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

NURSING PROCESS
(ADULT)

I. VITAL INFORMATION

Name: C.G.R Date of Interview: 02/29/2020

Age: 2 y.o Informant: C.S
Address: San Fernando, San Jose Antique Relationship to Patient: Son
Civil Status: Single
Date and Time Admitted: 02/27/2020 9:00 am
Chief Complaint: “grabe ubo na pira run ka adlaw” as verbalized by patient’s mother.
Ward: Pedia
Bed No.: 2009-5
Allergies: no known allergies
Religious Affiliation: Roman Catholic
Physician’s Initials: Dr. T.M
Impression/Diagnosis: MR Pneumonia
Pre-op Diagnosis (optional): none
Post-op Diagnosis (optional): none
Surgical Operation Performed (optional): none
Days Post-op (optional): none

II. CLINICAL ASSESSMENT

II.A: NURSING HISTORY

1. HISTORY OF PRESENT ILLNESS

1 week prior to confinement, patient C.G.R experienced coughing only
with associated nasal congestion. No consult done before they decided to go
in the Hospital. Last February 27, 2020 patient was brought in the hospital
because of severe coughing.

c. Relevant Family History

 According to his mother they have family history of Hypertension on paternal side,
and Pneumonia in maternal side.

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

 Because of his current status patient C.G.R daily activities are affected like playing
with his friends and watching TV.
 2. Past Health Problems/Status

(A-b.)
Patient C.G.R had childhood illnesses like mumps when he was 1 year old. He had
completed childhood immunizations.
(c.) No known allergies for food, drugs and animals.
d. No known injuries experienced.
e. Patient C.G.R was previously hospitalized last year (2019) due also to Pneumonia.
f. Medications

3. Family History of Illness

 Hypertension (+) paternal side
 Pneumonia (+) maternal side

4. Patient’s Expectations
“ amun gina expectar ja ay daad mag mayad run si jojo, kag di run mgabalik2 bala
ang ana nga ubo kag mayad nga pag atipan kana kang mga nurses kg doctor ja sa hospital.”
As verbalized by patient’s mother.

5. Patterns of Functioning

a. Breathing Pattern
 Respiratory of 23 bpm; on 2L oxygen via nasal cannula; positive for cough
upon auscultation.
b. Circulation
 Pulse rate of 87 bpm, afebrile, skin appears normal in color
and warm to touch, capillary refill of less than 2 seconds with
no signs of hematoma.

c. Sleeping Patterns
Usual Bedtime: 8:00 pm
Number of Pillows: 3 pillows (1 on the left side, 1 right side and 1 on the head)
Bedtime Rituals: her mother would tell a story to him before going to sleep
Problems regarding sleep: no problems regarding to sleep.
Usual Remedy: none

d. Drinking Patterns (Tabular Form)

Kinds of Fluid in 24 hours/Amount in ml or Number of Bottles
(Should include intake of alcohol, coffee, cola, tea, , and etc.; describe
type, number of bottles or glasses per day, and pattern of drinking –
e.g., morning, evening, or weekends)

e. Eating Patterns (Tabular Form)

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

Usual Food Taken

Time
(quantity) (range)
Breakfast: ½ cup rice, 1 boiled egg, 1 glass of milk
Lunch 1 cup rice, 1 serving adobong manok
Dinner ½ cup rice, fried fish
Snacks 1 glass of milk, bread

Food Likes: adobo

Food Dislikes: pinakbet

f. Elimination Patterns
1. Bowel Movement
Frequency: once a day
2. Urination
Frequency: 4x a day

g. Exercise:
h. Personal Hygiene
1. Bath
Type: Full Bath
Frequency: once a day
Time of Day: 9:00 am
2. Oral Care
Frequency: 3x a day
Care of Dentures: no dentures
3. Shaving
Frequency: none
i. Recreation
 Watching TV and playing with his toys
j. Health Supervision
 His health is under supervision of his parents.

B. PSYCHOSOCIAL ASSESSMENT

1. Psychosocial Nursing Assessment

Lifestyle Information:

 Patient C.G.R loves to play with his toys and friends during day
time and watch TV with his family.

Normal Coping Patterns:

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

 Since he is still a child, patient C.G.R is still under the

supervision and guidance of his parents on the things that he
is curious and he don’t know about.

