C.

ASSESSMENT DIAGRAM

Psychological Developmental Socio-Cultural

Day 1: The client appears lethargic since he is unresponsive The client is Cebuano who speaks Bisaya as his first language. He is
Late Adulthood
due to his current body weakness, abdominal pain, and that he a farmer who lives near a rice field. He serves as the pastor of a Born
Integrity vs. Despair
frequently sleeps majority of the day to cope it. He becomes Again Christian church for the past 20 years. When he feels sick, he
agitated whenever an assessment or vital signs are taken. frequently drinks salabat, which is ginger tean since he learned it
The client finds meaning and purpose in life through the children that he
from his mother way back is childhood. He is not a fan of
and his wife raised well as he verbalized, as well as being a church
Day 2: The client is awake, alert, and responsive. He is hospitalization and expresses his desire not to be hospitalized since
pastor at their local church serving God. He sees the hardships he
conscious of his environment and the people around him. He he stated that back in the days, people do not really go to hospitals
encountered along the way, as well as the bad habits he made in the past,
stated that he just has mild body weakness and that he is open for treatment. He would not go the hospital unless forced by his son.
as something that has made him stronger and wiser over the years. He
to assessments and questions. He claims to be in a good mood His diet frequently includes high-fat meats like pork and chicken
expresses his happiness with what he has accomplished in life. He is
since he is feeling much better. almost every day, especially at lunch and supper.
pleased with how his children have turned out in life. He stated that he
often had regrets about not being able to obtain a degree, but after
watching his children obtain theirs, he feels satisfied that he and his

Respiratory
Patient Information Subjective:
o “Usahay kay maglisod ko og ginhawa og sakit gyud
Name: Mr. Cutie Pie kayo akong tiyan”, as client verbalized.
Age: 62 years old o “Bag-o ko ni anhi diris ospital, medyo nag-lisod kog
Neurologic-Sensory Gender: Male
Subjective: “Kapoy akong lawas pirme”, as client stated. ginhawa”, as client stated.
Civil Status: Married
Objective: Chief Complaint: Body Malaise
o Awake and Alert Objective:
Impression/Admitting Diagnosis: Ascites Secondary to Liver o RR: (02/12/2023)
o Responsive and coherent Cirrhosis; Electrolyte Imbalance, Hypokalemia
o Environmentally oriented 6 PM – 22 bpm
Final Diagnosis: Hypokalemia: Electrolyte Imbalance, Massive
o Episodes of nausea 10 PM – 20 bpm
Ascites Secondary to Liver Cirrhosis Decompensated,
(02/13/2023)
o (+) pain stimuli Hyperuricemia; Hypoalbuminemia.
6 PM -20 bpm
o (+) soft touch stimuli
10 PM – 21 bpm
o Conscious of place and time
o Has ability to follow commands o O2 sat: (02/12/2023)
o GCS- 15 6 PM – 95%
o Shows appropriate facial expressions Reproductive/Sexuality 10 PM – 96%
Subjective: (02/13/2023)
Laboratory & Diagnostic Test: o “Dili na gyud ko active og labing-labing sukad 6 PM -95%
Medications: adtong miaging tuig nga murag dili nako 10 PM – 94%
Gerontological Consideration: Reduced conduction velocity, slower masabtan ang kakapoy sa akong lawas”, as
response and reaction time, decreased brain weight, decreased blood client verbalized. o Chest expansion symmetrical
supply to the brain, and alterations in sleep pattern. o Client was circumcised at age 9 o (+) Nasal flaring
Objective: o (-) Unusual anterior, posterior, and bilateral breath
Laboratory & Diagnostic Test: sounds
Medications:
Gerontologic Factors: Fluid-retaining capacity of seminal Laboratory & Diagnostic Test:
vesicles decreases, sperm count may decrease, venous and arterial Medications:
sclerosis of the penis occurs, and the prostate enlarges in most Gerontologic Considerations: Loss of elasticity and rigidity, decreased
men. ciliary action, reduced forced expiratory volume, reduced basilar
inflation, thoracic muscles become more rigid, and cough and laryngeal
reflexes are blunted.
