NURSING CARE PLAN

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I. Patient’s Profile

Name: Ms. AZ
Age: 21
Sex: Female
Religion: Protestant
Education: College Graduate
Civil Status: Single
Occupation: Office Secretary
Address: Quezon City
Date / Time of Admission: September 10, 2007 / 10:00 AM
Chief Complain: “Meron po ako nitong rashes na my tubig tubig sa loob dito sa tiyan at
likod ko” as said by the patient.
Attending Physician: Dr. Camilla Esteves
Final Medical Diagnosis: Chicken Pox

I. History of Illness:

A. History of Present Illness

Three days before the admission, the patient went to her office to do her job. She
was messaged though her mobile phone by her officemate and eventually a close friend
of her that she will be able to go back to work after exactly two weeks of being absent at
the office due to Chicken Pox. She was happy to hear about that. They missed each other
so they ate lunch together. The patient didn’t mind catching the disease because she
believes that she has strong immune system that will protect her from any disease and
that she had Chicken Pox Vaccine ten years ago.
Two days before the admission, she did her usual routine for an office day. She
went to her office, did her job, socialized with some officemates, window shop with her
close friend, and then went home. During the day, the patient noticed that she’s loosing
her appetite.
 One day before the admission, the patient woke up feeling tired with a slight
fever and sore throat. She decided not to go to the office for that day thinking that she
will be able to recover quickly if she’ll stay at home and rest. When she was washing her
face before eating her breakfast, she noticed presence of itchy skin rash on small portion
of her neck. She was alarmed because she knows that she has no allergies to anything but
then, she didn’t take any medications nor consult a physician that time. She almost stayed
in bed for the whole day eating only porridge her house helper cooked for her. In the
evening around 8 o’clock, she tried to contact her doctor regarding her rashes that is
continuing to develop throughout her trunk. Unfortunately, her doctor was performing a
surgical operation at UERM during that time so she decided to just sleep hoping that the
rash will go away when she wakes up the following morning.
Before the admittance, the patient woke up and saw that the rashes had developed
to blisters filled with fluid and that she has still fever and sore throat.
Upon admission, vital signs were take and showed that her body temperature is
o
38.20 C, RR is 18 breaths/ min., PR is 75 beats/min., and BP is 110/70 mmHg.

B. Past Biophysical Health

i. Restorative Interventions
The patient had no past surgeries
ii. Immunization
The patient had completed the immunization process required to be fully
immunized according to the immunization record she presented. It also showed that there
were no significant effects that might had endangered the health of the patient.
iii. Allergies
No allergies were noted from the patient
iv. Growth and Development
The patient have wide hips and has enlargement of breast. Appropriate growth
and development for her age.
v. Foreign travel
For the past few weeks, the patient didn’t went to any foreign places except in
her office at condo unit at Cubao.
Last year, the patient went to Alaska.
C. Family Health History

+
99’
Natural Death

Legend:
Patient
Diabetes Type 2

Hypertension

D. Social History

Ms. AZ belongs to a nuclear family. She has no siblings. She lives independently
from her parents. She lives in a condo unit located at the 4th floor of condominium
building at Quezon City. The condo unit is properly maintained by her house keeper and
she only takes in purified water. She’s a fresh graduate from UST and her first acquired
job is Secretary in a certain company in Cubao. She receives appropriate salary which is
enough to sustain her needs. Furthermore, she has friends and close friends from her
office. Almost everyday in her current way of life, she’s with her close friend and friends.
She drinks alcohol occasionally and attends gym sessions once a week.
II. Gordon’s Functional Health Pattern

1. Health Perception – Health Management Pattern

S > Patient verbalized, "Sa tingin ko, wala naman akong ginagawa na maaaring magdulot sa
akin ng sakit. Pinapanatili kong malinis ang aking pangangatawan at bahay. Normal naman
ang aking pamumuhay sa ngayon. Masaya naman ako kaya sa tingin ko ay malusog ako.
Normal lang ang magkasakit paminsan minsan. Tska ginagawa ko naman ang aking
makakaya upang mapanatili ang kalusugan ko kahit na paminsan minsan talaga ay nagiging
pasaway ako. Pagdating naman sa gamot, sinusunod ko naman ang sinasabi ng doctor.” The
patient added that she doesn’t take any over the counter medicines unless prescribed by her
doctor. In relation to the chief complaint, the patient verbalized, “ ang pagkakaalam ko,
nahawa ako sa kaibigan ko apat araw na ang nakakaraan. Akala ko mawawala din ito pag
tinulog ko, ‘yun pala, akala ko lang hanggang sa maging ganito na nga to.” It was also told by
the patient that she had completed her vaccinations for immunizations at that she undergoes
medical check-up annually as a requirement of the company she’s working to.

O > The patient came in wearing jogging pants and loose t-shirt. She’s neatly groomed with
poor posture. Expression conforms from emotions. No body odor. Looks tired and worried.
Vital signs: Temp. (axillary) is 38.20oC, RR is 18 breaths/ min., PR is 75 beats/min., and BP
is 110/70 mmHg.

