II.

NURSING ASSESSMENT
A. Biographic Data
NAME: AGE: GENDER: ADDRESS: DATE OF BIRTH: PLACE OF BIRTH: OCCUPATION: NATIONALITY: CIVIL STATUS: RELIGION: HIGHEST EDUCATIONAL ATTAINMENT: CHIEF COMPLAINT: ADMITTING DIAGNOSIS: FINAL DIAGNOSIS: DATE ADMITTED: TIME ADMITTED: Ms. CDC 51 y/o Female Malolos, Bulacan October 9, 1961 Malolos, Bulacan House-wife Filipino Married Roman, Catholic College Graduate (Banking and Finance course) Gusto ko lang matangal ang mga tumubong bukol sa suso ko as verbalized by the client. Invasive Ductal Carcinoma Stage 2A (T2 NoMo) Surgical Procedure Core Needle Biopsy February 2013 Not Acquired (Specimen still in process) May 28, 2013 (Wednesday) 10:00 am

B. History of Present Illness Prior to Hospitalization

She stated that she had her diagnostic examinations already before going to the institution for her operation. These are: a. CBC b. X-ray c. Mamography (reveals scattered tumors on her left breast) d. Urinalysis (she was detected to have a UTI) e. Core Needle Biopsy (which was released on February 25, 2013; Diagnosis of: Breast Mass Leftouter-upper quadrant - Invasive Ductal Carcinoma, Nottingham Grade 2). She stated that prior to hospitalization she had an asthma-attack; therefore she had her routine nebulizer therapy (Salbutamol) to relieve her condition.

During Hospitalization
She was admitted last May 28, 2013 (Wednesday) for her operation Modified Radical Mastectomy (MRM) of the Left Breast. Her initial Vital signs are : BP = 140/90mmHg Temperature = 36.7 degree celcius Pulse Rate = 66 Respiratory Rate = 20 cpm. She had undergone Pre-operational procedures like taking Pre-Operational medications (seen on drugstudy) and other diagnostic test and was placed NPO before proceeding to the Operation which was scheduled on the following day. May 29, 2013; Vital Signs were: BP = 140/80mmHg Temperature = 37.1 degree celcius Pulse Rate = 79 Respiratory Rate = 19 cpm. At 10:45 am, the procedure began without any complications and ended at exactly 12: 40 pm. She was placed on PACU for monitoring and was released at 3:00 pm to surgery ward with stable vital signs.

Upon Handling
Upon the day of handle (May 30, 2013; 4:10 pm), she was already resting in the ward and is talking and lively already. She stated that she was relieved that the operation went well. She stated that she feels the pain on the operation-site; Graded as 6 on the Pain Scale of 1 to 10; wherein 10 is the highest.

C. History of Past Illnesses

Upon the interview of the client, she stated that this was her 5 th hospitalization already. When asked where and what were the reason for her past hospitalization, she stated that she had been hospitalized many times for the removal of her recurrent cyst or tumor growing in her body. She was usually hospitalized on different hospitals in Manila. She stated that every time a tumor is removed from her body they were always ordered for biopsy they always have negative result; until last February 2013 wherein she had been diagnosed with Breast Cancer Stage 2. She also stated that she has asthma ever since which were usually triggered by hot weather, dusts, and perfumes. She had also undergone Total Abdominal Hysterectomy Bilateral Salphingo-Oophorectomy (TAHBSO) last 2002. When asked about her other past illnesses, she just stated that she had only experienced some mild fever, coughs and colds but no significant or serious accidents, disease or injuries. When asked what were the usual treatments/remedies she had done to relieve these, she just answered, self medication (usually biogesic, mefenamic acid, alaxan, neozep, robitussin), drinks more water and accupressure theraphy a.k.a.Hilot if with some pilay/lamig. When asked if these self remedies were effective, she answered halos/mostly. She also stated that she subdued herself in Alternative treatment regimen like eating more vegetables;

black rice which she believes (based on research) can help eliminate toxins in her system. She also drinks Soya Milk in a regular basis which she thinks also helps eliminate toxins and promote good health. When asked about her Immunization Status, she stated that she cannot remember all her Immunizations, but shes certain that she had complete Maternal Immunizations; those received by mothers on their pregnancy stages. She stated that she has allergy to poultry, thus minimize the intake. She has no allergies to medications as proven that she always has a negative skin test.

