West Visayas State University

COLLEGE OF NURSING
La Paz, Iloilo City

NURSING PROCESS
I. VITAL INFORMATION

Name: L.D.D Date of Interview: July 6, 2012

Age: 57 Informant: J.C. and J.A.L.
Sex: Female Relationship to Client: Patient herself
Address: Brgy. Paloc Sool Dumangas,Iloilo
Civil Status: Widowed
Date and Time Admitted:10/28/17;9:00 pm
Chief Complaint: “gasakit akon tyan”as verbalized

Ward:Female Surgical Service Ward

Bed No: 11
Religious Affiliation: Roman Catholic
Physician’s Initials:
Impression/Diagnosis: Gastric Outlet Obstruction 2° to Gastric malignancy c stage 4
liver metastasis
Pre-op Diagnosis:
Post-op Diagnosis:
Surgical operation performed: Frozen Section Biopsy ,Tube Jejunostomy JP Drain
Days Post-op:

II. CLINICAL ASSESMENT

II.A: NURSING HISTORY
1. History of Present Illness
a) Usual Health Status

L.D.D usually wakes up at around 5-6:00 am in the morning to make breakfast for her
children. She is a housewife and usually cleans the house. She doesn’t usually get sick
except for the usual common cold ,fever and flu. During these moments, she would just
take OTC drugs ,take sufficient rest and plenty of fluids. She considers brisk walking as her
form of exercise .L.D.D is a non smoker and a non alcoholic drinker. She is taking amlodipine as
her maintenance medication for her hypertension.
b) Chronologic Story
5 days prior to confinement, L.D.D had epigastric pain ,rated 8-9/10.No
other symptoms felt. She seek medical consult and was given omeprazole
and domperidone which had minimal effect.
2 weeks prior to confinement, L.D.D was admitted at a local hospital for 9
days because of persistence of symptoms. L.D.D. had blood transfusion and
serum potassium correction and was given lactulose. Days after admission,
there was vomiting with greenish in color which recurs intermittently.
5 days prior to confinement, L.D.D consulted a private physician and was
prescribed pantoprazole and buscopan which gave relief and was advised to
undergo colonoscopy and endoscopy. L.D.D complied with the advise. Thus
,this admission.

c) Relevant Family History

None as claimed by the patient.

d) Disability Assessment
L.D.D was not able to do her usual routine/activities of daily living due to her
current condition.

2. Past Health Problems

a. Childhood Illness
(+)mumps
(+)chicken pox

b. Immunization
Unrecalled as claimed.

c. Allergies
None as claimed by the patient.
 d. Accidents and injury
None as claimed by the patient.

e. Hospitalization for Serious Illness

f. Medications

3. Family History of Illness

(+)Hypertension,maternal
(+) Tuberculosis,paternal

4. Patients Expectations
A. What patient expects to occur during the hospitalization

“maayo gd eh.”as verbalized by L.D.D.

B. What patient expects regarding nursing care

“Buligan ko nila.”as verbalized by L.D.D.

5. Patterns of Functioning

a. Breathing patterns
Respiratory problems:None as claimed by the patient.
Usual remedy: N/A
Manner of breathing: effortless and even

b. Circulation
Usual Blood Pressure: 110-130/80 mmHg
Any history of chest pains, palpitations, coldness of extremities, etc.:
None as claimed

c. Sleeping patterns
 Usual Bedtime: 9:00-9:30 pm
No. of pillows:3,approximately 14x19x3 in size,two pillows under her head
and one pillow on her leg
Bed time rituals: Pray
Problems regarding sleep: none as claimed
Usual remedy:N/A

d. Drinking patterns
Total Fluid intake/day:1800-2300ml/day
TYPE OF LIQUID AMOUNT (ml)
Water 1500-2000 ml
Coffee 300 ml

TOTAL: 1800-2300 ml

e. Eating patterns
MEAL USUAL FOOD TAKEN TIME

6:00-7:00
Breakfast 1 cup of coffee,5 pieces pandesal
am

11:30-12:00
Lunch 1 cup of rice,1 medium sized bowl of vegetables,2-3 pieces
noon
of fish

