Mindanao State University

COLLEGE OF HEALTH SCIENCES

Marawi City

Name of Student Group F ______________ Clinical Instructor Ms. Sohaynee Moslem ______

Area of Assignment VSMMC- Neuro Ward Date Submitted ____April 18, 2011
_____

NURSING ASSESSMENT I

PATIENT’S PROFILE

NameMr. M Address Lamacan, Sibunga, Cebu

Age 37 yrs old

Sex Male Religion Roman Catholic Civil Status Married Occupation Carpenter

HEALTH HABITS

Frequency Amount Period/Duration

1. Tobacco everyday 1 pack 21 years

2. Alcohol Thrice a week 1 bottle 17 years

3. OTC-drugs/ non-prescription drugs none none none

A. CHIEF COMPLAINTS

Complication of craniectomy
B. HISTORY OF PRESENT ILLNESS (HPI) {location, onset, character, intensity, duration, aggravation, and alleviation, associated
symptoms, previous treatment and results, social and vocational responsibilities, affected diagnoses}.

A case of 37 years old, male, Filipino, Roman Catholic, married and residing at Lamacan, Sibunga, Cebu was brought for the second
time in VSMMC due to compications of his craniectomy. Patient manifested hydrocephalus on his left temporal accompanied with seizures
and elevated body temperature a week after he was discharged and so they immediately admitted the patient in VSMMC on April 08, 2011.

C. HISTORY OF PAST ILLNESS (previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance,
major illnesses, allergies, medications, habits, birth and developmental history, nutrition- for pedia)

The patient was hospitalized for the second time; patient had a head injury due to fall and undergone craniectomy, patient has no
infectious disease, was completely immunized, no major illness, and patient has an allergy on beans and meats, no medication taken prior to
hospitalization.

FAMILY HISTORY WITH GENOGRAM

Acquired Diseases: Heredo- familial Diseases:

Hypercholesterolemia X Diabetes
/
Kidney Disease X Heart Diseases
X
Tuberculosis X Hypertension
/
Alcoholism X Cancer
X
Drug Addiction X Asthma X

Hepatitis A X Epilepsy X
B X Mental Illness
X
 C X Rheuma/Arthritis X
Others (pls. specify) arthritis Others
(pls. specify)

D. PATIENT’S PERCEPTION OF:

1. Present Illness

“ma okey ran i siya, may awa and diyos” as verbalized by the SO

2. Hospital Environment

“ayos lang man ang environment diri” as verbalized by the SO

E. SUMMARY OF INTERACTION

The SN was able to gather information needed because the SO was cooperative, the SN was able to gain the trust of the SO that’s
why it is easy for him to gather information. The interaction between the SN and the SO was good.

REVIEW OF SYSTEMS

Name Date
Vital Signs: Height
Temperature Weight
Pulse Observation ____________________________________

Respiration

Blood Pressure
1.GENERAL

2. HEENT

3. INTEGUMENTARY
4. RESPIRATORY

5. CARDIOVASCULAR

6. DIGESTIVE

7. EXCRETORY

8. MUSCULOSKELETAL

9. NERVOUS

10. ENDOCRINE

DRUG STUDY
 BRAND NAME Prescribed and Mechanism
GENERIC NAME Recommended Of
CLASSIFICATION dosage, Action Indication Contraindication Adverse Reaction Nursing
frequency, route Responsibilities
of administration
 NURSING ASSESSMENT II

NameMr. M Age 37 y/o___ Sex Male_

Chief Complaint Complications of craniectomy_________________________
Impression/Diagnosis Status Epilepticus _____________
Date/Time of Admission April 08, 2011 Inclusive Dates of Care April
11-15, 2011 _ Diet: Soft diet _____________________
Allergies Beans and Meats __ Type of
Operation (if any) Craniectomy

NORMAL PATTERN BEFORE INITIAL CLINICAL APPRAISAL

HOSPITALIZATION
DAY 1 DAY 2

1.ACTIVITIES- REST
> Patient can turn himself > patient was immobile > patient was immobile > patient was immobile
a. Activities
side to side
> sleeping most of the time > sleeping most of the time > sleeping most of the time
b. Rest > Most of the time patient
was sleeping >patient was unconscious
c. Sleeping pattern >patient was unconscious >patient was unconscious
> patient was sleeping
around 8pm and wakes up
around 7am for his breakfast
2.NUTRITIONAL-
METABOLIC > blenderized food > blenderized food
> blenderized food > blenderized food
a. Typical > soft diet > soft diet
intake(food, fluid) > soft diet > soft diet
> none > none
b. Diet
> none > none
c. Diet restrictions > not taken > not taken
> not taken > not taken > valporic acid, tramadol, > valporic acid, tramadol,
d. Weight > valporic acid, tramadol, phenytoin, salbutamol, phenytoin, salbutamol,
> ferrous sulfate, tramadol phenytoin, salbutamol, paracetamol paracetamol
paracetamol
 e.
Medications/supplem
ent food

