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Cahulogan, Julliane Pearl J. BSN-1N Health Assessment
Cahulogan, Julliane Pearl J. BSN-1N Health Assessment
Activity 1
Nursing Assessment
Demographic Data
Name: Justine Era J. Cahulogan
Age: 15 Years Old
Gender: Female
Name of Parents: Perla J. Cahulogan (Mother)
Address: Nagsil, Mintrade Drive, R. Castillo St., Agdao, Davao City
Date of Birth: January 23, 2006
Place of Birth: Davao City
Nationality: Filipino
Occupation: Student
Civil Status: Single
Religion: Roman Catholic
Contact Number: 09123456789
Height: 151 cm.
Weight: 53 kg.
Cahulogan, Julliane Pearl J. BSN-1N Health Assessment
Health History
Past Health History: Seasonal Flu, Allergic rhinitis, Dengue, Chickenpox, UTI, Ear Infection
Present Conditions: Allergic rhinitis (Every morning)
Vaccines Receive: Complete Vaccines, including tuberculosis, all three doses of Diphtheria, Pertussis and Tetanus, polio, measles, BCG, Hepatitis and Rubella.
- No habit of alcohol consumption, smoking and chewing of tobacco and no use of other injectable drugs.
Admission/s: Admitted year 2011 due to Dengue.
Maintenance/Medicine/Supplements: Potencee Vitamin C, Hemarate FA Anti-Anemia, Allecur Cetirizine Hydrochloride
Surgery: None
General Health Appearance: Healthy
Physical Assessment
Eyes: Good
Health Perception Nutritional/ Metabolic Elimination pattern Activity Exercise Pattern Sleep/ Rest Pattern Cognitive Perceptual
Pattern Pattern
“Sakit akong tiyan human “Kada meal kay maka 2 o 3 “Sukad nga nag sakit akong “Kada adlaw ko ga cardio “Sakto ra akong tulog ug “Wala koy problema sa
nako mukaon atong isang ko ka cup sa rice. Ginalimit tiyan atung isang adlaw maski 1o minutes ra.” pahulay. Maka 5-8 hours ko akoang mata. Makakita
adlaw pa.” nako akoang carbs kay dli ko medyo basa na akoang tae. nga tulog kada adlaw.” gihapon ko ug tarong.”
gusto mutaba.” Pero naa say usahay nga
“Nag sigi sad ko ug libang ug dili.” “Inig human nakog trabaho o “Ga tulog ko usahay inig “Dli sad ko dali makalimot.”
suka tungod sa sakit sa tiyan. “Balance ra akoang pagkaon kung wala koy ginabuhat human nako ug trabaho.”
Wala nuon ko nalipong. Duda sa gulay, karne, ug isda.” “Wala koy problema saakong naga tan.aw ra ko ug salida sa “Wala sad koy problema sa
nako daan ang sud.an akong pag-ihi. Netflix.” pandungog.”
gi kaon.” “Naa sad koy gina take na Usahay gamay akong ihi,
vitamins, Potencee Vitamin usahay daghan.”
“Murag ga pitik-pitik ang C ug Hemarate FA Anti-
sakit.” Anemia.” Low Priority Low Priority
High Priority
Cahulogan, Julliane Pearl J. BSN-1N Health Assessment
Self Concept/ Self Perception Role/ Relationship Pattern Sexually- Reproductive Pattern Coping/ Stress Tolerance Value-Belief Pattern
“Okay raman ko.” “Wala koy problema sa akoang “Wala pakoy experience.” “Di man jud malikayan Ning “Dli ko relihiyoso nga tao.”
pamilya ug mga amigo.” problema sa kinabuhi.
Kung makaya ra ug tulog gina tulog
ra nako. Pero ug dli akong gina face
akong problema sa kinabuhi.”
Low Priority
“Usahay gina tabangan ko saakong
pamilya ug mga amigo sa akoang
Low Priority mga problema.”
Low Priority Low Priority
Low Priority
1. Health Perception: Stomachache, Diarrhea, and vomitting Acute Pain (Abdominal Pain), Wet Stool, and Vomitting
FINAL:
2. Bowel urgency
Cahulogan, Julliane Pearl J. BSN-1N Health Assessment
Name of the Patient: Justine Era J. Cahulogan Age: 15 Ward: St. Mary Room & Bed: 253-10
Chief Complaint: Acute Stomachache, LBM, and Vomitting Diagnosis: Diarrhea Physician: Dr. JP Japson
DATE/ CUES NEED/s NURSING PATIENT OUTCOME NURSING INTERVENTIONS IMPICATION EVALUATION
TIME DIAGNOSIS
S
M Subjective Cues: HEALTH -Acute pain -The patient’s stools become 1. Monitor VS and Assess and record the M
A “Sakit akong tiyan (stomachache) normal in consistency, and amount, frequency, and character of stools. 1 A
R human nako mukaon PERCEPTION , Diarrhea, and frequency is lessened within 3 When possible, measure liquid stools. R
C atong isang adlaw pa.” vomiting, days of admission. C
related to Rationale: Although bloody diarrhea is the
H PATTERN & H
“Nag sigi sad ko ug unsanitary - At the end of 3-4 hours of cardinal symptom, the clinical picture can vary
libang ug suka tungod food nursing care, the patient will from acute episodes with frequent discharge of
8, ELIMINATIO preparation. watery stools mixed with blood, pus, and mucus, 12,
sa sakit sa tiyan. Wala be able to:
nuon ko nalipong. accompanied by fever, abdominal pain, rectal
2 Duda nako daan ang N PATTERN a. Manifest the absence urgency, and tenesmus, to loose or frequent stools, 2
0 sud.an akong gi kaon.” of stomach pain. to formed stools coated with a little blood. 0
2 b. Manifest the absence 2
1 “Murag ga pitik-pitik of vomiting. 2. Assess serum electrolytes, particularly K+ , 1
@ ang sakit.” c. Manifest the absence for abnormalities. Alert the health care @
1:17 of diarrhea. provider to K+ less than 3.5 mEq/L. 3 3:41 PM
PM d. Verbalize the absence (Critical value: K+ less than 2.5 mEq/L.)
Objective Cues: of diarrhea. 1. Manifested
Grimmace Face Rationale: Hypokalemia is often present because the absence
Stomachache e. Verbalize absence of of colonic losses (diarrhea) and renal losses in of stomach
stomach pain. patients taking high doses of corticosteroids. pain.
f. Verbalize the absence 2. Manifested
Pain Scale: 3/3 of vomiting. the absence
0 – No Pain 3. Provide a covered bedpan, commode, or of
1 – Mild Pain bathroom that is easily accessible and ready 8 Vomiting.
2 – Moderate Pain to use at all times. 3. Manifested
3 – Severe Pain the absence
Cahulogan, Julliane Pearl J. BSN-1N Health Assessment
of corticosteroid foam.