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NURSING HISTORY:

I.

VITAL INFORMATION

CLIENTS NAME: Mrs. L.D. AGE: 83 years old SEX: F CIVIL STATUS: widowed RELIGION: Iglesia ni Cristo NATIONALITY: Filipino BIRTHDATE: July 01, 1928 BIRTHPLACE: Laloma, Quezon City CURRENT ADDRESS: Simeon Aguilar St., Passi City EDUCATIONAL ATTAINMENT: OCCUPATION: housewife CHIEF COMPLAINT/S: headache, dizziness, numbness, chestpain DATE AND ADMISSION TO ER: august 15, 2011 ATTENDING PHYSICIAN: Dr. F.D. MEDICAL DIAGNOSIS: CVD problem bleed VS, infarct problem at the right fronto-parietal area NUMBER AND DATES OF PREVIOUS HOSPITAL ADMISSIONS: WARD/UNIT, BED AND ROOM NUMBER: 3rd floor WVSUMC RM. 321 SOURCES OF INFORMATION: SIBLINGS

II.

HISTORY OF PRESENT ILLNESS:

The client was admitted August 15, 2011 8:15 a.m. with a chief complaint of Headache, dizziness, numbness and chestpain. 5 days PTA, the client complained of severe headache radiating on the lower back of her head. Incident happened in their house as verbalized by her daughter ang gulpi lang nga pagusdang amo ang ginhalinan. Due to the severity of the headache, she slept to relieve the pain felt. To their surprise, the client was already suffering from a silent attack of stroke. ADL were affected due to loss of alertness and decreased in daily activities. Client usually does household chores. Client was given Plendyl, a pain killer and Paracetamol as a relief. However, pain persisted until such

time that her daughter decided to bring Mrs. L.D. to the nearest hospital for admission. She was brought then to Passi City Hospital . Mode of transportation was their family car and was accompanied by her children. Upon arrival she was checked and examined by the staff nurses. Vital signs revealed: BP: 130/90, RR: 20BPM, PR: 84BPM, TEMP.: 37.4 C. Due to lack of medical assistance and attending physician, she was brought to WVSUMC. Client was unconscious prior to admission. Upon arrival, she was examined by the attending nurses in the ER. Vital signs revealed : BP: 120/90 RR: 15BPM, PR: 72 BPM, TEMP: 36.7 C.

III. PAST MEDICAL HISTORY The client did not sufferred from any childhood diseases, has good posture and has a positive outlook in life. She was been hospitalized and had undergone Caesarian Section during her 2nd Childbirth. She did not suffered any accidents, falls or injuries alll throughout. Surgical operation has been done during her CS delivery.

IV.

CURRENT HEALTH STATUS

No allergies upon verbal assessment. Client completed immunization during childhood. Absence of environmental hazards that could trigger an illness response. Client usually exercise by walking every morning. Client seldoms sleeps at daytime. Sleeping time is from 8pm to 4am. She uses two pillows when sleeping. Patient had no any problem in urinating and moving bowels, urine appears straw in color with slighly aromatic. Patient cannot recall menstrual pattern. Patient does not have any medications taking.

DIETARY PATTERN: MEALS USUAL FOOD TAKEN TIMING

BRAKFAST

LUNCH

1 cup of coffe, 1 cup of rice/fried rice, 1 fried egg, 1 fried dried fish. 2 cups of rice, 1 cup of laswa consisting of malunggay, eggplant, squash, okra and monggo, 1 slice of mango/piece of banana, 1 glass of water. 3 boiled sweet potato/saba and a cup of coffee. 1 cup of rice, fried fish/pork, ginisang Balatong, 1 glass of water.

7:00 8:00AM

11:30-12:30NN

3:00 4:00PM AFTERNOON SNACK SUPPER

6:30 7:30PM

V.

FAMILY HISTORY

The clients daughter stated that her family has a history of Hypertension and Diabetes. She also stated that they dont have a history of Tuberculosis and other heriditary diseases. Both parents of the client has a history of Hypertension and Diabetes. No specified date of death of the immediate family member was given. VI. PERSONAL HISTORY

Family lives in a house conducive for rest and relaxation. House is situated in an urban area. Nuclear type of family. Children usually does the decision when it comes to financial matters. Supported by her children, the client met the daily recommended needs for eating, clothing and personal needs. Client does the

household chores, wakes up every 4am and goes to themarket. She watches TV as a source of recreation. Travels and explores different places to cope her stress. Client is an active member of Iglesia ni Cristo and attends daily rituals and prayer gatherings. Relationship with the family member is intact as stated by her daughter. Clients wants a positive outlook in life. All she ever wanted is a happy and complete family though her husband died already and left her the responsibility to take care of their children. Her children are all professionals due to her hardwork and perseverance.

