NURSING HISTORY

Part I. Demographic Information

Name: Sonia Teologio Civil Status: Married Sex: Female Educational Attainment: BSEd Graduate
Address: Bayawan City, Negros Oriental Religion: Roman Catholic Occupation: Retired Teacher
Room and Bed no.: 364 F Docto(s) in charge: EGHM/GYC Nationality: Filipino
Chief Complaint:
Date & Time of Admission: Dec. 10, 2009
History of Present Illness:
Last January 2009 patient is diagnosed of Stage 2 Colon Cancer and was scheduled of surgery last April. Surgery was successful and was scheduled of colonoscopy this
December to check the condition of the colon and other adjacent organs.

General Impression of Client:

Received on bed lying in a supine position, awake, alert, and aware of self and environment, coherent and verbally responsive. The dress is appropriate to temperature
and weather, no offensive or unpleasant odor, hair slightly in disarray. Body movements are purposeful, no involuntary body movements. Understandable and slow-
paced speech and soft voice which shows association of thoughts. Verbal expressions match with non-verbal behavior, mood is appropriate to the situation.
 USUAL PATTERN INITIAL APPRAISAL ONGOING APPRAISAL

I. Health Perception-Health Management Pattern I. I.

 General health has been good.  General health has been fair.  Received on bed lying in a supine position awake,
 Uses the following to keep self healthy:  Sought admission due to scheduled lethargic, aware of self and environment,
Proper nutrition, brisk walking around the colonoscopy. coherent and verbally responsive with #1 1L D5LR
subdivision for 20 minutes, adequate sleep and  Claimed that she feels pain on her abdomen @ 100 cc level regulated @ 33 gtts/min, infusing
rest. and back occasionally but not like when she well. IV site intact, not swelling nor infiltrated.
 Have been diagnosed before of Stage 2 Colon was at home that the pain would last the  Vital signs:
cancer and was treated by surgery last April 2009 whole day. Rated pain as 5 in a scale of 0-10. 8 am
it was successful. She was checked-up for the next Describes pain as nagging which would T= 36.5˚C
3 months and she was negative of malignancy. radiate from her Right iliac region to her left P= 71 bpm
 Lately she had been experiencing pain from her iliac region then transfers to the lower R=18 cpm
left iliac region then transfers to her right, then portion of her back. BP= 110/80 mmHg
transfers to the lower portion of her back and  Vital signs:
then radiates to her lower extremities. She T= 36.7˚ 12nn
describes it as cramping and rated it as 5 in a scale P= 68 bpm T= 36.5˚C
of 0-10 where 0 as the least possible pain and 10 R= 18 cpm P= 67 bpm
as the highest. Claimed that it occurs suddenly for BP= 110/80 mmHg R= 18 cpm
the whole day or when she does household BP= 110/70 mmHg
chores. She diverts her attention to other  Phosphosoda is discontinued.
activities to minimize the feeling of pain.  Labs:
 Also lately she feels nagging pain on the joints of Urinalysis
her toes and fingers which occurs at night time Physical
and uses efficascent oil to lessen the pain. Color yellow
 In the past she has found it very easy to comply Transparency hazy Transparent
with Doctor’s prescriptions and nurse’s Spec. gravity 1.010 1.010-1.025
suggestions. Chemical
Glucose NEG NEG
Bilirubin NEG NEG
Ketone NEG NEG
Blood MOD NEG
pH 6.5
 Protein Trace NEG
Urobilinogen Normal Normal
Nitrite NEG NEG
Leokocytes NEG NEG
Microscopic
Pus cells 0-3 0-5
Red cells 7-14 0-2
Epithelial cells few NEG
Bacteria few NEG
Mucus threads few NEG
Carcino Embryonic Ag 4.1 ng/mL 0-5
CBC
Hemoglobin 12 gm% 12-14
Hematocrit 36.2% 37-44
WBC 5720/cumm 4.5-11T
Segmenters 61% 55-70
Lymphocyte 28% 20-35
Eosinophil 3% 1-4
Monocyte 8% 1-6
Basophil 0% 0-0.5
Platelet Count 280T/cumm 150-400T
Mean Corps Vol. 89.8 f/L 80-96
Mean Corps Hgb. 29.8 pg 27-31
Mean Corps Hgb. Conc. 33.1% 33-36

 Claimed of relief from pain on the abdomen and

lower portion of the back.

