Introduction

> Stress is a disruptive condition that occurs in response to adverse influences from the
internal/ external environments. It is a state produced by a change in the environment that
is perceived as challenging/ threathening.

> pain is an unpleasant sensory and emotional response/experience assosciated with

actual and potential tissue damage.

Objectives of the study

after 2 days of our community immersion the students will be to:

1. casefinding, a client who experience pain and stress

2. Assess and history taking of pain or stress

3. Formulate appropriate nursing care plan

4. Implement clients to attend the health teaching program

Description of the community

The community is not congested. The people are very friendly. They are all happy
people and live peacefully.
A. Family structure, characteristics and dynamics

Name Address Ag Sex Civil Status Position in the Relationship

e Family with the
head
Marcelo San 66 Male Married Husband(head Head
Malved Fernando )
a , Sto.
Thomas
Batangas
Rosita San 64 Femal Married Wife Wife
Malved Fernando e
a , Sto.
Thomas
Batangas
Lane San 33 Femal Married(deceased Daughter Daughter
Malved Fernando e )
a , Sto.
Thomas
Batangas
Marko San 31 Male Married Son Son
Malved Fernando
a , Sto.
Thomas
Batangas(
Italy)
John San 27 Male Married Son Son
Malved Fernando
a , Sto.
Thomas
Batangas(
Norway)

Mr. Marcelo is the hand of their family, provider and for decision making in the family
especially in financial and health. Mrs. Malveda is responsible for household chores and
take care of her children. Lane, graduated as teacher of Polytechnic University of the
Philipphine and successfully earn reputation but unfortunately she died due to delivery of
her first daughter. Mr. Marko was the older brother in the family, he graduated as
engineer in Adamson University an dcurrently working at Italy and was married to a
nurse. The youngest brother was Mr. John Malveda graduated as an engineer at PUP. He
is currently working in Norway. The type of the family was extended family there was no
readily observable conflict between members of the family. The children monitors their
mama and papa regarding matters in health care and maintenance of medicines.
B. House Plan

The family of Malveda have good shelter to sleep with 3 bedrooms 1 kitchen 3 comfort
rooms. They are comfortable in their house

They has adequate living space for living. The Mother and her grand daughters are
sleeping at bedroom 1 while the head of the family sleeps at bedroom 3. Bedroom 2 is a
guest room.

C. Kind of neighborhood

According to the patient their environment is conclusive and safe. She verbalized that the
people in the community are friendly and willing to help.

Chapter 2.

A. Biographical Information

Mrs. Rosita Malveda currently living at San Fernando, Sto. Thomas Batangas, a Filipino,
roman Catholic and was born at Batangas on December 13 1944. The source of
reliability of information is directly to the patient and was interviewed on June 30 2011

B. Chief Complaint/s

“Masaki yong paa ko at pasumpong sumpong ito, tska namamanhid ilang araw na” as
verbalized by the patient.
C Present Illness

According to the patient her left lower leg experienced pain and numb but can tolerate the
pain.

D. Past History

a. According to the patient she has no major injuries during childhood such as fever,
colds, mumps etc. She undergone 3 surgical procedure the thyroidectomy, CS section,
and appendectomy. The patient had no allergies to food, environment and drugs. She
completed her vaccines during her childhood. She doesn’t drink alcoholic beverage and
not smoking. According to her she usually maintain her anti-hypertensive drug and also
her vitamins

E. Family History

The client’s grand parents are already dead. Her father is deceased he has asthma. The
client have hypertension as well as her sister

Asthma

HPN HPN

64 60

Client indicator

Female

Male
F. Review of system

General Appearance

Client has a medium body frame, an upright posture and smooth rhythmic gait.
He is appropriately dressed, no body odor and obviously she has no physical deformity.
He is 5’6 in height and and a weight of 54kg.

V/S

blood pressure is 180/60mmHg, respiratory rate is 21 cpm, and pulse rate of 63 bpm,
temperature of 35.7 ‘C.

 Skin

Normal in racial tone between light to medium brown, warm to touch and dry.
Skin is elastic and mobile. No lesions in upper extremity, and has burn at the left
dorsum of left foot. Hair is evenly distributed, no bruises or birth marks. Noted
scar on thyroid area

• Hair

Hair is black and evenly distributed there are presence of white hair due to aging. The
scalp has no lesions, masses and nodules palpated. There are no any infestations.

• Head and Face

Head is appropriate to his body size. The hair is evenly distributed. Head contour
is smooth with uniform constituency and symmetrical facial movements and features.

