Revised 2019

Mindanao State University

COLLEGE OF HEALTH SCIENCES
Marawi City

Name of Student: _ 3rd Year- Section A2 Clinical Instructor: _ Prof. Norhanie A. Ali

Area of Assignment: ___Medicine Ward Date Submitted: _____June 6, 2023

NURSING ASSESSMENT I

PATIENT’S PROFILE

Name: _________Patient X Address: __Poktan, Butig, Lanao Del Sur Age: _66 y/o

Sex: __Male Religion: _Islam Civil Status: _____Married Occupation: Housewife

HABITS

Frequency Amount Period/Duration

1. Tobacco Daily 3 sticks per day (20-29 y/o)

2. Alcohol X X X
3. OTC-drugs/ non-prescription drugs a.) Losartan PRN OD 500 mg 2 months
b.) Paracetamol ____ PRN TID 500 mg___ ___500 mg TID PO

A. CHIEF COMPLAINTS:

Difficulty of breathing in 10 days, with edema in lower extremities.

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}.
A case of 66 years old housewife residing in Poktan, Butig, Lanao del Sur was admitted to Amai Pakpak Medical Center on February 22, 2023 at 11:20 AM complaining about her difficulty of
breathing. She verbalized that she feels difficulty of breathing in 10 days and decided to be admitted in the Amai Pakpak Medical Center because her family was worried and suggested her
to be admitted. She describes the feeling like being suffocated and verbalized that it would take 2-3 minutes. Also, she verbalized that she often wakes up after sleeping and has difficulty of
breathing but the only thing can relieve it is when she sits. In addition, it would be associated with nausea. The patient was undergone diagnostic test such as Blood chemistry test on Feb
22, 2023 8:19 PM, Immunology and serology test on Feb. 22, 2023 6:22 PM, and Hematology test on Feb 22, 2023 2:44 PM.
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 previous hospitalization of the patient was in November 2022 which she was diagnosed with pneumonia. The patient was showing signs of fever, and non-productive cough. The first
hospitalization of the patient was when she was a child. She experienced vehicular accident. The patient has a sprain in her left leg. The patient has a pneumonia and common cold. She has
undergone a normal delivery of her baby in the APMC. The patient has not been immunized during birth because she was born in her house. The only immunization she has done is a COVID-
19 vaccine (Pfizer 1st dose). The patient has major illnesses like diabetes, asthma, and pneumonia. She has allergies in seafoods especially shrimp. She has been taking losartan 50 mg OD.
The highest educational attainment of the patient is grade 3 elementary level. She was smoking in her middle adulthood (20-29 y/o) with amount of 3 sticks per day.

FAMILY HISTORY WITH GENOGRAM

Acquired Diseases: Heredo- familial Diseases:

Hypercholesterolemia __X Diabetes __✓(M)
Kidney Disease __X Heart Diseases __X
Tuberculosis __X Hypertension __✓(B)
Alcoholism __X Cancer __X
Drug Addiction __X Asthma __✓(M)
Hepatitis A __X Epilepsy __X
B __X Mental Illness __X
C __X Rheuma/Arthritis __X

Others (pls. specify) Pneumonia Others (pls. specify) __X

D. PATIENT’S PERCEPTION OF:

1. Present Illness

“Samanaya na mapipiya so ma g’gdam akn. Kyalibatan so mga kagdam akn a sakit.”

2. Hospital Environment

“Medyo ok lang gya sa hospital. Naba man tanto mapiya na naba pman mapiya.”

