Chapter IV NURSING HISTORY

A. History of Present Illness Prior to admission, the patient had an episode of abdominal pain by 2-3 weeks. She felt pain on her left iliac region. She also has an irregular

menstruation. Upon the onset of the symptoms, Mrs. E.G. took pain reliever to ease the pain; however, she and her husband still both decided to seek for medical assistance at Socsargen County Hospital. They consulted her attending physician and had an ultrasound of her pelvis. She was diagnosed with left

ovarian cyst. Thereafter, she was advised and scheduled for a Total Abdominal Hysterectomy Bilateral Salpingo Oophorectomy to remove the said cyst on July 25, 2010 for which the couple had agreed upon. B. Past Medical History Immunization and Childhood Illness According to the patient, she had an immunization of BCG, DPT, and OPV. She had a history of having chicken pox infection when she was on her 4th grade during elementary. She also experienced cough and colds, fever, diarrhea, constipation, sore throat, rashes, and nausea and vomiting.

Compliance to Health Management Mrs. E.G. often buys and takes neozep, biogesic, mefenamic acid, paracetamol, diatabs, loperamide, and multivitamins. She also uses herbal plants such as oregano, guava, bitter gourd, and ginger. If diseases occur, she goes to the barangay health center for management before directly going to the hospital. She also had check-ups in clinics.

Menarche Her menarche started when she was in her 4th grade. She was 9 years old back then on the year 1975.

Family History There is no known inherited condition present in her both paternal and maternal family. Shes the first in their family to be diagnosed with certain disease.

Activities of Daily Living Personal Hygiene The patient is able to bathe herself. She takes a bath everyday. She also practices washing her hands before and after eating her meals.

Nutrition She eats more of fruits and vegetables. She was able to eat meals

three times a day with snacks in between. She consumes at least 2L of water a day. She claimed that she has no allergies on food. She is taking vitamins. Elimination She voids 4-5 times a day. Her urine color is yellow which is dark sometimes. There is no burning sensation/ pain felt during urination. Rest and Sleep She can sleep for 7 hours per night. She sleeps at 10:30 PM and wakes up early at 5:30 AM. She usually takes a nap at noon. There is no difficulty in going to sleep felt by her. She is not using medications to promote her sleep. Exercise The patient ambulates within the house. She is also visiting their farm. She does simple exercises on the upper and lower extremities. Her movements are well-coordinated. Religion She is a Roman Catholic who has a strong faith in God. She goes to the church with her husband to attend the mass every Sunday.

Sexuality The patient is married, yet dont have a child. She had her pap

smear checked yearly. She has no history of Sexually Transmitted Disease. Her menarche was on the year 1975 when she was still 9y/o and her menstruation is irregular. Hospitalization In this year is her second hospitalization. When she was first diagnosed with ovarian cyst last January 2007, she was advised to be admitted and scheduled to remove her cyst by an operation. She agreed to be admitted during that time, March 2007, making it her first time of hospitalization. However, the operation was cancelled because the ovarian cyst became smaller as seen on the ultrasound result. C. Nursing Physical Assessment a. General Appearance IVF of D5NSS 1L x 100 as main line hooked at her left cephalic vein, infusing well and PNSS 1L x KVO hooked at her right brachial vein with a side drip of PNSS 500mL + Narapin + Morphine Sulfate x 10 mgtts/hr, infusing well Looks weak and tired Tries to be relaxed

Making herself comfortable Foley catheter attached to uro bag draining well with scanty amount of blood mixed with urine

Conscious and coherent Oriented to people, time and place Can respond to stimuli even when weak On bed rest with no bathroom privilege Vital Signs 7-27-10 8 AM 12PM 37.20C 74 bpm 26 cpm 120/80 mmHg Normal 36.5-37.50C 60-100 bpm 12-20 cpm 90/60 120/90 mmHg

T PR RR BP

370C 74 bpm 23 cpm 110/80 mmHg

b. Skin Light brown in color same all throughout the body Warm to touch

Good skin turgor No edema No masses noted No lesions found

c. Head Normocephalic Round-shaped Symmetrical facial features Evenly distributed black, short, thick hair Without lesions, lumps, or mass noted

d. Eyes Eyebrows evenly distributed and aligned Eyelashes are short and curled outward Conjunctiva pinkish in color with white sclera Pupils are equally rounded, both are reactive to light and accommodation Coordinated eye movement as both eyes follow the direction of the gaze fixed

Blinks voluntarily Without discharges Without sight problems

e. Ears Symmetrical Pinna at the level of the outer canthus of the eyes Auricle is firm, smooth, and free from lesions and pain No unnecessary and foul discharges No problems in hearing Flexible earlobes

f. Mouth Symmetric Pinkish Dry Without inflammation or lesions noted Tongue lies at the midline with free mobility No problems in speaking

Straight and white teeth

g. Neck Symmetrical with head in central position Not enlarged Coordinated movement with slight pain felt

h. Spine and Back Can turn to sides with slight discomfort due to surgical procedure Supports the body well No deformities found Spine is centrally positioned i. Thorax and Lungs Respiration rate is 24 cpm Vibrations are present and can be felt on the chest Clear breath sounds Normal chest movements during breathing

j. Breast No masses and lesions noted

Flesh colored Areolar areas and nipples are darker in pigmentation No discharges noted

k. Heart Heartbeats are present and audible Can be auscultated effectively more on the left side of the chest at her 5th intercostals space Cardiac rate is 74 bpm Pulse with regular rhythm

l. Abdomen With surgical incision on the left iliac region with dry and intact dressing Round Umbilicus centrally positioned Rises with inspirations and falls with expirations

m. Upper Extremities Both arms are the same in size and length Movement is coordinated with careful motion

No lesions and rashes observed

n. Lower Extremities Both legs are of the same size and length O lesions and rashes observed Hair equally distributed in legs No rashes found

o. Musculoskeletal Normal bone structure No symptoms and signs of possible deformities No masses present Range of motion is good though weak if prolonged

p. Genitourinary Placed underpad fully soaked with lochia rubra Slight pain felt during urination Foley catheter attached to uro bag draining well with scanty amount of blood mixed with urine