1 cup of rice,1 piece chicken 7:00-8:00

Dinner
pm

2-3 pcs banana cue 3:00-4:00

Snacks
pm

Food likes: pizza and fries

Food dislikes: talaba

f. Elimination patterns
1. Bowel Movement
Frequency: 2/day

Problems or difficulties: None as claimed

Usual remedy: N/A

 2. Urination
Frequency: 3-4/day

Problems: None as claimed by the patient

Usual remedy: N/A

g. Exercise
L.D.D considers brisk walking as her form of exercise.
h. Personal Hygiene
1. Bath
Type: full bath and half bath
Frequency: twice a day
Time of day: 6:00-7:00 am and 8:00-9:00 pm

2. Oral Care
Frequency: twice a day
Care of dentures:none

3. Shaving
Frequency: L.D.D claims that she does not shave.

4. Use of Cosmetics
shampoo
i. Recreation

j. Health Supervision

III. A. CLINICAL INSPECTION

1. Vital Signs Date and Time Taken:
T=
PR=
BP=
RR=
2. Height:
3. Weight:

4. Physical Assesment
Physical AssessmentGENERAL APPEARANCE:
Awake; lying on bed; wearing gray blouse and gray shorts ;with NGT to gravity drain;with foley
catheter; with JP drain; with IVF of D5NM1Lx8hours @ left metacarpal vein;no distress noted;
relaxed posture ;jaundice noted; cooperative; able to follow instructions; mood and affect
appropriate to situation ; speech understandable and in moderate pace ,clear tone and
inflection ;maintains good eye contact during the conversation; has slight body odor but no
breath odor noted.

A. INTEGUMENTARY SYSTEM
Hair: black, evenly distributed, no infestations noted; Scalp: firm, no dandruff noted, no masses
or lesions noted; Skin: dry and slightly wrinkled, jaundice noted , warm to touch; good skin
turgor <2 sec.; thickened callus noted in palms and soles, no edema noted, moisture in skin folds
and axillae noted; Nails: convex curvature angle of nail plate about 160 degrees ,intact
epidermis; untrimmed, convex-curvature in shape; Nail beds: yellow; Nail plate: smooth, yellow
and translucent.

B. NEURO-SENSORY SYSTEM
Head:Normocephalic;symmetric facial features;no masses or lesions noted.

Eyes:Eyebrows: hair evenly distributed ,skin intact ,symmetrically aligned ,equal movement; Eyelashes:
equally distributed ,curled slightly outward;Eyelids:Skin intact;no discharges noted;no discoloration
noted;approximately 15-20 involuntary blinks /bilateral blinking;Bulbar
conjunctiva:transparent;sclera:yellow;cornea:transparent;details of iris visible;Puplis:black in color;equal
in size;3mm in diameter;round ;smooth border;iris flat and round;PERRLA;Both eyes coordinated;move
in unison;with parallel alignment;able to read newsprint

Ears:Auricles:Color same as facial skin;symmetricslly aligned with outer canthusof eye;mobile;firm and
not tender;pinna recoils after it is being folded;External Ear canal:distal third contains hair follicles and
glands;yellow cerumen noted.

