PATIENT CARE RECORD

Patients name: Panganiban, Pedro Ilag. Room no: 221B

Ward: FSW

Date:

Chief Complaint: For schedule TURP Diagnosis: Benign Prostatic Hyperplasia

A. Health History
I.
Biographical data
Age: 20
Sex: Female Citizenship: Filipino Religion: Roman Catholic
Birthdate: 01/13/1949
Civil Status: Married
Educ. Attainment: High School
Graduate
Address: 641 Blumentritt St. Sampaloc, Manila
II.
History of Present Illness:
One Year prior to admission, patient experienced nocturia occurring 4-5x/night with
small amount oand yellow-colored urine each time, he urinates. Patient mentioned
that it was not accompanied by any abdominal pain, hematuria, dysuria, urinary
incontinence and urgency. No medication was taken and no consult was done. One
month prior to consult, patient verbalized an increase in frequency of urination,
from 4-5x/night to 10-12x/night and mentioned that it disrupts his sleeping pattern
and resulted to sleeping in the morning. He consulted with a private physician at
the Hospital ng Sampaloc where ultrasound was requested and it revealed an
enlarged prostate gland and a normal sonographic findings of the kidneys and
urinary bladder. He was advised to undergo right away a surgery and therefore she
was transferred to UST-OPD Surgery for 2nd opinion and in Hospital ng Sampaloc
they lack materials and manpower to have a surgery of what the patient needs.
Upon digital rectal exam, it was noticed that there is prostate enlargement and
patient was advised to undergo surgery.
III.
Past Health History
Patient has previous hospitalization last 2005 for hemorrhoidectomy. He was with a
history of being previous smoker with 7.5 pack per year smoking and occasionally
an alcoholic beverage drinker and denies any illicit drug use.
IV.

Family Health History

According to the Patient, his father had a Benign Prostatic Hyperplasia. On the other
hand, his family is negative to any conditions such as Allergy, Thyroid disease,
Hypertension, Cancer, Diabetes Mellitus nor PTB.

SUMMARY OF DIAGNOSTIC PROCEDURES

DATE

PROCEDURE

November 24, 2015

Complete Blood
Count

Dfferential Count

SIGNIFICANT
FINDINGS
WBC 27. 60 (4.5
10.0 X 10^9/L

Neutrophils 0.91
(0.50 0.70

Lymphocytes 0.09
(0.20 0.40)

November 22, 2015

Blood Chemistry

Sodium 136.00 (137

-147mmol/L)

INFERENCE
High white blood cell
count can results to
infections due to
bacteria or viruses, an
inflammation.
Neutrophilia can be
caused by acute
bacterial infections,
inflammation,
smoking or
physiological such as
stress.
Known as
lymphocytopenia can
be caused by immune
deficiency or an
infections.
Known as
hyponatremia is due
to too much water
intake or retention. It
is also due to
decreased sodium
intake.

NARRATIVE OF NURSING PROBLEMS, INTERVENTIONS AND OUTCOMES OF CARE

DATE
November 24,
2015

November 25,
2015

REMARKS
F> Risk for infection
D> incision site in the hypogastric region with dressing. With a fast drip
cystocleisis draining to a serosanguinous to serous exudate. With IV fluid
on his left hand. Temperature of 36. 8.
A> Assessed operative site and checked dressing. Advise patient to
note any sign of infections of surgical incisions, or invasive lines
such as redness, pain or elevated temperature. Advised patient to
a routine bath and personal hygiene. Advised to note if dressing is
soaked and would require a change of dressing. Encourage
ambulation or passive exercises. Encourage to turn to sides every 2
hours to prevent bed sores.
R> Verbalized understanding of health teachings. Participated in
nursing care.
F> Acute pain
D> verbalized sobrang sakit nung tahi ko. With a pain score of 8/10.
With unpleasant mood and facial grimace. With ongoing IVF of PNSS Il.
A> Placed to position of comfort. Encouraged deep breathing
exercises. Maintained a calm environment. Kept side rails up.
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

STRATEGY OF
IMPLEMENTATION

EVALUATION

Wound care

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.

