NURSING ASSESSMENT II

Name of Patient ___________PATIENT X___________________________ Age ____35 Y.O____ Sex ___FEMALE_____

Chief Complaint ___________DIFFICULTY OF BREATHING_____________
Impression/Diagnosis ACUTE DECOMPENSATED HEART FAILURE PROBABLY 2° TO RHEUMATIC HEART DISEASE, CARDIOMEGALY, HEART FAILURE - NEW YORK HEART ASSOCIATION FUNCTIONAL
CLASS III, COMMUNITY ACQUIRED PNEUMONIA-MODERATE RISK
Date/Time of Admission _ OCTOBER 18, 2018 at 1:15 pm _________ Inclusive dates of care __October 29 – November 01 2018 ________________________
Diet __NGT FEEDING/OF Feeding___________________ Allergies SEA FOODS AND CHICKEN________________
Type of operation (if any) _NONE___________________________________

NORMAL PATTERN BEFORE HOSPITALIZATION INITIAL CLINICAL APPRAISAL

1. ACTIVITIES – REST
Pt. is working as street
a. Activities vendors every day. She
spent most of her time
working then do household
chores when at home.
She rests for 1-2 every
b. Rest
noon and Sunday as her
only rest day.
Pt needs 2 pillow if she lies
supine.
Patient is asleep with no
activities being performed.
Patient is resting on bed
throughout the day.
DAY 1 DAY 2 DAY 3 DAY4
Pt. is on bed, awake Pt. is on bed, awake
Patient is asleep with no Pt. is on bed, awake and and alert. Patient and alert. Patient
activities being alert. Patient writes to writes to paper to writes to paper to
performed. spaper to communicate. communicate. Pt asks communicate. Pt asks
for suctioning. for suctioning.
Patient is calm and rests Patient is calm, Pt performs PROM.
Pt is calm, cooperative
Patient is resting on bed well. sometimes irritated
throughout the day. but still cooperative and rests well.
and rests well.

c. Sleeping Pattern She regularly sleeps 5 Pt. is asleep for about 6 Pt. is asleep for about 5 Pt. sleeps for about 3- 4 Pt sleeps for about 3- Pt sleeps for about 3
hours/day hours during 8 hour shift. hours during 8 hour hours during 8 hours 4 hours during 8 hours hours during 8 hours
shift. Pt wakes up if shift. Pt wakes up shift. Pt wakes up shift. Pt wakes up
called by her name or spontaneously. spontaneously. spontaneously.
during suctioning.
2. NUTRITIONAL –
METABOLIC

a. Typical intake Pt. usually gets 3 meals per
(food, fluid) day and drinks 3-6 glass of
water every day. Usually
b. Diet she eats rice, fish and
banana.
c. Diet Restrictions No diet restrictions except
to an allergy to seafood
and chicken.
d. Weight She weighs 45-48 kg. As
claimed by SO .
e. Meds/food Pt. is not taking any food
supplement supplement. Takes
medications such as
analgesics and Lagundi if
needed
Pt. is being feed through Pt. is being feed Pt. is being feed through Pt. is being feed Pt. is being feed
NGT with an osteorized through NGT with an NGT with an osteorized through NGT with an through NGT with an
food containing 1500 cal. osteorized food food containing 1500 osteorized food osteorized food
containing 1500 cal. cal. containing 1500 cal. containing 1500 cal.
Diet is limited to OF
Diet is limited to OF Diet is limited to OF Diet is limited to OF Diet is limited to OF
Pt. weighs 41 kg.
No food supplements Pt. weighs 40 kg. Pt. weighs 40 kg. Pt. weighs 40 kg. Pt. weighs 40 kg.
prescribed. No food supplements No food supplements No food supplements No food supplements
Patient is prescribed to prescribed. prescribed. prescribed. prescribed.
have Potassium chloride. Patient is prescribed to Patient is prescribed to .
have Potassium have Potassium
chloride. chloride.
.

3. ELIMINATION

a. Urine Pt urinates 5-6 times for Patient is on diaper with Patient is on diaper Patient is on diaper Patient is on diaper Patient is on diaper
(frequency, the day. Urine is an output of 400g. with an output of with an output of with an output of with an output of
color, yellowish in color and Diaper appears yellowish 480g. Diaper appears 300g. Diaper appears 350g. Diaper 180g. Diaper
transparency) transparent (as stated by in color with a pungent yellowish in color with yellowish in color with appears yellowish in appears yellowish in
the SO) odor. a pungent odor. a pungent odor. color with a pungent color with a pungent
b. Bowel Pt defecates once in Patient hasn’t defecated. Patient hasn’t Patient hasn’t odor. odor.
(frequency, every 2 days. defecated defecated Patient hasn’t Patient hasn’t
color,
defecated defecated
consistency)
4. EGO INTERGITY
According to the SO
a. Perception of Pt. has positive outlook Patient seems to Patient seems to Patient seems to be
Self in life. She uses her family believe that she will believe that she will eager for early
in coping with her be well soon. be well soon. recovery
b. Coping problems .
Mechanism She is fully supported by
her family especially by her
c. Support System mother.
She is fully supported by She is fully supported by She is fully supported by She is fully supported She is fully supported
Pt. is usually in good mood
her family especially by her her family especially by her family especially by by her family by her family
and never had depression.
d. Mood/Affect mother and siblings. her mother and siblings. her mother and siblings. especially by her especially by her
Pt seems to be in mother and children. mother and children.
mood. Pt seems to be in Pt seems to be in
mood. mood.
5. NEURO-SENSORY

