University of the East RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER #64 Aurora Boulevard, Barangay Doa Imelda, Quezon

City COLLAGE OF NURSING RLE: DUTY

SURGERY WARD

PRESENTED TO: Sir Lopez

SUBMITTED BY: Valbuena, Alynna Perseveranda, Mika SECTION: N3A Group: A4 DATE: October 8, 2012

A.

Clients Profile Name: M. B. Age: 75 years old Gender: Male Status: Married Address: Quezon City Education: Elementary Occupation: None Religion: Catholic Date and Time Admitted: October 3, 2012, 3:31 p.m. Chief Complaint: Nahihirapan ako umihi, pag pipigilin ko ang sakit. Diagnosis/Impression: Hyperplasia prostate. Attending Physician: Dr. Yrastorza

B. Current Health Status: Present Medical History 7 years PTA, px experienced the need to urinate but did not reach the bathroom on time. This happened twice in span of 1 week. No other symptoms were noted. Px underwent a transrectal ultrasound and results showed hyperplasia of the prostate. He was advised to take medications but px refused. He was also lost to follow up. 4 years PTA, px noted on increase in frequency in urination and his urine had a shade of red. He also can't control his urination. 3 years PTA, px had nocturia and hesitancy in urinating. Still nothing was done. 4 months PTA, px had headache, nausea and vomiting, decrease in appetite and fever. He was sent to QC General Hospital for evaluation. In the ER, px felt pain on the bladder and urethra, 8/10 in PS because of lack of beds on the said hospital. He was confined there and had a diagnosis of pneumonia, TB, hypocalcemia and hypertension. Cystometry was done and showed corticol cysts on the right and enlarged prostate gland, grade IV, 99 grams. Px was discharged after a month and his catheter was removed. 3 months PTA, day after discharge, px again felt pain on the bladder and urethra. Due to this, px's catheter was placed back and was sent home. He was

scheduled for prostate surgery as soon as possible. He went to UST hospital but due to financial constraints, he transferred to San Juan Medical center. His catheter was removed and he experienced again difficulty in urinating. He was transferred to UERMMMCI. A week after px was confined to UERM, px developed an infection so he was sent home to get well. An unrecalled medication was also given to relax the prostate. His catheter was charged every 2 weeks. On the day of admission, px is better and is now ready for surgery, hence admission.

Past Medical History On 1980, he developed Pulmonary Tuberculosis and treated for 4 months. Then, on 1995, he developed Hypertension. His highest BP at 170/100 ; usual BP is 140/80. He maintained on Neobloc 50mg BID, non-compliant. Social History Previous moderate alchohol drinker and stopped this June 2012. 10 pack year smoking (Since 1961-2012, 4 sticks/day) C. Family Health History

D. Gordons Functional Health Assessment: A. Health Perception Health Management Pattern Subjective The Patient Verbalized: Sa tingin ko healthy ako, nagagawa ko naman ang mga kailangan kong gawin. Umiinom ako, tuwing may okasyon. Umiinom ako ng vitamins. Nursing Diagnosis: B. Nutritional Metabolic Pattern Subjective The Patient Verbalized: Tatlong beses ako kumakain, may merienda. Hindi naman ako mapili sa pag kain eh. Umiinom ako pag may okasyon. Minsan nag papabili pa ako ng pag kain sa anak ko, kasi parang bitin yung kinakain ko. Objective Patients mouth is moist, pinkish. Gums is pink in color and tongue is pink moist and without lesions. Skin turgor is less than 2 seconds, capilliary refill of less than 2 seconds and nail beds are pink. Does not have any allergies to foods, no problem in chewing, (+) gag reflex. No presence of pallor, clubbing, wounds and abscess. Appetite changed when hospitalized. Objective Patient is a smoker. He drinks alcohol occasionally. VS of BP: 140/70; temp: 35.8 degress celsius, RR:22; and PR: 63 bpm.

Height: 54 Weight: 72 kg BMI: 27.24 (Overweight) Nursing Diagnosis: Altered Nutrition: More than body requirements C. Elimination Pattern Subjective The Patient Verbalized: Simula nung na-admit ako dito, di pa ako nakakatae. Kahapon lang ng umaga ako nag CR. Minsan yung kulay ng dumi ko ay dilaw minsan brown. Objective The patients skin is slightly warm to touch; urine color is light yellow, no signs of constipation such as bloated abdomen and abdominal pain. Patient has foley catheter. No blood in stool and urine noted. Abdominal color is symmetrical to upper and lower extremities.

Nursing Diagnosis: Risk for Constipation D. Activity Exercise Pattern Subjective The Patient Verbalized: Hindi ako nag eexercise. Objective The patient can walk, stand and sit. Noted respiration as quiet, in rhythmic pattern and does not use accessory muscles. Pulses are not easily palpable.

