“………”

An Individual Nursing Process

Presented to the Faculty of College of Nursing
Of Manila Doctors College
Pres. Disodado Macapagal Blvd. Pasay City

In Partial Fulfillment of the Requirements

For the Subject of RLE Class

Submitted By:

GROUP 13
Espiritu, Nephritery Joy
Esta, Pauline
Gaudiel, John Paul
Hilario, Kristine
Hortaleza, Lorenzo Ilham
Lagasca, Jennifer
Licay, Jane Xyreel
Maluya, Jason
Martinez, Ton Edric
Mercado, Kristabell
Pelayo, Dianne Kashmir
Reyes, Carmela Frances

Submitted To:
Ms. Evelyn Falguerra
Mr. Cadiz

Date Submitted:
March 23, 2010
 NURSING PROCESS

I. ASSESSMENT

A. General Data

Patient’s initials: R.D.D Informant: (mother) C.M.D

Address: Manila Date of Admission: 03-22-10
Age: 1 y.o Order of Admission: carried by mother
Sex: M No. of Days in this hospital: 1
Date of Birth: 03-08-09
Civil Status: N.A.
Occupation: N.A.

B. Chief complaint: mother of patient verbalized “tatlong araw na kasing namumula yang
mata niya eh tapos mga apat na araw nang may sipon at ubo kaya dinala ko na dit0.”

C. History of present illness

1 week PTA, neighbors of patient had sore eyes

4 days PTA, mother of patient noticed discharge from patient’s nose. She also heard her son
coughing. She gave ambroxol to patient 2.5 ml bid since this was the medicine prescribed to the
patient when he had pneumonia.

3 days PTA, mother of patient noticed redness of patient’s eyes. She then asked for some eye
drops from their neighbors (generic or brand name of eye drop unrecalled). She applied it to her
son’s eyes.

1 day PTA, persistent cough and colds were observed by the mother. Redness of the eyes
worsened and presence of excessive discharge was noticed. This prompted the mother to bring
her child to the health center the next day, hence patient was examined.

D. Past History

1. Childhood – pneumonia (january 2010)

2. Adult – N/A
3. Immunization – complete (BCG, DPT 1,2,3, HPV 1,2,3 OPV 1,2,3 AMV)
4. Previous Hospitalization – pneumonia (january 2010)
5. Operations – None
6. Injuries – None
7. Medications taken prior to confinement
a. ambroxol
8. Allergies – Not known
E. System Reviews

1. Health perception – Health Management

Prior to confinement, patient was fed by formula milk. “ huling sakit niyang anak ko,
pneumonia. Nung january lang yun.” As verbalized by the patient’s mother. The mother was the
only one who takes care of her for her father whole day everyday. Due to prior knowledge
regarding pneumonia, she administered ambroxol to patient when she noticed that her son has
cough and colds. She also administered eye drops (which she borrowed from their neighbors) to
the patient.

Upon confinement, patient was still fed by formula milk(Bear Brand). Her mother is still
the one taking care of her. She doesn’t leave her son’s side.

2. Nutritional Metabolic Pattern

Prior to confinement, patient was fed by formula milk (Bonamil). When he was 6
months, the mother shifted to Bear Brand. Mother verbalized “malakas yan dumede, kaya nga
mataba eh. Mga nakaka anim hanggang pito yan ng bote sa isang buong araw.”

Upon confinement, mother verbalized, “naku medyo lumonti ang pagdede niyan. Mga
nakaka lima nalang yan sa isang araw.”

3. Elimination pattern

Prior to confinement, patient’s diaper was changed 6-7 times a day. He passes out stool
every 1-2 hours after feeding. His stool is light yellow and soft but solid. He has pale yellow
urine.
Upon confinement, based from the mother’s statement, the client defecates 4-5 times
daily. His mother changes his diaper 4-5 times a day. His usual urine amounts to 100-200 cc per
changing of diaper.

4. Activity exercise pattern

Prior to confinement, when patient’s mother was asked about the child’s activity at home,
she answered, “malikot yan! Lagi lang bungisngis. Hindi naman yan iyakin eh. Ngayon lang kasi
nga masama pakiramdam.”

Upon confinement, patient is often lying on bed or carried by mother. Patient’s mother
verbalized,”Hindi na masyado yan nakikipaglaro tulad dati kai nga siguro dahil masama ang
pakiramdam. Iritable yan, konting inis lang iiyak yan.”

5. Cognitive-Perceptual pattern

Prior to confinement, patient responds to verbal and pain stimuli, “ bibo yan. Alam niya
pag tinatawag mo siya. Pag kinagagalitan yan iiyak din.” as verbalized by the mother. Also
according to her, the patient responds to pain stimuli as verbalized, “siyempre pag makulit,
pinapalo ko minsan sap wet pero mahina lang. siyempre alam niyang pinalo ko siya, iiyak.
Nakakatawa minsan.”

Upon confinement, patient still responds to both verbal and pain stimuli. Mother
verbalized “mas medyo sensitive lang siya ngayon sa sakit, lalo pag natatamaan yung mata niya,
umiiyal yan agad.”
 6. Sleep-rest pattern

Prior to confinement, patient often sleeps. “ kung hindi yan naglalaro, kumakain yan.
Kung hindi naman kumakain, tulog yan. Mga alas sais palang tulog na yan tapos magigising yan
ng alas singko ng umaga tapos tulog ulit yan ng mga alas nueve o alas diez, gigising ulit ng alas
doe. Matakaw yan sa tulog yang batang yan.“

Upon confinement, patient is often lying on bed or carried by mother, awake. “Lagi ito
nagpapabuhat, pag nilapag mo iiyak, siyempre may dinadaing kasi kaya siguro gusto lagi lang
binubuhat. Medyo hirap na siya makatulog, minsan putol putol yung tulog lalo sa hating gabi,
pati ako nagigising siyempre” as verbalized by the mother.
7. Self-Perception pattern

Patient is 6 months old (not assessed)

8. Role-Relationship pattern

Prior to confinement, patient was usually a jolly child. “Lagi yang tumatawa,
nakikipaglaro sa akin o kaya sa mga kapit-bahay namin.” As verbalized by patient’s mother.

Upon confinement, the informant verbalized “tumatawa pa rin naman yang anak ko,
nakikipaglaro pa din pero di tulad dati na parang walang kapaguran, irritable na kasi siya ngayon
dahil nga siguro sa ubo’t sipon niya pati na yung mga mata niya/”

9. Sexuality-Reproductive pattern

Patient is 6 months old (not assessed)

10. Coping stress tolerance

Prior to confinement, patient usually sleeps to cope up with stress. Patient’s mother
verbalized, “pag tapos niyan makipaglaro, lalo pag pinadede natutulog na agad yan. Yun, dun
niya binabawi lakas niya. Tapos pag gising bungisngis nanaman.”

Upon confinement, “ayan, lagi lang nakahiga o di kaya nagpapabuhat, dun nalang siguro
niya binabawi yung lakas niya.”

11. Values-Belief pattern

Prior to confinement,” Lagi yan kasama sa simba namin tapos sa gabi katabi ko yan
nagdadasal.” As verbalized by patient’s mother.

Upon confinement, “siyempre lagi ko naman pinagdadasal yang anak ko, ayoko kasing
nakikitang nahihirapan siya.”