D. Family History of Illnesses

The client stated that they have familial history of Breast Cancer and Cyst formations on her mothers side; Diabetes on her Fathers side. She also stated that 2 of her sisters died on breast cancer, another sibling died of Hypertension.

E. Developmental History
According to the client, she was raised by her siblings. She was the youngest among the 9 children of her parents. She stated that during her younger years they have not experienced any financial problems as observed that she had finished a college degree. Her parents disciplined them well and taught them about life. She had no problem growing up and stated that she had a lot of friends especially in their church.

F. Functional Health Pattern (Gordons Approach) A. Health Perception and Health Management Pattern Prior to Hospitalization
She stated that she was strong and always energized before being afflicted with tumors in her body. She also stated that she was lively and eager to always work to help her family. This is healthy according to her. But after acquiring the tumors she scored her Level of Health with 7, in the scale of 1 to 10; wherein 10 is the highest. She stated that she doesnt have any method to maintain her health. When asked when will she seek medical help during sickness, she stated during the symptoms appears. She stated that she doesnt drink alcohol and smoke cigarettes. She has not used any illegal drugs. She stated that she only consults a medical practitioner whenever she feels like his symptoms are getting worst.

During Hospitalization
She stated that she still does not feel healthy especially after finding out that she had a stage 2 Cancer. She stated that she still doesnt feel that energized to do some activities. She scored her present Level of Health as 4 in the scale of 1 to 10; wherein 10 is the highest.

B. Nutritional and Metabolic Pattern

72 HOUR DIET RECALL

Prior to Hospitalization During Hospitalization

DAY 5/27/2013 5/26/2013 5/25/2013 (Admission )

BREAKFAST LUNCH DINNER SNACKS Cannot Recall Cannot Recall Cannot Recall Cannot Recall Cannot Recall Cannot Recall Cannot Recall Cannot Recall Cannot Recall Cannot Recall Cannot Recall Cannot Recall

TOTAL INTAKE N/A N/A N/A

DAY 5/28/2013

BREAKFAST 1 pc. Of Pandesal (approx. 40g) 250ml of Soya Milk 500ml glass of water

LUNCH cup of Black Rice (approx. 10g) 1 saucer of Ginataang Gulay (approx: 30g) 500ml glass of water None (NPO)

DINNER SNACKS None (NPO) None (NPO)

TOTAL INTAKE (approx. 1500ml)

72 hour diet recall prior to hospitalization was not acquired because our client cannot recall what she had taken on those days. When asked about her food preferences, she stated that she likes to eat foods with liquids like soups, sinigang, tinola etc. and also vegetables. She also stated that she is not picky of foods; she eats vegetables and fruits. She stated that she usually eats 1 cup of black rice every day. She usually eat her breakfast at 7am, lunch at 11/12pm, dinner at 7/8pm and snacks, either 10am or 3pm. She stated that she has a moderate appetite. She usually eats bread as snacks partnered with Soya Milk. When asked how often her intake of Soya Milk is, she answered, everyday especially at snack time. She can drink up to 1Litter of Soya Milk in a day. Her usual water intake is 8 to 12 glasses a day, wherein her glass can usually contain 350ml of liquid. She stated that she adjusted her diet to help promote ger good health. Her last dental check-up was last January on a medical mission in their community. She usually takes a bath 1 to 2 times a day, usually 15mins. She seldom/not experiences dandruff and lice infestations. Her bathroom necessities include only soap, shampoo, clean water and a towel. She stated that she has no problem in wound healing. She stated that whenever she has coughs and colds, it is always accompanied by sore throat. But she has no problem in swallowing nor experiences nausea, vomiting or stomach aches.