II. Nutritional-Metabolic Pattern II.
 Eats oatmeal for breakfast and fish and vegetables
in the noon and evening.
 Claimed that if she cannot eat vegetable and has
II.
 Ate oatmeal for breakfast and fish and
vegetable for lunch.
 Ordered to have light dinner then general
 Still on NPO status until colonoscopy is done and
resumed full diet after.
 Had drank 50 ml of H2O after colonoscopy.
 Measurement of Intake:
 eaten meat her feces would be harder than the
usual.
 Drinks milk in the morning and evening and drinks
approximately 8 glasses of water a day.
 Physician had restricted her to eat red meat and
canned goods.
 Claimed that lately she likes to eat fish and
vegetables and dislikes meat.
 Appetite: Excellent
 Takes Centrum daily but had stopped taking it for
about 2 months until at present.
III. Elimination Pattern
Bladder
 No problems, no assistive devices
 Urinates light yellow colored urine
approximately 5x/day
Bowel
 No problems, no assistive devices
 Defecates brownish, formed stool once a day
Skin
 No problems
 Claimed that at the time when she has not yet
undergone surgery she has difficulty defecating
and her stools has traces of blood.
IV. Activity-Exercise Pattern
 Wakes up at 6 in the morning cooks rice or
liquids after. D5LR x 33 gtts/min = 550 cc
 NPO post midnight. H2O = 50 cc
 #1 D5LR @ 33 gtts/min will start at 6 pm. 600 cc
 Claimed that she has still a good appetite.  Claimed of not having gained or lose weight.
 Claimed that she is worried if she would  Complained of being hungry and thirsty after
again vomit after colonoscopy. colonoscopy.
 Verbalized, “Dili ba ko mag suka-suks ani day  Skin is relatively dry with minimal perspiration,
kay katong una kay nagsuka-suka man gud ko good skin turgor, light pink oral mucous
ato.” membranes, pale lips and light pink palpebral
conjunctiva and capillary refill was 1-2 secs.
 Complained of dry oral mucous membranes.
III.
III.
Bladder
Bladder  No problems, no assistive devices
 No problems, no assistive devices  Urinated dark yellow, hazy urine @ 100 cc
 Urinated light yellow, transparent urine level
thrice. Bowel
Bowel  Defecated loose, watery, brownish stool,
 Has not yet defecated since admission. 5x since evening until 6 am.
Skin Skin
 Relatively dry with minimal perspiration.  Relatively dry with minimal perspiration,
no unpleasant odor
 Measurement of output:
Urine = 100 cc
Insensible fluid loss = 333 cc
433 cc
 Bowel sounds = 2x/min
IV.
IV.
 Stated that she stands up and walks from bed to
 No mobility problems, capable of FULL self- CR to defecate.
 oatmeal, sweeps the floor, washes the clothes,
then every after eating takes a rest or reads
newspapers together with husband in the living
room.
 In the past she does brisk walking around the
subdivision for 20 minutes every morning but now
she does it when she doesn’t feel pain.
 In the leisure time she wants to watch television
especially drama.
V. Sleep-Rest pattern
 Usual Sleep pattern:
Onset: 9/10 pm
Awakening: 6 am
Sleep interruptions: urinates in between sleep
# of hours sleep: 8-9 hours
 Sleep aids: lights off
 Sleep problems: cannot sleep easily, prays the
rosary before she gets sleep in order to feel
sleepy.
 Claimed that her abdominal and back pain
interferes with her sleep and rest which would
make her irritable in the morning.
 Claimed that she feels rested and ready for daily
activities if she had dreamt In her sleep and if not
she doesn’t have enough energy and becomes
irritable.
care.
 Claims that she gets bored sometimes but
just talks with her husband.
 Claimed that she feels uncomfortable and
irritable if pain on her back would occur
because she has to find another comfortable
position.
V.
V.
 Claimed that she could not rest properly
because of the hot environment and the
sudden occurrence of the pain on her
abdomen and back.
 Claimed that she has difficulty getting herself
a rest because she is easily awakened by a
little sound.
 Claimed that she is also worried with her
condition because for her she is not the only
one who would be affected but also her
husband and children and because of those
she cannot properly rest.
 Sits at the side of the bed with feet dangling.
 Looks lethargic, eyes closes occasionally when
communicating and frequently yawns, slow-
paced speech.
 Claimed that she could be at any position without
any discomforts
 Claimed of not having enough rest because of her
insomnia.
 Able to do ROM exercises with no hesitation and
difficulty but in a slow motion.
 Verbalized, “Bitaw Ms. Sa mas mayo dagway kung
maglihok-lihok ko ug ginagmay aron pud dili ko
kayo magsige ug huna-huna sa akong sakit ug ma-
exercise pud ug ginagmay akong lawas.”
 Claimed of not generally rested and ready for
daily activities after sleep.
 Claimed of difficulty sleeping early because of
having insomnia.
 Had slept 2 am in the morning and had sleep
interruptions because of the urge to defecate and
difficulty getting into a deep sleep as verbalized.
 Claimed that she is worried with her son who is
hospitalized in Bacolod and her other son who is
in Cebu.
 Had slept after the colonoscopy procedure.
 Claimed that she would close her eyes she
remembers her child who is recently hospitalized
in Bacolod. She is worried if someone is taking
care of him or if he’s alright.
 Claimed that she is also bothered with her
condition if what would be the outcome of the

