NURSING HISTORY A.

Biographic data

Name: Pt. BV Address: Batangas Age: 65 Sex: female Marital status: married Occupation: unemployed Religious orientation: Catholic Health care financing and usual source of medical care: phi health

B. Chief Complaint

According to the patient she went to St. Lukes medical Center (SLMC) because she experienced painful and difficulty in defecating, the amount of her stool was very little and noticed some blood in her stool.

C. History of Present Illness Patient told us one year and two months PTA, patient started noticing that every time she defecate it was painful, the amount of stool was little and she noticed that theres blood on her stool. The pain only occurs whenever she defecate and the pain last only after her stool passed out. Symptoms persist so she eventually sought to consult her doctor in Batangas and advised colonoscopy but at that time they cant afford the amount to be paid for colonoscopy. She said that she was given unrecalled medications by her doctor. Seven months PTC no further consultations were made until two months PTA she sought to consult SLMC OPD where colonoscopy revealed

mass 10cm level this was collaborated with CT scan of the abdomen. Results showed adenocarcinoma. She has been advised for surgery. Throughout the care of her illness she experienced abdominal disturbance, anorexia, abdominal pain and weight loss. According to patient BV hindi ko maalagaan mga apo ko pati yung isang alaga namen nab aka hindi ko na naalagaan dahil naibenta na para sa pagpapagamot ko, kaya mahirap din.

D. Past medical History According to the patient she had cough and colds chickenpox and measles during her childhood. She cant recall if she has complete immunization because during her time immunizations are not yet available. The patient doesnt even know if she has BCG at birth, 3doses of DPT, 3 doses o OPV, 3 doses of Hepatitis B and 1 dose of measles. Patient has no known allergies according to her, no accidents or injuries happened to her. According to patient she has past hospitalization due to UTI. According to the pt. she doesnt take any medications or vitamins. E. Family History FAMILY MEMBERS Father Mother Sister 1 Sister 2 Sister 3 Brother 1 Brother 2 Daughter 1 Daughter 2 Son 1 AGE 78 82 68 66 63 67 64 36 34 27 WELLNESS STATE Deceased Deceased cancer Hypertension Diabetes diabetes Hypertension No know illness No know illness No know illness

Patients father and mother have are both deceased but they both died due to several complications according to patient. Her older brother and her younger sister are diabetic patients. Her younger brother and another older sister are both hypertensive patients. While patient BV and the eldest among them also have cancer but due to her age she cant remember what kind of cancer does her sister have .They have history of cancer in their family but only two of them was diagnosed with the said disease.

FUNCTIONAL HEALTH PATTERNS (Adapted from Marjorie Gordons) 1. Health Perception and Health Management Pattern

Pt. BV thinks that shes healthy she trusts her doctor that after the operation she will become healthier. She experienced colds rarely. Most of the time patient eats fish, vegetables and fruits since they reside in provincial area and she thinks that it helps her body to get enough nutrition and takes away toxins from her body. Pt. BV doesnt experience smoking nor does drinking alcohol. Pt. BV doesnt do self- breast examination due to lack of knowledge on how to perform the said examination. The patient states that every time her doctor asks her to take medication or advice her to do something that will help her for her health she obeys it. According to patient she doesnt even think any factor that was causes her disease. Her family sometimes believes in herbal medicines and faith healing.

2. Nutritional and Metabolic Pattern Pt. BV has a very good appetite she doesnt experience any difficulty in her eating pattern, every meal patient consumes 1 to cups of rice and most of the time she eats fish and vegetables. She doesnt take any vitamins or food supplements. She drinks 1-2 liters of water. She doesnt experience any change with her weight. When the patient becomes sick she states that she can recover easily. She has no known skin disease. 3. Elimination Pattern The patient has 1 bowel movement everyday but sometime she experienced constipation so she drinks a lot of water. Since the patient drinks a lot of water to avoid constipation she voids 8-9 times every day. She doesnt experience excessive sweating or have any body odor. 4. Activity-Exercise Pattern According to the patient she has enough energy for her daily activities. She doesnt have time for exercise since she always look after her grand children, for her that serves as an exercise. During her free time she spent time with her children and relax. Whenever she wants to be entertained she takes care of their cow or watch TV. She can take care of herself and doesnt require any support from other people.

5. Sleep- rest pattern Approximately she sleeps 8 hours at night but even 4hrs of sleep is ok for her. She doesnt have any problems in sleeping aside from when she has unresolved problems. She doesnt feel tired upon waking up. She takes nap whenever her grand children were on school sometimes at around 1pm-3pm. For her to relax she sit and watch TV in their living room. 6. Cognitive- perceptual Pattern Pt. BV doesnt use any hearing aids because she doesnt experience any difficulty in hearing. She experienced some difficulty in reading and was advised by her doctor to use eyeglasses. She had her eye check up last October 2010. She doesnt experience any change in memory lately. She easily learns things when once taught to her. She doesnt have any pain or discomforts and if ever she has she consults her doctor right away. 7. Self perception and Self control pattern Most of the time she feels good about herself her 3 children, grandchildren and her husband loves her. There are no changes in her body or the things she can do the only problem is she really experienced pain whenever she defecate that even she wanted to defecate she hold her anal splinter just to avoid difficulty in defecating. Since the illness stared she becomes more irritable. According to pt. BV small things can make her angry and become sad easily she doesnt have long patience. She does cooking as her coping mechanism for stress. 8. Role-Relationship Pattern Patient lives with her 3 children and their wives, grand children and her husband in Batangas. They dont have family problems when it comes to family relationship because her children obey her and they are close to her. sit and talk about the problem was the best ways for her to solve problems because she wants her problem to be settled right away so it wont be more complicated. Since her children are all working they dont need support from their parents financially. Her family was alarmed when they found out the she has adenocarcinoma especially her husband. Pt. BV can see that her husband and her children are very sad because of her state right now she cant even explain the sadness but her family tried to look ok just to give her strength. Her family wants her to undergo the operation to avoid complications. She doesnt belong in any organizations. She has her neighborhood friends and her in laws and specially her children so most of the time shes not alone.

9. Sexuality- Reproductive Pattern Pt. BV was menopause since 40 years of age. She had her menarche at the age of 14. Pt. BV cant recall her last menstrual period. The patient is G3P3 (3003). 10.Coping Stress Tolerance Pattern According to the patient she doesnt get tense easily. Solving the problem was the best way for her to relieve her tension. She doesnt prefer using medicines, drugs or any alcoholic drinks. Most of the time she talks to her husband to help her solve problems since her husband is supportive and kind. Big problems according to her may come and go they experienced a lot of difficulties most of the time they pray to God and ask for help and talk about it and help each other by giving opinions on how to solve the problem. 11.Value- Belief Pattern Her family is the most important thing in her life she value it so much. Religion is important to her and prayers is powerful according to pt.BV .she is not against or doesnt have any issue about hospitalization.