MANILA DOCTORS COLLEGE

Pres. Diosdado Macapagal Blvd., Metropolitan Park Pasay City

NURSING PROCESS

In Partial Fulfillment of the Course Requirement In NCM 103: RLE

PAIN ON THE LEFT LOWER QUADRANT RELATED TO SURGICAL RESSECTION

I.

ASSESSMENT A. General Data Patients Initials: T, E Address: Makati City Age: 65 years old Sex: Male Date of Birth: 02/25/1947 Occupation: N/A B. Chief Complaints Pain on the right lower quadrant of the abdomen, vomiting and experiencing headache. Informant: E.J and J.J (daughter and son) Date of Admission: June 20, 2011 Order of Admission: Carried by the relative No. of days in the hospital: 14 days Civil Status: Married

C. History of Present Illness August 2010 - The patient had experienced pain on right lower quadrant of the abdomen and they went to the hospital in Philippine General Hospital for consultation. He undergone biopsy and colonoscopy. The results strongly suggested Colon Cancer. February 2011 The patient and his family decided to go back to the hospital and he undergone a surgical ressection of the affected colon. 2 weeks prior to admission- The patient complained again of tolerable pain (pain scale 4) at the right lower quadrant of the abdomen, vomiting, he managed it by resting. Few hours prior to Admission - The patient made complaints of headeache and pain in the Right Lower Quadrant of his abdomen. The family decided to immediately bring the patient to the hospital and was confined at Manila Doctors Hospital. D. Past History 1. 2. 3. 4. 5. 6. 7. Childhood Illness: None Adult Illness: Hypertension and Diabetes Mellitus, Colon Cancer Adult Immunization: Complete Previous Hospitalization: January 2010- Biopsy and Colonoscopy at PGH Operations: February 2010 Injuries: None Medications prior to confinement: Micardis for Hypertension Metformin for DM

8. Allergies: None E. System Reviews (GORDONS)

1. Health Perception Health Management According to the clients son, prior to confinement, the health perception of his father is always positive, even though he has chronic hypertension and diabetes and has been diagnosed of cancer last ( July 7, 2010). He does not think that his condition will hinder him from functioning well. He maintains his health by taking his maintenance medication (micardis) for his hypertension and (metformin) for his diabetes. Also by exercising regularly and taking enough rest, he also has an executive check up once or twice a year and adheres to doctors orders when he consults his physician. During confinement, his father still has a positive attitude and has high hopes for his recovery. He now maintains his health by strictly following medication regimens and orders of his physician, also by accepting treatments and procedure; because he wants to recover as fast as possible. The general appearance of the patient is neat and well groomed; he is drowsy on the day of interview but can understand questions and affirms questions by nodding. 2. Nutritional Metabolic Pattern Before confinement, the patient drinks 4-6 glasses of water a day; he also drinks coffee in the morning. He eats fruits like mangoes and bananas regularly. Even though the client has hypertension the client likes to eat meat, especially when it is grilled. He also likes to eat rice on his meals but as much as possible he limits it to 1 cup, also he eats fishes and vegetable, because it is encouraged by his doctor. The patient has no difficulty in eating and has a strong appetite. Fats and excessive carbohydrates and sweets are restricted from the clients diet but he still eats food with such when he wants, but only on a minimal amount. During confinement the patient is on NPO because his status is post surgery. 3. Elimination Pattern Before confinement, the patient urinates for about 3-5 times a day. His urine, as characterized by his son, is colorless to yellowish in color. Patient did not experience any excessive urination and pain. The patient perspires a lot when its hot and after doing strenuous activities such as his daily walking and exercising in the morning. Patient moves his bowel once a day, and stool is solid brown in

