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Demographic Data and Nursing History

Name: T. F. L Sex: Male Age: 77 y/o Race: Asian Occupation: Carpenter Birth Date: 08/03/34 Nationality: Filipino Educational Attainment: High School Undergraduate Address: Sta. Catalina Place of Birth: Sta. Catalina Civil Status: Widowed Religion: Roman Catholic Room and Bed Number: MPS Doctor(s) in charge: Dr. Mark Anthony Aranas

Date and Time of Admission: January 30, 2012; 10:16 am Date and Time History was Taken: February 3, 2012; 1:30 pm

Chief Complaints Pain primarily at the umbilical area rated as 8 over 10, and persistent nausea and vomiting. History of Present Illness October of 2011, patient started to feel on and off pain over his abdomen. Rated 4 over 10 (10 as the highest) by then. A month after, began to felt change in bowel movement (decreased frequency and amount) and appetite. Last December, recognized a sudden drop of his weight with increased in the intensity of the pain in his abdomen (umbilical area), now rated 7 of 10. Decided to have a check-up and was prescribed with acetaminophen, buscopan and ranitidine by Dr. Corbadilla. However, the pain was still not resolved. Last January 21, 2012, persistent nausea and vomiting in large amounts was experienced along with severe abdominal pain all over his abdomen, rated 10 of 10. Immediately went to Holy Child Hospital, and from them, endoscopy and biopsy was done per order by Dr. Carriaga. Instructed to take in only milk (sustagen) while waiting for the results, pain relievers were prescribed. On January 30, 2012, a mass growth at his antrum was ruled out, and has decided to have it removed at the soonest time possible which then lead to his admission at NOPH surgery ward companied by his son, Rodrigo Tomias, on the same day at 10:16 am.

General Impression of Client Client lying in bed is awake, alert and responsive to external stimuli; oriented to time, place and person. Developmental level is on old age. With #2 D5LR infused at 30 gtts/min at left metacarpal vein with #5 Aminogen 500 ml 16 gtts/min via sidedrip. With NGT tube inserted at left nostril, drainage bag empty of gastric contents. Observed to have difficulty in speaking which he associated with the NGT tube at his pharynx. Complained of unending pain over the umbilical region of his abdomen rated as 5 of 10 (10 as the highest). Verbalized also fear for the upcoming operation, lack of sleep and hunger. However, was seen as calm and peaceful. Observed to have dry mouth and pale mucous membranes. Abdomen is hard and rigid when palpated lightly. Able to answer HWs questions with clarity and objectivity.

Functional Health Patterns


Usual Functional Health Pattern Initial Appraisal (February 3, 2012) On-going Appraisal (February 3, 2012) Health Perception- Health Management Pattern
Claims of his life as happy, and in content with everything he has and had done. Seldom experiences colds, cough and fever. Usually drinks plenty of water and herbal preparation (lagundi) as forms of relief. Claimed to have no pulmonary diseases or any experience of difficulty in breathing. Client is conscious and responsive. Claims of having no signs of mental illness. No history of convulsions and seizures. Significant other verbalized, himsog ra man na si papa, karon lang jud na siya nagkasakit Uses the following to keep self healthy: - Increased in intake of vegetables and fruits - Regular exercise and active lifestyle through his work as a carpenter - rest and water therapy - usually watches tv as form of relaxation and recreation. Never had undergo any major operations in any part of his body Stopped smoking and intake of alcoholic beverages since he got married when he was Complained of pain over his abdomen primarily at his umbilical area, rated as 5 of 10 (10 as the highest). Verbalized, sakit jud, dili mawala when asked to characterized the pain. Daughter in law verbalized, maygani run kay dili na kayo, nakainom man gud siya ug tambal Daughter in law verbalized, basta magsige na gani na siya ug lihok, dira mi makabalo nga sakit napud kayo ang iyang tiyan. Abdomen is hard and rigid over all quadrants when lightly palpated. Claims that ganahan ko maayo na para makauli nako Client is conscious and responsive upon contact with HW. Observed to be tired and sleepy with minimal movement as he lies in bed. Client is observed to be cooperative. Has some physical limitations in movement due to venoclysis at left arm, presence og NGT tube and abdominal pain. Daughter in law claimed, mayagni nipirma rapud siya dayon nga magpaopera siya haron matangtang ng Claimed, 5 japon when asked to rate pain in his abdomen. Verbalized, wala paman gud ko naoperahan kay kulang pakuno ug dugo Abdomen is hard and rigid over all quadrants when lightly palpated. Observed to be tired and sleepy with minimal movement as he lies in bed. Client is observed to be cooperative. Has some physical limitations in movement due to venoclysis at left and right arm, presence og NGT tube and abdominal pain. Has #2 D5LR infused at 30 gtts/min at left metacarpal vein with #5 Aminogen 500 ml 16 gtts/min via sidedrip. Has #1 PNSS 1 L infused at KVO rate at right metacarpal vein With NGT tube inserted at left nostril, drainage bag empty of gastric contents. No current laboratory results Medications include: Ampil Salbactam 750 mg q8h qNST Metronidazole 500g q8h IVTT Ranitidine 50 mg q8h IVTT

