assessment htp
TRANSCRIPT
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Name of Patient: Mrs. Capuyan, Mary Cebu Doctors University
Ward #: Gyne 10, 4B WARD,CDUH College of Nursing
Age: 49 years old Cebu City
NURSING ASSESMENT
HISTORY BODY
PARTS
INSPECTION PALPATION PERCUSSSION AUSCULTAT
The patients name isMrs. Capuyan, Mary,
a 49 year-old female,
single with a weight of
95 kilograms. Shes
currently living in
Purok Ternate, Ibabao,
Mandaue City. Patient
is in middle adulthood
stage of maturity.
The patient has a
history of
hypercholesterolemia
and hypertension.
Patient has noallergies in food and
neither smoker nor
alcoholic drinker.
Patient is now on hermenopausal stage.
The patient has
scheduled TAHBSO
on February 3, 2011
@ 7:30AM. Shewas admitted in
CDUH on February2, 2011 at 8:45AM.
The patient was noted
of severedysmenorrheal pain
on hypogastric area
during menses.
Menses at that timewere regular and with
moderate flow
onsuming 3-4 padser day, lasting 3
days and this
happened 3 years ago.She then sought
onsultation and TVS
howed myoma, 2 innumber, largest cm
ccording to patient.
Head
Hair
Scalp
Face-Forehead
-Eyes
-Eyebrows
-Eyelashes
-Sclera
-Conjuctiva
-Pupils
-Nose
-Patency
-Sinuses
-Lips-Tongue
-Uvula
-Ears
Neck
Anterior
Chest
Posterior
Chest
>symmetrical
>lumps
>black, long, and evenly
distributed
>white in color
>intact and firm
>symmetrical>fair in color, dry
>able to open and close,
with sunken eyes>black and equally
distributed
>black and equallydistributed
>anecteric sclera
>no inflammation, pink
in color>equally round, reactive
to light and
accommodation>located at the
center/midline, no
discharges>present
>not congested, not
inflammed
>pale and dry>positioned at the center,
reddish, and presence of
taste buds are evident>positioned at the center
>symmetrical, pinna is
elevated
>normal in length, samecolor with the body
>has equal chest
expansion, no scars
>spine is vertically
aligned
>no lesions
>no lesions
>no lumps,
masses or
lesions
>no unusuallumps
>soft
>no lumps
>no lumps
>no lumps
>no lumps
>(+) tempora
pulse
>(+) carotidpulse
>(+) apical p
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Name of Patient: Mrs. Capuyan, Mary Cebu Doctors University
Ward #: Gyne 10, 4B WARD,CDUH College of Nursing
Age: 49 years old Cebu City
NURSING ASSESMENT
HISTORY BODY
PARTS
INSPECTION PALPATION PERCUSSSION AUSCULTATIO
She also claimed that
he has a cyst on right
ovary. She was givenDepo injections for 6
months.
A month prior to heradmission, she
decided to seek
consultation with herOB-GYNE. TVS
was done showing
posterior walladenomyosis with
multiple myomalocated at leftposterior which
measured 6.2 x 4.4 x
5.2 cm, and right
ovarian cyst thatmeasured 7.1 x 4.6 x
6.4 cm. she was then
advised for surgery.
Vital Signs:
T: 36.7C
P: 72 bpmR: 20 breaths/min
BP: 120/80
Breasts
-Nipples andAreolas
Abdomen
Genitalia
Extremities:
-Upper
-Lower
>engorged
>relatively equal withslight variation
>round and pendulous
in shape
>same color with theskin of the body
>dark brown in color>round and oval in
shape
>no discharges
>globular,
symmetrical, withstretchmarks, with
dressing at the incision
site (lateral)
>with indwelling
catheter connected to
the Foley bag
>arms are symmetrical
in shape
>presence of IV in
left arm (IVF #1D5LR 1L @30
gtts/min
>no deformities
>extremities are
symmetrical
>weak and hasdifficulty in
ambulating due to pain
at the abdominal area
>no lumps,
lesions, oredema
>smooth
>no lesions andrashes
>smooth
>non-tender >no bruits
>no bowelsounds presen
all quadrant
>(+) radial an
ulnar pulse
>(+) brachial
pulse
>(+)popliteal
pulse
>(+)dorsalis
pedis pulse
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Name of Patient: Mrs. Capuyan, Mary Name of Student Nurse: Regis, Minfred Olen Cybi
Ward #: Gyne 10, 4B WARD, CDUH Physician: Dr. Raida Varona
Age: 49 years old
NURSING ASSESMENT
PSYCHOSOCIAL
or
CULTURAL
SPIRITUAL
DIAGNOSTIC
TESTRESULTS
NORMAL
VALUES SIGNIFICANCE
Erik EriksonsPsychosocial task:
Generativity vs.