3. ELIMINATION

a. Urine (frequency, > patient has a diaper for > patient has a diaper for > patient has a diaper for > patient has a diaper for
color, urination, with clear light urination, changed the diaper urination, changed the urination, changed the
transparency) yellow color and foul smell thrice, with clear light yellow diaper twice, with clear diaper twice, with clear light
urine color and foul smell urine light yellow color and foul yellow color and foul smell
> not yet defecated at day of smell urine urine
b. Bowel (frequency, > patient defecates twice a assessment > not yet defecated at day > not yet defecated at day
color, week with firm blackish color of assessment of assessment
consistency) stool
4. EGO INTEGRITY

a. Perception of self > patient’s support system > patient’s support system > patient’s support system > patient’s support system
was his family and relatives was his family and relatives was his family and relatives was his family and relatives
b. Coping especially his wife who especially his wife who especially his wife who especially his wife who
Mechanism always stay with him always stay with him always stay with him always stay with him
c. Support System

d. Mood/Affect
5. NEURO-SENSORY
> patient was conscious but > patient was unconscious > patient was unconscious > patient was unconscious
a. Mental state unable to talk

b. Condition of five
senses: > his senses are properly > 5 senses were not > 5 senses were not > 5 senses were not
functioning according to the functioning well functioning well functioning well
(sight, hearing, SO . . .
smell, taste,

touch)

6. OXYGENATION

a. Vital signs T: 37.8 ⁰C T: 37 ⁰C T: 37.8 ⁰C

Temperature RR: 26 cpm RR: 24 cpm RR: 26 cpm

Respiratory rate Not PR: 118 bpm PR: 108 bpm PR: 118 bpm

Heart rate taken BP: 100/80 mmHg BP: 120/90 mmHg BP: 120/100 mmHg

Blood pressure prior Patient has audible breath Patient has audible breath Patient has audible breath
sounds, has no history of sounds, has no history of sounds, has no history of
b. Lung sounds to respiratory problem respiratory problem respiratory problem
c. History of hospitalization
Respiratory

Problems
7. PAIN-COMFORT
> pain at the temporal part > patient was unconscious > patient was unconscious > patient was unconscious
a. Pain (location,
of the head every morning
onset,
and evening, lasts for
character,
several minutes
intensity, duration,
associated
symptoms,
aggravation)
> alleviates the pain by
resting
b. Comfort
measures/Alleviation

> patient was taking

c. Medications
tramadol for pain

8. HYGIENE AND > patient can move himself > patient was immobile and > patient was immobile > patient was immobile and
ACTIVITIES side to side, can able to performed TSB by the SN for and performed TSB by the performed TSB by the SN for
OF DAILY LIVING produce sound on his mouth his hygiene SN for his hygiene his hygiene
and can sit with assistance,
performed his hygiene by
TSB done by his wife
9. SEXUALITY

a. female (menarche,
menstrual
cycle, civil status,
number of
children, > patient was circumcised > patient was circumcised > patient was circumcised > patient was circumcised
reproductive status) when he was only 6 years when he was only 6 years when he was only 6 years when he was only 6 years
old, he is married and with 4 old, he is married and with 4 old, he is married and with old, he is married and with 4
b. male (circumcision, children children 4 children children
civil
status, number of
children)

LABORATORY AND DIAGNOSTIC PROCEDURES

DATE NAME OF THE PROCEDURE RESULT NORMAL VALUE NURSING IMPLICATION

 SUMMARY OF INTRAVENOUS FLUID

DATE/TIME STARTED INTRAVENOUS FLUID AND VOLUME DROP RATE NUMBER OF DATE/TIME
HOURS CONSUMED
 SUMMARY OF MEDICATION

DATE MEDICATIONS- dosage, frequency, route Remarks

ANATOMY AND PHYSIOLOGY
 PATHOPHYSIOLOGY

MEDICAL MANAGEMENT
NURSING MANAGEMENT
SURGICAL MANAGEMENT
 DISCHARGE PLAN

NAME ______________________________________________ DATE OF DISCHARGE: ____________________

CONDITION UPON DISCHARGE ___________ Nature: Home per request ( ) Discharge

against medical advice ( )
1. MEDICATIONS

2. EXERCISE

3. DIET

4. HEALTH TEACHING

5. SCHEDULE FOR THE NEXT VISIT

NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION