Assessment General Data: A. B. C. D. E. F. G. H. I. J. K. Name: Usito, Dionisio Unday Sex: Male Address: Lilac St., Marikina City Age: 77 Date of Birth:1/11/1936 Civil Status: Married for 54 years Wife: Feliciana Usita Place of Birth: Cagayan Valley Order of admission: ??? No. of days in the hospital: 11 days Date admitted: September 2, 2013 Informant: Nephew Mr. J and Son Mr. D Date of History Taking: September 13, 2013

Chief Complaint: Difficulty in Defecation; Pain in inguinal Area; Cough History of Present Illness: ( PATIENT HX IN CHART ) Four(4) months prior to admission the patient claims to have cough, he selfmedicate with guaifenesin which provided him temporary relief, no consultation was done, he was apparently asymptomatic until Seven(7) days prior to admission he is experiencing cough, productive of whitish phlegm associated with dyspnea, and shortness of breath, however denies fever, chills and orthopnea, persistence of symptoms prompted consultation hence was subsequently admitted to DelosSantos Medical Center. ( PATIENT HX OBTAINED FROM THE INFORMANT ) On May 2013 Prior to admission, the patient has a bulging mass in his right inguinal area, thus lead him to consult their family physician and diagnosed that he has hernia, he did not seek any medical attention because it is asymptomatic. After three (3) months prior to admission he has already felt pain in his inguinal area aggravated by cough, he has pain in defecation and due to the pain he cannot defecate well, for seven (7) days he cannot defecate normally because of pain the he was given dulcolax suppository once a day as per their family physician but this doesn’t give him relief. August 30 prior to admission he seek medical attention to a hospital in Marikina City, he was about to have a hernioraphy operation thus referring him to the Delos Santos Medical Center. Ongoing Appraisal: (SEPTEMBER 12, 2013) The patient is seen at Post Anaesthesia Care Unit (PACU) lying on bed in supine position hooked up with Intravenous Fluid of .9% NaCL 1 Liter x 80 cc/hr,

Until he gradually move the both feet.Oxygen 6 Liter per minute via facemask. We transfer him in his room which is a private room in the hospital the attending nurse endorsed the patient to the nurse on the ward. 2 hours later he can move his feet but still feels numbness as he verbalized “ I cannot feel my legs. he has 800 millilitres of Output and then we discarded the urine.9% NaCL 40cc/hr with nasal cannula and Foley catheter. as well as the personal and social history we also asked what kind of lifestyle he have prior to confinement. 2013) The patient is seen lying on bed in high fowlers position with Intravenous fluid . Non-invasive Blood Pressure (NIBP) Monitor and Foley Catheter. We also do physical examination but minimal only. (SEPTEMBER 13. He is awake but we aren’t able to talk to him because we don’t want to disturbed him a lot because he is a post operation patient. history of past and present illness. Complaints prior to admission. he has green precaution (droplet) as per physician. . we only asked his relative about his information regarding his life before operation. the attending nurse was about to transfer the client to his room he ask us to assess and discard the urine bag. We obtain his Personal Data. The patient is not talking but he smiles when we looks at him. We are rendering care for our patient by monitoring his vital signs every 15 minutes and assessing his level of consciousness everytime. This may indicate relief from his operation. he is from operation called Hernioraphy Scrotal Exploration Right with Transurethral Resection of Prostate (TURP) started at 7:00am under General Anesthesia the operation lasted for 4 hours. we didn’t have a chance to care for our client because we are out of duty but we checked his chart he was being compliant to his medication given by the attending nurse. At 11:00 am we are advise to monitor his blood glucose level we get his Capillary Blood Glucose (CBG) which is 196 mg/dl at 12:00 noon he was given two(2) units of Insulin (Apidra).”. and Paracetamol through Intravenous Push 600mg we still continue to monitor his vital signs every 15 minutes and asked if he can move his lower extremities.

Physical Assessment: (POST OP September 12.2013) Vital Signs        Temperature: Pulse Rate: Respiratory Rate: Blood Pressure: Weight: Height: Ideal Body Weight: .

Nails Nails in upper extremities are pale with more than 2-3 seconds capillary refill with curvature in his nails. J. C. . when pinched skin goes back to his normal state in 1-2 seconds. B. Skin: Skin is dry and warm to touch.Regional Examination: A. generally it is uniformed in color. F. P. L. I. N. H. G. Head and Face D. Q. with normal skin color generally brown complexion. noticeable wrinkles around his body due to aging process. M. K. O. E. Eyes Ears Nose Mouth and Pharynx Neck Spine Thorax and Lungs Cardiovascular Breast Abdomen Extremities Genitals Rectum and Anus Neurologic Exam TO BE COMPLETED PA….

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