Health Perception Management

and

Health

Nutrition and Metabolism

Elimination

PRE-ADMISSION ASSESSMENT Immediately seeks medical advice once ill Patient poorly followed prescribed maintenance medications due to financial constraints and belief that diabetes is not serious Instead, client took herbal medications of sabana and decocted mangosteen to lower blood sugar Patient didn¶t follow dietary modification strictly due to lack of control Client procured OTC drugs for minor ailments Client eats 3 times a day. His usual meals are rice, red meats, canned goods and dried fish. Drinks include coffee(I cup of coffee mixed with 3 tbsps of sugar) every morning, soft drinks once a day and powdered juice at times He loves sweet foods According to wife, client has good appetite and even has complaints of occasional hunger and extreme thirst Client experienced frequent urination even at night (3-5 times). ³Mapuno gud ang gamay nga arinola sa usa ka gabie dayon yellow kaayo iyang ihi pirmi,´ verbalized wife of client Client defecates every other day. Usual time is morning.

INITIAL ASSESSMENT Immediately seeks medical advice once illPatient taking medication (antibiotic, expectorant , antipyretic thru his IV)

On DAT Low fat and low salt diet Eats meals a day 3

Activity and Exercise

Since 2007, client has a sedentary lifestyle due to complaints of body malaise secondary to health condition. He used to work as a fish vendor together with his wife at Valencia Market. Has the ability to perform ADLs such as doing household chores.

Cognition and Perception

Not experiencing headache, seizures, blackouts, and dizziness. Patient is alert, awake and coherent. Able to communicate and respond to directions. Patient is in proper orientation. Speech is clear Vision is not impaired.

The patient was not able to defecate for just one day. Feces is yellowish brown and formed in consistency. Patient is wearing a diaper. Dark yellow and cloudy urine. ³Luya kaayo iyang lawas pirmi´, verbalized by wife. Cannot perform ADLs and exhibits malaise and restlessness slouche d in bed with episodic rigidity of lower extremities Headac he and occasional tremors noted. Patient is conscious but drowsy. Able to respond to directions such nodding if the answer is ³Yes´. Patient

Have six children-3 boys and girls with the eldest of age 23 and youngest of age 9. Patient is a 53 year old male. Able to perform ADL¶s is in proper orientation Speech is slurred Vision is not impaired. His family was also very supportive and understanding now that he is battling with his disease. Strong family support Patient Coping and Stress Tolerance Strong family support When he is stressed he prefers to drink little amount of liquor. He was able to provide the needs of his family Patient is happily married to his wife Has six children-3 boys and girls with the eldest of age 23 and youngest of ages 9 He also maintains good relationship with peers and neighborhood ³responsable man siya pero dili na jud siya makatabang kaayo sa negosyo tungod sa pangluya sa iyang lawas pirmi´ as stated by wife of client Patient is a 53 year old male. Doesn¶t know how to do Testicular Examination. . Self-Perception and Self-Concept of personality human being Jolly and fun. Has six children-3 boys and girls with the eldest of age 23 and youngest of age 9. Patient¶ s usual bedtime: 9pm6am) Has difficulty falling asleep due to frequent urination at night(3-5x/night) Totally dependent to care from others.Sleep and Rest Patient¶s usual bedtime: (10 or 11 pm ± 5-6 am) Usually sleeps late at night due to some chores and he is fond of watching television. He thinks the he is a burden to his family. Patient is totally dependent due to his illness. Sexuality and Reproduction The bond of their family grew stronger.loving type Indentifies worth as a Roles and Relationships Heightened self-esteem Responsible husband to his wife and father to his children. Fatigue and body malaise Has difficulty falling asleep due to frequent urination at night(3-5x/night) He became problematic and worried about his arising condition.

smoking and gambling.smokes and involves himself in minimal gambling at their place. Values and Beliefs Catholic Patient is a Roman advice quack Seeks spiritual regarding current health condition He approaches doctors in times of diseases. cannot perform the usual activities that he had before such as drinking. Patient is a Roman Catholic Seeks spiritual advice regarding current health condition. When the patient is stressed he prefers to cry until he falls asleep. .

affect (mood). obvious disability. inspect eye position and symmetry and position. lesions. posture. race. state of dress. moisture. speech patterns. body build.PROCEDURE GENERAL General appearance. weight. nutrition status. shape. vital signs INTEGUMENTARY SYSTEM Skin u Inspect: skin color and uniformity of color. gender.inspect and palpate ± Cyanosis . symmetry and size of pupils u Visual acuity (Snellen for distance. rashes. lesions. Rosenbaum for near vision) . hygiene. scalp. body odor. symmetry Eyes Inspect and palpate lids. height. hair pattern. distribution. gait. pallor.loss of normal angle between nail and nail bed d/t chronic oxygen deprivation Head inspection and palpation ± Size.is it true or d/t cold? ± Blanch test (aka capillary refill or CFT): delayed return of color indicates poor arterial circulation Clubbing . edema u Palpate: temperature. turgor. lashes. critters REVIEW OF SYSTEMS (Subjective) PHYSICAL EXAMINATION (Objective) NURSING PROBLEM Nails Nails . edema) Hair texture.

checks 6 ocular movements. tonsils. Weber and Rinne Nose and Sinuses u Inspect color of mucosa. and 6 u Pupil response to light and accommodation. lymph nodes u Auscultate carotids for bruits (bell) ± If bruit is heard. shape. tests CN 3. and also to accommodate for near vision (dilate for dimness and distance) u Direct and consensual pupil response u Corneal light reflex checks eye alignment Ears Inspect size. lesions Palpate for tenderness. presence of discharge ± There is a nasal speculum ± most people don¶t like it ± Assess for patency u Palpate for tenderness Percuss for tenderness over frontal and maxillary sinuses Mouth and Throat Inspect and palpate lips. whisper test. palpate . tongue. pharynx (color. 4. teeth. moisture). (PERRLA) ± Pupils constrict o light. position. any lesions u Review anatomy of ear and inner ear Gross hearing acuity: normal voice. lesions. palate Throat and Neck u Inspect and palpate neck for trachea (should be at midline). oral cavity. erythema. breath. thyroid. discharge.assess peripheral vision u EOMs .u Visual fields . presence of exudate.

for carotid thrill ± Palpate one side at a time u Perform ROM on neck (active and passive) Breast RESPIRATORY CARDIOVASCULAR Central Peripheral GASTROINTESTINAL URINARY MUSCULOSKELETAL .

GENITALIA NEUROLOGIC HEMATOLOGIC ENDOCRINE .

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