PATIENT CARE RECORD

Patients name: M.E.G. Room no: 221A Ward: FSW

Date:

Chief Complaint: Abdominal pain Diagnosis:

A. Health History
I.
Biographical data
Age: 35
Sex: Female Citizenship: Filipino Religion: Roman Catholic
Birthdate: 11/05/1980
Civil Status: Single Educ. Attainment: College Graduate
Address: Quezon City
Occupation: Purchaser
II.
History of Present Illness:
The patient was a known case of cholelithiasis diagnosed last 2016, initially
presenting as abdominal pain and jaundice which underwent laparoscopic
cholecystectomy last April 5, 2016. One day prior to her admission to USTH, she
complained of abdominal pain which she graded for about 10/10 and with
unexplained intensity and it was radiating to her back. She also experienced
vomiting during works and observed to have a tea-colored urine. She consulted to
her private physician and was advised and scheduled for an Endoscopic Retrograde
Cholangiopancreatography (ERCP) but the procedure was failed so theyve decided
to scheduled her for an emergency laparotomy which it hence her admission to the
institution.
III.
Past Health History
Patient has previous hospitalization last 2008 for Cesarean Section, April 5, 2016 for
Laparoscopic Cholecystectomy and April 16. 2016 for ERCP. She was with a history
of being a previous smoker with 4 pack per year smoking and an alcoholic beverage
drinker.
IV.

Family Health History

According to the Patient, her mother is positive for Diabetes Mellitus. On the other
hand, his family is negative to any conditions such as Allergy, Thyroid disease,
Hypertension, Cancer or PTB.

SUMMARY OF DIAGNOSTIC PROCEDURES

DATE

PROCEDURE

April 1, 2016

Complete Blood
Count

SIGNIFICANT
FINDINGS
WBC 30-40 HPF (0-5
HPF)

RBC 2-4 HPF ( 0-2

HPF)

INFERENCE
It can be increased to
those with urinary
tract infections.
Large numbers of
RBCs in the urine is
called hematuria and
indicates trauma or
disease.

Complete blood count and differential count - this laboratory procedure is performed in order for
the doctors to know if the patients blood is within normal and the results will reveal signs of
infection, dehydration, or the need for a post-surgery and more. The patient underwent TURP and
was ordered for a CBC and results to a high WBC. The WBC is ordered to monitor the patient who
has been diagnosed with an infection, immune disorder.
Blood chemistry it is a routine physical examination to help the physician to plan changes in
the meal and to examine the general health of a patient before undergoing a surgery and in
order to treat some conditions that can be seen in the results.

NARRATIVE OF NURSING PROBLEMS, INTERVENTIONS AND OUTCOMES OF CARE

DATE
April 22, 2015\6

April 23, 2015

REMARKS
F> Alteration in Comfort; Pain
D> Verbalized, Masakit yung sa tahi ko, with pain score of 7/10. With
facial grimace and unpleasant mood. With T-tube and JP drain inserted.
A> Encouraged deep breathing exercises. Maintained a calm and quiet
environment. Positioned comfortably. Encourage to turn to sides
every 2 hours to prevent bed sores.
R> Diminished pain with latest pain score of 4/10. With pleasant
mood. Participated in nursing care. No facial grimace.
F> Alteration in comfort; chronic pain
D> verbalized Masakit pa rin, may parang pumipitik-pitik akong
nararamdaman. With a pain score of 8/10. With unpleasant mood and
facial grimace. Seen to be irritated with the incision site and t-tube
inserted.
A> Placed to position of comfort. Encouraged deep breathing
exercises. Maintained a calm/quiet environment. Encouraged to
verbalize feelings. Provided comfort measures. Encouraged
relaxation techniques such as reading or diversional activities such
as talking with significant others.
R> verbalized diminished pain with latest pain score of 5/10. Participated
in nursing care, deep breathing, relaxation techniques and diversional
activities performed.

TEACHING PLAN
CONTENT AREAS

OBJECTIVE

Reducing the pain felt

due to surgical
incision.

Within 1 hour of
health teaching, the
patient will be able to
decide on the
appropriate action
needed to improve
the health status by:
1. Implementing
the actions
planned to
achieve
wellness
2. Actively
participate to
the
interventions
the nurse will
provide.
3. Demonstrating
techniques to
divert attention
from pain.

Diet

Within 1 hour of
nursing intervention,
the patient will be
able to provide or
enhance a proper
food/fluid intake by
Eating healthy foods
or prescribed food
and increasing oral
fluid intake.

STRATEGY OF
IMPLEMENTATION

Health teaching on
instructing the
patient to do
active ROM on
both arms, the
nurse will guide
the patient in
doing the
exercises.
teaching deep
breathing
exercises,
relaxation
techniques and
diversional
activities by
demonstrating it to
the patient

Health teaching on
educating the
patient by Eating
healthy foods
which are rich in
nutrients
Advise patient to
avoid eating junk
foods or fatty
foods.
Encourage patient
to increase oral
fluid intake to
prevent
dehydration.