 Integumentary
Subjective: Cardiovascular
Objective: Subjective:
o CRT : < 2 sec Objective:
o Skin turgor: 3 sec o PR: (02/12/2023)
o Sunken Eyeballs 6 PM – 92 bpm
o Saggy and wrinkly skin 10 PM – 85 bpm
o (+) Bipedal pitting edema +1 (02/13/2023)
w o Hair Loss at the hairline receding backwards 6 PM - 91 bpm
o Pallor palms 10 PM – 88 bpm
o Pupil, equal, round, reactive to light and accommodation
o Visible skin discolorations over arms and legs o BP: (02/12/2023)
6 PM – 100/70 mmHg
10 PM – 110/80 mmHg
Laboratory & Diagnostic Test: (02/13/2023)
Medications: 6 PM – 110/90 mmHg
Nursing Diagnosis: 10 PM – 110/80 mmHg
Gerontological Consideration: Graying and thinning hair, Ectropion of eyelids, Elongated
ears, Reduced muscle mass and skinfold thickness, deepening of axillary hollows and o CRT: < 2 sec
intercostal and supraclavicular gaps, thicker hair in ears and nose.
Laboratory & Diagnostic Test:
o Electrocardiogram:
- HR: 107 bpm
- P: 113 ms
- PR: 153 ms
Hematology - QRS: 89 ms
Subjective: - QT/QTc: 351/470 ms
Objective: P/QRS/T: 56/1/-34
Laboratory & Diagnostic Test: - RV5/SV1: 0.98/1.583 mV
o Hematocrit: 35.7% (37% – 49%) Diagnosis Information:
o Hemoglobin: 11.6 g/dL (14 – 18 g/dL) - Poor-quality Data (VI)
o MCH: 27.8 pg (31 – 37 pg) - Sinus Tachycardia
o Neutrophils: 75% (55-65% - T Wave Abnormality (II, III, aVF)
o Lymphocytes: 20% (25 – 35%) Medications:
o Capillary Blood Sugar: 118 mg/dL (82-120 mg/dL) Gerontologic Considerations: Cardiac output decreases, peripheral blood flow resistance increases
o Prothrombin Time: 15.3 secs (11-16 secs) by 1% per year, vessel elasticity decreases, 02 utilization decreases by 1% per year, stroke volume
decreases by 1% per year, more prominent arteries in the head, neck, and extremities, heart
Medications: pigmented with lipofusion granules, blood pressure rises to compensate for increased peripheral
Gerontological Considerations: Iron deficiency anemia and the anemia of chronic disease resistance and decreased cardiac output.
are the most common types of anemia in the elderly. Nutritional anemias due to folate or
vitamin B12 deficiency are treatable and should not be overlooked.
 Digestive/Gastro-Intestinal
Subjective:
o “Hilig ko og baboy og manok gyud og halosa taga adlaw gyud, naa ras pani-udto or
panihapon nga mao nay sud-an”, as client verbalized Immunologic
o “Nagasuka ko taga human og kaon” as client stated. Subjective:
o “Dili nako ganahan mu kaon og daghan kay mao ra gihapon kay mulaen ako tiyan og e suka, o Chicken pox during 6th grade
wala na gyud koy gana”, as patient verbalized. o Fever 3 to 4 times a year
o Vomiting 4 to 5 times a day o Cough and Cold 2 to 3 times a year
o “Wala gyud ko nakalibang sukad gahapon”, as client verbalized on 02/12/2023. o No known allergies
o “Naka-libang ko kas-a karon nga adlaw pero basa-basa siya”, as client verbalized on o Client was born at home and no recollection of whatsoever immunizations
02/13/2023. during his birth
o Abdominal Pain @ RUQ with Pain Scale of 4/10
o Consumes foods high in fat before hospitalization Objective:
Objective: o T: (02/12/2023)
o Tympanitic Abdomen on 4 quadrants 6 PM – 36.9 °C
o Abdominal Girth: 29 cm 10 PM – 37. 0 °C
(02/13/2023)
6 PM – 36.7 °C
Laboratory & Diagnostic Test:
10 PM – 36.9 °C
o Total Protein: 6.00 g/dL (6.6-8.7 g/dL)
o Albumin: 3.00 g/dL (3.8-5.1 g/dL)
Immunizations:
o Ultrasound Findings: o COVID vaccine (2 doses of Pfizer)
- Massive Ascites o Anti-rabies vaccine during his 30’s
- Liver Cirrhosis o Tetanus Toxoid during his 50’s
- Reactive Cholecystitis
- Mild Splenomegaly
Laboratory & Diagnostic Test:
- Bilateral Renal Parenchymal Disease.
