St.

Anthony’s College
NURSING DEPARTMENT
San Jose, Antique
VISION
St. Anthony’s College is a Catholic Educational Institution committed to holistic human formation through
Spirituality, Academic excellence and Community service.
MISSION
To provide quality, holistic, relevant educational programs, services and experiences for our students and other stakeholders
in Antique and the larger community.

NURSING PROCESS GUIDE

(ADULT)

I. VITAL INFORMATION

Name: L.C.M. Date of Interview: November 22, 2018

Age: 34 years old Informant: patient herself and P.M
Address: Brgy. Esperanza 3, Sibalom, Antique Relationship to Patient: Mother
Civil Status: Single
Date and Time Admitted: November 17, 2018
Chief Complaint: “Naga parangluya lawas na, hindi ka tikang-tikang kag wara ti gana
magkaon amo ra nga ginpa-admit para madextrosan.” As verbalized by her mother.

Ward: 3016
Bed No.: 1
Allergies: none
Religious Affiliation: IFI
Physician’s Initials: Dr. V
Impression/Diagnosis: T/C electrolyte imbalance, breast CA stage 2/4 S/P mastectomy R
Final Diagnosis: Breast CA stage 4 with pulmonary and brain metastasis, CAP- HR without
hypoxemia, DM type 2 Insulin requiring

II. CLINICAL ASSESSMENT

II.A: NURSING HISTORY

1. HISTORY OF PRESENT ILLNESS

a. Usual Health Status
“Masakiton gid man ra tana halin pag gamay na, kadya gani tana nagsalo ka

tanan nga sakit ka pamilya namun.” as verbalized by the mother.

b. Chronological Story
Thirty- three years prior to confinement, L.C.M. is admitted to the
hospital by her mother because of asthma. Everytime L.C.M. has asthma
attack, her mother immediately bring her to hospital because she having a
hard time feeding her daughter.
Twenty- five years prior to confinement, L.C.M. is going to attend their
school activity (scouting) but before the said event, she should undergo
medical examination. It was found out that her heart does not beat normally.
Without having any questions, P.M bring her daughter to Iloilo Doctor’s
Hospital for further examination along with her two other children. L.C.M is
diagnosed of Rheumatic Heart Disease and also her other siblings with the
same diagnosis. L.C.M.’s body weight is not appropriate with her age as a
child. Since she was diagnosed with RHD, her doctor prescribed Panador to
her drug maintenance.

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

L.C.M. worked as a teacher in Pis-anan, Sibalom, Antique a 7km away

from her home. Every morning, her father drives his motorcycle to drop her
to school. Patient claimed that her mother doesn’t want her to work far from
their care. She also claims that it was only her who did not graduated from
University in Iloilo, maybe because of her health status.
On June 2017, L.C.M. brought to St. Paul’s in Iloilo for surgery. A week
prior to her surgery, she feel pain every morning to her right breast and
noticing a clear discharge on her nipple and feel and found a lump. They
decided to seek surgery and Mastectomy was done on her right breast. Her
surgeon who performed the operation was not mentioned. The biopsy result
was negative according from the mother. The doctor did not prescribed any
maintenance but to have a laboratory check-up every 3months like Chest X-
ray and Ultrasound. The first 3months of laboratory check-up, the results is
normal. The next schedule of check-up, January 2018 to be exact, the
laboratory result reveals myoma, ovarian cyst and lung nodules. Second
surgery was again scheduled at St. Paul’s Hospital. After the surgery, Dr.P
adviced P.M to have her daughter a radiation therapy but they did not
proceed due to L.C.M. decided to undergo bone scan first. As her bone scan
result was normal, Dr. P prescribed chemo drugs as they’re having radiation
therapy. The therapy was shortened from the 28 days to 15 days because the
patient is taking or having an oral chemo. Chemo drugs is given within 6
cycles then after that, patient undergo CT scan and it was found out ther is a
metastasis.
A week prior to admission, L.C.M. file a leave of absence from her
work because she’s not feeling well. She always feel dizzy and loss her
appetite.
17 of November 2018, L.C.M. walks to the bathroom when she feel
dizzy and can’t move her legs and can’t even sit-down on her own. Her family
decided to bring her in the hospital.
Around 1:06 in the afternoon of the same day, L.C.M was admitted to
Antique Medical Center.

