II.

Nursing Process
I. NURSING PROCESS
A. ASSESMENT
1. PERSONAL DATA
a. Demographic Data
Name: Patient X
Age: 61 years old
Address: Tarlac
Gender: Male
Date of birth: January 11, 1959
Nationality: Filipino
Religion: Catholic
Admitting Diagnosis: Chronic kidney Disease secondary to Diabetes Mellitus
Date admitted: Feb 18, 2020
Time admitted: 12: 52 am

b. Environmental Status
He is 61 years old male who lives in Tarlac their house consists of 4 family members
including his wife and their children. They are nuclear type of family. Their house is
made of cement consist of 2 rooms and located near the basketball court. Their source of
water is deep well pump for cooking and for house chores. They used mineral for
drinking.

c. Lifestyle (habits, recreation, hobbies)

He works as a plumber before, doesn’t exercise and has a habit of sleeping after work and
during day off he usually spent his time sleeping or drink alcohol with his friends and
consume 3 emperador bottles a day. He eats his meal three times a day, usually fond of
eating fatty, salty and sweet foods.
GENOGRAM

MATERNAL PATERNAL

Grandmother Grand Father Grandmother Grandfather

Aunt uncle Mother Uncle Uncle Father Aunt Uncle Uncle

Sister Patient Brother Sister Brother Brother

Diabetes Mellitus Hypertension Prostate Cancer

Stroke CKD
 1. History of Past illness
The patient had his chicken pox when he was 10 years old, he also had cough and colds.
He doesn’t have any allergies to any foods, drinks, animals and any medication. He was
diagnosed with Diabetes Mellitus when he was 32 years old on and has a maintenance of
metformin 6 times a day. When he was 59 years old he experienced difficulty breathing, body
malaise and loss of appetite, he was admitted at Ramos Hospital for 2 weeks, he was
diagnosed with Chronic Kidney Disease and was advise that he needs to undergo dialysis but
the patient refused to submit his self to dialysis and was discharged. When he was 60 years
old, he experienced again difficulty breathing and body malaise and was admitted again at
ramos hospital and submit his self to dialysis. He undergone dialysis 2 times a week and the
amount that was remove from him is 4000 ml. After 3 months the family decided to
undergone dialysis once a week due to financial problem.

2. History of present condition

Three days prior to admission, the patient experienced body weakness, productive cough and
on and off fever. One day prior to admission he experienced difficulty breathing and severe
cough they decided to seek consultation at tph and was admitted.

PHYSICAL ASSESSMENT (IPPA)

13 Areas of Assessment

I. SOCIAL STATUS

They are considered nuclear family, according to his wife, he become hot tempered and irritable
when he undergone dialysis, he always shout at his wife and cursed whenever they approached him to
eat or drink his medicines. During hospitalization, the patient usually sleep and doesn’t interact that
much with his wife

NORMS:

Social status includes family relationship that states patient’s support system in time of stress and
in time of need. It meets a fundamental human need for socialites making life less stressful and social
support buffers the negative effects of stress. Thus indicating indirectly contributing to good health
outcomes. (Fundamentals of Nursing, Barbara Kozier, Seventh edition)
 Analysis/Interpretation:

Social status is not normal because the patient always shout at his wife even though they support him
and provide his needs.

II. MENTAL STATUS

The patient is able to state correctly the plays and time during the assessment, he also remember
his last hospitalization before the patient can able to read words shown to him like name and address.
He can able to write his name but with difficulty because of weakness.

NORMS:

The content of the patient message should make sense. The ability to read and write should match
the educational level. The patient should be able to correctly respond to the questions and to identify
all objects as requested. The patient should be able to evaluate and act appropriately in situations
requiring judgement. (Health Assessment and Physical Examination 3th edition by Mary Ellen Zator
Estes)

ANALYSIS:

Mental status is normal

III. Emotional Status

The patient is irritable when his wife asked him question during the interview. According to his wife,
he doesn’t interact with others unlike before he doesn’t experienced any symptoms of his disease.

Norms:

A human’s emotional status depends on his or her ability to cope up and be ready for whatever
can happen in their life. She or he may not be ready to be emotionally stable of unfortunate
happenings in life. (www.nursingceu.com)

Analysis:

His emotional status is not normal because he cannot cope up with his current condition.
IV. Sensory Perception

Sense of sight

Patient eyes are symmetrical and round, sclera is white in color, eyes is symmetrical in moving.
According to the patient he doesn’t see clearly that requires him to wear graded lenses of 1200 left
and 1050 to his right eye. No exopthalmia, lesions, and bruits observed.