5/29/2013

None (NPO)

None (NPO)

None (NPO)

5/30/2013 (Date of Handling)

500ml of Soya Milk

cup of Black Rice (approx. 10g) 250ml of Soya Milk 250ml glass of water

Not Acquired

none

No Oral Intake (Refer to IVF sheet) (approx. 1000ml)

Based on her 72 hour diet recall, her intake of food from day 1 was limited only to breakfast because she was ordered NPO on the following hours. She was NPO before and after the operation. She resumed her diet on May 30, 2013; She was ordered with Diet as tolerated with strict aspiration precaution. She stated that her appetite has not returned and she feels everything she placed in her mouth is bland. She drinks water and Soya Milk to return her strength. Her current Height is: 52; Her current Weight is: 119.04lbs.; Her BMI is: 21.77 (Normal).

C. Elimination Pattern
A. BOWEL ELIMANATION PRIOR TO HOSPITALIZATION
Once a day

DURING HOSPITALIZATION 5/28/2013

1

5/29/2013
0

5/30/2013
0

FREQUENCY

(normal as verbalized by the client) Usually Brown and firm (normal as verbalized by the client)

CHARACTERISTICS

Light brown; soft

N/A

N/A

DISCOMFORT

No discomfort

No discomfort

N/A

N/A

B. URINARY

PRIOR TO

DURING HOSPITALIZATION

ELIMINATION

HOSPITALIZATION
Usually 5-7 times a day (normal as verbalized by the client) 1-3 medium glass (approx. 600/900ml) (normal as verbalized by the client) (approx. 4500ml) Transparent to light yellow, aromatic odour No discomfort None

5/28/2013
3

5/29/2013
Cathetherized (I and O not in the chart)

5/30/2013
4

FREQUENCY

AMOUNT TOTAL URINE OUTPUT CHARACTERISTICS DISCOMFORT PROBLEM IN CONTROL

1-2 medium glass (approx. 600ml) (approx. 1800ml) Light yellow; Pungent odour No discomfort None

N/A

1 medium glass (approx. 300ml) (approx. 1200ml) Dark yellow; Pungent odour No discomfort None

N/A N/A N/A None

C. PERSPIRATION AMOUNT AND CHARACTERISTICS

Sweats a lot Decreased perspiration Decreased perspiration Decreased perspiration

The clients fecal and urine frequency and amount prior to hospitalization is considered normal according to her. She had trained herself to defecate once a day. Prior to hospitalization, she usually urinates 5-7 times per day in larger amount. Perspiration accounts for the insensible fluid loss. Decreased sweating during hospitalization is affected by the lack of physical activity due to being in bed all the time. Urine frequency during hospitalization is almost the same. Frequency and amount of feces and urine may change due to the difference of the amount of oral intake. Also, the medications she is taking may affect the renal function. Aging also decreases the functions of many body systems. Characteristics of stool and especially urine may be affected by the type of medication a client is taking. Medication by-products are excreted through urination. She stated that she was also diagnosed with UTI on the date of admission (see Diagnostics for further information).

D. Activity-Exercise Pattern Prior to Hospitalization

According to client her usual activities then includes, waking up at 6:00am, have her breakfast, do household chores, take a bath then watch her favourite noon-time shows. In the afternoon, she just lie down or goes out and chat with her neighbours then goes home again to cook and eat dinner then takes a bath then sleep. As a leisure or form of relaxation, she just watches television or chat with friends. She has no form of exercise.

During Hospitalization
She was not able to perform her usual activities. She just usually lies in bed and chat with her fellow patients. She just takes a nap when nothing else to do. She stated that she was bored inside the hospital. She stated that she needs help during her ADLs in the hospital due to the lined IVFs and her pain during movement.

