HISTORY TAKING OF PATIENT WITH

LEPROTOMY

SUBMITTED TO MISS NAZIMA BHATTI LECTURER MEDICAL SURGICAL NURSING

SUBMITTED BY NAVPREET KAUR MSC NURSING 1ST YEAR MEDICAL SURGICAL NURSING

BOIODATA OF PATIENT Name Age Sex Nationality Religion Education Occupation Ward Marital status Address Date of admission Time of admission Dr in charge Diagnosis Mr. Balwinder singh 72 year male Indian Sikh 10+2std Relied male surgical ward V.p.o begowal deist Jalandhar V.P.O Begowal deist Jalandhar 01-4-2012 11:48am Dr. Chanjiv Leprotomy

CHIEF COMPLAINTS patient come civil hospital Jalandhar with chief complaints of c/o pain in abdomen & vomiting since morning c/o pain decrease in appetite & weakness from last days. c/o general weakness from last 2 days PRESENT MEDICAL HISTORY Mr. Balwinder singh get admission in civil on 9-10-11 with the complaints of pain in abdomen & vomiting general weakness & He is diagnosis as leprottony PRESENT SURGICAL HISTORY LAPROTOMY is done & now feel better PAST MEDICAL HISTORY He was having mellitus from 5-6 years Hypertension from last 5-6 Alcoholic from last 30 year PAST SURGICAL HISTORY There is no any evidence of past surgical history

SOCIAL ECONOMIC STATUS Patient is his income is 5000 r s/month He belong to a nuclear family All water electrical facilities are available NUTRITIONAL HABITS Mr. Balwinder is non vegetarian SLEEPING PATTERN Sleeping pattern is alert b/c or due to pain in abdomen from few days PHYSICAL EXAMINATION General appearance Nourishment Health Activity Nourished Unhealthy Active

Mental status Patient was conscious Patient was co operative

Skin status Color Texture Rashes pale & fair Normal Absent

Head & face Eyes Ears Haring Shape Secretion Normal Normal Absent Eye brows Eye color Vision Normal Black Normal Scalp Infection Dandruff cleanse pedicle absent Absent Absent

Nose Inflammation Discharge Absent Absent

Mouth pharynx & lips Neck Chest Chime stroke Chest shape Absent Normal Movement Position Normal Normal Lips Tongue Adour Normal White color No

Extremities Upper extremities Lower extremis Normal Normal

Systemic examination Respiratory sounds Cardio vascular system G T system Genitourinary system No sound S1 & S2 sound audio Tenderness Normal

Vital sings S no 1 2 3 4 Vital sings Temperatur e Pulse Respiration B.P. Normal value 98.6f P. t value 98.6 F Remarks Normal Normal Normal hypertensio n Remarks

60-100/min 74/min 16-24/min 22/min 120-180mm/hg 140/90mm/h g Pt. value 14.5 g/dl 5000/cu mm 4.76m/cu mm 2,40,00cu mm

Lab investigation S no 1 2 3 4 Test HB TLC BBC PLATELET Normal value 11-16.5g/dl 9000-10000cu mm 3.8-4.8m/cu/mm 150,000-390,000

5 BLOODSUGAR 348 mg/dl 6 ECTOROLYLE a) NA 134mm/dl b) K 5-2mm/dl Medication S no 1 2 3 4 5 Drug Inj.lasis Inj Metrogul Tab. Aciloc Inj. Deriphyllin Inj. Gentamycin Dose Route 2ml 1ml 50ml 2ml 2ml Iv /Iv Iv Oral Iv/IM IV

70-140mg/dl 135-150mm/dl 3.5-5mm/dl Time Action OD OD TDS OD BD Diuretic Antibacterial Antacid Antiarrythnetic Antibiotic

HEALTH EDUCATION
Regarding Diet Pt diet pattern should be acc. To diet chart Encourage the pt to take nutritional food Advise him to dont take food outside from at home Advise the pt to take more milk fruits green leafy veg. etc Avoid smoking & alcohol Avoid oily food

Regarding Personal hygiene Patient must maintain personal hygiene To encourage the pt about mouth care Proper hand washing

Regarding Rest & sleep Provide proper rest & sleep to the pt Take proper sleep Provide calm & cool environment Provide comfortable position to the pt Follow up Pt must come for follow up Pt & her relatives should be encourage for proper follow up