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MANILA DOCTORS COLLEGE

Pres. Diosdado Macapagal Boulevard


Metropolitan Park, Pasay City

In partial fulfilment
Of the Requirements of the
College of Nursing in
Related Learning Experience

Right Varicocoelectomy

Submitted by:
Caberte, Iris D

Group CA5
BSN III – A2

Submitted to:
Sir Jameson Leonardo, RN
MANILA DOCTORS COLLEGE
Pres. Diosdado Macapagal Blvd., Metropolitan Park, Pasay city

I. ASSESSMENT

A. General Data

Resident’s Initials: E.T. Sex: Male


Address: Cebu city
Age: 30 yrs. old Civil Status: Single
# of days in the Hospital: 5 days Occupation: Seaman
Place of Birth: Cebu City
Date of Admission: 08/01/10
Order of Admission: Ambulatory
Informant: E.T.
Date of History Taking: 08/01/10

B. Chief Complaint

“Masakit yung bayag ko tapos kumikirot habang umiihi ako.” as verbalized by


the client.

C. History of Present Illness

4 months prior to confinement, the client felt right scrotal pain that is
unrelieved by analgesics with history of trauma, dysuria, and discharge.

2 months prior to confinement, the client consulted at Korea diagnosed to


have hydrocoele and was advised for surgery.

D. Past History
1. Childhood Illness: The client had chicken pox when he was in
elementary.
2. Adult Illnesses: None
3. Immunization: Unrecalled
4. Previous Hospitalization: None
5. Operation/s: None
6. Injuries: He fell at a tree when he was 8 years old.
7. Medications taken prior to confinement: He takes Memoplus gold
everyday as his multivitamins.
8. Allergies: None

E. Systems Review- Gordon’s Eleven Functional Health Pattern (July 21,


2010)

A. Health Perception- Health management

Prior to confinement, the client rarely gets illness. He experienced


headache and colds and his remedies for it were Amoxicillin, Biogesic and
Neosep which is taken three times a day. When he feels better, he stops the
medicine prescribed by the doctor and gets back to work. He doesn’t smoke but
he drinks alcoholic beverages occasionally.

During confinement, the client eats well and is not particular on the foods
that are served. He is in diet as tolerated.
B. Nutritional-Metabolic Pattern

Prior to confinement, the client had no eating problems such as difficulty


in swallowing and has no restrictions in diet. “Hindi ako mahilig kumain” as
verbalized by the client. Most of the time, he eats pork, beef, fish, chicken,
Korean foods and anything that were served to him by the ship. He eats 3 times a
day and his meal would consist of a cup of rice and a serving of viand. He drinks
3-4 glasses per day. He doesn’t wear dentures. The patient stated that his wounds
heal just fine.

During the confinement, the client eats the food served by the hospital. He
would only drink about 4-5 glasses of water a day. The patient weighs 126 lbs and
according to him, he loss weight for the past few months. His height is 5’6”. His
body mass index is 20.3 kg/m2 his body is in normal range.

C. Elimination Pattern

Prior to confinement, the client urinated 4-5 times a day with pain and
burning sensation. Whenever he feels constipated, he eats banana. He defecates 2
times a day. The client had odor problems when he perspires a lot during work
and playing basketball.

During confinement, the client’s defecation and urination patterns remains


the same. The client does not perspire a lot because of decreased activity. The
client’s stool is brown in color and soft in form while the client’s urine is clear to
yellowish in color.

D. Activity – Exercise Pattern

Prior to confinement, the client form of exercise is playing basketball and


his strenuous work. During his spare time, he listens to music and watch TV.

During confinement, the client spends most of his time in his room
watching TV, listening to music, and sleeping.

E. Sleep-Rest Pattern

The client usually wakes up at 3 am to study for PRC board exam and
doing his normal routine like morning care, cooks breakfast and eating breakfast.
He eats dinner at 7 pm and usually sleeps at 10 pm. He doesn’t have problem
difficulty of sleeping but he experienced awakening during night.