22 y/o. No chest pain, palpations, murmurs, HTN, DM, coldness/numbness/color changes in hands or feet, varicose veins, or swelling. Claimed of having no allergies since birth. Claimed to be fully immunized since birth. Hospitalized only once due to a vehicular accident when he was 55 y/o. Does not consider it as a serious injury. Verbalized, maau, makalingaw when asked about his perception of his previous life.

tumor sa iyang tiyan. Claims, sige kog pangihi, ikadaghan Claims, kulang kog tulog diri when asked if hes feeling alright with his stay in the hospital. Claims, wala raman pud ko hilanti atong gasakit ni akong tiyan, pero namiba lang jud akong timbang Had bed bath since admission. Finds easy to follow doctors order. Undergone biopsy and endoscopy as diagnostic tests. Verbalized fear regarding the upcoming surgery. Family members feel relieved that heir father would undergo surgery to removed to tumor in his antrum. Has #2 D5LR infused at 30 gtts/min at left metacarpal vein with #5 Aminogen 500 ml 16 gtts/min via sidedrip. With NGT tube inserted at left nostril, drainage bag empty of gastric contents. Medications include: Ampil Salbactam 750 mg q8h qNST Metronidazole 500g q8h IVTT Ranitidine 50 mg q8h IVTT Vitamin K 1 amp IVTT q8h Laboratory results are as follows: Urinalysis: Color: yellow Transparency: Shagy Specific Gravity: 1.015 Glucose: neg Urobilinogen: neg Protein: neg pH: 6.5 Microscopic Examinaton of Urine: Pus cells: 1-3/hpf RBC: 30-40/hpf

Vitamin K 1 amp IVTT q8h Captopril 1 tab SL q8h prn Bp>160 As of 8am, V/S were recorded as: T= 36.8C P= 69 bpm, regular and bounding. R= 19 cpm, effortless and regular Bp=160/90 mmHg As of 12nn, V/S were recorded as: T= 37.2C P= 84 bpm, regular and bounding. R= 18 cpm, effortless and regular Bp=150/80 mmHg

Bacteria: moderate Mucus Thread: neg Urates: few Blood Chemistry Na: 131.9 mmol/L RBS: 99 mg/dL BUN: 43 mg/dL Creatinine: 1.45 mg/dL ABO: AB+ CBC WBC: 10.5 K/uL Hgb: 9.0 Hct: 25.1 Platelet: 398 K/uL Lymphocyte: 15 % Monocyte: 7% Neutropjils: 75% Eosinophils: 2% Basophils: 1% As of 12 noon, V/S were recorded as: T= 37.6C P= 83 bpm, regular and bounding. R=22 cpm, effortless and regular

Nutritional- Metabolic Pattern


Wt: 86 kg, Ht: 59 Usually eats 3 times daily with snacks in between meals. Estimates his diet (breakfast, lunch dinner) as: Rice 1 cup Fish/Meat 1 piece/1 serving Soup 1 cup Wt: 76 kg, Ht: 59 Placed on NPO since yesterday. Complained of dry mouth and throat. Claims, gutom pero dili man pwede pakan-on Only had milk since he had his check-up last January 21, 2012 Verbalized, bisag tubig dili ko pa-imnon Wt: 76 kg, Ht: 59 Placed on NPO status Still seen lethargic and exhibits fatigued Is not experiencing indigestion or vomiting. No suspicious lesions throughout his body. Abdominal girth: 38 inches

