RESULT OF INTERVIEW WITH SIGNIFICANT FINDINGS A. Interaction Patterns According to the daughter of Aling Adela named Pat-pat, her mother is always busy at work. They (children) are always in-charged for planning activities at home. Sometimes if they are planning to go out as family, Aling Adela is not interested to join, she instead advises her children to b careful and take extra responsible. B. Economic Patterns Aling Adela is the only one who supports and works for her family. Her husband died a couple of years ago from emphysema. Aling Adela work "laundry woman" in their neighborhood. And sometimes work as extra in the farm during harvest of rice. The client wakes up as early as 4:00AM work until 6:00PM. Her eldest daughter Tin-tin admitted that the income of her mother is not sufficient to support them in their everyday needs a as other expenses such as payment for food and education. C. Cognitive Patterns Aling Adela just finished Grade 5 and has difficulty understanding her present condition. She sometimes cries at the corner and always thinks w would happen to her family if she suddenly passed away. List of Possible Nursing Diagnoses Ineffective Airway Clearance Impaired Gas Exchange Ineffective Coping Activity Intolerance Anxiety Ineffective Breathing Pattern Risk of Infection Impaired Social Interaction Knowledge Deficit Anticipatory Grieving Nursing Diagnosis #2_ Subjective, Objective, Measurement: Impaired Role Performance Hopelessness Impaired skin Integrity PRIORITIZATION OF PROBLEM AND CLUSTERED CUES/CLUES: Nursing Diagnosis #1 (Problem and Etiology qualifier secondary to/related to). Subjective, Objective, Measurement:__ Powerlessness Management, ineffective therapeutic regimen Impaired Oral mucus membrane Self care deficit Nursing Diagnosis #3_ Subjective, Objective, Measurement: Example: Ineffective airway clearance related to foreign body in airway as evidenced by: Objective: Ineffective cough

Phlebotomy Essentials
6th Edition
ISBN:9781451194524
Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Chapter1: Phlebotomy: Past And Present And The Healthcare Setting
Section: Chapter Questions
Problem 1SRQ
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RESULT OF INTERVIEW WITH SIGNIFICANT FINDINGS
A. Interaction Patterns
According to the daughter of Aling Adela named Pat-pat, her mother is always busy at work. They (children) are always in-charged for planning
activities at home. Sometimes if they are planning to go out as family, Aling Adela is not interested to join, she instead advises her children to be
careful and take extra responsible.
B. Economic Patterns
Aling Adela is the only one who supports and works for her family. Her husband died a couple of years ago from emphysema. Aling Adela works as
"laundry woman" in their neighborhood. And sometimes work as extra in the farm during harvest of rice. The client wakes up as early as 4:00AM and
work until 6:00PM. Her eldest daughter Tin-tin admitted that the income of her mother is not sufficient to support them in their everyday needs as wel
as other expenses such as payment for food and education.
C. Cognitive Patterns
Aling Adela just finished Grade 5 and has difficulty understanding her present condition. She sometimes cries at the corner and always thinks what
would happen to her family if she suddenly passed away.
List of Possible Nursing Diagnoses
Ineffective Airway Clearance
Impaired Gas Exchange
Ineffective Coping
Activity Intolerance
Anxiety
Ineffective Breathing Pattern
Risk of Infection
Impaired Social Interaction
Knowledge Deficit
Anticipatory Grieving
Nursing Diagnosis #2_
Subjective, Objective, Measurement:
Impaired Role Performance
Hopelessness
Impaired skin Integrity
PRIORITIZATION OF PROBLEM AND CLUSTERED CUES/CLUES:
Nursing Diagnosis #1 (Problem and Etiology qualifier secondary to/related to)
Subjective, Objective, Measurement:_
Powerlessness
Management, ineffective therapeutic regimen
Impaired Oral mucus membrane
Self care deficit
Nursing Diagnosis #3_
Subjective, Objective, Measurement:
Example: Ineffective airway clearance related to foreign body in airway as evidenced by:
Objective:
Ineffective cough
Transcribed Image Text:RESULT OF INTERVIEW WITH SIGNIFICANT FINDINGS A. Interaction Patterns According to the daughter of Aling Adela named Pat-pat, her mother is always busy at work. They (children) are always in-charged for planning activities at home. Sometimes if they are planning to go out as family, Aling Adela is not interested to join, she instead advises her children to be careful and take extra responsible. B. Economic Patterns Aling Adela is the only one who supports and works for her family. Her husband died a couple of years ago from emphysema. Aling Adela works as "laundry woman" in their neighborhood. And sometimes work as extra in the farm during harvest of rice. The client wakes up as early as 4:00AM and work until 6:00PM. Her eldest daughter Tin-tin admitted that the income of her mother is not sufficient to support them in their everyday needs as wel as other expenses such as payment for food and education. C. Cognitive Patterns Aling Adela just finished Grade 5 and has difficulty understanding her present condition. She sometimes cries at the corner and always thinks what would happen to her family if she suddenly passed away. List of Possible Nursing Diagnoses Ineffective Airway Clearance Impaired Gas Exchange Ineffective Coping Activity Intolerance Anxiety Ineffective Breathing Pattern Risk of Infection Impaired Social Interaction Knowledge Deficit Anticipatory Grieving Nursing Diagnosis #2_ Subjective, Objective, Measurement: Impaired Role Performance Hopelessness Impaired skin Integrity PRIORITIZATION OF PROBLEM AND CLUSTERED CUES/CLUES: Nursing Diagnosis #1 (Problem and Etiology qualifier secondary to/related to) Subjective, Objective, Measurement:_ Powerlessness Management, ineffective therapeutic regimen Impaired Oral mucus membrane Self care deficit Nursing Diagnosis #3_ Subjective, Objective, Measurement: Example: Ineffective airway clearance related to foreign body in airway as evidenced by: Objective: Ineffective cough
Nursing Care Plan Formulation
Instructions:
1. Refer to the clinical situation given below;
2. Cluster all cues/clues and make a list of prioritized nursing diagnoses;
3. Formulate a Nursing Care Plan with at least three prioritized (3) diagnoses: Apply PES (Problem, Etiology, Signs & Symptoms fo each nursing
diagnosis)
BIOGRAPHIC DATA:
Name of Client: Adela B. Cruz
Address: 22 Halcion St., Brgy. Panatag, Mandaluyong City
Age: 46
Educational Attainment: Grade 5 (Elementary Level)
Civil Status: Widow
Religion: Roman Catholic
Admitting Diagnosis: Asthma
Chief Complaint: Difficulty of breathing
Attending Physician: Jaycee H. Santos, MD
HISTORY OF PRESENT ILLNESS: On April 3, 2021 Aling Adela experienced difficulty of breathing. She was accompanied by her neighbor at
Zapanta Maternity Hospital and was given nebulization and unrecalled medications, 3 days PTA. Then she was brought again to San Jose District
Hospital due to difficulty of breathing and cough.