Understanding of Current Illness:

 His Parents are the one who knows about his current
condition.

Personality Style:

 Patient C.G.R is an adorable, loving and happy child but

sometimes he is shy to people he first met.

History of Psychiatric Disorder:

 none

Recent Life Changes or Stressors:

 none

Major Issues Raised by Current Illness:

 At the meantime he cannot be able to play with his friends and

go outside their house.

2. Mental Status Examination

Appearance

 Neat and Clean, maintain good eye contact

Behavior

 Obeys simple command

Speech

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

 Can speak short sentences.

Mood/Affect

Thoughts

 Appropriate

Ability to abstract

Impaired: NO

Memory

Impaired recent memory: NO

Impaired remote memory: NO

Number of objects able to remember after 5 minutes: 4

Concentration

Able to focus

Orientation

Person: YES Time: YES Place: YES Situation: YES

Judgment

Realistic decision making: YES

Insight

Good

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

II.C: CLINICAL INSPECTION

Patient: C.G.R Pedia ward-2007-B4

Date and Time Taken: February 13, 2020 8:00 am
II.B.1. Vital Signs T= 36.5 PR= 87 cpm O2SAT-99 %
BP= 110/80 mmHg RR= 23 bpm

II.B.2. Height
II.B.3. Weight 13kgs

Physical Assessment

Integument

 Skin: The client’s skin is soft, smooth and velvety in texture. He has good skin turgor
and skin’s temperature is cool.
 Hair: black hair. 
 Nails: The client has a light brown nails and has the shape of convex curve. Normal
nail beds, strong pulses.

 Head

 Head: The head of the client is rounded; normocephalic and symmetrical.

 Skull: There are no nodules or masses and depressions when palpated.
 Face: The face of the client appeared smooth and has uniform consistency and with
no presence of nodules or masses.

Eyes and Vision

 Eyebrows: Hair is evenly distributed. The client’s eyebrows are symmetrically aligned

and showed equal movement when asked to raise and lower eyebrows.
 Eyelashes: Eyelashes appeared to be equally distributed and curled slightly outward.

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

 Eyelids: There were no presence of discharges, no discoloration and lids close

symmetrically with involuntary blinks approximately 15-20 times per minute.
 Eyes
o The Bulbar conjunctiva appeared transparent with few capillaries evident.
o The sclera appeared white.
o The palpebral conjunctiva appeared shiny, smooth and pink.
o There is no edema or tearing of the lacrimal gland.
o Cornea is transparent, smooth and shiny and the details of the iris are
visible. The client blinks when the cornea was touched.
o The pupils of the eyes are black and equal in size. The iris is flat and round.
PERRLA (pupils equally round respond to light accommodation),
illuminated and non-illuminated pupils constricts. Pupils constrict when
looking at near object and dilate at far object. Pupils converge when
object is moved towards the nose.
o When assessing the peripheral visual field, the client can see objects in
the periphery when looking straight ahead.
o When testing for the Extraocular Muscle, both eyes of the client
coordinately moved in unison with parallel alignment.
o The client was able to read the newsprint held at a distance of 14 inches.

Ears and Hearing

 Ears: The Auricles are symmetrical and has the same color with his facial skin. The
auricles are aligned with the outer canthus of eye. When palpating for the texture,
the auricles are mobile, firm and not tender. The pinna recoils when folded. Has good
and symmetrical hearing.

Nose and Sinus

 Nose: The nose appeared symmetric, straight and uniform in color. There was no
presence of discharge or flaring. When lightly palpated, there were no tenderness
and lesions
 Mouth:

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

o The lips of the client are uniformly pinkish ; moist , symmetric and have a
smooth texture.
o Teeth and Gums: There are no discoloration of the enamels, no retraction
of gums, pinkish in color of gums
o The buccal mucosa of the client appeared as uniformly pink; dry, soft,
glistening and with elastic texture.
o The tongue of the client is centrally positioned. It is pink in color, moist
and slightly rough. There is a presence of thin whitish coating.
o The smooth palates are light pink and smooth while the hard palate has a
more irregular texture.
o The uvula of the client is positioned in the midline of the soft palate.
 Neck:
o The neck muscles are equal in size. The client showed coordinated,
smooth head movement with no discomfort.
o The lymph nodes of the client are non-palpable.
o The trachea is placed in the midline of the neck.
o The thyroid gland is not visible on inspection and the glands ascend during
swallowing but are not visible.

