Patient Health History (1)

T A B L E O F C O N T E N T S: I. Introduction II. Client's Profile III. Nursing Health History a. History of Present Illness b. Past Medical History c. Family Medical History d. Gordon's Level of Functioning IV. Assessment Process a. Review of System b. Physical Assessment V. Anatomy and Physiology VI. Pathophysiology VII. Laboratories and Diagnostic Procedures VIII. Medical Management IX. Nursing Management X. Drug Study XI. Nursing Care Plan XII. Discharge Plan XIII. Bibliography

Interview done: September 6, 2011

Source of Information: Patient

Biographical Data: Full Name: Yolanda Yambut Benavidez Date and Place of Birth: September 30, 1957 / San Vicente, Bulacan Age: 55 years old Sex: Female Race: Filipino Civil Status: Married

No. of Children: Four (4)

Religion: Roman Catholic Occupation: Housewife Home Address: Sampaloc, Manila

Reason For Visit (chief complaint): follow-up check up Diagnosis: G4P4 (4004) wound dehiscence, Bowel Evisceration, Perimenopausal Bleeding secondary to Endometrial Adenocarcinoma

III. NURSING HEALTH HISTORY A. History of Present Illness Last June 22, 2011, Mrs. Y.B., 55 year old - Filipino, Catholic Female, from Sampaloc, Manila sought consult at Ospital ng Maynila Medical Center (OMMC) due to continuous heavy menstrual flow. She had been seen and examined by the physician on duty (OB-Gyne), and had known that patient is suffering perimenopausal bleeding. Patient had undergone fractional Dilatation and Curettage to correct bleeding and to rule out cancer of the uterus. She was admitted to Ob-Gyne ward with diagnosis of Endometrial Adenocarcinoma. On the second week of August, Mrs. Y.B. Had undergone Extrafascial Hysterectomy Bilateral Salpingo-Oophorectomy (EHBSO) with Bilateral Lymph Node Dissection (BLND) and Peritoneal Fluid Cytology (PFC). After a series of Medical and Nursing Management in the ward, she was sent home. Patient seem well, until two days after, she noticed watery-bloody discharge at the site of suture which prompted her to consult at OMMC-Out Patient Department. She had examined by her attending phyiscian and had found out that she has wound dehisence and bowel evisceration. She had undergone Emergency Exploratory Laparotomy, wound exploration, wound debridment and wound resuturring (August 24, 2011). B. Past Medical History Mrs. Y.B. have a history of childhood illness such as mumps and chicken pox. Denies history of adult illnesses such as asthma, pneumonia, ulcer, epilepsy/seizures, arthritis, blood diseases such as anemia and hemophilia, tuberculosis, heart problems, kidney diseases, thyroid problems, strokes and migraine headaches. Currently diagnosed Diabetes Mellitus last 2010 with maintenance medications of Diamicron 80 mg per tablet, once a day and Metformin 500 mg, twice a day. Had diagnosed of Hypertension last January 2011 (with increase blood pressure of 150/90 from usual blood pressure of 120/80) with maintenance medications of Enalpril 20 mg per tablet and Hypace 20 mg per tablet once a day. Patient had undergone different surgeries before. Last 1989, she had bilateral Tubal Ligation at Far Eastern University (FEU) hospital. On June 22, 2011, she had Fractional Dilatation and Curettage at Ospital ng Maynila Medical Center (OMMC). And just recently,

August 2011 undergone Extrafascial Hysterectomy Bilateral Salpingo-Oophorectomy (EHBSO) with Bilateral Lymph Node Dissection (BLND) Emergency Exploratory Laparotomy, wound exploration, wound debridment and wound resuturring. Denies food, drug and environmental allergies. C. Genogram D.

Nursing Assessment Based on Functional Health Patterns 1. Developmental History

Developmental Level: Generativity vs. Stagnation Describes childhood as a very happy time for her. She was an average child and run and played-like all others. As the youngest and only girl child of her parents, all attention was given to her. States that her father spoiled her, provided her all she needs and wanted. She finished elementary at Asilo School in San Vicente, Bulacan and graduated high school at Roxas High School in U.N., Manila. She had dreamt to become a nurse but when her father died at the age of 57, she have not given an opportunity to continue her study in college. She decided to work as factory worker in sock factory near their house. She worked also as a saleslady at Benzon Department store for almost fifteen (15) years. Mrs. Y.B. Got married at the age of 28 and stopped working then when she gave birth to her first male child on the year of 1985. Currently lives in their house at Sampaloc, Manila. As Housewife, she is handson in attending the needs of her children and husband, doing household chores and finds cooking and planting medical plants as fun activities. She is an active member of community as former kagawad. Enjoyed the rest of her life together with her husband. 2. Health Perception-Health Management Pattern Mrs. Y.B. States when she has health problem, she just keep it on herself and find ways to solve it. Sought consultation immediately to hospital when she feels something wrong. She was not often go for professional examinations, like pelvic examination and pap smear and not even performing self-breast examination. She have regular blood pressure monitoring at their health center, with usual blood pressure of 120/80 mmHg. Mrs. Y.B also added that she actively participates to aerobic exercises program of their barangay. Furthermore, denies used of alcohol, tobacco, drugs and exposure to pollutants or

