Nursing Process Format

I. Biographic Data: Name: PSC Address: Camarin Age: 35y/o Gender: Male Marital Status: Single Room and Bed #: 418-B Chief Complaint: Right thigh mass Diagnosis: Benign Spindle Cell Tumor Attending Physician: Dr. Talens Nursing History A. Past Health History 1. Childhood Illness No Illness 2. Immunizations Complete Immunization 3. Allergies No known Allergy 4. Accidents No accidents 5. Hospitalization 6. 1st Admission 7. Medication used or currently taken o Ranitidine 500mg IV q8 o Tramadol 50mg IV o Diclofenac 70mg q8 8. Foreign travel (when, length of stay) N/A

Religious Affiliation: Catholic

II.

B. History of Present Illness Patient noticed a small 2x1 cm mass on his right thigh. It gradually increased in size, occasionally with pain on heavy exercise, non-tender due to increase in size lead to consult at OPD EAMC, was directed and evaluated hence admission.

C. Family History No history of Asthma, Diabetes Mellitus, Heart problems & Hypertension

III.

Patterns of Functioning A. Psychological Health 1. Coping Patterns Watching Television, sleeping 2. Interaction Patterns Talking to his girlfriend, doing household chores 3. Cognitive Patterns Patient is Active and alert 4. Self-Concept Patient is healthy as he stated. He is assertive and positive with herself. 5. Emotional Patterns Not that expressive but still he can say anything to his girlfriend. 6. Sexuality Active in sexual intercourse

7. Family Coping Patterns Patient has a good coping mechanism through mingling with his neighbor.

Interpretation: Patient is active, healthy and always in a Good condition. Analysis: Patient is healthy.

B. Socio-Cultural Patterns 1. Cultural Patterns Patient believes about Filipino Culture. 2. Significant Relationships He is in a relationship with his girlfriend. Now they are in 4th year now.

3. Recreation Patterns Patient decided to take a bike tour around the neighbor. 4. Environment Good environment inside the house. 5. Economic Budget is always present. They always budget the money for Foods, bills and for house supply.

Interpretation: Filipino culture is much patterned in his daily life.

Analysis: Patient is normal condition. C. Spiritual Patterns 1. Religious Beliefs and Practices Patient is catholic, but not practicing catholic

2. Values and Valuing He still believes in obeying in older people.

Interpretation: Still in a Filipino Culture.

Analysis: Patient is in normal condition.

IV.

Activities of Daily Living ADL 1. Nutrition Before Hospitalization

Patients diet consisted of energy giving food such as rice, bread and green leafy vegetables. Likewise, client has also stated that he does not consume much of meat but more on fish and vegetables.

During Hospitalization
Depending on the food, the hospital has given.

Interpretation and Analysis When client started to feel the symptoms of his disease, mostly to the pain, he lost her appetite and became weak.

2. Elimination 3. Exercise

Frequency of bowel movement and voiding pattern is normal.

Frequency of bowel movement and voiding pattern is normal.

Patients Elimination is normal.

Due to the condition client is in limited range of motion to do full body exercises.

Patients exercise is walking and biking. Patient is always taking a bath. Twice to thrice a day. Patient is not taking any drugs. Patient has adequate sleep.

Patients exercise is walking. Patient is taking a bath every day. Patient has only medication when he undergone operation. Has 6-7 hours of sleep a day.

4. Hygiene

Patient is always in good practices. Patient is not a substance abuse. Patient is in normal is sleep and rest.

5. Substance Abuse 6. Sleep and Rest

V.

Physical Assessment Normal General Appearance 1. Posture/ Gait 2. Skin Color 3. Personal Hygiene/ Grooming 4. Nutritional Status 5. Age Appropriateness 6. Verbal Behavior 7. Non-verbal Behavior Measurements 1. Temperature 2. Pulse Rate 3. Respiratory Rate 4. Blood Pressure 5. Weight 6. Height Actual Findings Interpretation and Analysis

Body Part (Technique Used)

Normal
Warm and equal bilaterally Skin surfaces nontender Texture is smooth, even and firm except where there is significant hair growth

Actual Findings
Warm and equal bilaterally Skin surfaces nontender Texture is smooth, even and firm except where there is significant hair growth Wound dressing is present No signs of bleeding Nail has a pink cast due to light complexion Capillary refill in 2 seconds Surfaces are rounded. Nail with uniform nail thickness; no splintering. None clubbed nails.

