Paragua J.B Rlencm 113 Individual Output Final 1

Republic of the Philippines
University of Cabuyao
(Pamantasan ng Cabuyao)
College of Health and Allied Sciences
Katapatan Mutual Homes, Brgy. Banay-banay, City of Cabuyao, Laguna, Philippines 4025
RLENCM 113 – Community Health Nursing 2
Interviewing and Screening Older Adults for Common Problems Residing

at Sitio Tanglaw, Brgy. Sala, Cabuyao City, Laguna
In Partial Completion of Community Health Nursing 2 Community

Area: Barangay Sala
Submitted By:
Joerin B. Paragua
3 BSN-B/Group 9
Submitted To:
Ms. Josephine B. Tulabing, RN, MAN
Date Submitted:
November 30, 2023
Page 1 of 12
TABLE OF CONTENT
Page No.
GERON CHECKLIST – NARRATIVES …………………………………………... 3
Part I ………………………………………………………………………………….. 3
Part II …………………………………………………………………………………. 4
Part III ……………………………………………………………….………………... 8
Mini-Cognitive Assessment ………………………………………………………… 5
Part IV ………………………………………………………………………………… 6
ASSESSMENT ……………………………………..……………………………….. 7
JOURNAL REFLECTION ………………………………………………………….. 8
DRUG STUDY …………………………..…………………………………………... 10

Paracetamol …...…………………………………………………………………….. 10
Decolgen ..……………………………………………………………………………. 12
Neozep …..………………………………………………………….………………... 14
3 NURSING CARE PLANS .…………..…………………………………………... 16

1ST Nursing Care Plan …..………………………………………………………….. 16
2nd Nursing Care Plan ..……………….……………………………………………. 17
3rd Nursing Care Plan ………………………………………….….………………... 18
NCM 114 – Care of Older Adult (RLE)
NAME OF ELDERLY: Lolita Rose B. Directo AGE: 63 Years Old

ADDRESS: Sitio Tanglaw, Brgy. Sala, Cabuyao City, Laguna
Page 2 of 12
Checklist for Interviewing and Screening Older Adults for Common Problems
PART I
Establishing Rapport:
• Introduce yourself by name.
• Greet the elderly person and shake their hand.
• Ask the elderly person their preferred name.
• Respond empathetically to the elderly person's emotions.
• Arrange to sit and adjust your voice volume to ensure effective communication.
• Explain the purpose of the interview.
• Do not interrupt during the opening statement.
Gathers Data:
 Begin with an open-ended question: “What do you feel is the biggest obstacle to your
day to-day activities?
Financial, everyone have that problem.
 Identify the seven main symptoms or problems that significantly affect daily activities.
Financial, Food, Electricity, Environment, Medication t
 Obtain information on current and past medical conditions.

Nothing to mention
 Inquire about past surgical history.

Never been into a surgery
 Collect a comprehensive medication history (use additional paper if necessary).

Ask for the names of medications, dosages, and reasons for use
-Biogesic (500 mg) – headache, backache
-Decolgen – headache, body aches, and fever.
-Neozep – clogged nose, runny nose,
Inquire about prescription medications, laxatives, vitamins, herbals, & cold medications
Nothing as mentioned
Ask about any recent changes in medication

 Allergies (reactions)
 Social History (living arrangements, work history, financial concerns, social/spiritual

support)
Living Arrangements: Together with my husband and sometimes with my grandchildren
Work History: Store Vendor
Financial Concerns: Lack of financial Income
Social Support: They only receive from her Son
Spiritual Support: We believe in Christ but we often go to church
 Family History (Alzheimer’s disease, depression, role as caregiver) None as mentioned
PART II
Geriatric Screening Questions:
Page 3 of 12
 Are you currently experiencing any difficulties with your memory?

Sometimes, I forgot where I put things
 Have you experienced any falls in the past year?

 Do you have any trouble with your hearing?

No, my ears are still working properly
 Do you have any trouble with your vision? Do you wear glasses?
I wear glasses, specially when I sewing due to my vision’s a little bit blurry
 Have you lost more than 10 lbs in the past 6 months?

No, my weight is still the same as the past months
 Do you feel sad or depressed?

