On going Assessment

Claimed that can stay sitting on side of the bed for 5 minutes without fatigue
Nods when asked whether there are positive changes in health while in hospital
Rated health as fair
[supply lacking] Vital Signs
RR: 23 cpm, irregular and shallow, with the use of accessory muscles
Dyspnea
Plain Ringers Solution 1 L @ R metacarpal vein running @ 10 gtt/min
Claimed to have difficulty in breathing every once in a while
Maglisud ko ug ginhawa usahay nya dali ko makutasan kung mutindog ko, as claimed by
the patient
The daughter of the patient verbalized,Maglisud siya ug ginhawa kung magpungko o
maglingkod sa higdaanan,
Kapuyun dayun ko kung mulingkod ko sa higdaanan, as calimed by the patient
The daughter verbalized,Dali kayo siya kapuyun,
Inability to perform activity as claimed
With O2 therapy @ 2L
SD Aminogen 500cc
New lab results: globulin: 2.8, Albumin 1.8, Total protein: 4.6
With diapers
No allergies to food and medicines
Doesnt eat pork meat and chicken meat, prefers to eat fish
Perceives eating as a way of improving health
Cannot move out of bed but can sit on side of bed as claimed
No colds in the past stay
Financially challenged but have complied to medications as claimed
Wants to stay hospital until fully well before going home
Dry wound at neck area
Eats only milk and oatmeal
Claimed to prefer eating vegetables rather than oatmeal but cannot tolerate large feedings
Edema on hand (Grade 3+, pitting edema)
Claimed to have gained muscle mass
Increased appetite in the past 2 days
Pain in swallowing; difficulty in swallowing
Drinks small sips of water, lukewarm milk
Approximately 5 glasses of water daily as claimed
Usually changes diapers at night
Approximately 10 diapers daily used for defecation, soft stools
Approximately 3 diapers daily for voiding, yellow to dark yellow in color and turbid
Nocturia
Claims to have pain in defecating for the past days
Usually sleeps at morning and wakes up at night
Sleeping time: 9:00 am
Claimed to have difficulty staying asleep and usually wakes up from sleep every 2 hours
Claimed to have insufficient energy after sleeping
On full self-care, sometimes do self-care with assistance from significant others
Cannot perform ROM
Experiences early awakening
Short attention span observed
Inability to express self and judgment as observed
Inability to make decisions, decisions are made by significant others
No difficulty in hearing
Can recall remote and recent memory
Claims to easily learn things by demonstrating and explaining
Does not feel pain in neck area because of pain medications as claimed
Whispers words
Slurred speech
Oriented to time, person, and place
Claimed to rely on significant others for feeding, personal hygiene, and bathing
Does not lose hope as claimed
Gets mad when disturbed from sleep
Does not maintain good eye contact to the student nurse as observed
Claimed that illness changes everything she can do independently and to her life roles
Family is important as claimed
Family feels dismayed of the other complications of ulcerative neck mass fibrosis in both
apices of the lungs
Have a good interaction towards family members
Daughters of the patient usually visits her
Claimed to have no problem towards relationship with husband
Claimed to have no intimate conversation with the husband since the illness started
Changes in life occurred since the illness became worst
Usually talks to daughters if problems exist in the family
Values God and has hope that God will heal her
Shows compassion to her daughters
Thinks highly of generosity and respect
Have not gone to church since illness started
Presence of a rosary on patients left wrist
Claims to have faith in God and a good relationship in Him