Fruits/Vegetables Snacks

1 cup Crackers, kamote, saging Claims, dili man ko pilian ug ka-on Verbalized, daghan when asked if he eats vegetables. Claims, panalagsa malipasan pud ko ug kaon labi na kung daghan trabaho No problem in chewing/swallowing. No pain felt in oral cavity. Client usually drinks at 10 oz of water every day. Drinks Sustagen 8 cups per day since he had his check up last January 21, 2012 Does not drink coffee but occasionaly drinks softdrinks. Does not take in vitamins or supplements Has complete set of teeth with 2 tooth extraction. Does not use dentures. No suspicious lesions throughout the body. Verbalized by his daughter in lawkung ma samad siya dali ra man pud mayo, iya ra tambalan ug lana Nail color: nail bed is pinkish, nail plate is transparent, free edge is translucent. Trims nails as necessary. No changes in hair color. Had remarkable drop in weight of 10 kilos since October

Verbalized, kinahanglan para sa akong operasyon when asked if he knows why he is places on NPO Daughter in law claims, na wad-an na ni siya ug gana mukaon sukad atong gasakit ni iyang tiyan ato Oktubre, mas samot na atong sige na siya ug sukasuka Has NGT tube inserted at his left nostril with clear drainage bag, free of gastric contents Complained of pain on his stomach (rated 5 of 10 with 10 as the highest), feels hard and rigid all throughout with light palpation. Verbalized, musakit basta mukaon ko Undergone biopsy and endoscopy as diagnostic tests. Endoscopy findings: Antrum is a huge ulcerating, beeding, infiltrating mass obliterating the pyloric ring Endoscopy Dx: Obstructing gastric malignancy Radiologic Remarks: Ascites Incidental finding of thickened stomach wall Bilateral pelvoliectasia Daughter in law verbalized, bantog rang sige siya ug suka-suka ug pangdug-ab, gatapok ra diay sa iyang tiyan ang iyang kinaon kay dili naman kaagi tungod sa nitubong tumor. Daughter in law claimed, katong gi endoscopy siya gi suction na lang pud iyang mga kinaon nga naa ra sa sulod sa tiyan. Claimed to have no weight changes since admission. Client receives Has #2 D5LR infused at 30 gtts/min at left metacarpal vein with #5 Aminogen 500 ml 16 gtts/min via sidedrip.Had taken 6oz of water since admission. Is not experiencing indigestion or vomiting. No suspicious lesions throughout his body.

Elimination Pattern .
Bowel movement is usually once every week. Stool is usually formed and brown reaching to about 1/4 cup. No history of kidney stones and kidney diseases. Urinates about 5 times daily. Claims of urine as yellow and reaching to about glass. No difficulty in bowel movement or in urination. Claimed dili ra man pud ko singtanon Had difficulty in evacuating fecal material since December 2011, but claimed as not painful. Defecated twice since admission. Claimed, mura ra ug tudlo kadako Verbalized, mu-utong man ko pero wala man jud mugawas, when asked if he does valsalva maneuver when defecating. Urinates usually about 8 times per day which he associates with presence of IV fluid. Claims, muras ra man gihapon ang color sa iyang ihi. (Light yellow in color) Voids freely without pain or discomfort. No sign of uneasiness or discomfort towards the environment Cool environment noted No foul odor noted Urinalysis: Color: yellow Transparency: Shagy Specific Gravity: 1.015 Glucose: neg Urobilinogen: neg Protein: neg pH: 6.5 Microscopic Examinaton of Urine: Pus cells: 1-3/hpf RBC: 30-40/hpf Bacteria: moderate Mucus Thread: neg Urates: few Defecated once since yesterday. Claimed, gamai ra kaayo Urinated usually about 4 times since yesterday. Had a catheter inserted at 9 am. Urine is yellowish and clear. Voids freely without pain or discomfort. No sign of uneasiness or discomfort towards the environment Cool environment noted No perspiration. \No foul odor noted