E. SUMMARY OF INTERACTION

The patient was interactive and cooperative during assessment. She answered all of my questions clearly. She was awake, alert, and coherent to time, date, place, and person. She was well-
groomed and has done make-up to her face.
 Physical Examination

Name: RAMOS, Al-Rajeb M. Date: Feb 25, 2023

Chief Complaint:_ Difficulty of breathing in 10 days, with edema in lower extremities. Height: 158 cm Weight: 52 kg
Initial Vital Signs: Temp: 36.0˚C RR: 22 cpm PR: 97 bpm O2Sat: _99%_ BP: 130/80 mmHg Pain Score: _N/A__ BMI: __20.3

Initial Assessment

Received lying on bed in fowler’s position conscious, alert, awake and oriented to time, place, person, and date with an ongoing PNSS 1000 ml regulated at 30
gtts/min, hooked at left lower forearm, infusing well. The patient was well-groomed and had a make up on her face. The patient was wearing a red t-shirt and
malong. The patient had a black hair but some part of it were white. The patient seems pretty normal and can do ADL such as taking a bath without assistance. She
GENERAL seems happy and energetic. The patient have an edema in the lower extremities. The patient often sitting upright and avoid lying on bed

H – Head was normocephalic and symmetrical with no tenderness, mass, depressions, and lesions, facial expressions were symmetrical, and no abnormalities was
noted as the patient raised his eyebrows, lowered the eyebrows, frowned, closed eyes tightly, puffed cheeks, smiled and showed his teeth. Hair was moist, dark
brown in color, thin with thick density and about 3 inches in length. Hair was evenly distributed on the scalp. No dandruff and lice were noted. Hair distribution is
normal.
E – Eyebrows were black in color, smooth, thin with thick density and was evenly distributed. eyelashes were short about 5mm length, straight and facing downward.
HEENT No masses, lesions, and edema were observed on the conjunctivas. Irises were dark brown in color, pupils were equal, round, reactive to light (pupils constrict before
light and dilate when light was pulled away) and accommodating. Sclera was pale white in color. No redness of the eyes noted. No lesions and discharges. Eyes were
symmetric and were unaided. Patient verbalized that he could see clearly. He could read 12 font size being 5 feet away from him.
E – Ears were normal in shape, symmetric, with no lesions, masses, tenderness, and discharges. Right and left pina were elastic. The patient was able to repeat the
phrase whispered to him, out of his sight 2 feet away from him.
N – Nose were clear, nasal septum aligned at the middle. No deformity, lesions, tenderness, masses, and discharge were noted. No nasal flaring was noted. Both
nares were patent and could smell properly. No tenderness upon palpation on maxillary and frontal sinuses.
T – Throat assessed through palpation was midline. No deformity, lesions, and swelling were noted. No masses, tenderness and lumps upon palpation. No difficulty
in swallowing. Uvula is midline. Tonsils appeared normal. Hard and soft palate were pale pink and no inflammation. Buccal membrane has a pale pink color with no
white patches.

Hair color is black and light brown scalp with no dandruff noted. Lips were red(make-up) and a little bit foundation her face. No abdominal hairs noted. There is a
presence of edema in the lower extremities of the patient. The pitting edema grading is 3+ which means 6 mm deep pit and 10-12 sec to rebound. Skin was smooth
with little moisture and was cold and clammy to touch with skin turgor of 1 second upon gently pulling the right and lower hands and forearms of the patient. no skin
INTEGUMENTARY discolorations were noted. Reduced subcutaneous fat was noted. Nail plates/beds were very pale pink in color. Capillary refill of less than 2 seconds which was tested
for. No visible pores noted. No diaphoresis noted. Soles and palms were pale pink.
 Respiratory rate was 22 cpm, with 99 % O2Sat. Lungs were clear upon auscultation with no crackles, and wheezing sounds on the anterior and lateral areas of all
lobes of lungs as well as the intercostal spaces of the ribs. There are a rhonchus sounds heard upon auscultation and decreased breath sounds indicating the patient
RESPIRATORY has pneumonia. No deformities on chest and has symmetric chest expansion. The patient has a non-productive cough. The patient cannot sleep well due to
paroxysmal nocturnal dyspnea. Upon admission, the patient’s O2sat was 68%. The patient has jugular vein detention upon assessing the jugular vein. The patient
was in oxygen therapy using nasal cannula during that time. The patient has been diagnosed with Asthma in 2017, and Pneumonia in November 2022.

