Mindanao State University

COLLEGE OF HEALTH SCIENCES

Marawi City

NAME OF STUDENT: Section E1 CLINICAL INSTRUCTOR: PROF. NORHANIE A. ALI

AREA OF ASSIGNMENT: Medicine Ward DATE SUBMITTED: 06/06/2023.

NURSING ASSESSMENT I

PATIENT’S NAME: PATIENT X ADDRESS: RAGAYAN, POONA BAYABAO (GATA), LANAO DEL SUR AGE: 59yrs old
SEX: FEMALE RELIGION: ISLAM CIVIL STATUS: WIDOW OCCUPATION: NONE

FREQUENCY AMOUNT PERIOD/DURATION

1. Tobacco X X X

2. Alcohol X X X

3. OTC- drug/nonprescription drug (Biogesic, Neozep and PRN 500mg 26yrs

Mefenamic)

A. CHIEF OF COMPLAINTS:

“Margn a kapakaginaw akn saman aya ka pitaro rakn pn o doctor a pagilay rakn na and kon pn oto a asthma akn” as verbalized by patient

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

This is a case of a 59-year-old female from Ragayan, Poona Bayabao (Gata), Lanao del sur. According to her, May 21 st of 2023 when the patient caught a cold
associated with a persistent cough, she thought that it is just a normal cold that can be treated in a just few days by drinking lots of water and using an Over the counter drugs such as Biogesic or
Paracetamol unfortunately her cold and cough has worsen to the point that she experienced shorter of breathing. On May 28 th, prior to admission the patient had shortness of breathing. On May
30th, the patient cannot tolerate the pain that she experiencing that make her think that it is the last day of her life, exactly 9:12 in the evening they arrived in Emergency room at Amai pakpak
medical center and Immediately they assessed her vital signs her Respiratory rate is quit abnormal because it is 44cpm and Oxygen Saturation of 89%, doctors first suspect her that she has covid
since she have most common symptoms but after they swab her, and the result came out negative after further laboratories and examinations they confirmed it that the patient has a Bronchial
Asthma Acute Exacerbation.
A. 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 has been hospitalized due to hypertension and no report of injuries. The patient has never undergone for any minor or major surgery and reported that she experienced
chicken fox and measles during her childhood days, and she also added that she had completed her immunization. The patient has a health maintenance for her hypertension and no
reports any major illness, no allergies, taking OTC drugs as needed and losartan every morning, she likes cleaning around the house and loves to stroll around not for just fun but to
have an exercise as well, she is G8P7.

FAMILY HISTORY GENOGRAM

Acquired Diseases: Heredo- familial Diseases:
Patient Hypercholesterolemia X Diabetes X
Daughter Kidney Disease X Heart Diseases X
Tuberculosis X Hypertension X
Son
Alcoholism X Cancer X
Husband (Deceased) Drug Addiction X Asthma X
Hepatitis A X Epilepsy X
B X Mental Illness X
C X Rheuma/Arthritis X
Others (pls. specify) Others (pls. specify) X

B. PATIENT’S PERCEPTION OF:

1. Present Illness

“Margn a kapakaginaw akn saman aya ka pitaro rakn pn o doctor a pagilay rakn na and kon pn oto a asthma akn” as verbalized by patient
2. Hospital Environment

“Mapiya mambo ka pkatabangan iran so madakl a kikinanglan na pakalibre tapn sa bayad ogaid na aya say abo sakit na so mga kakaba a mangaito a na didn kada” as verbalized by
the patient.
C. SUMMARY OF INTERACTION

The Patient is cooperative and has an understanding to everything. She entertains the student nurse and answers every question you ask. She was always smiling when you were
talking to her. She never get tired or irritated while you were asking personal questions perhaps she will answer you very detailed.
 PHYSICAL EXAMINATION
Name: Date: June 02,2023
Chief of Complaints: Difficulty of breathing Height:144cm Weight:49kg
Vital signs: T: 36.4℃ RR:23cpm PR:67bpm O2Sat:95% BP:130/90mmHg Pain score:6/10 BMI: 23.6

Received patient sitting at the bed with on going IVF of patient on right metacarpal. Patient is alert, conscious, and oriented to
time, place and people surrounding. Patient is cooperative and enjoy the company of the student nurses especially
GENERAL when you were asking a questions personal or not she will answer it clearly and detailed, patient is well groomed, nails
was clean cut, hair is combed properly and tucked in.