So far, I haven’t felt sad or depressed, because I’m too busy for grandchild
Activities of Daily Living (ADLs):
 Toileting – Do you experience any involuntary urine loss? Do you have difficulty
reaching the bathroom? No, but last night I felt difficulty of peeing
Score: 1/1
 Feeding – Do you have any difficulty feeding yourself? Are you able to feed yourself?
Do you follow a special diet?
No. I eat all by myself and haven’t felt any difficulty, Score: 1/1
 Dressing - Are you able to dress yourself? Do you have any difficulty with dressing?
I can wear anything without facing difficulty. Score: 1/1
 Grooming – Do you require assistance with cutting your nails or brushing your hair?
I still can cut my own nails and helping my husband to trim his nails
Score: 1/1
 Walking – How far are you able to walk?

I can walk so far and walking with my grandchildren sometimes in the morning
Score: 1/1
 Bathing – Are you capable of independently bathing yourself or do you require

assistance? Do you possess a shower chair to ensure safety? Are you concerned about
the risk of falling in the shower?
No, I don’t have anything to help me, because still manage to take a bath all by myself
and I’m slowly but surely to avoid slipping in the comfort room.
Score: 1/1
PART III
Instrumental Activities of Daily Living (IADLs)
 Telephone – Are you proficient in using the telephone? In the event of an emergency,
who would you contact? Do you have access to a lifeline or any other emergency
communication system?
Page 4 of 12
Yes, only keypad cellphone, my children are the only one we can call and but also we
have list of emergency hotlines
 Shopping – Do you handle your own shopping or do you rely on assistance from
someone else? If you require assistance, please specify who helps you with your
shopping needs.
I can handle shopping and sometimes I came along with my husband
 Food Preparation – Are you able to independently cook your own meals?
I always do the preparation, since my husband and I are both together
 Housekeeping – Are you capable of performing household chores and maintaining

cleanliness in your living space?
Yes, I can do the house chores and sometimes my husband help me
 Laundry – Are you able to manage your own laundry or do you require assistance?
I always do the laundry, especially the white clothes that needing manual washing
 Transportation – Do you currently drive or rely on alternative means of transportation?

How do you typically commute to your doctor’s appointment?
I can only rode a public vehicles, especially my husband and I are
going to the hospital
 Medication – How do you manage your medication regimen? Do you utilize a pill box or
any other organizational system? Do you require assistance in setting up your
medications?
We have the medicine that from the boticab and we put it here in the ecobag.
 Finances – Do you receive any assistance with managing your finances?

Yes, we receive assistance from our son and also coming from the senior citizen
benefits.
MINI-COGNITIVE ASSESSMENT (Administration)
 Instruct the patient to listen attentively and remember three unrelated words, such as
"red," "Broadway," and "42." Then, ask the patient to repeat the three words back to you
to ensure they have heard them correctly.
 Guide the patient to draw the face of a clock on a blank page or a page with a pre-drawn
circle.
 Once the patient has placed numbers on the clock face, instruct them to draw the clock
hands to indicate the time as 8:20. Do not provide any further instructions. If the clock
draw test (CDT) is not completed within three minutes, proceed to the next step.
 Ask the patient to recall the three words that were presented earlier.
Scoring
 Assign one point for each correctly recalled word after the CDT, resulting in a score
ranging from 0 to 3 for recall.
Score: 1/3
 Award two points for a normal CDT, where all numbers are depicted once, in the correct
order and position, and the hands show the requested time. Assign a score of 0 for an
abnormal CDT.
Score: 2/2
 Add the recall and CDT scores to obtain a Mini-Cog Score, which ranges from 0 to 5.
Score: 3/5
Page 5 of 12
Interpretation:
• A score of 3 or more indicates normal performance.
• A score of 2 or less suggests abnormal performance.
Commencing the mini cognitive assessment, I commenced by introducing the words "Tanghali,"
"Inom," and "Tubig" to the individual. Subsequently, I instructed him to repeat these words, and
his response demonstrated an accurate recall. Proceeding to the next phase of the evaluation, I
then tasked him with drawing a clock face, a challenge that he met with completeness and
precision, subsequent to the initial clock drawing task, I extended the assessment by presenting
an additional challenge. Specifically, I requested him to depict the clock hands indicating the
time as 12:30. Impressively, he adeptly rendered the clock, ensuring that the hands were
positioned precisely at the designated hour.
Concluding the comprehensive assessment, I revisited the previously presented words,

