New Nursing Process

8/6/2019 New Nursing Process

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NURSING PROCESS

I. ASSESSMENTA. General Data

Patients Initials : P.L.A.N.M Informant : Aunt

Address : Pandacan, Manila Date ofAdmission : June 18, 2011

Age : 21 y.o Order ofAdmission : Ambulatory

Sex : Female No. ofdays in hospital :

Date of birth : July 25, 1989

Place of birth : Manila

Civil status : Married

Occupation : N/A

B. Chief ComplaintsWatery Discharge

C. History of Present IllnessOne month PTA watery discharge with occasional uterine contractions with no

bloody show, consult done with AP : closed cervix, Dx advisedultrasound Px still with

persistent watery vaginal discharge consuming 1 panty liner per day still with no

hypogastric pain with uterine contractions, no bloody show, still no consult done, no

medications given 2 weeks PTA, patient consulted OGC due to persistence of watery

discharge, still consuming 1 panty liner per day with no bloody show, good fetal

movement, on consult: revealed closed intact BTW UAdone revealed UTI, given

amoxicillin 50mg TID x 7days.

One month before admission in Manila Doctors Hospital, the client experienced

occasional uterine contractions with no bloody show, consult done and found closed

cervix and advised to have ultrasound, still with persistent watery vaginal discharge

consuming 1 panty liner per day still with no hypogastric pain with uterine

contractions, no bloody show, still no consult done, no medications given 2 weeks

before admission, patient consulted Obstetric Gynecology Clinic because of persistence

of watery discharge and the patient is still consuming 1 panty liner per day with no

bloody show, good fetal movement, on consult, revealed closed intact


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D. Past History1. ChildhoodIllness/es : Chicken pox, mumps, sore eyes, fever, cough and colds2. Adult Illness/es : Heart disease, Kidney disease, UTI3. Immunization : Patient said that she is completely immunized but cannot avail her

baby book.

4. Previous Hospitalization : Heavy menstrual flow (thought to be miscarriage) [2009],Difficulty in breathing (December 2010), heart disease (2009), Liver disease (2009)

5. Operation/s : Coterize (2010), Raspa (2007)6. Injury : sprain at the right ankle (2006)7. Medications taken prior to confinement : Obimin, Hemerate, Calcium (Vitamins for

pregnancy)

8. Allergies : Unrecalled antibiotics, hard liquor (vodka and tequila) & Korean spicyfoods (the client cannot recall the names of the food but usually fishes & noodles)

E. System ReviewsA.)HEALTH PERCEPTION AND HEALTH MANAGEMENT

When asked about the clients definition of what is health, she toldus

that you have to eat plenty of fruits, fish and vegetables, less pork and beef,

must take multivitamins and have at least 8 glasses of water and 8 hours of

sleep. She rated her own health as 6/10 because she said that she had a couple

of complications for the past years like problems with her kidney. She assumed

that her abdomen increased in size like that of a 2-months-pregnant-woman

and that it was connected with her kidney disease. She thought she was

pregnant. She also said that she went in Manila Doctors Hospital to have a

check-up but the physician said that there was nothing wrong with her

abdomen, also there arent any presence of pain or tenderness. She did not take

any medications but went to an albularyo & the albularyo told her that her first

husband caused this. She did not take any rituals or other medications from the

albularyo. She said that her abdomen decreased in size after 4 days and then it

was on its normal size again. She also had heart problems when she was back

there in Korea & consulted a cardiologist. She didnt know the exact name of the

complication and the medications that were given to her because of language

barriers. She only said that her employer told her that she has to go back to the

Philippines because she is sick. She also discontinued taking the medications

after she has consumed all the medications. She also verified that she has low

potassium when she has consulted a doctor in MDH too anddescribes that

when she cries because of her problems with love life and family, she feels

numbness on her body & a tickling sensation.It starts first on her hands then up

to her arms, to her face anddown to her legs. She estimated to have

experienced it for 30 minutes, and she said that she took Calciumdurole and


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cannot remember the dosage and how many times per day she takes it. She also

had UTI on 2007 for 2 weeks. The medications she took were amoxicillin and

was taken three times a day. She also toldus that she simply eats whatever

random food is on the table, sometimes tuyo, tinola, sinigang, adobo and other

Filipino dishes. We asked her about her pregnancy condition, she said that she

felt normal because she experiences what any other pregnant woman

experiences like morning sickness and being temperamental and she never

misses a check up or appointment with her doctor. She said that she drinks

liquor and smokes 4-6 cigarette sticks per day even though she was pregnant.

