NURSING ASSESSMENT A.

PERSONAL HISTORY
NAME: Patient PRM ADDRESS: Sulivan Baliuag, Bulacan BIRTHDAY: November 24, 1982 AGE: 29 years old GENDER: Male STATUS: Single NATIONALITY: Filipino RELIGION: Jehovas Witness EDUCATIONAL ATTAINMENT: College undergraduate OCCUPATION: None HEALTH CARE FINANCING AND USUAL SOURCE OF MEDICAL CARE: None DATE OF ADMISSION: February 1, 2012 TIME: 3:19 pm CHIEF COMPLAINT: Non healing left foot wound ADMITTING DIAGNOSIS: Peripheral Arterial Occlusive Disease

B. CHIEF COMPLAINT AND REASON FOR VISIT

The clients reason for admission was due to the non healing wound on his left ankle and a gangrenous digit on his left foot. Dito na sa Ospital na ito ko naisipan magpadala para dito humingi ng second opinion kasi ang sabi nga sakin dun sa pangalawang ospital na pinuntahan namin ay kailangan na nga daw putulin yung paa ko, pagdating namin dito after nga ako matingnan ng doctor sinabi na kailangan na nga daw talagang putulin kaya naconfine na ko dito at inischedule na ko ng operasyon,as verbalized by patient PRM.

C. HISTORY OF PRESENT ILLNESS

The client has been suffering from his disease for almost 2 years but his suffering worsen last November of 2011 when he noticed that his wound on his left foot got worst; even if he do wound care and taking antibiotics; yet it becomes infected. Its been 2 years since he started to experience having wound on his lower extremities, particularly his feet. He easily gets wounded even without any sharps hitting his extremities. Hindi naman ako nasusugatan, basta-basta na lang ako nagkakasugat sa paa. Mas matagal gumaling ung mga sugat ko sa kaliwang paa kesa sa kanan. As added by Mr. PRM. During his first consultation regarding his wound, he was advised by his doctor to take Ciprofloxacin and to disinfect his wound using Povidone iodine and a mixture of cleansing with 1L of water, mixed with 1tbsp of Vinegar, Salt, Zonrox each, and 2 tbsp of hydrogen peroxide. He had been doing this regimen for almost a year. But despite of those regimes, he still continues to have wounds. He decided to consult again to another doctor; he was advised to continuously disinfect his wound and take Chlindamycin and CoAmoxiclav. 2months ago, he had a wound on his left foot, particularly started on the 5th digitalis. Its just a simple wound that gets worst after he had swam on a pool. Days passed, he noticed that the wound is not getting better and spreads out through his foot. It then affects other digits of his foot. He sought consultation at Baliuag District Hospital, and he was told by the doctor that he had an occlusive disease and needs to be amputated. Mr. PRM sought second opinion at Bulacan Medical Center, and was then confined for amputation

D. HISTORY OF PAST ILLNESS

Three years ago patient PRM was confined at Baliaug District Hospital because of Dengue and this was the first confinement on a hospital. He said that he had no known allergies to any food or drugs. He added that he doesnt have any injuries in the past, but he remembered that he had mumps when he was in high school. According to his mother, she could not remember the exact vaccinations her son received, but she was sure she had them. This was his second hospitalization since he had Dengue.

E. FAMILY HEALTH ILLNESS HISTORY

Mr. PRM is the oldest child among five children. They dont have family history of Diabetes Mellitus. Only hypertension and kidney disease

GENOGRAM Father Side

B.M 72
C.M 56

Mother Side
S.C 70
C.S. 79

R.M 50

E.R 48

M.A 46

E.B 43

R.C 53

L.M 48

E.V 47

R.C 45

R.M 44

C.C 42

LEGEND:

