Remedios Trinidad Romualdez Medical Foundation
College of Nursing
OB-Ward Duty Requirements
Abuyog district hospital
• Patient’s Profile
• Laboratory Results
• Physical Examination
• Pharmacology Sheets
• Nursing Care Plans
• Journal Readings
Submitted by:
Dichoso, Lowrence Precious C.
Group G
BSN II-B
Submitted to:
Ms. Joreena Alvaran
Clinical Instructor
March 29, 2010
Patient’s Profile
Interview and Assessment Date: March 29, 2010
Setting: Female Ward Abuyog Hospital
Name: Salanap, Floriana
Age: 50
Date of Birth: December 17, 1959
Birthplace: Abuyog, Leyte
Sex: Female
Civil Status: Married
Occupation: Housewife
Spouse: Salanap, Noel
Occupation: Carpenter
Address: Buntay, Abuyog, Leyte
Religion: Catholic
Race/Nationality: Asian/Filipino
Attending Physician: Dr. Bautista
Source of Information: Client, and her daughter
CHIEF COMPLAINT
“Highblood ako, maiha na inin mga lima ka.tuig na. Tigda nla naglipong an ak ulo
asya guinpaadmit ak ky dere na ngane ak nakakatukdaw.
HISTORY OF PRESENT ILLNESS
The client was admitted last March 26, 2010 at around 8:30 in the morning. Admitted
to the female ward per wheelchair – dizziness noted.
Admission Diagnosis: HCVD
Final Diagnosis: Hypertensive cardiovascular Disease, Diabetes Mellitus, type 2
Symptoms started: 45 years old
Onset of symptoms: Gradual
Often the problem occurs: During afternoon
Exact Location of distress: Head
Character of the complaint: intensity of pain (8 in the scale of 1-10 as the highest is 10)
Activity in which the client was involved when the problem occurred:
Doing household chores and walking
Phenomena or symptoms associated with the chief complaint: dizziness
Factors that aggravate the problem: foods with ginataan and oily foods
Factors that alleviate the problem: leaves of yabana, tanglad, daily exercise
PAST HISTORY
CHILDHOOD ILLNESSES:
The client have had: chickenpox, mumps and measles
CHILDHOOD IMMUNIZATIONS:
Date of last tetanus shot: 1976
ALLERGIES:
No allergies to any drugs, animals’ /insects and to any environmental agents
Type of reaction that occurs: none Reaction treated by: none
ACCIDENTS AND INJURIES:
None
HOSPITALIZATION FOR SERIOUS ILLNESS:
Reason: Hypertension
Dates: 2006, 2009
Course of recovery: 2 weeks or depending if blood pressure is still elevated
Surgery performed: none
MEDICATIONS:
Currently used prescription: Amlodipene, captopril
Over-the-counter medications: none
FAMILY HISTORY OF ILLNES
Parents: Sanchez, Guillerma – at home
Sanchez, Crisanto – cause of death is a illness in the head due to
the nature of the work: carpenter
Grandparents: no data gathered
There is Family history of hypertension and Asthma.
LIFESTYLE
PERSONAL HABITS:
Drinks COLA occasionally, the Amount is 1 bottle of 8 oz once a month.
DIET:
The typical diet is 1 cup rice/meal, vegetables, banana, gabi. Client eats three times
a day and have an afternoon snack of usually bread or kakanin. Mrs. Salanap herself
Cooks and shop for food. They don’t have ethnically distinct food patterns and no
Allergies noted.
SLEEP/REST PATTERN:
Daily sleep: 9:00 PM – 5:00 AM having 8 hrs of sleep everyday
Difficulty sleeping: Sometimes
Remedies used for difficulties: Get ample sleep on the next day
ACTIVITIES OF DAILY LIVING (ADLS):
There are no difficulties experienced in the basic activities of eating, grooming,
elimination, and locomotion. Except during when her head becames painful.
INSTRUMENTAL ACTIVITIES OF DAILY LIVING:
There are no difficulties experienced in food preparation, shopping, transportation;
housekeeping, laundry, and can manage to take her own medications.
RECREATIONAL/HOBBIES:
Exercise by stretching or walking, gardening, cleaning the house, watching TV
SOCIAL DATA
FAMILY RELATIONS/FRIENDSHIPS:
Her relatives that lives near their house usually helps in times of need. The family
was worried on Mrs. Salanap’s situation. Problem on one how to pay the hospital bills
greatly affects the client.
ETHNIC AFFILIATION:
She does not have any health customs and beliefs.
EDUCATIONAL HISTORY:
Studied up to 4th year college.