We also asked her if she knows the consequences of her actions and she said

yes but cant help it because she was so stressed because of financial problems

like paying her electricity, water and food expenses. She also said that she is

anemic & takes ferrous sulfate when she was 13. She does self breast

examination once a month when she was on Korea on year 2009 but not doing

it anymore here in the Philippines because she said that she does many things

and always forget about doing it. She takes a bath 2x a day, in the morning and

late in the afternoon when she is on her house but since she is in Manila

Doctors Hospital now, she only bathes herself once a day because it is colddue

to the air condition. She also doesnt perform hand hygiene before meals only

alcohol.

B.NUTRITIONALAND METABOLIC PATTERN

She has knowledge of proper nutrition. She also stated the three foodgroups

Go, Grow and Glow. The patient likes pork, any dishes with pork anddesserts and other

sweets but she doesnt like vegetables. The patient has decreased in weight from 110

lbs to 70lbs. She also said that her appetite depends on the food served. She has eating

discomfort like when the environment is not clean. She stated that Depende sa

paligid.. The patient doesnt heal well immediately. She doesnt have any skin problems

except for her CS stitch due to her recent operation. She said that she doesnt have any

dental problems right not but she toldus, Meron dati, may butas ako sa ngipin, kaso

nadala na a mga dentist, dina ako nagpabunot ulit kasi masakit.

She eats 5 times a day, breakfast, lunch, dinner accompanied by 2 snacks on the

afternoon. The patient consumes only 3 cups of rice every time she eats her meal. She

only drinks water every time she takes her medication and every after meals. She mostly

eats bread. The patient also says that she cooks her own food and for her son. She said

that they have food budgeting Oo shempre dumagdag na anak ko eh.. She smokes

cigarettes after eating. She drinks liquor about 10 bottle but depends upon the

occasion. She said that when she and her spouse were together like before, they eat a

lot in the restaurants and fast food.


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C.ELIMINATION PATTERN

The client defecates two times a day but not every day. She estimated that she

defecates 2 times every 2 days. She said that it is solid and there are no difficulties. She

urinates about 15 times a day and said that she didnt have a problem with it except

when she had her UTI. She described it as light yellow in color and not very pungent inodor except from prolong standing of course. She also said that she doesnt have

excessive and foul-smelling perspiration and odor. She doesnt also perform habits or

rituals to help ease her defecation andurination.

D.ACTIVITY-EXERCISE PATTERN

She doesnt do any exercise because she is lazy to do so but she prefers to lay in

bed.It feels relaxing according to her. She does the laundry, cleaning the house &

looking after her children. She works as a vocalist on their band in Korea. The client has

enough energy during her work but she stated Wag lang mamamaos.. She works in

the evening andusually sleeps in the morning after her work.In weekdays, she works at

6pm 12am and in weekends she works at 5pm 3pm. But sometimes she likes to go

out for strolling.

E. SLEEP-REST PATTERNWhen asked about the number of hours of sleep, she said that sometimes it is 8

hours more or less. She stated that she also takes naps on the afternoon like at 3 or 4pm

andusually wakes up at night or early in the next morning. She also said that even

though she oversleeps, she feels like her sleep was not enough and that she doesnt feel

refreshed and satisfied. She also emphasized that she doesnt experience any difficultyin sleeping anddoesnt take any medications and rituals prior to sleeping. She also

stated that the kind of environment that she was sleeps on was very comfortable

because she is surrounded by her family and many relatives. She also said that she

wakes up every night just to void. When asked if she experiences nightmares, she told

us that she doesnt usually have nightmares, but if she does as the client jokes - she sees

the face of her husband.

F. COGNITIVE-PERCEPTUAL PATTERNOur client is a high school graduate. She can speak and understand Filipino

but few when it comes to English. She also knows how to speak and understand in

Korean because she works there on the year 2009. She hears without difficulty. She

doesnt have any hearing difficulty and doesnt use hearing aid. She is near sighted

and use contact lenses when she is in Korea. She also said - Ewan ko, natututunan ko

by experience. Natututunan ko pag nakikipagusap Although she doesnt know the


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grade.Her last eye check up was in 2010. She didnt have any changes in her memory,

smell and taste.

