CHAPTER 1- ASSESSMENT

A. Nursing Health History

DEMOGRAPHIC DATA

Patient M.M. is a 35 years old female, who lives at Sucat, Paranaque City and was born
on May 08, 1981, a Roman Catholic. The information was given by her sister and father
The interview was conducted last July 05, 2016.

CHIEF COMPLAINT

Masakit daw yung tiyan at di na siya makabangon sa kanyang kama. as

verbalized by the clients sister while the patient is asleep.

MEDICAL DIAGNOSIS

Chronic Kidney Disease secondary to diabetic nephropathy Diabetes Mellitus II

HISTORY OF PRESENT ILLNESS

Prior to admission patient was experiencing dizziness and epigastric pain for 2 days. On
the 3rd day patient M.M. cannot stand nor stand on her bed without assistant and thats the
time they went to a nearest hospital which is Medical Center Paranaque and medical
assistance was given immediately.

HISTORY OF PAST ILLNESS

According to her sister, Patient M.M. already had DM II since 11 years old and she
injects insulin on her own. She stopped going to school (4th year college) when her right
eye got blind because of unexplainable infection. Shed been stroked in 2011 (CVA).
 FAMILY HISTORY

Male - Hypertension -
Female - Kidney Failure -
Patient - Deceased -
Diabetes -

PATERNA MATERNAL
L

No available information
M.M. 59 C.M 52

C.ML 67 L.M. 49

MR. M 41 M.M. 35

Interpretation:
The patient family history shows that her patriarchal side and mother cause of death is
(DM, HPN) that patient M.M. has acquired from them since she was a child.

SOCIAL HISTORY

Patient M.M. smokes 3 sticks of cigarette a day. It started since 1st year college and shes
a heavy alcohol drinker for 19 years.

PERSONS REVIEW OF SYSTEM

PSYCHOLOGICAL:
According to the father of Patient M.M., He sees her daughter as a cheerful and out-going
person. She loves to draw houses, buildings and other majestic architectures of places. She quit
going to school because of her eye due to infection during her teenage days that made her right
eye loss of vision or retinopathy. Despite of disabilities she tries to help some house chores.
Patient M.M. loves to watch Korean movies and stay all night just to finish a 12 Episode drama
movie per day. She loves to go-out and going to malls. Patient M.M. always pray every morning
and prays at night. Shes a devoted daughter of God. Despite of absence of maternal guardian
who died at the age of 49 years old. Patient M.M. is still happy and looking forward to every
chapter of her life.

ELIMINATION

Patient M.M. has a foley catheter inserted which made her easily to eliminate her urine output
and to avoid bladder distention and defecates at least (2x) twice a day.

REST AND ACTIVITY

Patient M.M. had decreased level of consciousness and no rest at all because of the series of
laboratory test and procedure that being given to her. Shes slept in the afternoon for almost 3-4
hours and takes a nap for 1 hour everyday.

SAFETY AND ENVIRONMENT

The patient doesnt have any allergies in food and drugs. Patient M.Ms room is well ventilated
and conducive to be sleep of.

OXYGENATION

Patient M.M. with O2 cannula was ordered because of difficulty of breathing with Respiratory
rate of 14 cpm.

NUTRITION

Patient M.M. was in a strict monitoring caloric diet because of her condition (DM type II) She
needs to limit her blood sugar (CBG = 236 mg/dL) Osteorized feeding was given.

(Limit calorie intake = 1600 kcal)

(Admission weight = 61 kgs. Latest weight during confinement = 55 kgs.)

POSSIBLE NUTRIONAL DIET TO PATIENT WITH DM II

 24 hours Diet recall

Breakfast Lunch Dinner

1 cup of lugaw 1 apple cut into bite sizes 1 cup smash banana
1 glass of water 1 brown rice with steamed 1 boiled egg
chicken 1 glass of water with straw

B. Physical Examination

General Survey
Orientation: Grooming/Hygiene: Posture & Body Odor and
The patient wasnt oriented with
The patient cannot Gait: Breath Odor:
the time, place and person Not No Bad breath
maintain grooming
Mental Orientation:
applicable odor
The patient answers incoherent and proper hygiene.
because the
words to a question being asked
patient was
not able to
 stand nor sit
on its own

Temperature: 37.1o C Pulse Rate: 78 bpm O2 sat: 97% Blood Pressure:

Respiratory Rate: 14
140/80mmHg
cpm

Body Part Normal Findings Actual Findings Analysis and

Interpretation
Skin I: Skin is a uniform Brown skin, uniform
whitish pink or brown, skin color except to
depending on the race, the areas exposed. Abnormal
no odor of
Warm and slightly
perspiration, smooth,
rough to touch, poor
no lesions.
skin turgor
P: Smooth, moisture
Pale skin color
in skin folds; normal
(Pallor)
skin turgor; elastic and
mobile, skin return to
its normal contour
rapidly when pinched,
no edema.
Hair I and P: Uniform in Uniform black hair,
color, hair feel thin, thick smooth and firm
Normal
straight, coarse, thick hair, scalp is pale
or curly, sparse white and moist.
no masses and
dandruff may be
tenderness,
visible, no signs of
lesions on scalp, oily
scalp
P: no masses and
tenderness.
Nails I: Pink nail bed, Pink nail bed, convex Normal
convex in curvature, in curvature, smooth
There are no signs of
smooth texture. texture. variation in the clients
P: Blanch test normal; Blanch test is normal, nails.
prompt return of pink returned of pink color
color in less than 2 in less than 2 seconds
seconds.
Head & Face I: Normocephalic, Normocephalic,
Abnormal
symmetrical facial asymmetrical facial
features, no lesions, features, no lesions,
uniform in color. uniform in color.