a. Mental State No alteration on the Mental status cannot be Mental status cannot be Mental status cannot be Mental status cannot Mental status cannot
mental state. assess. assess. assess. be assess. be assess.
b. Conditions of 5 Pt has no mental problem. Patient was lethargic Patient was lethargic. Pt was awake and Pt was awake, Pt was awake,
senses: (sight, GCS of E3M5V1T conscious with GCS of conscious and follows conscious and follows
hearing, smell, All senses are intact except All senses are intact except E4M5V1T command with GCS of command with GCS of
taste, touch) for hearing. for hearing. All senses are intact All senses are intact E4M6V1T E4M6V1T
except for hearing. except for hearing. All senses are intact All senses are intact
except for hearing. except for hearing.
6. OXYGENATION
8am 2pm 8am 2pm 8am 2pm 8am 2pm 8am 2pm
a. Vital signs

Temperature T: 36.6°C 37.0°C T: 36.4°C 37.2°C T: 36.8°C 37.1°C T: 35.9°C 36.8°C T: 36.9°C 37.0°C
38.0
Respiratory Rate RR:14cpm 17cpm RR:14cpm 13cpm RR:16cpm 15cpm RR:14cpm 20cpm RR:16cpm 14cpm
NO record
Heart Rate HR: 44bpm 48bpm HR: 43bpm 46bpm HR: 48bpm 48bpm HR: 48bpm 52bpm HR: 50bpm 48bpm
NO record BP:80/50 90/60 BP:100/60 100/70 BP:90/50 90/60 BP:90/60 90/60
Blood Pressure BP:90/80 90/60
NO record
b. Lung sounds Wheezing as described
by the SO
Bilateral crackling sound Bilateral crackling Bilateral crackling Bilateral crackling Bilateral crackling
C. History of
Patient was diagnosed to was noted upon sound was noted upon sound was noted upon sound was noted sound was noted
respiratory
have bronchial asthma auscultation. auscultation. auscultation. upon auscultation. upon auscultation.
problems
since 2008
Patient was diagnosed to Patient was diagnosed Patient was diagnosed Patient was Patient was
have bronchial asthma to have bronchial to have bronchial diagnosed to have diagnosed to have
since 2008 asthma since 2008 asthma since 2008 bronchial asthma bronchial asthma
since 2008 since 2008
7. PAIN – COMFORT
a. Pain (location, Pt. usually complains of Pt. usually complains of Pt. usually complains of Pt. usually complains of Pt. usually complains Pt. usually complains
onset, having difficulty of having difficulty of having difficulty of having difficulty of of having difficulty of of productive coughs.
character, breathing and productive breathing and productive breathing and breathing and breathing and This is associated with
intensity, coughs.. Sometimes this is coughs. This is associated productive coughs. This productive coughs. This productive coughs. dyspnea, SOB.
duration, associated with chest pain, with dyspnea, SOB. is associated with is associated with This is associated with Excessive secretion
associated SOB and marked limitation Excessive secretion dyspnea, SOB. dyspnea, SOB. dyspnea, SOB. aggravates the
symptoms, of activity. aggravates the DOB of pt. Excessive secretion Excessive secretion Excessive secretion coughing reflex of pt.
aggravation) Stress or too much activity aggravates the DOB of aggravates the DOB of aggravates the DOB of
exacerbates DOB Relieved through pt. pt. pt.
suctioning secretion;
b. Comfort Relieved through use of performing chest and back Relieved through Relieved through Relieved through Relieved through
measures/ Lagundi or analgesic or tapping and use of suctioning secretion; suctioning secretion; suctioning secretion; suctioning secretion;
alleviation nebulizer. adequate oxygen and performing chest and performing chest and performing chest and performing chest and
Salbutamol; Analgesics; nebulizing. back tapping and use of back tapping and use of back tapping and use back tapping and use
Lagundi capsule or adequate oxygen and adequate oxygen and of adequate oxygen of adequate oxygen
c. Medication
leaves. Salbutamol and nebulizing. nebulizing. and nebulizing. and nebulizing.
antibiotics
Salbutamol and Salbutamol and Salbutamol and Salbutamol and
antibiotics antibiotics antibiotics antibiotics
8. HYGIENE AND Pt. takes a bath every day.
ACTIVITIES OF DAILY She has clean fingernails
LIVING and no hair or body lice.
She is busy working as
street vendor. When she is
at home she is busy doing
the household chores.
Pt. has poor hygiene. Pt. has better hygiene. Patient looks neat Patient looks neat Patient looks neat
Nails are long and dirty. Hair is fixed. Nails are with her hair fixed and with her hair fixed with her hair fixed
Hair is messy. trimmed and cleaned bedside organized. and bedside and bedside
Patient has no activity as organized. organized.
she is on bed. Patient has no activity
Patient has no activity
as she is on bed.
as she is on bed. Patient has no activity Patient has no activity
as she is on bed as she is on bed

9. SEXUALITY

a. Female Menarche at the age of 14. Patient have no Patient have no Patient have no Patient have no Patient have no
(menarche, Patient‘s menstruation is menstruation. menstruation. menstruation. menstruation. menstruation.
menstrual cycle, civil within normal. Menstrual Patient is not pregnant. Patient is not pregnant. Patient is not pregnant. Patient is not Patient is not
status, cycle occurs once per pregnant. pregnant.
number of children, month, married and has
reproductive status) two children.

b. male
(circumcision, civil
status, number of
children)