Guidelines I. Mental status a. State of Mental Consciousness b.

Orientation

Normal conscious, alert and coherent Oriented to time, place, person, and situation

Day 1 (08-15-11) Conscious and coherent with GCS of 14-15. Knows the time of the day, the place where she is, her situation, and knows or distinguishes between the people she had interacted with Understands and answers some questions briefly. Has short attention span, easily gets distracted with people touching her. Understands instructions but sometimes refuses to follow instructions asked to do. She needs further explanation of the procedure in order for her to follow the procedure to be done to her. Can hear clearly on both ears without use of hearing aids. Both eyes are able to see clearly without use of visual aids Can speak and understand Tagalong and Cebuano well. Very sensitive to touch and pain. Feels changes in temperature. Able to smell. Differentiates foul smells and pleasant smells.

Day 2 (08-16-11) Conscious and coherent with GCS of 14-15 Knows the time of the day, the place where she is, her situation, and knows or distinguishes between the people she had interacted with Understands and answers questions asked accordingly Still has short attention span but is more focused than the previous day. Follows and understands the instructions given to her.

c. Intellectual Capacity d. Attention Span e. Ability to Understand

Understands ideas and answers questions Attentive and able to focus Comprehends ideas and instructions being given

II. Status of Special Senses a. Auditory Perception b. Visual Perception c. Speech Perception d. Tactile Perception e. Olfactory Perception

Can hear on both ears Able to see clearly without use of visual aids. Able to speak native tongue fluently. Able to feel touch, pain and changes in temperature. Can distinguish smells

Can hear clearly on both ears without use of hearing aids. Both eyes are able to see clearly without use of visual aids Can speak and understand Tagalong and Cebuano well. Very sensitive to touch and pain. Feels changes in temperature. Able to smell. Differentiates foul smells and pleasant smells.

III. Motor Ability a. Current Mobility

Ambulatory at all times

b. Posture c. Range of Joint Motion

height 139 cm (8-14-11) Able to extend and flex extremities without pain. Good muscle and nerve status None 36.5-37.5 C 16-20bpm, regular Clear breath sounds on both lung fields None None 60-100bpm Regular, strong pulses None

d. Muscle and Nerve status e. Loss of extremities IV. Body Temperature a. Range V. Respiratory Status a. Respiratory rate and character b. Breath Sounds c. Use of Respiratory Aids d. Interference with Respirations VI. Circulatory Status a. Pulse Rate b. Character of Pulse c. Intravenous Fluids VII. Nutritional Status a. Condition of the Buccal Cavity b. Diet

Flat on bed. She prefers not to move on her bed. Limited mobility because of swollen left leg and she is guarding her movements in order not to stimulate pain. Not assessed. Upper extremities are able to move. Can flex and extend arms. But cant move the lower extremities because of pain. Weak muscle strength. none 36.9-37.5C- Afebrile 20-26cpm, regular breathing pattern. Clear breath sounds None None 74-78bpm Weak palpable pulses D5 0.33% NACL @ 78gtts/min infusing well at the Right metacarpal vein Cracked lips; pinkish and moist oral mucosa. With some missing teeth. Diet as tolerated

Flat on bed. Limited mobility because of swollen left leg and she is guarding her movements in order not to stimulate pain. Not assessed Upper extremities are able to move. Can flex and extend arms. But cant move the lower extremities because of pain. Weak muscle strength. none 37.5-38.3C- Febrile 19-24cpm, regular breathing pattern. Clear Breath sounds None None 78-88bpm Weak palpable pulses IVF dislodged as of 6:30 am; phlebitis noted. Cracked lips; pinkish and moist oral mucosa. With some missing teeth. Diet as tolerated

Pinkish, smooth and moist oral mucosa. With complete set of teeth. Diet as tolerated

c. Food Tolerance d. Weight VIII. Elimination Status a. Bowel b. Bladder c. Use of Device IX. Female Reproductive Status a. Age of Menarche b. Pattern of Menses c. Pregnancy d. Vaginal Discharges X. Integumentary Status a. Skin

With appetite 26 kg (8-14-11) Able to defecate daily. 5-30 bowel sounds in 5 minutes. Able to void freely and can produce urine not less than 30cc per hour. None 12 years old Regular; 3-5days every 2830 days cycle None None Soft, smooth and fair skin. With good skin turgor.

With decreased appetite. Selects food she wants to eat. Not assessed. Able to defecate on diaper. Voiding freely; with Diaper None 12 years old Irregular as verbalized by the mother. Sometimes skips a month. LMP- July 12, 2011 None None Fair skin. Good skin turgor except on the left leg which is edematous. Upper left leg circumference is not assessed. left lower leg appears pale and edematous with some scaling of the sole. Long coarse black hair. Not combed properly. No parasites seen. Trimmed nails, pinkish nail beds with CRT of 2-3 secs. Able to sleep 4-6 hours at night. And able to have naps

With decreased appetite. Able to consume of the food served. Not assessed. Not able to defecate during the entire shift. Voiding freely; with Diaper None 12 years old Irregular as verbalized by the mother. Sometimes skips a month. LMP- July 12, 2011 None None Fair skin. Phlebitis noted on the Right hand. Still edematous left leg. Upper left leg circumference is still not assessed. left lower leg appears pale and edematous with some scaling of the sole. Long coarse black hair. Not combed properly. No parasites seen. Trimmed nails, pinkish nail beds with CRT of 2-3 secs. Able to sleep 4-6 hours at night. And able to have naps

b. Hair c. Nails

Clean, evenly distributed hair

Short, well trimmed and clean nails; pinkish nail beds. CRT of 1-3 secs XI. State of Physical Rest and Comfort a. Sleep and rest Pattern Able to sleep for 5-8 hours a day.

b. Presence of Discomfort

None

c. Use of Supportive Aids XII. Emotional Status a. Emotional Reaction

None Emotionally stable, able to express feelings appropriately.

during day time for about 10-20 minutes. Pain felt upon movement of left leg. Increased intensity of pain upon movement and Shows guarding actions when someone is touching areas or body parts near the left leg. Pain scale of 8/10. Pillow under her left foot She is very irritable and hard to talk to. She easily gets mad at someone, especially with her mother. She complains a lot to her mother and is very demanding on her commands. She cries a lot when she is moved in her bed and when her wants were not met. She shows signs of anger towards her situation and expresses herself in that way. She hardly talks to someone else but her family.

during day time for about 30-40 minutes. Pain noted on the Right hand. Pain scale of 5/10. Still feel Pain increasing in intensity upon movement of left leg. Pain scale of 8/10. Shows guarding actions and is very sensitive to touch. Pillow under her left foot Patient is still irritable but not as intense as the previous day. She still cries when she is being moved in her bed.

b. Ability to Relate to Others

Able to relate with others spontaneously and exchange thoughts in a calm manner. Respects the integrity of the person talking to.

She talks to the student nurse when she is asked. She is more cooperative.

Nursing Diagnosis