CHAPTER THREE
3.0. Introduction
This chapter comprises of the demographics bio data of the client and history of the patient
which includes particulars of the patient, sources of data, nursing history, assessment and
management and discharge plan.
3.1. Client’s bio data
Initials: Mrs O.F
Sex: Female
Age: 62 years
Occupation: Retired Teacher
Ethnicity: Yoruba
Religion: Christianity
Marital status: Married
No of children: Four
A.) Age of oldest: 39 years
B.)Age of youngest: 23 years
Siblings: Three
A.) No of brothers: 2
B.) No of sisters : 1
Date of admission: 9-7-2023
Provisional diagnosis: Bleeding per rectum
Date of discharge： 30-3-2024
Final diagnosis: Colorectal cancer
Obstetrics and gynecological history
[Link] of still births: Nil
B.)Abortion: Nil
3.2 Nursing history of Mrs O.F using Gordon Marjory’s functional health pattern.
Gordon’s functional health patterns is a method devised by marjory Gordon to be used by
nurses in the nursing process to provide a more comprehensive nursing assessment of the
patient.
Health perception and health management pattern
Past medical history: She is a known hypertensive patient who was diagnosed five years ago,
she claim to be regular on anti hypertensive drugs. She has been having recurrent rectal
bleeding since two years ago.
Present medical history: Mrs O.F was diagnosed of Colorectal cancer and Abdominoperineal
resection and permanent colostomy done on her where after she was transferred to the female
surgical ward for management.
Nutritional metabolism patterns
Mrs O.F eats normally and balanced [Link] takes about 2 liters of water per day. She eat all
kind of food does not have food allergies.
Elimination pattern
She urinates normally and eliminates at least once daily.
Activity and exercise pattern
Mrs O.F is an active woman, She engages in daily activities before hospitalization.
Sleep and rest pattern
Mrs O.F Sleeps two to three hours during the day and sleep at least 8 hours at night even when
admitted her sleep pattern has not changed.
Cognitive and perspective pattern
Mrs O.F is fully conscious and well oriented to the spheres of life(time,place and person). Her
special senses are functioning properly and she doesn’t forget things easily.
Self perception self concept pattern
Mrs O.F used to feel good about herself but not any longer due to her present state of health,
resulting to low self esteem due to hospitalization .
Roles and Relationship pattern
Mrs O.F loves with her husband and relates well with her children and relatives .
Sexuality and relationship patterns
Mrs O.F reported she maintain good sexual relationship with her husband and also a menopausal
woman. She had four children .
Coping and stress tolerance
She copes with stress by taking enough rest and sleep afterwards .
Value and belief pattern
She believes in the existence of God. Her religion is very important to her and she values her
health. She values good morality and also expect good morality from people around her.
3.3 Physical examination (Head to Toe assessment)
Physical examination starts at the head and finishes at the extremities and can be performed by
four different methods which are
● Inspection
● Palpation
● Percussion
● Auscultation
Examination from head to toe
Inspection: It can be defined as the visual examination of the body using the eye and a lighted
instrument if needed
Inspection includes the following
● Head: Her head is rounded and symmetrical with her face appearing smooth and uniform
in appearance
● Eyes: There is no presence of discharge, no discoloration and lids close symmetrically with
involuntary blink approximately 15-20 times per [Link] sclera appears white and
cornea transparent. The pupils of the eyes are black and equal in size
● Ear:Her auricles are symmetrical and has the same colour with her facial skin.
● Nose: Nose is in good anatomical structure with the septum.
● Mouth : There are no discoloration of the enamel,no retraction of gums. The tongue is
centrally positioned and the uvula positioned in midline of soft palate
● Neck: The neck muscles are equal in size and the thyroid gland not visible on inspection,
the glands ascend during swallowing but are not visible.
● Extremities: The extremities are equal, no extra digit .
Palpitation : it is examination of the body using the sense of touch
● Abdomen : The abdomen is palpated , there was pain on the lower left side of the
abdomen .
Percussion: It involves tapping fingers or hand quickly and sharply against part of the body to
help locate organ boarders , identify organ shape and position and determine if the organ is solid
or filled with fluid or gas.
● Lungs / chest : Her chest is intact with no tenderness and masses .
Auscultation: It involves listening for various lungs, heart and bowel sound with stethoscope
● Bowel sound: There is reduction in her bowel sound( Hypo active bowl sound).
3.4 Investigations carried out on the patient
3.6 Day to Day care of Mrs O.F
Observation: Vital signs were monitored and charted promptly
Medications: All prescribed drugs were made available and served at due times
Physical care: Assisted bathroom bath and oral toileting were done to stimulate and keep her
body well groomed . Her wound is dressed everyday with the use of normal saline and povidone
iodine
Psychological care: Mrs O.F was reassured, her fear and anxiety was allayed.
Investigations: She was encouraged to carry out necessary investigations
Diet and nutrition: Mrs O.F was served attractive and nutritious diet intermittently
Input and output: Mrs O.F input and output was closely monitored and charted
Sleep and rest: Mrs O.F rest during the day and sleep at least 8 hours at night
Spiritual care: Mrs O.F was encouraged and allowed to perform her prayers.
3.7 Nursing care plan
3.8 Discharge plan
Physician told relatives that their patient will soon be discharged from the hospital.
Health education of Mrs O.F on Discharge
Health education being the process of influencing positive behavioural changes that lead to
improved state of health. The patient and her relatives were educated on the importance of
adequate rest due to her condition and that this rest will aid quick recovery, she was encouraged
to eat low fibre diet and eat foods high in protein to help support wound healing and there
should be restriction of salt intake. The importance of strict drug adherence according to
doctor’s prescription was also buttressed and lastly, the patient’s husband was advised to give
psychological support to enable the client achieve her optimum state of health, and when any
signs and symptoms is noticed they should report to the hospital immediately and appointment
date said should be kept well.
Home discharge.
Mrs O.F was discharged on the 30th of march 2024 when she was clinically and physically
stable. On discharge patient was encouraged to keep to all given advice.
She was told to keep to appointment date given to her for her medical check-up.