NURSING ASSESSMENT II

Name of Patient: Nida Rakim Age: 48 years old Sex: Female

Chief Complaints: Chest pain due to abdominal enlargement Inclusive Dates: Oct.9-11

Impression/Diagnosis: Massive ascites 20 liver cirrhosis 20 Hep. B infection Allergies: None

Date and time of Admission: October 4, 2017__________________ Diet:Diet As Tolerated
Type of Operation (if any):________________________________

Normal Pattern Before Hospitalization Initial (loading) Clinical Appraisal

(typical pattern) Day 1 (first day of duty) Day 2 (second day of Day 3 (third day of
duty) duty)
1. Health Perception-
Health Management a.) Patient a.) Patient a.) Patient a.)Patient reported that she a.)Patient reported that
a. Perceived perceived her reported pain in reported that “dli is now more okay with her she is worried because
health status sya kaginhawa ug
health status as her chest while condition.
b. Perceived healthy despite lying down. tarung”
b.)Lying- on bed, restless
health management her abdomen. b.) Lying-on bed, restless
b.) Sitting on b.) Sitting on
c. Healthcare b.) Resting/s the side of the the side of the c.)
Behaviors: health leeping and eat bed, restless bed, restless c.)
promotion and healthy foods.
illness prevention c.) Patient is c.) Patient is
activities, medical c.) Doesn’t worried that she worried about her
treatments, follow-
up care do follow up can’t sleep well. chest
check-up
2. Nutrition-Metabolic a.) Ration ( w/c consists of 1 rice, a.) Has eaten only energen and a.)She only take coffee as her breakfast a.Only coffee and only consume
a.) She always eat fish,
a. Daily food vegetables & beef and drinks banana and vegetables) and drank drank only 3 glasses of water. and only drinks half of the mineral water. only half of the mineral water.
and fluid 8 glassses of water every 3 glasses of water.
consumption b.)Doesn’t have food preferences. b.)Doesn’t have food preferences. b.) Doesn’t have food preferences.
day.
b. Food b.)Doesn’t have food preferences. preferences
c.)Doesn’t use dietary supplements. c.)Doesn’t use dietary supplements. c.)Doesn’t use dietary supplements.
c. Use of b.) Doesn’t have food
dietary supplements preferences c.)Doesn’t use dietary supplements.
d.) Presence of skin lesions on her d.)Presence of skin lesions on her both d.) Presence of skin lesions on her
d. Skin lesions d.) Presence of skin lesions on her both of her extremities. of her extremities. both of her extremities.
and ability to heal c.) Doesn’t use dietary
supplements both of her extremities.
e. e.) Her skin is dry, wrinkly and poor e. Her skin is dry, wrinkly and poor skin e.) Her skin is dry, wrinkly and poor
Integumentary e.)Her skin is dry, wrinkly and poor skin turgor. turgor. skin turgor.
d.) There were no
condition skin turgor.
presence of skin lesions. f.)Unrecalled weight & height; T: f.) Unrecalled weight & height; T: 36.30C f.) Unrecalled weight & height; T:
f. Weight,
f.)Weight & Height are not 36.80C 36.10C
height, temperature e.) Her skin is dry, wrinkly
and poor skin turgor. taken/can’t recall; T: 36.70C

f.)Weight, height & temperature

not taken
Patient’s Name / Room No. | 1
3. Elimination
Urinated 4x a day with a Urinated once with a Urinated once presence of Urinated once presence of Urinated once presence of
a. Bowel and
urinary excretion yellowish-red yellowish-red hematuria; didn’t hematuria; hasn’t hematuria; patient has
patterns appearance; micturated appearance; micturated micturated; Patient micutrated; Patient doesn’t micturated only once;
only once a week; there only once brown in color; doesn’t use use laxatives/ routine; No Doesn’t use
b. Perceived
regularity or is irregularity of patient doesn’t use laxatives/routine; No changes in quality or laxatives/routine;
irregularity of elimination; patient is laxatives/routine; No changes in quality or quantity. Presence of little amount
elimination taking furosemide for changes in quality or quantity. of watery stools
her to urinate, they were quantity
c.Use of laxatives or
routines changes in time or day of
her micturition where
d. Changes she always micturated
in time, modes.
once then after 4 days.
Quality or quantity
of excretions

