Beruflich Dokumente
Kultur Dokumente
I. Social Status
Demographic Data
Mrs. Y is a 39 year old female, Born on August 1, 1970 via NSD by a midwife.
She is the eldest of the 11 siblings. The Family resides in Navotas Cardona, Rizal.
She has 5 offspring, 2 are working already while the remaining are still studying.
Socio-Economic Factor
Environmental Factor
Mrs. Y resides in a medium size house made up of concrete with 3 rooms and
2 large windows which resulted to good ventilation. The house is located in a
congested area. Artesian well is their source of water. Their excreta disposal is with
water carriage.
Mrs. Y is conscious and coherent, oriented to time and date, she is a high
school undergraduate and is able to read and write and follow instructions, able to
maintain eye to eye contact. Her chronological age is directly proportional to her
developmental age where her focus includes financial security, career and family
according to Sullivan’s stages of development. She is open and approachable and is
able to converse with the student nurses.
During Assessment, Mrs. Y talks about her childhood memories, showing that
her long term memories are still intact.
III. Emotional Status
Vision
Smell
Client’s nose has no deviation in terms of shape and size, nose is pointed and
no discharges were seen during assessment, according to the patient, she doesn’t
have any history of sinus infection or epitaxis.
Before the next procedure, permission was asked to the patient to do another
test, using a peeled apple and the skin of an orange, without the patient’s
knowledge, we ask her to identify the two samples by smelling. After smelling she
correctly identified the two fruits.
Test shows that there are no abnormalities or obstructions were identified in
the sense of smell.
Hearing
Taste
Mrs. Y’s lips were moist and symmetrical in shape; tongue is pinkish in color, no
presence of tooth
Decay, but there is a presence of tooth cavities, no dentures and no teeth loss, no
signs of gingivitis, buccal area are moist. We assess using a tongue depressor.
To assess her sense of taste, Patient is asked to do some test. She was asked
to taste a pinch of sugar and a pinch of iodized salt without knowing the two
samples are. After the test Mrs. Y identified the two samples correctly.
Touch
In assessing Mrs. Y’s sense of touch, she was asked to close her eyes, a
cotton ball was stroke to the back of her neck, then using another cotton ball, we
poured an alcohol on it and rubbed it on the same area, and she stated that she felt
a sensation of wet and cold on her skin.
Using the case of BP apparatus which is rough in texture and the medical kit
which is smooth in texture, the patient is asked to touch the two materials and ask
the texture while blindfolded. After the test, she correctly identified the difference of
two materials.
V. Motor Ability
Her chest expansion was symmetrical with ease during respiration. Rhythm
and respiration pattern are regular. She has an effective airway clearance and
effective breathing pattern which provide adequate gas exchange and results to a
good level of consciousness. Lungs were auscultated for adventitious sounds, after
auscultation, no adventitious sounds were heard. No supraclavicular or suprasternal
retraction were seen during inspiration
Taken at radial pulse, her capillary refill is within 1 to 2 seconds taken at right
forefinger, pulse scale is 2 + which is easily palpable.
Blood Pressure
Date and Time BP
September 21 120/80 mmHg
2pm
September 22 130/80 mmHg
8am
10:30am 100/60 mmHg
10:45am 110/70 mmHg
11:30am 100/70 mmHg
11:45am 120/80 mmHg
12:00pm 120/80 mmHg
12:30pm 120/80 mmHg
12:45pm 110/70 mmHg
1:00pm 120/90 mmHg
2:00pm 140/90 mmHg
September 23 130/90 mmHg
6 – 2pm
2 – 10pm 130/90 mmHg
September 24 130/90 mmHg
6 – 2pm
2 – 10pm 120/90 mmHg
Patient’s BMI
66.0kg
1.58m
=26.58 (overweight)
X. Elimination Status
Mrs. Y stated that prior to surgery; she defecates once a day every morning
with a semi-solid consistency without difficulty. She urinates 4 to 5 times a day
approximately 50 to 70cc per urination according to Mrs. Y’s statement. Urine is
amber in color.