OCCUPATIONAL HISTORY:
Currently, the client is unemployed.
ECONOMIC STATUS:
The children and her husband are the ones paying for the hospital bills. The client is
in a ward room and the client’s illness presents financial problem because of low
income in the family.
HOME AND NEIGHBORHOOD CONDISTIONS:
They did not adjust the physical facilities at home because it is already safe for the
client. There is availability of neighborhood and community services that met the
clients need.
PSYCHOLOGICAL DATA
MAJOR STRESSORS: financial crisis
USUAL COPING PATTERN: accept and find ways to solve any problems and pray
COMMUNICATION STYLE:
The client was able to verbalize appropriate emotion, uses eye movements, touch,
interacts well with support persons and there is congruence of nonverbal behavior
and verbal expressions.
PATTERNS OF HEALTHCARE
The client’s primary care provider is the doctors on duty on the Abuyog District
Hospital. She does not have a Specialist, no Dentist, and do not consult to a Folk
practitioners. She considers the care being provided adequate and access to health care is
not a problem.
Physical Examination
PROCEDURE NORMAL FINDINGS DEVIATIONS FROM
NORMAL
Physical Development Appears to be stated chronological
age
Behavior Cooperative behavior and attitude
Mood Mild anxiety
Dress Dressed for occasion
Gait Rigid gait with arthritis
VITAL SIGNS
BP 140/90 mmHg
TEMP. 36.5 ᵒC
RR 21 Cpm
PR 106 bpm
SKIN ASSESSMENT
Skin color Varies from light to deep brown
Edema No edema
Skin lesion Some birthmarks, no abrasions
Skin moisture Moisture in skin folds and axillae
Skin temperature Uniform; within normal range
Skin turgor When pinched, skin slowly
springs back to previous state
HAIR ASSESSMENT
Growth over the scalp Evenly distributed hair
Hair thickness Thick hair
Hair texture and oiliness Resilient hair
Presence of infections/ No infection or Infestation
infestation
NAIL ASSESSMENT
Fingernail plate shape Convex curvature;angle 160ᵒ Excessive thinness
Fingernail and toenail texture Pallor (may reflect poor arterial
Fingernail and toenail bed color circulation)
Tissues surrounding nails Intact epidermis
Blanch test or capillary refill Delayed return of pink or usual
color (may indicate
circulatory impairment)
SKULL AND FACE ASSESSMENT
Skull size, shape and symmetry Rounded; smooth skull
Any nodules and depressions Absence of nodules and lesions
Facial features Symmetric
Eyes for edema or hollowness None
Symmetry of facial movements Symmetric facial movements
EYE SRTUCTURE
Eyebrows Hair evenly distributed: skin intact
Eyelashes Equally distributed
Eyelids No discharge, No discoloration
Bulbar conjunctiva Transparent; sclera appears white
Palpebral conjunctiva Shiny, smooth, and pink
Lacrimal gland No edema or tenderness
Lacrimal sac and nasolacrimal duct No edema or tearing
Cornea Transparent, shiny and smooth Neither pupils constricts;
Pupil’s direct and consensual Absent Response on
reaction to light illumination
Both pupils fail to constrict,
Laboratory Results
I. Blood Chemistry
NORMAL VALUES RESULT INDICATIONS
Fasting blood sugar 7.7 mmol/L Increased level; provisional diagnosis of diabetes
(4.1-5.9 mmol/L)
Triglyceride 1.37 mmol/L Normal
(Less than 1.70 mmol/L)
Blood Uric Acid 281 umol/L Normal
(F:155-357 umol/L)
Creatinine (serum) 60 umol/L Normal
(F:53-106 umol/L)
Blood urea Nitrogen 3.30 mmol/L Normal
(2.1-7.1 mmol/L)
II. Hematology
Laboratory Result Normal Values Clinical Significance
WBC Count 10.8 x 10 /L 4.5-11.3 - Normal
Hematocrit 0.93 0.36-0.46 -Increased level; maybe due to dehydration; may reflect a
condition called polycythemia vera that is, when a person has
more than the normal number of red blood cells. This can be
due to a problem with the bone marrow or, more commonly,
as compensation for inadequate lung function (the bone
marrow manufactures more red blood cells in order to carry
enough oxygen throughout your body).
Neutrophils 0.66 0.45-0.65 - Increased level; in response to bacterial infection or
inflammatory disease. Severe elevations in neutrophils may
be caused by various bone marrow disorders, such as chronic
myelogenous leukemia
Lymphocytes 0.13 0.20-0.35
- Normal
Eosinophils 0.01 0.02-0.04 -Decreased level; result of infection.