G. SELF-PERCEPTIONAND SELF-CONCEPTShe described herself as maayos. She feels good most of the time. The patient sees

herself in relation to other people better than them. She says that she is unique. She

doesnt express herself in other people that she is not close and comfortable with only

to her friends and family. Her goal in the next 5 years of her life is magpayaman and

umasenso sa buhay kasi may anak eh.. She plans to return to her work as a vocalist in

Korea this January 2012. The client is a very happy person., as she described. She

stressed that if someone hurts her son, shell be angry. She feel annoyed to the people

who are lazy. She feel tearful and sad when shes far away from her family and

especially her son. She said Yung anak ko lang ang nagpapawala ng pagod ko. Yung

kahit anong lungkot at pagod mo galling trabaho, pag hinalikan ka lang ng anak mo,

mawawala na.. She doesnt notice if her mood changes, her family just notices it.

H. ROLE RELATIONSHIP PATTERNShe has an extended type of family. She lives with 6 families but she is not with her

parents and siblings. Her two sons are the most important in her life. She says that shes

a good mother to her children and she added Gagawin ko ang lahat para sa kanila..As

a daughter she states Pasaway ako eh.. She is not that gooddaughter to her parents.

Shes fulfilled playing the role of a mother to her children.If she had problems, she

prays Pag may problema ako, nagdadasal lang ako, umiiyak ako sa kanya.. Her family

is dependent to her. Sometimes ser tito arranges some family activities like outing as

swimming and partying at the disco anddrinking alcohol with them. She never likes to

be alone, she wants to be in a group surrounded with happy people.

I. SEXUALITY-REPRODUCTIVE PATTERNShe stated that 13 was her age of menarche. She consumes 2-3 pads usually on

her secondday which she describes as her gripo day because of heavy menstrual flow.

She stated that her menstruation duration is 4 to 5 days per month. She stated that sheis regular and have her menstruation occur every 28 days to count. She doesnt

experience dysmenorrhea every time only a few times. She also doesnt experience

dizziness, headache or vomitingduring her period. Her flow has sometimes blood clot

on it especially on her secondday. She was also admitted to the hospital once when she

was still a teenager because her menstruation flow was really heavy and that she had

mistaken it to be a miscarriage since she has a boyfriend and is sexually active that time.


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The client said that at the age of 16, she became sexually active. She uses Dianne

contraceptive pills.

J. COPING-STRESS TOLERANCE PATTERNWhen asked about the meaning of stress, she gave an answer saying

that stress is something that can make a person depressed and sad but can

make him or her stronger. The client stated that she has been stressed for over

one year straight because of complications with her husband mainly in

communications and misunderstandings since they have longdistance

relationship and that her husband and the client spoke different dialects

without mastery ofusage of each others language. The things that she does

when she is stressed are throwing of things because of anger, go out with her

friends on an outing

usually swimming, visit her relatives, cry, drink, smoke cigarettes. She also said

that most of her companion when she is stressed are her family and it really

helps to confess to them her problems that causes her stress. She feels better

after sharing her problems that causes her stress. She feels better after sharing

her problems and she also noted that she doesnt keep her problems to herself

instead, shares them to her loved ones. She took disuldrin once to make herself

at ease temporarily. She said that she has experienced chestpain when she is

really very depressed and cant help crying and she said that minsannamamanhid, ayun na nga sabi ngduktor ko dati dahil rin raw yun sa mababa

potassium ko, nakakaramdam rin ako ng hirap sa paghinga dhail sa pag iyak

pero nawawal ren naman pag tumatahan nako at umiinom ng tubig, dahil na rin

siguro yon sa sakit ko raw sa puso, literal at hindi literal.

H. VALUE-BELIEF PATTERN

She thinks that vitamins makes a person healthy and she added Pero

sabi nila sex daw nakakataba depende na lang ren siguro kung hiyang ka. Health is important toher, she added Kapag nawala yan, wala na talaga.. She states that if there are things that she

wants pinagsisikapan ko talaga para makuha ko, ayun na nga nagabroad ako. Her sons were

the most important people in her life. She believes in God. Her religion is Iglesia ni Kristo. She

says that religion is important in her life because without God were nothing.As verbalized by

the client. But she doesnt believe in the superstitious but said that wala naming masama pag


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di ka sumunod.. She also experienced to consult a quack doctor for her health sinusumpa

kasi daw ako ng tatay nguna kong anak.

F.) FAMILY ASSE

SSME

NT Name Relation Age Occupati

Sex

Dianne cousin 23 N/A F

Linda grandmother 74 Construction F

Tatay uncle 38 N/A M

G.) HEREDO

* Family Illness

Mothers side

Fathers side.