Pulse rate was 97 bpm upon palpation of the right radial pulse, with 130/70 mmHg. Pulse rate had regular rhythm with the expected amplitude. All pulses (temporal,
carotid, radial, brachial, apical, dorsalis pedis, posterior tibial, and popliteal pulse) were palpable with normal rate, rhythm, and amplitude. Bilateral femoral pulses,
CARDIOVASCULAR left posterior tibial pulse, and left dorsalis pedis pulse were not palpated due to patient’s refusal. The patient has edema in the lower extremities. The patient has
difficulty sleeping due to her condition paroxysmal nocturnal dyspnea. There is a functional holosystolic murmur of mitral regurgitation has been heard upon
auscultation. The patient was in respiratory distress.

Lips were red in color due to the lipstick and had slightly dry small, peeled skin on the central upper part of the lower lip which was not bleeding. Oral mucosa and
DIGESTIVE tongue were pale pink in color, smooth, and moist. Molar teeth were incomplete and teeth were yellow in color, 1 molar on the right side and left side of the teeth
were absent, last left molar tooth had cavity, and upper right first premolar tooth had not yet totally developed. No dentures. Patient had no difficulty
swallowing/dysphagia. The abdomen is soft, non-tender, non-distended. There is presence of abdominal distention (intermittent) and has been suspected with
ascites.

Patient reported to have urinated twice within 24 hours with concentrated clear yellow appearance with no odor with an estimated amount of 300 ml through a
urine bottle assisted by the SO. There is a 1 bowel movement with a constituency smooth, sausage/snake and a color yellow.
EXCRETORY

Right and left upper extremities were normal and symmetric in size with no contractures with a muscle strength of 4/5. Right leg had a muscle strength of 3/5, had
 normal movement against gravity. Both legs are difficult to move due to the presence of edema.

MUSCULOSKELETAL

The patient has 4 child and married. The patient didn’t allow me to examined her genitilia
REPRODUCTIVE

The patient was conscious, alert, awake, and oriented to time, place, person, and date. All senses are intact. Patient had trouble distinguishing between sharp and
dull during sensory function test. Cranial nerves were intact and well-functioning. The patient could smell on each side of his nostrils, eyes were unaided, could
NERVOUS follow the fingers coming to visual field from all directions, had normal papillary reaction to light in both eyes and is accommodating, and could clench his jaw.
Corneal reflex were normal and the facial nerves were at expected. Patient could open his mouth and move his tongue from side to side, has gag reflex, could turn
her head and shrug his shoulders against assistance. No impairment of memory.

No abnormal hair growth was noted. No abnormal growth of any additional muscle was noted. No presence of beard and mustache were noted and no armpit hair.
No thyroid problems. The patient has thin physical appearance. Has height of 158 cm and weight of 50 kg. BMI of 20.3. Normal functioning salivary, sebaceous,
ENDOCRINE eccrine, apocrine, lacrimal, and thyroid gland. Reported to have no diabetes which can implicate normal pancreatic gland

NURSING ASSESSMENT II
Name Patient X Age _66 y/o_ Sex __Male
Admitting Chief Complaint Difficulty of breathing in 10 days, with edema in lower extremities.
Impression/Diagnosis: Heart failure, Hypertensive cardiovascular disease
Date/Time of Admission Feb 22, 2023 11:20 AM Inclusive Dates of Care Feb 25-26 2023
Diet: Bland, low-residue diet Allergies: Seafoods especially shrimp Type
of Operation (if any) None

NORMAL PATTERN BEFORE HOSPITALIZATION INITIAL CLINICAL APPRAISAL

DAY 1 DAY 2

The patient’s activities are cleaning

1.ACTIVITIES- REST the house and gardening. After the The patient’s activities in the The patient’s activities in the
hospital were lying, and ambulatory hospital were lying, and ambulatory
a. Activities activities had been done, she would
with assistance. The patient sleeps with assistance. The patient sleeps
usually sit or lie on a bed. The at 7 PM and wakes up at 6 AM at 8 PM and wakes up at 5 AM
b. Rest patient was experiencing
c. Sleeping pattern paroxysmal nocturnal dyspnea
which made her difficult to sleep.