• Eyes

The eyes are straight and normal, eyebrows and eyelashes are evenly distributed.
Eyelids have an effective closure. Eyeballs are symmetric, conjunctiva is pink in color,
sclera is white, pupils are equal and reactive to light and accommodation, sinuses non
tender. Has a normal visual field and respond to six ocular movements.

• Ear

Ear is within normal racial tone. It is symmetric in size and position. Pinna recoils
when folded and some cerumen found at external canal. Client difficulty of responding to
a normal whisper at 6ft.

• Nose

Nose is normal in racial tone, the septum is at the midline. Air moves freely
through the nares as the client breathe. Mucosa is pink and clear without any lesions.
Sinuses are not palpable.

• Mouth
 Lips are pink and mucosa is moist. Tongue is at the midline. Teeth are incomplete
but has presence of dentures. Gums is pink and the soft and hard palate as well. Both
palate are palpable. Frenulum is at the midline. No presence of breath odor.

• Pharynx

Uvula is at the midline, mucosa is pink in color. Tonsils are not inflamed.
Posterior pharynx is congested. Gag reflex is present when elicited.

• Neck

Neck muscles are equal in size, muscle strength is good presence of scar at
thyroid area. Lymph nodes are not palpable. The trachea is in the midline. Thyroid gland
is not palpable.

• Breast and Axilla

Patient refused to assess her breast. But according to her breast are symmetrical
and there is no presence of nodules or discharges.

• Chest and Lungs

Chest shape is AP lateral ratio 1:2. Lung expansion on posterior and anterior are
both symmetrical. Tactile fremitus are symmetrical. Broncho vesicular is his breath
sound. Apical pulse is present. Has a normal heart sounds in pulmonic, tricuspid, aortic
and mitral valve.

• Abdomen

Abdomen is rounded in contour and symmetrical in posterior and anterior portion.

Skin is within normal racial tone which is brown. There are no presence of scars due
to several operation like CS delivery and AP and 2 bowel sound/min. Liver is not
palpable. Bladder is not distented.

• Upper and Lower Extremities

Motor strength on both upper and lower extremities are both good with the grade
of 5.

No obvious physical deformities but with burn site at left dorsum foot, peripheral pulses
are palpable.

• Genitalia

The client refused to assess this region.

Person Review of System

Psychological

I.Self –perception Self-concept pattern

She describes herself as happy go lucky type of person, approachable according to her,
she lives to share her experience and proud to her children being attained their current
status and degree

II. Role Relationship Pattern

She is happy with her husband even though there children is far from them. She stated
that her family and children of her sons and daughter, relatives are most significant
people in her life. She has good relationship with her neighbors and people in barangay.

III. Sexuality and Reproductive pattern

She stated that she undergone CS section, according to her she has no any sexual
deformities. She is in the stage of menopause.

IV. Cognitive perceptual pattern

She had no hearing difficulty. In our assessment she has hard time of responding in a
whispered voice

V. Coping stress tolerance pattern

She was able to cope up by engaging herself to recreational activities like watching
television everytime

Elimination

She usually defecates every other day and urinates everyday without difficulty

Activities and exercise pattern

Her exercise is usually walking and engaged to household works

VI. Sleep and rest pattern

Client sleeps at around 10pm and wakes up at around 4am in the morning, she loves to
sleep every afternoon

Safe environment

She doesn’t have any allergies in food, environment and medication.

Oxygenation

According to her she has no any difficulty in breathing

Nutrition

Meals Food Intake Fluid Intake Biochemical

Appraisal
Breakfast 1 cup of rice 1 glass of water Adequate protein and
1medium slice of carbohydrates
fish

Lunch 1 cup of rice 1 glass of water Adequate protein and

 1 bowl of vegetable carbohydrates
Dinner 1 cup of rice 1 glass of water Adequate protein and
1 medium size of carbohydrates
fish
1small slice of meat

Anthropometry

Patient height is 150cm 54 kg head circumference of 54 cm chest circumference of 88cm

and abdomen of 35cm

Developmental Theories

Psychological theory ( Generativity vs. stagnation )

According to Erickson generativity is defined as concern for establishing and guiding the
next generation. There is concern of providing for humankind that is equal to concern of
providing for self.

Analysis:

According to her, she is satisfied with her life, her family. She is happy of having
grandchildren

Psychosexual Theory (Genital stage)

According to Sigmund Freud energy is directed toward attaining a nature

relationship.This stage involves activation of pregenital impulses. These impulses are
usually displaced and individual passes to genital maturity.

