assessment htp

8/3/2019 Assessment Htp

1/14

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


2/14

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


3/14

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.


4/14

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


5/14


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


6/14


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


7/14


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.


8/14

Name of Patient: Mrs. Capuyan, MaryAge: 49 years old


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.


9/14



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.


10/14


Age: 49 years old


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


11/14



HEALTH TEACHING PLAN


12/14

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


13/14


14/14

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