Right Varicocoelectomy
Content
MANILA DOCTORS COLLEGE Pres. Diosdado Macapagal Boulevard Metropolitan Park, Pasay City
In partial fulfilment Of the Requirements of the College of Nursing in Related Learning Experience
Right Varicocoelectomy
Submitted by: Caberte, Iris D Group CA5 BSN III – A2
Submitted to: Sir Jameson Leonardo, RN
MANILA DOCTORS COLLEGE Pres. Diosdado Macapagal Blvd., Metropolitan Park, Pasay city I. ASSESSMENT A. General Data Resident’s Initials: E.T. Address: Cebu city Age: 30 yrs. old # of days in the Hospital: 5 days Place of Birth: Cebu City Date of Admission: 08/01/10 Order of Admission: Ambulatory Informant: E.T. Date of History Taking: 08/01/10 B. Chief Complaint Sex: Male Civil Status: Single Occupation: Seaman
“Masakit yung bayag ko tapos kumikirot habang umiihi ako.” as verbalized by the client. C. History of Present Illness 4 months prior to confinement, the client felt right scrotal pain that is unrelieved by analgesics with history of trauma, dysuria, and discharge. 2 months prior to confinement, the client consulted at Korea diagnosed to have hydrocoele and was advised for surgery. D. Past History 1. Childhood Illness: The client had chicken pox when he was in elementary. 2. Adult Illnesses: None 3. Immunization: Unrecalled 4. Previous Hospitalization: None 5. Operation/s: None 6. Injuries: He fell at a tree when he was 8 years old. 7. Medications taken prior to confinement: He takes Memoplus gold everyday as his multivitamins. 8. Allergies: None E. Systems Review- Gordon’s Eleven Functional Health Pattern (July 21, 2010) A. Health Perception- Health management
Prior to confinement, the client rarely gets illness. He experienced headache and colds and his remedies for it were Amoxicillin, Biogesic and Neosep which is taken three times a day. When he feels better, he stops the medicine prescribed by the doctor and gets back to work. He doesn’t smoke but he drinks alcoholic beverages occasionally. During confinement, the client eats well and is not particular on the foods that are served. He is in diet as tolerated.
B.
Nutritional-Metabolic Pattern
Prior to confinement, the client had no eating problems such as difficulty in swallowing and has no restrictions in diet. “Hindi ako mahilig kumain” as verbalized by the client. Most of the time, he eats pork, beef, fish, chicken, Korean foods and anything that were served to him by the ship. He eats 3 times a day and his meal would consist of a cup of rice and a serving of viand. He drinks 3-4 glasses per day. He doesn’t wear dentures. The patient stated that his wounds heal just fine. During the confinement, the client eats the food served by the hospital. He would only drink about 4-5 glasses of water a day. The patient weighs 126 lbs and according to him, he loss weight for the past few months. His height is 5’6”. His body mass index is 20.3 kg/m2 his body is in normal range. C. Elimination Pattern
Prior to confinement, the client urinated 4-5 times a day with pain and burning sensation. Whenever he feels constipated, he eats banana. He defecates 2 times a day. The client had odor problems when he perspires a lot during work and playing basketball. During confinement, the client’s defecation and urination patterns remains the same. The client does not perspire a lot because of decreased activity. The client’s stool is brown in color and soft in form while the client’s urine is clear to yellowish in color. D. Activity – Exercise Pattern
Prior to confinement, the client form of exercise is playing basketball and his strenuous work. During his spare time, he listens to music and watch TV. During confinement, the client spends most of his time in his room watching TV, listening to music, and sleeping. E. Sleep-Rest Pattern
The client usually wakes up at 3 am to study for PRC board exam and doing his normal routine like morning care, cooks breakfast and eating breakfast. He eats dinner at 7 pm and usually sleeps at 10 pm. He doesn’t have problem difficulty of sleeping but he experienced awakening during night. During confinement, the client feels relaxed and comfortable. His sleeping pattern remains the same. F. Cognitive- Perceptual Pattern
Priot to the confinement, he client neither wears eyeglasses nor hearing aids. His vision is 20/20. He does not experience any problems with her memory. He understands both Filipino and Bisaya language. He makes his own decision. During confinement, the client’s vision and hearing is still the same. The client is calm, oriented with time & date, people around his and the place.