toxins. She have been able to take prescribed medications for her Diabetes Milletus and Hypertension and follow medical treatments. Client's Rating of Health: Scale from 10-1 (10 as best and 1 as worst). Patient perceived her health status five (5) years ago scaled 9, 5 as of her health status today and 7 as her health status 5 years from now. Sees health deterioration as normal aging process and states “life start at 40, anyway my other siblings died because of diabetes”. Said that her illness has affected her normal daily activities and feels sad that he was not able to take care of her plants and worried about the condition of their house. 3. Nutritional-Metabolic Pattern states that on an average day, she is on regular diet ad follows: Eats breakfast of 1 cup of rice, 1 fried egg, a cup of vegetable viand and coffee at 7am. Eats Lunch at noon, usually before 11:30 am. Eats light supper around 7pm. She tries not to snack but will have biscuits if she feels urge. Drinks three (3) glasses of water a day. Her son states “mahilig siya sa matamis” (she likes sweets), usually can consume one can of coke-zero per day-no tea. Voices no dislikes or food intolerance. Currently, within hospitalization, she follows DM diet per instruction. Two months ago, patient have tooth extraction. Denies problems with proper fit, eating, chewing, swallowing, sore throat, sore tongue or colds. Denies tolerance to heat or cold or voice changes. 4. Elimination Pattern Bowel Habits: soft, formed, medium, brown bowel stool in every bowel movement once a day. No laxatives, enemas and suppositories were being used. Don't feel any discomfort during defecation. Bladder Habits: Voids 3-5 times a day, clear yellow urine. Denies current problems with dysuria, hematuria, hesitancy, incontinence or nocturia. Complaint of urgency in cold environment. Had polyuria and polydipsia prior to diagnosis of Diabetes Milletus. 5. Activity-Exercise Pattern Activity of Daily living on an average day: Arises at 6am. Eats breakfast and water her plants in their mini-garden. She also participates on aerobic exercises in their barangay. At 9 am she

does house keeping. In early afternoon, she cooks and prepares the table for lunch. At around 1 p,. she goes to the community barangay to visit and chat with kagawad friends. Goes home around 3 pm to take rest and have a short sleep. Watched television at 5pm onwards. Spend small talk to husband and cleaned own room for 30 minutes to one hour period before going to sleep. Patient verbalized that her recent illness really do affect her activities of daily living. 6. Sexuality-Reproduction Pattern Menstrual History: Begins menstruating at thirteen (13) years old, at regular interval, usually last for three (3) to five (5) days. Consuming eight (8) pads per day and have dysmenorrhea. Have noticed that her menstrual flow is unusual, continuous and too heavy since she is more than 50 years old prior to diagnosis of Endometrial Adenocarcinoma. Obstetric History: She had four (4) times pregnancies and gave full term birth via Normal Spontaneous Delivery (NSD) at Far Eastern University (FEU) hospital (Gravida 4, Para 4). No complications with pregnancy or childbirth. She had her first sexual intercourse at the age of 28 and have one sexual partner. They are sexually active. After giving birth to their 4th child, she had undergone bilateral Tubal Ligation on 1989. describe pain and discomfort during sexual intercourse. Denies history of any sexually transmitted diseases. Denies problem with vaginal itching. Patient doesn't have regular pelvic and pap smear examination. 7. Sleep-Rest Pattern Before she hospitalized, she goes to bed at 10pm. Denies difficulty falling asleep or sleeping. Feels well rested when she arises at 6am. Never used sleep medications. Denies orthopnea and nocturnal dyspnea. Enjoys chatting with her husband and uttering a short prayer each evening. Currently, states “hindi ako makatulog kagabi...(i can't sleep at night)”. Patient looked sleepy and tired. States she misses so much her children and worried with recent condition of their house. 8. Sensory-Perceptual Pattern Vision: States no problem with vision. Denies diplopia, itching, excessive tearing discharge, redness pr trauma to eyes. No use of reading eyeglasses and with a vision of 20/20.

Hearing: believes she is “a little slow to grasp and I think it may be because of my hearing”. Does not wearing hearing aid. Cannot recall last hearing test.. denies tinnitus, pain, discharge or trauma to ears. Have ask for questions to be repeated when asked at normal voice tone. Smell: denies difficulty of smell, pain, post-nasal drip, sneezing or frequent nosebleeds. Touch: states “occasionally mu feet feel numb”, subsides on own. Taste: no difficulty tasting foods. 9. Cognitive Pattern Talks in a soft-voice, clear and slow. Can follows verbal cues. Expresses ideas and feelings, clearly and concisely. Can recall post weekly events but has trouble recalling dates and times of events. Learns best by demonstrating examples than writing information then viewing it. Makes major decisions jointly with husband after prayer. 10. Role-Relationship Pattern Mrs. Y.B. Has been married for 27 years. Describes relationship as the best part of her life right now. Have four (4) children, first, second and third are all males and the youngest child is female. All children can take care of themselves already. Her first and second child are now working as newspaper delivery boy and the third one is an ice-cube delivery boy, Having good compensation. Her only daughter got married and lives separately. Explains her relationship with other members and community are friendly and “family-like”. 11. Self Perception-Self Concept Pattern Describes self as a normal person. Talkative, outgoing and likes to be around by people but hates noisy environment. Happy with the person she has become. States a weakness is that she worries about “little things” more now than she used to and tends to be imitated more easily. Cannot place specific onset of these feelings. 12. Coping Stress Tolerance Pattern States with the support of husband and friends. She handled well her stress. She prays and eats when under stress. She do have positive outlook in life as she is looking forward to go home and recover. 13. Value-Belief Pattern

Mrs. Y.B. is a Roman Catholic, Values relationship with husband, family and God. Believes God is loving, supportive and forgiving. Prayer for her is extremely important and makes her feel relaxed. She and her husband regularly attends to church every Sunday.