Nursing Assessment

117 cm .5 C P.Vs taken on January 28.37 kg Height.36. 2013 T.98 cpm R.27 bpm BP Weight.

ACTUAL FINDINGS As we assessed the patient.02 (overweight) because of the excess peritoneal fluid . her diet include of rice. her eating pattern was not altered BMI is 27. Before her present illness was diagnosed. indicators of local nutrient supply. She expressed desire to recover from her illness as soon as possible. fish vegetables and salt as condiments and her appetizer. She talked about her present and expresses her concerns about it. Patient drinks 4-5 glasses of water every day. we observed that she was aware about her condition.   Patient eats 3 times a day. In her present condition.FUNCTIONAL HEALTH PATTERN Health Perception/Health Management PATTERN DESCRIBES Client's perceived pattern of health and well-being and how health is managed. Nutritional-Metabolic Pattern of food and fluid consumption relative to metabolic need and pattern. She showed compliance in her medication regimen. she knew all about the tests and diagnostic exams that she underwent.

output of 900-1000cc in and skin). Includes 24 hrs. Activity . the patient is usually active . Before the present hospitalization. she usually play games and recreation. She did not client's perception experience difficulty of of “normal" function.Elimination Patterns of excretory The patient had maximum function (bowel. urinating and was able to defecate once a day.Exercise Patterns of Patient verbalized that exercise. outdoor bare footed . leisure. bladder. activity.

Before hospitalization. place and date. The patient and her mother answered every question we asked of them.Cognitive-Perceptual Sensory-perceptual and cognitive patterns. Patient appeared to be oriented in time. She was cooperative during our interview. patient P sleeps usually from 10 pm and awakens at 8 am During hospitalization she verbalized that her sleep pattern is ok. rest. she didn’t experience disturbances when she sleeps. She also verbalized her concerns about her hospitalization Sleep-Rest Patterns of sleep. . and relaxation.

Self-Perception/Self Concept Erik-Erikson developmental theory – School Age: 6 to 12 Client's self-concept Years pattern and perceptions . She’s on her 3rd grade in primary school. This is also a very social stage of development and if we experience unresolved feelings of inadequacy and inferiority among our peers. called the Latency. Her parents especially her father is the breadwinner of the family and the one paying her hospitalization bills. -Our patient is the youngest among her siblings. we can have serious problems in terms of competence and self-esteem. we are capable of learning. thus developing a sense of industry. her mother is a housewife so patient’s mom is the one tending to the patient’s need . often of self. During this stage. creating and accomplishing numerous new skills and knowledge.

Role-Relationship Client's pattern of role engagements and relationships. Patient is the youngest among the 4 siblings –patient said she’s on her 3rd grade in primary school. Patient is 9 y/o and not sexually active yet . She’s living with her family and patient said she has a good relationship with her siblings and classmates in school Sexuality-Reproductive Patterns of satisfaction and dissatisfaction with sexuality pattern. reproductive pattern.

expressed her concern about her family where to get money to financially sustain her hospitalization is the biggest stressor in her life. family.Coping / Stress Tolerance General coping pattern With the current and effective of the pattern hospitalization the patient in terms of stress tolerance. She believed that God will cure her illness. beliefs Client is a Roman Catholic (including spiritual). Patient said her mother’s presence prevents her from getting extremely anxious Patient verbalized she gets afraid and anxious when her mom is not beside her Value . .Belief Patterns of values. and who goes to church every goals that guide client's Sunday together with her choices or decisions. Then the client also expressed her concern about her schooling because of her big number of absences.

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