c. Relevant Family History

The patient’s grandfather on her mother’s side died because of Colon
cancer.

d. Disability Assessment
due to her hospitalization, the patient is unable to continue her
teaching and may not able to earn money for her maintenance in
chemotherapy. She also verbalizes that he is concerned for the possible
situation of her students when she’s gone due to her hospitalization.

2. Past Health Problems/Status

e. Childhood Illness
(+)Chickenpox- date unrecalled
(+) Measles- date unrecalled
f. Immunization
The patient’s mother claims that the immunizations of her children is
completed. She paid the midwife to immunize her children. It is her intention
to make her children free from any diseases.
g. Allergies
None to drugs, animals, insects and other agents

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

h. Accidents and Injuries

Patient verbalized that she did not have any form of accidents
or injuries in the past.
i. Hospitalization for serious illnesses
the patient was sent to the hospital every time she had asthma attack,
rheumatic heart disease and lastly, when she had her mastectomy, radiation
and chemotherapy.
j. Medications
-Panadol
-Sumapen
-Xeloda

3. Family History of Illness

(+) HPN- father
(+) Prostate Cancer- Father
(+) Cancer- Grandfather on Mother side

4. Patient’s Expectations (Verbatim)

a. What he/she expects to occur during this hospitalization?
“Daad mahagan- hagan man ang pamatyag ko kag magbalik ang gana
ko magkaon.” As verbalized by the patient
b. What he/she expects regarding nursing care.
“Gina-expect ko nga mayad ang trato da sa mga pasyente kag taw-an
da ako ka tyempo kay syempre private hospital, kag kon may kinahanglan ko doctor
rugyan dayun para itugyan ako.” As verbalized by the patient.

5. Patterns of Functioning

a. Breathing Patterns
Respiratory Problems: Asthma

Usual Remedy: Seretide inhaler

Manner of Breathing: severe wheezing when breathing both in and

out.

b. Circulation
Usual Blood Pressure
Any history of chest pain, palpitations, coldness of extremities, etc.
(heart disease, heart murmur, high blood pressure, anemia, varicose
veins, leg swelling or ulcers)

c. Sleeping Patterns
Usual Bedtime: 9:00-10:00pm

Number of Pillows: 3 pillows

Bedtime Rituals: doing her school works before sleeping.

Problems regarding sleep: none

Usual Remedy: coffee

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

d. Drinking Patterns

Type of Fluid Amount

Water 1.5 L/ day

Softdrinks 36 oz/ day

Powered juice drink 1 L/ day

coffee 2 cups/ day

e. Eating Patterns

Usual Food Taken Time

Breakfast 1 cup of riceor 3 slices of pan bread, 1pc egg, 300 ml water 6:00 - 6:30 am

Lunch 2 cups of rice, 1 cup “sinabawang isda”, 450 ml water 12:00 - 1:00pm

2-3 pcs of boiled banana or corn, 1 cup of coffee, 350 ml

Snacks 3:00 - 4:00 pm
water

Dinner 1 cup of rice, 1 -2 pcs of fried fish, 400 ml of water 7:00 - 8:00 pm

Food likes: Sweets

Food dislikes: Sour foods

f. Elimination Patterns

1. Bowel Movement

Frequency: once a day

Problems or Difficulties: None

Usual Remedy: NA

2. Urination

Frequency: 8-10 times a day

Problems or Difficulties: None

Usual Remedy: NA

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

g. Exercise

Patient does not exercise but verbalized, “kis-a sa school kung may
activities, ti need ko nga magparticipate.”