A> Ineffective health maintenance

Knowledge deficit

2. Nutritional – Metabolic Pattern

S > Patient verbalized, “Halos araw-araw kumakain ako sa labas kasama ang mga kaibigan
ko. Wala kasing magluluto ng makakain doon sa bahay. Masyado naman na akong pagod pra
magluto pa. Madalas sa fast food kami. Dalawang beses ako kumakain araw-araw. Hindi na
ako kumakain ng breakfast eh. May mga snack breaks din sa office, pag ganun, kumakain
ako ng biscuit at umiinom ng kape. Nagbabaon ako ng sarili kong tubig pag pumupunta
akong trabaho. Siguro, mga 8 baso din ng tubig sa maghapon ang naiinom ko. Umiinom ako
ng Centrum tatlong beses sa isang araw. Tinanong ko kasi dati sa doctor ko kung ano ang
magandang bitamina, yun ang binigay niya.”

O > Patient’s skin has presence of blisters and moist. Hair is shiny and black. Oral mucosa is
moist. CN #s 5, 9, 10, and 11 are intact upon assessment. Abdomen is convex, no visible
lumps or protrusion, it has symmetric contour, symmetric movements due to respiration, has
audible bowel sounds, tympany over the stomach and gas-filled bowels, dullness over organs
such as liver and spleen, no tenderness, complaints about pain when palpated is absent.

A> Imbalanced nutrition: less than body requirements

Readiness for enhanced fluid balance
Risk for impaired skin integrity

3. Elimination Pattern

S > Patient verbalized, “Umiihi ako ng maraming beses sa isang araw. Siguro, mga 8 beses sa
isang araw. Kulay yellow ang ihi. Dumudumi ako mga 3-4 beses bawat linggo. Hindi naman
ako nahihirapan sa pagdumi. Hindi rin ako nakakaranas ng masakit na pag-ihi at pagdumi.
Madalas, pinipigilan ko ang aking pagdumi lalo na kapag wala ako sa bahay. Masasabi kong
wala akong problema sa pagdumi. ”

O > Client’s output of urine per day is 450 ml. Urine color is straw-like and clear.
Client’s output of bowel per day is 225 g. Bowel odor is aromatic because of the ingested
food and is cylindrical in shape.
Intact perineal skin and hairless. Anal sphincter is in good tone. Rectal wall is smooth
and not tender.

A > Readiness for enhanced urinary elimination

Risk for Constipation

4. Activity – Exercise Pattern

S > The patient verbalized, “Sa pagpasok ko sa trabaho, nagjijeep ako tapos konting lakad
paakyat sa opisina ko. Naglalakad-lakad kami ng mg kaibigan ko sa mall tuwing may oras
para magsaya. Pumupunta din ako sa gym. Nagtatagal ako dun ng 2 hanggang 3 oras bawat
lingo. Wala naman akong problema sa paghinga. Hindi rin ako mabilis mapagod.”

O > There’s equal strength on each side of the body. Musculoskeletal system has neither
deformities nor tenderness, and moves smoothly in coordinated movement. Muscles are firm,
equal size on both side of the body, and fasciculation or tremors are absent. Has muscle grade
of 2+ and muscle strength of 5+. The patient has upright posture and steady gait with both
arms swaying alternately. She walks unaided and can maintain balance.
There were no pulsations, heaves or lifts noted in the precordium. Aortic pulsations are
present in the epigastric area. And upon auscultation the anatomical sites, it was noted that the
heart sounds are essentially normal or within normal range.
Her carotid arteries have symmetric pulse volumes, full pulsations with thrusting quality.
And upon auscultation, there were no sound heard. The jugular veins are not visible.
The peripheral pulses of the patient have symmetric pulse volumes and have full
pulsations. There were no superficial veins were present in the arms and legs and also no
phlebitis.
The thorax is essentially normal anatomically and physiologically.

A>

5. Sexuality – Reproductive Pattern

S > Patient verbalized, “Virgin pa ako. Hindi pa ako nakikipagtalik ni minsan. Nagsimulang
lumaki ang aking hinaharap nung ako’y 11 y/o. Una akong nagkaroon noong 13 y/o ako.
Tapos tinubuan ng mga buhok sa katawan nung taon din na yun. Wala naman akong
problemang nakikita or nararamdaman sa aking ari. Huli akong nagkaroon 8 araw na ang
nakakaraan.

O > Upon palpation of the breast, no lumps were felt. Genitalia was not assessed.

A>

6. Sleep – Rest Pattern

S > Patient verbalized, “Nako! Nakakatulog ako ng hanggang walong oras. Pagkagaling ko sa
labas, total kumain na naman ako, maghihilamos nalang tapos tulog. Pero syempre, hindi ko
hinahayaan na gumising ako ng tanghali na. Natutulog ako ng nakaelectricfan. Minsan lang
ako gumamit aircon, malamig kasi. Tahimik ang bahay pag tulog ako. Natutulog ako sa kama
ko na my foam. Tatlong unan lang naman ang ginagamit ko. Pero ang maganda kamo eh
parang ang tagal ng tulog ko kahit na ganun lang kaiksi yung oras. Ang sarap matulog!” The
patient also added that she do naps at office.

