VI.

Nursing Assessment
NURSING SYSTEM REVIEW CHART
Name: Mrs. R.O Date: September 1,2011 Vital Signs: Pulse: 79 bpm BP: 140/90 mmHg Temp: 38.3 C Height: 56 Weight:70 kgs EENT: impaired vision blind throbbing headache (pain scale 6/10) pain reddened drainage dizziness Asses eyes, ears, nose reading eye glasses throat for abnormality no problem vomiting with cleared liquid RESP: moderate amount (12:30pm)_ asymmetric tachypnea vomit not noted apnea rales cough barrel chest cough-productive whitish bradypnea shallow rhonci sputum sputum diminished dyspnea cough-productive whitish orthopnea labored wheezing sputum -still noted pain cyanotic Asses resp, rate, rhythm, depth, pattern, breath sounds, comfort no problem CARDIO VASCULAR arrhythmia tachycardia numbness frequent scanty urination diminished pulses edema fatigue frequent scanty urination still irregular bradycardia murmur noted tingling absent pulses pain Asses heart sounds, rate rhythm, pulse, blood pressure, clrc., fluid retention, comfort no problem GASTRO INTESTINAL TRACT obese distention mass dysphagia rigidly pain Asses abdomen, bowel habits, swallowing, bowel sounds, comfort no problem GENITO-URINARY and GYNE Difficulty of sleeping pain urine color vaginal bleeding Difficulty of sleeping not noted hermaturia discharge noctoria anymore Asses urine freq., color, control, odor, comfort/ Gyn-bleeding, discharge no problem skin warm to touch NEURO skin warm to touch not noted paralysis stuporous unsteady seizures lethartic comatose vertigo tremors body malaise confused vision grip body malaise not noted Asses motor function, sensation, LOC, strength, Grip, galt, coordination, orientation, speech, no problem IV site: #4 PNSS 1L @ MUSCULOSKELETAL and SKIN 30gtts/min appliance stiffness itching petechiae hot drainage prosthesis swelling #5 PNSS 1L @ 30gtts/min lesion poor turgor cool deformity Fever with chills wound rash skin color flushed atrophy pain ecchymosis Temp: 38.3C diaphoretic moist Temp: 37.2C Asses mobility, motion. Galt, alignment, joint function /skin color, texture, turgor, integrity no problem LEGEND: Blue- Morning Black-Afternoon Red- Evening

NURSING ASSESSMENT II
SUBJECTIVE COMMUNICATION: Comments:wala [ ] hearing loss may problema [ ] visual changes verbalized by the [ ] denied patient OBJECTIVE [x] glasses [ ] languages [ ] contact lens [ ] hearing aid R L Pupil: 3mm - 3mm [ ] speech diff. Reaction: Pupil Equally Round React to Light and Accommodation

OXYGENATION: [ ] smoking History none [x ] cough [x ] sputum [ ] denied CIRCULATION: [ ] chest pain [ ] leg pain [ ] numbness of extremities [ ] denied

Comment:medyo taod-taod na akong ubo as verbalized by the patient Comment:wala man problema nga sakit or benhod as verbalized by the patient

Resp. [x ] regular [ ] irregular Describe: patient has a regular respiration R right lung is symmetric to the left lung L left lung is symmetric to the right lung

Heart Rhythm [ ] regular [x] irregular Ankle Edema No presence of ankle edema . Pulse Car. Rad. DP Fem* R + + + + __ L + + + + + __ Comments: irregular heart rhythm [x] dentures Full [ ] [ ] [ ] none Partial [x] [ ] with Patient [ ] [ ]

NUTRITION: Diet: low sodium; diabetic diet_ [ ]N [ ]V Comments: Character gasuka lage ko [x] recent change in weight, appetite karonas [ ] swallowing verbalized by the difficulty patient. [ ] denied ELIMINATION: Usual bowel pattern [ ] urinary frequency Once a day 12 times a day_ [ ] urgency [ ] constipation [ ] dysuria remedy [ ] hematuria for got the date_ [ ] incontinence [ x ] polyuria Date of Last BM [ ] foly in place Sept. 1, 2011 [ ] denied [ ] diarrhea character pt. has no diarrhea MGT. OF HEALTH ILLNESS: [x] alcohol [ ] denied (amount, frequency) Occasionally drinker__ [ ] SBE Last Pap Smear: year 1996_ LMP: _April 21, 2011__

Upper Lower

Comments: Bowel Sounds: ___ Normative____ Comments: Abdominal Distention Patient has 12 Present: [ ] yes [X] no Urine* (color, times of urinating consistency, odor) per day and yellowish color_ usually bowel pattern once a day____________ _______________ _______________ Briefly describe the pt.s ability to follow treatments ____ (diet, meds, etc.) for chronic health problems (if present). Willing to follow what the physician said and take medication on time and low sodium; diabetic diet

SKIN INTEGRITY: [ ] dry [ ] itching [ ] other [ ] denied ACTIVITY/ SAFETY: [ ] convulsion [x ] dizziness [ ]limited motion Of joints Limitation in Ability to [ ] ambulate [ ] bathe self [ ] other [ ] denied

Comment: init ako katol2x si mama kay as pamati karun naa mo action verbalized by the patient verbalized by s.o

[ ] dry [ ] cold [ ] pale [ ] flushed [x ] warm [ ] moist [ ] cyanotic * Rashes, ulcers, decubitus (describe size, location, drainage) patient has warm to touch (38.3C)

Comments: medyo siya kalihok. Luya gaka lipong ko as kayo verbalized b the patient

[ ] LOC and orientation: patient is conscious and responsive, orient to time, place and situation Gait: [ ] walker [ ] cane [ ] other [ ] steady [ ] unsteady pt can sit, stand and toothbrush in his room [ ] sensory and motor losses in face Or extremities: patient complete sensory and motor able to move extremities freely slowly and surely [ ] ROM limitations: The patient can move freely if wanted but slowly [x] facial grimace [x] guarding [ ] other signs of pain: No other signs of pain observed______ [ ] side rail release form signed (60+ years) ___________N-O-N-E_____________

COMFORT/SLEEP/AWAKE: [ ] pain Comments:dili kayo ko (location, frequency, pagtulog ni mama katulog as verbalized by remedies) the patient [ ] nocturia [x ] sleep difficulties [ ] denied

COPING:

Occupation: Business women Observed non-verbal behavior: patient is Members of Household: 3 member Mrs. talkative when every time we had question R.O, J.O and helper she answer you directly. Most Supportive Person: Mrs. J.O The person and his phone number that can be reached anytime : 3428049__