P: Smooth, non- Non tender, no masses

tender, no masses or or depression.
depression.
Eyes I: Thick eyebrows, Thick eyebrows,
effective closure of effective closure of
Abnormal
fallen lashes, bilateral fallen lashes, bilateral
blink response, blink response are
eyeballs are seen, eyeballs are
symmetric and firm, symmetric and firm,
coordinated eye coordinated eye
movement movement.
Eyelids: Eyelids: Without
Without redness,
redness, swelling,
swelling, lesions
lesions
Conjunctiva:
Conjunctiva:
pink in color, the
Pink in color, bulbar
lower and upper
conjunctiva is
conjunctiva are clear
transparent with small
and free of swelling or
blood vessels visible
lesion, moist and
in it, no swelling or
smooth in appearance.
lesions are noted.
Sclera:
Sclera:
Sclera is white, with
 small some small Sclera is white,
superficial vessels and without exudates and
without lesion, or lesion or foreign
foreign bodies. bodies
Cornea and lens: Cornea and lens:
Moist and shiny, with Moist and shiny, with
no discharge, no discharge and
cloudiness. irregularities.
Pupil: Pupil:
Equal in size, black, Equal in diameter,
round normal, black, round, about
papillary responses are 4mm in size, papillary
equal when light is responses are equal
shone to the eye. when light is shun to
the eye. The patient
right eye had loss its
vision (Retinopathy).
Ears I: Color same as facial I: Color same as facial
skin, symmetrical, skin, symmetrical, no
Normal
without swelling, drainage and lesions
bleeding, lesions, or are noted.
External auditory
masses, symmetrical
canal, No tenderness
in position, no
when palpated, no
discharge,
External auditory lesion, redness and
canal, no lesion, no swelling, skin is
redness, swelling, intact, mobile and
foreign bodies. Skin is firm, pinna recoils
intact, mobile, firm after it is folded.
and not tender; pinna
recoils after it is
folded.
Nose Symmetrical in the Located at the midline
midline of the face, of the face, no
Normal
without swelling, swelling, bleeding,
bleeding, lesions, or lesions or masses are
masses, each nostril is noted, the nostrils are
patent, color same as patent color same as
facial skin, septum facial skin, no
midline, naresare discharge.
Internal nose:
patent, no discharge
Nasal mucosa is pink,
and flaring, no lesions.
without swelling, and
Internal nose:
Nasal mucosa is pink moist. Nasal septum is
or dark pink, moist, at the midline and
nasal septum is intact without perforation,
and free of ulcers. lesions or bleeding,
Sinus:
dark pink in color.
No evidence of
Sinus:
swelling around the No evidence of
nose, sinuses are non- swelling around the
tender to palpation. noise, non-tender
sinus when palpated.

Noted: Nasogatric
Tubing is inserted
Mouth & Pharynx No foul smell of Slightly dry and
breath, lips and cracked lips.
Mouth sores are
membranes appear
visible on sides.
pink, moist and
smooth with no
evidence of lesions
and inflammation.
Palate:
Hard and soft palate is Not Normal
concave and pink in
 color without lesions,
or malformation, hard
palate has many
ridges, soft palate is
smooth, uvula
positions in midline of
soft palate, no
discharge.
Tongue:
In the midline of the
mouth, pink in color,
moist, rough without
lesion in uniform pink
in color, soft, moist,
smooth texture,
symmetry of contour,
ability to purse lips,
smooth, white, shiny
tooth enamel, pink
gums, moist, firm
texture to gums,
tongue is in central
position, pink color,
smooth, base with
prominent veins,
moves freely.
Neck P: no masses, no No masses, no
Normal
tenderness, muscle is tenderness, muscle is
symmetrical, and no symmetrical, and no
spasm. spasm.
Thorax/Lungs I: Symmetrical chest With an APL diameter.
Chest excursion is
excursion. No
symmetrical
 retraction when No retraction when
breathing, without use breathing
Normal
of accessory muscles
when breathing
No masses or
tenderness, tactile
fremitus, symmetrical
chest excursion.
Cardiovascular/ No chest pulsations, No chest pulsations,
Heart Normal
veins and arteries not veins and arteries are
prominent. not prominent.
No signs of swelling No signs swelling and
and tenderness. tenderness.
Breast & Axilla I: Breast are
.The patient refused to Normal
symmetric, Areola is
be assessed. The patient refused to
Dark brown, Nipples
be assessed
are everted, No
discharges.
P: Absence of masses,
Not tender upon
palpation.

Abdomen I: No visible masses or With no evidence of

lesions, bilaterally. masses or lesions,
Normal
Symmetrical, symmetrical,
umbilicus in midline umbilicus is in
and inverted, no midline and inverted,
pulsations. no pulsation heard.

Burborygmig sounds
was noted upon
auscultation before
NGT feeding
Musculoskeletal I: Equal size on both Scaly on both lower Abnormal
 sides of body; No extremities
contractures; No
tremors with smooth
coordinated
movements and equal
strength on each side
of body.
Genitals Not assessed Not assessed Not assessed
Rectum & Anus I: Intact perianal skin, Not assessed Not assessed
anal sphincter has
good tone.

Neurological Assessment (Glasgow Coma Scale)

Parts Grade Interpretation

Eyes 4/4 Normal
Verbal 5/5 Normal
Motor Response 6/6 Normal
TOTAL GCS 15/15 Normal