G.
Self Perception- Self Concept Pattern
Prior to confinement, the client feels calm, relaxed, and good about himself. He doesn’t get angry or annoyed easily. He is always full of hope when problems arise, and is very optimistic because for him “Nandiyan parati ang diyos.” During confinement, the client feels good about himself. His eye contact is consistent. He is relaxed most of the time. His body posture is quite relaxed and assertive. H. Roles-Relationships Pattern
Prior to confinement, he feels lonely whenever he is the shop with inter island trips. He is 4th in the family. Mobile phone was there way of communication. His monthly income was a big contribution to the financial status of their family. He is not a member of any social group. During confinement, the client’s roles and relationship remains the same. I. Sexuality- Reproductive Pattern
Prior to confinement, the client has a girlfriend for 2 weeks. He had sexual experience and uses condoms as contraceptives. He doesn’t have problems dealing with women. During confinement, the client established a good relationship with the staff nurse. His girlfriend and other friends accompany him on his room. J. Coping-Stress Tolerance Pattern
Prior to confinement, the client is able to cope with different situations because he is optimistic. Whenever problems arise, he weighs which his best for him. He also pray and asks for forgiveness and guidance. He remains calm and relaxed when tough times come because he believes that all problems have a solution. He thinks stress was the cause of his illness, “Pagod, init kasi sa makina ng barko nagtratrabaho, halos walang tulog, tapos laging nagbubuhat ng mabibigat.” as stated by the client. During confinement, the client stated that he wants to get back to work to earn money for his family. He is most of the time relaxed lying on the bed watching TV and talking with friends. K. Values Belief Pattern Prior to confinement, the client prays every night in the cabin if he is at work and hear mass every Saturday if he is in the Philippines. The client’s religion is Roman Catholic. He believes that prayer is a big help for every problem. During confinement, the client’s belief is still the same. He prays every night for the success of his surgery and for speedy recovery.
F. Family Assessment NAME E.T. E.T. C.T. R.T. RELATION Client Father Mother Brother AGE 30 65 83 24 SEX M M F M OCCUPATION Seaman None None Computer Progammer EDUCATIONAL ATTAINMENT College graduate High school graduate High school graduate College graduate
G. Heredo – Familial Illness Maternal: Cardiomegaly Paternal: Arthritis H. Developmental History Theory (Theorist) Psychosexual (Sigmund Freud) Age 13 yrs. old and above Developmental Task Genital Stage . Patient’s Description The client has a girlfriend for 2 weeks. He had sexual experience and uses condoms as contraceptives. He doesn’t have problems dealing with women. The client’s family and girlfriend support him in whatever he decides for. He is friendly with his co-workers and doesn’t have problems dealing with them and with his boss. The client is mature enough to make his own decisions based on what is best for him and his family. He is open up for any opinion. He is able to determine what is right from wrong. The client is a law abiding citizen even at work. “Naniniwala ako sa karma kaya mahirap na.” as stated by the client. The client prays at night before going to bed. He asks for forgiveness and strength to overcome his problems. Included in his prayers was his family.
Psychosocial (Erik Erikson)
19-40 yrs. old
Intimacy vs. Isolation
Cognitive (Jean Piaget)
12 and above
Formal Operations Stage
Moral (Kohlberg)
35 and above
Post conventional Level
Spiritual ( James Fowler)
21- 45 yrs.old
Stage 4 IndividuativeReflective faith
I. Physical Examination (August 2, 2010) Vital Signs BP = 120/80 PR = 68 bpm RR = 19 bpm T = 36.5 °C Anthropometric Measurements: Actual Weight: 126 lbs Actual Height: 5’ 6” Regional Examination: A. Skin Inspection: -Skin colour is brown -No presence of rashes or any lesions -Absence of edema Palpation: -No presence of rashes or any lesions -Absence of edema -Skin is dry and warm to touch -Good skin turgor -Absence of palpable mass and nodules B. Nails Inspection: -Clean with minimum length of nails -Nail bed colour is pink Palpation: -Smooth in texture. -Capillary refill about 1-2 seconds D. Hair Inspection: -Evenly distributed -Black in colour -Presence of body hair and evenly distributed -Little visible dandruff -No infestation of lice C. Head and Face Inspection: -Normocephalic and symmetric -With symmetrical facial movements -No swelling Palpation: -Smooth skull contour -Absence of nodules and masses D. Eyes Inspection: -Brown eyelids with no presence of lesions. -Brows are symmetric and have equal hair distribution. -Eyelashes are curved outward and evenly distributed -Upper and lower conjunctiva pink in colour -Sclera appears white -Cornea is transparent and appears shiny and smooth -Pupil of both eye is black in colour, round, reactive to light and accommodation.
