
Post-op Diagnosis (optional):
Surgical Operation Performed (optional):
Days Post-op (optional):

II. CLINICAL ASSESSMENT

II.A: NURSING HISTORY

1. HISTORY OF PRESENT ILLNESS

a. Usual Health Status
She was usually feeling good without having any feeling or signs of illnesses,
she was able to do activities of daily living without difficulty.
b. Chronological Story
One day she was about to feed her pigs and she was holding a bucket which
contains the food of her pigs, while walking she accidentally stepped on a branch
and stumbled but she was able to support herself with her hands while the bucket
that contains the food of her pigs spilled on her face. Few days after that she felt

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

numbness on her both hands, the next 3 days after that she was admitted to the
hospital.

d. Disability Assessment
Patient wasn’t able to do activities of daily living due to the numbness of her
hands.
2. Past Health Problems/Status

a. Childhood Illness
Chicken pox, Measles
b. Immunization
Has complete immunization
c. Allergies
No known allergies to food and drugs
d. Accidents and Injuries
Didn’t have any major accidents or injuries
e. Hospitalization for serious illnesses
None
f. Medications
 Omeprazole 40mg OD
 Lactulose 30cc @ HS
 Alanerv 300mg BID
 Diphenhydramine 1 ampule 50mg @ HS
 Tranexamic Acid 500mg now

3. Family History of Illness

 Hypertension
 Arthritis

4. Patient’s Expectations (Verbatim)

a. What he/she expects to occur during this hospitalization?
“Daad maayad ron ako kag makaguwa sa hospital”, as verbalized by the
patient.
b. What he/she expects regarding nursing care.
“Daad matatapan nanda permi ako rigya kag di da malipatan mag patumar
kanakon kang akon mga bulong pero asta tulad nami man sanda, mayad man
mag tatap kanakon.”

5. Patterns of Functioning

a. Breathing Patterns
No signs of any respiratory problem
Usual Respiratory rate is 19cpm

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

b. Circulation
No history of high blood pressure
Usual BP is 110/80mmHg
Body temperature: 36.2oC
Pulse rate: 67bpm

c. Sleeping Patterns
Usual Bedtime: 8pm to 9pm
Number of Pillows: 2 pillows, one under her head and one between
her legs.
Bedtime Rituals: Reading the bible
Problems regarding sleep: None
Usual Remedy:

d. Drinking Patterns
Morning: 1 glasses of water after her breakfast.
Afternoon: 2 glasses of water after her lunch and sometimes drinks
12oz of softdrinks at 4pm after doing work in her house or after
sweeping dry leaves in front of her house in the afternoon.
Evening: drinks 1 glass of water after dinner.

e. Eating Patterns

Usual Food Taken

Time
(quantity)
Breakfast 1 cup of rice and fish or sometimes egg or vegetables
Lunch 1 cup of rice and vegetables or pork
Dinner 1 cup of rice and fish or vegetables
Snacks 12oz of softdrinks and bread

Food Likes vegetables

Food Dislikes Spicy foods

f. Elimination Patterns
1. Bowel Movement
Frequency: Every 2-3 days
Problems or Difficulties: Constipation
Usual Remedy: Drinking lots of water
2. Urination
Frequency: 4-6 times per day
Problems: sometimes have low urine output
Usual Remedy: drinking lots of water

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

g. Exercise
Doing household chores, sweeping dry leaves in front of their house in the
morning.

h. Personal Hygiene
1. Bath
Type: Full bath
Frequency: once a day
Time of Day: Usually takes a bath between 8am to 10am
2. Oral Care
Frequency: 1-2 times a day
3. Use of Cosmetics: none

h. Recreation
Sweeping dry leaves in front of their house. Watching TV.

B. PSYCHOSOCIAL ASSESSMENT

1. Psychosocial Nursing Assessment

Lifestyle Information: Patient is a housewife.

Normal Coping Patterns: Patient loves to watch television.

Understanding of Current Illness: Patient is aware of her condition

Personality Style: Patient is friendly and cooperative

History of Psychiatric Disorder: None

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

Recent Life Changes or Stressors: None

Major Issues Raised by Current Illness: None

2. Mental Status Examination

Appearance

 clean

Description: Patient is well groomed

Behavior

 Calm

Speech

Appropriate

Description: is talkative

Mood/Affect

 Appropriate

Thoughts

 Appropriate

Description: is oriented

Ability to abstract

Impaired: NO

Memory

Impaired recent memory: NO

Impaired remote memory: NO

Concentration
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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

 Able to focus

Orientation

Is oriented about time, place, why she is in the hospital and is oriented of the
people around her.