Activities- Exercise Pattern


Client is described by his significant others as himsug and workaholic Considers watching tv an dplaying with his grandchildren as forms of recreation. Verbalized, carpenter man ko, so kung daghan trabahuon, kinahanglan jud humanon Considers his job as his form of regular exercise. Daughter in law claims, kusog pa na mu dok dok ug martilyo, makagama pa gani na ug cabinet Sleeps when feels tired and weak. Perceived ability for: Feeding: 0 Bathing: 0 Toileting: 0 Bed mobility: 0-2 (depending on degree of movement) Grooming: 0 General mobility: 0-1 ADL: 5:00 am Wakes up 6:30 Hygiene, eating 8:00 Works 10:00 Rests 12:00pm lunch 2:00 Goes to Sleep 4:30 Works 7:00 Dinner 8:30 Sleep Needs assistance when performing some ADLs. Has limitations on movement due to presence of IVF, NGT tube and pain over his abdomen Can walk without assistance. Capillary refill: 2 seconds Has poor skin turgor and mobility Claimed, katolgon man ko, when asked why he keeps lying on bed Daughter in law verbalized, maglakaw lakaw man pud na siya diri, kanang dili dagay sakit ug luya iyang pamati Cool environement noted. Perceived ability for: Feeding: 0 Bathing: 0 Toileting: 0 Bed mobility: 0-2 (depending on degree of movement) Grooming: 0 General mobility: 0-1 ADL: Since admission, always want to lie down on bed. As of 12 noon, V/S were recorded as: T= 37.6C P= 83 bpm, regular and bounding. R=22 cpm, effortless and regular CBC: WBC: 10.5 K/uL Hgb: 9.0 Hct: 25.1 Platelet: 398 K/uL Lymphocyte: 15 % Perceived ability for: Feeding: 0 Bathing: 0 Toileting: 0 Bed mobility: 0-2 (depending on degree of movement) Grooming: 0 General mobility: 0-1 Did not go out of bed since yesterday. Capillary refill: 3 sec

Monocyte: 7% Neutropjils: 75% Eosinophils: 2% Basophils: 1%

Sleep- Rest Pattern


Awakens at around 5:00 a.m. and goes to bed by 8:30 p.m. Sleep reaches maximum of 9 hours. Usually wakes up (about 2 times) during the course of the sleep at night. Does not experiences insomnia. Claims, dali ra man pud ko makatulog labi na ug kapoy gikan trabaho No particular things he wants to see, hear or feel for him to get to sleep. Goes to a 2 hour nap in the afternoon. Experiences occasional sleep since admission. Slept last night at 12 in the midnight. Exhibits some fatigue and exhaustion for which he claimed as related to his hospital stay and upcoming surgery Pain disturbs sleep. Client verbalized mag mata mata k okay sakit ako tiyan. Pero matulog ra ug balik kung makaya. Putol putol akong tulog. Looks tired and sleepy. Able to sleep supine in bed. No necessary things that is needed for him to get asleep aside from the presence of his mother. Able to sleep only for 3 hours straight but can be able to go back to sleep. Seldom sleeps during the day. Only had 5 hours of uninterrupted sleep Verbalized, mas mayo na lang ron ako paminaw Exhibits some fatigue and exhaustion Pain disturbs sleep. Looks tired and sleepy. Able to sleep supine in bed. No necessary things that is needed for him to get asleep aside from the presence of his mother. Cannot sleep during the day.

Cognitive- Perceptual Pattern


Speech is coherent No problem in vision, hearing, smell, taste and touch. Verbalized by daughter in law, mas mayo pa man gani na kaysa namo anang pagtuhog ug lundris sa dagom, dili pajud na siya mag antipara ana Sleeps when stressed. No history of convulsion,

Slurred speech observed, associated with presence of NGT tube Does not wear eyeglasses/hearing aids. Responsive to clients questions. Answers with objectivity No problem in vision, hearing, smell, taste and touch. Verbalized dry mouth due to NPO status. Feels tired but is able to respond to HWs stimulation.

Slurred speech observed, associated with presence of NGT tube Does not wear eyeglasses/hearing aids. Responsive to clients questions. Answers with objectivity No problem in vision, hearing, smell, taste and touch. Verbalized dry mouth due to NPO status.

loss of cognition or memory, no balance or coordination problems, no loss of sensations. Learns things at moderate. Able to be pacified when feels uneasy through diverting his attention from the source of irritability. Feels good to see be able to work and see his grandchildren. The one who makes decision for himself and for his family

Responsive to environment. Able to listen to children when told of what is not to be done.

Feels tired but is able to respond to HWs stimulation. Responsive to environment. Able to listen to children when told of what is not to be done.