Nose:External nose:Symmetric and straight;not tender;no lesions noted

Throat:Tonsils:pink and smooth;no discharges noted;grade 1

Cranial Nerve How Elicited Normal Response Actual

Observation
CN 1 Olfactory Hold scent Identify scent Patient was able to
under one correctly with each identify the scent of
nostril with the nostril coffee on each
other nostril nostril.
occluded while
the patient
closes his eyes.
Repeat with the
other nostril.
CN 2- Optic Near vision: Ask Near vision: client Patient reads print
the client to reads print 14 of 14 inches
read a inches without distance with
newspaper or difficulty. difficulty without
eye glasses.
 magazine Far vision:20/20
paragraph. visual acuity for
Far vision: right and left eyes.
Use a Snellen’s
chart and check
distance vision.
CN 3,4,5- Six cardinal Both eyes move in a Both eyes of the
Oculomotor, fields of vision: smooth, patient moved in
Trochlear, Ask client to coordinated coordinated
Abducens follow object as manner in all direct manner in all
it moves in the directions. directions. Pupils
six cardinal Pupils equally were equally round
fields. round and reactive and reactive to light
Response to to light and and
light and accommodation. accommodation.
accommodation:
Ask client to
look straight
ahead and shine
light obliquely
toward facial
midline.
CN V- Trigeminal Motor: Motor: Patient was able to
Ask patient to Eyes should blink feel the cotton on
open his mouth simultaneously every part of his
while palpating bilaterally. Patient face.
tempero should chew and
mandibular move
joint. temporomandibular
Sensory: joints.
Stroke patient’s
face lightly with Sensory:
a cotton and Should be able to
instruct patient identify light touch.
to nod each
time he feels the
cotton touching
his face. Touch
the forehead,
cheeks and chin
on both sides of
the face.
CN 7- Facial Motor: Motor: Patient was able to
Ask patient to Able to smile, smile, frown, bare
smile, frown and frown, bare teeth, teeth, puff out
wrinkle the puff out cheeks, cheeks, raise and
forehead, bare raise, and lower lower eyebrows,
teeth, puff out eyebrows, and and close eyes
cheeks, purse close eyes tightly. tightly; All
lips and raise All movements movements
eyebrows. should be symmetrically done.
Sensory: symmetrically done.
Touch the
anterior two- Sensory:
thirds of the Should identify
tongue with taste.
 cotton
applicator
dipped in sugar.
The eyes of the
patient should
be closed and
ask him to
identify the
taste.
CN 8- Acoustic Ask patient to Patient should Patient was able to
repeat repeat whispered repeat whispered
whispered word word from a word “Chicken Joy”
from a distance distance of one at a distance of one
of 1 foot. foot. foot.

CN 9- Observe the Gag reflex must be Intact gag reflex;

glossopharyngeal patient if gag intact. Tongue Patient was able to
reflex is present. without tremors move tongue
Ask the patient upon sticking out without tremors
to move tongue and should move upon sticking out
side to side and freely. and moves freely.
his tongue out
CN 10- Vagus Allow client to Will be able to sip Patient was able to
sip water. water and swallow sip water and
without difficulty. swallow without
difficulty. (Observed
during taking of
medications)
CN XI- Spinal Ask the patient Should be able to Patient was able to
Accessory to turn head move head freely move head freely
against and shrug shoulders and shrug shoulders
resistance. Ask against resistance. against resistance.
the patient to
shrug shoulders
against
resistance.
CN XII- Ask the patient Tongue should Patient’s tongue
Hypoglossal to protrude move symmetrical moves symmetrical
tongue, move it with smooth with smooth tongue
to each side tongue movement movement and
against and bilateral bilateral strength.
resistance of strength.
tongue
depressor.

C. RESPIRATORY SYSTEM
Nose: midline; no lesion and discharges noted; non tender and no masses noted upon palpation;
nasal septum present, intact and no deviation; patent both nostrils; RR=____ bpm; Chest:
Manner of breathing: shallow inhalation and expiration; automatic and effortless, regular and
even, and produces no noise; no deformities; lesions noted on anterior chest; equal movement;
anteroposterior to transverse diameter in ration of 1:2; non tender; tactile fremitus symmetrical
on both sides upon palpation; clear lung fields; full and symmetric excursion, no adventitious
sounds heard upon auscultation.
 D. CARDIOVASCULAR SYSTEM
Neck veins not distended, blood pressure= mmHg; pulse rate= bpm; Peripheral pulses:
Temporal: 51 bpm; Brachial: 92 bpm; Radial: 80 bpm; Apical Pulse= 100 bpm; Capillary refill:
right upper extremities= < 2 seconds; left upper extremities= <2 seconds; right lower
extremities= < 3 seconds; left lower extremities= < 3 seconds; no heart murmurs noted; no extra
heart sounds heard upon auscultation.

E. GASTROINTESTINAL SYSTEM
Lips: slightly moist, slightly dark in color, no lesions or masses noted; Teeth: Upper: 12 present;
Lower: 8 present; Tongue: pink and moist, smooth and protrudes in midline, no lesions or
nodules noted; Throat: Uvula and soft palate in midline; positive gag reflex; Abdomen: rounded,
symmetric with no apparent masses or bulging; Incision site noted on epigastric covered with
dressing approximately:_16cm______; Bowel sounds RUQ-3, RLQ-3, LUQ-4 and LLQ-2
cycles/min.

F. GENITO-URINARY SYSTEM
Urinary bladder: non tender and non-distended as claimed; with Foley catheter and uro bag
attached; color of urine:_________; approximately _____30-50___cc/hr drained.