Stagnation
> Following thesuccessful
development of an
intimaterelationship, the
adult can focus on
supporting futuregenerations.
Role Relationship:The patient is a
mother of two. It is
a nuclear type of
family. She doesthe household
chores and takes
care of thefamilys needs.
Coping/ StressTolerance:
Mrs. Capuyan is
a Roman Catholic
and believes tosurrender to God,
unload her burdens
to Him. Prayer isher way of coping
with stress. She
always face those
challenges that shewill encounter
bravely. Likewise,
she diverts herattention to her
work and solves
problemindependently.
Religion:
Mrs. Capuyan
is a Roman
CatholicChristian.
Religious
Practice:
The patient is
a church goer
and attendsmass every
Sunday if she
has an available
time and freetime from work.
Relationship
with God:
Mrs. Capuyan
firmly believes
that God is the
Supreme Being,as her Creator
and Savior
Date Taken:February 2, 2011
HEMATOLOGY:
Hemoglobin
Hematocrit
Red Blood Cells
White Blood Cells
Mc HgbMc Volume
McHc
Platelets
Neutrophils
Eosinophils
Monocytes
Lymphocytes
11.4
36.7
4.6
6,900
79.424.7
31
328,000
49
5
7
9
12.3-15.3
35.9-44.6
4.50-5.90
4,000-11,000
80-9627-31
32.0-36.0
150,000-450,000
40-70
1-5
0-8
20-40
Decreased in vario
anema
Decreased in anem
Decreased in
hemorrhageIncreased with acute
infections
Decrease in blood loDecrease in blood lo
Decrease in blood lo
Normal
Normal
Normal
Normal
Decreased with apla
anemia
SOURCE:
-Brunner and Suddharths
Textbook of Medical-Surgical Nursing, 11thedition.Volume 2.Philadelphia: Lippinco
Williams & Wilkins,2008.pp.2577- 2580.
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Name of Patient: Mrs. Capuyan, Mary
Age: 49 years oldWard #: Gyne 10, 4B ward, CDUH
NURSING CARE PLAN
PROBLEMS/
CUES
NURSING
DIAGNOSIS
SCIENTIFIC
BASIS
OBJECTIVE
OF
CARE
NURSING
INTERVENTIONS
RATIONALE
I. Physiologic
Overload
Alteration in Comfort
Objective Cues:
-PR=72 bpm
-RR=18 breaths per
minute-BP= 120/80 mmHg
-respiration almost
below baseline since
patient felt pain uponbreathing
-facial grimace notedupon movement
-pain at the incision
site in the abdomen
that last for 15-20seconds and is a sharp,
stabbing pain upon
movement and istreated with Tramadol
(Tramal) 50 mg IVTTevery 6 hours.
Subjective Cues:
Kung maglihok-lihok
ko, musakit ug samotakong
tinahian.Maskina
nghigda rako, sakitgihapon, as
verbalized by the
patient.
-Painscore of 8, in a
painscale of 0-10where 10 being the
most painful and 0 as
no pain
Alteration in
Comfort:Acute Pain
related to
abdominal
incision
As clientsawaken from
general
anesthesia, thesensation of
pain becomes
prominent.
Pain can beperceived
before full
consciousness
is regained.Acute
incisional paincauses clients
to become
restless and
may beresponsible for
temporary
changes invital signs. It
is difficult forthe client to docoughing and
deep breathing
exercises when
theyexperience
pain.
SOURCE:Perry, A. and
Potter, P.,
Fundamentalsof Nursing, 6th
Edition, p.
1634
After 8hours of
rendering
holisticNursing Care,
the patient
will be able
to:
1.report
alleviation of
pain asevidenced by
decreasepainscore
from 8 to 5,
with 10 being
the highestand 1 as the
lowest
Measures to:A. Alleviate or
control pain
1. use relaxation
and distraction
technique
2. promote
diversional
activities such asback rubs or
massage, etc.