MALE FEMALE PATIENT KIDNEY DISEASE

PRM 29

S.M 28

M.M 25

M.C 23

L.M 20

DECEASED W/ UNKNOWN CAUSE HYPERTENSION

FUNCTIONAL HEALTH PATTERN 1. HEALTH PERCEPTION/ HEALTH MANAGEMENT PATTERN

PRIOR TO HOSPITALIZATION PRM viewed health as being healthy and free from any diseases. Dapat hindi ka nagkakasakit saka dapat malusog tayo. As verbalized by PRM. When PRM had experienced his condition, he never forgets to take the prescribed medications and to clean his wounds regularly. He had much concern on his wounds. Every time he felt that something is wrong, he visits the clinic and sought for consultation. He cleans his wound twice a day with the use of Povidone iodine and a mixture of cleansing solution of 1L of water, mixed with 1tbsp of Vinegar, Salt, Zonrox each, and 2 tbsp of hydrogen peroxide. He complied with his medication regimen. He does not have regular exercise. Even before he stopped working at Quezon City, hes always at home, and does nothing because of he feel discomfort on his left foot. Nahihirapan akong gumawa ng mga gawain kasi masakit ung paa ko saka namaga na, kaya tumigil na ko sa pagtatrabaho, kaya sa bahay na lang. added by PRM. PRM is a chain smoker and also a secondary smoker. He takes 5-10 cigarettes a day. Madalang lang ako manigarilyo, naimpluwensyahan lang ako ng mga kasamahan ko sa trabaho kaya napapadami. Saka delivery boy ako sa dati kong trabaho kaya madalas ako makalanghap ng usok. DURING HOSPITALIZATION During hospital stay, the most important thing for PRM is to get amputated, as it was said to them of his doctor. He doesnt want to suffer longer from his non-healing and getting worst foot. He is much concern on to restore health, be okay, so she could go home as soon as possible. He strictly follows things nurses and the doctors suggested him to do.

2. NUTRITIONAL METABOLIC PATTERN PRIOR TO HOSPITALIZATION

Patient PRM has a good appetite. During breakfast patient PRM usually eats bread and drinks coffee with creamer. He takes 7-8 glasses of water a day. He does not take any food supplement 72hour diet recall Date January 29, 2012 Breakfast 1cup of coffee with creamer 1 glass of water 4 pcs of bread(pandesal) 4 pcs of bread(pandesal) 1cup of coffee with creamer 1 glass of water 3 pcs of bread(pandesal) 1cup of coffee with creamer 1 glass of water Lunch 2 1/2 glasses of water 1 bowl of chopsuey1 cup of rice 2glasses of water 1 pc of fried fish 1 cup of rice Dinner 3 glases of water 1 bowl of sinigang na bangus 1 cup of rice 2glasses of water 1 saucerl of pinakbet cup of rice

DURING HOSPITALIZATION
Patient was on DAT (diet as tolerated) as of Wednesday since the day of his confinement February 1, 2012, and then the client was ordered to be on NPO (nothing per orem) on the night of February 12, 2012. 72hour diet recall Date February 10, 2012 Breakfast 1glass of water 1cup of coffee Fita crackers 9 pcs 1glass of water 1cup of Coffee mammon Lunch 2glasses of water 1 pc Fried fish 1 cup rice 2glasses of water 1 saucer ginisang togue 1 cup rice Dinner 2glasses of water 1 cup of rice 1 saucer Adobo 2glasses of water 1 bowl of sinigang na bangus 1cup rice NPO

January 30, 2012

February 11, 2012

Februar y 1, 2011

3 glasses of water 1 bowl of tinolang manok 1 cup of rice 1/3 small saucer of patis

3glasses of water 1 cup of rice 1 slice of paksiw (milkfisk)

February 12, 2012

1cup of Coffee 1 pack sky flakes

2glasses of water 6 tsp of porridge

3. ELIMINATION PATTERN PRIOR TO HOSPITALIZATION

Elimination Bowel Urine Frequency 1-2 times a day 5-6 times a day Color/ Consistency Light brown, formed stool Light yellow urine Discomfort No discomfort No discomfort Elimination Bowel

DURING HOSPITALIZATION
Frequency 1-2 times a day Color/ Consistency Light brown, formed stool Light yellow urine Discomfort No discomfort

Urine 5-6 times a day No discomfort Usually patient PRM defecates at least 1-2 times a day it is formed and brown in color. He urinates 4-5 times a day for approximately with yellowish color urine. The patient defecates once or twice a day with a light brown, formed stool and Normally he doesnt feel any pain while voiding and defecating. urinates 5-6 times a day without any discomfort.