"Tanghali," "Inom," and "Tubig." Notably, the individual promptly recalled and recited only one
word. This thorough evaluation not only underscores his capacity to retain and reproduce
information but also highlights his proficiency in visual-spatial tasks. Collectively, these
observations contribute to a positive assessment of his cognitive abilities.
PART IV
Up and Go Test
To ensure the patient's comfort, please stand close by to offer support if needed.
 Kindly ask the elderly patient to sit in an armless chair.
 Instruct them to stand without using their hands, walk to a designated mark 10 feet
away, turn, walk back to the chair, and sit down again. If they are unable to stand without
using their hands, allow them to do so.
 Inform the patient that they will be timed during this test.
 Observe the following closely and be prepared to provide a description for each: - Body
posture while seated: Good posture, the back is slightly hunched
- Initial stance and stride length: Fair stance, she walked a lot of steps
- Quality of turning: She manage to turn well
- Spatial awareness when seated: Flexible awareness and can seat in good position
Scoring: This performance measure has been validated, and a time exceeding
9 seconds indicates a twofold increase in the risk of falls.
Closing:
 Inquire about any other concerns the patient may have.
 Summarize the key points discussed during the session.
 Express appreciation for the patient's time and cooperation.
 Offer a handshake as a gesture of goodwill.
If necessary, provide an additional sheet of paper.

Remember to record the patient's vital signs during each visit to the elderly.
Page 6 of 12
On the 10th of November 2023, the patient's vital signs were recorded as follows:
Temperature: 36.5°C
Pulse Rate: 60 BPM
Respiratory Rate: 16 BPM
Oxygen Saturation: 96%
Blood Pressure: 110/70 mmHg
During the follow-up visit on the 17th of November 2023, the patient's vital signs were
documented as:
Temperature: 36.5°C
Pulse Rate: 65 BPM
Respiratory Rate: 17 BPM
Oxygen Saturation: 98%
Blood Pressure: 110/80 mmHg
These recordings provide a comprehensive overview of the patient's physiological parameters,

indicating stability in temperature, pulse rate, respiratory rate, oxygen saturation, and blood
pressure between the two visits.
ASSESSMENT:
Head to Toe Assessment:
Level of Consciousness: Pain:

- Awake - Back
- Alert - Intensity: 3/10
Orientation: Eyes:
- Aware of Name - Equal
- Place - Round
- Time - Puffy
- Situation - Eyebrows are evenly distributed
- Eyelashes are evenly distributed
- Accommodate to distance
- Reactive to Light
Ears: Mouth:
- Symmetrical - Moist
- Skin Intact - Lips: Brown
- Gums: Light Pink
Hair: Chest:
- Clean - Rhythm: Normal
- Sparse/Hair Loss - Heart Sounds: Normal
- Hair is evenly distributed - Breath Sounds: Clear
- Neatly Groomed
Do you experience any type of abused?