3. encourage clientto have a complete
bed rest
4. reposition clientevery 2-3 hours
5. provideinformation
regarding causes of
discomfort
6.administer
analgesics asprescribed by the
physician
1. relaxes muscand restric
attention awa
from pain.
2. diverting th
activities of th
patient alloher to think
feel less abo
the pain.
3. too muc
tension on th body oc
when there
lack of slee
which worsenthe feeling
pain.
4. promot
comfort anprevents pressuon the joints.
5. reduce pa
with anxiety anfear of unknow
outcomes.
6. serves as pa
control.
SOURCE:
Doenges,
Moorhouse anMurr-Nursing
Care Plans, 7
Edition
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Name of Patient: Mrs. Capuyan, Mary
Age: 49 years old
Ward #: Gyne 10, 4B ward, CDUHNURSING CARE PLAN
PROBLEMS/
CUES
NURSING
DIAGNOSIS
SCIENTIFIC
BASIS
OBJECTIVE
OF
CARE
NURSING
INTERVENTIONS
RATIONALE
II. Physiologic Deficit
A. Altered Physical
Mobility
Objective Cues:
-impaired ability to
move around/walk,from bed to chair,
from sitting to lying to
bed
-abdominal pain due toa midline incision
-needs assistance when
trying to move-noted facial grimace
when trying to move
Subjective Cues:
Lisod kaau ilihok-
lihok jud.Sakit akongtahi, as verbalized by
the patient.
Altered
Physical
Mobility:Weakness
related to
abdominalpain at the
incision site
Acuteincisional pain
causes to
become
restless andmay be
responsible for
temporarychanges in
vital signs.
Many
alterations inphysiological,
socio-cultural
anddevelopmental
functioning are
related toimmobility.
Often the
focus ofimmobility is
on the easilyvisiblephysical
problems, such
as skin
impairment,but the
psychosocial
anddevelopmental
aspects of
immobilityshould not be
overloaded.
SOURCE:
Perry, A., and
Potter, P.,
Fundamentalsof Nursing, 6th
Edition, p.
1442
2. Promoteand increase
strength of
the affected
part
Measures to:Promote and
increase strength of
the affected part
1. Observe
movement when
client is unaware ofobservation
2. Note emotional
or the behavioralresponses to
problems of
immobility
3. Instruct patient
in use of side railsor roller pads
4. Support affectedbody part using
pillow or rolls, footsupport
5. Schedule
activities with
adequate restperiods during the
day
6. Encourage
participation in
self-care,occupational or
diversional or
recreational
activities
1.To note anyincongruencies
with reports of
abilities.
2.Feelings of
frustrations orpowerlessness
may impede
attainment of
goals.
3.For position
changes andtransfer.
4.To maintainposition of
function and
reduce risk ofpressure ulcers
which adds theburden.
5.To reduce
fatigue.
6.Enhances self
concept and
sense ofindependence.
SOURCE:
Doenges,
Moorhouse and
Murr-NursingCare Plans, 7th
Edition
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Name of Patient: Mrs. Capuyan, Mary
Age: 49 years old
Ward #: Gyne 10, 4B ward, CDUHNURSING CARE PLAN
PROBLEMS/
CUES
NURSING
DIAGNOSIS
SCIENTIFIC
BASIS
OBJECTIVE
OF
CARE
NURSING
INTERVENTIONS
RATIONALE
B. Disturbed
Sleeping Pattern
Objective cues:
- restlessness
-irritability
-sunken eyes
-wakefulness
-weak
-dark circles under
eyes
-5 hours of sleep with
awakenings
Subjective cues:
Naglisod pa jud ko
katulog kay musakitman gud akong tahi,
as verbalized by the
patient.
Disturbed
SleepingPattern:
sleeplessness
related touncomfortable
sleep
environmentand prolonged
discomfort
Both the
quality andquantity of
sleep are
affected by anumber of
factors. Illness
causes pain orphysical
distress can
result in sleep
problems.People who
are ill require
more sleepthan normal.
Environment
can promotehigher rate of
decreased
sleep.
Manipulationof the
environment isnecessary.
source:
Maternal andChild Health
Nursing 5th
Edition, AdelePillitteri, p.
