Perpetual Succour Hospital Nursing Service Department Post Graduate Nurses Training

NIGHTINGALES APPRENTICE Presents

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Demographic Data Occupation: None Attending Physicians: Dr. K Dr. L Source of Data/Information: Patient 40%,S.O.30%, Chart 30%

Name: Tapispisan, M. J. M. Age: 64 years old Birthdate: October 31, 1948 Gender: Male Civil Status: Married

Reasons for seeking care Sakit kayo akong tiyan, kung naa palang 20 nga pain scale, 20 jud mao niari mi diri , as verbalized by the patient. Current health history One day prior to admission, patient had sudden onset of abdominal pain afer having his meal. Patient was given with Pantoprazole 40mg 1 tab at home which gave temporary relief. Persistence of abdominal pain prompted the family to bring the patient to Our Lady of Maternity General Hospital. Patient was started with PNSS 1 liter at 20gtts/minute, CBC, Sodium, Potassium, Creatinine was taken. Was given with Ranitidine 50mg IVTT, Buscopan IVTT, Plasil IVTT, Omeprazole IVTT, and Ketorolac IVTT. Patient was subsequently referred to this institution per patients request and fro further evaluation and management. Past health history A. B. C. D. E. F. G. H. I. J. Childhood Illness Hospitalization : Hospitalized last July 2013 with diagnosis of osteosarcoma at PSH under Dr. __ Surgeries : Underwent exploratory laparotomy with removal of tumor at abdominal area, last July 2013 at PSH under Dr. __ Serious Injuries : no know serious injuries Serious or Chronic Illness : Been diagnosed of osteosarcoma last july 2013 Immunizations Allergies : No known food environmental and drug allergies Medication : Takes Pharmaton 1 tab daily as vitamins Recent travel Military service : Has serve military for 10 years (1991 2001)

Gordons Functional health assessment HEALTH PERCEPTION AND MANAGEMENT Experienced cough , colds, fever in the past. Exercise at least 15- 20 minutes daily such as push-ups and stretching. Takes Pharmaton 1 tablet a day as a maintenance vitamin. NUTRITIONAL- METABOLIC Usually takes fruits and vegetables. Has good dentures. Has good appetite. No swallowing difficulty. Elimination Has colostomy at the left side draining soft brown colored stool. States that when still at home stool draining in colostomy, depends on type of food intake, consistency also depends in food intake. Colostomy drains 2 -3 times a day usually at 9 am and 4 pm. Has normal urination around 8 times a day, draining amber yellow urine.

Activity Exercise Does exercise such as push up and stretching for 15 20 minutes daily. Does carpentry at home. Also loves to watch television. Usually retires at 10pm and wakes up at 7am with no sleeping difficulties. Does not use medications or any rituals to induce sleep.

Sleep Rest No sleeping problems. Usually retires at 10 pm and wakes up at 7 am. Takes naps for 1 hour daily usually at 1 2 pm. No rituals or use of any medication to induce sleep. Considers carpentry, cooking, and tailoring as his form of relaxation. Cognitive Perceptual Has ability to follow and understand directions, retained information, make decisions and self problems. Is near sighted. Wears eye glasses graded 300/20 at right eye, and 250/20 at left eye. Self perception self concept Role Relationship Lives with wife and 2 children. Family perceives condition as Gods challenge. Doesnt feel lonely since family have been supportive. Sexuality Reproductive Coping Stress tolerance Wife is most helpful in taking things over. Family members are always available for him. Used alcohol at year 1974 to 1981 to feel relaxed. Smoked for ____ years, at 5 10 sticks daily to still feel relaxed.

Value Belief Pattern Plans to continue usual activities at home, such as carpentry and tailoring. Is also planning to teach institution for airforce. Considers self as religious. Prior to admission, goes to church every Sunday and does scripture reading daily. GENOGRAM- referred

ASSESSMENT Subjective: Kung mulihok ko, sakit ang akong colostomy, as verbalized by the patient. Objective: -Pain quality __ -Pain severity__ -Verbalizes pain in left lower quadrant -facial grimace -guarding behaviour -restlessness -change in abdominal muscle tone (flaccid to rigid) -diaphoresis -with bp = , T= , P= , R= ,

SCIENTIFIC ANALYSIS Surgical procedure causes disruption of skin layers which causes the activation of nocireceptors In dermis and tissues and which the receptor send impulses to CNS or interpretation. There is a pain perception that may let a person feel acute pain. (Brunner&Suddarth2006;p.1083

NURSING DIAGNOSIS Acute pain, related to post operative procedure

GOALS After 30 minutes of nursing intervention, patient will be able to: Report pain is relieve of controlled Follow prescribed pharmacological regimen Verbalized non pharmacologic methods that provide relief Demonstrate use of relaxation skills and diversional activities as indicated for individual situation

INTERVENTIONS Independent: 1. Determined presence of possible pathophysiologica l cause of pain (e.g, Surgery) 2. Obtained clients assessment of pain to include location, characteristics, onset or duration frequency, quality, intensity and precipitating factors 3. Observed non verbal cues or pain behaviours.

RATIONALE To assess etiology or precipitating contributory factors

EVALUATION

To assess clients response to pain

Observations may or may not be congruent with verbal reports To medicate prophylactically as appropriate To promote nonpharmacological pain management To destruct attention on reduce tension

4. Noted when pain occurs 5. Provided comfort measures, quiet environment, and calm activities 6. Encourage diversional activities, such as, watching tv and

socialization with others 7. Encouraged verbalization of feelings about the pain Dependent 8. Administered Tramadol 50mg IVTT

to assist client to explore methods for pain control

to control pain

Subjective: Objective:

Impaired skin integrity related to continuous contact of bowel secretions with skin

After my nursing care and interventions, patients skin is free of irritation caused by contact with fecal output from ostomy.

1. Maintain inact perstomal skin using the pouch method