Arellano, Aigina Lucelle H.

BSN 4

August 6,2013

Client Information Clients initials: CD Rm/Wd: 5A Room 512 Age: 48 years old Sex: M CS: Married Nationality: Filipino Religion: Roman Catholic Admitting or Working Diagnosis: CVD Infarction and Infected Stomas Ulcer at Left Ankle

A. Nursing History (Based on the Functional Health Pattern by Gordon) 1. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN 1.1 Clients description of his/her health: The patient stated that this is his third time to be hospitalized. The first was when he was operated for removal of kidney stone. He is also aware that his second hospitalization is because he had a mild stroke accompanied by seizures. But before it happened, he describes himself as an athletic person. He said he always play basketball, volleyball and bowling with his friends when he has time after work. He admitted that because of his condition, all of his activities before had been set aside. 1.2 Health Management: The client stated that before his first hospitalization he used to go on check- up when hes not feeling well and sometimes this check-up is part of his incentives from the company. He also stated that he does exercise every day and assure that hes taking enough rest and sleep. Whenever he feels sick or is sick, he just takes whatever medication is available and applicable for his condition, like paracetamol if he experiences fever. 1.3 History of present illness Few hours prior to admission, patient started to feel weakness and numbness on his right arm. He also have a wound in his left ankle which according to him was originates from just a little one. With persistence of feeling weak and numb of his right body side, patient consulted and was subsequently admitted. 1.4 Past illnesses: The client experienced Mild Stroke and Seizure last 2010. The client also stated that he had undergone Nephrolithotomy.

1.5 History of hospitalization: The patient admits that this is his second time to be admitted in the hospital. 1.6 History of illness in the family: (+) Hypertension (Father) 2. NUTRITION AND METABOLIC PATTERN 2.1 Usual food intake (before consultation) Breakfast 1 cup of rice and fish or bread and coffee Lunch 1 cup of rice and fish or meat Supper 1 cup of rice and vegetables or meat Snacks biscuits Preferences: Rice and Laswa(Ilocano mixed veggies)

2.2 Usual fluid intake (type, amounts): - Water (approximately 8-10 glasses per day) - Coffee (approximately 1 cup per day) 2.3 Any food restrictions: Patient was put on Low salt Low Fat diet upon further assessment during admission related to his present condition. 2.4 Any problems with ability to eat: None 2.5 Any supplements (vitamins, feeding): Vitamin B Complex 3. ELIMINATION PATTERN 3.1 Bladder: Usual frequency/day: 6-10 times a day Color: light yellow Complaints the usual pattern of urination: None 3.2 Bowel: Usual pattern/day (time, frequency, color and consistency): Every morning or night, at least once a day, brown, and semi-solid Complaints of usual pattern of bowel movement: None Home remedies: None 3.3 Any assertive device: None

3.4 Skin (condition): The patients skin is slightly dry and warm to touch. It has a good skin turgor.

4. ACTIVITY EXERCISE PATTERN 4.1 Usual daily/weekly activities Leisure: Playing basketball, volleyball and bowling with friends. He likes to cook for his family sometimes. Exercise: Stretching and jogging every day or playing basketball. 4.2 Any limitations of physical ability: Since the client is admitted in the hospital and had right sided body weakness he cannot do some of his previous leisure. 4.3 History of dyspnea or fatigue: The patient reports no history of Dyspnea or fatigue. 5. SLEEP-REST PATTERN 5.1 Usual sleep pattern: Bedtime 9 pm Hours slept 8-9 hours No. of pillow/s 1 pillow Sleep routines 1 to 2 hours siesta in the afternoon 5.2 Any problems regarding sleep: The client stated that he doesnt have any difficulty in sleeping.

6. COGNITIVE-PERCEPTUAL PATTERN 6.1 Any deficits in sensory perception (hearing, sight, touch): The client has no deficit in hearing and seeing because he can response to all the questions that being ask to him but cannot withhold an object for a long time. And when ask not to release my finger upon holding theres only minimal resistance. 6.2 Ability to read and write. Any difficulty in learning? The client is able to read and write and has no difficulty in learning. He is working as a machine operator in Avon. 6.3 Any complaints? (e.g. pain): The patient complaints right arm weakness and numbness as well as pain on his infected foot on his left ankle.

7. SELF-PERCEPTION

7.1 What the client is most concerned about: The patient is most concern about this fast recovery because he stated that he needs to work for his family. 7.2 Present health goal: When asked about his present health goal, he said that he wants to get well as soon as possible so that he could resume his usual activities and be productive like he used to. 7.3 Effect of present illness to self: The client wasnt able to do his previous activities including his work.