Palpation: -Absence of edema, masses and nodules -No tenderness noted -Visual fields: client can see objects in periphery on the left eye -Extra ocular movement test: able to follow six directions of gaze on the left eye -Visual acuity test: able to read newsprint E. Ears Inspection: -Same colour as surrounding skin -Symmetrical -No presence of cerumen or any discharges. -Absence of masses -Hearing Acuity test: able to hear normal voice tone -Weber's test: air conduction is greater than bone conduction Palpation: -No tenderness noted F. Nose Inspection: -Located at the midline. -Same colour as surrounding skin -No swelling or inflammation. -No presence of exudates and mucus secretions. Palpation: -No tenderness noted G. Mouth and Pharynx Inspection: -Lips pink in colour -Absence of swelling, lesions and ulcerations -Tongue able to move freely -Complete set of teeth H. Neck Inspection: -Located at the midline. -Able to flex and hyper extend neck without discomfort Palpation: -No tenderness noted -No palpable lymph nodes I. Spine Inspection: -Straight -No signs of bulging or deviations. Palpation: -No presence of lumps or masses. J. Thorax and Lungs Inspection: -Do not use accessory muscle to breathe. -Normal rate and rhythm of respiration Palpation: -Symmetrical chest excursions. -No presence of abnormal masses and deformities.
Percussion: -Symmetrical resonant sounds heard Auscultation: -No presence of abnormal breath sounds K. Cardiovascular/Heart Inspection: -No visible pulsation. -No exaggerated lifts and thrills in the area. -No distended and bulging veins Palpation: -No presence of lumps and masses. Auscultation: -Cardiac rate and rhythm normal -Absence of heart murmurs and bruits L. Breasts Inspection: -Colour same as surrounding skin -Round shape, symmetrical and intact skin -Nipples are round, equal in size, same colour and both nipples points in same direction -No discharge noted -Absence of masses Palpation: -Absence of tenderness M. Abdomen Inspection: -Uniform colour of the abdomen -Round in shape -No prominent pulsation -No presence of any distention or any bulging. -Umbilicus is located at the midline with no presence of discharges Auscultation: -Presence of bowel sounds Percussion: -Tympani over the abdomen Palpation: -Absence of tenderness N. Extremities Inspection: -Symmetrical body parts. Palpation: -Firm and smooth. -No swelling or any nodules. -No muscle tenderness O. Genitals (base on the chart taken 08/1) Inspection: -Left scrotum look like bag of worms -Asymmetrical testicles Palpation: - Non-tender, twisted mass along the spermatic cord P. Rectum and Anus - Not Assessed
II. Personal/Social History Hobbies: He likes to play basketball, listen to music and watch TV. Vices: He doesn’t smoke but he drinks alcoholic beverages occasionally. Social Affiliation: None Client’s usual day like: The client usually wakes up at 3 am to study for PRC board exam and doing his normal routine like morning care, cooks breakfast and eating breakfast. He eats dinner at 7 pm and usually sleeps at 10 pm. Rank/Order in the family: 4th children. Travel: Alaska, Australia, Mexico, Brazil, South Africa, China, Singapore, Taiwan, Indonesia, India, etc. Educational Attainment: College graduate of BS Marine Engineering Occupation: seaman. III. Environmental History Before confinement the patient lives at a studio type house. Their house is well constructed. Services such as electricity, water supply, and regular garbage collection are present. Their house is accessible to health care facilities such as Health Centre, Hospital, and Pharmacy. Commercial Establishments is also accessible. Means of transportation such as jeepney, bus, taxi, pedicab, and tricycle are present. IV. O.B. GYNE History (Not Applicable) V. Pediatric History (Not Applicable) VII. Laboratory Tests (None)
