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NURSING HEALTH ASSESSMENT

I.FINAL DIAGNOSIS

Alzheimers

II. HEALTH HISTORY AND PHYSICAL ASSESSMENTA. Demographic (Biographical Data)

1. Client’s Initial C.A.T2. Gender Female3. Age/B-day/B-place 83 Y.O. / 8-24-1930 / Cebu4. Civil Status Married

5. Nationality Filipino6. Religion Roman Catholic7. Address & Telephone Number Blk 14 Lot 40 Phase 1 Solar Homes Subd. Dasmarinas City, Cavite 4114

(0917-363-****)8. Educational Background High School9. Occupation Housewife10. Source of Medical Care Clinic11. DOA 3-2-2013 @ 1:30 pm

B. SOURCE AND RELIABILITY OF INFORMATION

The client was unable to prove any information; she remained asleep throughout both duty rotations. Her daughter in laws, son and husband served as her primary source of information. The patients chart served as a secondary source of information. Laboratory and other diagnostics were derived from the patients chart. Some information were derived from the patient’s chart.

C.CHIEF COMPLAINTS

“Lagi syang nanghihina” as verbalized by pt’s daughter in law.“Napansin naming nahihirapan syang huminga” as verbalized by the husband.

D. History of Present Illness

The pt’s Alzheimer’s disease came about 7 years ago in Cebu. It began when she was brought to Soto’s Hospital for a check-up d/t a lump on her neck. The patient had no complaints of it being painful but it was diagnosed as a cancerous tumor. Surgery was not offered as an option for her d/t her old age; it would be harder for her to recover. As an alternative, medication was prescribed to her as a form of therapy. Although a promising outcome was not given, the patient and her family took the chance with hope. The doctor warned them of the possible side effects of the medication which was Alzheimer Disease. Months passed but the tumor was still the size of a large marble; at around 6 months, the entire family accepted this and just decided to continue living the rest of her life with her as normal and comfortable as possible.

The pt use to work as a ticket checker at a theatre, but was forced to quit due to her disease. While her cancer did not seem to progress, her Alzheimer’s did on the other hand. Along with her progressing disease, the pt complained of knee pain. In the early stages, she would forget where the pots and pans were, or what she was doing in a certain room as she would be entering it. But the disease progressed and began to get worst 3 years ago. Her husband took over the everyday tasks that she use to do such as cook, clean, laundry and groceries.

The pt was administered to the St. Paul Emergency Room on March 2, 2013 at 9:20 am. By 1:30pm, she was transferred to the O.B ward in a private room. She had an intravenous line of… She had vital signs of… Based on her laboratory results, she was given the prescribed medications at the proper times.

E. PAST HEALTH

a. Pediatric/Childhood/Adult Illness

The client had no any major or serious illness during her childhood. Her husband and children stated that she lived a healthy life. However she did smoke a lot of cigarettes. The patient’s husband stated that she already had the chicken pox when she was 15 but no other complications happened except for a few scars that it left. There were times when the patient had the flu and sometimes accompanied by a cough but it does not cause her serious harm because she is fully immunized.

b. Injuries and Accidents

The patient’s daughter in law verbalized that the only time the patient had a serious accident was last July when the patient was left home alone. The daughter in law explained that the patient was left on her wheel chair in the front yard within closed confines of their home while the husband left quickly to buy something. Meanwhile, the daughter in law was in her own home next door but was unaware of her being alone by herself. Since the patient has Alzheimer, she is unaware of the aftermaths of every action; she rolled her wheelchair down the stairs and she rolled with it all the way down.

The patient’s daughter in law further stated that the patient had suffered from cuts, bruises, a fever and a bump on the head. She was quickly rushed to the nearest clinic called GMF in Bayan.

.

c. Hospitalizations and Operations

The daughter in law stated that she has not been hospitalized or operated on except for the time she visited the hospital in Cebu for a check-up and this recent hospitalization. She further explained that the pt was not admitted to the hospital during the times of delivering her children; she gave birth at a clinic.

d. Reproductive History

The patient’s husband said that the patient had her menarche when she was 11 years of age. She was spending some time in the fields with a few friends when one of her friends noticed a large red stain on her dress. Perplexed, she quickly ran home to use to restroom. To her surprise, she saw her entire underwear drenched with blood. The husband said that the client mentioned to him before that it was around 14 years of age that she began to develop her breasts and pubic hair. She did not develop any acne during or before her menstruation but she did experience dysmenorrhea. The patient had a regular menstruation cycle.