Norms:

The normal vision of an average person is 20/20 in distance of 20 feet away and doesn’t wear any
corrective graded lenses. The eyes must be symmetrical during the six cardinal gaze test and
symmetrical in movement. (Health Assessment and Physical Examination, Mary Ellen Zator Estes)

Analysis:

Within the given data sense of sight is not normal because he doesn’t see clearly without his
eyeglass

Sense of smell

His nose is in the midline of the face and is symmetrical. With no secretions noted. Common
foods such as coffee were provided and also alcohol in a cotton ball. He was able to identify the odor.

Norms:

The person can smell and identify the aroma of a given object like perfume or any other. The
person should be able to distinguish the foul and good smelling.

Analysis:

She has normal sense of smell

Sense of hearing

For the auditory assessment the voice whisper test was used. Words were whispered while he was
instructed to repeat every words being whispered. The procedure was then repeated to the other ear.
After whisper test he was able to hear them clearly with no deformities noted. No swelling,
discharged and lesions except for minimal earwax observed on both ears.
Norms:

The auditory of the person is normal if the patient don’t have any tinnitinus or any ear problem.
He should be able to hear in the minimum of 2 feet away. ( health Assessment and physical
examination, Mary Ellen Zator Estes)

Analysis:

Based on the given data, auditory acuity is normal.

Sense of taste

Examined using variety of food which taste salty, bitter, and sweet (granules of sugar and coffee).
He was able to differentiate each taste. The patient has dark lips and slightly dry and chapped, her
tongue has yellowish whitish buds. Foul odor is being noted with no deformities that can affect her
sense of taste.

Norms:

A person usually identifies the taste of bitter, sweet and sour. By the use of our sense of taste we
can fix or adjust the taste of our cooked food based on our taste capacity. ( health assessment and
physical examination, Mary Ellen Zator Estes)

Analysis:

Based on the assessment the sense of taste is normal

Sense of touch (tactile sensitivity)

The examination of sensation he was instructed to close his eyes and tell what he feels when he
was being pricked on his palm. He responded and stated that the pricking is painful. Using a small
glass with cold water pat on his skin for few second, and was able to identify that is cold.

Norms:

The tactile sensitivity or hypersensitivity is an unusual or increased sensitivity to touch that

makes the person feel peculiar, noxious, or even in pain. It is also called tactile defensiveness or
tactile oversensitivity. Like other sensory processing issues, tactile sensitivity can run from mild to
severe.
 Analysis:

The sense of touch or the tactile sensitivity is normal.

V. Motor Stability

His neck is symmetrical with head in central position. The patient cannot move or stand without
assistance during assessment he complains difficulty moving from one place to another because of
body weakness. Assessment of range of motion was done through instructions which include the
ability of the patient to bend his elbow. He can move his shoulder laterally and medially as well as
rotating his shoulder in the same manner with complains of pain and weakness. The patient cant able
to flex and elevate his lower extremities due to pain.

Norms:

Normal motor stability includes the ability perform different activities. It should be firm and
coordinated movements. (Estes, 2006)

Analysis:

The motor stability is noted abnormal due to impairment with some physical mobility due to body
weakness and pain.

VI. Body Temperature

Date Temperature Analysis

February 18, 2020 36.5 Normal
Februry 19, 2020 36.3 Normal
February 20, 2020 36.7 Normal

Norms: Normal body temperature is within 36.4 C to 37.4 C. (Health assessment and
physical examination 3rd edition by Mary Ellen Zator Estes)
Analysis:
Upon assessing body temperature during assessment and follow-up are normal

VII. Respiratory Status

Date Respiratory Analysis

 February 18, 2020 26 Above Normal
Februry 19, 2020 23 Above Normal
February 20, 2020 21 Above Normal

The respiratory rate during day 1 of the assessment is 26 breathes per minute. He is seen
breathing by mouth with O2 via nasal cannula. Day 2 is 23 breathes per minute. Day 3 he’s
breathing by nose normally and has 21 breath per.
Norms:
Normal respiratory rate for adult is 12-20 cpm, average is 18. In terms of pattern, normal
respirations must be regular and even in rhythm. The normal depth of respirations in non-
exaggerated and effortless (Health assessment and physical examination edition by Mary
Ellen Zator Estes)
Analysis:
Upon assessing body respiratory during assessment and follow-up are not normal