Self- Perception- Self- Concept Pattern


Considers his life as happy and in content with what he has done and achieved Claims to be healthy except now that he is admitted. Allows him to explore things on his own with the provision of safety. Wants to work, finds it enjoyable. Finds no remarkable change from his previous years Concerned with his upcoming surgery. Verbalized, karon pajud ko nahospital tungod sa sakit Claimed, ganahan nako mubalik sa amo Has a sense of independence and confidence as he communicates with the HW Paralinguistic cues consistent with verbal communication Body cues not evident. Patient does not move often. Verbalized, wala when asked if he is fearful of his upcoming surgery. Has a sense of independence and confidence as he communicates with the HW Paralinguistic cues consistent with verbal communication Body cues not evident. Patient does not move often.

Role- Relationship Pattern


Family originated from Sta. Catalina. Widowed since 2003. Has 7 children and 12 grandchildren Verbalized, dawaton nalang jud. Pero ok ra man ko when asked how does he feel towards being a widow Did not had any intimate relationship with other woman since 2003 Is being watched over by his 2 daughter in law Daughter in law claimed, kami juy magbantay ani niya, bason gud lamang ug mayo ra ang opersyon Daughter in law verbalized, naa ra iyang mga pagumangkon, maoy ni donar ug dugo para sa iayng operasyon Daughter in law verbalized, kami tanan concerned sa iyang pagkahospital Being watched with his 2 sons Verbalized, namauli pa kariyot, when asked if where were those who watched over him yesterday. Eldest son verbalized, murag maoperahan na na siya karon.

Has his own income, uses it to augment the necessities of the household. Language spoken at home: cebuano. Able to follow simple instructions/advices by significant others Claims, wa raman, when asked if he has someone from the family or neighborhood that he has a fight with Has good relationship with family members and neighborhood Lives with the family of his 2nd child (9 members in their household) Senior citizens member Some relatives and friends live near their house. Feels good with this situation. Daughter in law claims, wala man na siyay kaaway. But0an rajud na siya sa amo Considers himself as a little bit of a spoiler to his apos Daughter in law claims, palangga ra man niya tanan iyang mga anak ug apo, pero kung masayop, mangasaba jud siya

Claimed, ganahan nako mubalik sa amo

Sexually Reproductive Pattern


Circumcised Has 7 children Did not experience having testicular exams. No unusual discharges or lesions in his penile area. No sexual contact for about 15 years already Does not use contraceptives with his previous sexual intercourse Testicles have no masses, lesions, tenderness or nodules. Did not have any bloody discharges in her penis now that he is hospitalized. Does not feel erection Verbalized no association between sexual function and hospitalization Testicles have no masses, lesions, tenderness or nodules. Did not have any bloody discharges in her penis now that he is hospitalized. Does not feel erection

Seldom experiences erection

Coping Stress Tolerance Pattern


Copes to stress with the help of the people around him Seldom gets irritated, keeps quite and rests if he does Considers self as good in handling stressors in his life Feels hospitalization is stressful but at the same time helpful in relieving his illness. No sings of stress induced behavior Took him about 3 months before he got admitted due to the pain he is experiencing in his stomach Verbalized, kay gasuka naman ko, dayon sakit na pud kaayo akong tiyan when asked if what are the major things the let him decide to have himself admitted Signed informed consent for surgery without doubt or coercion Verbalized satisfaction in the care he is receiving in the hospital Verbalized fear for his upcoming first surgery Verbalized, maghilum ra when asked if what things he does to correct his fear Feels hospitalization is stressful but at the same time helpful in relieving his illness. No signs of stress induced behavior

Value- Belief
Believes in some superstitions with regards to health because family believes so. Religion is Roman Catholic. Does not have any regular schedule of attending mass Able to do the sign of the cross Considers believing in GOD a helpful tool in coping with problems in life Considers praying as important with his current situation. Does not correlate any previous experiences or hobbies with his current situation. Believes that this admission might cause some changes in his future life (may not be able to go back to work) Does not have any questions or clarification that he wish to be answered Considers praying as important with his current situation. Does not correlate any previous experiences or hobbies with his current situation. Does not have any questions or clarification that he wish to be answered

College of Nursing Silliman University Dumaguete City

SUBMITTED TO:
Asst. Prof. LEIZL JOY ESCOBAR

SUBMITTED BY:
RIMEL VON PATULA TARAH STEFI ANNE T. MEJORADA

February 8, 2012