PATIENTS PROFILE

Patients Name: Patient Y

Age: 64
Address: Poblacion, Buguias, Benguet
Civil Status: Married
Religion:Roman Catholic
Admission Diagnosis: Pacreatic Cancer Head Mass Probably Malignant
Final Diagnosis: Pacreatic Cancer Stage IV T4 N1 M1 Liver Obstructive Jaundice 2
Principal Operation: Biopsy of Pancreatic Head mass, cholecystojejonostomy
Jejonojejunostomy-Biliary bypass
Chief complaint: Abdominal pain, yellowish discoloration of eyes

HISTORY OF PRESENT ILLNESS:

1 month prior to admission , patient experienced abdominal pain rated as 7/10 ,
dull, localized on the epigastric areas, frequently radiating to the back , with no
other associated s/s such as nausea, vomiting, fever, headache, or altered bowel
habits. No medicine was taken nor consultation until pain persisted. Hence, consult
was sought and was diagnosed as peptic ulcer with unrecalled medicine given.
Another consult was done on another physician revealing a liver pathology. Livelin
forte was prescribed. However, no relief was obtained. 1 week PTA, consulted at
another physician, ultrasound was done revealing mass on the pancreatic head and
several nodes in the liver. Surgical management was highly considered. Patient was
then admitted at BGHMC for further evaluation and management. There was also
noted yellowish discoloration of the yes, week PTA.

FAMILY HISTORY:
The patient has no history of hypertension, DM , Cardiac diseases , nor asthma. But
they have family history of Cancer in the family.
13 Areas of Assessment:
A. Psychososcial Status:
Patient X is a father of 4 sons and currently lives with the two of them
together with his wife.He is a farmer and is socially active in their community.
He was an occasional drinker and decided to stop on the year 2001. He is not
a smoker.
Upon diagnosis and manifestation of late symptoms. On his admission,
Philhealth and seniorcitizen org. helped him in his financial needs. He is also
visited by his family and friends in the surgery ward.

B. Mental Status:
He is oriented with place, time, person and events. He is slightly conversant.
However, he is coherent. He is currently, anxious due to his condition.
C. Environmental Status:
Since he is a farmer, he is exposed to chemicals such as pesticides. They are
living in a simple home with toilet room. Their trashes are gathered in trash
bin / plastic bags which are collected on a given schedule. They use spring
water for drinking and for cooking. In the hospital, he verbalized that he is
fine with environment. However he is slightly disturbed with room lighting.
D. Sensory Status:
He uses his reading glasses sometimes. He developed poor hearing. His
sense of smell is normal. However, his sensation on sharp objects is reduced.
He also reported moderate abdominal pain (4/10) radiating towards his back.
E. Motor Status:
He can move all his extremities. However, he has limited and slowed
movements because of his abdominal pain associated with body weakness.
He is able to do sitting and side lying position but in a short time only. He can
also ambulate but with assistance.
F. Integumentary Status:
He has jaundice all over his body and his sclera. Uneven distribution of white
hair on his head was observed. He has dry skin and untrimmed nails noted. A
Jackson prat is attached in his abdominal area, on the operated area.
G. Nutritional Status:
His weight was 65 kg last October 2014 then begun to lose weight rapidly
down to 38 kg. According to him he eats 3 times a day and prefers
vegetables than meats. After the operation, clear liquid diet was ordered.
H. Fluids and Electrolytes
He is receiving BMMS 1L x 8 hours . He urinates 2-3 times in an 8 hour shift
with an amount of 150-250cc. His fluid intake amounts to 150-250 cc.
I.

Elimination Status:
In an 8 hour shift he urinates 3 times amounting to 150-250 cc. the he
defecated twice. He has dark urine and a stool which is small in sizes, watery
and yellowish brown in color.

J.

Temperarture:
His skin is warm to touch. Is temperature ranges from 36-36.5 degrees
Celsius.

K. Cardiac Status
Heart sounds and pulses are at regular rate and rhythm. His blood pressure
ranges from 150/80-170/80. His pulse rate ranges from 78-96 bpm.

L. Respiratory Status:
He experiences occasional productive cough with yellowish phlegm. His RR
ranges from 14-20 bpm.
M. Sleep and Comfort Status:
He sleeps a lot during the shift.