4. Activity Exercise a.Sitting all day, laid in bed a.Sitting all day, laid in bed a.Sitting all day, laid in bed
a.) Usually stays at home a.Sitting all day, laid in bed
a. Patterns
of personally or in her store, cooking,
relevant exercise,
activity, leisure, and
recreation
b.)Walking, eating,
b. Walking, eating, b. Walking, eating, b. Walking , eating, dressing b. Walking, eating dressing
b. ADLs that dressing
dressing dressing
require energy
expenditure
c. Her chest pain and the
c. Her chest pain and the c.Her chest pain and the
c.Factors interfering c.)None water coming out from
c. Her chest pain water coming out from her water coming out from her
with the desired her abdomen
pattern abdomen abdomen.

5. Sleep – Rest a. Slept only for 2 hours

a. Usually sleeps at 8 am a. Slept only for 1 hour a. Slept only for 2 hours a. Slept only for 2 hours and
a. Patterns of sleep a. and
rest-/relaxation in a 24-h and wakes up at 4:30 am
period and rest for 30 minutes. and rest only for 30 rest only for 15 minutes. and rest only for 15
minutes minutes.
b.
b. Can’t sleep well,
Perception of quality and
b. Can’t sleep well, b. Can’t sleep well, irritable
irritable
quantity of sleep and rest irritable b.Can’t sleep well, b. Can’t sleep well,
irritable irritable
c. Doesn’t use sleep aids
c.Use of sleep aids and routines c. Doesn’t use sleep aids
c. Doesn’t use sleep aids. c. Doesn’t use sleep aids.
& routines c. Doesn’t use sleep aids.
Patient’s Name / Room No. | 2
6. Cognitive – a. Patient can’t see clearly, can
a. Patient can’t see clearly, can a. Patient can’t see clearly, can a. Patient can’t see clearly, can a. Patient can’t see clearly, can hear
Perceptual hear clearly, can taste sweet &
hear clearly, can taste sweet & hear clearly, can taste sweet & hear clearly, can taste sweet & clearly, can taste sweet & sour, can
a. Adequac sour, can smell between good sour, can smell between good & sour, can smell between good & smell between good & bad. sour, can smell between good &
y of vision, & bad. bad. bad. b. Reported that she has pain in her bad.
hearing, taste, b. Reported that she has pain b. Reported that she has pain in b. Reported that she has pain in b. Reported that she has pain in
chest. Pain scale of 7/10
touch, smell
in her chest. Pain scale of 6/10 her chest. Pain scale of 6/10 her chest. Pain scale of 6/10 c. Can speak & understand bisaya & her chest. Pain scale of 7/10
and takes a rest to ease the then she only rest to ease the c. Can speak & understand maranao c. Can speak & understand
b. Pain pain. pain. bisaya & maranao bisaya & maranao
perception and
c. Can speak & understand c. Can speak & understand
management
bisaya & maranao bisaya & maranao

c. Languag
e, judgment,
memory, decisions

7. Self-Perception – a. Described herself as a a. Displays optimism that a. Displays optimism that a. Displays optimism that she a. Displays optimism that
Self-Concept
a. Attitudes positive person and she can recover. she can recover and can recover and sometimes she can recover and
about self thinks that she can do sometimes worried. worried. sometimes worried.
anything.
b. Perceive
b. The patient is a bit
d abilities, worth, b. The patient is a bit
self-image, insecure about her body b. The patient is a bit b. The patient is a bit b. The patient is a bit
emotions
insecure about her body
because of her abdomen. insecure about her body insecure about her body insecure about her body
because of her
because of her abdomen. because of her abdomen. because of her abdomen.
c. Body abdomen. c.Weak body posture, can
posture and move independently and c.Weak body posture, can c.Weak body posture, can c.Weak body posture, can
movement, eye c. Good body posture
has a good eye contact. move independently and move independently and has move independently and
contact, voice and despite on her big
speech patterns has a good eye contact. a good eye contact. has a good eye contact.
abdomen, has good
movement and good eye