XI. On-going Appraisal August 1, 2010, E.T. was admitted in MDH at 11F. He is on DAT diet. He is for right varicocoelectomy on August 2, 2010 at 11 AM. August 2, 2010, Post right varicocoelectomy. Ordered Faspic PO 1 tab tid, Stafloxin PO 500 mg 1 tab tid, Plasil IV 2 cc q4h prn, and cold compress over post operative site. To consume IV #1 D5NR IL x 35 cc/hr with remaining of 400 mL. August 3, 2010, May go home. Shifted from cold compress to warm compress on the post operative site. XII. Discharge Plan M – edications Continue ongoing medications: Faspic PO 1 tab tid and Stafloxin PO 500 mg 1 tab tid E – xercise Physical activity should be restricted the first 48 hours. During that time you should remain relatively inactive, moving about only when necessary. During the first two weeks following surgery you should avoid lifting any heavy objects (anything greater than 15 pounds), and avoid strenuous exercise which might endanger the integrity of your incision. T – reatment 1.) Continue warm compress on post operative site. 2.) Eat frequent small meals. 3.) Take antibiotics on a full course. 4.) Provide aseptic technique when changing the dressing. Dispose contaminated material properly. H – ealth Teachings 1) Abstain from sexual activity for one week 2) Bathing or showering should be avoided for 24 to 48 hours 3) Outer dressing should be removed 48 hours after the procedure 4) Pain medications should be taken as prescribed by the doctor 5) Weightlifting or jogging or strenuous activities should be avoided for approximately two weeks O – PD Refer to Physician/Psychiatrist for OPD follow-ups. This visit, to check your incision and progress, is usually scheduled for five to seven days following your surgery. During your first appointment the wound dressing will be removed D – iet You may return to your normal diet within 24 hours following your surgery. Suggest clear liquids and a very light meal the first evening. S – igns and symptoms Educate the family and significant others of client about the signs and symptoms of patients with varicocoele such as: Positive Symptoms – Pain, dysuria, lumpy scrotum, palpable vein, shrinking of testicles, feeling of heaviness of testicles Negative Symptoms – visible enlarge vein, infertility
In partial fulfilment Of the Requirements of the College of Nursing in Related Learning Experience
Right Varicocoelectomy
Submitted by: Caberte, Iris D Group CA5 BSN III – A2
Submitted to: Sir Jameson Leonardo, RN
MANILA DOCTORS COLLEGE Pres. Diosdado Macapagal Blvd., Metropolitan Park, Pasay city I. ASSESSMENT A. General Data Resident’s Initials: E.T. Address: Cebu city Age: 30 yrs. old # of days in the Hospital: 5 days Place of Birth: Cebu City Date of Admission: 08/01/10 Order of Admission: Ambulatory Informant: E.T. Date of History Taking: 08/01/10 B. Chief Complaint Sex: Male Civil Status: Single Occupation: Seaman
“Masakit yung bayag ko tapos kumikirot habang umiihi ako.” as verbalized by the client. C. History of Present Illness 4 months prior to confinement, the client felt right scrotal pain that is unrelieved by analgesics with history of trauma, dysuria, and discharge. 2 months prior to confinement, the client consulted at Korea diagnosed to have hydrocoele and was advised for surgery. D. Past History 1. Childhood Illness: The client had chicken pox when he was in elementary. 2. Adult Illnesses: None 3. Immunization: Unrecalled 4. Previous Hospitalization: None 5. Operation/s: None 6. Injuries: He fell at a tree when he was 8 years old. 7. Medications taken prior to confinement: He takes Memoplus gold everyday as his multivitamins. 8. Allergies: None E. Systems Review- Gordon’s Eleven Functional Health Pattern (July 21, 2010) A. Health Perception- Health management
Prior to confinement, the client rarely gets illness. He experienced headache and colds and his remedies for it were Amoxicillin, Biogesic and Neosep which is taken three times a day. When he feels better, he stops the medicine prescribed by the doctor and gets back to work. He doesn’t smoke but he drinks alcoholic beverages occasionally. During confinement, the client eats well and is not particular on the foods that are served. He is in diet as tolerated.
B.