VI. Cognitive-Perceptual Pattern
 Has difficulty seeing things or people if not using
the eyeglasses.
 Has difficulty hearing clearly and needs a louder
voice from the person who would talk to her.
 Has change in memory lately> It takes time for her
to remember names of people and some recent
events.
 Does feel pain on her right and left iliac region
and on her lower back part. Rated it as 5 in a scale
of 0-10. It just appears suddenly and sometimes if
she does household chores repeatedly in a day.
Does divert her attention to minimize or lessen
the feeling of pain.
 Claimed that she is now scared not minding the
urge to defecate if she feels such she directly goes
to the CR.
 Stated that when she had her colonoscopy last
January it was difficult for her because she would
always vomit and she had also difficulty
defecating. Claimed that because of this she had
phobia of having colonoscopy.
 Verbalized, “Day nahadlok na jud ko mousob tong
nahitabo sauna. Kung dili pa ni kinahanglan jud
dili ra ko magpacolonoscopy.”
colonoscopy.
VI.
VI.  Claimed that she is relieved with the pain she felt
on her abdomen and on her back and had
 Claimed that she only feels pain on her lower stopped holding the affected part.
back part but only occasionally and rated it as  Stated that maybe it would again suddenly
5 in a scale of 0-10. appear when they would be in their house.
 Claimed that she has phobia having  Has moderately paced speech which shows
colonoscopy. association of thoughts.
 She would want to review on how colonoscopy is
done and asks what is the medication that is
given before the procedure. She stated where the
tube is inserted and where should it follow and
stated that it should be done to know if there are
new growths inside her colon.
 After the nurse informed her of the time the
procedure is to be done she would want to take a
deep breath and would focus her mind on why
the colonoscopy has to be done.
 Taught of doing deep breathing exercises and
return demonstrated it satisfactorily.
 Encourage to divert attention to other activities
and to minimize doing household chores to
lessen occurrence of pain.
 Claimed that for now she is focused on her
condition, she is always asking on what are the
possible things or steps to be done for her
condition to prevent complications.
 Claimed that after colonoscopy she didn’t feel
nauseated and there is quite discomfort inside
her rectum.