O > The patient looks calm with no presence of distress that might have been caused by lack
of sleep. Attention span averages to 45 min.

A> Readiness for enhanced sleep

7. Sensory – Cognitive Perceptual Pattern

S > The patient verbalized, “ako si Miss AZ. Nakatira sa Quezon City. Ang kinain ko
kaninang umaga ay lugaw na niluto ni Inday. Ipinanganak ako noong June 14, 1986. Kung
magkakaroon ako ng isang milyon, magtratravel ako sa mundo.”

O > Client is well-oriented to time, place, person and event.

CNI – Olfactory
The patient was able to smell the calamansi extract and the choco powder.
CNII – Optic
The patient has 20 – 20 vision.
CNV – Trigeminal
The patient was able to blink, she also responded to light and deep sensation
tests, and wasable to clench her teeth.
CNVIII – Vestibiolocochlear
Webers (+), Rhines (+), AC > BC

A> Readiness for enhanced knowledge

8. Role – Relationship Pattern

 S > The patient verbalized, “Sa ngayon, namumuhay ako independently from my parents.
Binibisita ko sila tatlong beses sa isang buwan. Masaya naman daw sila para sa akin dahil
nagkaroon sila ng anak na mapagkakatiwalaan. Naniniwala kasi sila na mas matututo ako
kung mamumuhay ako ng hiwalay sa kanila. Pero ipinangako naman nila sa akin na hindi nila
ako pababayaan. Siyempre, pinapadalhan ko din sila ng panggastos buwan buwan. Pagdating
naman sa mga kaibigan ko, natutuwaako at nakilalal ko sila. Sabi nila, mabait dawakong
kaibigan. Hindi ko alam kung sinasabi nila yun dahil lagi akong nanlilibra sa pizza hut o
sadya lang. Ang masasabi ko lang tungkol sa pakikitungo ko sa tao ay nagiging masaya ako
pag may mga tao akong nakikita at nararamdaman na alam kong hindi ako iiwan pag
kailangan ko ng tulong. Mga taong handing makidamay sa akin. Sa trabaho ko naman,
importanteng nagagawa ko ng maayus ang mga ito upang hindi saying sa oras.”

O> The patient communicates effectively through her moderate pace of talking and
understandable words. She talks calmly and politely.

A> Readiness for enhanced communication.

D > Coping, family, readiness for enhancement

9. Self -Perception – Self -Concept Pattern

S > Patient verbalized, “Binibigyan ko ng halaga ang aking sarili. Importante sakin na
mananatili ang aking dignidad. Ayaw kong nababalewa ang aking mga hinain at higit sa lahat,
ayokong sinisira ang aking pagkatao.”

O > The patient sits erectly and calm, maintains eye contact, talks in moderate pace with
understandable words and slightly loud voice, mood varies according to questions ask, she’s a
little worried and thought process is good.

A> Readiness for enhanced self-concept

10. Coping – Stress Tolerance Pattern

S > Patient verbalized, “Maraming bagay ang nagdudulot sakin ng stress. Isa dito ang trabaho
ko plus yung manliligaw ko. Ang kulit kasi eh! Pag parang hindi ko na kaya, natutulog lang
ako ara makalimutan ko ang mga ito. Minsan namamasyal ako o ‘di naman kaya ay pupunta
ako sa kaibigan ko.”

O > The patient’s behavior conforms with her mood. Thought process is good.

A> Readiness for enhanced coping.

11. Value – Belief Pattern

S > The patient verbalized, “Sa tingin ko, maraming klase ng mabuti. Naniniwala ako na ang
pagiging totoo ay mabuti. Naniniwala din ako na dapat hindi pinipilit ang sarili. Tama ang
isang bagay kung ito ay nakapagdulot kabutihan para sa lahat. Naniniwala din ako na dapat
huwag ng magsimba kung ayaw talaga dahil mas lalo ka lang magkakasala. Naniniwala ako
na hindi importante ang relihiyon. Sa tingin ko, mas importante ang paniniwala sa Diyos. ”
“Hindi ako naniniwala masyado sa mga pamahiin,” adds the patient.

O > The patient has a Bible with her. Doesn’t do the sign of the cross.

A> Readiness for enhanced religiosity.

 Assessment Nursing Dx Rationale Planning Intervention Scientific Rationale Evaluation
S>
“Masaya naman ako Knowledge deficit
kaya sa tingin ko ay r/t information
malusog ako.” misinterpretation as
manifested by her
“Akala ko belief about being
mawawala din ito healthy.
pag tinulog ko, ‘yun
pala, akala ko lang
hanggang sa maging
ganito na nga to.”
O>
• She’s neatly
groomed with
poor posture.
• Looks tired and
worried.