After surgery, the patient has a diaper and IFC connected to urine bag with
amber color urine with a recorded urine output of 400cc with an IVF input of 700cc.
The IFC was removed on her 2nd day post-operation. She only defecates on the 3rd
day when she Dulcolax suppository was inserted.
She had a positive flatus but negative bowel movement in the first and second day
post-procedure.
1st Day Post Surgery 2nd Day Post Surgery 3rd day Post Surgery
>IFC was inserted. >IFC was removed. >Inserted Dulcolax
> (-) Bowel Movement >(-) Bowel Movement Suppository.
>(+) Flatus >(+) Flatus >(+) Bowel Movement
According to Mrs. Y, she had her menarche when she was 11 years old. With
an OB score of G7P5 (5025). She had 2 abortions more than 3 years ago because
according to Mrs. Y, she doesn’t want to have a child anymore. Abdominal Girth was
measured by using a tape measure, it measured 48cm. She had no history of any
surgical operations such as BTL and did not undergo Caesarian Section.
She uses oral contraceptive as her contraception or family planning method.
Prior to surgery, patient stated that she has vaginal bleeding with presence of
blood clot consuming 3 to 4 pads a day fully soaked with a bright red in color.
According to the patient her menstruation lasted 20 days that started in July of this
year accompanied with menstrual cramp and sometimes low back pain, her usual
menstrual period lasted 3 to 5 days.
Post-operatively, the patient stated “Dati nung di pa ako naooperahan
dinudugo ako at may konting buo-buo na dugo ngayon nawala na”.
XII. Physical Rest and Comfort
Prior to hospitalization, Mrs. Y sleeps 4 hours a day without any routine going
to sleep. She stated “Lagi akong puyat, apat na oras lang madalas ang tulog ko kasi
nagtitinda ako ng isda madaling araw pa lang, tapos basta may chance matulog ay
matutulog talaga ako kaso sandali lang talaga”.
Post-operatively, the patient usually sleeps within 6 to 8 hours at night and
wakes up during medication then she usually takes a nap at day time. Patient is
uncomfortable due to pain She stated during our post-op assessment to her
“pwedeng mamaya na lang, masakit talaga yung opera sa akin”. She usually lies on
bed.
Skin
Prior to operation, Mrs. Y have good skin turgor with no history of skin allergy,
no presence of tattoo, no bed sore, no skin lesions. Patient has a fair complexion.
After the surgery, the client’s skin turned into a slight pale in color in the
second day, temperature is warm to touch but with good skin turgor, and no
presence of bedsore were seen.
Hair
Presences of dandruff were seen during assessment, no lice were seen, and
patient has thick wavy hair.
Nails
Breast
Extremities
the patient was assessed for homan’s Signs; her legs was dorsiflexed, after
the test, the patient did not feel any calf pain and she don’t have any signs of
thrombophlebitis and edema in the lower extremities.
Pain
Prior to hospitalization, the patient stated “kapag meron ako, kumikirot lagi
puson ko”
Neck
Prior to operation, patient has no enlarged lymph nodes nor pain or stiffness
and no thyroid enlargement. After the operation, patient’s lymph nodes become
palpable.
NURSING PROBLEMS
The following are the nursing problems that have been established during
assessment.
-Encourage activities
that will divert -To diverts’ patients’
attention like perception of pain.
listening to music or
reading magazine.
>provide assistance
until patient is fully >lessens effort
able to assume self-
care
Dependent:
-administer pain
reliever as prescribed
such as toradol prior -to reduced pain
to bathing
Collaborative:
>Instructed and
assisted SO to clean
the patient’s body
>Promote grooming
with a wet towel of patient
>Stressed and
performed proper
hygiene and
grooming
to patient