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H.DEVELOPMENTALHISTORY

Theorist Age Task Patient descriptionErik Erickson YoungAdults, 19 to 40

years

Intimacy vs.Isolation

-Once people have

established their

identities, they are

ready to make long-term commitments to

others, they become

capable of forming

intimate, reciprocal

relationships and willing

to make sacrifices and

compromises that such

relationships require.If

people cannot form

these intimate

relationships, perhapsbecause of their own

needs- a sense of

isolation may result.

Sigmund Freud puberty onward Genital stage-Physical sexual changes

reawaken repressed

needs. Direct sexual


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feelings towards others

lead to sexual

gratification.

Jean Piaget adolescence Formal Operations-This stage brings

cognition to its final

form. This person no

longer requires

concrete objects to

make rational

judgements.At his

point, he is capable of

hypothetical and

deductive reasoning.

Teaching for the

adolescent may be

wideranging because

he'll be able to considermany possibilities from

several perspectives.

Lawrence Kohlberg Adolescence Stage 4: Maintainingsocial order

-The respondent becomes

more broadly concerned

with society as a whole.

Now the emphasis is on

obeying laws, respecting

authority & performing

ones duties so that thesocial order is maintained.

James Fowler Adolescence -The person is not fullyconscious of having

chosen to believe

something, the beliefs are

not the result of any type

of analytical thought.Any

attempts to reason with a

person about her beliefs,

any suggestion of

demythologizing his

beliefs is seen as a threat.

Most people in this stage

see themselves a s

believing what everybody

else believes and would

be reluctant to stop

believing it because of the

need they feel to stay

connected with their


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C.) SkullInspection: There are no presence ofdandruff & itchiness.No history of loss of consciousness &

seizure. Dizziness experienced sometimes since admission and also headache.No facial pain and

head injury. The skull shape is rounded and smooth in contour. The outher canthus of the eye

are also symmetrical. The client is able to frown, puff, raise and lower both eyebrows, close eyes

tightly, and smile with teeth flashed.

Palpation: There are no lumps, bumps & depressions palpated.No nodules and masses found.

D.) EyesInspection: She said that her family has history of cataract eye problems but didnt know where

it started. She does not visit the ophthalmologist or takes in eye medications. She has used

contact lenses and frequently cleanses it with the solution during her stay in Korea year 2009.

She said that her eyes were a bit blurred by did not know the exact grade of her eyes. Her

eyebrows were evenly distributed, it is also similar in alignment as the other eyebrows. The eye

lashes were also evenly distributed and are all curled slightly upward. The upper and lower lids

has no presence of lesions. Both bulbar and palpebral conjunctiva is pink in color, smooth in

texture and also no presence of lesions. There are few capillaries visible when the client was

asked to look up, down and sideways both.In consensual reaction, the clients pupils both

constricted when the pen light was used. The clients trigeminal or 5th

cranial nerve was also

intact because she has corneal sensitivity when the tip of the cotton touched her cornea. Both

the clients pupils were black in color, rounded in shape and symmetrical in size. The cornea was

shiny and moist and also smooth.Accommodation was performed and the results were, the

clients pupils constrictedupon looking at a near object and when the client was asked to look at

a father object, both pupils dilated.Also when the penlight was moved near her nose, in the

middle, both pupils converged. The clients peripheral vision is also working. The light reflex fell

also symmetrically on both sides of the pupils. The client is able to read the newsprint when her

arms were stretched.

Palpation: The upper and lower lids has no masses and tenderness. There were also no

tenderness felt when the lacrimal gland, lacrimal sac and nasolacrimal duct were all palpated

and no tearing was visible.

E.) Ears and hearingInspection: There are no other family history of hearing problems and hearing loss except for old

age and there are no presence of ear problems and pain on the client. The auricle was inspected

and turned out to be light brown in color, symmetrical in location with the other which is

described as slightly elevated than both of the outer canthus of the eyes. Otoscope was used

and there are no presence of liquid or solid cerumen, the tympanic membrane was seen and

described as pearly grey. The client is able to hear the ticking of a second handed wrist watch

and also can hear a whisper behind her. Tuning fork were also used for Webers test which


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resulted negative because the client is able to feel the vibration and can hear equally the sound

with both ears and resulted to positivity in Rinnes test because the air conduction was greater

than the bone conduction; 8sec : 10sec.

Palpation: The auricles is elastic because it recoils back after it is pinned. There are no

tenderness when palpated through the ear area including the tragus.