Never as she mentioned.
How do you feel if your members of the family will bring you to the home for the aged?
Why?
Page 7 of 12
- She said that would never happen due to the responsibility that she’s doing for her family,
especially for his grandchildren’s
JOURNAL REFLECTION:
Page 8 of 12
Excitement fills me as I anticipate our upcoming Community Health Nursing (CHN) rotation,
knowing that the activities ahead may be bustling. However, upon my arrival at the municipal
office on the first day, my perspective undergoes a quick shift. Our group efficiently divides into
various tasks: the initial three individuals are assigned to BEMNOC, the subsequent two focus
on immunization, another two are designated for immunization duties, and the following pair
joins the immunization efforts. Finally, I find myself assigned to vaccination at Sala Cover Court.
This allocation not only provides a clear structure but also allows me to embrace the diversity of
tasks within the CHN rotation. It may be a bit tiring, but it proves worthwhile as I witness the
relief on people's faces after they receive their vaccinations.
On the second day, our visit to Sitio Tanglaw brings forth genuine smiles and friendly greetings
from the residents, setting a positive tone for our time there. Upon arriving in the area, we visit
the residence of the leader, and Ma'am obtains permission to utilize their office, a modest
house-type structure with minimal furnishings. Before we proceed, Ma'am reminds us of
valuable guidelines, emphasizing the significance of respecting cultural nuances, such as
sticking with a partner and approaching elders with care. Paired up, we conduct interviews with
the elders under Ma'am's supervision, particularly Nanay Lolita Rose. I am pleasantly surprised
by their remarkable willingness to cooperate, and it becomes evident that in this specific
community, there is a sense of openness and receptiveness to our inquiries. To foster trust, I
assure them that the information shared will remain private, creating an environment conducive
to openness. Choosing to sit in front of them contributes to a more comfortable setting,
eliminating potential discomfort from standing during the interview. Nanay's quick and
unwavering responses highlight the depth of her willingness to share valuable insights. This
experience underscores the importance of cultural sensitivity and building rapport when
engaging with communities. The genuine hospitality and cooperative spirit exhibited by the
residents of Sitio Tanglaw make this visit not only informative but also a poignant reminder of the
richness that comes from connecting with people on a personal level.
On the third day, our responsibilities shift to BEMNOC due to the government's weekend non-
operational hours. Engaging in a quiz covering GPTPALM, EDD, and AOG, Ma'am presents a
thought-provoking question that prompts some overthinking. Following the quiz, we share our
interview experiences from the previous day, and fortunately, I complete my tasks before lunch,
alleviating any potential stress. This creates an opportune moment for a relaxed conversation
about our interview encounters.
The fourth day brings a change in plans, redirecting us to CHO1 before returning to Sitio
Tanglaw. Assigned to gather data from Sala Brgy Hall, along with Ma'am, when we return to
CHO1, we walk to BEMNOC and encounter a considerable number of pregnant women
participating in a mini-program for expectant mothers. Performing the four types of maneuvers in
person for the first time provides enlightening insights. While a slight correction is made during
the fundal height measurement, subsequent adjustments ensure accuracy. Ma'am outlines
tasks for the next day, involving a comprehensive head-to-toe assessment and follow-up
questions. Additionally, she reviews the PowerPoint presentation, which will serve as the
foundation for our upcoming quiz.
On the fifth and final day in CHN Sala, our return to Sitio Tanglaw involves leaving our
belongings at their office. I initiate the head-to-toe assessment with assistance, and despite
uncertainties about correctness, the process concludes satisfactorily. The day encompasses a
quiz and a detailed tour of Sitio Tanglaw, navigating its twists and turns. After completing our
agenda, we return to CHO1 for lunch, with two individuals designated to BEMNOC, while the
rest of us utilize our time in the room. Ma'am Tulabing's seamless collaboration streamlines our
tasks, and her genuine guidance is genuinely appreciated, enhancing the overall learning
experience.
Page 9 of 12
DRUG STUDY:
PARACETAMOL (500 MG)
GENERIC CLASSIFICATION MECHANISM OF DOSAGE AND INDICATION CONTRAINDICATI SIDE EFFECTS NURSING
NAME, BRAND ACTION ADMINISTRATION ON CONSIDERATION
NAME
Acetaminophen's The typical adult Acetaminophen is - Avoid Gastrointestinal - Nurses should
Generic Name: Analgesics and exact mechanism dosage of commonly Acetaminophen : carefully calculate and
Acetaminophen Antipyretics isn't fully understood, acetaminophen is indicated for the when having - Diarrhea administer the correct
but it's believed to 500mg to 1000mg relief of mild to allergy or - Nausea dosage based on the
Brand Name: reduce pain and every 4 to 6 hours moderate pain sensitivity. - Vomiting patient's weight, age,
Panadol, fever by inhibiting an as needed, with a and the reduction and overall health.
Paracetamol, enzyme called maximum dose of of fever. It's - Individual Allergic - Provide clear
s with severe Reactions:
Dayquil Sinex, cyclooxygenase 4000mg per day. widely used for instructions to patients
liver disease or
Diphen, (COX). Unlike Always follow the various - Itching about the proper use,
damage should
Dolofin, nonsteroidal anti- dosing instructions conditions, such - Rashes including dosing
use
Dologen inflammatory drugs on the medication as headaches, acetaminophen
- Swelling intervals and the
(NSAIDs), label or as directed muscle aches, with caution, as importance of not
acetaminophen has a by your healthcare toothaches, and excessive use exceeding
limited effect on provider. It's crucial to manage fever can lead to liver recommended doses.
inflammation. Its to avoid exceeding associated with damage. - Consider the
action in the central the recommended illnesses like patient's medical
nervous system may dose, as excessive colds and flu. - Chronic history, especially
contribute to its intake can lead to Additionally, it's alcohol use regarding liver
increases the risk
analgesic (pain- serious liver often included in conditions or allergies,
of liver damage
relieving) effects. damage. For combination with as these may impact
when combined
Page 10 of 19
children, the other medications with the suitability of

