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

Hair: Black, Curly, Shiny, No presence of flakes and lesions

Skin: Fair color and Mildly Dry

Nails: Clean, Trimmed, Pinkish

Eyes: Good

Mouth: Well cleaned

Nose: Clear from Mucus

Cahulogan, Julliane Pearl J.
Health Perception
“Sakit akong tiyan human
nako mukaon atong isang
adlaw pa.”
“Nag sigi sad ko ug libang ug
suka tungod sa sakit sa tiyan.
Wala nuon ko nalipong. Duda
nako daan ang sud.an akong
gi kaon.”
“Murag ga pitik-pitik ang
sakit.”
“Kada buntag ko gina sipon
tungod kay naa koy allergic
rhinitis mawala raman sad
sya inig human nakog inom
ug cetirizine.”
“Naa koy maintenance para
sa akong allergy, Allecur Low Priority
Cetirizine Hydrochloride.”
High Priority
BSN-1N
Nutritional/ Metabolic
Pattern
“Kada meal kay maka 2 o 3
ko ka cup sa rice. Ginalimit
nako akoang carbs kay dli ko
gusto mutaba.”
“Balance ra akoang pagkaon
sa gulay, karne, ug isda.”
“Naa sad koy gina take na
vitamins, Potencee Vitamin
C ug Hemarate FA Anti-
Anemia.”
“Dili nako usahay ma
kumpleto ang walo (8) ka
baso nga tubig kada adlaw
kay makalimot sad ko.”
Health Assessment
11 GORDONS FUNCTIONAL HEALTH PATTERNS
Elimination pattern Activity Exercise Pattern Sleep/ Rest Pattern Cognitive Perceptual
Pattern
“Sukad nga nag sakit akong “Kada adlaw ko ga cardio “Sakto ra akong tulog ug “Wala koy problema sa
tiyan atung isang adlaw maski 1o minutes ra.” pahulay. Maka 5-8 hours ko akoang mata. Makakita
medyo basa na akoang tae. nga tulog kada adlaw.” gihapon ko ug tarong.”
Pero naa say usahay nga
dili.” “Inig human nakog trabaho o “Ga tulog ko usahay inig “Dli sad ko dali makalimot.”
kung wala koy ginabuhat human nako ug trabaho.”
“Wala koy problema saakong naga tan.aw ra ko ug salida sa “Wala sad koy problema sa
pag-ihi. Netflix.” pandungog.”
Usahay gamay akong ihi,
usahay daghan.”
Low Priority 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

Gordon’s Pattern: NEED: Problem

1. Health Perception: Stomachache, Diarrhea, and vomitting Acute Pain (Abdominal Pain), Wet Stool, and Vomitting

2. Elimination Pattern: LBM Loose liquid stools

FINAL:

1. Acute Pain (Abdominal Pain), Wet Stool, and Vomitting

2. Bowel urgency
Cahulogan, Julliane Pearl J. BSN-1N Health Assessment

Activity 2 NURSING CARE PLAN

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

Rationale: This will control odor and decrease the of diarrhea.

VS: patient’s anxiety and self-consciousness. Easy 4. Verbalize
T: 37.02 C access promotes patient safety and enables the the absence
BP: 120/80 patient to cope with diarrhea more effectively. of diarrhea.
PR: 120
4. Empty the bedpan and commode promptly. 5. Verbalize
RR: 17 absence of
9 stomach
Rationale: This will remove the source of odor and
decrease the patient’s anxiety about incontinence. pain.
6. Verbalize
5. Administer hydrophilic colloids, the absence
anticholinergics, and antidiarrheal of
medications as prescribed. 4 vomiting.
“Dili na basa ang
Rationale: These agents decrease fluidity and
tae nako ma’am.
number of stools as well as inhibit GI peristaltic
activity.
Wala nasad ko ga
6. Administer topical corticosteroid or suka ug wala na
aminosalicylate preparations and antibiotics 5
via retention enema, as prescribed. ga sakit akoang
Rationale: These agents reduce mucosal tiyan.”
inflammation in patients with mild disease limited
to the rectum and sigmoid colon. In patients with
acute moderate to severe disease and with more
extensive (pancolonic) disease, oral or intravenous
(IV) corticosteroid therapy is initiated. In patients
not responding to steroids or aminosalicylates,
immunosuppressive immunomodulatory therapy
may be initiated to reduce inflammation.

7. If the patient has difficulty retaining the

enema for the prescribed amount of time,
consult the health care provider about use 6
Cahulogan, Julliane Pearl J. BSN-1N Health Assessment

of corticosteroid foam.

Rationale: Corticosteroid foam is easier to retain

and administer.

8. Administer probiotics or fish oil, as

prescribed.
7
Rationale: Probiotics are beneficial bacteria that
restore balance to the intestinal environment, with
resulting reduction in inflammation. Omega-3 fatty
acids found in fish oil appear to benefit patients
with active UC by decreasing inflammation; they
must be taken in large quantity.

9. Assess the pain, severity, location.

2
Rationale: This will allow us to determine what
type of pain and how severe it is.

10. Perform Comfort Measures:

a. Watch Tv
b. Talk to the patient.
10
Rationale: This will give comfort to the client.

11. Allow the client to rest.

Rationale: Resting will allow the patient to feel 11

relief in her situation.
Cahulogan, Julliane Pearl J. BSN-1N Health Assessment