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METROPOLITAN MEDICAL CENTER,COLLEGE OF ARTS, SCIENCE AND TECHNOLOGY

1357 G. MASANGKAY ST. COR. MAYHALIGUE STA.CRUZ, MANILA1357 G. MASANGKAY ST. COR. MAYHALIGUE STA.CRUZ, MANILA

SUBMITTED BY:GALES, VERJANE JOY CYROS M.

III-BB/BB3

SUBMITTED TO:MS. DELA CRUZ

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NURSE PATIENT INTERACTION

ORIENTATION PHASE

NURSE PATIENT TECHNIQUE ANALYSIS

01. MagandangUmaga po.

MagandangUmaga din

Acknowledging Weacknowledge by

means of greeting the

client.02. Ako po siVerjane Joy

Cyros M. Gales

ako po yungmagiging

student nurseniyo sa araw na

ito.

Ah gnon ba.

Giving

Information

Introducing Self

to the client

03. Nandito poyung Clinical

Instructornamin para

mag obserba saamin.

Okay GivingInformation

Telling thepatient that I’mwith my Clinical

Instructor toobserve.

WORKING PHASE

NURSE PATIENT TECHNIQUE

ANALYSIS

01. GoodMorning po ulit.kukuha lang po

ako ng Body

Temperature nimam.

O sige Acknowledging Acknowledgingby greeting andby telling them

that we aregoing to take thevital signs of the

patient.02. Wala naman

po. Normal poyung

Temperatureniya.

May lagnat basiya?

Ah ganon ba

GivingInformation

Telling thedaughter of thepatient that thetemperature is

normal.03. Maam maari

po bang O sige ProvidingAsking a

permission if we

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05. ilan po

ba kayongmagkakapatid?

4 kaming

magkakapatid 3babae, 1 lalaki

Seeking

Clarification

Clarifying how

many siblingsdoes Mrs.Villanueva

have.06. Ano

pongdahilan

kung bakitninyo dinala

si Mrs.villanueva?

Bumaba yungsugar level

niya, wala nagana kumain

Using openended Question

To determine if what is the

chief complaint.

07. Ito poba yungunang

pagkakataon na dinalaniyo siya sa

hospital?

Oo ito yungunang

pagkakataon.Using open

ended Question

Asking if this isthe first time he

admits in thehospital.

08. Anopong sakitmeron sa

pamilya ngmother

niyo?

Wala namanakong alam na

may sakit safamily ni mama.

GivingInformation

Asking whatparticular

disease thatfamily have.

03. Mammay

karaniwanpo bang

ginagawa simam mgahobbies po

niya

Kain lang ngkanin taposminsan nag

jojogging sila nikuya sa luneta.

Using openended Question

What are thehobbies of the

client?

TERMINATION PHASE

NURSE PATIENT TECHNIQUE ANALYSIS

1. MamSalamatpo.babaliknalangpo ako

O sige! Clarifying Timeor sequence

We clarify thatafter 2 hour

we will comeback to take

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02. Salamatpo pala sa

impormasyonna sinabi ninyo

tungkol kayMrs.

Villanueva

Wala yunSummarizingand Planning We gatherinformation

about thepatient.

03. MaramingSalamat po sapakikikooperas

yon niyo saamin.

Walanganuman

AcknowledgingWe

acknowledgethe time shehas given us.

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BIOGRAPHIC DATA:BIOGRAPHIC DATA:

NAME : Villanueva, Fructusa Guan

ADDRESS : 968 masinop st. Tondo, Manila

BIRTHDAY: 11-16-1932

BIRTHPLACE : Sorsogon

RELIGION: Catholic

NATIONALITY: Filipino

MARITAL STATUS: Married

ADMISSION NO: 97811-001

ADMISSION DATE: December 07, 2009

ADMISSION DIAGNOSIS: Hypoglycemia

ATTENDING PHYSICIAN: Dr. Jaime Filardo Cayetano

HISTORY OF PRESENT ILLNESS: The patient was admitted in Metropolitan Medical Center last December 07, 2009

with an admitting diagnosis of Hypoglycemia.

PAST HISTORY:

Mrs. Villanueva verbalized “ di ko na maalala kung kumpleto ako ng bakuna ko”

and has no allergies to any drugs, animals, insects or other environmental

agents.

This is the first time that the patient was hospitalized.