2.NUTRITIONAL- METABOLIC
a. Typical intake(food, fluid)
b. Diet
c. Diet restrictions
d. Weight
e. Medications/supplement
food
3. ELIMINATION
The patient would usually eat
vegetables, fruits, rice, tulay,
chicken, and beef. The patient’s diet
usually contains high protein and
high cholesterol even though she
must avoid this kind of diet. The
patient’s weight is 54 kg. The
patient’s medication was Losartan
50 mg OD.
The patient usually urinates twice a
The patient eats ½ cup of rice,
vegetables, fruits, manok and bihon.
The patient’s diet is low cholesterol,
bland and low residue. The patient
is not allowed to have a high-
cholesterol diet. The patient’s
weight is 50 kg. The patient was
prescribed to take spironolactone
80 mg, clopidogrel 15 mg,
atorvastatin 20 mg, budesonide 1
mg, lactulose 30 cc, losartan 50 mg,
and amlodipine 5 mg.
The patient urinated 1 time with
The patient eats ½ cup of rice,
vegetables, fruits, manok and bihon.
The patient’s diet is low cholesterol,
bland and low residue. The patient
is not allowed to have a high-
cholesterol diet. The patient’s
weight is 50 kg. The patient was
prescribed to take spironolactone
80 mg, clopidogrel 15 mg,
atorvastatin 20 mg, budesonide 1
mg, lactulose 30 cc, losartan 50 mg,
and amlodipine 50 mg.
The patient urinated 1 time with
 a. Urine (frequency, color,
transparency)
b. Bowel (frequency, color,
consistency)
day with yellow color. The patient
usually defecates twice a day, with
yellow color, and the consistency of
a sausage/snake.
yellow color during my assessment.
The patient’s amount of urine is 300
ml. The patient defecates only once
during my assessment with a brown
color and the consistency of a
sausage/snake
yellow color during my assessment.
The patient’s amount of urine is 200
ml. The patient defecates only once
during my assessment with a brown
color and the consistency of a
sausage/snake.

4. EGO INTEGRITY
a. Perception of self
b. Coping Mechanism
c. Support System
d. Mood/Affect
The patient reported that she had a
positive perception of herself. She
was independent and was able to do
anything she wanted. She usually
does household chores and
gardening to ease her worries and
entertains herself. Her support
system was his family and friends.
The patient was cheerful and active.
The patient verbalized that she
remains positive about herself. She
was trying to be independent as she
can. She verbalized that she relied
on the power of Almighty Allah. Her
support system is her family and
friends. The patient seems happy.
The patient verbalized that she
remains positive about herself. She
was trying to be independent as she
can. She verbalized that she relied
on the power of Almighty Allah. Her
support system is her family and
friends. The patient seems happy.

5. NEURO-SENSORY
a. Mental state
b. Condition of five senses:
(sight, hearing, smell, taste,
The patient was conscious, alert,
awake, and oriented to time, place,
person, and date. She had no history
of mental illnesses or disorders. The
patient’s 5 senses are all intact.
The patient was conscious, alert,
awake, and oriented to time, place,
person, and date. She had no history
of mental illnesses or disorders. The
patient’s 5 senses are all intact.
The patient was conscious, alert,
awake, and oriented to time, place,
person, and date. She had no history
of mental illnesses or disorders. The
patient’s 5 senses are all intact.

touch)

Vital signs were not assessed and

6. OXYGENATION monitored. Patient has history of T – 36.0°C T – 36.5 °C
pneumonia and asthma.
a. Vital signs P – 97 bpm P – 88 bpm

Temperature R – 22 cpm R – 21 cpm

Respiratory rate BP – 130/80 mmHg BP – 110/80 mmHg

Heart rate SpO2 – 99% SpO2 – 99%

Blood pressure There is a presence of rhonci sounds There is a presence of rhonci sounds
during auscultation. The patient has during auscultation. The patient has
b. Lung sounds a history of pneumonia and asthma. a history of pneumonia and asthma.
c. History of Respiratory