Thorax, Lungs, and Abdomen

 Lungs / Chest: The chest wall is intact with no tenderness and masses. There’s a full
and symmetric expansion and the thumbs separate 2-3 cm during deep inspiration
when assessing for the respiratory excursion.
 The spine is vertically aligned. The right and left shoulders and hips are of the same
height.
 Heart: There were no visible pulsations on the aortic and pulmonic areas. There is no
presence of heaves or lifts.
 Abdomen: The abdomen of the client has an unblemished skin and is uniform in
color. The abdomen has a symmetric contour. There were symmetric movements
caused associated with client’s respiration.
o The jugular veins are not visible.
o There is no pain when palpated.
o Soft and nontender

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

Extremities

 The extremities are symmetrical in size and length.

 Muscles: The muscles are not palpable
 Joints: There is no swelling of joints.

NEUROLOGIC AND SENSORY SYSTEM

 Conscious; maintains good eye contact, could not sustain long conversations,
oriented to place, person and time. Understands language spoken to him, follows
request appropriately, facial expressions appropriate.

RESPIRATORY SYSTEM
RR= 23 bpm, irregular rhythm; no chest pain; asymmetry chest noted expansion.

CARDIOVASCULAR SYSTEM
BP=110/80 mmHg; PR= 87cpm, no chest pain, external jugulars flat.

MUSCOLOSKELETAL SYSTEM
 Joints non tender to palpation; joints and muscles symmetric; not full ROM except
on abdominal area; able to grip both hands.
GASTROINTESTINAL TRACT
 Flat, nondistended, without lesions, all four quadrants normo active nontender,
without organomegaly nontender. With NO NGT attach.

GLASGOW COMA SCALE

ACTION BEST RESPONSE SCORE
EYES OPEN SPONTANEOUSLY 4
TO SPEECH
TO PAIN
NONE
VERBAL ORIENTED 5
CONFUSED
INAPPROPRIATE WORDS
INCOMPRENSIBLE SOUNDS
NONE
MOTOR OBEYS COMMAND 6
LOCALIZE PAIN

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

FLEXION WITHDRAWAL
ABNORMAL FLEXION
ABNORMAL EXTENSION
FLACCID
Total Score: 15

Bickley, Lynn (2008). Bates’ Guide to Physical Examination and History Taking. 10 th Edition.
II.D. NURSING PROGRESS NOTES (On-Going Appraisal)

S
O
A
P
I
E
Source: Kozier K., Erb G., Berman A., and Snyder S., (2008), Fundamentals of Nursing:
Concepts, Process and Practice. 8th Edition. Pearson Education, Inc.: New Jersey

II.D. OTHER SOURCES OF LABORATORY

1. HEMATOLOGY
Name of Examination: COMPLETE BLOOD COUNT
Definition: basic screening test and is one of the most frequently ordered
laboratory procedures. The findings in the CBC give valuable diagnostic information about
the hematologic and other body systems, prognosis, response to treatment and recovery.

I. Preparation: (if applicable): Explain test procedures. Explain that slight discomfort
may be felt when skin is punctured.

II. Dehydration and over hydration can dramatically alter values; for example, large
volume of IV fluids can dilute the blood, and the values will appear as lower counts.

Purpose: used to evaluate your overall health and detect a wide range of disorders,
including anemia, infection and leukemia.

Date: 02/27/2020

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

Results Normal Values Significance of

Abnormal Results
Hgb: 122.00 g/L F-120-160 Within normal limi
M-135-180
Hct: 0.35 L/L F-0.37-0.47 Within normal limits
M- 0.40-0.54
RBC: 4.40 x 1012/L F-4.2-5.4 Within normal limits
M-4.6-6.2
WBC: 8.7x 109/L Within normal limits
4.5-11
Platelet Count: 265 x10
g/L

3. RADIOLOGICAL EXAMS AND OTHER SPECIAL EXAMS

Name of Examination: CHEST AP VIEW

Definition: When a chest x-ray is taken with the back against the film plate and the x-ray
machine in front of the patient it is called an anteroposterior (AP) view. As opposed to from
back to front (which is called posteroanterior).
Preparation: (if applicable)
Purpose: The AP view examines the lungs, bony thoracic cavity, mediastinum, and great
vessels. This particular projection is often used frequently to aid diagnosis of acute and
chronic conditions in intensive care units and wards.

