nursing assessment (as a guide)

7/31/2019 Nursing Assessment (as a Guide)

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I. NURSING ASSESSMENTA. NURSING HISTORY

RAMSEL

PERSONAL DATA

Mr. Thor (not his real name) is 52 years old male born on February 28, 1960. His parents

are Rowena and Thor II. The parents hail from manila city. Thor is married to Ms. Ru 45 female

they have two sons. Thor is married for 25 years. Their sons names are Goku 20 years old and

Naruto 18 years old. Mr. Thor has a business here in Pampanga and in manila. They are Roman

Catholic.

FAMILY HISTORY RHEA

The authors have observed that the Family can be described as not closely knit.

According to Ms. Ru while there are four in their house. There are some conflict between the

Father and sons; if a conflict arises it is usually resolve in a short period of time.

PAST ILLNESS

RAMSEL

December 2006

Mrs. Ru she elaborate that Mr. Thor has seen changes in behavior and the body built of

his husband. That time his husband does not tell anything about his condition. He always gets

easily tired and low appetite. He always feels of difficulty of breathing.

February 2011

Mr. Thor seen to be thin not like before. His activity daily living lessens due to his

condtion. Still continue his work. She does not state what medication he used.

PRESENT ILLNESS MOISES

June 2-12 2012

According to Ms. Ru that the patient experience getting easily tired while he work and

when travel long distance especially here in Pampanga, when the patient Thor stay here in

Pampanga together with his business partner and while they are bonding in the party place. Mr.

Thor suddenly experienced difficulty of breathing and decided to rest in their house. And one

time, he was seen by his wife coughing out blood.


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June 25July 1 2012

Five days prior to admission Mr. Thor experienced cough and difficulty in breathing and

suddenly collapse. Ms. Ru elaborate that Mr. Thor has productive cough with blood sputum yet

is husband expectorated only few amount. Thats the time Mrs. Ru decided to get Mr. Thor to go

to hospital.

July 2, 2012

Accompanied by her wife Mr. Thor was admitted at the emergency room of a certain

hospital on July 2, 2012 with the chief complaint of difficulty of breathing. His medical

diagnosis is to consider bronchogenic cancer stage IV. He was brought to Intensive Care Unit at

around 3:15 pm

The physician ordered the following diagnostic exam on the day of admission; CT scan,

ABG, hematology. Omeprazole (amount and doasage) all meds..

LIFESTYLE MOISES

MS. Ru keeps herself busy with two sons and performing house chores and taking care

of his own business is a networking business. Ms. Ru states that Mr. Thor is workaholic and has

many things to accomplish. Sometimes Mr. Thor does not go home because of workload in the

office. She states that Mr. Thor is chain smoker he evenly consume two packs of cigarettes in

one day in the past 25 years of their marriages. She cant control his husband because limited

spare of time that they live together. Mr. Thor frequently drinks alcohol.

*PACK YEAR = 40 sticks / 20 sticks = 2 x 25 years = 50 pack year

ACTIVITY DAILY LIVING SHIELA

Mrs. Ru described that the patient dedicated to his work even that have many business in

manila and here in Pampanga. The patient does not have adequate rest because sometime he need

to finished his work. He to go sleep like 2:00 am in the morning. His working time start at

exactly 7:00 am. He spends most of his time in work.

EATING PATTERN AND FOOD SOURCES SHIELA

Mr. Thor had 3 meals a day with 1-2 snacks in between most of the time because of he is

always busy in his work. Mr. Thor always eat in the fast food chain he like preservatives foods

like can good and barbeque, steam tilapia and steam meat.

HOME AND NEIGHBORHOOD CONDITION SHIELA


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Thor family lives in 4 rooms and 4 bathrooms in a 2 storey house Dimasalang Street.

There house is near in the terminal of jeepney near their house. Ms. Ru shared sometime they

disturbed in the nose of the jeepney near their house especially late at night.

ALLERGIES AND MANAGEMENT RHEA

Upon interviewing Mrs. Ru state that Mr. Thor is allergic to seafood and dust. At one

time Mr. Thor experienced DOB for 12 days.

ACCIDENT RHEA

Mr. Thor has been experienced mild accident like physical bruises.IMMUNIZATION STATUS RAMSEL

Mrs. Ru stated that according to mother of Mr. Thor has received complete immunization

during that time. Records of Mr. Thor not present at the time of interview.

HEALTH PRACTICES AND BELIEFS RHEA

In times of illness Thors Family would bring him to the hospital simply because they

have accessible to their place it can be reached by public or private vehicles. Upon interview

Mrs. Ru stated she is satisfied with the service and the approach of the staff nurse and personnel

given to his husband.