o WBC: 6,170 L (4.0 – 10.0 x 107 / L)
- Sonographically Normal CBD, Pancreas, Abdominal Aorta,
Kidneys, Urinary Bladder, Prostate. o Neutrophils: 75% (55-65%)
Medications: o Lymphocytes: 20% (25 – 35%)
o Lactulose 30cc OD HS o Monocytes: 5% (3 - 6%)
o Omeprazole 40 mg IV OD o Platelet Count: 393,000/L (150 – 450 x 106/L)
o HNBB 20 mg IV NOW THEN q6h PRN FOR PAIN
o Aminoleban 500 cc IV drip for 12 hrs OD x 2 doses Medications:
Gerontologic Considerations: The immune system becomes slower to respond. This
Nursing Diagnosis: increases your risk of getting sick. Flu shots or other vaccines may not work as well or protect
o Imbalanced nutrition: less than body requirements r/t inadequate interest in food AEB by you for as long as expected. An autoimmune disorder may develop.
body weight below ideal weight range for age and gender
o Fluid volume excess r/t compromised regulatory mechanism secondary to cirrhosis of the
liver as manifested by pallor, weak in appearance, edema, irritability, and abdominal girth of
29”
Gerontologic Considerations: Impaired taste sensation, dilated esophagus, decreased saliva and salivary
ptyalin, smaller liver, decreased intestinal bloodflow, decreased esophageal motility, atrophy of gastric
mucosa, decreased stomach motility, hunger contractions, and emptying time, slower peristalsis.
 Metabolism-Endocrine
Genitourinary Subjective: Family hx of Diabetes Mellitus
Subjective: Objective:
“Sukad adtong pirme na gasakit ako tiyan og ga-luya ko, naga ihi-ihi man ko o Weight: 39 kg
ginagmay, pero ginagmay ra pud ang mugawas”, as patient stated.
o Height: 147.30 cm
o BMI: 18.0 (18.5-24.9)
Objective:
o Urine Output of the 8 hour shift: Laboratory & Diagnostic Test:
(02/12/2023) o Sodium: 136.2 mmol/L (135-145 mmol/L)
6 PM – 20 cc o Potassium: 3.19 mmol/L (3.5-4.9 mmol/L)
10 PM – 30 cc
(02/13/2023) Medications:
6 PM – 60 cc o Essentiale Forte 1 tab BID
10 PM – 40 cc
o KCl tab, 2 tabs TID x 6 doses
o Urine Output of 24 hours:
(02/12/2023) – 180 cc
Nursing Diagnosis: Imbalanced nutrition: less than body requirements r/t inadequate interest in
(02/13/2023) – 320 cc
food as evidenced by body weight below the ideal weight range for age and gender, electrolyte
imbalance
Laboratory & Diagnostic Test:
o Sodium: 136.2 mmol/L (135-145 mmol/L)
o Potassium: 3.19 mmol/L (3.5-4.9 mmol/L) Muskolo-Skeletal
o Creatinine: 0.75 mg/dL (0.4-1.4 mg/dL) Subjective:
o SGPT: 6.0 mg/dL (Up to 42 mg/dL) o “Kapoy lingkod, gusto ra ko mag higda pirme”, as client verbalized.
o SGOT 15.0 mg/dL (Up to 37 mg/dL) o The client stated, “Kapoy kayo e lihok akong lawas sir.”
o Blood Uric Acid: 11.0% (3.4– 7.0% mg/dL) o (+) Body weakness noted
o Blood Urea Nitrogen: 20.4 mg/dL (20-50 mg/dL)
o Total Protein: 6.00 g/dL (6.6-8.7 g/dL) Objective:
o Albumin: 3.00 g/dL (3.8-5.1 g/dL) o Normal Gait when walking, no deviations noted
o ROM Upper Extermities: 4 (Good)
Medications: o ROM Lower Extremities: 3 (Fair)
o Febuxostat 40 mg 1 tab OD o Able to move Upper Extremities without assistance and against resistance
o Spironolactone 50 mg 1 tab BID o Able to move Upper Extremities without assistance but with slight problems
o Furosemide 40 mg IV OD with BP precaution against resistance
o (+) Facial grimace when Lower Extremities are pushed against resistance
Gerontologic Considerations: Reduced renal mass size, decreased tubular function, decreased
bladder capacity, decreased nephrons, renal blood flow reduces 53% and glomerular filtration rate Laboratory & Diagnostic Test:
decreases 50% between the ages of 20 and 90, weaker bladder muscles. Medications:
Nursing Diagnosis:
o Acute pain related to liver enlargement secondary to ascites as evidenced by
facial grimace, irritability, restlessness, anxiety, fatigued, agitation, pallor,
guarding of body part and verbalization of pain with a pain scale of 4/10,
decreased in activity tolerance, and fatigue
o
Gerontologic Considerations: Shortening of vertebrae, bones more brittle, slight knee flexion,
loss in bone mass and bone mineral, slight kyphosis, slight hip flexion, slight wrist flexion,
impaired motions of flexion and extension.