LOURDES COLLEGE NURSING PROGRAM Cagayan de Oro City

NURSING ASSESSMENT TOOL

Name of Student: Group 1 I. DEMOGRAPHIC DATA Rotation Area/Date of Assessment: Surgical Ward/ August 12, 2010

Name of Patient: patient CO Address tagoloan misamis oriental Age: 83 year old Sex: male Civil: Status married Source of Information: daughter= 4 (reliability 1-4 w/ 4=very reliable) Occupation: none Religion: Roman Catholic Date of Admission: September 12,2011 Admitting Diagnosis: pneumothorax secondary to multiple rib fractures secondary to vehicular accident, pedestrian vs. 6 wheeled Change in Diagnosis since admission: none II. REASON FOR HOSPITALIZATION
A. Chief Complaint (What is troubling you? or What brought you to the hospital? Chief complaint should be recorded in the clients own words.)

Nabanggaan man gud siya ug jeep dayon pagkaikaduha ka adlaw, nanghubag dayon iya nawong dayon maglisod siya ug ginhawa, gipaadmit dayon namo siya as verbalized by daughter. B. History Present Illness: (When the symptoms started; whether the onset of symptoms was sudden or gradual; how often the problems occurs; Exact location of the
distress; Character of the complaint (e.g. intensity of pain or quality of sputum, emesis or discharge; Activity in which the client was involved when the problem occurred; Symptoms associated with the chief complaint; Factors that aggravate or alleviate the problem.)

Two days prior to admission, patient was allegedly side-swiped by a 6-wheeled vehicle. Patient was then brought to ER with X-RAY done revealing multiple rib fractures. 12 hours prior to admission, patient was noted to have facial swelling difficulty of breathing, consultation done in a local hospital and was subsequently referred to Northern Mindanao Medical Center for further evaluation and management.
C. Name and of surgeries/procedures done since admission:
Chest X-RAY September 12, 2011 Closed thoracostomy tube insertion September 12, 2011 Closed thoracostomy tube insertion September 14, 2011 BLOOD TYPING, CBC WITH PCT

D. General Appearance: (Observe body build, height and weight in relation to the clients age, lifestyle and health; observe the clients posture and gait, standing, sitting and walking; observe clients over all hygiene and grooming; note body and breath odor; observe for signs of distress in posture like bending over because of abdominal pain; observe facial expressions like grimacing or labored breathing; note obvious signs of health or illness like skin color or respiratory distress; assess the clients attitude: cooperative, uncooperative, cheerful, depressed, anxious, angry talkative, tearful, quiet; assess appropriateness of the clients responses.):
Upon assessment, patient was noted to be generally weak, (-) shortness of breath and has difficulty speaking. Patient also had a closed thoracostomy tube attached to thoracic pump regulated at 400 cm H2O and another thoracostomy tube attached to water-sealed bottle. Patient verbalized sakit akong kilid (pointing CTT insertion site) kung molihok ko ug kung matandugan. Patient also claimed pain upon coughing. Bruise formation was also noted from neck running to the back and to the right hip region. Patient also had abrasions in the skin in mandibular area and in the left arm down to the fingers. Swelling was also observed in the face including the left and right peri-orbirtal area. His skin is cool to touch. Upon palpation, third space fluid can be felt in the left and right arms. Patient weighs 56 kilograms. All throughout the assessment patient is restless and tired. Speech is unclear and by the help of daughter, assessment went well.

III. HEALTH PRCEPTION AND HEALTH MANAGEMENT A. Previous Hospitalization: (Previous hospital admissions and medical or surgical diagnosis and treatments received; date and name of previous surgeries; accidents at home, at work, or while driving

none
B. Family Health History: (Familial risk factors: Diabetes, Thyroid <specify>, TB, Stroke, Heart Disease, High BP, Kidney Disease, Epilepsy, Cancer, Mental Illness, others.)

none
C. What Other Health Problems Have You had: (Does the client have or ever had: Diabetes, Hypertension, TB, Cancer, Radiation, Chemo, Heart Disease, Seizures, Hepatitis, Renal Disease, Pacemaker, Stroke, Emphysema, Asthma, Arthritis, Psychiatric Illness, Depression, Recent life changes; Any conditions which affect current health

none
D. Any Health Compliance Problem? (Had it been easy to follow suggestions from physicians or nurses previously? Had there been any prescribed medications or OTC drugs? If Yes: not the drug name, dose, timing, purpose, side effects or problems encountered, taken regularly? Had there been any restrictions imposed by physician, religious or cultural beliefs? none

E. Tobacco/ Alcohol Use ( amount/ day & # of years)

IV. ALELRGIES: (Describe reactions to allergies on food, medication, others.

No known allergies to food and medication or others.