On September 1930, when she was 40 years of age, she had her LMP. The patient had 7 children total, and all of them were full term. Her husband stated that her family had no history of any reproductive diseases and whenever she had her monthly period, she experienced dysmenorrhea, but the blood coming out was of small amount. Her cycle was normal, but there were times that the client experienced heavy menstruation and it made her feel sick maybe due to blood loss, but other than that, there were no complications. She did not take any oral contraceptive pills to delay her pregnancy.

e. Immunization

BCG: / - / At Birth / - / School EntranceDPT: / - / 1st dose /- / 2nd dose /- / 3rd doseOPV: /- / 1st dose /- / 2nd dose /- / 3rd doseAMV: /- /TT: /- / 1st dose /- / 2nd dose /- / 3rd dose /- / 4th dose /- / 5th doseHBV: /- / 1st dose /- / 2nd dose /- / 3rd doseOthers:

f. Allergies

/ / Foods, please specify: NONE/ / Drugs or medications , please specify: NONE/ /Chemicals, please specify NONE

/ / Other environmental allergens, please specify NONE

g. Medications

The patients daughter in law stated that the client did not take any other medications prior to her hospitalization other than OTC drugs such as Biogesic and a Pharex, a vitamin B Complex for her bones which would be taken OD as 50ml tablets.

It was also mentioned that she use to take medication for her cancer, but the family could not recall its name.

GENERIC NAME: Multivitamins and MineralsBRAND NAME: Pharex

. INDICATION: Vitamin B-complex deficiencies, neuritis, polyneuritis, diabetic

neuritis, neuralgia, lumbalgia, sciatica, intercostals and trigeminal neuralgia, peripheral neuroparalysis arthralgia and myalgia.

GENERIC NAME: ParacetamolBRAND NAME: BiogesicINDICATION: Relief of fever, minor aches and pain felt. The drug may relief

fever through central action in the hypothalamic heat regulating center

F. FAMILY HISTORY : Family was unable to provide

The family of the patient was unrecalled by the family members. However, the son stated that all deaths in the patient’s side of the family were due to old age; the patient is the last living.

The family of the patient’s husband has no diseases. His parents died d/t old age, while all 3 of his siblings are still alive and well. His sister Lydia is 78 years of age, his brother Pedro is 65 and is currently a mayor in Cebu, and Angeles, his other brother is also alive and well.

There is no evident disease in their children as verbalized by the patient’s son. The son verbalized that she had a very good relationship with her husband’s family and

as well as her own family. The husband stated that not once did their children hear them have an altercation because they made sure that it was done behind closed doors and it was talked out.

G. SOCIO-ECONOMIC HISTORY

Family Members Occupation Monthly IncomeCorazon Trinidad Theatre Php2,500

Regulo Trinidad Acevedo Optical Php2,500

Giogany Trinidad Engineer Php50,000

Giovannie Trinidad Electrician Php18,000

Giodinno Trinidad Watch Repair Php1,000

Giosinne Trinidad Optical Php20,000

Gualberto Trinidad Watch Repair/Fisherman Php2,000/day

Although the client has many children that works for a living, only one that works abroad sends them money to live off on a day to day basis. When the client use to work at the theatre, she made Php2,500/month as well as her husband, Regulo Trinidad who worked at Acevedo Optical. Their son, Giogany is an engineer that makes Php50k/month, Giovannie is an electrician who made Php18k/month, and Giodinno is a watch repair man that made Php1k/month. Their daughter Giosinne works at an optical clinic and makes Php20k/month while Gualberto is both a watch repairman as well as a fisherman and brings in php2k/day. Their daughter who works abroad named Maria Gemma works as a secretary at a hotel but her income is unknown because she does not call often.

H. PSYCHOSOCIAL ASSESSMENT

PATIENT’S AGE: 83 years old DEVELOPMENTAL STAGE: Maturity to deathDEVELOPMENTAL TASK: Integrity vs. Despair

As we grow older and become senior citizens, we tend to slow down our productivity, and explore life as a retired person. It is during this time that we contemplate our accomplishments and are able to develop integrity if we see ourselves as leading a successful life. Erik Erikson believed if we see our lives as unproductive, feel guilt about our pasts, or feel that we did not accomplish our life goals, we become dissatisfied with life and develop despair, often leading to depression and hopelessness. Success in this state will lead to the virtue of wisdom.

