METROPOLITAN MEDICAL CENTER,

COLLEGE OF ARTS, SCIENCE AND TECHNOLOGY

1357 G. MASANGKAY ST. COR. MAYHALIGUE STA.CRUZ, MANILA

SUBMITTED BY:
GALES, VERJANE JOY CYROS M.
III-BB/BB3

SUBMITTED TO:
MS. DELA CRUZ
 NURSE PATIENT INTERACTION

ORIENTATION PHASE

NURSE PATIENT TECHNIQUE ANALYSIS

01. Magandang Magandang Umaga Acknowledging We acknowledge by

Umaga po. din means of greeting
the client.
02. Ako po si
Verjane Joy Cyros
M. Gales ako po Giving Information Introducing Self to
yung magiging Ah gnon ba. the client
student nurse niyo
sa araw na ito.
03. Nandito po
yung Clinical Okay Giving Information Telling the patient
Instructor namin that I’m with my
para mag obserba sa Clinical Instructor to
amin. observe.

WORKING PHASE

NURSE PATIENT TECHNIQUE ANALYSIS

01. Good Morning
po ulit. kukuha lang O sige Acknowledging Acknowledging by
po ako ng Body greeting and by
Temperature ni telling them that we
mam. are going to take the
vital signs of the
patient.
02. Wala naman po. May lagnat ba siya? Giving Information Telling the daughter
Normal po yung Ah ganon ba of the patient that the
Temperature niya. temperature is
normal.
03. Maam maari po Asking a permission
bang magtanong O sige Providing General if we can ask
patungkol kay mama leads something about
niyo. Mrs.villanueva
Naku walang bisyo
04. Nainom po ba si yan sa buhay niya ni Using open ended Is the patient is a
mamo kaya softdrinks nga di yan Question smoker.
naninigarilyo? nainom eh. tsaa lng.
 05. ilan po ba 4 kaming Seeking Clarifying how
kayong magkakapatid 3 Clarification many siblings does
magkakapatid? babae, 1 lalaki Mrs. Villanueva
have.
06. Ano pong Bumaba yung sugar
dahilan kung level niya, wala na
bakit ninyo gana kumain Using open ended To determine if
dinala si Mrs. Question what is the chief
villanueva? complaint.
07. Ito po ba
yung unang Oo ito yung unang Asking if this is the
pagkakataon na pagkakataon. Using open ended first time he admits
dinala niyo Question in the hospital.
siya sa
hospital?
08. Ano pong
sakit meron sa Wala naman akong Giving Information Asking what
pamilya ng alam na may sakit particular disease
mother niyo? sa family ni mama. that family have.
03. Mam may
karaniwan po Kain lang ng kanin Using open ended What are the
bang ginagawa tapos minsan nag Question hobbies of the
si mam mga jojogging sila ni client?
hobbies po kuya sa luneta.
niya

TERMINATION PHASE

NURSE PATIENT TECHNIQUE ANALYSIS

1. Mam
Salamat po.
babalik We clarify that
nalang po O sige! Clarifying Time or after 2 hour we
ako sequence will come back to
pagkalipas take the patients
ng vital signs.
dalawang
oras.
 02. Salamat po
pala sa Wala yun Summarizing and We gather
impormasyon na Planning information about
sinabi ninyo the patient.
tungkol kay Mrs.
Villanueva
03. Maraming We acknowledge
Salamat po sa Walang anuman Acknowledging the time she has
pakikikooperasyon given us.
niyo sa amin.
 BIOGRAPHIC DATA:

NAME: Villanueva, Fructusa Guan

ADDRESS: 968 masinop st. Tondo, Manila

BIRTHDAY: 11-16-1932

BIRTHPLACE: Sorsogon

RELIGION: Catholic

NATIONALITY: Filipino

MARITAL STATUS: Married

ADMISSION NO: 97811-001

ADMISSION DATE: December 07, 2009

ADMISSION DIAGNOSIS: Hypoglycemia

ATTENDING PHYSICIAN: Dr. Jaime Filardo Cayetano

HISTORY OF PRESENT ILLNESS:

The patient was admitted in Metropolitan Medical Center last December 07, 2009 with an admitting
diagnosis of Hypoglycemia.

PAST HISTORY:

Mrs. Villanueva verbalized “ di ko na maalala kung kumpleto ako ng bakuna ko” and has no allergies
to any drugs, animals, insects or other environmental agents.
This is the first time that the patient was hospitalized.