h. Personal Hygiene

1. Bath

Type: Full bath

Frequency: twice a day before going to school and before sleeping

Time of Day: 6:30 – 7:00 am

2. Oral Care

Frequency: 3 times a day

Care of Dentures: NA

3. Use of Cosmetics:

Patient seldom uses cosmetics, she only uses soap and

shampoo and also toothpaste. Also using nail polish twice a month.

i. Recreation
Watching tv and playing with her nieces and chatting with her friends.

j. Health Supervision
Patient knows her medical condition and goes to the doctor if any
forms of discomfort occurs

B. PSYCHOSOCIAL ASSESSMENT

1. Psychosocial Nursing Assessment

Lifestyle Information:

The patient is a single woman, currently residing with her parents in

their own house. She currently work as a secondary education teacher in Pis- anan National
High School. They inhabit a rural neighborhood as described by P.C.M. despite of this, the
patient considers God, aside from her family to be the most important source of her
strength during tough situations. The patient graduated Bachelor of Science in Secondary
education and earned her diploma at University of Antique.

Normal Coping Patterns:

Patient claims that whenever she feels stressed, her automatic response is to
binge eat. She considers it to be effective because she feels relieved after doing so. Listening
to music while resting is also one of her favorite coping strategy whenever she feel tensed.

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

Understanding of Current Illness:

L.C.M. states that she is aware of her illness and expresses

concern over the possibility of leaving her job and her family.

Personality Style:

The patient’s personality is quiet strong and she has an independent nature
that might have affected her compliance to the proper care and management of her
condition. She has also a tendency to follow her own rules and desires.

History of Psychiatric Disorder:

The patient claims as to have neither experienced any psychiatric disorder

nor had taken any drugs or medications indicated for people who are psychiatrically
deviated. There is also no history of any mental illness in their familial line.

Recent Life Changes or Stressors:

When she was diagnosed of having a breast cancer.

Major Issues Raised by Current Illness:

According from the mother of the patient, aside from her daughter
hospitalization, financial constraints is their major issues. From the bills and medications,
she needs to cover up their loans that they use for the previous hospitalization.

CLINICAL INSPECTION
Date and Time Taken:

II.B.1. Vital Signs T= PR=

BP= RR=

II.B.2. Height: 5’1”

II.B.3. Weight: 60 kg

4. PHYSICAL ASSESSMENT

A. Integumentary
Skin: warm to touch, brown in color, diaphoretic, sites exposed to sun are
slightly darker; good skin turgor; Hair: black; properly kempt; shoulder length;
covers the scalp to normal gender distribution; Nails: pale nail beds, dirty;; no
clubbing; capillary refill of <2 sec: lips pink, scattered scars noted on both legs; 2 nd
digit is necrotic and non responsive to stimuli; 3rd digit id cyanotic with no
sensation; wound covered with elastic bandage, dry and no odor noted.

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

B. Neurologic
Alert, oriented to time, person, and place; able to name familiar objects;
expresses thoughts and answers questions appropriately. Eye: smooth and
symmetric in movement; anicteric sclera; pink conjitiva; iris is dark brown; Nose;
Smooth; symmetric; color is consistent with general skin tone; no discharges; intact
nasal septum; Ears: bilaterally equal in size; no lesions or discharges noted;
Mouth: pink mucosa; 32 teeth present; all molars are in poor condition due to
dental carries; uvula in midline; no lesions; tonsils at grade +1; Cranial nerves are
intact: CN1- able to smell, sniff and differentiate one odor from another; CN2- able
to read name of medication; CN3, 4 & 6 – PERRLA; CN5- able to differentiate
sharp from dull objects as observed during meals; CN7- able to smile or frown
appropriately to situation; CN8- able to hear a well modulated voice from 4-5 feet
away; CN9 & 10- swallowing reflex observed, able to establish taste of food. CN11-
accessory muscles in neck functional; CN12- functional as evident in tongue
movements; Impaired sensation in the 2nd and 3rd digit of L foot. The big toe of the
L foot is starting to loose sensation.