8. ROLE RELATIONSHIP PATTERN 8.1 Language spoken: The patient speaks Filipino and can speak English. 8.2 Manner of speaking: The patient speaks in a slow medium-pitched tone. 8.3 Significant person to client: The significant persons to client are his whole family. 8.4 Complaints regarding family: When asked about this matter, the patient was silent at first and said that he has no complaints regarding his family. 8.5 Living with (members of family): The patient lives with his wife and 4 children. 9. SEXUALITY AND SEXUAL FUNCTION 9.1 Anticipated change in sexual relations because of illness - According to clients, because of his present condition his sexual activity with his wife is limited. The client stated that his wife understands their situation. 9.2 Knowledge of sexual functioning - Patient is aware of his sexual functioning as a man. 10. COPING STRESS MANAGEMENT PATTERN 10.1 Decision making ability The patient said that at 48, he is capable of making his own and family decision with regards to all matters. 10.3 Management of stress:

Paikot ikot lang ako sa bahay kapag naiistres ako at kung minsan ay nagluluto ng kung anong meron sa bahay as verbalized by the client. 10.4 Expectations from nurses to provide comfort and security during hospitalization: The client expects that all the nurses will take good care of him while in the hospital. 11. VALUE BELIEF SYSTEM 11.1 Source of strength and meaning: The client mentioned that right now God and his family is his source of strength and meaning. 11.2 Importance of God to client: The client said that relationship with God is very essential and with his present condition and with the previous decisions that he made, he feels like he did not consulted and communicated well to God thats why hes considering that he might have made a mistake that lead his to be hospitalized and be in this illness state. 11.3 Religious practices (type and frequency) When it comes to attending masses, the patient said that he attends to it when theres a especial occasion. 11.4 Request for religious person/practice: None

A. PHYSICAL ASSESSMENT 1. Head-to-Toe Examination

Date performed:

August 5, 2013

1.1 General Survey The client is a 48 years old male. Upon assessment on August 5, 2013, the client is conscious and weak in appearance. He is oriented and can respond to questions correctly. Skin has no signs of pallor and jaundiced but there are presence of bruises on his left arm. The client is hooked with IVF no. 7PNSS x 16 hours, infusing well in the left metacarpal vein. The physical appearance of the client is appropriate with his age. He has bandage on his left ankle without any discharge noted. 1.2 Vital Signs T: 36.6 C PR: 65bpm RR: 21cpm BP: 120/80 mmHg 1.3 Head and Face a. Cranium The patients head is normocephalic and proportional to body size. Presences of nodules or masses are not noted. The cranium has a wellrounded skull shape and with smooth, uniform consistency. Theres no a lesion or masses noted. Hair is dry, evenly distributed and intact to the scalp. The color of the hair is black with presence of white hair. a. Temporal arteries The temporal arteries are palpable and pulsating well b. Face Facial features and movements are symmetrical. The patient is able to raise her eyebrows, close her eyes, frown, and smile. His face manifests a feeling of slight tiredness. Equal size of palpebral fissures, no signs of edema and lesions.

a. Cranial nerves V and VII The cranial nerves V and VII: function is normal because patient was able to elicit the blink. Also, he was able to do facial movements equally such as frowning.

b.

Nose and cranial nerve I The external nose is symmetrical, straight and uniform in color. Nasal flaring was not noted. Color is the same with the entire face; there was no tenderness noted upon palpation. Lesions and tenderness were both absent. Nasal mucosa was pinkish. Both left and right nares were patent, with no discharges; air could freely move in and out when the patient breathes. The nasal septum is intact and in the midline without deviations. The frontal and maxillary sinuses were non-tender upon palpation. Sense of smell was good. Patient was able to differentiate water from that of alcohol, through scent Nose and cranial nerve I The nose is symmetrically aligned to the center of the face, theres no presence of mass and lesions noted. No evidence of swelling of the sinuses. No obstructions and discharges were found. The cranial nerve was not able to assess because the client is comatose.

c.

1.4 Eyes and vision a. External eye structure Both eyes are not symmetrically aligned but intact to skin. There is no noted edema and tenderness in the lacrimal gland but there is a minimal discharge. The eyelashes are also equally distributed. No other markings in the sclera. The pupils are black in color, equal in size, round in shape. Iris is also round in shape which constricts w/ light for about 2cm and dilates w/o light.

b. Extraocular muscle function (cranial nerve III, IV & VI) The client can perform the six cardinal signs of gaze. There is coordination with his two eyes. c. Pupillary reflexes The pupil is 2-3 mm round. Pupils are equally round reactive to light and accommodation. The pupil constrict when exposed to light and does not eventually dilates when there is no light.

d. Internal eye structure with ophthalmoscope N/A

1.5 Ears & Hearing a. External ear

The external ear is normal because the auricle has the same color as the facial skin. The auricle is aligned with the outer canthus of the eye about ten degrees from vertical. The pinna recoils when it is folded. It has a smooth contour and has no lesions. There is no deformity. b. Hearing The client has no difficulty in hearing, because she responded to all the questions that I asked. c. Ear canal and tympanic membrane with otoscope. N/A

