Professional Documents
Culture Documents
Sanchez
N2F
NURSING PROCESS
I. DEMOGRAPHIC PROFILE:
Name: M.L.R.
Age: 29
Gender: Female
Address: Quezon City
Religion: Roman Catholic
Date of Birth: August 6, 1979
Place of Birth: Quezon City
Civil Status: Single
Nationality: Filipino
+ HP
N
DM +
+ +
HP HPN
DM HP N
N +
+
P
x
LEGEND:
O: The patient is wearing a shirt and pants. She is properly groomed and doesn’t have any body odor. Her
height is 5’1 and her weight is 132lbs. (BMI: 23.4). Her vital signs are: BP- 120/80mmHg, PR- 82bpm, RR- 18bpm
and temperature- 36.6°C.
O: Patient’s hair is unevenly distributed, the center has lesser number of hairs than the surrounding part, and it
is dry and thin. No dandruff was noticed. Skin is slightly pale, warm and moist. No suspicious rashes. No lesions
found. Nasal orbit appears wet. Oral mucosa appears wet. Her height is 5’1 and her weight is 132lbs and the BMI
is 23.4. The abdominal bowel sound is normal high-pitched gurgles heard at 5-20 seconds interval.
O: The bladder is not distended and the abdomen is symmetrical. There are no audible bowel sounds.
Tympanitic sound was heard over the area of the stomach; dullness over spleen and liver. There was no tenderness
in the abdomen. The liver and bladder are not palpable. There are no hemorrhoids found inside the anus. Patient’s
urine output per day is 840cc. The urine is light yellow in color and is faint aromatic. The bowel output is once a
day. The bowel is cylindrical in shape and brown in color.
O: The patient appears to be weak and skin is pale in color .The patient is able to walk but is not standing erect. Her
muscle strength is rated 75% which is normal full movement against gravity and against minimal resistance. She can
do active range of motion on light activities and an increased respiratory rate and shortness of breath in moderate
and heavy activities. The muscle tonicity is in the normal condition of tension/tone of a muscle at rest. The
extremities are warm and has capillary refill of less than 3 seconds. Her vital signs are: BP- 120/80mmHg, PR-
82bpm, RR- 18bpm and temperature- 36.6°C.
O: The patient has a visible dark spot under the eye. She has a poor posture and frequent yawning. The patient
seems restless and tired.
O: Client is well-oriented to time, place and event. Client answers the question without difficulty, her pattern
of speech is coherent, and she speaks in a soft voice. Client does not have difficulty recalling past situation. Client is
able to express well what she wants to say. The cranial nerve assessment:
CNI – Olfactory: The patient was able to smell the vinegar and the coffee.
CNII – Optic: The client has 20/20 vision.
CNV – Trigeminal: The client was able to clench her jaw.
: Blink reflex, Kinesthesia: client was able to determine
the movements of the arm while her eyes closed.
: Proprioception: client was able to determine the
position of the arm while eyes closed.
: Sterognosis: client was able to determine the objects
while eyes closed.
CNVII – Facial: The client was able to determine the taste the lemon and
sugar correctly.
CNVIII – Vestibulocochlear: Weber (-), Rinne AC > BC
O: The client is cooperative during the interview and there is an organized thought process and clear speech
pattern.
O: The client is closely bonded and has good communication with her family. The client also communicates to
others effectively. She was with her mother and sister when she got admitted.
O: The client has normal breasts. No cyst in the breasts. The pubic hair is evenly distributed.
O: Patient became emotional while she was interviewed. The patient is not observed to have religious routines.