Problems

The patient has been feeling of

7. PAIN-COMFORT The patient did not felt any pain. abdominal with a pain scale of 8/10, The patient did not felt any pain
associated with nausea. The comfort
a. Pain (location, onset,
measures are when she was in C
character, intensity,
position while pressing her
duration,
abdomen. The patient’s medication
associated symptoms,
is acetaminophen.
aggravation)

b. Comfort
measures/Alleviation

c. Medications

8. HYGIENE AND ACTIVITIES The patient took a bath every day The patient took a bath every day The patient took a bath every day
OF DAILY LIVING and she brushed her teeth every and she brushed her teeth every and she brushed her teeth every

9. SEXUALITY
a. female (menarche, menstrual
cycle, civil status, number of
children, reproductive status)
b. male (circumcision, civil
status, number of children)
day. Her fingernails and toenails
were properly trimmed. She could
do all activities of daily living (ADL)
such as doing household chores and
gardening.
The patient is in menopausal stage,
married, has 4 children, and not
sexually active
day. Her fingernails and toenails
were properly trimmed. She has
make-up on during assessment. She
tried to be independent as much as
possible.
The patient is in menopausal stage,
married, has 4 children, and not
sexually active
DISCHARGE PLAN
day. Her fingernails and toenails
were properly trimmed. She has
make-up on during assessment. She
tried to be independent as much as
possible.
The patient is in menopausal stage,
married, has 4 children, and not
sexually active
NAME ____Patient X ______________________ DATE OF DISCHARGE: ____Not yet discharged

CONDITION UPON DISCHARGE Not yet discharged ___________ Nature: Home per request ( ) Discharge against medical advice ( )

1. MEDICATIONS  Losartan 50 mg OD PO
 Avorstatin 20 mg OD PO
 Amlodipine 5 mg OD PO

 Avoid heavy lifting

 Avoid sports or strenuous activities (depending on the advice of the doctor)
2. EXERCISE  Do light exercises such as walking
 Talk with your primary provider for specific exercise program recommendations
 Begin with low-impact activities such as walking
 Start with warm-up activity followed by sessions that gradually build up about 30 mins.
 Follow the exercise period with cool-down activities
 Avoid performing physical activities outside in extreme hot, cold, or humid weather
 Wait 2 hr after eating a meal before performing the physical activity
 Ensure that you are able to talk during the physical activity; if you cannot do so, decrease the intensity of activity
 Stop the activity if severe shortness of breath, pain or dizziness develops

 Avoid high-cholesterol foods such as fried chicken.

 Avoid foods that contained high amounts of salt and processed foods.
3. DIET  Limit intake of fluids from 6-9 cups a day.
 Eat a low-sodium diet
4. SCHEDULE FOR THE NEXT VISIT Not yet discharged

