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ST. PAUL UNIVERSITY MANILA

St. Paul University System

College of Nursing and Allied Health Sciences

NURSING CARE STUDY

(Application of Nursing Process)

I. ASSESSMENT

A. General Information

Client’s initials: T.D.L. Rm/Wd: FMW d Date Admitted: July 6,2010

Age: 5 3y/o Sex Female CS Widowed Nat Filipino Rel Roman Catholic

Educ. Attainment: Gradeschool graduate Occupation: food vendor d

Admission complaint/s Loss of balance, vomiting, non-communicative, facial asymmetry

Admission diagnosis CVA d

Admitting VS: T P __79 dBeats/min R 26 Breaths/min

Breaths/min: BP 180/150 mmHgdd

B. Nursing History (Based on the Functional Health Pattern by Gordon)

1. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN

1.1 Client’s description of her/his health:

Before Admission:

“Okay naman sya. Araw-araw sya nagtitinda. Sigla-sigla pa nga nyan eh,”

as verbalized by the client’s significant other.

At present:

At present, the client feels weak and always sleepy. He is very warm to

touch and has an elevated blood pressure.

1.2 Health Management:

Self: The client usually eats fish and avoids eating fatty foods.

1.3 History of present illness

“Mataas na talaga BP nyan dati pa kaso lang ayaw nya uminom ng gamot.

Takot,” as verbalized by the client’s significant other.

1.4 Past illnesses:

The client’s past illnesses is hyperternsion.

1.5 History of hospitalization (when, where and why):

“Ngayon lang yan naospital takot nga kasi yan magpacheck-up. Sa clinic

ko lang yan dinadala,” as verbalized by the client’s significant other.

1.6 History of illness in the family:

“Yung papa ko mataas din BP. Yung kapatid kong namatay may asthma,”

as verbalized by the son.

1.7 Expectations of hospitalization:

The client’s son expects that her mother will be cured and will feel better

after the hospitalization.

1.8 Anticipation of problem with caring, for self upon discharge:

“Hindi ko na alam kung sino ang mag-aalaga sa kanya pag-uwi. Baka

yung mga anak na nya muna kasi nakaratay din ang anak ko. Kaso ang

problema hindi mababait ang anak nya,” as verbalized by the client’s

significant other.

1.9 Knowledge

The client has no knowledge of the importance of the treatments

prescribed to her before. She only knew the importance of it when she was

admitted to OSMUN.

2. NUTRITION AND METABOLIC PATTERN

2.1 Usual food intake (before admission)

Breakfast

Before her admission, the client usually eats binatog for her

breakfast.

During admission, the client eats foods that are low in fat and salt

and high in fiber.

Lunch

Before admission, the client’s usual intake is 1 cup of rice and a

viand which is usually fish.

During admission, the client eats foods that are low in fat and salt

and high in fiber.

Supper

Before admission, the client’s usual intake is 1 cup of rice and a

viand which is usually fish.

During admission, the client eats foods that are low in fat and salt

and high in fiber.

Snacks

Before admission, the client’s snack is usually binatog.

During admission, the client does not have snacks.

Preferences

The client’s favorite foods are binatog and fish.

2.2 Usual fluid intake (type, amounts)

The client’s usual fluid intake is 8-10 glasses of water in one day.

2.3 Any food restrictions:

The client cannot eat fatty foods because of her hypertension.

2.4 Any problems with ability to eat:

The client has no problems with regards to ability in eating.

2.5 Any supplements (vitamins, feedings)

The client does not have any supplements.

3. ELIMINATION PATTERN

3.1 Bladder:

Usual frequency/day: Color: Yellow

The client usually urinates four to five times a day

Complaints on the usual pattern of urination:

The client has no complaints on the usual pattern of urination.

Home remedies:

There are no home remedies used.

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ST. PAUL UNIVERSITY MANILA St. Paul University System College of Nursing and Allied Health Sciences NURSING CARE STUDY (Application of Nursing Process) I. ASSESSMENT A. General Information Client's initials: T.D.L. Rm/Wd: FMW d Date Admitted: July 6,2010 Age: 5 3y/o Sex Female CS Widowed Nat Filipino Rel Roman Catholic Educ. Attainment: Gradeschool graduate Occupation: food vendor d Admission complaint/s Loss of balance, vomiting, non-communicative, facial asymmetry Admission diagnosis CVA d Admitting VS: T P __79 dBeats/min R 26 Breaths/min Breaths/min: BP 180/150 mmHgdd B. Nursing History (Based on the Functional Health Pattern by Gordon) 1. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN 1.1 Client's description of her/his health: Before Admission: "Okay naman sya. Araw-araw sya nagtitinda. Sigla-sigla pa nga nyan eh," as verbalized by the client's significant other. At present: At present, the client feels weak and always sleepy. He is very warm to touch and has an elevated blood pressure. 1.2 Health Management: Self: The client usually eats fish and avoids eating fatty foods. 1.3 History of present illness "Mataas na talaga BP nyan dati pa kaso lang ayaw nya uminom ng gamot. Takot," as verbalized by the client's significant other. 1.4 Past illnesses: The client's past illnesses is hyperternsion. 1.5 History of hospitalization (when, where and why): "Ngayo ...
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