Mindanao State University COLLEGE OF HEALTH SCIENCES Marawi City Name of Student Group F Area of Assignment _____ ______________

Clinical Instructor Ms. Sohaynee Moslem ______

VSMMC- Neuro Ward NURSING ASSESSMENT I

Date Submitted ____April 18, 2011

PATIENT’S PROFILE NameMr. M Age 37 yrs old Sex Male Religion Roman Catholic Address Lamacan, Sibunga, Cebu Civil Status Married Occupation Carpenter

HEALTH HABITS Frequency 1. Tobacco 2. Alcohol 3. OTC-drugs/ non-prescription drugs everyday Thrice a week none none Amount 1 pack 1 bottle none Period/Duration 21 years 17 years

A. CHIEF COMPLAINTS

Complication of craniectomy

B. HISTORY OF PRESENT ILLNESS (HPI) {location, onset, character, intensity, duration, aggravation, and alleviation, associated symptoms, previous treatment and results, social and vocational responsibilities, affected diagnoses}.

A case of 37 years old, male, Filipino, Roman Catholic, married and residing at Lamacan, Sibunga, Cebu was brought for the second time in VSMMC due to compications of his craniectomy. Patient manifested hydrocephalus on his left temporal accompanied with seizures and elevated body temperature a week after he was discharged and so they immediately admitted the patient in VSMMC on April 08, 2011.

C. HISTORY OF PAST ILLNESS (previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance, major illnesses, allergies, medications, habits, birth and developmental history, nutrition- for pedia) The patient was hospitalized for the second time; patient had a head injury due to fall and undergone craniectomy, patient has no infectious disease, was completely immunized, no major illness, and patient has an allergy on beans and meats, no medication taken prior to hospitalization.

FAMILY HISTORY WITH GENOGRAM Acquired Diseases: Hypercholesterolemia / Kidney Disease X Tuberculosis / Alcoholism X Drug Addiction Hepatitis X A B X X X Asthma Epilepsy Mental Illness X X X Cancer X Hypertension X Heart Diseases X Heredo- familial Diseases: Diabetes

The interaction between the SN and the SO was good. specify) D. Present Illness “ma okey ran i siya. Hospital Environment “ayos lang man ang environment diri” as verbalized by the SO E. may awa and diyos” as verbalized by the SO 2. REVIEW OF SYSTEMS Name Vital Signs: Temperature Pulse Respiration Blood Pressure Date Height Weight Observation ____________________________________ . SUMMARY OF INTERACTION X arthritis Rheuma/Arthritis X Others The SN was able to gather information needed because the SO was cooperative. specify) (pls. the SN was able to gain the trust of the SO that’s why it is easy for him to gather information. PATIENT’S PERCEPTION OF: 1.C Others (pls.

GENERAL 2. HEENT 3. INTEGUMENTARY .1.

4. EXCRETORY 8. ENDOCRINE DRUG STUDY . NERVOUS 10. DIGESTIVE 7. RESPIRATORY 5. MUSCULOSKELETAL 9. CARDIOVASCULAR 6.

route of administration Mechanism Of Action Indication Contraindication Adverse Reaction Nursing Responsibilities .BRAND NAME GENERIC NAME CLASSIFICATION Prescribed and Recommended dosage. frequency.

paracetamol > not taken > valporic acid. Activities b. phenytoin. phenytoin. salbutamol.ACTIVITIES. fluid) b.NURSING ASSESSMENT II NameMr. tramadol. paracetamol > blenderized food > soft diet > none > not taken > valporic acid. tramadol > blenderized food > soft diet > blenderized food > soft diet > none > none > not taken > valporic acid. salbutamol. Weight > blenderized food > soft diet > none > not taken > ferrous sulfate. 2011 11-15. Diet c. paracetamol . tramadol. M Chief Complaint Complications of craniectomy_________________________ Impression/Diagnosis Status Epilepticus _____________ Date/Time of Admission April 08. salbutamol. tramadol. Sleeping pattern > Patient can turn himself side to side > Most of the time patient was sleeping > patient was sleeping around 8pm and wakes up around 7am for his breakfast > patient was immobile > sleeping most of the time >patient was unconscious > patient was immobile > sleeping most of the time >patient was unconscious > patient was immobile > sleeping most of the time >patient was unconscious 2. Diet restrictions d.NUTRITIONALMETABOLIC a. 2011 _ Diet: Allergies Beans and Meats __ Operation (if any) Craniectomy Age 37 y/o___ Sex Male_ Soft diet Inclusive Dates of Care April _____________________ Type of NORMAL PATTERN BEFORE HOSPITALIZATION INITIAL DAY 1 CLINICAL APPRAISAL DAY 2 1. Rest c. Typical intake(food. phenytoin.REST a.