Vital Signs

Vital Signs Upon Admission 8, 2010 Temperature= T-37C Pulse Rate= P-76 bpm Heart Rate= P-76 bpm Respiratory Rate= 28 cpm Blood Pressure= BP- 110/70 mmhg Nutrition/Metabolic Pattern

Date: August Latest Vital Signs: 2010 Temperature= 36.5C Pulse Rate= 72 bpm Heart Rate= 72 bpm Respiratory Rate= 18 cpm Blood Pressure= 140/90 mmHg

Date: August 12,

SUBJECTIVE (REPORTS) Usual diet: (type) dat Cultural/Religious Restrictions: does not have any cultural and religious restrictions Carbohydrate/Protein Intake: g/d Carbohydrate= 1 cup, Fats: None Vitamin/Food Supplement use: none Food Preferences: rice, fish, vegetables and soup, meat No. of Meals Daily: three times a day Dietary Pattern/Content: Breakfast: 1 cup rice and vegetables Lunch: 1 cup rice and fish Dinner: 1 cup rice and soup with fish Last Meal Intake: lunch Loss of Appetite: observed Nausea/Vomiting: none Heartburn/Indigestion: none Related to: Relieved By: none Allergy/Food Intolerance: none Mastication/Swallowing Problems: none Dentures: none Usual Weight: 56 kilogram Changes in Weight: none Do you get hot or cold easily?: none

OBJECTIVE (EXHIBITS) Current Weight: 56 kilogram Height: 52 BMI: 23.3 kg/m Body Build: normal Skin Turgor: Elastic/Good___x_____ Slow/Poor__________ Skin Color: Pink__x___ Pale_x___ Jaundiced_x_ Clammy_ x_ Cyanotic__ x___ Skin Temperature: Warm_____ Cool_ x__ Dry_ x___ Moist_ x____ Edema: General__ x____ Dependent_ __ Periorbital__ x_ Ascites_ x_ Thyroid Enlargement: none Condition of Teeth/Gums: incomplete, Appearance of Tongue: pinkish Oral Mucous Membranes: Moist___ Dry_____ Halitosis______ Presence of IV (location & solution): PNSS 1 liter right at 10 gtts/ min Presence of Tube Feeding (location & solution: none Dx Tests: Serum Glucose (glucometer): x Cholesterol: none CBC: WBC= 10.6 30^3/uL Lipid Profile: none Hgb: 10.8 g/dL Others: none Albumin: T3T4: none Others: none

Elimination SUBJECTIVE (REPORTS) Usual Bowel Pattern: any time Laxative Use: BU none Character of Stool: Soft__ Hard_ x Well-Formed_x__ Loose_ x_ Mushy_ x_ Watery_ x Froth x_ Brown____ Dark Brown x _ Black_ x__ Aromatic__ x__ Malodorous____ Constipation: none Diarrhea (indicate # of times of BM/24h): none History of Pain: none Bleeding: none Possible Cause: none Hemorrhoids: none Usual Voiding Pattern: none Output last 24 Hrs: 520 cc Incontinence/When: Urgency: none Frequency: none Retention: none Character of Urine: Color: Pale Yellow__x__ Dark Yellow___ Amber_x__ Teacolored__x__ Red__x__ Clarity: Clear____ Hazy__x__ Clots___x_ Pain/Burning/Difficulty Voiding: none History of Kidney/Bladder Disease: none Diuretic Use: none OBJECTIVE (EXHIBITS) Abdomen: Tenderx Not tender_____ Soft____ Distended_x___ Firm_x___ Round_x___ Palpable mass: _x_____ Size/Girth: none Bowel Sounds: Location: RLQ_x____ RUQ_x___ LUQ____ LLQ_x___ Type: Normoactive: _____ Hypoactive: _x_____ Hyperactive: __x____ Hemorrhoids: none Stool guaiac: none NG/G tube for Lavage: none Output (describe: none Bladder Palpable: none Overflow voiding: none Costovertebral Angle (CVA) Tenderness: none Presence of Foley: none Condom Catheter: none Diaper: Character of Urine: Color: Pale Yellow_x___ Dark Yellow____ Amber_x__ Teacolored_x___ Red_x___ Clarity: Clear____ Hazy____ Clots__x__ Dx Test: Urine Exam: none Stool Exam: none Others: nne