Head: Head is normochepalic and has no lesions, lumps, or masses. Hair has a visible gray in some part but not completely gray
Eyes: Eyebrows are symmetric and black in color, but few are turning in white. Eyelashes are evenly distributed. Eyelids are
HEENT swollen. No presence of discharges is noted.
Ears: Ears are symmetric. There is no presence of tenderness, lesions, and discharges.
Nose: nasal flaring is noted and a nasal discharge.
Throat: No presence of swelling and masses.

INTEGUMENTARY Senile turgor is noted due to aging, patient has no lesion or masses in the body and no discoloration.
 Pulse rate is 67 bpm with blood pressure of 130/90 mmHg. Chest expansion is equal. Patient has no history of any cardiovascular
CARDIOVASCULAR
problem.

RESPIRATORY Respiratory rate of patient is 23 cpm and saturation of oxygen at 95% via room air. No oxygen therapy is used. Wheezes at right
lung field and crackles is heard as Auscultated. Patient also has a persistent cough

GASTROINTESTINAL
Patient has a complete incisor, canine and premolars but she only have 6 molars, mouth appear healthy and moist, no abdominal
pain, no loss in appetite, has normal sound of bowel movement and can defecate without using any kind laxative.

NEUROLOGICAL Sense Smelling and touching is functioning well, Vision is no longer 20/20, no sign of cataract, PERRLA, hearing is intact as
well. Patient is Alert and conscious around her surrounding

MUSCULOSKELETAL Deterioration of vertebral support and body weakness is noted due to aging but can walk, sit and eat without assistance.

Menarche starts on 15 years age and the patient is G8P7, Menopause at the age of 50 years old, no history of any cervical
REPRODUCTIVE diseases.

EXCRETORY The patient verbalized that she voids 3 to 6 times a day, and no burning is felt in every void and no foul odor is smelled.
 NURSING ASSESSMENT II

Name: PATIENT X Age 59____ Sex F____

Admitting Chief Complaint DOB
Impression/Diagnosis Bronchial Asthma Acute Exacerbation.
Date/Time of Admission May 30, 2023 Inclusive Dates of Care _ _
Diet: No diet is recommended but eats vegetables,rice and fish Allergies None
Type of Operation (if any)

NORMAL PATTERN BEFORE HOSPITALIZATION INITIAL CLINICAL APPRAISAL

DAY 1 DAY 2

1.ACTIVITIES- REST The patient was usually doing a house The patient shows body weakness, The patient shows body weakness, The patient shows body weakness
a. Activities hold chores and stroll around, and rest and tiredness. She spends most of and tiredness. She spends most of but can walk from bed to comfort

b. Rest after luhor prayer for an hour and sleep the time in bed. And sleeps all the the time in bed. And sleeps all the room. She rests most of the time and
every 9:30pm and wake up 4:00am time due to tiredness and Shortness time due to tiredness and shortness sleeps every 8:00pm to 4:00am.
c. Sleeping pattern
of breathing. of breathing.