PHYSICAL ASSESSMENT: 13 FUNCTIONAL AREAS GENERAL SURVEY: Received patient L.D. asleep in a side-lying position, female, 83 years old, filipino, widowed, Iglesia ni Cristo. Accompanied by daughter, oriented to person and place but not time according to folks, NGT tube attached, patent; Folly Catheter in place, patent, 54 in height, weighs 45 kg., body type is proportionate, gait is uncoordinated, tremors noted upon movement. has good hygiene and grooming, no body odors noted, mod and affect is appropriate to the situation, slow pace when speaking, organization of thought is logical. Patient is restless and lethargic. V/S revealed BP: 110/90, RR: 20 cpm, PR: 60 bpm, TEMP.: 37.4 c

FUNCTIONAL AREAS: 1. RESPIRATORY FUNCTION RR of 20 cpm, regular in rate and rhythm, spontaneous and non-labored with no signs of pulmonary distress, equal chest expansion upon inspection, harsh breath sounds, crackles heard upon auscultation. 2. CIRCULATORY FUNCTION PR of 62 bpm, regular, synchronous. BP taken at the left upper arm with patient in supine position. palpebral conjunctiva shiny, smooth and pink in color, nailbeds highly vascular and pink in lightened skinned. palms prompt, return of usual color less than 4 seconds in blanch test. edema not noted. lub-dub rythmic sounds heard upon auscultation with s1 sounds heard prominently at the apical area, jugular veins not visible.

3. SPECIAL SENSES FUNCTION A. EYES Visual acuity is good, visual fields are normal, normal vision in both eyes, normal eye movements noted, eyebrows are evenly distributed, eyelids are intact, lids close symmetrically, discharges, discoloration, redness, inflammation, edema or infection not noted. eyelashes are equally distributed and curled slighty outward, sclera are whitish but cloudy in appearance, moist, absence of PERRLA noted upon inspection, cornea is transparent, shiny and smooth with thin grayish white ring around the margin caked arcsus senilis and reacts by blinking when touched, both pupils are equal in size, round and light brown in color. sluggish reaction of left pupil, right pupil nonreactive to light and accomodation

B. EARS Both auricles are symmetrical in size, shape and color, firm and aligned with the outer canthus of the eyes, pinna recoils after being folded. tenderness, masses and swelling not noted upon palpation including mastoid process. presence of dry and sticky cerumen in various shades of brown noted in both ear canals, normal voice tone is not audible, request repitition of words.

C. NOSE External nose is symmetrical and straight, uniform in color, no discharges and nasal flaring noted, patency is good, air can pass freely as client breaths through the nares, mucosa is pink in color and septum is located midline, no tenderness, masses and swellingnoted upon palpation of the nose, maxillary and frontal sinuses are non-tender to touch.

D. MOUTH Lip is pink in color, soft, dry, slightly smooth textured, contour is symmetrical, mucosa is slightly moist, smooth, soft, elastic and pink in color, teeth are smooth, white in color, shiny tooth enamel, all 32 teeth are intact, gums is pink in color and moist, firm in texture, tongue is located at the center of the mouth, pink in color, moist and slightly rough in texture, movement is stricted and base of tongue is smooth to touch, salivary glands are the same color as of the buccal mucosa and floor of mouth, palates are pinkish in color, smooth, same with the tonsils, no inflammation, redness and lesions noted upon inspection.

4. REST AND COMFORT FUNCTION

Sleeps during daytime and wakes up during night time. no pain felt upon assessment. 5. ELIMINATION FUNCTION Urine is straw in color and no pain felt upon urinating. Voids moderate amount of urine 3 times a day. Patient refuse for further assessment. 6. NUTRITION NGT tube feeding in place, patent and infusing well. IVF of D5 LR 1L infusing well at the Left Cephalic vein,abdomen is symmetrical in shape and size, uniform in color, no enlargement or any tenderness noted, fat is evenly distributed but in only small amounts. 7.NEUROLOGIC FUNCTION Decreased LOC noted, lethargic at all times, GCS upon admission is 8 (V2,M5,E1) GCS score of 11 out of 15. with verbal scale of 3, motor scale of 5, and eye opening scale of 3, negative rombergs test noted. 8.MOTOR FUNCTION UE- muscle tone is smooth but not fully developed, right arm is stronger than the left arm, muscle strength is 25% or less of normal strength. stifness, swelling, inflammation and deformitiesnot noted. Tenderness not noted upon palpation. Brachial pulse and radial pulse are palpable. Skin color is fair.

LE- right leg is freely movable compared to the left leg, muscle tone is smooth, small amounts of fat is present on both feet and legs, dorsalis pedis and popliteal pulse are palpable, no swelling, lesions or any deformities noted. Neck muscle- equal in size; head centered. Head movementlimited ROM, unequal strength right is stronger than left, stiffness noted. Lymph nodes not palpable, with trachea in central placement in midline of the neck, with spaces are equal on both sides. Thyroid glands not visible on inspection. 9. REPRODUCTIVE FUNCTION

Patient refuses for further assessment. 10.THERMOREGULATORY FUNCTION Temperature is within normal range, no chills and diaphoresis noted, skin is warm to touch. 11.SKIN INTEGRITY AND INTEGUMENTARY FUNCTION Skin is brown in color, no vascularities, scars and lesions noted, hair is long, smooth to touch and evenly distributed into the scalp, nailbeds are highly vascular and pink in color, has good skin turgor, returns to normal state when pinched. 12.SOCIAL FUNCTION Client is able to speak but in slow pace, with slurred speech, writes in paper when communicating with her children. 13.MENTAL AND EMOTIONAL FUNCTION Good immediate memory, is able to recall numbers announced, good recent memory, is able to recall son who visited earlier, good remote memory, is able to recall disease, unable to explain illness well due to impaired speech,

noncompliant to interventions AEB ngt removal and refusal to medications.