During confinement, the client feels relaxed and comfortable. His sleeping
pattern remains the same.

F. Cognitive- Perceptual Pattern

Priot to the confinement, he client neither wears eyeglasses nor hearing


aids. His vision is 20/20. He does not experience any problems with her memory.
He understands both Filipino and Bisaya language. He makes his own decision.

During confinement, the client’s vision and hearing is still the same. The
client is calm, oriented with time & date, people around his and the place.
G. Self Perception- Self Concept Pattern

Prior to confinement, the client feels calm, relaxed, and good about
himself. He doesn’t get angry or annoyed easily. He is always full of hope when
problems arise, and is very optimistic because for him “Nandiyan parati ang
diyos.”

During confinement, the client feels good about himself. His eye
contact is consistent. He is relaxed most of the time. His body posture is quite
relaxed and assertive.

H. Roles-Relationships Pattern

Prior to confinement, he feels lonely whenever he is the shop with inter


island trips. He is 4th in the family. Mobile phone was there way of
communication. His monthly income was a big contribution to the financial status
of their family. He is not a member of any social group.

During confinement, the client’s roles and relationship remains the same.

I. Sexuality- Reproductive Pattern

Prior to confinement, the client has a girlfriend for 2 weeks. He had sexual
experience and uses condoms as contraceptives. He doesn’t have problems
dealing with women.

During confinement, the client established a good relationship with the


staff nurse. His girlfriend and other friends accompany him on his room.

J. Coping-Stress Tolerance Pattern

Prior to confinement, the client is able to cope with different situations


because he is optimistic. Whenever problems arise, he weighs which his best for
him. He also pray and asks for forgiveness and guidance. He remains calm and
relaxed when tough times come because he believes that all problems have a
solution. He thinks stress was the cause of his illness, “Pagod, init kasi sa makina
ng barko nagtratrabaho, halos walang tulog, tapos laging nagbubuhat ng
mabibigat.” as stated by the client.

During confinement, the client stated that he wants to get back to work to
earn money for his family. He is most of the time relaxed lying on the bed
watching TV and talking with friends.

K. Values Belief Pattern


Prior to confinement, the client prays every night in the cabin if he is at
work and hear mass every Saturday if he is in the Philippines. The client’s
religion is Roman Catholic. He believes that prayer is a big help for every
problem.

During confinement, the client’s belief is still the same. He prays every
night for the success of his surgery and for speedy recovery.
F. Family Assessment

EDUCATIONAL
NAME RELATION AGE SEX OCCUPATION
ATTAINMENT
E.T. Client 30 M Seaman College graduate
High school
E.T. Father 65 M None
graduate
High school
C.T. Mother 83 F None
graduate
Computer
R.T. Brother 24 M College graduate
Progammer

G. Heredo – Familial Illness


Maternal: Cardiomegaly
Paternal: Arthritis

H. Developmental History
Theory (Theorist) Age Developmental Task Patient’s Description
Psychosexual 13 yrs. Genital Stage The client has a girlfriend for 2
(Sigmund Freud) old and . weeks. He had sexual experience
above and uses condoms as
contraceptives. He doesn’t have
problems dealing with women.

Psychosocial 19-40 Intimacy vs. Isolation The client’s family and


(Erik Erikson) yrs. old girlfriend support him in
whatever he decides for. He is
friendly with his co-workers and
doesn’t have problems dealing
with them and with his boss.
Cognitive 12 and Formal Operations Stage The client is mature enough to
(Jean Piaget) above make his own decisions based
on what is best for him and his
family. He is open up for any
opinion. He is able to determine
what is right from wrong.
Moral 35 and Post conventional Level The client is a law abiding
(Kohlberg) above citizen even at work.
“Naniniwala ako sa karma kaya
mahirap na.” as stated by the
client.