C. Respiratory
RR= 20 breaths/min; breathing patterns: deep inhalation and shallow
expiration; regular rate and rhythm; slight murmurs hears in R lung; no use of
accessory muscles when breathing.

D. Cardiovascular/ Circulatory
Peripheral pulses are palpable; no abnormal heart sounds; cardiac rate is
regular in rhythm and rate ; apical pulse noted at 5th intercostals space. With IVF of
PNSS 1L X 125cc/hr attached to L cephalic vein.

E. Urinary/ Genitourinary
Voids in a bedpan; voids to amber colored urine 4-6 in shift; no problems
regarding urination. Voided to approximately 1240cc of amber colored urine.

F. Gastrointestinal
Umbilicus is at the center, everted; hyperactive bowel sounds of 23 cycles
at RUQ; complains of flatulence;

G. Reproductive
Regular menstruation of 28 days; sagging breasts.

H. Endocrine
Latest glucose result of 18.40 mol/L N=3.89-5.84 mmol/L

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

I. Musculoskeletal
Impaired phyical mobility; right is the dominant hand; no lesions noted on
upper and lower extremities; radial pulse palpable; brachial pulse palpable; Full
ROM of upper extremities; able to apply force; able to shrug shoulders against
resistance. Upper extremities rated 5/5 in muscle strength; L lower extremity rated
at 1/5 and the R to be 4/5.

J. Lymphatic

K. Hematopoetic

II.D. NURSING PROGRESS NOTES (On-Going Appraisal)

(Use SOAPIE: Format. Refer to example given)

2/13/95
8:00 AM S- “My skin is itchy on my back and arms, and it’s been like this for a
week”
O- Skin appears clear – no rash or irritations noted. Marks where client
has scratched noted on left and right forearms. Allergic to elastoplast
but has not been in contact.
A- No previous history of pruritus
Altered comfort (pruritus) cause unknown
P /I - Instructed not to scratch skin
Applied calamine lotion to back and arms at 8:30AM.
Cut fingernails.
Assess further to determine whether recurrence associated with
specific drugs or foods.
Refer to physician and pharmacist for assessment.
E- States, “I’m still itchy. That lotion didn’t help.”

Source: Kozier K., Erb G., Berman A., and Snyder S., (2008), Fundamentals of Nursing:
Concepts, Process and Practice. 8th Edition. Pearson Education, Inc.: New Jersey

II.D. OTHER SOURCES OF LABORATORY

1. CLINICAL CHEMISTRY
Name of Examination:
Definition:
Preparation: (if applicable)
Purpose:

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

Date:

Results Normal Values Significance of

Abnormal Results

2. HEMATOLOGY
Name of Examination:
Definition:
Preparation: (if applicable)
Purpose:
Date:

Results Normal Values Significance of Abnormal

Results

3. RADIOLOGICAL EXAMS AND OTHER SPECIAL EXAMS

Name of Examination:
Definition:
Preparation: (if applicable)
Purpose:

Date:
Results:
Impression:
Significance:

IV. TEXTBOOK DISCUSSION

a. Definition
b. Anatomy and Physiology of organs/systems involved
c. Signs and Symptoms
c. Pathophysiology (Schematic Diagram)
d. Management
1. Medical
2. Surgical (if applicable)
3. Nursing

III. DRUG STUDY

V. PROBLEM LIST (Identified Nursing Diagnoses numbered according to priority)

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

VI. NURSING CARE PLAN

Cues Nursing Scientific Goals/Objectives/ Intervention Rationale Evaluation

Diagnosis Basis Outcome Criteria
(Rationale)
 Include (Minimun of  Define the Subject+verb+condition  Classify into Include date
date S/Sx 3 Nursing nursing +criteria+time frame Independent, of evaluation
have Diagnosis) diagnosis Dependent
been ND+ related  Discuss The patient will perform and Justify
identified factor briefly the self-care activities after Collaborative
 Cluster underlying health teaching by nursing
cues pathophysio 3:00pm July 15, 2011 interventions
logy of the
nursing
diagnosis
References

*Use italicized statement as your guide only.

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