4. ACTIVITY AMD EXERCISE PATTERN PRIOR TO HOSPITALIZATION

He does not have regular exercise, his exercise was irregularly; once a week in particularly. Even before he stopped working at Quezon City, hes always at home, and does nothing because of he feel discomfort on his left foot. Nahihirapan akong gumawa ng mga gawain kasi masakit ung paa ko saka namaga na, kaya tumigil na ko sa pagtatrabaho, kaya sa bahay na lang. added by PRM. His spare time or leisure activities include spending her time relaxing, by watching television shows, sometimes doing some simple household chores. Hes just at home always.

DURING HOSPITALIZATION
During hospitalization, PRM needs help whenever he will go to the toilet room. He is accompanied by his mother through on a wheel chair. He is also helped for changing his clothes. He wasnt able to ambulate freely in the ward due to his left foot, he needs assistance. The only thing he does in the ward is to sit on a chair near his bed and lie down.

5. SLEEP PATTERN PRIOR TO HOSPITALIZATION

PRM had difficulty in sleeping because of discomfort brought by his left foot. He pays attention on his wound whenever he lay down. He felt pain and itchiness on his wound that disturbs his sleep. He added that he felt heaviness on his foot. But he never takes any sleeping pills. He typically went to bed at around 8:009:00 pm, then wakes up at 6:00-7:00 in the morning. Whenever he wakes up at midnight, he falls asleep again afterwards. He has schedules of naps every afternoon, and usually its a 1-1 hours sleep

DURING HOSPITALIZATION
During hospitalization, he usually has a continuous rest and sleeps. He only get awaken at night when the nurses gives medication and of obtaining vital signs.PRM told us that sleeping in the hospital is not as comfortable as in their house. He takes naps too if theres a chances to. He gets bored during hospital stay for he only just sits and lay down on his bed, his only everyday routine in hospital.

6. SELF-PERCEPTION AND SELF CONCEPT PRIOR TO HOSPITALIZATION DURING HOSPITALIZATION

Before hospitalization, the patient sees himself as a jolly and friendly When he found out that he needs to undergo below knee amputation person. He makes friends easily and said that she does not want to make enemies he cant help to feel self pity but then again, he just accepted it since its the with anyone. He makes sure that no one is hurt when he makes decision. PRM does only way for him to become better. He just looks into things in a positive not easily get mad or annoyed with jokes and is always cheerful. He said that being way. with his family is what makes him happy the most.

7. COGNITIVE- PERCEPTUAL PATTERN

PRM is conscious and coherent and has normal speaking ability prior to and during admission. He is able to communicate and comprehend effectively and has appropriate interactive skills. He is very friendly and concerned to other people as well. According to him, he doesnt have any problems in hearing and in her eyesight. He does not use any reading glasses and even any hearing aids. In terms of decision making, he makes sure that on every decision he make, no one is stepped and hurt.

8. ROLE-RELATIONSHIP PATTERN
PRM is single and not yet married. He stays with his mother house. He has a good, harmonious relationship with his family. They dont have any problem or argument at home. They all communicate with each other. They do things and face struggles with helping hands. His mother is the one who stays with him in the hospital. His father and other sibling already visited him, according to PRM.

9. SEXUALITY-REPRODUCTIVE PATTERN
PRM is single and not yet married. He had his circumcision when he was 12 years old.

10. COPING STRESS PATTERN

PRMs main concern regarding confinement is his non-healing wound which he will undergo a below knee amputation. At first when he knew that his legs will be amputated, he cried and get sad. Mahirap ang maputulan ng paa, syempre apektado na ang pamumuhay ko diba. As added by PRM. But because of his family that was there to support him, he then accepted the treatment for him. As if he had no choice but to agree with it and accept it. Whenever big problems arrived, PRM communicates with his family as his support system. He expressed that life should still goes on and they should not lose hope through this, he can easily cope up with problems in life.

11. VALUES-BELIEF PATTERN

PRMs religion is a Jehovas Witness. He told us that his religious beliefs and faith was tested because of his confinement. He was ordered for blood transfusion of 2 units of PRBC. But as according to their religion, its prohibited- its against to their belief that blood transfusion is a sin. Nung una nagdadalawang isip ako kung magpapasalin ba ko ng dugo kasi bawal. Pero pinagisipan ko din naman bago magdesisyon, at napili ko na magpasalin na lang kasi kailangan., as verbalized by PRM. He was admitted that he created a sin. However, he added that he prayed and asked for forgiveness on his decision made. Nonetheless, he always pray and asks for guidance and fast restoration of health.