Respiration SUBJECTIVE (REPORTS) Dyspnea/Related to: none Cough/Sputum: none History: Bronchitis: none Asthma: none Tuberculosis: none Emphysema: none Recurrent Pneumonia: none Exposure to Noxious Fumes: none Smoker: no Pack/day: 2 sticks/day No. of Pack-Years: Use of Respiratory Aids: none Oxygen: none Lpm: none OBJECTIVE (EXHIBITS) Respiratory: Rate 18 Depth_shallow_____ Symmetry________ Regular____ Quiet_x___ Labored_x___ Nonlabored__x__ O2 use in Lpm: none Use of accessory muscles: _x___ Nasal flaring: _x___ Retractions: __x___ Fremitus: increased_x___ Decreased_____ Absent_x___ Normal_x___ Location: RUL_x___ RML_____ RLL_x___ LUL_x___ LLL_x___ Breath Sounds: Clear_____ Decreased_x____ Absent_x____ Normal_x____ Rhonci: RUL_x___ RML_x___ RLL_x___ LUL_x___ LLL_x___ Crackles: RUL_x___ RML_x___ RLL_x___ LUL____ LLL_x___ Wheeze: RUL__x__ RML_x___ RLL_x___ LUL_x___ LLL_x___ Anterior Lung__x_ Posterior Lung_x_ Stridor_x_ Pleural Friction Rub_x__ Voice Sound: Bronchophony (99): Unclear/Muffled_x____ Clear Transmission____ WhisperedPectoriloquy(1,2,3):Unclear/Muffled_x_Clear Transmission___ Egophony (ee): Unclear/Muffled_x___ ee=ay_x____ Cyanosis: none Clubbing of Fingers: none Cough: Nonproductive___________ Productive___x______ Sputum Characteristics: Color:Light Yellow/Clear_x Mucoid_x Yellow/Green_x Rust/Blood Tinged_x__ Black_x___ Pink_x___ Odor: Odorless_____ Foul-Smelly_x____ Consistency: Thick__x____ Thin__x____ Forthy__x____ Amount:Scanty__x__Minimal__x___ Moderate__x_Large Amount___x__ Respiratory Therapy Rx: none Respiratory Aids: Chest Tube_x_ Tracheostomy_x_ Incentive Spirometer__x__ Mentation/Restlessness: Alert_x__ Drowsy____ Stuporous_x_ Restless_____ Others: none

Circulation SUBJECTIVE (REPORTS) History of: Hypertension:__x_____ Heart Trouble: none Rheumatic Fever: none Ankle/Leg Edema: none Phlebitis: none Slow Healing: none Claudication: none Dysflexia: none Bleeding Tendencies/Episodes ctt insertion site Palpitations: none Syncope: none Extremities: Numbness: none Tingling: none Cough/Hemoptysis: none Chest Pain (Describe): none OBJECTIVE (EXHIBITS) BP: R and L: Lying/Sitting/Standing: 130/90 mmHg in lying position Pulse Pressure: 40 mmHg Auscultatory Gap: Pulses (Palpitation): Pulse Volume/Strength (4 Point Scale): Absent=(0), Thready/Weak=(1+), Normal=(2+), Increased=(3+), Bounding=(4+) Radial Pulse Rate: 72 bpmRegular_____ Irregular_x____ Pulse Strength_2____ Apical Pulse Rate: Regular_____ Irregular_x____ Pulse Strength_____ Pedal Pulse (Left) Regular___ Irregular___ Pulse Strength_____ Pedal Pulse (Right) Regular_____ Irregular___ Pulse Strength_____ Cardiac (Palpitation): Thrill _______ Heaves: _________ Friction Rub: none Murmur: none Vascular Bruit: none Jugular Vein Distention: none Breath Sounds: decreased Extremities: Temperature: cool Color: fair brown Capillary Refill: 1 second refill Homans Sign: Varicosities: none Nail Abnormalities:none Edema: extremities Distribution/Quality of Hair: equally distributed Trophic Skin Changes: none Color: General: brown Mucous Membranes: moist Lips: dry Nailbeds: normal Conjunctiva: pinkish Sclera: white Diaphoresis: mild IV Fluids:Solution: PNSS Rate: 10 gtts/min IV Site: Location: right Redness : _x__Swelling: _x___ Edema_x____ Heplock Site: none Date Changed: none