1.6 Neck a. Musculoskeletal structures The muscles in his neck were equal in size. His neck movement was coordinated but with a slow movement.. He can also turn his head on one side against minimal resistance of hand with the similar strength and shrug his shoulders up against the resistance of hand with equal strength. The trachea is in the midline.

b. Lymph nodes The lymph nodes are non-palpable. c. Thyroid gland The thyroid gland has no enlargement noted upon palpation.

d. Musculoskeletal function and cranial nerve XI The musculoskeletal function and cranial nerve XI function is normal because the patient was able to move his neck from left to right, up and down with minimal resistance. e. Carotid arteries The carotid arteries are pulsating with symmetric pulse volumes.

1.7 Upper Extremities a. Musculoskeletal structures, skin, nails Muscles are equal in size. Theres weakness and numbness noted in his right arm. The capillary refill is 3 seconds on both right and left hand nail beds. The five fingers are intact. b. Musculoskeletal functions

The patients radial and brachial pulses were regular but with weak pulsation. Good range of motion was noted in his left arm while there is a difficulty in hyperextension noted in his right arm. Palm is able to stay in both prone and supine in a good manner without difficulty. He was not able to exhibit strong hand grip on right arms. There were tremors noted. c. Brachial and radial arteries The brachial and radial arteries have weak pulsation. d. Deep tendon reflexes N/A 1.8 Anterior Chest a. Breasts and axillae The breasts have no tenderness, masses or nodules and the 2 nipples are brown in color. Skin is uniform is pale; it is also smooth and intact. The axilla has presence of hair. There are no lymph nodes have no masses, tenderness and nodules. b. Thorax The patient has a regular and normal breathing pattern; quiet and rhythmic respirations, with respiratory rate of 21 cyles in one full minute. No tenderness and masses upon palpation. No adventitious breath sounds on both left and right lung fields were heard during auscultation. Tactile fremitus on both lungs are symmetrical. Posterior chest was not assessed. There is no difficulty of breathing; The chest expansion is symmetric with clear breath sounds. No lesions, masses noted. c. Precordium The apical pulse can be auscultated and no irregularities in the heart beat rhythm were noted. With no abnormal heart sounds or murmurs. 1.9 Back a. Musculoskeletal structure The musculoskeletal structure is normal because spine is midline and shoulder and hips are at same height. The skin is intact and without lesions.

b. Fist percussion over spine and kidneys There is presence of scar at the back in the line of the lowest rib due to removal of kidney stone. There is no noted tenderness over

kidney. Percussion of the kidney resulted to dull sound and the spine has a blunted sound. 1.10 Neck veins The veins on the left side and right side of the neck are pulsating not distended. 1.11 Abdomen a. 4 abdominal quadrants Unblemished skin, uniform in color with symmetric contour. There is a symmetric movement caused by respiration. Tympanic sound upon percussion. b. Specific organs Liver There is no enlargement of the liver noted when client held his breath upon inspection. Borders are smooth upon palpation. There is dullness upon percussion and the site is not tender Spleen The spleen has no evidence of enlargement when client held her breath upon inspection and is not palpable Kidneys The kidneys have a dull sound during percussion and are palpable and no tenderness is noted. 1.12 Lower Extremities a. Musculoskeletal structures, skin, and toe nails Muscles are equal in size on both sides of the body. There is presence of wound in his left ankle for about 3 inches in size and with presence of pus upon inspection. Stabbing pain with the pain scale of 4/10. Theres no noted foul odor. The capillary refill is 2-3 seconds. b. Musculoskeletal function Equal muscle strength and muscle tone on each leg side. It exhibits coordinated and firm movements. c. Popliteal,posterior tibial and pedal arteries The popliteal pulse is pulsating well. d. Deep tendon reflexes and planter reflex :N/A

1.13 Genito-Urinary Not applicable because client refused.

Summary of abnormal findings: The client is conscious but weak in appearance. There are presence of bruises on his left arm. The color of the hair is black with presence of white hair. His face manifests a feeling of slight tiredness. There is no noted edema and tenderness in the lacrimal gland but there is a minimal discharge. His neck movement was coordinated but with a slow movement. Theres weakness and numbness noted in his right arm. The patients radial and brachial pulses were regular but with weak pulsation. There is a difficulty in hyperextension noted in his right arm. There were tremors noted in both hands. There is presence of scar at the back in the line of the lowest rib due to removal of kidney stone There is presence of wound in his left ankle for about 3 inches in size and with presence of pus upon inspection. Stabbing pain with the pain scale of 4/10.

Reference: Marieb, E. 2006. Essentials of Human Anatomy and Physiology 8th Edition; Kozier, B. 2004. Fundamentals of Nursing 7th Edition