dosage is weight- to enhance its acetaminophen.
dependent and effectiveness for - Some - Regularly assess
should be specific medications, like patients for any signs
determined by a symptoms. certain of adverse effects,
antiseizure drugs,
pediatrician. Always follow the such as nausea,
can interact
Remember to recommended vomiting, or allergic
negatively with
consider any other dosage and acetaminophen. reactions.
medications you're guidelines, and - Be aware of
taking to avoid consult a - While potential interactions
unintentional healthcare generally with other medications
acetaminophen professional if considered safe the patient is taking, as
overdose. you have any when used as certain drugs may
concerns or directed, affect the metabolism
questions about pregnant and of acetaminophen.
its use. Breastfeeding
Page 11 of 19
DECOLGEN (200 MG)

BRAND CLASSIFICATION MECHANISM DOSAGE AND INDICATION CONTRAINDICATI SIDE EFFECTS NURSING CONSIDERATION
NAME, OF ACTION ADMINISTRATI ON
GENERIC ON
NAME
It works by This
Generic - Antipyretic inhibiting the Adults and medicine is -If the patient is Side Effects - Assess the patient's
Name: - Analgesic production of children 12 years used for the allergic to any persistent, severe current health status, including
- Decongestant certain and older: Orally, relief of ingredient in the headache; vital signs, respiratory status,
Tricor chemicals in the 1 tablet every 6 clogged product. nervousness, and the presence of any
brain that cause hours, or, as nose, runny -If the patient has restlessness, underlying medical conditions.
pain and fever, recommended by nose, high blood pressure insomnia/sleeplessness, - Provide clear instructions
Brand dizziness, anxiety, to the patient regarding the
decongestants a doctor. postnasal or severe heart
Name: proper dosage, frequency, and
that work by drip, itchy disease unless confusion, high BP,
duration of Decolgen use.
narrowing the Missed Dose: If and watery recommended by a palpitation, chest
Fenofibrate tightness, tremor,
blood vessels in the patient eyes, doctor. - Monitor vital signs
the nasal missed a dose, sneezing, -If the patient has agitation, irritability, regularly, especially if the
passages. This just take the next headache, anemia, kidney or nausea, blurred vision. patient has cardiovascular
constriction dose if still body aches, liver disease unless Muscle weakness, GI conditions, as decongestants
reduces needed for the and fever recommended by a discomfort, nausea, like phenylephrine can affect
swelling and condition being associated doctor. vomiting, diarrhea or blood pressure and heart rate.
congestion in treated, and the with the -If the patient is constipation
the nasal subsequent common pregnant or
tissues, making doses at the cold, allergic breastfeeding.
it easier to recommended rhinitis,
Page 12 of 19
breathe, while time or schedule sinusitis, flu,

antihistamines (i.e., every 6 and other
that help relieve hours). minor
symptoms such Do not double respiratory
as sneezing, the dose. tract
runny nose, and infections. It
itchy or watery also helps
eyes by decongest
blocking the sinus
action of openings and
histamine, a passages.
chemical
released during
an allergic
reaction
Page 13 of 19
Neozep (10mg)
BRAND NAME, CLASSIFICATION MECHANISM OF DOSAGE AND INDICATION CONTRAINDICATI SIDE EFFECTS NURSING
GENERIC NAME ACTION ADMINISTRATION ON CONSIDERATION
Brand Name: Belongs to the Phenylephrine HCl, a Neozep Forte: Neozep Forte is If the patient is -Increased blood - Prior to administering
Neozep Forte class of anilide nasal decongestant, These medicines indicated for the allergic to any pressure Neozep, it is crucial to
preparations. Used clears obstructed air should be taken relief of symptoms ingredient in the -Nervousness assess the patient's
Generic Name: to relieve pain and passages and nasal orally (by mouth). associated with product. -Restlessness medical history, includin
Chlorphenamine fever. sinuses due to Dose of colds, allergies, If the patient has -Difficulty any known allergies, pr
Maleate congestion making Phenylephrine HCl and respiratory high blood sleeping. existing medical
breathing easier. + Chlorphenamine pressure or severe -Drowsiness
infections. It helps conditions, and curren
It also reduces Maleate + heart disease -Dry mouth,
in clearing nasal medications.
postnasal drip. Paracetamol every unless -Blurred vision,
Paracetamol is an 6 hours: Adults and congestion, recommended by constipation, - Verify if the patient ha
effective fever Children 12 years reducing a doctor. -Urinary any known allergies,
reducer and pain and older: 1 tablet. postnasal drip, If the patient has retention especially to the
reliever. Or, as providing relief anemia, kidney or components of Neozep
recommended by a from allergy liver disease Allergic reactions can
Neozep Forte: doctor. symptoms, and unless range from mild skin
These medicines addressing fever recommended by rashes to severe
contain Neozep Non- and pain. a doctor. anaphylaxis, so carefu
Phenylephrine HCl, Drowsy: Adults and If the patient is screening is essential
Chlorphenamine Children 12 years Non-Drowsy is pregnant or
Maleate and and older: Orally, 1 breastfeeding.
indicated for the - Assess the patient's
Paracetamol. tablet every 6 hours,
relief of symptoms current medication
Chlorphenamine or, as
Maleate, an anti- recommended by a associated with regimen to avoid
allergy, relieves doctor. colds and potential drug
Page 14 of 19
symptoms such as respiratory interactions. Neozep