2.NUTRITIONAL- The patient has no diet restrictions. The patient loses her appetite, she The patient has no appetite, but she The patient has no diet restrictions.
METABOLIC She eats three times a day and drinks always depends on IVF most of the doesn’t have any restriction in food, She eats three times a day and
a. Typical intake (food, 5-7glasses of water a day. She was not time. Weight gradually loss and but she usually eats soft food such drinks 4 to 5 glasses of water a day.
fluid)
taking any vitamins but takes some received medication through IVTT, as porridge, weight is the same She received medication through
b. Diet OTC drugs like Paracetamol as except for his maintenance losartan when she was admitted, and she IVTT, except for his maintenance
c. Diet restrictions needed. The patient has a maintenance and the other prescribed received medication through IVTT, losartan and the other prescribed
d. Weight of losartan for her hypertension. Azithromycin received it through PO and nib Azithromycin received it through
e. Medications/supplement oral and she also received it through oral and she also received it through
food nebulizer. nebulizer.
3. ELIMINATION
a. Urine (frequency, color,
transparency)
b. Bowel (frequency, color,
consistency)
4. EGO INTEGRITY
a. Perception of self
b. Coping Mechanism
c. Support System
d. Mood/Affect
5. NEURO-SENSORY
a. Mental state
b. Condition of five senses:
(sight, hearing, smell,
taste,
touch)
Frequent urination color is yellow. Patient voids 3 a day and urination
Usually voids 3 to 6 times a day and
defecates once every day characterized
with a stool color of brown and intact
stool form. No burning felt or foul
smell
Patient is content in her life, whenever
she feels lonely or have a problem that
she faced, she is praying much more
and ask Allah’s guidance. Her family
support her especially her daughters
and sons, she is not moody and doesn’t
get angry or irritated in small things
instead she smiles a lot.
Patient has no history of any mental
illness and disorders. The patient is
conscious, coherent, and oriented to
time, date, place, and persons.
The patient’s five senses are intact.
color are yellow. Since her
admission no burn felt or foul smell.
Also reported that she defecates
every other day since her admission.
The patient shows tiredness and
body weakness. She just seeking
Allah’s mercy and guidance. Her
family supports her and is always by
her side, especially his by
granddaughter who always stays by
her side ever since admission.
Patient has no history of any mental
illness and disorders. The patient is
conscious, coherent, and oriented to
time, date, place, and persons.
Patient's sense of light, smell,
Patient voids 3 a day and urination
color are yellow. Since her
admission no burn felt or foul smell.
Also reported that she defecates
every other day since her admission.
The patient shows tiredness and
body weakness. She just seeking knows when she will get back at
Allah’s mercy and guidance. Her
family supports her and is always
her side, especially his
granddaughter who always stays by
her side ever since admission.
Patient has no history of any mental
illness and disorders. The patient is
conscious, coherent, and oriented to
time, date, place, and persons.
Patient's sense of light, smell,
Patient voids 3 a day and urination
color are yellow. Since her
admission no burn felt or foul smell.
Also reported that she defecates
every other day since her admission.
Patient’s believe that only Allah
home and she prays a lot to ease the
pain she feel, her family is the
primary support and she doesn’t get
irritated in hospital instead she was
thankful that the doctor and nurses
helping her.
Patient has no history of any mental
illness and disorders. The patient is
conscious, coherent, and oriented to
time, date, place, and persons.
The patient’s five senses are intact.
 hearing, and touch function well. hearing, and touch function well.

6. OXYGENATION Vital signs are not taken and no history T=36.2°C T=36.4°C T=35.6°C
a. Vital signs of respiratory problem.
P= 90 bpm P= 65 bpm P= 92 bpm
Temperature
R=44 cpm R= 23 cpm R= 22 cpm
Respiratory rate
BP= 140/90 mmHg BP= 130/90 mmHg BP= 130/80 mmHg
Heart rate
Blood pressure
b. Lung sounds Patient’s experienced shortness of Patient’s experienced shortness of Patient’s experienced shortness of
c. History of Respiratory breathing, Wheezing and Crackles breathing, Wheezing and Crackles breathing, Wheezing and Crackles
Problems are noted. Patient is suspect of are noted. are noted
COVID.

7. PAIN-COMFORT The patient feels shortness of Patient having trouble breathing The Patient still feel shortness of The Patient still feel shortness of
a. Pain (location, onset, breathing, fever, and productive cough radiating at the back and pain feels breathing but the pain is no longer breathing but the pain is no longer

character, intensity, 3 days prior to admission. No comfort like someone’s choking her that felt like before, with pain score of felt like before, with pain score of
duration, reported. makes her difficult to breath 6/10. 4/10.
associated symptoms, properly.

aggravation)

The patient was nebulized. The patient was nebulized.

The patient received oxygen therapy
b. Comfort
measures/Alleviation stat to alleviate the pain and make
her breath properly.

c. Medications
8. HYGIENE AND Patient takes a bath thrice a week. She Patient can't take bath as usual to Patient can't take bath as usual to Patient can't take bath but received
ACTIVITIES usually does household chores and routine process. The patient can't do routine process. The patient can't do tepid sponge bath. She can sit, eat,
OF DAILY LIVING strolls around the neighborhood. usual ADLs and shows tiredness usual ADLs and shows tiredness and walk without assistance.
and body weakness. and body weakness.

9. SEXUALITY Menarche starts on 15 years age and Menarche starts on 15 years age and Menarche starts on 15 years age and Menarche starts on 15 years age and
the patient is G8P7, Menopause at the the patient is G8P7, Menopause at the patient is G8P7, Menopause at the patient is G8P7, Menopause at

a. female (menarche, age of 50 years old, patient is widow the age of 50 years old, patient is the age of 50 years old, patient is the age of 50 years old, patient is
menstrual and no history of cervical disease. widow and no history of cervical widow and no history of cervical widow and no history of cervical
cycle, civil status, number disease. disease. disease.
of
children, reproductive
status)
b. male (circumcision, civil
status, number of children)