G. RESPRODUCTIVE SYSTEM
Not assessed.
H. ENDOCRINE SYSTEM
Thyroid: midline, symmetrical, firm, ascends during swallowing; hair present on axillae, upper
and lower extremities, and pubic area; no excessive hair growth or sweating noted; hands and
feet appropriate to body size.

I. MUSCULOSKELETAL SYSTEM
Neck: nontender; muscle strength of 5/5; Upper extremities: symmetric, no deformities, equal
in length, Muscle strength of 5/5 right, 4/5 left; able to perform active ROM; Lower extremities:
symmetric, no deformities, equal in length, no lesions, masses or edema noted; Muscle strength
of 5/5 bilaterally; able to perform active ROM.

J. LYMPHATIC SYSTEM
Lymph nodes non tender and non palpable,
K. HEMATOPOETIC SYSTEM
No bleeding or bruising noted; Positive in Allen’s test; Capillary refill <2 seconds bilaterally on
lower extremities and right upper extremity and <2 seconds on left upper extremity.

III. B. PSYCHOSOCIAL ASSESSMENT

LIFESTYLE INFORMATION

L.D.D is widowed currently residing at Brgy. Paloc Sool,Dumangas,Iloilo .She usually

wakes up at around 5:00-6:00 am. She then drinks her hot cup of coffee and pandesal
and takes a full bath right after.She takes Losartan 50mg and amlodipine 5mg as
maintenance medications to manage hypertension. She doesn’t smoke or drink alcoholic
beverages.
NORMAL COPING PATTERNS
L.D.D copes with her problems by talking over matters with her children.

UNDERSTANDING OF PRESENT CONDITION

“Gin operahan ko kay ga sinakit ang akon nga tyan.” As verbalized by L.D.D

PERSONALITY STYLE

L.D.D is an approachable and cooperative person.

HISTORY OF PSYCHIATRIC DISORDER

None as claimed

RECENT LIFE CHANGES or STRESSORS

She was unable to do her ADL due to her current condition and financial problems.

MAJOR ISSUES RAISED BY CURRENT ILLNESS

“kwarta gd eh.” As verbalized by L.D.D

Mental Status Examination

Appearance:
Neat Clean Disheveled Poor grooming
Erect posture Good eye contact inappropriate make-up
others ___________

Description: L.D.D is wearing a floral dress. L.D.D is neat and clean and with good eye
contact.

Behavior:
Calm Appropriate Restless Agitated Compulsions
Unusual actions others____________

Description: L.D.D is at ease, relaxed and calm all throughout the conversation.
Behaves in a way appropriate to his current condition.

Mood/ Affect:
Appropriate Labile Flat Depressed
Worried Anxious Angry Hopeless
others________

Description: L.D.D’s mood changes during the conversation while affect appropriate
with the mood displayed by L.D.D.When conversing about her problems,she appears
sad but when talking about happy thoughts,L.D.D is also happy.

Thoughts:
Appropriate Low self- esteem Suicidal ideations
Hallucination Delusions Phobias others__________

Description: L.D.D’s thoughts were realistic and appropriate to the situation.

Ability to Abstract:
Impaired: yes no

Description: L.D.D was asked to interpret the saying,”aanhin mo ang damo kung patay
na ang kabayo.”She answered,”waay eh.Pabay an mo nlg.”

Memory:
Impaired recent memory: yes no
Impaired Past Memory yes no

Number of objects able to recall after 5 minutes:5/5

Description: L.D.D was able to remember 5 objects namely pencil ,tree, pillow, bag and
watch .She was able to remember her wedding date and the birthdays of her children.
Estimated Intelligence:
Below average Average Above Average

Description: L.D.D was able to enumerate the 3 former presidents of the Philippines
namely Noynoy Aquino,Ferdinand Marcos and Gloria Arroyo.
Concentration:
Able to focus Easily Distractable
Able to subtract backwards by 7s from 100 until number 93.

Orientation:
Person ∕ Time ∕ Place ∕ Situation ∕

Description: L.D.D was able to identify herself,approximate time of the day,the place
and situation or condition she is in now.

Judgment:
Realistic decision making: yes no

Description: When asked,”Ano imo nga obrahon Ma’am kung my masimhutan ka nga
aso sa sulod sang sinehan?”.She answered,”ma gwa kay basi my sunog.”

Insight:
Good fair poor

Description:L.D.D was asked of her plan after discharge and she answered,”wala mn
ah.mangamuyo nlg ko para mg ayo.”