Interpretation and Analysis

The clients skin in observation is at normal condition or at healthy state.

Skin
Palpation

Inspection

Nails
Inspection

Hair
Inspection

Skin is uniform whitish pink or brown color No bleeding Have a pink cast in light skinned and brown at dark skinned Capillary refill (Should return to normal 2-3 seconds) Surface is slightly rounded or flat. Curved nails are normal. Uniform nail thickness throughout; no splintering or brittle edges. Black to pale blonde; may turn to gray or white; and chemically changed Terminal hair found in the eyebrows, eyelashes, scalp, axilla or in genital areas after puberty Hair may be thin, straight, coarse, curly or thick. Shiny or resilient. Generally round, with prominences in the frontal and occipital area. No tenderness noted upon palpation. No signs of infestation or lesion Seborrhea/dandruff may be present Equal palpebral fissure Symmetrical and in line with each other.

The patients nail looks normal and healthy.

Hair appears to be black in color Terminal hair at eyebrows, eye lashes and scalp are present.

The clients hair is normal and at healthy state.

Palpation

Hair is thick with soft waves and Shiny Symmetrical facial movements and features -No tenderness -No edema Anteriorly smooth, soft and flat. No infestations or lesion present. No dandruff present The clients skull is normal and at healthy state.

Skull

Scalp
Inspection

The clients scalp and hair is normal and at healthy state.

Eyebrows
Inspection

Symmetrical -Black in color

The clients eyebrows is normal

Eyelashes
Inspection

Eyelids
Inspection

Conjunctiva
Inspection

Nose and paranasal sinuses

Inspection

May be black, brown or depending on race. Must be evenly distributed. Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes are open. Meets completely when eyes are closed. Symmetrical. Both conjunctivae are pinkish or red in color. With presence of many minutes capillaries. Moist. No foreign objects Symmetrical; midline of the face Without swelling, bleeding, lesions, or masses. Each nostril patent. No pain during palpation

Equally distributed Slightly curled No discharge No discoloration Lids close symmetrically

The clients eyelashes is normal The clients eyelids is normal

Pinkish in color Moist

The clients conjunctiva is normal

Palpation

Symmetrical; located at midline of the face. No swelling, bleeding, lesions or masses Patent both nostrils No pain or discomfort

The patients nose is normal.

Lips and oropharynx

Inspection

Lips and membranes pink and moist with no lesions or inflammation. Symmetrical; moves freely. Gums have pale-red strippled surface. No swelling or bleeding. Tongue is midline. Pink, moist, rough without lesions.

Lips and membranes are moist, dark flesh colored; no lesions or inflammation Tongue in midline and moves freely Gums have pale -red in color No swelling or bleeding Tongue in midline and moves freely

The patients mouth is healthy.

Gums and Teeth

Inspection

The patients gums are healthy.

Tongue
Inspection

The patients tongue are healthy.

Neck
Inspection

Symmetrical with head in central position Able to move head without discomfort or noticeable limits Muscles should be symmetrical without palpable masses or spasms

Symmetrical with head in central position Able to move head w/o discomfort

The clients neck is normal.

Palpation

Symmetrical with no edema or palpable masses or spasms

Abdomen
Inspection

Abdominal contour flat or rounded Uniform in color or pigmentation No organ enlargement palpable, or any masses, bulges, or swelling

Abdominal contour rounded Uniform in color

The clients abdomen is normal.

Palpation

No friction rubs/or palpable enlargements

Extremities
Upper extremities Inspection Without lesions, scar, or inflammation No edema The clients upper extremities are at good condition and no complications.

Without lesions, scar, or inflammation No edema is present

Palpation

Lower extremities Inspection

scars

Without lesions or Wide range of motion

Lesions or scars not present Limited range of motion No edema Loss of sensation and numbness on both legs is present

The clients lower extremities are at good condition and no complications.

Palpation

No edema Absence of numbness