Due to her current state, the client was unable to provide any information regarding her self. However, her husband and son were able to provide as much as they can. The family explained that during the early stages of her sickness when she was still lucid, the patient expressed that whatever happens to her, that she wanted them to know that she does not regret anything that has happened to her in life. Although she was not able to finish school because she married early, she does not regret it because she had a very loving and meaningful relationship with her husband. Her husband always showed her worth while her children always reassured her that they loved her. They further explained that the client stated that she accepted what was happening to her a long time ago because she feels that she has lived her life to the fullest though it is of a simple one.

I. FUNCTIONAL ASSESSMENT

1. Self concept, Self Esteem

The client’s last educational attainment was 3rd year in High School. She was 15 years old when she ceased attending so that she can help her family by working. She had plans on returning but she met her soon to be husband and was married by the age of 17. It was reported by her children that she did not regret dropping out of school nor marrying at an early age because she had a happy marriage life with beautiful, loving and obedient children. She felt her worth was not measured by the educational attainment she received but in someone higher; she felt her life was lived to the fullest and she did not think any less of herself.

2. Occupation

In the past, the client worked as a ticket clerk at a movie theatre. Though her job was repetitive each day, she enjoyed it because she saw many different kinds of people

and she enjoyed conversing with many of them. She made around php2,500 each month. With her husband’s income, they were able to make just enough to provide for her family’s needs. She only made just enough and would try to save if there was any left over from what they spent each month. As the client’s disease progressed, she was forced to quit her job. She did not participate in any community activities nor volunteer due to her illness.

3. Activity and Exercise

While she was still well, the client exercised by walking at least 1 kilometer every day down the street from her home. Her daily chores also served as her means of exercised. She did not do any sports or other strenuous activities. Her body remained healthy because of the healthy food she would consume everyday and just the right amount of exercise her body needed. Currently, the family would take turns to massage her muscles and slowly stretch out her joints and do some minimal ROM exercises since she is not able to do so by herself. Most of her time is spent sitting on her wheelchair at home watching people and vehicles pass by their house or watching tv. Back in the day, she did not have any hobbies, so as a means of passing time or relaxing, the patient smoked cigarettes.

4. Sleep and Rest

As verbalized by her husband and daughter in law, the patient rarely sleeps for unknown reasons. Her usual sleeping patter is 3 hours per day. It was explained that even back then when she was healthy, the most she would sleep each night would be 4-5 hours. The amount of sleep the patient receives each day seems to be enough as evidenced by not falling asleep during the day and looking wide awake. Once in a while, the patient would take a nap when she feels like it on her wheelchair. The family would then transfer her to the bed so that she is able to sleep comfortably.

5. Nutrition/Elimination

Patient voids urine 2-3 times a day, and drinks small sips of water that is equivalent to 3-4 glasses of water each day. Her urine is clear and yellow. It was stated that patient does not complain of any pain whenever urinating or passing of stool. There are no other diseases that run in the family in relation to painful urination and defecation.

The client eats 3 meals a day plus an afternoon snack. Ever since her disease began to progress, her husband has been preparing the meals, shops for their groceries at the market and washes all the dishes. The client always has her husband to eat with her; she is now spoon fed small portions of food at a time to avoid aspiration. The money that they receive each month from their daughter allocated for groceries and other bills are enough to suffice their needs. It was reported by the husband that around 1k is spent every 2 days for their food. As a way to prepare food, a gasoline stove is used. The patient prefers foods such as banana’s, mangoes, mashed potatoes and foods as such that are soft in consistency.