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.

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
Social, Spiritual and
Psychological

5. Follow-up after a week

after discharge.
6. Advise to follow dietary
regimens prescribed by
the doctors
7. Encourage patient to
have faith and pray to
God for guidance and
faster recovery.
8. Encourage the patient
to spend a time of
silence in a day for a
moment of prayer.
9. Advise patient to
socialize with
significant others and
spare a little time for
conversations
10.Instruct patient/family
about leisure resources
available in the
community
11.Encourage
patient/family yo
verbalize their
understanding of the
discharge instructions
and give demonstration
of any care procedures.

DATE

CUES/CLU
ES

11/25/15

Cues:
Patient
verbalized
Sobrang
Sakit
nung tahi
ko
Clues:
Pain scale:
8/10
Facial
grimace
Unpleasan
t mood
Surgical
incision
on
hypogastri
c region

NURSING
DIAGNOSI
S
Acute Pain
related to
postoperative
surgical
incision

SCIENTIFIC
RATIONALE

OBJECTIVE

NURSING
INTERVENTION

Pain is a
typical
sensory
experience
that may
be
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.

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

1. Provide comfort
measures such
as repositioning
of the patient
management
2. Encourage use
of relaxation
techniques such
a deep
breathing
exercises
3. Encourage
diversional
activities such
as reading
books or
magazines or
newspapers and
socialize with
significant
4. Encourage to
verbalize
feelings of pain.
Establish
Rapport with
the patient.
5. Monitor Vital
Signs
6. Perform pain
assessment to
include location,
characteristics,
duration, onset,
frequency,
intensity or
severity.
7. Raise the side
rails at all
times.

ANALYSIS

1. It reduces
muscle
tension a
fatigue
2. to promot
non
pharmaco
gic pain
3. to distrac
attention
pain.
4. To be abl
to follow
the situat
of the
patient
5. It serves
a baseline
data to
check if
there are
any
deviation
from his
vital signs
6. Pain is a
subjective
experienc
and must
described
by the cli
in order t
plan
effective
treatmen
7. For safety
measures
the patien

DATE

CUES/CLUE
S

11/24/1
5

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

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

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
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.

OBJECTIVE

NURSING
INTERVENTION

Within 1-2 hours 1.

of nursing
interventions,
the patient will
be able:
1. To remain free 2.
from
symptoms of
3.
infection
2. To state
symptoms of
infection of
which to be
aware
3. Demonstrate 4.
appropriate
care of
infectionprone site
4. Maintains
white blood
cell count and
5.
differential
within normal
limits
5. Demonstrate
6.
appropriate
hygienic
measures
such as hand
washing, oral
care.

ANALYSIS

Educate patient 1.
on adequate
protein and
caloric intake for
healing
Advise patient
to increase fluid 2.
intake
Instruct client on
hand washing
when touching
materials and
touching the
3.
dressing.
Observe and
report signs of
infection such as
redness,
warmth,
discharge, and 4.
increased body
temperature
Encourage
adequate rest to
boost the
immune system
Use careful
technique when
changing and
5.
emptying
urinary catheter
bags; avoid
crosscontamination
7. Keep area of
incision site
clean and dry
6.

Tissue repa
requires
increased
protein and
carbohydra
s.
Proper
hydration is
needed for
transportat
of oxygen a
waste
Hand wash
is the most
important
means to
prevent the
spread of
infection
With the
onset of
infection th
immune
system is
activated a
signs of
infection
appear
Chronic
disease and
physical an
emotional
stress
increase th
clients nee
for rest
Clients are
most at risk
for crossinfection
during bag
changing a
emptying.
7. Wet area ca
be lodge ar
of bacteria