DAY 1

SYSTEM SUBJECTIVE
OBJECTIVE PROBLEM IDENTIFIED
AM PM
GENERAL
APPEARANCE
"Sakit kayo ang gi
operahan sa ako , as
verbalized by pt.

P- incision site
Q- excruciating
R- abdomen(incision
site)
S-8/10
T- continuous

Awake, alert and conversant,
lying on bed, oriented to time
and place, with patent VF of
D5LR @ 30 gtts/min.
Awake, alert ,coherent, conversant,
lying on bed in low fowler's position
with Plain LR @ 40 gtts/min, with
FBC, epidural catheter and
penrose, facial mask grimacing,
weak (due to incision)

ACUTE PAIN


Risk for infection




NEUROLOGIC

"Wala raman ko
nalipong

-ntact cranial nerves
-cooperative
-well-oriented to time, place
and person
-patient was able to smile,
raise eyebrows, frown, puff
out cheeks, close eyes
-good sensation to pain


-ntact cranial nerves
-cooperative
-well-oriented to time, place and
person
-patient was able to smile, raise
eyebrows, frown, puff out cheeks,
close eyes
-good sensation to pain

No probIem identified
INTEGUMENTARY

"wala raman ko
nangatul

-With incision at right upper
quadrant of the abdomen
-Warm to touch
-Dry intact dressing
-Temp-35.9
-No edema and cyanosis
noted

-With incision at right upper
quadrant of the abdomen
-Warm to touch
-Dry intact dressing
-Temp-36.5
-No edema and cyanosis noted
IMPAIRED SKIN INTEGRITY
RISK FOR INFECTION
HEAD AND HAIR

"labad ako ulo Head:
O Symmetry of facial
movements
Head:
O Symmetry of facial
movements
ACUTE PAIN
O No wounds noted
O intact
Hair:
O equal hair distribution

O No wounds noted
O intact
Hair:
O equal hair distribution

EYES





EARS


NOSE






THROAT


MOUTH


"Dili raman magsakit
ako mata

"Dili rapud sakit
i.tulon
O Blurring of vision(-)
O Conjunctiva moist, no
drainage, no lid lag,
symmetrical to ear.

O No discharges and
bleeding
O Hearing intact

O Patent airway
O No discharges
O No tenderness
O No masses
O No nasal flaring

O Present gag reflex

O Dry lips and buccal
mucosa
O No signs of cyanosis
O Presence of caries
O No lesions or ulcers

O Blurring of vision(-)
O Conjunctiva moist, no
drainage, no lid lag,
symmetrical to ear.

O No discharges and bleeding
O Hearing intact

O Patent airway
O No discharges
O No tenderness
O No masses
O No nasal flaring

O Present gag reflex

O Dry lips and buccal mucosa
O No signs of cyanosis
O Presence of caries
O No lesions or ulcers

No probIem identified
NECK
"Dili raman sakit ug
ilihok nako ako liog
-no palpable lymph nodes
-no jugular vein distention
noted
-no palpable lymph nodes
-no jugular vein distention noted No probIem identified
RESPIRATORY
SYSTEM
"Wala raman ko
naglisud ug ginhawa
-RR- 21bpm
-No use of accessory muscle
-Equal cheat expansion, clear
breath sound
-RR-21
-No use of accessory muscle
-Equal cheat expansion, clear
breath sound



-no presence of cough -no presence of cough
CARDIOVASCULAR
"Wala raman gasakit
ako dughan
-PR=64 bpm
-BP=90/60 mmHg
-No murmur
-Palpable pulses in
extremities
-PR=59 bpm
-BP=70/40 mmHg
-No murmur
-Palpable pulses in extremities
DECREASED CARDIAC OUTPUT
GIT/
ABDOMEN
-no episodes of vomiting
-on NPO
-Round and soft
-no episodes of vomiting
-Absence of bowel sounds
-Dry intact dressing
-Round and soft
-Positive tenderness (pain)
No probIem identified
GUT

-yellowish urine
- no hematuria and dysuria
-Output: 800mL
-yellowish urine
- no hematuria and dysuria
-Output: 1160mL
No probIem identified
MUSCULOSKELETAL
-No body weakness
-able to move without
assistance
-Body weakness
-Limited mov't due to pain BODY WEAKNESS
DAY 2
SYSTEM SUBJECTIVE
OBJECTIVE PROBLEM IDENTIFIED
AM PM
GENERAL
APPEARANCE
"Medyo sakit pa sya
gamai , as verbalized
by pt.