564
3. establish
adequatesleep pattern,
from 5 hours
of sleep 6-7hours of
sleep without
awakenings
Measures to
promote sleep:
1.provide adequate
sleep and rest,restrict daytime as
appropriate then
reduce mentalactivity late in the
day
2.encourage to
have a comfortablepositioning
3.provide evening
snack, warm milk,
bath, backrub/general massage
with lotion
4.encourage to
listen soft music
and have anenvironment
conducive for
sleeping
5.provide some
reading materials
before sleeping
source:
NCP, 11th ed., byMarilyn Doenges ,
et.al.
1.although
prolonged
method and
physical activeresults in fatigu
which can
increaseconfusion
programmed
action without
over stimulationpromotes sleep
2.promotes wel
being and
relaxation
3. promotes
drowsiness and
relaxation , ithelps to address
skin care meds
4.promotes
relaxation and
drowsiness
5. promotes
peace of mind
and relaxation
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Name of Patient: Mrs. Capuyan, Mary
Age: 49 years old
Ward #: Gyne 10, 4B ward, CDUH
SOAPIE # 1
S - Kung maglihok-lihok ko, musakit ug samot akong tinahian.Maskina nghigda rako, sakit
gihapon, as verbalized by the patient.
O the patient is seen with facial grimace caused by the acute pain being felt. The pain occurred
about an hour ago after the sorgery with a painscore of 8/10 at the abdominal area. The painlasted for approximately 15-20 seconds and is characterized by a sharp pain, aggravated by
ambulation and rush movements; relieved by lying or resting in bed and can be treated by
administration of Tramadol as pain reliever.
A- Alteration in Comfort: Acute pain related to surgical incision at the abdomen
P After 8 hours of student nurse-patient interaction, the patient will be able to : alleviate pain asevidenced by a painscore of 5/10 from a painscore of 8/10 in a painscale of 0-10 where 10 is
the most painful and 0 is painless
I > promoted position of comfort like flexing the knees, sitting up or leaning forward
>provided alternative measures like quiet diversional activities
>encouraged to perform deep breathing exercises
>performed perilite exposure on affected area for 15 minutes>encouraged verbalization of feelings
>administered analgesics as prescribed by the physician
E After giving holistic nursing care to the patient, the patient verbalized that the degree of pain
felt was reduced to a tolerable level, as evidenced by a pain score of 5 from 8 in the painscale
of 0-10 where 10 is the most painful and 0 is painless.
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Name of Patient: Mrs. Capuyan, MaryAge: 49 years old
Ward #: Gyne 10, 4B ward, CDUH
SOAPIE # 2
S- Lisod kaau ilihok-lihok jud.Sakit akong tahi, as verbalized by the patient.
O- altered ability to move around/walk; difficulty in transferring from bed to chair and from
sitting to lying down to bed; needs assistance upon movement; noted facial grimace when trying
to move; respirations=18 breaths/min; abdominal incision at the midline
A- Altered Physical Mobility: weakness related to acute pain at the incision site
P- Promote and increase strength of the affected part for early ambulation
I- instructed to use side rails upon movement; scheduled activities with adequate rest periodsduring the day; assisted client upon movement; provided comfort measures when pain felt upon
movement;Observed movement when client is unaware of observation; Supported affected body
part using a pillow; encouraged participation in self-care, occupational or diversional orrecreational activities
E- sakit mn gihapon siya pero dili na kaau pareha ganiha ky naa namay pain reliever.
Makalihok-lihok nako ginagmay, as verbalized by the patient.
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Name of Patient: Mrs. Capuyan, Mary
Age: 49 years oldWard #: Gyne 10, 4B ward, CDUH
DRUG THERAPEUTIC RECORD
DRUG CLASSIFICATION/MECHANISM
INDICATIONS/
CONTRAINDICATIONS
PRINCIPLE OF
CARE TREATMENT EVALUAT
.Tramadol
Tramal)50 mg IVTT q
6H
Pharmacologic
Class:Opioid agonist,
analgesics
Mechanism of
Action:
Centrally actingsynthetic analgesic
compound not
chemically related toOpioisd that is
thought to bind toOpioid receptors andinhibit reuptake of
norepinephrine and
serotonin.
Relieves pain.
CI: hypersensitivity to
drug or any of itscomponents, patients
at risk for seizures
I: moderate to
moderately severe
pain
AE: CNS- anxiety,
confusion,
coordinationdisturbance, malaise,
dizziness CV- vasodilation GI- abdominal
pain, anorexia,
diarrhea, nausea and
vomiting, constipation
-For better
analgesic effect,give drug before
onset of pain.