runny nose, Missed dose: infections. It is contains multiple activ
sneezing, and itchy, If the patient missed designed to ingredients, and some
watery eyes. a dose, just take the provide relief from may interact with othe
next dose if still nasal congestion, medications the patient
Neozep Non- needed for the postnasal drip, taking.
Drowsy: This condition being
fever, and pain,
medicine contains treated, and the
while minimizing - Consider the patient'
Phenylephrine HCl subsequent doses
at the drowsiness. overall health status,
and Paracetamol. especially if they have
recommended time
or schedule (i.e., condition
every 6 hours).
NURSING CARE PLANS:
Page 15 of 19
COUGH
ASSESSMENT NURSING GOAL/EXPECTED NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS OUTCOME
Subjective Data: Ineffective airway After 8 hours of - Establish rapport - To develop trust and GOAL MET
Nahihirapan ng clearance related nursing intervention cooperation of the After 8 hours of effective nursing
huminga ang apo ko to excessive the patient will be - Monitor vital sign especially the patient intervention the patient is able to have
respiratory rate patient airway as manifested by:
dahil sa sipon at accumulation of able to have patent
plema verbalized by secretions airway as - to obtain baseline data - RR 18 cpm
- Monitor the feeding intolerance,
the patient secondary to manifested by: abdominal distention and emotional - Decreased crackles upon auscultation
Pneumonia stressor - To mobilize secretion - Decreased presence of mucoid nasal
Objective Data: - RR within normal discharge
- RR 25 cpm range - Advise frequent change in position - To liquefy secretion
- Crackles heard - Decrease crackles
upon auscultation heard upon - Encourage to Increase fluid intake - To moisten secretion and
- Presence of mucoid alleviate congestion
auscultation - Perform nebulization as ordered
nasal discharge - Decrease presence
-Productive cough - To mechanically dislodge
of nasal discharge - Perform back tapping or chest secretion from the
irritable
physiotherapy after each nebulization bronchial walls
- Use of accessory
muscle
ACUTE PAIN (BACKPAIN)
ASSESSMENT NURSING DIAGNOSIS GOAL/EXPECTED NURSING INTERVENTIONS RATIONALE EVALUATION
Page 16 of 19
OUTCOME
Subjective Data: Acute pain related to After 8 hours of Independent: Investigate - Helpful in determining After 8 hours of nursing
Inflammatory process nursing interventions: report of pain, noting pain management needs Intervention
"Minsan sumasakit ang - The patient will be characteristics, location, and effectiveness of the
able to Incorporate intensity (0-10 scale) program -The patient will be able to
likod ko kakabuhat sa
relaxation skills and incorporate relaxation skills
apo ko” as verbalized by diversional activities Provide firm mattress and - Soft or sagging mattress and diversional activities into
patient into pain control small pillow and large pillows inhibits pain control program
program the proper body alignment
Suggest patient assume The patient reported alleviate
Objective Data: Long-Term: position of proper comfort - In acute phase, total bed of pain and enhanced overall
- Facial mask of pain. Within three months, while in bed or chair. Promote rest may be necessary to quality of life.
- Self narrowed focus the client will report bed rest as indicated Limit pain.
- Fatigue enhanced overall - Prevents general fatigue
Vital Signs: quality of life, indicating Encourage frequent changes and joint stiffness
no signs of acute pain of position - Heat promotes muscle
T: 36.5 relaxation and mobility,
P: 60 Apply warm or moist decreases pain and
compress on the affected relieves morning stiffness
R 16 area several times a day. - Promotes relaxation and
ΒP. 110/70 reduces muscle tension
Provide gentle massage.
BLURRY VISION
Page 17 of 19
ASSESSMENT NURSING GOAL/EXPECTED NURSING RATIONALE EVALUATION