P- post-op incision
site
Q- tolerable pain
R- abdomen (incision
site)
S-3/10
T- upon movement
Awake, alert and conversant,
lying on bed, oriented to time
and place, with patent VF of
D5LR @ 30 gtts/min, with
epidural cather, FBC and
penrose drain in place, on
NPO.
Awake, alert and oriented, memory
intact able to provide history. in a
semi- fowlers position, with VF
D5LR @40gtts/min , with FBC,
epidural catheter and penrose drain
ALTERED BODY COMFORT : ACUTE PAN
NEUROLOGIC
"Wala raman ko
nalipong
-ntact cranial nerves
-cooperative
-well-oriented to time, place
and person
-patient was able to smile,
raise eyebrows, frown, puff
out cheeks, close eyes
-good sensation to pain

-ntact cranial nerves
-cooperative
-well-oriented to time, place and
person
-patient was able to smile, raise
eyebrows, frown, puff out cheeks,
close eyes
-good sensation to pain





No probIem identified
INTEGUMENTARY
"wala raman ko
nangatul
-With incision at right upper
quadrant of the abdomen
-Warm to touch
-Dry intact dressing
-Temp-36.2
-No edema and cyanosis
noted
-With incision at right upper
quadrant of the abdomen
-Warm to touch
-Dry intact dressing
-Temp-37.2
-No edema and cyanosis noted
IMPAIRED SKIN INTEGRITY

RISK FOR INFECTION

HEAD AND HAIR

"wala raman ga.sakit
ako ulo
Head:
O Symmetry of facial
movements
O No wounds noted
O intact
Head:
O Symmetry of facial
movements
O No wounds noted
O intact

Hair:
O equal hair distribution

Hair:
O equal hair distribution

EYES





EARS


NOSE






THROAT


MOUTH


"Dili raman magsakit
ako mata

"Dili rapud sakit
i.tulon
O Blurring of vision(-)
O Conjunctiva moist, no
drainage, no lid lag,
symmetrical to ear.

O No discharges and
bleeding
O Hearing intact

O Patent airway
O No discharges
O No tenderness
O No masses
O No nasal flaring

O Present gag reflex

O Dry lips and buccal
mucosa
O No signs of cyanosis
O Presence of caries
O No lesions or ulcers

O Blurring of vision(-)
O Conjunctiva moist, no
drainage, no lid lag,
symmetrical to ear.

O No discharges and bleeding
O Hearing intact

O Patent airway
O No discharges
O No tenderness
O No masses
O No nasal flaring

O Present gag reflex



O Dry lips and buccal mucosa
O No signs of cyanosis
O Presence of caries
O No lesions or ulcers

No probIem identified
NECK
"Dili raman sakit ug
ilihok nako ako liog
-no palpable lymph nodes
-no jugular vein distention
noted
-no palpable lymph nodes
-no jugular vein distention noted No probIem identified
RESPIRATORY
SYSTEM
"Wala raman ko
naglisud ug ginhawa
-RR- 21bpm
-No use of accessory muscle
-Equal cheat expansion, clear
breath sound
-no presence of cough
-RR-22 bpm
-No use of accessory muscle
-Equal cheat expansion, clear
breath sound
-no presence of cough

CARDIOVASCULAR
"Wala raman gasakit -PR=64 bpm -PR=78 bpm



ako dughan -BP=90/60 mmHg
-No murmur
-Palpable pulses in
extremities
-BP=120/80 mmHg
-No murmur
-Palpable pulses in extremities
GIT/
ABDOMEN
"sakit ako tinahian

P- post-op incision
site
Q- tolerable pain
R-abdomen (incision
site)
S-3/10
T- upon movement
-no episodes of vomiting
-on soft, no fat diet
-dry intact dressing
-Round and soft
-no episodes of vomiting
-Absence of bowel sounds
-Dry intact dressing
-Round and soft
-Positive tenderness (pain)
Risk for infection