Nutritional-Metabolic Pattern
Prior to confinement, the client had no eating problems such as difficulty in swallowing and has no restrictions in diet. “Hindi ako mahilig kumain” as verbalized by the client. Most of the time, he eats pork, beef, fish, chicken, Korean foods and anything that were served to him by the ship. He eats 3 times a day and his meal would consist of a cup of rice and a serving of viand. He drinks 3-4 glasses per day. He doesn’t wear dentures. The patient stated that his wounds heal just fine. During the confinement, the client eats the food served by the hospital. He would only drink about 4-5 glasses of water a day. The patient weighs 126 lbs and according to him, he loss weight for the past few months. His height is 5’6”. His body mass index is 20.3 kg/m2 his body is in normal range. C. Elimination Pattern
Prior to confinement, the client urinated 4-5 times a day with pain and burning sensation. Whenever he feels constipated, he eats banana. He defecates 2 times a day. The client had odor problems when he perspires a lot during work and playing basketball. During confinement, the client’s defecation and urination patterns remains the same. The client does not perspire a lot because of decreased activity. The client’s stool is brown in color and soft in form while the client’s urine is clear to yellowish in color. D. Activity – Exercise Pattern
Prior to confinement, the client form of exercise is playing basketball and his strenuous work. During his spare time, he listens to music and watch TV. During confinement, the client spends most of his time in his room watching TV, listening to music, and sleeping. E. Sleep-Rest Pattern
The client usually wakes up at 3 am to study for PRC board exam and doing his normal routine like morning care, cooks breakfast and eating breakfast. He eats dinner at 7 pm and usually sleeps at 10 pm. He doesn’t have problem difficulty of sleeping but he experienced awakening during night. During confinement, the client feels relaxed and comfortable. His sleeping pattern remains the same. F. Cognitive- Perceptual Pattern
Priot to the confinement, he client neither wears eyeglasses nor hearing aids. His vision is 20/20. He does not experience any problems with her memory. He understands both Filipino and Bisaya language. He makes his own decision. During confinement, the client’s vision and hearing is still the same. The client is calm, oriented with time & date, people around his and the place.
G.
Self Perception- Self Concept Pattern
Prior to confinement, the client feels calm, relaxed, and good about himself. He doesn’t get angry or annoyed easily. He is always full of hope when problems arise, and is very optimistic because for him “Nandiyan parati ang diyos.” During confinement, the client feels good about himself. His eye contact is consistent. He is relaxed most of the time. His body posture is quite relaxed and assertive. H. Roles-Relationships Pattern
Prior to confinement, he feels lonely whenever he is the shop with inter island trips. He is 4th in the family. Mobile phone was there way of communication. His monthly income was a big contribution to the financial status of their family. He is not a member of any social group. During confinement, the client’s roles and relationship remains the same. I. Sexuality- Reproductive Pattern
Prior to confinement, the client has a girlfriend for 2 weeks. He had sexual experience and uses condoms as contraceptives. He doesn’t have problems dealing with women. During confinement, the client established a good relationship with the staff nurse. His girlfriend and other friends accompany him on his room. J. Coping-Stress Tolerance Pattern
Prior to confinement, the client is able to cope with different situations because he is optimistic. Whenever problems arise, he weighs which his best for him. He also pray and asks for forgiveness and guidance. He remains calm and relaxed when tough times come because he believes that all problems have a solution. He thinks stress was the cause of his illness, “Pagod, init kasi sa makina ng barko nagtratrabaho, halos walang tulog, tapos laging nagbubuhat ng mabibigat.” as stated by the client. During confinement, the client stated that he wants to get back to work to earn money for his family. He is most of the time relaxed lying on the bed watching TV and talking with friends. K. Values Belief Pattern Prior to confinement, the client prays every night in the cabin if he is at work and hear mass every Saturday if he is in the Philippines. The client’s religion is Roman Catholic. He believes that prayer is a big help for every problem. During confinement, the client’s belief is still the same. He prays every night for the success of his surgery and for speedy recovery.