Spiritual 21- 45 Stage 4 Individuative- The client prays at night before


( James Fowler) yrs.old Reflective faith going to bed. He asks for
forgiveness and strength to
overcome his problems.
Included in his prayers was his
family.
I. Physical Examination (August 2, 2010)
Vital Signs
BP = 120/80 PR = 68 bpm
RR = 19 bpm T = 36.5 °C

Anthropometric Measurements:
Actual Weight: 126 lbs
Actual Height: 5’ 6”

Regional Examination:
A. Skin
Inspection:
-Skin colour is brown
-No presence of rashes or any lesions
-Absence of edema
Palpation:
-No presence of rashes or any lesions
-Absence of edema
-Skin is dry and warm to touch
-Good skin turgor
-Absence of palpable mass and nodules
B. Nails
Inspection:
-Clean with minimum length of nails
-Nail bed colour is pink
Palpation:
-Smooth in texture.
-Capillary refill about 1-2 seconds

D. Hair
Inspection:
-Evenly distributed
-Black in colour
-Presence of body hair and evenly distributed
-Little visible dandruff
-No infestation of lice

C. Head and Face


Inspection:
-Normocephalic and symmetric
-With symmetrical facial movements
-No swelling
Palpation:
-Smooth skull contour
-Absence of nodules and masses

D. Eyes
Inspection:
-Brown eyelids with no presence of lesions.
-Brows are symmetric and have equal hair distribution.
-Eyelashes are curved outward and evenly distributed
-Upper and lower conjunctiva pink in colour
-Sclera appears white
-Cornea is transparent and appears shiny and smooth
-Pupil of both eye is black in colour, round, reactive to light and
accommodation.
Palpation:
-Absence of edema, masses and nodules
-No tenderness noted
-Visual fields: client can see objects in periphery on the left eye
-Extra ocular movement test: able to follow six directions of gaze
on the left eye
-Visual acuity test: able to read newsprint

E. Ears
Inspection:
-Same colour as surrounding skin
-Symmetrical
-No presence of cerumen or any discharges.
-Absence of masses
-Hearing Acuity test: able to hear normal voice tone
-Weber's test: air conduction is greater than bone conduction
Palpation:
-No tenderness noted

F. Nose
Inspection:
-Located at the midline.
-Same colour as surrounding skin
-No swelling or inflammation.
-No presence of exudates and mucus secretions.
Palpation:
-No tenderness noted

G. Mouth and Pharynx


Inspection:
-Lips pink in colour
-Absence of swelling, lesions and ulcerations
-Tongue able to move freely
-Complete set of teeth

H. Neck
Inspection:
-Located at the midline.
-Able to flex and hyper extend neck without discomfort
Palpation:
-No tenderness noted
-No palpable lymph nodes

I. Spine
Inspection:
-Straight
-No signs of bulging or deviations.
Palpation:
-No presence of lumps or masses.

J. Thorax and Lungs


Inspection:
-Do not use accessory muscle to breathe.
-Normal rate and rhythm of respiration
Palpation:
-Symmetrical chest excursions.
-No presence of abnormal masses and deformities.
Percussion:
-Symmetrical resonant sounds heard
Auscultation:
-No presence of abnormal breath sounds

K. Cardiovascular/Heart
Inspection:
-No visible pulsation.
-No exaggerated lifts and thrills in the area.
-No distended and bulging veins
Palpation:
-No presence of lumps and masses.
Auscultation:
-Cardiac rate and rhythm normal
-Absence of heart murmurs and bruits
L. Breasts
Inspection:
-Colour same as surrounding skin
-Round shape, symmetrical and intact skin
-Nipples are round, equal in size, same colour and both nipples
points in same direction
-No discharge noted
-Absence of masses
Palpation:
-Absence of tenderness

M. Abdomen
Inspection:
-Uniform colour of the abdomen
-Round in shape
-No prominent pulsation
-No presence of any distention or any bulging.
-Umbilicus is located at the midline with no presence of discharges
Auscultation:
-Presence of bowel sounds
Percussion:
-Tympani over the abdomen
Palpation:
-Absence of tenderness

