Professional Documents
Culture Documents
Nursing Health Assessment
Nursing Health Assessment
I.
Occupation/
source of income
Monthly income
Electrician
Not disclosed
None (student)
None (student)
H.Psychosocial Assessment
Patients age: 40 years old
Developmental stage: adulthood
Developmental task: generativity vs. stagnation
During middle adulthood (ages 40 to 65 yrs), we establish
our careers, settle down within a relationship, begin our own
families and develop a sense of being a part of the bigger picture.
We give back to society through raising our children, being
productive at work, and becoming involved in community
activities and organizations. By failing to achieve these objectives,
we become stagnant and feel unproductive. Success in this stage
will lead to the virtue of care.
Patient was able to achieve this stage. Before she got pregnant
she had a job in the government. She has good relationship with
her daughter. She develops the virtue of care as she establishes it
to her daughters. Although shes having problems with her
spouse, shes able to cope up for her children.
I. Functional assessment
1. Health- perception-health management
pattern
Patient is worried about her health condition but
mostly the future condition of her baby. She takes
her medications for her hypertension because that
is her main concern. She is also aware that her
father had a history of hypertension and diabetes
mellitus.
2. Nutritional-Metabolic pattern
She eats fruits and vegetables every day. Especially
fruits rich in potassium since she have potassium
deficiency.
3. Elimination pattern
She defecates at least twice a day. But she
experiences increased in frequency in urination. She
voids up to 10 times a day due to her medications
and also to her pregnancy.
4. Activity-exercise pattern
Patient is hypertensive and also has potassium
deficiency so thats why she doesnt engage in any
exercise activities. Although she spends her leisure
time with watching shows in televisions and
listening to music. She also spends time with her
baby as she let him hear music.
5. Sleep-rest pattern
Person has sleep pattern disturbance r/t
environmental stimuli. She said shes not used to
noisy environment. And she falls asleep at home
with the help of her television. Person looks relaxed.
6. Cognitive- perceptual pattern
Patient doesnt have any sensory deficit. She was
able to express herself clearly and logically. She is
well educated.
7. Self-perception-self-concept pattern
2. integument
R.O.S
her wt. is
maintained. She
experience
fatigue and
weakness
No history of skin
disease, recent
hair loss, and no
changes in shape
P.E
Patients wt: 165 lbs
(+)
hyperpigmentation in
the axilla area and
nape
of the nails
3. head
Experiences
frequent dizziness
4. eyes
Uses glasses only
when reading
5. ears
No presence of
problems
6. nose and sinuses Experiences nasal
stuffiness and
congestion
7. mouth and throat No presence of
any problems
8. neck
No presence of
any problems
9. breast and axilla Experiences
breast tenderness
due to lactation
10.
respiratory No presence of
any problems
11.
cardiac
hypertensive
12.
Gastrointestinal
13.
Urinary
14.
genitalia
No presence of
any problems
Experiences
frequent urination
due to
medications
No presence of
any problems
Bp: 130/70
prehypertensive
Previous bp upon
admission is 140/90