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SCHOOL OF NURSING AND ALLIED HEALTH STUDIES

A.Y. 2010-2011, 2nd Semester

NURSING
PROCESS

YEL C. CALAYAG
BSN 3 B GROUP 1

MS. VENUS PADUA, RN, MAN


CLINICAL INSTRUCTOR

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I. HEALTH HISTORY

A.) Demographic Data


Client’s Name : Mr. JWN
Gender : Male
Age : 33 years old
Marital Status : Single
Nationality : Filipino
Religion : Roman Catholic
Address : Anabu 1, Imus, Cavite
Educational Background : College graduate
Occupation : BPO Representative
Date of Admission : February 05, 2011

B. Source and Reliability of Information


 Chart
 Patient
 Relative

C. Reasons for seeking Care/Chief Complaints


 “Nangangati ‘yung singit ko,” as verbalized by the client.
 “Medyo masakit pa rin ‘yung sugat,” as verbalized by the client
 Pain and inflammation in inguinal area
“Namaga ‘yung sa may singit niya. Masakit kaya hindi siya masyado makalakad,”
as verbalized by the client’s relative.

D. History of Present Illness/Present Health

2 Weeks prior to admission, the client experienced scrotal swelling accompanied by skin

erosion of both scrotum and right inguinal area which led to infection after the client

persistently scratched the area. The client then consulted a doctor which gave him Cloxacilin

and Clindamycin. The swelling of the right scrotal area wound subsided but formed a mass

which later affected the right inguinal area as well. Persistence of condition in spite of taking

medications prompted consultation and admission to St. Dominic Medical Center.

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E. Past Medical History/Past Health

A. Childhood illnesses:

Pneumonia, common cold and cough

C. Immunization:

Patient verbalized that he has complete vaccinations both those of

adult and childhood vaccines.

D. Previous Hospitalization:

Client has no previous hospitalization

E. Operations:

Patient undergone removal of inguinal mass on February 22, 2011

F. Injuries:

Client had no history of injuries

G. Allergies:

Patient has to known allergies

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REVIEW OF SYSTEMS:

REVIEW OF SYSTEMS FINDINGS


A. Weak looking

General/Overall Health • Hair is slight no well kept

State • Feels sleepy

• Has difficulty in ambulating


B.

Integument • Skin of the face is oily


C.

Head • Patient does not complain of headaches and

dizziness.
D.

Cardiovascular • BP: 120/80 mmHg

• No murmurs or abnormal heart sounds


E. • Normal breath sounds

Respiratory • Not in respiratory distress

• No nasal flaring

• Not using accessory muscles for breathing


F. • No abdominal pain

Gastrointestinal • No difficulty of defecating


G. • Post-operative incision present on right inguinal

Genitourinary area

• Dressing on scrotal and inguinal area intact

LABORATORY STUDIES/DIAGNOSIS:

• CBC (February 15, 2011)

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TEST NORMAL VALUES ACTUAL FINDINGS
Hematocrit 37% - 49% 48%
Hemoglobin 13.0 - 16.0 mg/dl 11.8 %
White Blood Cells 4.5-11.0 X1000 cells/mm³ 21.38 X1000 cells/mm³
Platelet (µL)
150-450X1000 cells/mm³ 265 X1000 cells/mm³
(µL)
Red Blood Cells 4.5 – 5.3 million/mm³ 5.2 million/mm³
Segmenters 54% - 62% 56%
Lymphocytes 25% - 33% 35%

• CBC (February 20, 2011)

TEST NORMAL VALUES ACTUAL FINDINGS


Hematocrit 37% - 49% 48%
Hemoglobin 13.0 - 16.0 mg/dl 11.8 %
White Blood Cells 4.5-11.0 X1000 cells/mm³ 22.40 X1000 cells/mm³
Platelet (µL)
150-450X1000 cells/mm³ 265 X1000 cells/mm³
(µL)
Red Blood Cells 4.5 – 5.3 million/mm³ 5.2 million/mm³
Segmenters 54% - 62% 56%
Lymphocytes 25% - 33% 35%

ULTRASOUND ON INGUINAL AREA (February 16, 2011)


Impression:
Cellulits of Right Inguinal Region
Right Inguinal Hypoedleric
>Structure may represent abcess formation

