Central Luzon College of Science & Technology National Hi-way, Upper Kalaklan, Olongapo City, Philippines 2200 Tel.

Nos. (047) 223-5888 / 224-1288 www.clcst.edu.ph

Objectives

Nurse Centered Objectives: At the end of this study, the student nurse will be able to: 1. Have critical thinking skills necessary for providing safe and effective nursing care. 2. Have a comprehensive assessment and implement care base on our knowledge and skills of the condition 3. Familiarize themselves with effective inter-personal skills to emphasize health promotion and illness prevention. 4. Impart the learning experience from direct patient care. Patient and Family Centered Objectives: At the end of the study, the patient/significant others will be able to: 1. Identify measures that could minimize the risk of occurrence of the disease. 2. Identify possible risk factors that may have contributed to the development of colonic mass. 3. Develop the familys support system and distinguish their respective roles improving patients health status. 4. Involve them in promoting the health care of the patient.

Central Luzon College of Science & Technology National Hi-way, Upper Kalaklan, Olongapo City, Philippines 2200 Tel. Nos. (047) 223-5888 / 224-1288 www.clcst.edu.ph

Chapter II Personal Profile: 1. Demographic Data Patient X was born on February 14, 1955, 57 years old female and residing at Olongapo City. 2. Socio-economic and Cultural Belief Patient X is a widowed housewife. She is a Roman Catholic. She was a previous user of smoking and drinker which she stopped when she was in 50 years old. Family History: Patient X has no family history indicated. Past Medical History: 1. General Health The patient was conscious and coherent. Pale in appearance and with body weakness. 2. Childhood Illness The only illness he experienced was common cold, cough and fever.

Central Luzon College of Science & Technology National Hi-way, Upper Kalaklan, Olongapo City, Philippines 2200 Tel. Nos. (047) 223-5888 / 224-1288 www.clcst.edu.ph

3. Immunizations Patient X has complete immunization. Health History: Admission Date: December 5, 2012 ( 10:00 pm ) Attending Physician: Dr. Trinidad, Dr. Rasalan, Dr. Cacaua Diagnosis: S/P Exploratomy lap, Sigmoidectomy, end-end anastomosis 2 r/o Colonic Mass History of Present Illness: Patient X was admitted last December 5, 2012 around 10:00 pm at James L. Gordon Memorial Hospital ( Surgery Ward ), accompanied by her relatives with a chief complaint of constipation and abdominal pain. 1 week prior to admission, patient X experienced abdominal pain and constipation. There is also changes in the caliber of her stool.

Central Luzon College of Science & Technology National Hi-way, Upper Kalaklan, Olongapo City, Philippines 2200 Tel. Nos. (047) 223-5888 / 224-1288 www.clcst.edu.ph

Physical Assessment: Lifted from the chart ( 12-05-12 ) Conscious and coherent BP= 100/60 CR= 77 RR= 21 BT= 36 (-) pallor (-) crackles Flat abdomen, soft (-) tenderness (-) edema, (-) cyanosis

General Survey: Awake, afebrile Airway: Adequate mouth opening Chest: (-) wheeze Cardiac: (-) murmur Abdomen: flat, soft, non-tender Extremities: no joint deformities, (-) edema

Central Luzon College of Science & Technology National Hi-way, Upper Kalaklan, Olongapo City, Philippines 2200 Tel. Nos. (047) 223-5888 / 224-1288 www.clcst.edu.ph

Review of System: Neuro/EENT: (-) weakness, (-) numbness Pulmonary: (-) cough, (-) DOB, (-) sputum production Cardiovascular: (-) fatigue, (-) chest pain GI: (+) abdominal pain, (-) diarrhea, (+) constipation, (-) hematochezia, (-) hematemesis GU: (-) dysuria, (-) hematuria Endocrine: (-) tremor Hematology: (-) bleeding December 07, 2012 (8:00am) Seen patient lying on bed, awake wih ongoing IVF of PNSS at 100 cc level x 30 gtts/min. inserted at left metacarpal vein, with ongoing D5W + 400 mg tramadol @ 400 cc level regulated q 6hrs., with ongoing KCL drip of 90 cc PNSS + 40 meqs with indwelling folley catheter to urine bag. Vital signs taken as follows: BP= 110/70 CR= 94 RR= 16 BT=36.6

Central Luzon College of Science & Technology National Hi-way, Upper Kalaklan, Olongapo City, Philippines 2200 Tel. Nos. (047) 223-5888 / 224-1288 www.clcst.edu.ph Health Management Nutritional / Metabolic Elimination He has no previous hospitalization and no family history of any disease or abnormality He likes to eat vegetables, fish and meats He doesnt have a hard time voiding and defecating. He defecatesonce a day. He said that it was normal for him Activity / Rest Cognitive / Perception Self Perception / Self-concept He has enough hours of sleep. He sleeps 8-10 hours a day. His sense of sight, smell and hearing is normal Patient X felt embarrassed and at the same time, ashamed because of what happened to him. He is also sad and depressed because he will be having a hard time doing his usual routine. He used to play basketball when he has time. Role / Relationship

Patient X is second among three siblings. They have no conflicts among relatives or family members. Patient X cope his stress by talking to his friends, and relatives. Patient X has no vices. He

Coping/StressTolerance

doesnt smoke and he doesnt drink alcohols. Values/Beliefs Patient X believes and has faith in God.