color. The patient noted alternating diarrhea (character is watery and moderate in amount) and constipation before he was diagnosed of colon cancer. During his confinement the patient did not experience any changes or difficulty in urination nor defecation. But after surgery his bowel movement was not active, but his urination did not change. 4. Activity-Exercise Before confinement, the patient has sufficient energy when doing activities such as routine self care and other necessary chores. The patients source of exercise is by using a treadmill about 30 minutes to 1 hour every morning. During leisure time, the patient watches TV and has small chats with his neighbors or other family members, he also likes to read the news paper and listen to the radio. During the confinement the patient activity is limited, before operation he only walks from his bed to the bath room and for leisure, he watches TV and reads the news paper. After his surgery the patient is on complete bed rest with out bathroom privileges. 5. Sleep-Rest Before confinement, the patient wakes up at around 5:30 in the morning . And at night, the patient sleeps around 9:00 or 10:00 pm. Before sleeping, the patient usually watches TV. He does not experience problems in sleeping Patient does not experience any nightmares or early awakenings. During confinement, patients son mentioned that his father sleeps almost all day in the hospital. The patient usually wakes up around 6:00 in the morning and will stay awake for a few minutes but he would tend to sleep again. He had slight difficulty in sleeping on the first night of his hospitalization but it did not occur in the succeeding nights. 6. Cognitive-Perceptual Before confinement, his son said that the patient does not experience difficulty in hearing. He can also hear whispered words and does not wear any hearing aids. The patient uses eye glasses for reading. The patient has good attention span and does not get easily distracted by external stimuli. There is no impairment on his sense of smell, taste and touch. Patient is assertive; he can easily express what she wanted to say. On decision making they discuss it with his family. The patient speaks Tagalog language. During confinement, the patient can hear them when he is being asked and he responds by nodding. Patient is drowsy upon the interview. After the surgery he is temporarily dependent on his sons decision making, he has also difficulty in moving but has no changes in sensorium. 7. Self perception- Self concept Before confinement, the patients son describes him as a person who is always happy and as someone who loves to crack jokes and be positive all the time. The patient thinks well before making decisions. He finds strength from God and his family. His family is his support whenever he has problems. It worries him a lot when they are having some family problems and misunderstandings. According to the patients son, he sees his father as someone who is very strong because he can cope up with problems and changes in his life without being hopeless. During confinement, the patient communicates by nodding when affirming questions, according to his son; he can still see the optimistic side of his father despite his present condition. 8. Role-Relationship The patient is in a nuclear family. Before confinement, the relationship of the patient to his family members is fine, even though his sons are out of the country; they still maintain an open communication. He is now retired from work, but still performs a paternal role in his family, by giving advice to his sons and taking care of his grand children. During confinement, the relatives of the patient felt sad because of his condition, but still they are praying and hoping for the patients recovery. The relationship of the patient to his family did not change at all, in fact his condition brought his family together. 9. Sexuality- Reproductive According to the patients son, the patient can easily get along with others and can easily make friends. He is not sexually active anymore.

10. Coping/Stress Tolerance According to the patients son, the patient experiences stress, but handles it by resting; by means of lounging in the house or sleeping and doing leisure activities, like reading the news paper or watching TV, sometimes he goes out with the family, and also according to his son, being an optimist surely relieves the stress of his father. During confinement, the patient is in stress, but he relieves it by resting and being positive, also it is relieved when there are family members and friends that visit him. 11. Values/Belief Patient is a Catholic and he goes to mass during Sundays whenever he has the time. Patients son mentioned that he knows that his father has a strong faith in God and knows that God will always help them in everything he does. Patients son said that they believe that everything happens for a reason and God would not give us challenges that we cannot resolve. God is their source of strength. He does not get everything that he wants in life due to some reasons. The patient always wanted his children to have a good life.

F. Family Assessment Relation MI M.J E.J J.J Wife Daughter Son Age 62 36 31 Sex Female Female Male Occupation Professor Call Center Agent Nurse Educational Attainment College Graduate College Graduate College Graduate

G. Heredo- Familial Illness Maternal: Diabetes and Cancer Paternal: Hypertension

H. Developmental History
THEORIST Psychosexual Theory Freud AGE 65 TASK GENITAL STAGE PATIENT DESCRIPTION The patient was observed to have capable and distinct relationship with others especially to his children. When he was confined, the closeness with his family and other significant people bind much more than before since he suffered from pressure and stressed. His family is always there for him to give what he needs and wants not just materially but through comfort and care all the time. The patient as a father, though he was retired from his work, he still gives the needs of all the family members as much as he can, thats why he feels useful and accomplished. He feels success because he contributes to the world by being active not just in their home but in the whole community according to his son. On the other hand, now hes confined, he feels unproductive, according to his son, but still he always thinks positive and praying for his recovery.

Psychosocial theory Erickson

65

GENERATIVITY VS. STAGNATION

Cognitive Theory Piaget

65

FORMAL OPERATIONAL STAGE

Moral Theory Kohlberg

65

POST CONVENTIONAL MORALITY STAGE

Spiritual Theory Fowler

65

Conjunctive faith

During the interview, his children answer all the questions for us. When he was not confined, in terms of decisioning, he really depends on himself alone but when it comes on major decisioning, he consults his family. As of now, his family is the one who gives and always finds time to talk to him in order to reduce his anxiety and loneliness due to his condition. He always relies on his family whenever he has difficulties by softly speaking, and through nodding . The patient loves all the significant persons that is very special to him. When they have excess money they give solicits to their barangay according to his family it will help, to become their community a productive one. He complies on all the given laws. Hes very accountable and do everything under the rules and regulations. His actions are very careful for him to prevent consequences that might affect his loved ones according to his children. As a n older adult he is very much open to other. He respects his fellowmen on what beliefs they are believing and owed to. He accepts everyones opinions and suggestions, he let the reality speak for itself, regardless of its impact on him. Hes the one who has the initiative to discover new things, and ones he discovered it he value it for the sake of others.