6. Interpersonal Relationship/Resources

The patient shares her home with her husband, one dog and one cat. Their pets help the patient relax and be entertained, says her husband. The animals are very loving and somehow know to behave and be gentle when around her. Only one of her sons live right next door along with the patients daughter in law and grandchildren. The daughter in law stated that the grandkids are very fond of their grandparents and love to give her hugs and kisses and tell stories. They understand her situation and are very patient with her and love her regardless. All her grandchildren that live next door, ages 24, 32, 24, 12 and 9 visit her every single day. The patients daughter in law is very helpful in helping in things that the patients husband needs help in doing; moreover she helps take care of the patient as if it was her own mother. The rest of her children are all spread out in places such as Trece, Bulacan, Makati and Bicol and also in the United States. They visit whenever there is a special occasion. When the patient was still well, she was the one to do all of the cleaning and cooking in the house. Her family members were very proud to boast that she makes excellent meals such as pinakbet, sinigang, bicol express and such. Her family are always there for emotional and physical needs.

7. Coping and Stress Management

Family was not able to provide information

8. Enviromental Hazards

The patient’s home is a one story house safe with a gate and bars on their windows. Their large windows serve as a fire escape in case of a fire emergency. Both the patient and her husband have been residing in their home for 5 years. Although they like their house, the husband complains that their neighborhood is a bit chaotic. There is a lot of noise from street children fighting and neighbors quarreling; there are also a lot of “tambays”. Facilities such as the grocery store, drug store, church and health care

facilities are nearby and you would only need to ride a tricycle or jeep to reach them. The chapel is within their compound while for groceries, they just take a tricycle to get to Bayan. According to the patient’s husband, there has been an incident of theft from their maid that they had for 2 months; even though they welcomed her into their homes and tried to treat her so that she felt at home, she still stole 10k pesos. The monthly allowance the couple receives is sufficient enough to provide for their every day needs as well as repairs in the house if need be. The patient’s husband receives around 3,500 pesos a month from his pension, plus 12,000 pesos from their daughter abroad each month. Two-thousand a month is spent on electricity and water, one-thousand is paid for the house, 2,000 pesos each week for food and other miscellaneous things.

J. REVIEW OF SYSTEMS

SYSTEM REVIEW OF SYSTEM

PHYSICAL EXAMINATION

1. General ASSESSMENT: Received pt on semi-fowler position Patient was sleeping. With venoclysis of D5LR 1L X 24O

hooked at LMCV, running at a rate of 13-14 gtts/min, received at 450 cc, intact and infusing well.

With vital signs as of 4 pmo T: 36.7 oCo PR: 70 bpmo RR: 19 cpm, regular with

bilaterally equal chest expansions

o BP: 110/80 mmHg Capillary refill <2 seconds

2. Integument “wala naman Kaming nakikita” – as verbalized by family member

SKININSPECTION:

(-) good skin turgor Warm to touch

HAIRINSPECTION:

Thinning Black and Grey No parasites evident

NAILSINSPECTION:

Capillary refill <2 seconds Round and hard with whitish nail bed

3. Head “Wala naman” – as verbalized by family member

INSPECTION: Symmetrical and firm (-) lesions on scalp

4. Eyes “Malabo na paningin nya” – as verbalized by family member.

Unable to conduct assessment because the patient was sleeping and forced her eyes shut.

5. Ears “Wala naman siguro” – as verbalized by family member

INSPECTION: (-) discharges on external ear (-) hearing aides

6. Nose and sinuses “Okay naman siguro- as verbalized by the family member

INSPECTION: (+) some nasal flaring (-) lesions (-) nasal discharges Sinuses are clear upon

transillumination

PALPATION: (-) tenderness on sinuses

7. Mouth and throat “Medyo natutuyu lng labi nya”

INSPECTION: Dry lips and oral mucosa (+) gag reflex (-) hx of any infections on throat (-) mumps

PALPATION: (-) swelling

8. Neck “Meron nga syang buko sa leeg nya”

INSPECTION: (+) lump on right side of neck

9. Breast and axilla “Wala naman kaming napapansin”

Family refused

10. Respiratory “Ayun, minsan nahihirapan sya huminga”

INSPECTION: (+) cough Symmetrical thoracic breathing RR: 19 cpm, regular with bilaterally

equal chest expansions

AUSCULTATION (+) wheezing (+) crepitus

PERCUSSION Hyperresonant sound was produced

upon percussion

11. Cardiac “Wala naman syang dinadaing saamin” – as verbalized by family.

INSPECTION: Regular rhythm bilateral

AUSCULATATION: Apical Pulse 70 bpm at 5TH ICS MCL

on the left

Normal heart sounds Regular rate

12. Gastrointestinal “Wala naman siguro. Pero pansin naming, madalas syang nagkakagas” – as verbalized by family member.

AUSCULTATION: Normal bowel sounds @ 10 BS per

minute

PERCUSSION Tympanic sounds were produced

PALPATIONS: Non tender Normal liver span No enlarged organs

13. Urinary “Wala naming problema” – as verbalized by patient’s family member.

No physical Examination

14. Genitalia “Wala naman syang problema” – as verbalized by patients family member

Family refused

15. Peripheral Vascular

“May mga sugat sya” – as verbalized by family member.

