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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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