I. Physical Assessment
Date: July 4,2011 (4:00pm) Height: 152.4 cm Usual weight: 180 lbs Actual Weight: 190 lbs Ideal Body Weight: 19.18kg/m2

Vital Signs Temperature: 36.9 C PR: 78 bpm RR: 20 cpm BP: 130/70mmHg Regional Examination A. Skin and Hair I: Skin color is brownish Some macula light brown in color on both arms dry skin unevenly distributed hair, less hair on parietal area P: uniform warm temperature; absence of edema when skin is pinched, it returns back to original form in a 4 seconds poor skin turgor B. Nails I: P:

fingernails have convex curvature; pinkish in color; intact skin; clean good capillary refill in 2 seconds

C. Head and Face

I: P: smooth, absence of nodules or masses D. Eyes I: E. Ears I: P: F. Nose I: P: symmetric, normocephalic, rounded shape; symmetric facial features and movements; no edema or hollowness of the eyes

evenly distributed eyebrows, intact skin; outward curl of eyelashes, able to blink, bulbar and palpebral conjuctiva are pink in color, no lesions; watery eyes no tenderness of the lacrimal gland, sac, nasolacrimal duct; transparent cornea, smooth, eye blinks with corneal sensitivity; black, round pupil, grayish-blue lens of the eyes constricts in direct and indirect consensual response, constricts at far objects and dilates at near objects, converges; can see peripheral views; eyes are coordinated; covered eye doesnt move; cannot read newsprints

Presence of rashes on back of the ear no impacted cerumen, same color as the face, elastic, cannot hear ticking of watch can hear normal voice sound no tenderness or edema

same color as the face, no lesions, no edema, midline nasal septum; pinkish mucosa, presence of cilia, no tenderness on the sinuses

G. Mouth and Pharynx I: symmetric contour, able to purse lips, pinkish lips gums are pinkish in color, uses full dentures uvula is at the midline between tonsils; tongue is at the midline; reddish tonsils presence of gag reflex P:

 no nodules, masses H. Neck I: P: I. Spine I: P:

no abnormal swellings or masses, able to move the neck in several directions, thyroid gland moves up when swallowing, no enlargement of thyroid gland palpable submandibular lymph nodes, midline trachea

Kyphotic posture Straight spinal column Spine vertically arrange No deformities and contracture No swelling No lessions no tenderness, no masses or lumps

J. Thorax and Lungs A. Posterior I: Kyphotic posture, position of the spine is at midline Pal: No lumps, masses; no tenderness; no problem with chest excursion; fremitus over the lung region Per: resonant over lung area except between scapula A: ronchi heard B. Anterior I: no deformities, no lesions, no scars P: no masses, no tenderness P: vesicular over lung area A: ronchi heard K. Cardiovascular/Heart I: no lifts or heaves no vein distension and engorgement no visible pulsations P: PR is 78 bpm A: pulse beat is best heard at the apical area L. Abdomen I: Skin over the abdomen is brown in color, inverted umbilicus, symmetric contour, round, distension presence of lesion swelling at the left lower quadrant

incision on the left lower quadrant

A: audible bowel sounds, 7 borborygmic per minute absence of arterial bruits and friction rub Per: Not assessed, refused Pal: Not assessed, refused

M. Extremities I: equal size of muscles, no contractures, no tremors, flaccid, equal muscle strength, no swelling of joint Presence of macula Presence of scratches P: no edema, no tenderness ROM: able to flex, hyperextend, extend N. male Genitals I: has presence of rugae no lesions no tenderness no discharge with presence of pubic hair in the pubic area O. Rectum and Anus Not assessed, refused P. Appearance and Mental Status Well-oriented Body build fits age and lifestyle No body and breath odor Appropriate responses Thoughts are relevant Conscious Alert and awake No signs of distress

II. Personal/Social History

Habits: Watching television, reading newspaper, using treadmill for 30 mins-1hr, listening to radio Vices: None Lifestyle: The client has sedentary lifestyle. Social Affiliation: None Clients usual day like: He wakes up at around 5:30 in the morning and then eats breakfast. After eating, he will watch television for 2-3 hours then go for an exercise for 30 mins- 1 hour. He will rest for 15-30 minutes, then he will eat for his lunch. Afterwhich, around around 1-2PM he will watch television again, and then take a nap for 2-3 hours. 5 PM he will read newspaper then he will listen to the radio, if not he will go out to chat is friends and neighborhood. Sometimes he will water their plants and then, at 6 PM he will have his dinner. At 7 PM he will watch television again then around 9 or 10 in the evening he will go to sleep. Rank in the family: Father Travel: The client went to USA, HK, and Vietnam. Educational attainment: College Graduate

III. Environmental History

The patient is residing in a quiet and peaceful place of Makati City with a mixed and owned type of house. The client is currently living at a 2-storey house. Their house has 3 bedrooms with good ventilation (5 windows for the whole house), 4 comfort rooms with a flushed-type system, and then adequate living room and dining area. Their water is MAYNILAD, they used it for bathing, washing as well as for their drinking. Some vectors can be seen in their house, they use insecticide to kill it. Their electricity is supplied by MERALCO. Churches, hospitals, drugstores, market place are easily reach. Transportation is not a big deal, jeepneys, pedi

cabs, tricycles are very much available. The collection of garbage in their community is twice a week. Food is properly kept and covered or else place in refrigerator.