FAMILY HEALTH HISTORY:

The family has no known disorder except according to his daughter “ wala

naming nababanggit si mama na sakit na meron sila “; She has 4 siblings 1 boys

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LIFESTYLE:

The patient usually drinks coffee and soft drinks but not a alcoholic drinker and

non-smoker person. He likes to eat vegetables, meat, fish etc... And has a sleep

pattern of 7-8 hours. Every Sunday Mrs. Villanueva and his son go to luneta to go

jogging.

SOCIAL DATA:

Mrs. Villanueva is a housewife. When it comes from paying the hospital bill it is

self-pay with phil. Health card.

PATTERNS OF HEALTH CARE:

They don’t have family physician, they only seek to a doctor if they have problem

regarding health. When having a fever, cough and colds their pattern of health care is self

care and self medication.

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REVIEW OF SYSYTEM:SKIN:SKIN:

There is no fever, warm to touch

HAIR:HAIR:Short and thin hair

HEAD:HEAD:

Q: “Mam, hindi po ba masakit yung ulo ninyo o kaya naman nahihilo?

A: “Hindi naman ako nahihilo o kaya sumasakit yung ulo.As verbalized by the

patient

EYES:EYES:

Q: “Hindi po ba Malabo yung mata niyo?”

A: “Hindi naman, normal lang naman yung mata ko.” As verbalized by the

patient.

EARS:EARS:

Q: “Wala naman po bang problema sa pandinig ni mam?”

A: “.Hirap na sa pandinig si mama kelangan isisigaw mo pa sa kanya yung

sasabihin mo” As verbalized by the daughter of the patient

NOSE:NOSE:

Q: “Hindi po ba nahihirapan huminga o kaya naman meron pong sipon si mam?”

A:”Inuubo siya, yun lang naman” As verbalized by the daughter of the patient.

MOUTH AND THROAT:

Q: “ Wala naman pong dinadaing na masakit sa banding laluman si mam?

A: “ Hirap siya lumunok” as verbalized by the daughter of the patient

NECK:NECK:

Q: “May sumasakit po ba sa leeg ni mam?

A: “Ay wala naman din” as verbalized by the daughter of the patient.

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RESPIRATORY:RESPIRATORY:

Q: “Hindi naman po ba nahihirapan huminga si mam?”

A: “wala naman siya sinasabi pero may ubo siya” as verbalized by the daughter of the

patient.

CARDIOVASCULAR:CARDIOVASCULAR:

Q: “Wala naman po bang masakit sa bandang puso ni mam?”

A: “Wala naman nararamdamang na sakit si mama” as verbalized by the daughter of the

patient.

GASTROINTESTINAL:

Q: “Hindi naman po sumasakit yung tiyan ni mam?”A: “Hindi naman din” as verbalized by the daughter of the patient

MUSCULOSKELETAL:MUSCULOSKELETAL:

Q:

A:

ENDOCRINE:ENDOCRINE:

Q: “Nahihirapan po ba kayong umihi?”

A: “Hindi malakas nga umihi yan si mama eh, nakaka pitong beses siya kung umihi” as

verbalized by the daughter of the patient

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PHYSICAL ASSESSMENT The part of the health assessment representing a synthesis of the information

obtained in a physical examination. It involves the detailed examination of the

body from head to toe using the techniques of observation/ inspection, palpation,percussion and auscultation

GENERAL SURVEY:

Physical Examination was done last December 08, 2009. The patient was on bed,

conscious. She was wearing a hospital gown. The patient admitted in the hospital

because of the admitting diagnosis of hypoglycemia.

VITAL SIGNS:

1600HT 36.5

PR 75CR 78RR 18BP 110/70

BodyParts

Technique NormalFindings

AbnormalFindings

Analysis

Skin Inspection Color good,warm and

faircomplexion,moist, there

is no skinlesion.

None Normal

Head Inspection Symmetrical

None Normal

Hair InspectionPalpation

Black, shorthair inlength

smoothhair.

Distributedhair

None Normal

Eyes Inspection Black Colorthe iris andhas normal

None Normal

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NoseInspection

Nodischarge in

the nose

None Normal

Neck PalpationInspection

There is nolymphnodes

None Normal

Thorax/Lungs

Inspection

Palpation

Regularchest

NormalBreathing

None Normal

Abdomen

InspectionPalpation

Brown skin None Normal

Lowerextremities

PalpationInspection

Abnormal

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