N. Extremities
Inspection:
-Symmetrical body parts.
Palpation:
-Firm and smooth.
-No swelling or any nodules.
-No muscle tenderness

O. Genitals (base on the chart taken 08/1)


Inspection:
-Left scrotum look like bag of worms
-Asymmetrical testicles
Palpation:
- Non-tender, twisted mass along the spermatic cord

P. Rectum and Anus


- Not Assessed
II. Personal/Social History
Hobbies: He likes to play basketball, listen to music and watch TV.
Vices: He doesn’t smoke but he drinks alcoholic beverages occasionally.
Social Affiliation: None
Client’s usual day like: The client usually wakes up at 3 am to study for PRC
board exam and doing his normal routine like morning care, cooks breakfast and
eating breakfast. He eats dinner at 7 pm and usually sleeps at 10 pm.
Rank/Order in the family: 4th children.
Travel: Alaska, Australia, Mexico, Brazil, South Africa, China, Singapore,
Taiwan, Indonesia, India, etc.
Educational Attainment: College graduate of BS Marine Engineering
Occupation: seaman.

III. Environmental History

Before confinement the patient lives at a studio type house. Their house is
well constructed. Services such as electricity, water supply, and regular garbage
collection are present. Their house is accessible to health care facilities such as
Health Centre, Hospital, and Pharmacy. Commercial Establishments is also
accessible. Means of transportation such as jeepney, bus, taxi, pedicab, and
tricycle are present.

IV. O.B. GYNE History (Not Applicable)

V. Pediatric History (Not Applicable)

VII. Laboratory Tests (None)


XI. On-going Appraisal

August 1, 2010, E.T. was admitted in MDH at 11F. He is on DAT diet. He is for
right varicocoelectomy on August 2, 2010 at 11 AM.

August 2, 2010, Post right varicocoelectomy. Ordered Faspic PO 1 tab tid,


Stafloxin PO 500 mg 1 tab tid, Plasil IV 2 cc q4h prn, and cold compress over
post operative site. To consume IV #1 D5NR IL x 35 cc/hr with remaining of 400
mL.

August 3, 2010, May go home. Shifted from cold compress to warm compress on
the post operative site.

XII. Discharge Plan


M – edications
Continue ongoing medications: Faspic PO 1 tab tid and Stafloxin PO 500
mg 1 tab tid

E – xercise
Physical activity should be restricted the first 48 hours. During that time you
should remain relatively inactive, moving about only when necessary. During the
first two weeks following surgery you should avoid lifting any heavy objects
(anything greater than 15 pounds), and avoid strenuous exercise which might
endanger the integrity of your incision.

T – reatment
1.) Continue warm compress on post operative site.
2.) Eat frequent small meals.
3.) Take antibiotics on a full course.
4.) Provide aseptic technique when changing the dressing. Dispose contaminated
material properly.

H – ealth Teachings
1) Abstain from sexual activity for one week
2) Bathing or showering should be avoided for 24 to 48 hours
3) Outer dressing should be removed 48 hours after the procedure
4) Pain medications should be taken as prescribed by the doctor
5) Weightlifting or jogging or strenuous activities should be avoided for
approximately two weeks

O – PD
Refer to Physician/Psychiatrist for OPD follow-ups. This visit, to check
your incision and progress, is usually scheduled for five to seven days following
your surgery. During your first appointment the wound dressing will be removed

D – iet
You may return to your normal diet within 24 hours following your
surgery. Suggest clear liquids and a very light meal the first evening.

S – igns and symptoms


Educate the family and significant others of client about the signs and
symptoms of patients with varicocoele such as:

Positive Symptoms – Pain, dysuria, lumpy scrotum, palpable vein, shrinking of


testicles, feeling of heaviness of testicles

Negative Symptoms – visible enlarge vein, infertility

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