EVALUATION
After 1 hour of health
teaching, the patient
was able to decide on
the appropriate action
needed to improve
the health status by:
1. Implementing
the actions
planned to
achieve
wellness
2. Actively
participate to
the
interventions
the nurse will
provide
3. Demonstrating
techniques to
divert attention
from pain.
After 1 hour of
nursing intervention,
the patient will be
able to provide or
enhance a proper
food/fluid intake by
Eating healthy foods
or prescribed food
and increasing oral
fluid intake.

DISCHARGE PLAN
GOAL
On the day of discharge,
patient/family will be able to
receive verbal and written
instructions concerning:
1. Medications
2. Exercises
3. Treatment
4. Hygiene
5. Out-Patient
6. Diet
7. Social, Spiritual and
Psychological

1.

2.

3.

4.

5.
6.

7.

8.

9.

STRATEGY OF
IMPLEMENTATION
Assess needs of
patient/family in the
discharge process
Give adequate
instruction about the
importance of following
take home medications
Advise patient to
promote rest and deep
breathing exercises.
Encourage to do active
range of motion with
slow progressions in
frequency and provide
assistance if needed.
Provide patient and
family written and
verbal information
regarding to seek
medical advice from
health care professional
in case of complication
and provide support for
the patient and family
needs assistance,
explanation and
support every time
patient requires
treatment.
Follow-up after a week
after discharge.
Advise to follow dietary
regimens prescribed by
the doctors
Encourage patient to
have faith and pray to
God for guidance and
faster recovery.
Encourage the patient
to spend a time of
silence in a day for a
moment of prayer.
Advise patient to
socialize with
significant others and
spare a little time for
conversations

EVALUATION
On the day of discharge,
patient/family was able to
receive verbal and written
instructions concerning:
1. Medications
2. Exercises
3. Treatment
4. Hygiene
5. Out-Patient
6. Diet
7. Social, Spiritual and
Psychological

10.Instruct patient/family
about leisure resources
available in the
community
11.Encourage
patient/family to
verbalize their
understanding of the
discharge instructions
and give demonstration
of any care procedures.

DATE

CUES/CLU
ES

04/22/16

Cues:
Patient
verbalized
Sobrang
Sakit
nung tahi

NURSING
DIAGNOSI
S
Acute Pain
related to
postoperative
surgical
incision

SCIENTIFIC
RATIONALE

OBJECTIVE

NURSING
INTERVENTION

Pain is a
typical
sensory
experience
that may
be

Within 1-2
hours of
nursing
interventions,
the patient will
be able:

1. Provide comfort
measures such
as repositioning
of the patient
management
2. Encourage use

ANALYSIS

1. It reduces
muscle
tension a
fatigue
2. to promot
non

ko
Clues:
Pain scale:
8/10
Facial
grimace
Unpleasan
t mood
Surgical
incision
on
hypogastri
c region

DATE

CUES/CLUE
S

11/24/1
5

Cues:
Patient
verbalized,
Kahapon
lang ako ng
umaga
naoperaha
n

NURSING
DIAGNOSI
S
Risk for
infection
related to
surgical
incision
secondary
to
impaired
immune

described
as
unpleasant
awareness
of a body
stimulus to
body harm.
Individuals
experience
s pain due
to daily
aches or
hurts or
occasionall
y through
surgeries
or
illnesses.

SCIENTIFIC
RATIONALE
Persons at risk for
infection are those
whose natural
defense
mechanisms are
inadequate to
protect them from
the inevitable
injuries and
exposures that

1. To
reduce
pain
from a
scale of
8/10 to
5/10
2. To
demons
trate
non
pharma
cologic
measure
s
3. To
verbaliz
e
feelings
of pain
4. To
report
relief
5. Demons
trate
use of
relaxati
on
techniqu
es and
diversio
nal
activitie
s.

3.

4.

5.
6.

7.

OBJECTIVE

Within 1-2 hours 1.

of nursing
interventions,
the patient will
be able:
1. To remain free 2.
from
symptoms of
3.
infection

of relaxation
techniques such
a deep
breathing
exercises
Encourage
diversional
activities such
as reading
books or
magazines or
newspapers and
socialize with
significant
Encourage to
verbalize
feelings of pain.
Establish
Rapport with
the patient.
Monitor Vital
Signs
Perform pain
assessment to
include location,
characteristics,
duration, onset,
frequency,
intensity or
severity.
Raise the side
rails at all
times.

3.

4.

5.

6.

7.

