Fill in the Admission below, using the data available in the case to study

A case to study

JA. A 37 year old woman, was the mother of five children, and the wife of RA, a carpenter in
Illionis. RA lives at 115 Riverview, Middletown, Ph.312 437 6677. JA was referred by her family
physician, Dr. Scott to the continence clinic at St. James’ Medical Center 30 miles from her
home.

The admission interview was conducted by a registered nurse. JA reported the use of
continence aids to manage frequent seepage of stool, which began after a hemorrhoidectomy.
The surgery was performed 4 days after a vaginal delivery of her fifth child, a boy weighing 10
pounds, 2 ounces. The hemorrhoids were very painful throughout the last trimester of
pregnancy and during the delivery. JA elected to have surgery done in the immediate
postpartum period because her oldest daughter was home from college for the summer.

JA’s primary exercise was caring for her husband, the children and her home. She and her
husband went bowling every Wednesday evening and visited her parents every other Sunday
after church. The remainder of their social life revolved around their family life and the children’s
activities.

Anorectal manometric assessment and protoscopy were done by Dr.N, who reported a less
than normal maximal squeeze pressure, intact internal and external anal sphincters, a small
rectal fissure and perianal redness. Dr. N suggested a trial of pelvic floor exercises, addition of
fiber to her diet, use of desitin ointment for perianal redness, and regular physical activity three
times a week. He recommended that she return in 2 months, and if she had not improved he
would begin a course of biofeedback. JA expressed relief that she did not require additional
surgery and agreed to follow Dr. N’s recommendations.
NURSING ASSESSMENT : WRITING

ADMISSION FORM

St. James Medical Center Hospital Reg. No :

Admission Card Ward/Dept :
SURNAME (IN BLOCK LETTERS) FIRST NAME (S)

ADDRESS & TELEPHONE NO. DATE OF BIRTH

CIVIL STATE OCCUPATION (In the case of a child, father’s

Married occupation
Single
Widow
others
RELIGION NAME & ADDRESS OF NEXT OF KIN

NAME & ADDRESS OF G.P TELEPHONE NO.

(If no phone, give a number where messages
may be sent. Add ‘messages only).

SURGEON OR PHYSICIAN IN CHARGE OF CASE

MEDICAL INFORMATION

Relevant medical history:

Allergies:

Bowels:

Urinary:

Menstruation:

Hearing:

Vision:

Oral:

……..