VITAL INFORMATION

Name: Felisa Gallardo Guzon

Room Number: AB209

Age:52 yrs. old

Gender: Female

Civil status: Married

Date of birth:

Birthplace: Iligan City

Cultural Group:

Primary Language:

Religion: Catholic

Highest Educational Attainment: College Graduate

Occupation: Accountant

Usual Health Care Provider: 1st: Self medication

2nd: Physician

3rd: Hospitalization

Reason for health contact: cough and body malaise

Date of confinement: December 5,2010

Source of history: 50% patient & SO, 50% patient's chart

Attending Physician: Dr. Richito Sarmiento

Impression/Final Diagnosis: Breast Cancer

Description of Patient:

Dec. 8-10

NOC

12D- patient is in moderate high back rest position, with edema on the face particularly on the

right side, eyes closed but awake, with edematous body with wounds on the neck and chest

complaints of pain

A- reassessed patients status checked ivf site, due meds given,provided comfort and needs,

encourage to sleep and rest, kept monitored for any unusualities

1:20D- ivf was infiltrated

1:35A- terminated ivf, prepared materials for reinsertion, reinserted ivf

6R- pt awake and was sitting on bed, not dyspnic, afebrile with bp of 130/70 coherent

am

8D- lying on bed awake with patent ivf, edema noted all over body and on right side of face,

wounds noted on neck and chest, appears weak , responsive and oriented

afebrile, not in respi distress.

A-assessment done checked and recorded v/s, regulated ivf to prescribed rate, raise side rails,

provided comfort, encourage relaxation exercises and rest. needs attended, kept monitored.

2R-pt on bed awake, no complaints of pain, edema noted all over body and right side of face,

wound noted on neck and chest, appears weak, afebrile, not in respi distress

Pm

4D- awake conversant, edema noted all over body and right side of the face, unable to tilt head,

not dyspnic, with complaints of pain, dry wound noted on neck , chest and shoulders

A-assessed condition v/s taken, instructed pt not to void until ultra sound is carried out. needs

attended, kept monitored for complaints and pain.

5:15A- wheeled pt to ultrasound dept.

5:30D- received pt from ultrasound dept. still c complains of pain c patent ivf and infusing well,

10R- awake c complaints of pain, open wounds, still with edematous body noted, still unable to tilt

head with complaints of nausea c not episodes of vomitting as claimed by pt.