FAMILY HEALTH HISTORY:

The family has no known disorder except according to his daughter “ wala naming nababanggit si
mama na sakit na meron sila “; She has 4 siblings 1 boys and 3 girl
 LIFESTYLE:

The patient usually drinks coffee and soft drinks but not a alcoholic drinker and non-smoker person.
He likes to eat vegetables, meat, fish etc... And has a sleep pattern of 7-8 hours. Every Sunday Mrs.
Villanueva and his son go to luneta to go jogging.

SOCIAL DATA:
Mrs. Villanueva is a housewife. When it comes from paying the hospital bill it is self-pay with phil.
Health card.

PATTERNS OF HEALTH CARE:

They don’t have family physician, they only seek to a doctor if they have problem
regarding health. When having a fever, cough and colds their pattern of health care is self
care and self medication.
 REVIEW OF SYSYTEM:
SKIN:
There is no fever, warm to touch
HAIR:
Short and thin hair

HEAD:
Q: “Mam, hindi po ba masakit yung ulo ninyo o kaya naman nahihilo?
A: “Hindi naman ako nahihilo o kaya sumasakit yung ulo.As verbalized by the patient

EYES:
Q: “Hindi po ba Malabo yung mata niyo?”
A: “Hindi naman, normal lang naman yung mata ko.” As verbalized by the patient.

EARS:
Q: “Wala naman po bang problema sa pandinig ni mam?”
A: “.Hirap na sa pandinig si mama kelangan isisigaw mo pa sa kanya yung sasabihin mo” As
verbalized by the daughter of the patient

NOSE:
Q: “Hindi po ba nahihirapan huminga o kaya naman meron pong sipon si mam?”
A:”Inuubo siya, yun lang naman” As verbalized by the daughter of the patient.

MOUTH AND THROAT:

Q: “ Wala naman pong dinadaing na masakit sa banding laluman si mam?
A: “ Hirap siya lumunok” as verbalized by the daughter of the patient

NECK:
Q: “May sumasakit po ba sa leeg ni mam?
A: “Ay wala naman din” as verbalized by the daughter of the patient.

.
RESPIRATORY:
Q: “Hindi naman po ba nahihirapan huminga si mam?”
A: “wala naman siya sinasabi pero may ubo siya” as verbalized by the daughter of the
patient.

CARDIOVASCULAR:
Q: “Wala naman po bang masakit sa bandang puso ni mam?”
A: “Wala naman nararamdamang na sakit si mama” as verbalized by the daughter of the
patient.

GASTROINTESTINAL:
Q: “Hindi naman po sumasakit yung tiyan ni mam?”
A: “Hindi naman din” as verbalized by the daughter of the patient

MUSCULOSKELETAL:
Q:
A:
ENDOCRINE:
Q: “Nahihirapan po ba kayong umihi?”
A: “Hindi malakas nga umihi yan si mama eh, nakaka pitong beses siya kung umihi” as
verbalized by the daughter of the patient
 PHYSICAL ASSESSMENT
The part of the health assessment representing a synthesis of the information obtained in a physical
examination. It involves the detailed examination of the body from head to toe using the techniques of
observation/ inspection, palpation, percussion and auscultation

GENERAL SURVEY:

Physical Examination was done last December 08, 2009. The patient was on bed, conscious. She was
wearing a hospital gown. The patient admitted in the hospital because of the admitting diagnosis of
hypoglycemia.
VITAL SIGNS:

1600H
T 36.5
PR 75
CR 78
RR 18
BP 110/70

Body Technique Normal Abnormal Analysis

Parts Findings Findings
Skin Inspection Color good, None Normal
warm and fair
complexion,
moist, there is
no skin lesion.
Head Inspection Symmetrical None Normal

Hair Inspection Black, short None Normal

Palpation hair in length
smooth hair.
Distributed
hair
Eyes Inspection Black Color None Normal
the iris and has
normal vision.
Ears Symmetrical to Difficulty in Abnormal
Inspection the size of the hearing
head.
Nose No discharge None Normal
Inspection in the nose
Neck Palpation There is no None Normal
Inspection lymph nodes

Inspection Regular chest None Normal

Thorax/ Normal
Lungs Palpation Breathing

Abdomen Inspection Brown skin None Normal

Palpation
Lower Palpation Abnormal
extremities Inspection