Perception of self b. Bowel (frequency. Support System d. color. Coping Mechanism c. Urine (frequency. with clear light yellow color and foul smell urine > patient defecates twice a week with firm blackish color stool > patient’s support system was his family and relatives especially his wife who always stay with him > patient has a diaper for urination. changed the diaper thrice. with clear light yellow color and foul smell urine > not yet defecated at day of assessment > patient’s support system was his family and relatives especially his wife who always stay with him > patient’s support system was his family and relatives especially his wife who always stay with him > patient’s support system was his family and relatives especially his wife who always stay with him . consistency) 4. with clear light yellow color and foul smell urine > not yet defecated at day of assessment > patient has a diaper for urination.e. changed the diaper twice. transparency) b. changed the diaper twice. EGO INTEGRITY a. Medications/supplem ent food 3. ELIMINATION a. color. with clear light yellow color and foul smell urine > not yet defecated at day of assessment > patient has a diaper for urination. Mood/Affect > patient has a diaper for urination.

> 5 senses were not functioning well . touch) > his senses are properly functioning according to the SO > 5 senses were not functioning well . Mental state > patient was conscious but unable to talk > patient was unconscious > patient was unconscious > patient was unconscious b.8 ⁰C RR: 26 cpm PR: 118 bpm BP: 120/100 mmHg Patient has audible breath sounds. smell. > 5 senses were not functioning well . OXYGENATION a. 6.5.8 ⁰C RR: 26 cpm PR: 118 bpm BP: 100/80 mmHg Patient has audible breath sounds. Vital signs Temperature Respiratory rate Heart rate Blood pressure b. NEURO-SENSORY a. has no history of respiratory problem . taste. has no history of respiratory problem T: 37. hearing. History of Respiratory Problems Not taken prior to hospitalization T: 37. has no history of respiratory problem T: 37 ⁰C RR: 24 cpm PR: 108 bpm BP: 120/90 mmHg Patient has audible breath sounds. Lung sounds c. Condition of five senses: (sight.

intensity. HYGIENE AND ACTIVITIES OF DAILY LIVING > patient can move himself side to side. Comfort measures/Alleviation c. PAIN-COMFORT a. aggravation) b. Medications > pain at the temporal part of the head every morning and evening. can able to produce sound on his mouth and can sit with assistance. character. Pain (location.7. lasts for several minutes > patient was unconscious > patient was unconscious > patient was unconscious > alleviates the pain by resting > patient was taking tramadol for pain 8. performed his hygiene by TSB done by his wife > patient was immobile and performed TSB by the SN for his hygiene > patient was immobile and performed TSB by the SN for his hygiene > patient was immobile and performed TSB by the SN for his hygiene . associated symptoms. duration. onset.

9. reproductive status) b. number of children. he is married and with 4 children > patient was circumcised when he was only 6 years old. civil status. he is married and with 4 children LABORATORY AND DIAGNOSTIC PROCEDURES DATE NAME OF THE PROCEDURE RESULT NORMAL VALUE NURSING IMPLICATION . number of children) > patient was circumcised when he was only 6 years old. female (menarche. civil status. he is married and with 4 children > patient was circumcised when he was only 6 years old. he is married and with 4 children > patient was circumcised when he was only 6 years old. SEXUALITY a. male (circumcision. menstrual cycle.

SUMMARY OF INTRAVENOUS FLUID DATE/TIME STARTED INTRAVENOUS FLUID AND VOLUME DROP RATE NUMBER OF HOURS DATE/TIME CONSUMED .

SUMMARY OF MEDICATION DATE MEDICATIONS.dosage. frequency. route Remarks .

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ANATOMY AND PHYSIOLOGY .

PATHOPHYSIOLOGY MEDICAL MANAGEMENT .

NURSING MANAGEMENT .

SURGICAL MANAGEMENT .

DISCHARGE PLAN NAME ______________________________________________ CONDITION UPON DISCHARGE against medical advice ( ) ___________ DATE OF DISCHARGE: ____________________ Nature: Home per request ( ) Discharge .

DIET 4.1. EXERCISE 3. MEDICATIONS 2. SCHEDULE FOR THE NEXT VISIT NURSING CARE PLAN CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION . HEALTH TEACHING 5.

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NURSING CARE PLAN CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION .

NURSING CARE PLAN CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION .

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