Nursing Diagnosis: E. Sleep Rest Pattern Subjective Objective The Patient Verbalized: Nakakatulog Patient is alert and attentive. Patient ako ng mga walong oras. Ksaso dito is oriented to time, place, and hindi ako makatulog kasi ang ingay person. Can recall past events. tapos may gigising sakin para mag Speech is understandable. Answers vital signs. Nakapikit lang yung mata question immediately. ko pero hindi ako makatulog. Hindi rin kasi ako makatulog pag hindi ko bahay, alam mo yung namamahay? Ganun kasi ako. Nursing Diagnosis: Disturbed sleep pattern r/t unfamiliar environment F. Sensory Cognitive Pattern Subjective The Patient Verbalized: Normal naman ang paningin, pandinig, at panglasa ko. Kaso dati nag sasalamin kung magddrive ako peron ngayon ok nanaman. Nursing Diagnosis: Objective The patient can smell vinegar, and coffee. Can taste sugar, and coffee. Does not use any hearing aid, but seldom asks you to repeat what you are saying. Can answer simple mathematical question, conscious, and awake.

G. Sexuality Reproductive Pattern Subjective Objective The Patient Verbalized: Oo, Behavior is congruent to gender. gumagamit kami ng pang family Patient is calm planning, naka IUD si misis. Kung hindi kami siguro nag family planning baka mas madami pa ng anak ko ngayon. Nursing Diagnosis: Readiness for enhanced reproductive pattern. H. Self Perception Self Concept Pattern Objective Patient maintains eye to eye contact from time to time. Sometimes show signs of anxiety. Speaks softly. Action congruent with expressed feelings, and thoughts. Nursing Diagnosis: Anxiety r/t surgical procedure I. Coping Stress Subjective The Patient Verbalized: Na wawalan ako ng ganang kumain kapag may problema ako. Kadalasan pag may problema ako, umiinom ako peroo noon yun, ngayon hinahayaan ko nalang lumipas problema ko. Pag nag kakasakit ako yung asawa ko ang nag aalaga sakin. Nursing Diagnosis: Objective Sometimes seen restless, anxious Subjective The Patient Verbalized: Medyo kinakabahan nga ako kasi hindi ko alam kung papano yung mga gagawin sakin.

J. Role Relationship Subjective Objective Presence of daughter in the ward. The Patient Verbalized: Meron akong pitong anak. Yung pang alawa at pangatlo patay na. tumigil na ko sa pagiging driver nung 2005 pa. Yung pera na pang gastos namin sa pension na nang gagaling, sa SSS. Hindi naman kami nag aaway away, pag may problema ang mga anak ko nag sasabi sila sakin, at pag ako namna yung may problema ako naman yung lalapit sakanila. Nursing Diagnosis: K. Value Belief Subjective Objective The Patient Verbalized: Nag bibible There were no religious items seen on study ako, na tutunan kong maging bedside. malapit sa Diyos. Nursing Diagnosis: Readiness for enhanced spiritual being.

E. Intra care: before, during, after. BENIGN PROSTATE HYPERPLASIA BEFORE NPO Explained that the patient will not take any solid or liquid by mouth from (what time). Relative/watcher was informed/educated about the diet restriction/NPO. Explained that the patient is on NPO but the diet that will be served will be able for the watcher/relative. Explained the importance and purpose of NPO to the patient and relative. Deep Breathing Exercises Explained the importance and frequency of deep breathing exercises. Demonstrate deep breathing exercise. Return demonstration of the deep breathing exercises. Early Ambulation

Encouraged patient to turn from side to side. Explained the sequence of ambulation from high backrest, then sitting on bed and finally sitting with foot dangling at bedside. Demonstrated how to perform high backrest, sitting at bedside. Explained that pain may occur with movement. Explained the use and importance of binder. Explained the importance of early ambulation in relation to early recovery. 1. Early healing process 2. Early adjustment to activity of daily living. 3. Early discharge. Pain Management Explain the meaning of pain scale 0-10. Explain that pain in expected post-operatively. Spiritual Informed patient/relative of the availability of religious services. Hour of masses, communion and confession. Explained the need for sacrament of the sick for patient undergoing major surgery (if patient is a catholic) O.R Location Explained to the patient and relatives the location of the operating room. Informed the patient/family where they are going to stay while the operation is on going. Explained the replacement process of drugs/supplies used from the OR stock. Response to Teaching Understood instruction. Return Demonstration done. Teaching not complete.

AFTER A. Before Leaving the O. R. The nurse verbally confirms with the team the name of the procedure recorded and signed by the surgeon with the time and date. Instrument, sponge and needle counts are correct. Specimen is labeled including the name of the patient, are there any equipment problems to be addressed. B. Post Operative intervention: Promote healing and comfort, restore the highest possible wellness and prevent associated risk. Maintain patent airway. Monitor vital signs and note for early manifestations of complications. Monitor level of consciousness Maintain on proper positioning. NPO until fully awake, with passage of flatus and (+) gag reflex. Monitor patency of the drainage. Monitor intake and output. Ensure safety. Pain medication given as ordered. Prevent post-op complications. Deep breathing and coughing exercises to remove secretions. Leg exercises to promote circulation. Ambulation as soon as possible to prevent respiratory, circulatory, urinary and gastrointestinal complications. Hydration after NPO to maintain fluid balance. Diet, usually given when bowel sounds and gag reflex return. Inspect dressing hourly and change dressing daily Inspect for signs of infection such as redness, swelling, purulent exudates. Maintain wound drainage.