INSPECTION: (-) varicosities on lower extremities (+) bed sores Capillary refill <2 seconds

16. Musculoskeletal “Yung tuhod nya, lagging nasakit” as verbalized by

INSPECTION: (+) full ROM via passive ROM

family member

17. Neurologic “Wala naman siguro”

No physical Examination

18. Hematologic “Wala din naman” as verbalized by family member.

No Physical Examination

19. Endocrine “Hindi sya pawisin” as verbalized by family member.

INSPECTION: (+) heat and cold tolerance

20. Psychiatric “Yung Alzheimer nya” as verbalized by family member

No Physical Examination

III. LABORATORY STUDIES AND DIAGNOSTICS

TEST INDICATIONS NORMAL ACTUAL NURSING RESPONSIBILITIES

CBC3-6-13

The complete blood count (CBC) is a screening test, used to diagnose and manage numerous diseases. It can reflect problems with fluid volume (such as dehydration) or loss of blood. It can show abnormalities in the production, life span, and destruction of blood cells. It can reflect acute or chronic infection, allergies, and problems with clotting.

WBC : 5.0 – 10.9

RBC : 4.2 – 5.4

HEMAGLOBIN:12.0 – 15. 0

HEMATOCRIT: 37.0 – 47.0

>Differential Count

Segmenters: 50-70

Lymphocytes: 20-40

Platelet Count:150-500

8.3

L 3.9

L 11.1

L 34.1

H 79

21

402

PRETEST:Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.

INTRATEST:If the patient has a history of allergic reaction to latex, avoid the use of equipment containing latex.

Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement.

Observe standard precautions, and follow the general guidelines.

Remove the needle and apply direct pressure with dry gauze to stop bleeding.

Observe/assess venipuncture site for bleeding or hematoma formation and secure gauze with adhesive bandage.

UrineAnalysis3-5-13

A urinalysis consists of a number of physical, chemical and microscopic tests of a urine sample as part of a checkup to help diagnose a

Bun : 2.14-7.14

Creatine :45-84

Uric Acid: 142.8 – 339.2Na : 135 – 148

Random Blood Sugar : 6.1 –

3.5

46

163.0

140

L 4.7

Promptly transport the specimen to the laboratory for processing and analysis.

POST-TEST:A report of the results will be sent to the requesting HCP, who will discuss the results with the patient.

Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient's symptoms and other tests performed.

1. Instruct the patient to void directly into a clean, dry container. Sterile, disposable containers are recommended. Women should always have a

urinary tract or metabolic disease.

Routine Physical

A routine physical exam often includes a urinalysis to screen for early signs of medical problems. Abnormal waste products or abnormal levels of cells may indicate disease.

Monitoring Disease

For patients who already have an existing condition like diabetes or kidney disease, urinalysis helps to monitor their status and determines whether their course of treatment requires adjustment.

Urinary Tract Symptoms

Patients who have urinary

8.02

K : 3.5 – 5.3 3.5clean-catch specimen if a microscopic examination is ordered. Feces, discharges, vaginal secretions and menstrual blood will contaminate the urine specimen.

2. Collect specimens form infants and young children into a disposable collection apparatus consisting of a plastic bag with an adhesive backing around the opening that can be fastened to the perineal area or around the penis to permit voiding directly to the bag. Depending on hospital policy, the collected urine can be transferred to an appropriate specimen container.

3. Cover all specimens tightly, label properly and send immediately to

symptoms undergo urinalysis to help doctors diagnose urinary tract diseases, like infections. Abnormal test results in such cases commonly include blood and increased white cells in the urine.

the laboratory.4. If a urine sample

is obtained from an indwelling catheter, it may be necessary to clamp the catheter for about 15-30 minutes before obtaining the sample. Clean the specimen port with antiseptic before aspirating the urine sample with a needle and a syringe.