NURSING CARE PLAN

 CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective Cues Acute pain related to Within 8 hours of my clinical Independent: Independent Within 8 hours of my clinical
abdominal distention as duty, the patient will be able: duty, the patient was able:
“P’sakit gya tiyan akn” evidenced by facial grimace, 1.) Assess for potential 1.) Assess for potential
 To verbalize the types of pain types of pain that  To verbalized the
c-position while pressing her decrease of the pain decrease of the pain
may be affecting the
abdomen, irritated and score from 8/10 to 2.) Demonstrate deep score from 8/10 to
client
Objective cues discomfort expression 5/10 breathing exercises 5/10
2.) To reduce the pain
 To verbalize the relief to the patient. he/she felt  To verbalized the
 Facial grimace
from the pain relief from the pain
 Abdominal 3.) Encourage 3.) To evaluate coping
enlargement  To displays a relaxed verbalization of abilities and to  To displayed a
manner feelings about the identify areas of relaxed manner
 Pain score 8/10 pain additional concern
4.) To reduce edema and
 C position while 4.) Apply cold or ice pack hematoma formation
pressing her if necessary. and reduce pain
sensation. The
abdomen
5.) Identify diversional duration of
 Irritated and activities appropriate application depends
on the degree of
discomfort to the patient age,
patient comfort and
expression physical abilities, and as long as the skin is
personal preferences. carefully protected.
Vital Signs:
5.) To prevent boredom,
6.) Provide comfort
T – 36.0°C reduce muscle
measures such as tension, increase
P – 97 bpm massage, backrub, muscle strength, and
and position change enhance coping
R – 22 cpm abilities.
Dependent: 6.) To improve general
BP – 130/80 mmHg
circulation and to
1.) Administer reduce local pressure
SpO2 – 99%
medication as and muscle fatigue.
ordered.
Dependent
2.) With the help of CI,
evaluate and 1.) To help the patient to
document the client’s be relieved from pain
response to
analgesia.
2.) Increasing/
decreasing dosage,
stepped program
helped in self-
management of pain
 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective cues: Activity intolerance related to Within 8 hrs of my clinical Independent Within 8 hrs of my clinical
decreased Cardiac output as duty, the patient would be 1. To know if the duty, the patient was able:
“Suko dati na d ako d 1. Monitor the patient’s activities are
evidenced by fatigue, able:
galbakan sa walay ago adn pn weakness, and restlessness. response to activities. helping the patient  To demonstrated
a mga garden. Imanto na d  To demonstrates tolerance for desired
2. Give encouragements
akn kasuwa so mga galbak tolerance for desired 2. To give confidence activities
akn andang ka permenti ako to the patient
activity to the patient and
malbod dukawan. Type akn 3. Encourage the be more motivated
mangalb’k akn so andang a patient to speak out
psuwaan.” if the exercise 3. To lower the
intensity of the
program is hard to do
exercise program
4. Encourage the 4.
Objective cues:
patient to move as the body would
Fatigue more as possible. used to moving and
thus improving
Weakness 5. Encourage the cardiovascular
patient to voice out capacity.
Restlessness her complains or
concerns on exercise 5. To make sure that
Vital signs
program the patient was
T – 36.0°C fully committed
6. Advise the SO or
P – 97 bpm family of the patient
to join with the 6. To motivate the
R – 22 cpm patient more.
patient in the
BP – 130/80 mmHg exercise program
Collaborative
SpO2 – 99% Collaborative The physical therapist are
the experts in making an
With the help of physical exercise program which
therapist, make an exercise would help the patients to
program, to improve the be more tolerant for
tolerance for desired activity. desired activity
 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective Cuses:
“Oman adn a p’kasuwa suwa
sa lawas akn na ma al’k ako
dn lagd gya kap’lbag gya ae
akn ago giya kyapakala a
tiyan akn”
Anxiety related to the clinical
manifestations of heart
failure
Within 8 hrs of my clinical
duty, the patient would be
able:
 To verbalize a
decrease of anxiety
Independent Within 8 hrs of my clinical
duty, the patient was able:
1. Demonstrate the To make the patient feel
relaxation techniques more relax  To verbalized a
e.g. deep-breathing decrease of anxiety
exercise to the
patient

2. Educate the patient To alleviate anxiety

about the clinical
Objective Cues: manifestations of
Facial grimace heart failure.
To create a supportive
Irritated and discomfort 3. Listen actively to the
environment and sends a
expression patient.
message of caring
Restlessness 4. Use therapeutic
communication to To make sure that the
V/s patient’s feeling wasn’t
the patient
hurry
T – 36.0°C Dependent

P – 97 bpm 1. If the therapeutic To make the patient feel

R – 22 cpm communication and more relax
relaxation techniques is not
BP – 130/80 mmHg working, administer
medications as ordered.
SpO2 – 99%
Collaborative
The referral is the last plan
Referral to the psychiatrist
of a nurse if the patient
doesn’t respond to the
interventions.