Percieved ability for: (prior to hospitalization)

__O__Feeding __O__Bathing __O__Dressing __O__Grooming __O__Home Maintainance __O__Toileting __O__Bed Mobility __O__Gen. Mobilty __O__ Cooking

Percieved ability for: (during hospitalization)

__2__Feeding __2__Dressing __2__Bathing __2__Grooming __2__Toileting __2__Bed Mobility __2__Gen. Mobility

(Code Level)

LEVEL 0 LEVEL 1 LEVEL 2 LEVEL3 LEVEL 4

Full Self Care Requires use of Equiment or device Requires Assistance or Supervision from another person Requires Assistance or Supervision from another person or device Is Dependent and does not Participate

E. Sleep-Rest Pattern Prior to Hospitalization

The client usually sleeps at 8pm which spans at about 8-9 hours of sleep which is usually continuous. She then wakes up around 6 am. She stated that she usually has no difficulty falling asleep. But sometimes, she wakes up in the middle of the night to urinate. She sometimes has trouble falling asleep again. As a form of relaxation, she just watches television. She usually takes a nap in the afternoon, usually around 2-3pm. When asked if she feels well rested after sleeping, she answered Okay lang-as verbalized by the client. Score of 7 in sleep quality; 10 is the highest.

During Hospitalization
According to the client, she had slept well inside the ward. She stated that she feels lethargic after the operation. Last night (May 29, 2013) she slept at 8pm and woke up at 5am. Her sleep is continuous. Score of 6 in sleep quality; 10 is the highest. She feels tired upon waking up.

F. Cognitive-Perceptual Pattern Prior to Hospitalization

The client has no significant problems in her 5 senses. The client stated that she learns fast when observing something. She stated that she usually experienced being forgetful and sometimes it can affect also her performance. She stated that she can make her own decisions but she still seeks advice from her family and friends.

During Hospitalization
The client has no problem in her 5 senses. The client still has vague understanding with her condition.

G. Self-Perception and Self-Concept Pattern Prior to Hospitalization

When asked to describe herself, she stated Positive thinker ako, especially noong nagsimula akong magkasakit- as verbalized by the client. When asked what her best characteristics are, she answered being persevering and Optimistic. She considered her Family and Friends both as strength and weakness. She stated that she still wants to live more and spend time with her family. When asked on her opinion on how she perceives how her family looks at her, she answered ulirang nanay at malakas ang loob.

During Hospitalization
The same except that she has this feeling of incompleteness after her left breast was removed. She stated that Even if I am optimistic, di naman maiaalis yung ganoong pakiramdam. She stated that she expects other people to pity her because of her condition, but stated that kahit ganoon eh malakas parin ang faith ko kay lord na di niya ako pababayaan, everything is Gods-will, I gladly accept what he gives me.

H. Role-Relationship Pattern Prior to Hospitalization

The client lives together with her own family. She stated that she was a lucky woman who got married to a very lucky man and had wonderful children. She describes her family as okay naman, she also stated that she usually gives a lot of motherly advices not only to her family but also to her friends, one of the benefits of being an optimists. She gets her

During Hospitalization
The same. She stated that she really feels the support and care of her Family, siblings and friends; as evidenced by taking care of her in the hospital, bringing her foods and visiting her.

strength from the love and care she feels from her family. When asked who has the greatest authority with regard to decision making in their family, she stated that Kami ng asawa ko- as verbalized by the client. She stated that the most important thing in her life is her family. When asked how she is in the community, she answered Marami akong kumpare at kumare sa amin-as verbalized by the client. She stated that she joins in community activities like sweeping and in processions.

I. Sexuality-Reproductive Pattern Prior to Hospitalization

According to the client she has no problems with regards to her sexuality. She stated that as a married couple, they have not experienced any problems based on the sexual aspects of the relationship. But she stated that in her current age, they are quite old for that thing. Other data not acquired; client refused and asked to change the topic. The same.

During Hospitalization

J. Coping Stress-Tolerance Pattern Prior to Hospitalization

According to the client, the biggest problem in life for her is her recurrent hospitalization because of her condition. It is the cause why her family is experiencing financial insuficiencies. Her usual form of coping is by talking to her family and friends and also by praying. The same.

During Hospitalization

K. Value Belief-Pattern Prior to Hospitalization

The client stated that the most important thing in her life is her family. According to the client she believes in supernatural phenomena like aswang, kulam etc. she also believes in local sayings/Pamahiin like not sweeping at night and pasma etc. According to her, her relationship with God is important. She stated that it is one of the things that helps clear her mind and gives her strength. As a proof of this; she religiously attends Sunday mass and prays before going to bed. She is also an active member of their parish church. The same.

During Hospitalization