Judgment

Realistic decision making: YES

Insight

Good

II.C: CLINICAL INSPECTION

Date and Time Taken:01/28/2020

II.B.1. Vital Signs T= 36.2oC PR= 67

BP=110/80mmHg RR=19

II.B.2. Height
II.B.3. Weight

II.B.4. Review of Systems

General Appearance: (posture and goat, over-all hygiene and grooming, body
and breath odor in relation to activity level, signs of distress in posture or facial
expression, obvious signs of health or illness)

Skin: Is brown in color, has no lesions noted.

Head, Eyes, Ears, Nose, Throat (HEENT).

Head: Skull is generally round, no tenderness upon palpation. Scalp is lighter color
than the complexion, is oily, no scars noted, free from lice and dandruff, no lesions
noted, and no tenderness or masses on palpation. Hair black to gray in color, is evenly
distributed.
Eyes: Eyebrows are symmetrical and in line with each other, is black to gray in color
and is evenly distributed. Eyes are evenly placed and inline with each other.
Eyelashes are black in color, and turned outward. Eyelids are symmetrical, upper
eyelids cover the small portion of the iris, sclera, and cornea when eyes are open,
meets completely when eyes are closed. Conjunctiva are both pinkish in color, no
foreign objects and is moist. Sclera is white in color, no yellowish discoloration, some
capillaries are visible. Pupil is equally round.

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

Ears: Earlobes are bean-shaped and is symmetrical. Skin has the same color as in the
complexion, no lesions noted on inspection, no discharges or lesions noted at the ear
canal.
Nose and sinuses: Nose is in the midline, no discharges, both nares are patent, no
tenderness upon palpation.
Throat (or mouth and pharynx): Gums are pinkish in color and no bleeding. Tongue is
pinkish with white buds on the surface, no lesions noted, able to move the tongue
freely and with strength. Uvula is positioned in the midline, pinkish to red in color, no
swelling or lesions noted.

Neck: Neck is straight, no visible mass or lumps, is symmetrical, no jugular venous

distention

Back. No mass or tenderness upon palpation.

Posterior Thorax and Lungs: No tenderness or mass in the upper back upon palpation.
No wheezing or crackle sounds heard during auscultation. Spine is vertically aligned,
left and right shoulders are at the same height.

Anterior Thorax and Lungs: No tenderness upon palpation. No wheezing or crackle

sounds heard during auscultation. With normal breath sounds without dyspnea,
effortless respiration.

Abdomen: Is uniform in color, not distended, symmetrical movements when

breathing.

Lower Extremities: Equal in size, smooth coordinated movements, has normal full
movement against gravity and full resistance, no deformities or swelling in the joints.

II.D. OTHER SOURCES OF LABORATORY

CT Scan of the Brain

Definition: A CT Scan of the brain is a noninvasive diagnostic imaging procedure that uses
special X-rays measurements to produce horizontal, or axial, images (often called slices) of
the brain. Brain CT scans can provide more detailed information about brain tissue and brain
structures than standard x-rays of the head, thus providing more data related to injuries
and/or diseases of the brain.
Preparation: Patient should be asked to change clothes into a patient gown. If the doctor
ordered a brain CT scan without contrast, patient can eat, drink and take prescribed
medications prior to exam. If the doctor ordered a CT of the brain with contrast, tell patient
not to eat anything 3 hours prior to brain CT. Encourage patient to drink clear liquids.
Purpose: CT Scan of the head uses special x-ray equipment to help assess head injury, severe
headaches, dizziness, and other symptoms of aneurysm, bleeding, stroke, and brain tumors.

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

It also helps the doctor to evaluate face, sinuses, and skull or to plan radiation therapy for
brain cancer.
Impression
 Left frontal and subarachnoid hemorrhages, with slight regression.
 Right parietal contusion versus infarct
 Right Basal Ganglia Lacunar infarct
 Partially sclerotic right mastoid
 Plain axial tomographic sections of the head were done as follow up
examination since 1.23.2020
 Reveal slight regression of the hyperdensities in the right frontal and in
the involved frontal sulci.
 There is no significant change in the previously noted hypodense area in
the right parietal and small hyperdensity in the right basal ganglia.