SOCIAL DATA MOISES

They live in wealthy family because their children have own their own businesses thats whythey are apart from each other. He perceived that having just a little signs of illness will not

result to a big problem that he is facing now. He had 3 spouses but his wife Ru, refused to tell the

details. He copes in his stress through increasing his number of cigarettes in a day and sometimes

drinking alcohol. He doesnt believe in tawas and fortune tellers. As a social being, he

occasionally interact with his friends through attending gathering or party.

MOISES

ACTUAL PHYSICAL ASSESSMENT

The actual physical assessment from the chart dated July 5, 2012


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VITAL SIGNS Initial TIME

8AM 9AM 10AM 11AM 12PM 1PM

TEMP 37.9 37.4 37.8 36.8 36.8 36.7 36.7

PR 79 86 77 78 83 80 84

RR 32 30 28 26 27 24 25

BP 130/90 120/80 160/100 170/110 140/100 130/90 150/110

The actual physical assessment from the chart dated July 6, 2012

VITA

LSIGNS

Initial TIME

8AM 9AM 10AM 11AM 12PM 1PM

TEMP 37.5 37.3 36.8 36.9 36.5 36.8 36.9

PR 77 88 79 83 85 87 83

RR 28 32 28 27 27 29 25

BP 130/90 130/80 150/100 160/110 150/100 160/90 140/100


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B. PHYSICAL EXAMINATION

JULY 5, 2012 (FIRST NURSE-PATIENT INTERACTION)

General Appearance MOISES

Patient Thor was wearing hospital gown. The patient has a nasal cannula and nasogastric

tube inserted into the right nares. He was in semi fowlers position. Upon assessment Mr. Thor

has close tube thoracostomy infusing well at the right lungs. Due to limited numbers of visitors

allowed, the patient seemed to be in a gloomy and sad look and weakness noted marking obvious

illness, with hacking cough, obvious weight loss (from 65kg to 52 kg), his cooperating but too

weak to talk, his mood is appropriate in the situation, his quality of speech is rapid and slurred or

hoarse, relevance of thought is logical, with vital signs of BP 130/90 mmHg, PR 79 bpm, RR 23

bpm, 36.9 C.

Skin

RAMSEL

INSPECTION

He has fair skin and scattered freckles on the face and shoulders. When assessing the right

hand it was observe that the thumb was spoon like in appearance

PALPATIONRough in texture and warm temperature on both hands. When skin is pinch the skin back

to its usual place after one seconds (good skin turgor)

Head and neck RHEA

INSPECTION

The patient has short curly hair with even distribution with some white hair . Symmetric

facial features and movements. Symmetric nasolabial folds.

PALPATION

His neck is limited range of motion and pain in movement due to presence of mass and has

grade two edema (neck) during palpation.

Eyes and vision SHIELA

INSPECTION


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The outer cantus of the eye is a line with the tip of the ear lobes. No signs of inflammation of

the eyelids upon inspection and palpation and positive papillary light reaction. With palpebral

conjunctiva.

Ears and Hearing MIOSES

INSPECTION

Ears are equal in size and similar in appearance. Skin is smooth and without nodules.

PALPATION

No tenderness or pain when palpated. Normal voice tones audible,

Nose and Sinuses RAMSEL

INSPECTION

Nares are asymmetrical in structures and with NGT

Mouth and Throat RHEA

INSPECTION

Lips are dry and presence of caries. There is an incomplete dentition. Hoarseness of voice.

Thorax SHIELA

INSPECTION

Presence of retraction and contraption in the right lungs.

AUSCULTATION

During auscultation coarse crackles on both lungs with increasing sounds on the

tracheobronchial.

Heart SHIELA

INSPECTION

No pulsations

AUSCULTATION


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Apical pulse audible at 4th

to 5th

left intercostal space, near the sternal areaSwishing sound

heard at the beginning , middle or end of systolic pause. Grade II (very faint, heard only after the

listener has turned in)

Abdomen MOISES

INSPECTION

Normal paler with white striae, withno lesions masses, and skin discoloration

AUSCULTATION

The abdomen has 14 bowel sounds per minute

PERCUSSION

Tympany elicited upon percussion of the abdominal area

PALPATION

No protrusion, depressions upon palpation

Extremities RHEA

INSPECTION

The upper and lower extremities has slight weakness (rate 4) active motion against full

resistance

PALPATIONHas bilateral pedal edema ++ (grade 2 pitting edema)

Back and Spine RAMSEL

INSPECTION

The patient was able to maintain a straight posture in sitting position and no spinal

deviations.

nursing assessment (as a guide)

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