VII. Self-Perception – Self-Concept Pattern
 Describes self as one with a happy personality,
claimed that she is also sensitive, she easily gets
hurt and cry.
 Feels that she has achieved everything she
dreamed of for her children and her life but is sad
with what she is going through with her disease
condition.
 Claimed that sometimes her condition makes her
feel weak.
 Stated that she is confused where she got such
condition when in fact she doesn’t feel the same
when she has not yet retired.
VIII. Role-Relationship Pattern
 Claimed that before surgery she is passive in their
house. She cannot do any activity because of the
many discomforts she felt. But now she resumes
to being a housewife.
 Claimed that her children are much worried of her
now than before. They would call her daily.
VII.
VII.
 Claimed that her condition made her worry
all the time. She worries if her condition
would worsen or if she would get better.
 Claimed that it worries her more when she
learned from her ultrasound done during her
admission that a growth was found on her
liver.
 Claimed that it worries her if there would be
enough money for the treatment process.
 Describes self at this time as weak but claims
that she is doing her best to be productive
through her little ways.
 Claimed that she would like to have daughter
because the way a daughter expresses their
feelings for their parents is different from the
one with a son.
VIII.
VIII.
 Claimed that she is worried of the expenses
for her hospitalization because her children
would be the one to pay and thinks that she
is a burden to them.
 Verbalized, “Nagpareserve man unta mi ug
private room pero murag kalas na man kay
mogawas na man pud ko ugma dayon usikan
pud ko sa kwarta nga gipadala sa akong mga
anak basig moingon unya sila nga abi kay
gihatagan ko ug kwarta dili pud ko kabal mo
 She would always ask if how big is the growth on
her colon and how many polyps are there.
 She also asks about what the physician has been
saying about her condition when having
colonoscopy.
 Asks if she would be able to get well or minimize
the growth on her colon and the occurrence of
the signs and symptoms.
 Describes self at this time as weak and is really
depressed with her condition after knowing the
outcome of the surgery.
 Claimed that she is hopeful that she conquer all
of the sadness and be able to have the courage
and strength to face all of these.
 Worries if she would still be able to do what she
usually do in their house.
 Hopeful that her family would always be there for
her to help her cope with her condition.
 It was seen in the faces of her son and husband
that they are worried with the outcome of the
colonoscopy.
 Worries if the money of their family would be
enough for the expenses that she would have in
order to prevent complications from her
condition.
 Claimed that her son from Cebu would always call
 tipid usik-usikan ra pod nako.”
 Claimed that she is also ashamed with his
eldest son because he has a problem with his
family and yet he had to take a leave from his
work to take care of her.
 Claimed that even though she has an illness
she and her husband still has the final say of
the things that should be done on their
family.
her and text her that she will be able to get well
and that she will be able to face it with courage.
 Claimed that her son form Bacolod is always
asking if when the colonoscopy start and what
would be happening next.
 Genogram:

= patient
Legend
= operated for Ovarian cyst and myoma
= Died of Ulcer

= Chronic bronchitis = died (male)

= Colon Cancer + died (female)

= Died of tuberculosis + living and well

IX.

IX. Sexuality-Reproductive Pattern
 Claimed that though they are not that intimate
with her husband now than before they would
always talk with each other about any concerns in
their life.
 They would always look for each other and be
with each other everywhere they go.
X. Coping-Stress Management Pattern
 Claimed that since she had known about her
condition she worries about it night and day.
 Before the surgery, difficulty defecating is one of
the stressful aspect of her bowel problem.
IX.
 Claimed that the only one available with her
to cope with her condition is her husband.
 As I was approaching the patient her
husband was sitting beside her and talking to
her.
 Husband claimed that he really cares for his
wife and if possible he would not want his
wife to suffer and feel the pain and stresses
she is going through right now.
 Husband claimed that he would always be
with his wife wherever she goes and would
take care of her.
X.
 Claimed that she is worried with the growth
that is found in her liver and about what
would be the outcome of the colonoscopy,
whether there is absence of masses or if
there would be growth.
 Claimed that she is worried if she would feel
the same way as what she had felt before
after her colonoscopy.
 She would always ask if what would happen
to her and is hopeful that the mass that is
seen on her liver would be healed.
 Claimed that her one way of coping stress is
to talk to someone what she feels and
thanked that student nurses are available for
her to talk to because her husband would
sometimes not empathize with her.
 Her husband always stays at her side.
 Husband claimed that he is worried with the
condition of his wife.
 They talked about what they are planning to do
after knowing the outcome of the colonoscopy.
X.
 Before the colonoscopy was done she asked the
nurse inside the unit if everything would be fine
when the procedure would begin.
 She would always think that maybe there is still
hope that the growth that occurred on her colon
is benign and there are still medications that
would prevent those masses to grow bigger and
to make those masses grow smaller and
eventually be absent.
 Stated that it really helps that her husband is
always there for her.
 Claimed that she is happy that she had not
experienced nausea and vomiting after
colonoscopy.
 Verbalized that she is thankful that even though
her children from Cebu is far from her it didn’t
stopped them from encouraging her mother and
giving her the spirit to fight for her condition.
 XI.

 Claimed that at this time God is only the one who

XI. Value-Belief Pattern
 Claimed that she values her family more than
anyone else in the world and if not because of
them she cannot cope well with her condition and
she would be more depressed.
 Claimed that she also value her life because she
would still want to be with her children and
grandchildren that’s why she want to be treated
and wants to follow what the physician advices
and prescribes.
XI.
 Claimed that at this time she values her
children and husband who is always there for
her.
 She also values the physician’s advices so that
she would get better.
could help her.
 Hopes that there would be a miracle that will
happen.
 Stated that maybe this is one of the trials that
God gave to them and He tested them on how
faithful they are to Him.
 Silliman University
COLLEGE OF NURSING
Dumaguete City