Activity/Safety/Mobility Status SUBJECTIVE (REPORTS) Activity/Rest: Occupation: none Usual Activities: on bed due to condition Leisure Time Activities/Hobbies: x Limitations Imposed by Condition: Sleep Hours: 5 Naps: 2 Aids: none Insomia: none Related to: none Rested on Awakening: none Feelings of Boredom/Dissatisfaction: none Hygiene: Activities of Daily Living: Independent/Dependent (Level): Mobility: dependent Feeding: dependent Hygiene: dependent Dressing/Grooming: dependent Toileting: diapered Preferred Time of Personal Care/Bath: morning, tsb Equipment/Prosthetic Devices Required: none Assistance Required: Provided By: daughter Safety: Allergies/Sensitivity: none Reaction: none Exposure to Infectious Diseases: never been exposed Immunization History: Previous Alteration of Immune System: Cause: none History of sexually Transmitted Disease (Date/Type): none Testing: none High Risk Behaviors: none Blood Transfusion/Number: none When: none Reaction: none Describe: none Geographic Areas Lived/Visited: clean and safe Workplace Safety/Health Issues: safe History of Accident Injuries: reason of hospitalization OBJECTIVE (EXHIBITS) Activity/Rest: Observed Response to Activity: Cardiovascular: normal Respiratory: good Mental Status (i.e. Withdrawn/Lethargic): restless Neuro/Muscular Assessment: normal Muscle Mass/Tone: good Posture: not good Tremors: none ROM: below partial range Strength: none Deformity: none Hygiene: General Appearance: weak Manner of Dressing: hosp. gown Personal Habits: good Body Odor: present Condition of Scalp: scalp flakes Presence of Vermin: none

Safety: Temperature: cool Diaphoresis: mild Skin Integrity (Mark Location on Diagram): none Scars: none Rashes: none Lacerations: Ulcerations: none Encchymoses: none Blisters: none Burns (Degree/Percent): none General Strength: Muscle Tone: none Gait: good ROM: not full of range due to incision Paresthesia/Paralysis: none Results of Cultures: none Immune System Testing: none Tuberculosis Testing: none

Fractures/ discoloration: ribs 5th-8th right Arthritis/unstable joints: none Back problems: none Changes in moles: none enlarged nodes: none Delayed healing: none Cognitive limitations: none Impaired vision/hearing: none Prosthesis: ambulatory device: none

Cognition & Perception/Sensory Reflex

SUBJECTIVES (REPORTS NEUROSENSORY Fainting spells/dizziness dizziness Headache: none Location: none Frequency: none Tingling/numbness/weakness (location) none \Stroke/ brain injury(residual effect): none Seizures: none Type: none Aura: none Frequencypostical state none How controlled :none Eyes vision loss: none Last examination: none Glaucoma: none Cataract: none Ears: none Hearing loss: none Last examination: none Sense of smell: none Epitaxis: none OBJECTIVES (EXIBITS) NEUROSENSORY Mental status(duration of change): Orientated disoriented:time: place: Person: Situation: Check all that apply: Alert: x drowsy: lethargic: x Stuporous: : x comatose: x Cooperative: x combative: x Delutions: x hallucination : x Affect (describe): Memory recent: not impaired Remote: clear recall of important events Glasses: none contacts: none hearing aids: none Pupil: round

