ST. PAUL UNIVERSITY MANILA St.

Paul University System College of Nursing and Allied Health Sciences

NURSING CARE STUDY (Application of Nursing Process) Name: Arellano, Aigina Lucelle H. BSN IV Date: August 14, 2013

A. Demographic Data Clients initials: CA Clients birthday: November 25, 1935 Address: 1721 Rd. Fabie Estate Sta. Ana Manila Room/Ward: 5A/512 Date Admitted: August 9, 2013 Age: 87 years old Sex: Female Civil Status: Separated Nationality: Filipino Religion: Roman Catholic Educ. Attainment: High School Graduate Occupation: None Admission Complaint/s: Difficulty of breathing Admitting or Working Diagnosis: Community Acquired Pneumonia Admitting Vital Signs: T- 36.7 PR- 79 Beats/min RR- 23 Breaths/min BP- 140/80 Arrived on unit by: N/A Accompanied by: her daughter Allergies: None Medications: Clopidogrel, Lansoprazole, Levofloxacin, Fluimucil

A. Nursing History (Based on the Functional Health Pattern by Gordon) 1. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN 1.1 Clients description of his/her health: The client stated that before her hospitalization she can still do some stretching every morning and play with her grandchildren but despite of that situation she is aware that she is hypertensive. She also stated that she is asthmatic but it doesnt hinder her to do her daily activities. 1.2 Health Management: The client stated that she has maintenance for her high blood and she always complies to it. She also stated that she goes for a check-up with her doctor. According to her daughter she also used to puff seretide for her asthma. 1.3 History of present illness 2 weeks PTC client noted throat itchiness, no fever , no cough and no abdominal pain. 3 days PTC client have cough, productive with presence of yellowish phlegm. Client is afebrile and not nauseated.

Few hours PTC persistent of cough associated with difficulty of breathing, patient consulted and was subsequently admitted. 1.4 Past illnesses: The client has Hypertension and Asthma. 1.5 History of hospitalization: The patient stated that she have been hospitalized for many times 1.6 History of illness in the family: (+) Asthma (Mother) (+) Hypertension (Father) (+) Heart Disease (First son) 2. NUTRITION AND METABOLIC PATTERN 2.1 Usual food intake (before consultation) Breakfast Bread and sandwich spread plus coffee Lunch 1 cup of rice and soup with meat Supper 1 cup of rice and vegetables with meat Snacks biscuits or bread

2.2 Usual fluid intake (type, amounts): - Water (approximately 8-10 glasses per day) - Coffee (approximately 1 cup per day)

2.3 Any food restrictions: Patient was put on Low Salt Low Fat diet as ordered by the doctor. 2.4 Any problems with ability to eat: None

3. ELIMINATION PATTERN 3.1 Bladder: Usual frequency/day: 6-10 times a day Color: light yellow Complaints the usual pattern of urination: None 3.2 Bowel: Usual pattern/day (time, frequency, color and consistency): Every morning or night, once a day, brown or semi-solid in consistency. Complaints of usual pattern of bowel movement: None Home remedies: None 3.3 Any assertive device: None 3.4 Skin (condition): The patients skin is slightly dry and warm to touch.

4. ACTIVITY EXERCISE PATTERN 4.1 Usual daily/weekly activities

Leisure: watching television Exercise: stretching and walking around their place 4.2 Any limitations of physical ability: The client cannot walk for a very long time. 4.3 History of dyspnea or fatigue: The client had experienced dyspnea for many times.

5. SLEEP-REST PATTERN 5.1 Usual sleep pattern: Bedtime 10 pm Hours slept 6-8 hours No. of pillow/s 1 pillow Sleep routines 1-2 hours siesta in the afternoon 5.2 Any problems regarding sleep: None

6. COGNITIVE-PERCEPTUAL PATTERN 6.1 Any deficits in sensory perception (hearing, sight, touch): The client has difficulty in hearing according to her relative. 6.2 Ability to read and write. Any difficulty in learning? The patient is able to read and write and has no difficulty in learning. 6.3 Any complaints? (e.g. pain): The patient complaints of productive cough that is hard to expel.

7. SELF-PERCEPTION 7.1 What the client is most concerned about: The patient is most concern about her fast recovery. She doesnt want to stay in the hospital for so long 7.2 Present health goal: When asked about her present health goal, she said that she wants to get well as soon as possible so that she could resume her usual activities and be productive like she used to. 7.3 Effect of present illness to self: Dahil sa ubong to hindi pa ako makauwi namimiss ko na ang bahay naming as verbalized by the client.