8. Role- a. Perceived of the idea a. Perceived of the idea on a. Perceived of the idea a. Perceived of the idea on a. Perceived of the idea on
Relationships
on how important is the how important is the on how important is the how important is the family how important is the
a. Perceptio
n of major roles, family to him. family to him. family to him. to him. family to him.
relationships, and
responsibilities in
current life situation
b. Has clear ties with the b. Satisfied by his family’s b. Satisfied by his family’s b. Satisfied by his family’s b. Satisfied by his family’s
b. Satisfact family. care for him. care for him. care for him. care for him.
ion with or
disturbances in
 roles and
relationships

Patient’s
Name / Room No. | 3
 9. Sexuality-
Reproductive a. Patient is satisfied on a. Patient is satisfied on a. Patient is satisfied on a. Patient is satisfied on her a. Patient is satisfied on
a. Satisfacti her relationship with her her relationship with her her relationship with her relationship with her her relationship with her
on with sexuality or husband. husband. husband. husband. husband.
sexual
relationships b. Regular menstruation. b. Regular menstruation. b. Regular menstruation. b. Regular menstruation. b. Regular menstruation.

b. Re
productive
pattern c. Menarche by the age c. Menarche by the age of c. Menarche by the age of c. Menarche by the age of 14 c. Menarche by the age of
of 14 and 14 and perimenopause at 14 and perimenopause at and perimenopause at age 14 and perimenopause at
c. Female
menstrual and
perimenopause at age 30 age 30 age 30. 30. age 30.
perimeno-pausal
history

10. Coping – Stress

Tolerance
a. Patient doesn’t feel a. Patient is slightly a. Patient is slightly a. Patient is slightly stressed a. Patient is slightly
a. Capacit stressed and was able to stressed and wasn’t sleep stressed and wasn’t able and wasn’t able to sleep well stressed and wasn’t able
y to resist sleep well. well due to her condition. to sleep well due to her due to her condition. to sleep well due to her
challenges to condition. condition.
selfintegrity b. Talking with family and b. Talking with family & b.Talking with family &
friends friends. b. Talking with family & friends. b. Talking with family &
b. Methods
of handling stress
friends. friends.
c. Family & friends as her c. Family & friends are her c. Family & friends are her
c. Support
support system. support systems. c. Family & friends are her support systems. c. Family & friends are her
systems support systems. support systems.
d. Described herself as d. Described herself as d. Described herself as
d. Perceived capable & strong. capable & strong. d. Described herself as capable & strong. d. Described herself as
ability to control capable & strong. capable & strong.
and manage
situations

11. Value-Belief
a.)Patient is Islam, a.) Patient is Islam, a.) Patient is Islam, a.) Patient is Islam, believes a.) Patient is Islam,
a. Values,
goals, or beliefs believes in Allah. believes in Allah. believes in Allah. in Allah. believes in Allah.
(including
spirituality) that
guide choices or
decisions b. Doesn’t have conflicts b.) Doesn’t have conflicts b.) Doesn’t have conflicts b.) Doesn’t have conflicts b.) Doesn’t have conflicts
regarding values, beliefs regarding values, beliefs or regarding values, beliefs regarding values, beliefs or regarding values, beliefs
b. Perceived or expectations expectations or expectations expectations or expectations.
conflicts in values,
beliefs, or
expectations that
 are health related

Patient’s
Name / Room No. | 4