A woman with Endometrial carcinoma EuIemia B.

Flores is 57-year-old was admitted at

the Chemotherapy area in the OB ward last November 03, 2011 at 11:20am.

Patient has no noted allergies in any Iood and medication. Patient wears eyeglasses and
she has dentures in the upper and lower quadrant. Patient`s recent stressor was having cancer.
She always prays Ior her health and her Iamily and Iriends was always there to support her. She
is calm and Ieeling anxious with Iacial grimace present.

Patient has good general appearance. She Ieeds herselI and eats 3 times a day. She has
normal skin color and has good skin turgor. She is able to ask Ior assistance whenever she wishes
to go to the bathroom. She was ambulated with assistance due to muscle weakness on her lower
extremities. Patient eats all and she is alert and clear. She has 3 or more chronic disease present
which is Cancer, Hypertension and Arthritis.

Patient knows that she has endometrial cancer and she is just waiting Ior her doctor to
arrive on Wednesday. She is willing that her Iamily will involve on her care and she is expecting
that she will stay in the hospital Ior 1 week.

Patient needs assistance when ambulating, eliminating, and dressing. She needs post
discharge assistance with ADLs/physical Iunctioning and her Iamily are capable oI and willing
to provide assistance post discharge.

Chief concern:
Headache and dizziness

HISTORY OF CHIEF CONCERN
EuIemia Flores is a diagnosed case oI Endometrial Carcinoma S/P TAHBSO, PFC,
BLNO 1 year PTA. Patient underwent Cobalt treatment and chemotherapy.
2 months PTA, patient had cough, productive with whitish phlegm. Consult done and
medication oIIerded no relieI on the condition. There was associated hoarseness oI voice and
throat sore.
1 month PTA, patient noted dizziness, out oI balance while walking. There was
associated mild headache at the cerebral area. Consult done. There is no associated vomiting and
diplopia. Condition persisted and Iorce consult.

Family Profile
The client lives with her Iamily at Palao, Bangued (Capital), Abra. She Iinished
secretarial and she is a housewiIe with 3 children. She is a roman catholic. Client denies tobacco
use, alcohol use and drug use.

History of past illnesses:
The patient was hospitalized because oI hypertension and heart disease. She undergone
operation last 2008 in Abra Provincial Hospital wherein a metal was inserted on her right leg.
She was also hospitalized when she was diagnosed with endometrial cancer. She had undergone
a surgical procedure which is TAHBSO last July 2010 in Abra provincial Hospital.

History of family illnesses:
Patient has Iamily history oI Hypertension.

Gynecological History:
Menarche at 14 years old; cycle duration: 30 days; duration oI menstrual Ilow: 3-4 days.
She used 2-3 pads per day. She is not experiencing dysmenorrheal while having her menstruation
period.

Obstetrical History:
G4 P3 (3, 0, 1, 3). Patient has her Iirst pregnancy last 1985 and the second was in the year
1987 and the third was 1991. In her Iourth pregnancy, the baby died in the year 1998. Every
pregnancy was planned because they have stable liIe with her husband. She always attended
hospital clinic Ior prenatal care.

ASSESSMENT

INTEGUMENTARY SYSTEM
Examined skin oI Mrs. Flores. UniIorm skin coloring (white) with pink undertones. Skin
on all areas but the hands is soIt and warm. Skin returns to position when pinched. Brown hair
and, shiny and evenly distributed. Nails are Iirm and the cuticle is pink and intact and without
ridging or pitting.

HEAD AND NECK
Examined head and neck oI Mrs. Flores. Patient denies history oI any sensory changes or
sensory diIIiculties. Overall skin coloring consistent, with pink undertones. Head symmetric and
normal in size. Eyes are symmetric. No lesions or redness noted. Red reIlex intact. Pupils are
equal and reactive to light. External and internal ears Iree oI discharge, lesions, or tenderness.
Nose and sinuses are nontender. Lips and mouth are Iree oI lesions. Carotid pulse strong
bilaterally. No bruits auscultated. Trachea is midline. Thyroid not enlarged. No lymph notes are
palpable.

THORAX AND LUNGS
Mrs. Flores states that she has productive cough with white phlegm Ior the past week and
Ieels weak. RR is ranging Irom 18-26 breaths/min.

CARDIOVASCULAR SYSTEM
Mrs. Flores denies chest pain. T36; BP130/80;P82bpm;RR26/min. Pulse has
normal rhythm.

ABDOMEN
Mrs. Flores denies abdominal pain. On physical examination, abdomen is soIt, slightly
distended, umbilicus midline, and no scars present.

NEUROLOGIC
Mrs. Flores is alert and oriented to person, place, and time. She has diIIiculty in talking.

MUSKULOSKELETAL
Mrs. Flores has muscle weakness in her lower extremities. She Ieels pain when she
coughs.

Mrs. Flores belongs to Middle adulthood.. During middle age, the primary developmental task is
one oI contributing to society and helping to guide Iuture generations. When a person makes a
contribution during this period, perhaps by raising a Iamily or working toward the betterment oI
society, a sense oI generativity- a sense oI productivity and accomplishment- results. In contrast,
a person who is selI-centered and unable or unwilling to help society move Iorward develops a
Ieeling oI stagnation- a dissatisIaction with the relative lack oI productivity.

Central tasks of Middle Adulthood
Express love through more than sexual contacts.
Maintain healthy liIe patterns.
Develop a sense oI unity with mate.
Help growing and grown children to be responsible adults.
Relinquish central role in lives oI grown children.
Accept children's mates and Iriends.
Create a comIortable home.
Be proud oI accomplishments oI selI and mate/spouse.
Reverse roles with aging parents.
Achieve mature, civic and social responsibility.
Adjust to physical changes oI middle age.
Use leisure time creatively.