8. ROLE RELATIONSHIP PATTERN 8.1 Language spoken: The patient speaks Tagalog. 8.2 Manner of speaking: The patient speaks in a medium-pitched tone.

8.3 Significant person to client: The significant persons to client are her whole family. 8.4 Complaints regarding family: When asked about this matter, the patient said that she has no complaints regarding her family. 8.5 Living with (members of family): The patient lived together with her only daughter. 9. SEXUALITY AND SEXUAL FUNCTION 9.1 Anticipated change in sexual relations because of illness - According to patient, She had been separated to her husband for a very long time 9.2 Knowledge of sexual functioning - Patient is aware of her sexual functioning as a woman. She also said that she is already old for that matter. 10. COPING STRESS MANAGEMENT PATTERN 10.1 Decision making ability The patient said that she is already old not to make her own decision. 10.3 Management of stress: When it comes to being stressed, the patient just watches tv or sleep. 10.4 Expectations from nurses to provide comfort and security during hospitalization: Since it is her first hospitalization, the patient expects that the health team will do their best for her fast recovery. 11. VALUE BELIEF SYSTEM 11.1 Source of strength and meaning: The patient mentioned that right now God is her source of strength and meaning. 11.2 Importance of God to client: The patient said that relationship with God is very essential and with her present condition. She mentioned that God is the only one who can help her for this time. 11.3 Religious practices (type and frequency) The client said that she attends mass every Sunday. She also prays before sleeping. 11.4 Request for religious person/practice: None

B. PHYSICAL ASSESSMENT

Date performed:

August 5, 2013

1. Head-to-Toe Examination

1.1 General Survey The client is a 87 years old female. Upon assessment on August 13, 2013, the client is conscious and coherent. She appears weak in appearance with non labored spontaneous breathing. She is oriented about the time, place and person. She can responds to questions correctly but have difficulty in hearing. Skin has no signs of pallor and jaundiced but there are presence of bruises on her right arm due to blood extraction for CBC. The client is hooked with IVF no. 3PNSS 1L x 24 hours, infusing well in the left metacarpal vein. She is with Oxygen inhalation at 2LPM via nasal cannula. The physical appearance of the client is appropriate with her age. She is complaining of productive cough. 1.2 Vital Signs T: 37.1C PR: 87bpm RR: 26cpm BP: 150/80 mmHg 1.3 Head and Face a. Cranium The patients head is normocephalic and proportional to body size. Presences of nodules or masses are not noted. The cranium has a wellrounded skull shape and with smooth, uniform consistency. Theres no a lesion or masses noted. Hair is dry, evenly distributed and intact to the scalp. The color of the hair is color white. a. Temporal arteries The temporal arteries are palpable and pulsating well. b. Face Facial features and movements are symmetrical. The patient is able to raise her eyebrows, close her eyes, frown, and smile. His face manifests a feeling of weakness. Equal size of palpebral fissures, no signs of edema and lesions. a. Cranial nerves V and VII The cranial nerves V and VII: function is normal because patient was able to elicit the blink. Also, he was able to do facial movements equally such as frowning.

b.

Nose and cranial nerve I The external nose is symmetrical, straight and uniform in color. Nasal flaring was not noted. Color is the same with the entire face; there was no tenderness noted upon palpation. Lesions and tenderness were both absent. Nasal mucosa was pinkish. Both left and right nares were patent, with no discharges; air could freely move in and out when the patient breathes. The nasal septum is intact and in the midline without deviations. The frontal and maxillary sinuses were non-tender upon palpation. Sense of smell was good. Patient was able to differentiate water from that of alcohol, through scent

c.

Nose and cranial nerve I The nose is symmetrically aligned to the center of the face, theres no presence of mass and lesions noted. No evidence of swelling of the sinuses. No obstructions and discharges were found.

1.4 Eyes and vision

a.

