II. NURSING PROCESS A. ASSESSMENT 1. Personal History a.

Demographic Data Elsa is a 42 years old female, affiliated in the Roman Catholic Church and a Filipino citizen. She was born on May 19, 1972 in Arayat, Pampanga. She is an independent daughter and has her own family already, both her parents already passed away and her husbands parents are living with them. Her family is currently residing at Macapagal Village, Mabalacat Pampanga. She was admitted last February 26, 2014 with a diagnosis of Dyspepsia with mild dehydration cholecystolithiasis. b. Socio-economic and cultural factors The family falls under the extended type. Her own family with her husband is composed of three members namely: Elsa herself, husband Jack, and their son Olaf, who is their first and only child plus her husbands parents namely Grandpa Cristoff and Grandma Anna. Their family has a good relationship with each other. She is already independent from her parents. She was able to finish high school. Husband Jack works as a security guard and earns a minimum of 3000php a month, while Elsa is a plain housewife. Their family is categorized as not poor, and according to Elsa, the familys income is enough to support and suffice the needs of t he family with the help of some of their relatives. The patient came originally from Pampanga. She belongs to the Roman Catholic religion and is going to church every Sunday together with her family. Their family uses herbal medications such as sambong. They also believe in quack doctors (albularyos/nagtatawas/hilot) but they still prefer medical treatment. c. Environmental factors

Elsas family is living in a house made up of concrete wood structure which they own. Their ventilation is adequate because they have 6 windows and two doors as their source of ventilation. According to Elsa, they maintain cleanliness in their house. Their usual meal is a rice meal. Her family use mineral water as their source of drinking. She eats 3 to 4 times a day. 2. Family Health-Illness History

EXPLANATION: The genogram above shows that the father and mother of Elsa are already deceased. Elsas father died because of Tuberculosis while her mother died because of Pneumonia. Elsas grandfather from father side had Diabetes and her grandmother is hypertensive. Also, Elsas grandmother from her mothers side is Diabetic too. According to Elsa, diabetes is their family lines genetic disease conditions. Not only her grandparents had diabetes but also her youn gest brother. 3. History of Past Illness The patient did not have any of the childhood illnesses such as chickenpox, mumps, and measles, but already had fever, coughs, and colds. According to the patient, her immunizations are complete. She has no allergies to certain drugs, food or any other environmental agents. The patient back when she was 20 y/o was admitted for 2 weeks in Jose Reyes Memorial Hospital in Manila with a diagnosis of Myoma. She received an operation of removal of the huge tumor that had grown inside her cervix. About 9 yrs ago June 25, 2005, she gave birth to her 1st child via cesarean section. She stayed for ten days in JBL. 4. History of Present Illness On the 26th of February 2014, Elsa experienced vomiting, malaise, epigastric pain, and she cannot eat; then her husband Jack, immediately brought her to ONA at 10:40 in the morning. They have done home management since the vomiting already started 2 days ago as stated by the patient, she is taking Buscopan and s medicinal herb sambong. The patient then was diagnosed to have Cholecystolithiasis. Initial vital signs were taken and as follows: PR of 103bpm, RR of 22bpm, T of 36.1C and BP of 100/80mmhg. 5. Physical Examination (Cephalocaudal Approach) Initial Assessment (Lifted from the chart) Date of Admission: February 26, 2014 Chief Complaint: Abdominal pain

Daily Vital Signs Date Temperature Axilla (C) Pulse rate (bpm) Respiratory Rate(bpm) Blood Pressure (mmHg) Physical Examination: General : conscious, coherent Skin: (-) pallor, (-) cyanosis HEAD - HEENT: (-) colds Chest/Lung: CBS Rectum: (-) CVA tenderness Musculoskeletal: (-) weakness ADMITTING IMPRESSION: 100/80 mmHg 100/60 mmHg 22 bpm 18 bpm 103 bpm 96 bpm February 26 36.1C March 3

39.4C

Small cholecystolithiasis left Renal cyst Sonographically normal liver, biliary tree, pancreas, spleen, right kidney, uterus and ovaries Non visualized ureters Under filled urinary bladder

Review of systems: General: No at loss Skin: (-) rash HEENT: (-) colds Musculoskeletal: (-) weakness, (-) edema Respiratory: (-) cough Cardiovascular: (-) chest pain GI: (-) LBM

First Nurse-Patient Interaction Date of physical assessment: March 3, 2014 General Survey: Received patient in a sitting position in the bed, conscious and coherent; with ongoing IVF #2 PLRS 1L @ 700cc level regulated at KVO infusing through the right metacarpal vein; slightly febrile, good skin turgor, moist mucous membrane; VS as follows: T of 39.4C, PR of 96bpm, RR of 18bpm, BP of 100/60mmHg @ 10:30 am. Vital Signs: T: 39.4C PR: 96bpm RR: 18bpm BP: 100/60mmHg

SKULL AND FACE normocephalic shape skull with absence of nodules or masses upon palpation symmetrical facial features and facial movements was able to smile, frown, raise eyebrows, and puff her cheeks

HAIR AND SCALP hair is long, black and straight upon inspection evenly distributed with no lice and dandruff noted

SKIN AND NAILS cold and clammy skin with absence of edema and nodules fair skin complexion good skin turgor no presence of lesions has short fingernails and toenails without presence of pallor

EYES AND VISION dark eyebrows are evenly distributed and symmetrically aligned with equal movements black pupil eyelashes are also equally distributed and curled slightly outward and upward eyelids close symmetrically with skin intact and no discharge or discoloration bulbar conjunctiva is transparent and sclera appears white without pale palpebral conjunctiva lacrimal ducts have no edema or tearing upon palpation

cornea is transparent, shiny and smooth with visible details of iris pupils are equally round and reactive to light accommodation left and right eye can see clearly in the periphery when looking straight ahead and is able to read newsprint at a given distance no discharges noted upon inspection

EARS AND HEARING no tenderness behind the ears auricles are same as the color of facial skin aligned with outer canthus of eyes not tender and recoil after being folded left and right ear can hear clearly a normal voice tones

NOSE AND SINUSES symmetrical and straight no discharges or flaring has uniform color and not tender nasal septum is intact and in midline air moves freely on both nares as client breathes facial sinuses are not tender no lesions

MOUTH AND OROPHARYNX without dry and pale lips without dental caries

tongue is at the center and pinkish in color with no lesions, no tenderness noted and moves freely

NECK muscles equal in size head centered can move her head smoothly and with no discomfort lymph nodes are not palpable trachea is in the midline of the neck thyroid gland is not visible upon inspection and ascends during swallowing upon palpation carotid artery and jugular veins are not distended or visible

THORAX AND LUNGS chest symmetric volume no tenderness noted no masses noted full and symmetric chest expansion resonant sound upon percussion over the lungs breathing is rhythmic, quiet and effortless no adventitious breath sounds upon auscultation spine is vertically aligned

HEART presence of pulsation normal heart rate

irregular in rhythm peripheral pulses are symmetrical with that of the apical pulse

ABDOMEN uniform in color, flat, soft non-tender and no masses

UPPER EXTREMITIES and LOWER EXTREMITIES muscles are equal in size no contractures no tremors no bone deformities no tenderness palpated can sense sharp and blunt objects was able to adduct her arm, supine and prone her hands, shrug her shoulders against resistance, and flex and extend her arms