RESULT OF PHYSICAL ASSESSMENT (as of April 5, 2021): Client is wearing a "daster", she hasn't taken a bath for 2 days. Client stands 5'1"
and weighs 50 kilograms. Her hair is not combed. Client cannot perform her activities of daily living.
Vital signs take as follows:
BP120/80 mm Hg
RR-32 bpm
PR-88 bpm
T-37.2 °C
Mrs. Cruz's skin is brown in color, no lesion but texture is rough and dry. The nurse recalls that according to Kozier, Fundamentals of Nursing
page 702 implies that the degree to which the skin protects the underlying tissues from injury depends on the general health of the cells, the
amount of the subcutaneous tissue, and the dryness of the skin. Skin that is poorly nourished and dry is less easily protected and none vulnerable
to injury. Adela was also complaining "my skin is itchy, when I scratch it, it whitens out".
• Examination of the skull shows no palpable mass, no lesions, hair are very distributed and black in color with some white strands. Facial
expression due to difficult and labored breathing, there is flaring of nares and dryness of the mucus membrane.
• Chest examination revealed crackles upon auscultation and she uses her accessory muscles of respiration to breathe, forcing the shoulder
girdle upward and causing the supraclavicular fossae to retract on inspiration. Abdominal muscles also aid in her breathing.
• Upper and lower extremities are symmetrical, no lesion, able to do simple extension, flexion, and no audible clicks heard during joint movement.
Active range of motion exercises are not performed because it aggravates the difficulty of breathing.
Transcribed Image Text:Nursing Care Plan Formulation Instructions: 1. Refer to the clinical situation given below; 2. Cluster all cues/clues and make a list of prioritized nursing diagnoses; 3. Formulate a Nursing Care Plan with at least three prioritized (3) diagnoses: Apply PES (Problem, Etiology, Signs & Symptoms fo each nursing diagnosis) BIOGRAPHIC DATA: Name of Client: Adela B. Cruz Address: 22 Halcion St., Brgy. Panatag, Mandaluyong City Age: 46 Educational Attainment: Grade 5 (Elementary Level) Civil Status: Widow Religion: Roman Catholic Admitting Diagnosis: Asthma Chief Complaint: Difficulty of breathing Attending Physician: Jaycee H. Santos, MD HISTORY OF PRESENT ILLNESS: On April 3, 2021 Aling Adela experienced difficulty of breathing. She was accompanied by her neighbor at Zapanta Maternity Hospital and was given nebulization and unrecalled medications, 3 days PTA. Then she was brought again to San Jose District Hospital due to difficulty of breathing and cough. RESULT OF PHYSICAL ASSESSMENT (as of April 5, 2021): Client is wearing a "daster", she hasn't taken a bath for 2 days. Client stands 5'1" and weighs 50 kilograms. Her hair is not combed. Client cannot perform her activities of daily living. Vital signs take as follows: BP120/80 mm Hg RR-32 bpm PR-88 bpm T-37.2 °C Mrs. Cruz's skin is brown in color, no lesion but texture is rough and dry. The nurse recalls that according to Kozier, Fundamentals of Nursing page 702 implies that the degree to which the skin protects the underlying tissues from injury depends on the general health of the cells, the amount of the subcutaneous tissue, and the dryness of the skin. Skin that is poorly nourished and dry is less easily protected and none vulnerable to injury. Adela was also complaining "my skin is itchy, when I scratch it, it whitens out". • Examination of the skull shows no palpable mass, no lesions, hair are very distributed and black in color with some white strands. Facial expression due to difficult and labored breathing, there is flaring of nares and dryness of the mucus membrane. • Chest examination revealed crackles upon auscultation and she uses her accessory muscles of respiration to breathe, forcing the shoulder girdle upward and causing the supraclavicular fossae to retract on inspiration. Abdominal muscles also aid in her breathing. • Upper and lower extremities are symmetrical, no lesion, able to do simple extension, flexion, and no audible clicks heard during joint movement. Active range of motion exercises are not performed because it aggravates the difficulty of breathing.
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