External eye structure Both eyes are not symmetrically aligned but intact to skin. There is no noted edema and tenderness in the lacrimal gland but there is a minimal discharge. The eyelashes are also equally distributed. No other markings in the sclera. The pupils are brown in color, equal in size, round in shape. Iris is also round in shape which constricts w/ light for about 2cm and dilates w/o light.

b. Extraocular muscle function (cranial nerve III, IV & VI) The client can perform the six cardinal signs of gaze. There is coordination with his two eyes. c. Pupillary reflexes The pupil is 2-3 mm round. Pupils are equally round reactive to light and accommodation. The pupil constrict when exposed to light and does not eventually dilates when there is no light. d. Internal eye structure with ophthalmoscope N/A

1.5 Ears & Hearing a. External ear The external ear is normal because the auricle has the same color as the facial skin. The auricle is aligned with the outer canthus of the eye about ten degrees from vertical. The pinna recoils when it is folded. It has a smooth contour and has no lesions. There is no deformity.

b. Hearing The client has difficulty in hearing, because I need to repeat my questions several times for her to respond to all the questions. c. Ear canal and tympanic membrane with otoscope. N/A

1.6 Neck a. Musculoskeletal structures The muscles in her neck were equal in size. Her neck movement was coordinated.She can also turn his head on one side against minimal resistance of hand with the similar strength and shrug her shoulders up against the resistance of hand with equal strength. The trachea is in the midline.

b. Lymph nodes The lymph nodes are non-palpable. c. Thyroid gland The thyroid gland has no enlargement noted upon palpation.

d. Musculoskeletal function and cranial nerve XI The musculoskeletal function and cranial nerve XI function is normal because the patient was able to move his neck from left to right, up and down with resistance. e. Carotid arteries The carotid arteries are pulsating with symmetric pulse volumes.

1.7 Upper Extremities a. Musculoskeletal structures, skin, nails Muscles are equal in size. Theres no weakness and numbness noted in her both arms. The capillary refill is 3 seconds on both right and left hand nail beds. The five fingers are intact. b. Musculoskeletal functions The patients radial and brachial pulses were regular but with strong pulsation. Good range of motion was noted in her both arms. Palm is able to stay in both prone and supine in a good manner without difficulty. She was able to exhibit strong hand grip on both hands. c. Brachial and radial arteries

The brachial and radial arteries have regular and strong pulsation. d. Deep tendon reflexes N/A 1.8 Anterior Chest a. Breasts and axillae The breasts have no tenderness, masses or nodules and the 2 nipples are brown in color. Skin is uniform is pale; it is also smooth and intact. The axilla has presence of hair. There are no lymph nodes have no masses, tenderness and nodules. b. Thorax The patient has no difficulty in breathing but with abnormal breathing pattern; quiet and rhythmic respirations, with respiratory rate of 26 cyles in one full minute. There is tenderness present upon coughing. No tenderness and masses upon palpation. There is presence of crackles on both left and right lung fields during auscultation. Tactile fremitus on both lungs are symmetrical. Posterior chest was not assessed. The chest expansion is symmetric with no lesions, masses noted. c. Precordium The apical pulse can be auscultated and no irregularities in the heart beat rhythm were noted. With no abnormal heart sounds or murmurs. 1.9 Back a. Musculoskeletal structure The musculoskeletal structure is normal because spine is midline and shoulder and hips are at same height. The skin is intact and without lesions.

b. Fist percussion over spine and kidneys There is no noted tenderness over kidney. Percussion of the kidney resulted to dull sound and the spine has a blunted sound. 1.10 Neck veins The veins on the left side and right side of the neck are pulsating not distended. 1.11 Abdomen a. 4 abdominal quadrants Unblemished skin, uniform in color with symmetric contour. There is a symmetric movement caused by respiration. Tympanic sound upon percussion.

b. Specific organs Liver There is no enlargement of the liver noted when client held his breath upon inspection. Borders are smooth upon palpation. There is dullness upon percussion and the site is not tender Spleen The spleen has no evidence of enlargement when client held her breath upon inspection and is not palpable Kidneys The kidneys have a dull sound during percussion and are palpable and no tenderness is noted. 1.12 Lower Extremities a. Musculoskeletal structures, skin, and toe nails Muscles are equal in size on both sides of the body. There is no lesions, masses and tenderness noted. The capillary refill is 2-3 seconds. b. Musculoskeletal function Equal muscle strength and muscle tone on each leg side. It exhibits coordinated and firm movements. c. Popliteal,posterior tibial and pedal arteries The popliteal pulse is pulsating well. d. Deep tendon reflexes and planter reflex :N/A

1.13 Genito-Urinary Not applicable because client refused.

Summary of abnormal findings: The client is conscious but weak in appearance. The color of the hair is color white. The client has difficulty in hearing, because I need to repeat my questions several times for her to respond to all the questions. There is presence of crackles on both left and right lung fields during auscultation Increase in respiratory rate: 26cpm.

Reference: Marieb, E. 2006. Essentials of Human Anatomy and Physiology 8th Edition; Kozier, B. 2004. Fundamentals of Nursing 7th Edition