PROBLEM LIST

Problem No. Problem

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1 Activity intolerance

2 Risk for infection

3
Acute pain

4 Impaired mobility

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NURSING CARE PLAN

Nursing Assessment Nursing Diagnosis Planning Nursing Rationale Evaluation


Intervention
INDEPENDENT
Subjective: Activity intolerance At the end of 4 -instructed patient do At the end of 4
No cues related to prolonged hours of nursing simple range of hours of nursing
immobility interventions, the motion exercises on -to promote good interventions, the
Objective: patient will be able both upper and lower circulation on arms and patient verbalized an
-weak looking to verbalize an extremities legs understanding on
-stays in bed most of the understanding on how to gradually
time how to gradually -Advised client to -to promote gradual increase activity as
increase activity as walk around the room increase in mobility feeling of wellness
feeling of wellness is pace that can be progresses.
progresses. tolerated

-Advised client to
increase intake of -to increase body energy
foods rich in nutrients
and high in calories

-promoted bed rest -to facilitate relaxation


after activities and rest

-Monitored vital -to monitor changes in


signs vital signs

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Nursing Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

Subjective: Risk for infection At the end of 1 hour of At the end of 1 hour of
“Nangangati ‘yung related to scratching of nursing intervention, nursing intervention, the
singit ko,” as post-operative inguinal the client will -instructed client not to -scratching may lead client verbalized an
verbalized by the incision. verbalize an scratch operative site to contamination of understanding on how to
client understanding on how when feeling itch. wound or dressing prevent infection of
to prevent infection of surgical site.
Objective: surgical site. -instructed client to
-presence of post- wash inguinal area -to prevent growth of
operative incision at with antiseptic bacteria in the inguinal
inguinal area solutions regularly area

-instructed the patient -to prevent


about the hygiene transmission of the
measure. microorganisms
(proper hand
washing)

-Given medications as
ordered.

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Nursing Nursing Planning Nursing Intervention Rationale Evaluation
Assessment Diagnosis

Subjective: Impaired • After 1 hour of INDEPENDENT After 1 hour of


No cutes mobility related nursing interventions, nursing
body weakness the client’s significant - assisted in ambulation when -to prevent fall interventions, the
Objective: as manifested by others will verbalize the patient goes to the toilet secondary to loss of client’s significant
-weak looking difficulty of and demonstrate balance and others verbalized
-difficulty in ambulating proper ways in coordination while and demonstrated
ambulation alone. assisting the client and walking proper ways in
reducing the risk for assisting the client
injuries and reducing the
-to avoid possible risk for injuries
-instructed significant others not injuries caused by
leave the patient unattended falling from bed

-Assisted client and relatives in -to prevent injuries.


learning appropriate safety
measure.

-monitored vital signs.

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Nursing Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

Subjective: Acute pain related to At the end of hours INDEPENDENT After 6 hours of
post-operative nursing • Demonstrated proper -to reduce feeling of nursing
“Medyo masakit pa rin ‘yung incision at inguinal intervention, the deep breathing pain interventions the
sugat,” as verbalized by the area client will learn exercise patient appetite
client ways on how to enhanced.
reduce feeling of • Instructed client to -to prevent
Objective: pain. avoid touching or stimulation of pain GOAL MET.
-presence of post-operative scratching wound and prevent infection
incision at inguinal area area The patient
-pain scale of 5/10 consumed served
• Promoted adequate -to replace fluid lost dinner
fluid intake.

• Promoted bed rest. -to conserve energy


and prevent
movements that
stimulates pain in
inguinal area

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MEDICATIONS:

Generic/ Brand Name Classification Indication Dosage Action Adverse effects Nursing Patient Teachings
Consideration
-Assess -teach patient to
Paracetamol Analgesics and treatment for 500mg 1 tab when Decreases fever - stimulation, patient’s fever or recognize chronic
anti- Pyretics fever Temp is greater than by inhibiting the drowsiness, pain poisoning
37.6 effects of nausea,
pyrogens on the vomiting, -assess allergic -inform patient that urine
hypothalamic abdominal pain, reaction may become dark brown
heat regulating
centers and by -Assess
hypothalamic hepatotoxicity
action leading to
sweating and -monitor liver
vasodilatation. and renal
function

-Monitor I and O

-assess for
chronic
poisoning

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