F. Family Assessment NAME E.T. E.T. C.T. R.T. RELATION Client Father Mother Brother AGE 30 65 83 24 SEX M M F M OCCUPATION Seaman None None Computer Progammer EDUCATIONAL ATTAINMENT College graduate High school graduate High school graduate College graduate
G. Heredo – Familial Illness Maternal: Cardiomegaly Paternal: Arthritis H. Developmental History Theory (Theorist) Psychosexual (Sigmund Freud) Age 13 yrs. old and above Developmental Task Genital Stage . Patient’s Description The client has a girlfriend for 2 weeks. He had sexual experience and uses condoms as contraceptives. He doesn’t have problems dealing with women. The client’s family and girlfriend support him in whatever he decides for. He is friendly with his co-workers and doesn’t have problems dealing with them and with his boss. The client is mature enough to make his own decisions based on what is best for him and his family. He is open up for any opinion. He is able to determine what is right from wrong. The client is a law abiding citizen even at work. “Naniniwala ako sa karma kaya mahirap na.” as stated by the client. The client prays at night before going to bed. He asks for forgiveness and strength to overcome his problems. Included in his prayers was his family.
Psychosocial (Erik Erikson)
19-40 yrs. old
Intimacy vs. Isolation
Cognitive (Jean Piaget)
12 and above
Formal Operations Stage
Moral (Kohlberg)
35 and above
Post conventional Level
Spiritual ( James Fowler)
21- 45 yrs.old
Stage 4 IndividuativeReflective faith
I. Physical Examination (August 2, 2010) Vital Signs BP = 120/80 PR = 68 bpm RR = 19 bpm T = 36.5 °C Anthropometric Measurements: Actual Weight: 126 lbs Actual Height: 5’ 6” Regional Examination: A. Skin Inspection: -Skin colour is brown -No presence of rashes or any lesions -Absence of edema Palpation: -No presence of rashes or any lesions -Absence of edema -Skin is dry and warm to touch -Good skin turgor -Absence of palpable mass and nodules B. Nails Inspection: -Clean with minimum length of nails -Nail bed colour is pink Palpation: -Smooth in texture. -Capillary refill about 1-2 seconds D. Hair Inspection: -Evenly distributed -Black in colour -Presence of body hair and evenly distributed -Little visible dandruff -No infestation of lice C. Head and Face Inspection: -Normocephalic and symmetric -With symmetrical facial movements -No swelling Palpation: -Smooth skull contour -Absence of nodules and masses D. Eyes Inspection: -Brown eyelids with no presence of lesions. -Brows are symmetric and have equal hair distribution. -Eyelashes are curved outward and evenly distributed -Upper and lower conjunctiva pink in colour -Sclera appears white -Cornea is transparent and appears shiny and smooth -Pupil of both eye is black in colour, round, reactive to light and accommodation.
Palpation: -Absence of edema, masses and nodules -No tenderness noted -Visual fields: client can see objects in periphery on the left eye -Extra ocular movement test: able to follow six directions of gaze on the left eye -Visual acuity test: able to read newsprint E. Ears Inspection: -Same colour as surrounding skin -Symmetrical -No presence of cerumen or any discharges. -Absence of masses -Hearing Acuity test: able to hear normal voice tone -Weber's test: air conduction is greater than bone conduction Palpation: -No tenderness noted F. Nose Inspection: -Located at the midline. -Same colour as surrounding skin -No swelling or inflammation. -No presence of exudates and mucus secretions. Palpation: -No tenderness noted G. Mouth and Pharynx Inspection: -Lips pink in colour -Absence of swelling, lesions and ulcerations -Tongue able to move freely -Complete set of teeth H. Neck Inspection: -Located at the midline. -Able to flex and hyper extend neck without discomfort Palpation: -No tenderness noted -No palpable lymph nodes I. Spine Inspection: -Straight -No signs of bulging or deviations. Palpation: -No presence of lumps or masses. J. Thorax and Lungs Inspection: -Do not use accessory muscle to breathe. -Normal rate and rhythm of respiration Palpation: -Symmetrical chest excursions. -No presence of abnormal masses and deformities.