Date: 02/28/2020
Impression: BRONCHOPNEUMONIA
Significance:

URINALYSIS
A urinalysis is simply an analysis of the urine. A urinalysis test is performed by collecting a
urine sample from the patient in a specimen cup. Usually only small amounts (30-60 mL)
may be required for urinalysis testing. The sample can be either analyzed in the medical
clinic or sent to a laboratory to perform the tests. Urine can be evaluated by its physical
appearance (color, cloudiness, odor, clarity), also referred to as a macroscopic analysis. It
can be also analyzed based on its chemical and molecular properties, including microscopic
assessment.

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

Date: 02-27-2020

Clinical Microscopy

Routine Analysis

Physical examination

Color: straw MICROSCOPIC FINDINGS

PUS cells: 10.20 /hpf
Red blood cells: 5.10 /hpf
Transparency: slightly hazy
Specific Gravity: 1.070 CRYSTALS:
Amorphous: FEW

Chemical Analysis

pH: 6.0
Protein: TRACE
Glucose: NEGATIVE

IV. TEXTBOOK DISCUSSION

a. Definition
Pneumonia is an infection that inflames the air sacs in one or both lungs.
The air sacs may fill with fluid or pus (purulent material), causing cough
with phlegm or pus, fever, chills, and difficulty breathing. A variety of
organisms, including bacteria, viruses and fungi, can cause pneumonia.

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

Pneumonia can range in seriousness from mild to life-threatening. It is most

serious for infants and young children, people older than age 65, and
people with health problems or weakened immune systems.
b. Anatomy and Physiology of organs/systems involved

c. Signs and Symptoms

The signs and symptoms of pneumonia vary from mild to severe, depending
on factors such as the type of germ causing the infection, and your age and
overall health. Mild signs and symptoms often are similar to those of a cold
or flu, but they last longer.

Signs and symptoms of pneumonia may include:

Chest pain when you breathe or cough

Confusion or changes in mental awareness (in adults age 65 and older)
Cough, which may produce phlegm
Fatigue
Fever, sweating and shaking chills
Lower than normal body temperature (in adults older than age 65 and
people with weak immune systems)
Nausea, vomiting or diarrhea
Shortness of breath
Newborns and infants may not show any sign of the infection. Or they may
vomit, have a fever and cough, appear restless or tired and without energy,
or have difficulty breathing and eating.
d. Management
To help prevent pneumonia:

Get vaccinated. Vaccines are available to prevent some types of pneumonia and the flu.
Talk with your doctor about getting these shots. The vaccination guidelines have changed
over time so make sure to review your vaccination status with your doctor even if you
recall previously receiving a pneumonia vaccine.
Make sure children get vaccinated. Doctors recommend a different pneumonia vaccine for
children younger than age 2 and for children ages 2 to 5 years who are at particular risk of
pneumococcal disease. Children who attend a group child care center should also get the
vaccine. Doctors also recommend flu shots for children older than 6 months.
Practice good hygiene. To protect yourself against respiratory infections that sometimes
lead to pneumonia, wash your hands regularly or use an alcohol-based hand sanitizer.
Don't smoke. Smoking damages your lungs' natural defenses against respiratory
infections.
Keep your immune system strong. Get enough sleep, exercise regularly and eat a healthy
diet.
Treatment

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

Antibiotics. These medicines are used to treat bacterial pneumonia. It may take time to
identify the type of bacteria causing your pneumonia and to choose the best antibiotic to
treat it. If your symptoms don't improve, your doctor may recommend a different
antibiotic.
Cough medicine. This medicine may be used to calm your cough so that you can rest.
Because coughing helps loosen and move fluid from your lungs, it's a good idea not to
eliminate your cough completely. In addition, you should know that very few studies have
looked at whether over-the-counter cough medicines lessen coughing caused by
pneumonia. If you want to try a cough suppressant, use the lowest dose that helps you
rest.
Fever reducers/pain relievers. You may take these as needed for fever and discomfort.
These include drugs such as aspirin, ibuprofen (Advil, Motrin IB, others) and
acetaminophen (Tylenol, others).

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

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