I.

Assessment General Data: A. B. C. D. E. F. G. H. I. J. K. Name: Usito, Dionisio Unday Sex: Male Address: Lilac St., Marikina City Age: 77 Date of Birth:1/11/1936 Civil Status: Married for 54 years Wife: Feliciana Usita Place of Birth: Cagayan Valley Order of admission: ??? No. of days in the hospital: 11 days Date admitted: September 2, 2013 Informant: Nephew Mr. J and Son Mr. D Date of History Taking: September 13, 2013

Chief Complaint: Difficulty in Defecation; Pain in inguinal Area; Cough History of Present Illness: ( PATIENT HX IN CHART ) Four(4) months prior to admission the patient claims to have cough, he selfmedicate with guaifenesin which provided him temporary relief, no consultation was done, he was apparently asymptomatic until Seven(7) days prior to admission he is experiencing cough, productive of whitish phlegm associated with dyspnea, and shortness of breath, however denies fever, chills and orthopnea, persistence of symptoms prompted consultation hence was subsequently admitted to DelosSantos Medical Center. ( PATIENT HX OBTAINED FROM THE INFORMANT ) On May 2013 Prior to admission, the patient has a bulging mass in his right inguinal area, thus lead him to consult their family physician and diagnosed that he has hernia, he did not seek any medical attention because it is asymptomatic. After three (3) months prior to admission he has already felt pain in his inguinal area aggravated by cough, he has pain in defecation and due to the pain he cannot defecate well, for seven (7) days he cannot defecate normally because of pain the he was given dulcolax suppository once a day as per their family physician but this doesnt give him relief. August 30 prior to admission he seek medical attention to a hospital in Marikina City, he was about to have a hernioraphy operation thus referring him to the Delos Santos Medical Center. Ongoing Appraisal: (SEPTEMBER 12, 2013) The patient is seen at Post Anaesthesia Care Unit (PACU) lying on bed in supine position hooked up with Intravenous Fluid of .9% NaCL 1 Liter x 80 cc/hr,

Oxygen 6 Liter per minute via facemask, Non-invasive Blood Pressure (NIBP) Monitor and Foley Catheter, he has green precaution (droplet) as per physician. We are rendering care for our patient by monitoring his vital signs every 15 minutes and assessing his level of consciousness everytime, he is from operation called Hernioraphy Scrotal Exploration Right with Transurethral Resection of Prostate (TURP) started at 7:00am under General Anesthesia the operation lasted for 4 hours. At 11:00 am we are advise to monitor his blood glucose level we get his Capillary Blood Glucose (CBG) which is 196 mg/dl at 12:00 noon he was given two(2) units of Insulin (Apidra), and Paracetamol through Intravenous Push 600mg we still continue to monitor his vital signs every 15 minutes and asked if he can move his lower extremities, 2 hours later he can move his feet but still feels numbness as he verbalized I cannot feel my legs.. Until he gradually move the both feet, the attending nurse was about to transfer the client to his room he ask us to assess and discard the urine bag, he has 800 millilitres of Output and then we discarded the urine. We transfer him in his room which is a private room in the hospital the attending nurse endorsed the patient to the nurse on the ward.

(SEPTEMBER 13, 2013) The patient is seen lying on bed in high fowlers position with Intravenous fluid .9% NaCL 40cc/hr with nasal cannula and Foley catheter. He is awake but we arent able to talk to him because we dont want to disturbed him a lot because he is a post operation patient, we only asked his relative about his information regarding his life before operation. The patient is not talking but he smiles when we looks at him. This may indicate relief from his operation. We obtain his Personal Data, Complaints prior to admission, history of past and present illness, as well as the personal and social history we also asked what kind of lifestyle he have prior to confinement. We also do physical examination but minimal only, we didnt have a chance to care for our client because we are out of duty but we checked his chart he was being compliant to his medication given by the attending nurse.

Physical Assessment: (POST OP September 12,2013) Vital Signs Temperature: Pulse Rate: Respiratory Rate: Blood Pressure: Weight: Height: Ideal Body Weight:

Regional Examination: A. Skin: Skin is dry and warm to touch, noticeable wrinkles around his body due to aging process, generally it is uniformed in color, with normal skin color generally brown complexion, when pinched skin goes back to his normal state in 1-2 seconds. B. Nails Nails in upper extremities are pale with more than 2-3 seconds capillary refill with curvature in his nails. C. Head and Face D. E. F. G. H. I. J. K. L. M. N. O. P. Q. Eyes Ears Nose Mouth and Pharynx Neck Spine Thorax and Lungs Cardiovascular Breast Abdomen Extremities Genitals Rectum and Anus Neurologic Exam

TO BE COMPLETED PA.