NURSING
INTERVENTION
Educate patient 1.
on adequate
protein and
caloric intake for
healing
Advise patient
to increase fluid 2.
intake
Instruct client on

pharmaco
gic pain
To distrac
attention
pain.
To be abl
to follow
the situat
of the
patient
It serves
a baseline
data to
check if
there are
any
deviation
from his
vital signs
Pain is a
subjective
experienc
and must
described
by the cli
in order t
plan
effective
treatmen
For safety
measures
the patien

ANALYSIS

Tissue repa
requires
increased
protein and
carbohydra
s.
Proper
hydration is
needed for

Clues:
Incision site
with
dressing
Fast drip
cystoclei
sis
draining
to
serosang
uinous to
serous
fluid.
IV fluid
attached
on his
left hand
WBC count:
27.60 x
10^9/L
(4.5
10.0)

system
functionin
g

occur throughout
the course of
living. Infections
occur when an
organism (e.g.,
bacterium, virus,
fungus, or other
parasite) invades a
susceptible host.. If
the hosts
(patients) immune
system cannot
combat the
invading organism
adequately, an
infection occurs.
Open wounds,
traumatic or
surgical, can be
sites for infection;
Infections can be
transmitted, either
by contact or
through airborne
transmission,
sexual contact, or
sharing of
intravenous (IV)
drug paraphernalia.

DATE

CUES/CLUE
S

SCIENTIFIC
RATIONALE

11/24/1
5

Cues:
Patient
verbalized,
Kahapon
lang ako ng
umaga
naoperaha
n

NURSING
DIAGNOSI
S
Risk for
infection
related to
surgical
incision
secondary
to
impaired
immune
system

Clues:

Persons at risk for

infection are those
whose natural
defense
mechanisms are
inadequate to
protect them from
the inevitable
injuries and
exposures that
occur throughout
the course of

2. To state
hand washing
transportat
symptoms of
when touching
of oxygen a
infection of
materials and
waste
3.
Hand wash
which to be
touching the
is the most
aware
dressing.
3. Demonstrate 4. Observe and
important
appropriate
report signs of
means to
care of
infection such as
prevent the
infectionredness,
spread of
prone site
warmth,
infection
4. Maintains
discharge, and 4. With the
white blood
onset of
increased body
cell count and
infection th
temperature
differential
5. Encourage
immune
within normal
adequate rest to
system is
limits
boost the
activated a
5. Demonstrate
immune system
signs of
appropriate
6. Use careful
infection
hygienic
technique when
appear
measures
changing and
5. Chronic
such as hand
emptying
disease and
washing, oral
urinary catheter
physical an
care.
bags; avoid
emotional
crossstress
contamination
increase th
7. Keep area of
clients nee
incision site
for rest
clean and dry
6. Clients are
most at risk
for crossinfection
during bag
changing a
emptying.
7. Wet area ca
be lodge ar
of bacteria
OBJECTIVE

NURSING
INTERVENTION

Within 1-2 hours 8. Educate patient 8.

of nursing
on adequate
interventions,
protein and
the patient will
caloric intake for
be able:
healing
9.
Advise patient
6. To remain free
to increase fluid 9.
from
intake
symptoms of
10.Instruct
client on
infection
hand washing
7. To state
when touching
symptoms of

ANALYSIS

Tissue repa
requires
increased
protein and
carbohydra
s.
Proper
hydration is
needed for
transportat
of oxygen a

Incision site
with
dressing
Fast drip
cystoclei
sis
draining
to
serosang
uinous to
serous
fluid.
IV fluid
attached
on his
left hand
WBC count:
27.60 x
10^9/L
(4.5
10.0)

functionin
g

living. Infections
infection of
occur when an
which to be
organism (e.g.,
aware
bacterium, virus,
8. Demonstrate
fungus, or other
appropriate
parasite) invades a
care of
susceptible host.. If
infectionthe hosts
prone site
(patients) immune
9.
Maintains
system cannot
white blood
combat the
invading organism
cell count and
adequately, an
differential
infection occurs.
within normal
Open wounds,
limits
traumatic or
10.Demonstrate
surgical, can be
appropriate
sites for infection;
hygienic
Infections can be
measures
transmitted, either
such as hand
by contact or
washing, oral
through airborne
transmission,
care.
sexual contact, or
sharing of
intravenous (IV)
drug paraphernalia.

materials and
waste
10.Hand
wash
touching the
is the most
dressing.
11.Observe and
important
report signs of
means to
infection such as
prevent the
redness,
spread of
warmth,
infection
11.With
the
discharge, and
onset of
increased body
infection th
temperature
12.Encourage
immune
adequate rest to
system is
boost the
activated a
immune system
signs of
13.Use careful
infection
technique when
appear
changing and
12.Chronic
emptying
disease and
urinary catheter
physical an
bags; avoid
emotional
crossstress
contamination
increase th
14.Keep area of
clients nee
incision site
for rest
clean and dry
13.Clients are
most at risk
for crossinfection
during bag
changing a
emptying.
14.Wet area ca
be lodge ar
of bacteria