5. Observe standard precautions when handling urine specimens.

6. If the specimen cannot be delivered to the laboratory or tested within an hour, it should be refrigerated or have an appropriate preservative added.

B. PHARMACOTHERAPEUTICS/MEDICINES

GENERIC (BRAND) NAME

CLASSIFICATIONSTOCK DOSE

INDICATIONDOSAGE

FREQUENCY

N.R.

G: Fluimucil

B: N – Acetyl-L- C: Mucolytic

SD: 600mg/tab c ½ glass water

I: Treatment of respiratory infections characterized by thick and viscous hypersecretions: acute bronchitis, chronic bronchitis, and its exacerbations; pulmonary emphysema, mucoviscidosis and bronchieactasis

D: 600mg/tab with ½ glass water

F: OD in the evening

Nursing Considerations for Clients Taking Fluimucil

Due to the high doses required, the patient should be watched for an over dosage of this medication, signs may include nausea and vomiting.

Nurse should also WOF increased blood pressure and hypoxia.Patients suffering from bronchial asthma must be strictly monitored during therapy. Should bronchospasm occur, the tx must be suspended immediately. It should be used with caution in asthmatic patients and patients with a history of peptic ulceration. The possible presence of a sulfur-like odor does not indicate an alteration of the product but is a characteristic of the active ingredient contained in preparation. It is preferred not to mix other drugs with Fluimuci solution.

Patient Teachings for Clients Taking Fluimucil:

Hypersensitivity reactions have been reported in patients receiving acetylcystein including bronchospasm,

angioedema, rashes, and pruritus. Other adverse effects include N/V, fever, syncope, sweating, blurred vision, and disturbances of liver function. Any signs should be reported immediately.

G: Guaifenesin

B: Robitussin

C: Expectorant, Antitussive

SD: 100 mg/5 mL syrup; 100 mg/5 mL, 200 mg/5 mL liquid; 200 mg cap

I: Aids in expectoration by reducing adhesiveness and surface tension of secretions

To combat dry, nonproductive cough associated with colds and bronchitis.

D: 15ml/NGT

F: T.I.D

Nursing Considerations:

CLINICALALERT! Name confusion has been reported between Mucinex (guaifenesin) and Mucomyst (acetylcysteine); use caution

Assessment

History: Allergy to guaifenesin; persistent cough due to smoking, asthma, or emphysema; very productive cough; pregnancy

Physical: Skin lesions, color; T; orientation, affect; R, adventitious sounds

Interventions

WARNING: Monitor reaction to drug; persistent cough for more than 1 wk, fever, rash, or persistent headache may indicate a more

G: Albuterol

B: Combivent

C: Bronchodilator

SD: Aerosol inhaler: 90/18 mcg or 100/20mcg (albuterol/ipratropium) per actuation of the inhaler

I: Albuterol is used in the tx of bronchospasm or narrowing of the airways caused by emphysema or bronchitis in patients who require a second bronchodilator.

D: 2 puffs

F: 4x qd not to exceed 12 inhalations per day.

serious condition

Health Teachings:

Do not take for longer than 1 week; if fever, rash, or headaches occur, consult your health care provider.

You may experience these side effects: Nausea, vomiting (eat frequent small meals); dizziness, headache (avoid driving or operating dangerous machinery).

Report fever, rash, severe vomiting, persistent cough.

Follow dose with a full glass of water if not contraindicated

1. Use cautiously with patients with known sensitivity to atropine, soybeans, soya, lecithin, and peanuts

2. Assess vital signs before drug administration3. Observe for paradoxical bronchospasm (wheezing). If condition occurs, withhold medication and notify physician or other health care professional immediately.

4. Instruct patient to contact

health care professional immediately if SOB is not relieved by medications accompanied by diaphoresis, dizziness, palpitations or chest pain.

5. Advise patient to rinse mouth with water after using the nebulizer to minimize dry mouth.

HEALTH ASSESSMENT

(DLS-UMC)

SUBMITTED BY:

Jesslee M. Llanes SN’15BSN 2-1

SUBMITTED TO:Mrs. Daisy Doctor RN, MAN

March 20, 2013