CUES/EVIDENCES NURSING DIAGNOSIS OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

Subjective: Anxiety related to past 1) Within the 2 day care Independent:

 Claimed that she experience and of the the patient recognizes  Goal met: Has
has phobia having outcome of surgery anxiety signs at a low 1) Document behavioral  Symptoms often moderately paced
colonoscopy. intensity level as and verbal expressions of provide information speech which
 Claimed that she is evidenced by moderately anxiety. regarding the degree shows association
worried about paced speech and would of anxiety. of thoughts. She
what would be the ask about how the Physiological would want to
outcome of the procedure is done. symptoms and/or review on how
colonoscopy, complaints intensify colonoscopy is
whether there is 2) Patient’s anxiety is as the level of anxiety done and asks
absence of masses relieved as evidenced by: increases. what is the
or if there would medication that is
be growth. a) Querying physician 2) Acknowledge  Acknowledgement of given before the
 Claimed that she is about concerns related to awareness of patient’s patient’s feelings procedure.
also worried with the type of medication anxiety. validates the feelings  Goal not met: She
her condition used before surgery and and communicates was not able to
because for her about the sequence and acceptance of those ask the physician
she is not only the steps of the procedure. feelings. because she was
one who would be asleep when the
affected but also b) Querying staff about 3) Reassure patient that  The presence of a physician arrived
her husband and last minute concerns. she is safe. Stay with trusted person assures in the unit.
children and patient if this is necessary. patient of her security  Goal met: Before
because of those c) Verbalizes and safety during a the colonoscopy is
she cannot understanding of the period of anxiety. done she asked
properly rest. procedure. the nurse inside
  Claimed that she is  Staff’s anxiety may be the unit if
worried if she d) Relaxes quietly after 4) Maintain a calm and easily perceived by everything would
would feel the being visited by health tolerant manner while the patient. The be fine when the
same way as what team members. interacting with patient. patient’s feeling of procedure will
she had felt before stability increases in a begin.
after her 3) Before discharge the calm and non-  Goal met: She
colonoscopy. patient would be able to threatening stated where the
 Stated that when state clearly step by step atmosphere. tube is inserted
she had her the routine she does in and where should
colonoscopy last her house and one  Utilizing anxiety- it follow and
January it was importance of continuing 5) Assist in developing reduction strategies stated that it
difficult for her those normal life anxiety-reducing skills enhances patient’s should be done to
because she would activities. (relaxation deep sense of personal know if there are
always vomit and breathing, positive mastery and new growths
she had also 4) Within the 2 day care visualization, reassuring confidence. inside her colon.
difficulty the patient would be able self-statements).  Goal met: After
defecating and to demonstrate use of  Helps patient to feel the nurse
because of this she effective coping 6) Provide open accepted in present informed her of
had phobia of mechanisms and active environment in which condition without the time the
having participation in treatment patient feels safe to feeling judged and procedure is to be
colonoscopy. regimen. discuss feelings or to promotes sense of done she would
refrain from talking. dignity and control. want to take a
Objective: deep breath and
 Teary eyes when  Accurate information would focus her
she would talk 7) Explain procedures, allows the patient to mind on why the
about the providing opportunity for deal more effectively colonoscopy has
diagnosis of her questions and honest with reality of to be done.
colon cancer last answers. Stay with patient situation, thereby  Goal met:
January. during anxiety-producing reducing anxiety and Verbalized, “Bitaw
 Slow-paced procedures and fear of the unknown. Ms. Sa mas mayo
speech consultation. dagway kung
maglihok-lihok ko
ug ginagmay aron
pud dili ko kayo
 magsige ug huna-
huna sa akong
sakit ug ma-
exercise pud ug
ginagmay akong
lawas.”
 Goal met: She was
very vocal of what
she is feeling to
the student nurse,
to her husband
and son and it was
clearly seen that
she is eager to
participate in the
procedure that
was to be done
and always asks
what medications
are needed to
treat her condition
 Silliman University
COLLEGE OF NURSING
Dumaguete City

CUES/EVIDENCES NURSING DIAGNOSIS OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective: Altered Comfort: Pain 1) Within the 2 day care Independent:

 Claimed that she related to tissue trauma the patient’s pain is  Goal met:
feels pain on her minimized if not relieved as 1) Evaluate patient’s  It is important to Verbalized relief
abdomen and back evidenced by verbalization response to pain and help patient from pain on the
occasionally but of relief from pain and medications or express as factually abdomen and on
not like when she rating pain in a range therapeutics aimed at as possible the the back.
was at home that tolerable by patient. abolishing / relieving pain. effect of pain relief  Goal met: Claimed
the pain would last measures. that she could be
the whole day. 2) Within my care the at any position
Rated pain as 5 in a patient’s laboratory values 2) Evaluate what pain  The meaning of the without
scale of 0-10. would be within the means to the individual. pain will directly discomforts.
Describes pain as normal range: influence patient’s  Goal met: Had
nagging which a) Blood = Neg response. Pain will stopped holding
would radiate from b) Red cells= 7-14 influence activity, the affected part.
her Right iliac c) epithelial cells= none family role, self-  Goal met: Taught
region to her left d) bacteria= none concept etc. of doing deep
iliac region then e) Mucus threads= none breathing exercises
transfers to the 3) Assess patient’s  Some patients may and return
lower portion of 3) Patient would verbalize expectations for pain relief. be content to have demonstrated it
her back. that she could be at any pain decreased; satisfactorily.
 Claimed that she position comfortably others will expect
feels before discharge. complete
uncomfortable and elimination of pain.
irritable if pain on 4) Patient would minimize This will impact on
her back would or stop holding the their perception of
occur and finds a affected parts before the effectiveness
comfortable discharge. of the treatment
position. modality and their
  Claimed that she 5) Patient would be able to willingness to
does feel pain on satisfactorily perform the participate in
her right and left pain relaxation techniques further treatments.
iliac region and on by tomorrow morning.
her lower back 4) Provide comfort  Provides support
part. Rated it as 5 measures, e.g., backrub; (physical,
in a scale of 0-10. deep breathing exercises emotional);
and calm and quiet reduces muscle
Objective: environment. Encourage tension; enhances
use of guided imagery and relaxation;
 Occasionally holds relaxation techniques. refocuses
the affected parts. attention,
 Blood (Urine) = enhances self-
Mod control and coping
 Red cells (Urine)= abilities.
7-14/ hpf
 Epithelial cells=
few
 Bacteria= few
 Mucus threads=
few
 Silliman University
COLLEGE OF NURSING
Dumaguete City

CUES/EVIDENCES NURSING DIAGNOSIS OBJECTIVES NURSING INTERVENTIONS RATIONALE EVLUATION

Subjective: Risk for Fluid Volume 1) Within my care the Independent:

 Claimed that she is Deficit related to past patient would maintain a) Monitor vital signs  Early signs of  Goal partially met:
worried if she experiences of excessive adequate hydration as frequently, noting intestinal Patient was not
would again vomit losses through normal evidenced by moist increased pulse, postural hemorrhage/ able to maintain
after colonoscopy. routes, e.g., vomiting mucous membranes, good BP changes, tachypnea and hematoma adequate hydration
 Verbalized, “Dili ba skin turgor and capillary apprehension. formation, which because she was
ko magsuka-suka refill and stable vital signs. may cause on NPO status until
paghuman ug hypovolemic after colonoscopy
colonoscopy Ms. 2) Patient would verbalize shock. is done. Claimed of
Kay katong una kay minimal discomforts on her dry mucous
nagsuka-suka man rectum and feeling of b) Palpate peripheral  Provides membranes. Skin
gud ko ato.” nausea and vomiting after pulses. Evaluate capillary information about turgor was good
 Stated that when colonoscopy. refill. Skin turgor and status general circulating and capillary refill
she had her of mucous membranes. volume and level time was 1-2
colonoscopy last of hydration. seconds.
January it was c) Monitor I&O (include all Vital signs:
difficult for her sources, e.g., emesis,  Direct indicators of 8 am
because she would tubes, diarrhea), noting hydration/organ T= 36.5˚C
always vomit and urine output, specific perfusion and P= 71 bpm
she had also gravity. Calculate 24-hour function. Provides R=18 cpm
difficulty balance, and weigh daily. guidelines for fluid BP= 110/80 mmHg
defecating. replacement.
12nn
T= 36.5˚C
P= 67 bpm
R= 18 cpm
BP= 110/70 mmHg
  Goal met: Claimed
that after
colonoscopy she
didn’t feel
nauseated and
there is quite
discomfort inside
her rectum.

Silliman University
COLLEGE OF NURSING
 Dumaguete City

SUBMITTED TO:
MR. PHILIP FERROLINO

SUBMITTED BY:
MICHELLE THERESE A. HERUELA
C2
Date: December14, 2009