Facial droop: none swallowing: doesnt have difficulty Handgras/ release, R/L: none Posturing: requires assistance when moving Deep tendon: none reflexes paralysis: none

Cognition & Perception/Sensory Reflexes

SUBJECTIVE (REPORTS) Pain/Discomfort: Primary Focus: pain in ctt insertion site Location: right lower lobe Intensity (0-10 with 10 = most severe): 8/10 Frequency: when moved Quality: acute Duration:1 min Radiation: Precipitating/Aggravating Factors: fracture rib How Relieved: rest Associated Symptoms: none Effect of Activities: Relationships: none Additional Focus: none OBJECTIVE (EXHIBITS) Pain/Discomfort: Facial Grimacing: Posturing: not good Emotional Response: good Change in BP: Guarding Affected Area: Behaviors: good Narrowed Focus:ctt incision site Pulse:

Sexuality/Reproductive
SUBJECTIVE (REPORTS) Sexually Active: Use of Condoms: Birth Control Method: Sexual Concern/Difficulties: Recent change in frequency/interest: MALE: (SUBJECTIVE (REPORT) Penile discharge: Prostate disorder: Circumcised: OBJECTIVE (EXHIBITS) Comfort level with subject matter

Vasectomy:

OBJECTIVE (EXHIBITS) Breast: Penis: Testicles:

Practice self-examination: Breast: Testicles: Last protoscopic/prostate examination:

Genital warts/lesions:

Discharge:

Sexual/Reproductive
FEMALE: SUBJECTIVE (REPORTS) n/a Age at menarche: Length of cycle: Duration No. of pads used/day: Last Menstrual Period: Pregnant Now: Bleeding between periods: Menopause: Vaginal Lubrication: Vaginal Discharge: no vaginal discharge Surgeries: Hormonal Therapy/Calcium Use: Practices breast self-examination: Last mammogram: Pap smear: OBJECTIVE (EXHIBITS) Breast Examination: Genital warts/lesions: Discharge:

Self-Concept/Coping
SUBJECTIVE (REPORTS) Stress Factors: financial problems Ways of Handling Stress: praying Financial Concerns: yes Relationship Status: good Cultural Factors / Ethnic Ties: none Religion: Roman Catholic Practicing: non-practicing Lifestyle: simple Recent Changes: none Sense of Connectedness/Harmony with self: close Feeling of Helplessness: none Hopelessness: none Powerlessness: none OBJECTIVE (EXHIBITS) Emotional Status: (Check those that Apply): Calm: __x____ Anxious: __x____ Angry: __x____ Withdrawn: __x____ Fearful: __x____ Irritable: __x____ Restive: ______ Euhporic: __x____ Observed Physiologic Responses: Changes in Energy Field: Temperature: cool Color: brown Distribution: Movement: Sounds:

Self-Concept/Coping/Social Interaction
SUBJECTIVE (REPORTS) Marital Status: married Years in Relationship: 50 yrs old Perception of Relationship: good Living with: son Concerns/Stresses: financial concern Extended Family: none Other Support Person(s): none Role within family structure: father Perception of relationship with family members: none Feeling of Mistrust: none Rejection: none Unhappiness: none Loneliness/Isolation: none Problems related to illness/condition: none Problems with communication: none Genogram (Diagram): none OBJECTIVE (EXHIBITS) Speech: Clear: Slurred: ______ Unintelligible: __x____ Aphasic: __x____ Unusual speech pattern/impairment: related to present condition Use of speech/communication aids: none Laryngectomy present: no present Verbal/nonverbal communication with family/SO(s): communicate with her family verbally and signs Family Interaction (behavioral) pattern: very close to each other

Values & Beliefs

SUBJECTIVE (REPORTS) Cultural Factors/Ethnic Ties: none Religion: Roman Catholic Practicing: non-practicing 1. Spiritual and religious practices- Go to mass occasionally during Sunday 2. Cultural beliefs or practices- She believes that through prayers her problem will be solve 3. Familial traditions- All Souls Day in respect to the dead of relative rarely celebrate Christmas and New Year due to financial problem OBJECTIVE (EXHIBITS)