-Because
constipation is a
common adverseeffect, anticipate
need for laxative
therapy.
-asses patients
condition beforestarting the
therapy
-assess patients
familys
knowledge ofthe drug therapy
-check renal andhepatic function
periodically
-encourage
patient to take
drug with food
if stomach upsetoccurs
-monitor intakeand output of
patient closely
-administer drug
as ordered by
the physician
The pain
relieved ttolerable
level, from
painscore8 to 5 in a
painscale
0-10 whe10 is the
most pain
and 0 ispainless.
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Name of Patient: Mrs. Capuyan, Mary
Age: 49 years old
Ward #: Gyne 10, 4B ward, CDUH
DRUG THERAPEUTIC RECORD
DRUG CLASSIFICATION/MECHANISM
INDICATIONS/
CONTRAINDICATIONS
PRINCIPLE OF
CARE TREATMENT EVALUAT
2.
MetronidazoleDazomet)
500 mg IV
drip q 8H x 3doses
Pharmacologic
class:Antibacterial,antiprotozoal,
amebicide
Mechanism of
Action:
Direct-actingtrichomonacide and
amebicide that work
at both intestinal andextraintestinal sites.
Hinders growth ofselected organisms,including most
anaerobic bacteria
and protozoa.
CI: hypersensitivity to
drug, used cautiouslyin patients with history
of blood dyscrasia or
CNS disorder,pregnant women
I: amebic hepaticabscess,
trichomoniasis,
bacterial infectionscaused by anaerobic
microorganisms, PID,Giardiasis
AE:CNS- confusion,
depression,
drowsiness, fatigue,fever
CV- edema,
thrombophlebitis GI- abdominal
cramping
-Give drug with
meals to minimizeGI distress.
-Use only after T.vaginalis has been
confirmed.
-Give drug for 7
days instead of 2g
single dose.
-Tell patient not
to use alcohol ordrugs that
contain alcohol.
-A metallic taste
and darks/red
brown urinemay occur.
-Take in withmeals.
-Proper hygiene.
Patient is
free frominfection.
The
occurrencinfection
prevented
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Name of Patient: Mrs. Capuyan, Mary
Age: 49 years oldWard #: Gyne 10, 4B ward, CDUH
HEALTH TEACHING PLAN
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Objectives Content Methodology Evaluation
General Objectives:
After 8 hours of student
nurse-patient interaction, the
client will be able to gainknowledge, attitude and
skills in the care of post-
operative patients of Total
Abdominal Hysterectomywith Bilateral Salpingo-
oophorectomy.
Specific Objectives:
After 45 minutes of
student nurse-patientinteraction, the client will be
able to:
1. define TAHBSO;
I. Definition
TAHBSO (Total Abdominal
Hysterectomy with Bilateral Salpingo-oophorectomy) is the removal of the
entire uterus and ovaries as well as the
cervix.
Informal
Discussion
The patient wasable to define
TAHBSO in her
own words.
2. identify the different
potential postoperative
complications;
II. Potential Complications
1. Incisional infection- an acute or
chronic condition in which theuterus, fallopian tubes and ovaries are
infected. The inflammation is the
result of infection spreading from an
adjacent organ or ascending from thevagina.
2. Hemorrhage- the escape of blood
from a ruptured blood vessel,externally or internally. Loss of
several liters of blood in a few
minutes may result in shock, collapseor death.
3. Urinary Tract Infection- are caused
by the presence of pathogenic
microorganisms in the urinary tractwith or without signs and symptoms,
maybe due to inability to or failure
to empty the bladder completely,catheterization and decreased host
defenses.
4. Bowel Obstruction- physicalblockage of the passage of intestinal
contents with subsequent distention
by fluid and gas.
5. Thrombophlebitis- inflammation of
the wall of a vein with secondary
thrombosis occurring within the
affected segment of vein.
Informal
Discussion
The patient was
able to restate the
possiblecomplications
discussed by the
student-nurse.
3. enumerate measures for
patient relief
III. Measures to relieve pain
1. Bed rest for the first 24 hours.2. Splint incision when moving or
Informal
Discussion
The patient was
able to identify bedrest and deep
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