DIAGNOSIS OUTCOME INTERVENTIONS
Subjective Data: Impaired Visual Short-Term Goal: Independent: Independent:  The client indicated that both of his
"Malabo na itong mga Sensory Perception Within the next week, - Examine the client's - Recognizing eyes' clarity of vision had improved
mata ko, minsan due to age- the client's vision will living space for elements Environmental variables can after all of the nursing interventions.
di na ako makaaninag" related become clearer. that may be causing their be changed to improve  The successful implementation of
vision impairment (e.g., safety and lower the environmental improvements and the
Objective Data: Long-Term Goal: obstructions, bad lighting). possibility of vision-related collaborative initiatives resulted in a
 Hazy or fuzzy The patient will incidents. safer living environment.
vision in the preserve ideal visual  When the recommended eye drops
eyes performance and stop - Work together with were used as directed, the symptoms
-Working together with the
 Wearing reading further of teary eyes were relieved.
the client to develop The client guarantees a
reduction in vision  The new corrective lens prescription
glasses that are lighting optimization and customized approach,
that was obtained through
rated 250 for the environmental hazard accounting for their own coordination with the physician
left eye and 300 reduction methods. living circumstances and improved visual acuity.
for the right. preferences.  The effectiveness of the nursing care
plan is demonstrated by the client's
Dependent: Dependent: improved ability to do daily activities
- Apply prescription - - Managing with better vision and overall
drugs or eye drops as prescription drugs treat pleasure. The medical staff's follow-
directed. conditions like up visits will help to check and
inflammation or dry eyes preserve visual health.
that may be the underlying
reasons of hazy vision.
Page 18 of 19
- Work with an - Including an

ophthalmologist to ophthalmologist provides a
determine whether the thorough evaluation of the
existing prescription patient's visual acuity,
needs to be adjusted or if allowing for precise
corrective lenses are prescription modifications.
necessary.
Page 19 of 19

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Republic of the Philippines

RLENCM 113 – Community Health Nursing 2

Interviewing and Screening Older Adults for Common Problems Residing

In Partial Completion of Community Health Nursing 2 Community

JOURNAL REFLECTION ………………………………………………………….. 8

DRUG STUDY …………………………..…………………………………………... 10

3 NURSING CARE PLANS .…………..…………………………………………... 16

NCM 114 – Care of Older Adult (RLE)

NAME OF ELDERLY: Lolita Rose B. Directo AGE: 63 Years Old

 Obtain information on current and past medical conditions.

 Inquire about past surgical history.

 Collect a comprehensive medication history (use additional paper if necessary).

Ask about any recent changes in medication

 Social History (living arrangements, work history, financial concerns, social/spiritual

 Family History (Alzheimer’s disease, depression, role as caregiver) None as mentioned

 Are you currently experiencing any difficulties with your memory?

 Have you experienced any falls in the past year?

 Do you have any trouble with your hearing?

 Have you lost more than 10 lbs in the past 6 months?

 Do you feel sad or depressed?

Activities of Daily Living (ADLs):

 Walking – How far are you able to walk?

 Bathing – Are you capable of independently bathing yourself or do you require

 Housekeeping – Are you capable of performing household chores and maintaining

 Transportation – Do you currently drive or rely on alternative means of transportation?

 Finances – Do you receive any assistance with managing your finances?

MINI-COGNITIVE ASSESSMENT (Administration)

Concluding the comprehensive assessment, I revisited the previously presented words,

If necessary, provide an additional sheet of paper.

These recordings provide a comprehensive overview of the patient's physiological parameters,

Level of Consciousness: Pain:

Do you experience any type of abused?

children, the other medications with the suitability of

DECOLGEN (200 MG)

breathe, while time or schedule sinusitis, flu,

symptoms such as respiratory interactions. Neozep

NURSING CARE PLANS:

ACUTE PAIN (BACKPAIN)

ASSESSMENT NURSING DIAGNOSIS GOAL/EXPECTED NURSING INTERVENTIONS RATIONALE EVALUATION

ASSESSMENT NURSING GOAL/EXPECTED NURSING RATIONALE EVALUATION

- Work with an - Including an

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