THE NURSING
PROCESS FORMAT
I. PERSONAL DATA
Name of Client : Juan dela Cruz
Address : 1011 Dapitan St., Sampaloc Mla.
Nationality : Filipino
Birthdate : Jan. 3, 1997 Birthplace : Manila
Religion : Catholic Age : 26
Educational Attainment : High School Graduate
Occupation : Cotton Textile Worker
Civil Status : Married Gender : Male
II. ADMISSION DATA
Chief Complaint : cough, shortness of breath
Date of Admission : January 18, 2007
Ward/Room & Bed No. : Medical Ward Rm. 401 Bed 2
Provisional Diagnosis : Asthma
Attending Physician : Dr. Perez
III. NURSING HISTORY
History of Present Illness : Present condition started 3 days PTA with pt. having
respiratory infection, no meds taken, then suddenly
developed shortness of breathing that prompted him to seek
admission.
Past Medical History : No history of childhood disease, hospitalized last year Feb.
2006 due to asthma.
Family Medical History : Father with hypertension, mother with history of food allergy.
Occupational History : Started working 2 years ago as textile weaver at Gentex.
Developmental History : (developmental milestones / tasks for pediatric client).
B. Head –to- Toe Assessment
Body Part Technique Findings Analysis & Interpretation
Chest Inspection Use of accessory Due to marked bronchial
muscles, retraction constriction associated with
RR – fast, labored, asthma
wheezes (+) both
consultation
lung fields
C. Activities of Daily Living
ADL Before During Analysis
Hospitalization Hospitalization Interpretation
Sleeping Pattern Usually retires at Sleep for only 4 hrs With difficulty of
10pm and wakes up and complained of having good
at 5am. Total hrs of inability to sleep adequate sleep due
sleep and rest – 6 to discomfort
hrs a day brought about by
difficulty of
breathing.
VIII. ECOLOGIC MODEL
A. Hypothesis – factors like heredity, occupation, predispose the development of
Asthma but the presence of viral infection lowers the resistance and triggers an
attack.
B. Predisposing Factors:
B.1. Host
a. Age f. Civil Status
b. Sex g. Hereditary – mother with history of allergy
c. Race h. Occupation – cotton textile weaver
d. Lifestyle i. Nutritional Status
e. Resistance – low resistance due to respiratory infection
B.2. Agent
a. Biologic – viral infection d. Mechanical
b. Nutritive e. Chemical
c. Physical – change in weather condition (too cold; too humid)
B.3. Environmental
a. Physical - workplace
b. Biologic
c. Socio-economic
C. Ecologic Model
D. Analysis – agent increases in virulence that make them more powerful than the host
thus causing the disease.
E. Conclusion – precipitating cause is predominantly infection in the lower respiratory tract
and greatly influenced by secondary factors changes in
temperature and exposure to noxious fumes.
F. Recommendation
> General health of the pt. (nutrition) should be considered
> Nonspecific factors in the environment eg. Irritants, change in the temperature should
be avoided
> Avoidance of respiratory infection
IV. ASSESSMENT (PERSON/GORDON MODEL)
V. PHYSICAL ASSESSMENT
A. General Survey
Findings Analysis & Interpretation
Height 5’6
Weight 140 lbs.
Vital Signs :
Temperature 37’c normal
Pulse Rate 100 Increased why?
Respiratory Rate 26/min Increased
Blood Pressure 120/80 normal
VI. LABORATORY AND DIAGNOSTIC PROCEDURE RESULTS
Laboratory / Diagnostic Normal Values Findings Analysis &
Procedure Interpretation
ABG PaCO2 40mmHg 43 mmHg Increased-
respiratory acidosis
due to inadequate
excretion of CO2
due to inadequate
ventilation.
VII. DRUG ANALYSIS
Generic/Trade Action Dosage Indication Nursing
Responsibilities
Salbutamol Short acting Beta 2 1 nebule side effect observe for side
(ventolin) agonist, relax airway every 6 tremor of effect; give the
muscles and hours
skeletal muscle medication
enhance mucociliary nebulization
clearance and slight tachy- observing the
vascular permeability cardia right time, route,
headaches dosage.
IX. Pathophysiology (Schematic Diagram)
Exposure to factors
Amount of acetylcholine
Release of mast cell products
histamine bradykinin prostaglandin
Smooth muscle glands of airway
mucus membrane excessive mucus
bronchospasm
swelling production
X. LIST OF PRIORITIZED NURSING PROBLEMS
CUES NURSING RATIONALE GOAL /’ NURSING RATIONALE EVALUATION
DIAGNOSIS OBJECTIVE INTER
-VENTIONS
“Nahihirapan Ineffective Asthma is an Goal Facilitative Broncho-
akong airway obstructive -achievement 1)Administer dilators
huminga, clearance R/T airway of airway bronchodilator dilates the
masyadong bronchocons- disease clearance as prescribed airway;com-
maraming triction and characterized within 1 hour. by bat mucosal
plema. increase by response Objective – nebulization/ edema and
mucus of the bronchi after 1 hour of spasm.
Oral meds
production to various nursing
Labored 2)Observe for
breathing; use stimuli intervention The drug is
resulting in side effects
of accessory 1)Client will 3)Evaluate the carefully
dyspnea,
muscle exhibit at least effectiveness adjusted with
cough, his tolerance
3 signs of of nebulization
wheezing and clinical
Wheezes (+) effective and assess for
both lung airway decreased response.
fields shortness of shortness of
breath breath Improper
RR – 26/min wheezes Developmental administration
in RR by treatment
PR – 100/min 1)Discuss
(20/min) possible ways will render it
PaCO2 48 ineffective.
2. client will of minimizing
mmHg
state 3 ways exposure to
he can factors such as Knowledge
minimize allergens on prevention
exposure to 2) Increased reduces risk
predisposing resistance to of developing
factors respiratory disease.
infection
XI. Discharge Plan METHOD/S
M - continue oral and inhaled medication Ambroxol 30 mg. one tab. TID
E - avoid exhaustion, induced by strenuous exercise; breathing exercise
T - Salbutamol and Ventolin once a day by nebulization
H - avoidance of extrinsic factors
avoidance of respiratory infection
general health measures – adequate sleep, good diet, avoidance of fatigue
O - January 25, 2007
D - Highly nutritious food, avoid food with additives/preservatives
XII. Bibliography
Author, title of the Book, Publisher, year