Analysis:

The client is on menopause, she has no time for sexual activities

Cognitive Theory (formal to post formal operation)

According to Jean Piaget memory and problem solving are maintained. Learning
continues and can be enhanced by increased motivation at this time of life

Analysis:

Client is cooperative and likes to share her past experiences when she was interviewed

Moral Theory (Post-conventional)

Kohlberg defined middle adulthood as preconventional level which takes step to support
others right

Analysis:

She is friendlywith her companion. When she is right, she support and defend it but if it
is wrong she condemn it.

Spiritual Theory(Paradoxical consolidative age)

Fowler defined middle adulthood at this stage individual can view true number of
viewpoints. People tend to be less dramatic about religion beliefs.

Analysis:

She stated that she prays everyday and goes to church every Sunday.

List of Prioritized Nursing Diagnosis

Nursing Diagnosis Rank Justification

Acute pain r/t inflammation
of joints as evidenced by
pain scale of 6/10
1 This is the 1st prioritized
accdg. to Maslow’s It is
under physiologic needs
specifically pain avoidance
it need immediate concern
to alleviate anxiety and pain

Impaired physical mobility 2 Impaired mobility of the

r/t inflammation of joints
specifically right knee as
evidenced of difficulty of
walking and numbness of
leg
Fear r/t sensory impairment
as evidenced by difficulty
of hearing
patient is when patient has
pain on her left foot
specifically affecting her
knee and ankle. It must be
prioritized because
immobility is very essential
to do things
3 3rd prioritized because
according to Maslow’s it is
under safety and security
needs it needs immediate
concern to alleviate patient
concern

Impaired dentition r/t age as 4 it is least prioritized because

evidenced by presence of dentition is normal for all
dentures, upper and lower aging people

Risk for fall r/t body 5 this is the last prioritized

weakness because this is a risk
problem
Assessment Diagnosis Scientific explanation Planning Intervention Rationale Evaluation
SD Acute pain r/t StimulusNociceptor LTO Independent: >to have baseline Partially met:
“Namamanhid inflammation of peripheral nerve After 3 weeks of Assess pain and for future the patient was
yong kaliwang joints as synapsespinal nursing pain scale comparison able to
paa ko at evidenced by pain decussation Lateral intervention the including understood the
sumasakit ito” as scale of 6/10 spinothalamic client will be able temperature underlying
verbalized by the tractReticular to demonstrate condition and the
patient formationthrombus control relief pain/ provide comfort > to promote pain was relieved
formationthalamus discomfort measures, quiet nonpharmacological and controlled
OD somatosensory cortex parietal environment and pain management
pain scale of 6/10 lobehypothalamuslimbic STO calm activities
numbness of left systemPAIN After 60 min. of
leg w/ pain ref: nursing promote regular > to maintain
Female 64 y/o Pathophysiology3rd ed. intervention the activites patient physical
Barbara Gould client will be able activity
to discuss/
verbalize encourage > to decrease
understanding of therapeutic inflammation and
definition of application of muscle spasm
rheumatoid heat and cold
arthritis and compress
enumerate non-
pharmacologic encourage to > it allow to relaxed
method/treatment facilitate deep the muscles to
breathing exercise reduce pain
and distraction

Collaborative
Administer to relieved pain
analgesics as
prescribed by the
physician

Diet low salt low for nutritional

fat low requirement
cholesterol
Assessment Diagnosis Scientific explanation Planning Intervention Rationale Evaluation
SD Impaired physical Decreased synovial fluid  LTO Independent: >to have baseline outcome met:
“Namamanhid mobility r/t friction of synovial joint After 1 week of Assess pain and for future the patient was
yong kaliwang inflammation of inflammed joint nursing pain scale, comparison able to verbalized
paa ko at joints specifically swelling, redness at site  intervention the inflammation ways of how to
sumasakit ito” as right knee as Pain difficulty of walking client will be able joint maintain proper
verbalized by the evidenced of impaired physical mobility >to maintain or body function
patient difficulty of decrease strength provide bed rest > to prevent fatigue
walking and and function of
OD numbness of leg affected or promote health > for proper blood
pain scale of 6/10 compensatory leg teaching such as flow to the body
numbness of left > Demonstrate ROM
leg w/ pain effective physical
Female 64 y/o mobility
provide safety > to decrease
STO accidental injuries
After 8 hours of or falls
nursing
intervention the Collaborative
client will be able Administer anti-
to discuss/ inflammatory
verbalize ways of drugs as
how to maintain prescribed by the
proper body physician
function