Percussion: -Symmetrical resonant sounds heard Auscultation: -No presence of abnormal breath sounds K. Cardiovascular/Heart Inspection: -No visible pulsation. -No exaggerated lifts and thrills in the area. -No distended and bulging veins Palpation: -No presence of lumps and masses. Auscultation: -Cardiac rate and rhythm normal -Absence of heart murmurs and bruits L. Breasts Inspection: -Colour same as surrounding skin -Round shape, symmetrical and intact skin -Nipples are round, equal in size, same colour and both nipples points in same direction -No discharge noted -Absence of masses Palpation: -Absence of tenderness M. Abdomen Inspection: -Uniform colour of the abdomen -Round in shape -No prominent pulsation -No presence of any distention or any bulging. -Umbilicus is located at the midline with no presence of discharges Auscultation: -Presence of bowel sounds Percussion: -Tympani over the abdomen Palpation: -Absence of tenderness N. Extremities Inspection: -Symmetrical body parts. Palpation: -Firm and smooth. -No swelling or any nodules. -No muscle tenderness O. Genitals (base on the chart taken 08/1) Inspection: -Left scrotum look like bag of worms -Asymmetrical testicles Palpation: - Non-tender, twisted mass along the spermatic cord P. Rectum and Anus - Not Assessed
II. Personal/Social History Hobbies: He likes to play basketball, listen to music and watch TV. Vices: He doesn’t smoke but he drinks alcoholic beverages occasionally. Social Affiliation: None Client’s usual day like: The client usually wakes up at 3 am to study for PRC board exam and doing his normal routine like morning care, cooks breakfast and eating breakfast. He eats dinner at 7 pm and usually sleeps at 10 pm. Rank/Order in the family: 4th children. Travel: Alaska, Australia, Mexico, Brazil, South Africa, China, Singapore, Taiwan, Indonesia, India, etc. Educational Attainment: College graduate of BS Marine Engineering Occupation: seaman. III. Environmental History Before confinement the patient lives at a studio type house. Their house is well constructed. Services such as electricity, water supply, and regular garbage collection are present. Their house is accessible to health care facilities such as Health Centre, Hospital, and Pharmacy. Commercial Establishments is also accessible. Means of transportation such as jeepney, bus, taxi, pedicab, and tricycle are present. IV. O.B. GYNE History (Not Applicable) V. Pediatric History (Not Applicable) VII. Laboratory Tests (None)
XI. On-going Appraisal August 1, 2010, E.T. was admitted in MDH at 11F. He is on DAT diet. He is for right varicocoelectomy on August 2, 2010 at 11 AM. August 2, 2010, Post right varicocoelectomy. Ordered Faspic PO 1 tab tid, Stafloxin PO 500 mg 1 tab tid, Plasil IV 2 cc q4h prn, and cold compress over post operative site. To consume IV #1 D5NR IL x 35 cc/hr with remaining of 400 mL. August 3, 2010, May go home. Shifted from cold compress to warm compress on the post operative site. XII. Discharge Plan M – edications Continue ongoing medications: Faspic PO 1 tab tid and Stafloxin PO 500 mg 1 tab tid E – xercise Physical activity should be restricted the first 48 hours. During that time you should remain relatively inactive, moving about only when necessary. During the first two weeks following surgery you should avoid lifting any heavy objects (anything greater than 15 pounds), and avoid strenuous exercise which might endanger the integrity of your incision. T – reatment 1.) Continue warm compress on post operative site. 2.) Eat frequent small meals. 3.) Take antibiotics on a full course. 4.) Provide aseptic technique when changing the dressing. Dispose contaminated material properly. H – ealth Teachings 1) Abstain from sexual activity for one week 2) Bathing or showering should be avoided for 24 to 48 hours 3) Outer dressing should be removed 48 hours after the procedure 4) Pain medications should be taken as prescribed by the doctor 5) Weightlifting or jogging or strenuous activities should be avoided for approximately two weeks O – PD Refer to Physician/Psychiatrist for OPD follow-ups. This visit, to check your incision and progress, is usually scheduled for five to seven days following your surgery. During your first appointment the wound dressing will be removed D – iet You may return to your normal diet within 24 hours following your surgery. Suggest clear liquids and a very light meal the first evening. S – igns and symptoms Educate the family and significant others of client about the signs and symptoms of patients with varicocoele such as: Positive Symptoms – Pain, dysuria, lumpy scrotum, palpable vein, shrinking of testicles, feeling of heaviness of testicles Negative Symptoms – visible enlarge vein, infertility