VIII. Circulatory Status

Date Pulse Rate Analysis

February 18, 2020 85 Normal
Februry 19, 2020 87 Normal
February 20, 2020 81 Normal

Date Blood Pressure Analysis

February 18, 2020 150/90 Above Normal
Februry 19, 2020 160/100 Above Normal
February 20, 2020 150/90 Above Normal

Norms:
Normal cardiac rate for an adult is 60-100 beats per minute while the normal blood pressure
is 120/80 mmHg. The working capacity of the heart diminishes with aging. The heart rate of
older people is slow to respond to stress and slow to return to normal after stress. Reduced
arterial elasticity results in diminished blood supply to the parts of the body especially the
extremities. (Health assessment and physical examination by Mary Ellen Zator Estes)

Analysis:
Upon assessing cardiac rate during assessment and follow-up are normal while the blood
pressure is not normal
IX. Nutritional Status
Prior to hospitalization he verbalized that he takes his meal 3x a day. And consume 5 glasses
of water he’s fond of eating fatty, salty and sweet foods. He was restricted to consume 1 litre
of water a day but still the patient did not comply. During hospitalization his diet were low
salt, low fat and CHON 1 gram/kg a day. During third day of hospitalization the patient was
in NPO for peritoneal dialysis insertion

Norms:
Consider cultural and religious variations. Normal eating pattern is at on the minimum of
three times per day depending upon the metabolic demands and needs of the patient. Fluid
intake is on the average of 8-10 glasses per day (Monahan, 2002).
Analysis:
The patient nutritional status is not normal due to his condition.

X. Elimination Status
Prior to hospitalization he defecates once a day black color stool moderately soft and
urinates 3 to 4 times a day yellow in color. When he started his dialysis the patient only
urinates 2 times a day before and after the treatment. He undergo dialysis 2 times a week but
after three month the family decided to do his dialysis once a week due to financial problem
the volume that was remove from the patient was 4000 ml.
Norms:
An individual usually defecate one to two times a day or every 2 day and urinates
30cc/hr. (Nutrition by Alex Abelos)

Analysis:
Her elimination status is not normal because of his condition

XI. Reproductive Status

The patient was circumcised at the age of 13 years old and refuse to have his reproductive
assess. He became sexually active when he was 23 years old.
Norms:
The first menstruation which is menarche occurs at an average of 9 to 17 years old. (Maternal
and Child Health Nursing 4th edition by Pilliterri)
 Analysis:
The reproductive status is normal.

XII. Sleep-rest Pattern

Before he stated that he sleep atleast 8 hours a day. He normally sleeps at 9 pm and wakes up
5 am, he also takes a nap during the afternoon for 1 to 2 hours.
3 days prior to admission the patient experienced difficulty of sleeping because of his cough
and on off fever. During admission he verbalized difficulty of sleeping due to the
environmental changes like noisy environment and because of his cough.
Norms:
Sleep refers to altered consciousness with general slowing of physiologic process while
rest refers to relaxation and calmness, both mental and physical.
A person usually sleeps for about 7 to 9 hours a day and takes a rest using some of
activities that will help you to relax including reading, watching television and others.
Analysis:
Sleep-rest pattern is altered due to environmental factors and current health condition

XIII. State of skin appendages

He has dark skin color and dry with fistula in his upper chest. Discoloration of the third
and fourth digit of the right hand and a heplock. There is an open wound at the right foot
about 3 cm, noted redness around the wound, tender and warm to touch. His left hand is
swollen because of his previous IV insertion.
Norms:
Obvious changes in the integumentary system (skin, hair, nails) with age. The skin
becomes drier and more fragile, the hair loses color, the finger nails and toe nails become
thickened and brittle, and i women over 60, facial hair increases. These integumentary system
changes accompany progressive losses of subcutaneous fat and muscle tissues, muscle
atrophy, and loss of elastic fibers. (Fundamental of nursing 7 th edition by Barbara kozier)
Analysis:
The skin and appendages is not normal due to presence fistula and an open wound that is
inflamed.