F.) Nose and SinusesInspection: There are no allergies on the nose, has history ofdifficulty in breathing and was

brought in Manila Doctors Hospital (December 2010), no further injuries, nosebleeds,

medications and changes in sense of smell except when she has colds. The external nose were

low bridge, brown and smooth in texture, no discharge from the nares. The client has patency

on both nostrils when asked to cover one and breath to the other nostril and vice versa without

difficulty. The internal nose doesnt have any other discharge or drainages except for clear and

watery discharges, there are no redness, swelling and lesions. The nasal septum was located on

the middle of both nostrils.No lesions and is intact.

Palpation: No tenderness palpated on the external of the nose. There are also no tenderness nor

masses when the maxillary, frontal, ethmoid and sphenoid sinuses were palpated.

G.)Mouth and OropharynxInspection: The client doesnt have dental check ups. Her last visit according to her is when she

was still 9 years of age. There are also no presence of singaw.No dentures used and

medications of treatments. The outer lips are moist, no lesions, symmetrical, smooth and

pinkish brown in color. The inner lips are also smooth, lesion-free, no singaw and moist. The

teeth andgums were also intact and appears to be lesion-free. The tongue is positioned on the

center of the mouth and is pink in color with thin whitish coat.It has no lesions. The client is also

able to protrude and move sideways, her tongue without any difficulty. The lingual frenulum is

positioned on the center at the floor of the mouth and is intact with the tongue. There are no

presence of lesions or masses at the floor of the mouth. There are also no swelling or redness on

the gums. The hard palate is more pinkish than the soft palate which appears to be lighter in

pink shade. Both dont have lesions or other drainages or discharges. The soft palate is

smoother in texture than the hard palate. The uvula is also located on the center position, no

swelling or redness and lesions. The oropharynx is not inflamed and pink in color. The client also

has gag reflex.

Palpation: No tenderness was palpated on the tongue.

H.)NeckInspection: There are no presence of neck lumps, neck pain or stiffness, thyroid problems and

medications or radiations. The client also is able to move her head freely and both

sternocleidomastoid and trapezius muscles were functioning because the client is able to move


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her head towards the ches, then her ears near her shoulders on both sides which all determines

the function of the sternocleidomastoid muscle and is able to hyperextend the neck- that is, the

chin is pointedupwards which in turns, determines the function of the clients trapezius muscle.

The client is also able to resist by shrugging of her shoulder and facing to the left and right. The

thyroidglanddoesnt have visible masses and the client is able to swallow without difficulty.

There are also no enlargement of the thyroidgland.

Palpation: There are also no enlarged lymph nodes palpated and no tenderness and other

masses. The trachea is also located in the center of the neck, no masses were also palpated

when the client was asked to swallow.

I.) Thorax and lungsInspection: The client doesnt have history of cancer, Tuberculosis, and currently has no cough

and sneezing. The spinal alignment doesnt have abnormal curvatures. There is also smooth

respiration without obstruction. The breathing patterns were effortless and soundless

Palpation: The posterior thorax doesnt have tenderness and smooth anddoesnt have any

lesions. The vocal fremitus was equal in vibration.

Percussion:

Auscultation: The client is able to breathe clearly with no bruits upon auscultation.

J.) Heart/CardiovascularInspection: The client has heart disease as indicated on the Health management / health

perception pattern in Gordons. Her family also has high cholesterol levels, There is also history

of stroke, heart attack and heart failure. So far there are no presence of lifts or heaves on the

precordium.No jugular veins were visible at the side of the neck.

Palpation: The carotid artery has a thrusting quality in pulsations.

Auscultation: The s1 can also be heard louder on the aortic area and the s2 on the pulmonic.

There is also 56 heart beats per minute recorded.

II.) Personal history

Habits : Do the laundry, clean the house, care and Rank/Order in the family: second eldest

daughter

look out for her son, text, browse the internet, Travel : Korea (2019-2010)

watch tv and sleep. Educational attainment : High school

graduate

Vices : smoke cigarettes anddrink liquor


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Lifestyle : Active

Usual day: Working in the house or singing on a gig

Social affiliation: none

III.) Environmental History

She lives in Pandacan, Manila anddescribed her environment as magulo, maingay,

parati may nag-aaway kadalasan mag-asawa at malayo ang nilalakad ko bago ako makasakay sa

tricycle or jeep o kaya bus.

IV.) OB/GYNE HISTORY

Menarche (age) : 13 years old when: unrecalled

Amount and characteristics: heavy flow

during the secondday & darkish red in

color

Duration: 4-5 days

Deliveries :

G =

P =

OPERATIONS:

T =

P =

A =

L =

Documents

New Nursing Process