ASSESSMENT
GENERAL ASSESSMENT
With an Ongoing IVF of DSLRS 1L × 30ghs 1min @ 100cc level; infusing well
Essentially normal
With good hygiene and good grooming
Looks appropriate with his actual age
Weak in appearance
56.2kg in weight
VITAL SIGNS:
Temperature: 38.1⁰c
Pulse rate: 123bpm
Respiratory rate: 23cpm
O2sat: 97%
MENTAL STATUS ASSESSMENT
ORIENTATION
Oriented to name, place, time and date
SENSORY
Conscious and coherent
SPEECH AND COMMUNICATION
With clear and soft tone voice
No pressured speech noted
No thought alteration
THINKING
With appropriate thinking
MEMORY
Had the ability to recall events
PHYSICAL ASSESSMENT
SKIN
Capillary refill went back immediately
Skin is smooth and warm to touch
Good skin turgor
Skin is dry without lesions noted
With pale complexion
SCALP AND HAIR
Scalp is clean and dry; no lesions inspected
With black hair; no tenderness
Hair is evenly distributed
HEAD AND SKULL
Normocephalic
Head is symmetric, round, erect and midline
No mass, tenderness noted
With smooth skull contour
EARS
Aligned to the outer canthus of the eyes
Equal in size
No lesions, discharge noted
With good hearing acuity
FACE
Eyebrows were evenly distributed
With symmetrical facial movement
No lesions and moles noted
With even skin tone compared to the rest of the body
EYES
PERRLA (pupil equally round reactive to light and accommodation)
With good visual acuity noted
With clear selera noted
NOSE
Mucosa is pinkish in clear
No lesions noted
With poor smelling acuity
MOUTH AND OROPHARYNX
Pale and dry lips noted
No lesions and swelling noted
With complete set of teeth
With good oral hygiene, no foul odor noted
Tongue is reddish, moist and moderate in size
With pinkish and dry oral mucosa
Uvula is at midline and hangs freely with no lesions inspected
NECK
Neck is symmetric with head centered
No bulging masses noted
With normal range of motion
Had the same color to the face
Trachea is at midline
No lesions inspected
CHEST, THORAX, HEART AND LUNGS
There is a massive heterogeneously enhancing lobulated solid mass occupying almost all of the
left hemithorax
Impinging the visualized normal left lung posterior inferiorly and displacing the
cardiomediastinal structures contra laterally
The mass measures about 16.9 x 14.7 x 24.9cm (pxwxcc)
No evident air bronchograms
The pulmonary vascularity is normal
There is no pleural effusion or thickening
No demonstrable pneumothorax
The heart is not enlarges
Minimal pericardial effusion is seen with a thicknessof about 1.0cm
The tracheobronchial airway is patent and normal in caliber
There are no enlarged axillary lymph nodes
The chest wall is intact and within normal limits
UPPER EXTREMITIES
Arms were proportionate to the color and size of the body
Capillary refill went back immediately
With complete set of fingers
With normal range of motion
ABDOMEN
No tenderness and lesions noted
With borborygmi sound noted upon auscultation
GENITOURINARY/ ELIMINATION
Urine color is dark yellow
With normal genital noted
LOWER EXTEMITIES
Non pitting bipedal edema inspected
With complete set of toes
Toenails were clean and trimmed
Able to walk and stand
MASLOW’S HIERARCHY OF NEEDS
PHYSIOLOGIC NEEDS
Provide a wrinkle free bed and cleanliness so that he could sleep and rest well
He loves to eat
He loves listening to music sometimes
On DAT
Ongoing IVF of DSLRS 1L × 30ghs 1min @ 100cc level; infusing well
SAFETY AND SECURITY
Observed 16Rs in preparing and administering prescribed medication
The patient felt safe and secured with the facilities and services provided by the hospital
He felt safe and secured because his family was there, as well as the healthcare professionals
who could care for and attend his needs.
LOVE AND BELONGINGNESS
By the presence of his family, attending physician, nurses on duty and student nurses
throughout his support, affection, and reassurance would be a manifestation that he loved and
cared.
SELF-ESTEEM
Patient had a low self-esteem and prior to his hospitalization he was having mixed emotions due
to his conditions and thinking that he was a burden to his family.
SELF-ACTUALIZATION
He yearned for a faster recovery to be able to assume his role in the family and was looking
forward to regain his full strength and potential to perform activities of daily living.
NURSING MANAGEMENT
IDEAL
Assessment
Assess for symptoms of active disease
Auscultate lungs for crackles
Encouraged deep-breathing exercises
Prevent smoke or stay away from secondhand smoke
Monitor adverse effect
Promote bed rest
Administer prescribed medication
Check patient’s name, types of surgery or procedure and history
Explain to the client that healing and restoration of full strength and mobility may take months
Explained prescribed activities restriction and necessary lifestyle modification because of
impaired mobility
Facilitate home medication
ACTUAL
Assessed vital signs taken and recorded
Safety and security ensured
Repeat FBS in Am
Hook to o2 inhalation 1-2 1pm via nasal cannula
Continue IV medication
For “ E” CTT left @ lung
For C×R PA upright prior to
For chest CT scan with contrast
IVF TF: D5LRS 1L + 2 amps vitamin B. COMPLEX × 10
D5NM 1L + 1 vial amino acids × 8
HEALTH EDUCATION
Encourage to decrease risk by not smoking
Encourage deep breathing exercises
Promote bed rest
Promotes maximal inspiration to enhances lung expansion
Prevent smoke or stay away from secondhand smoke
Advice to take medicine with food to help avoid an upset stomach
Advice to eat a healthy diet like vegetables and fruit
When travelling by a car the use of a safety belt can avoid suffering a blow to the chest
Get plenty of rest and avoid physical activity that may intensify pain or breathing problems.
Instruct to limit his activity so he doesn’t get too tired. Plan frequent rest periods.