ALTERED COMFORT: PAIN
GUT

-with FBC
-yellowish urine
- no hematuria and dysuria
-Output: 1100
-with FBC
-yellowish urine
- no hematuria and dysuria
-Output: 1300mL
Risk for infection
MUSCULOSKELETAL
-No body weakness
-able to move without
assistance
-no body weakness

DAY 3
SYSTEM SUBJECTIVE
OBJECTIVE PROBLEM IDENTIFIED
AM PM
GENERAL
APPEARANCE
"ok nako compare
kagahapon
Awake, alert and conversant,
lying on bed, oriented to time
and place, able to walk, with
patent VF of D5LR @ 40
gtts/min.
Awake, alert and oriented, memory
intact able to provide history. in a
semi- fowlers position, with VF
D5LR @ 20 gtts/min.

NEUROLOGIC
"Wala raman ko
nalipong
-ntact cranial nerves
-cooperative
-well-oriented to time, place
and person
-patient was able to smile,
raise eyebrows, frown, puff
out cheeks, close eyes
-good sensation to pain

-ntact cranial nerves
-cooperative
-well-oriented to time, place and
person
-patient was able to smile, raise
eyebrows, frown, puff out cheeks,
close eyes
-good sensation to pain


INTEGUMENTARY
"wala raman ko
nangatul
-With incision at right upper
quadrant of the abdomen
-Warm to touch
-Dry intact dressing
-Temp-35.7
-No edema and cyanosis
noted
-With incision at right upper
quadrant of the abdomen
-Warm to touch
-Dry intact dressing
-Temp-35.6
-No edema and cyanosis noted
IMPAIRED SKIN INTEGRITY
RISK FOR INFECTION
HEAD AND HAIR

"labad ako ulo Head:
O Symmetry of facial
movements
O No wounds noted
O intact
Hair:
O equal hair distribution

Head:
O Symmetry of facial
movements
O No wounds noted
O intact
Hair:
O equal hair distribution


EYES


"Dili raman magsakit
ako mata

O Blurring of vision(-)
O Conjunctiva moist, no
O Blurring of vision(-)
O Conjunctiva moist, no




EARS


NOSE






THROAT


MOUTH


"Dili rapud sakit
i.tulon
drainage, no lid lag,
symmetrical to ear.

O No discharges and
bleeding
O Hearing intact

O Patent airway
O No discharges
O No tenderness
O No masses
O No nasal flaring

O Present gag reflex

O Dry lips and buccal
mucosa
O No signs of cyanosis
O Presence of caries
O No lesions or ulcers

drainage, no lid lag,
symmetrical to ear.

O No discharges and bleeding
O Hearing intact

O Patent airway
O No discharges
O No tenderness
O No masses
O No nasal flaring

O Present gag reflex

O Dry lips and buccal mucosa
O No signs of cyanosis
O Presence of caries
O No lesions or ulcers

NECK
"Dili raman sakit ug
ilihok nako ako liog
-no palpable lymph nodes
-no jugular vein distention
noted
-no palpable lymph nodes
-no jugular vein distention noted
RESPIRATORY
SYSTEM
"Wala raman ko
naglisud ug ginhawa
-RR- 19 bpm
-No use of accessory muscle
-Equal cheat expansion, clear
breath sound
-no presence of cough
-RR=24 bpm
-No use of accessory muscle
-Equal cheat expansion, clear
breath sound
-no presence of cough

CARDIOVASCULAR
"Wala raman gasakit
ako dughan
-PR=63 bpm
-BP= 100/60mmHg
-No murmur
-Palpable pulses in
extremities
-PR= 72bpm
-BP=110/70mmHg
-No murmur
-Palpable pulses in extremities

GIT/
ABDOMEN
"Dili naman sakit ako
tinahian
-no episodes of vomiting
-on soft, no fat diet
-no episodes of vomiting
-Dry intact dressing


"dili rapud sya sakit ug
mutulon
-Round and soft -Round and soft
GUT

-yellowish urine
- no hematuria and dysuria

-yellowish urine
- no hematuria and dysuria


MUSCULOSKELETAL
-able to move without
assistance
(-) body weakness
-able to walk and sit without
assistance
(-) body weakness