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NURSING CASE STUDY
TOTAL ABDOMINAL HYSTERECTOMY BILATERAL SALPINGO OOPHORECTOMY

2. NURSING CASE STUDY
ADMISSION/FINAL DIAGNOSIS
I. HEALTH HISTORY
A. DEMOGRAPHIC (BIOGRAPHICAL DATA)
1. Client’s initials: J. L. B.
2. Gender: Female
3. Age: 44 years old Birthdate: April 24, 1969; Birthplace: San Mateo, Rizal
4. Marital (Civil) Status: Married
5. Nationality: Filipino
6. Religion: Roman Catholic
7. Address and Phone Number: 376 Lipahan, Pulong Bunga, Silang, Cavite 09209640936
8. Educational Background/Other Significant Framing: High School Graduate
9. Occupation (usual and present): Housewife
10. Usual Source of Medical Care: Hospital
B. SOURCE AND RELIABILITY OF INFORMATION
Data were obtained from the patient who seems reliable. The client’s chart was also
incorporated as a secondary source of information.
C. REASONS FOR SEEKING CARE OR CHIEF COMPLAINTS (top 3)
“sobrang sumasakit ang puson ko”

3. “sobrang lakas ng regla ko, nag umpisa sya ng ganito kalakas nung April netong taon
lang..umpisa nun buwan buwan na ganito”
“napapatagal yung buwanang dalaw ko”
D. HISTORY OF PRESENT ILLNESS/ OR PRESENT HEALTH
Two months prior to admission, the client experienced abnormally heavy and prolonged
menstruation and dysmenorrhea as well. She reported that from three feminine pads moderately
soaked it increased to five pads fully-soaked per day, and from her regular three-day period, it
increased to five days accompanied with menstrual pains (a scale of eight out of ten from the pain
scale) but no consultation occurred.
Two weeks prior to admission, there was persistence of the above symptoms and the
client decided to consult a doctor and had an ultrasound (trans-v) which showed the back part of
her uterus to have an abnormality and also showed that her left ovary has an overgrowth. After
these discoveries, she was scheduled for an operation to remove her uterus, fallopian tubes and
her ovaries. The client was admitted to the hospital two days before her scheduled operation.
E. PAST MEDICAL HISTORY OR PAST HEALTH
J.L.B. is a housewife who considers daily household chores to be her exercise. As a child,
she did not experience any serious illnesses, just had simple cough and colds. She also did not
experience any injuries or accidents in the past and this is her first hospitalization and operation.
J.L.B. had her menarche at the age of twelve and her last menstrual period was June 10,
2013. She is G2P2; G1 - 1996, girl, 7 lbs, NSD; G2 - 1998, girl, 6.7 lbs, NSD. Had a history of UTI
with her second pregnancy, unrecalled medications but treated completely. She undergone Total
Abdominal Hysterectomy and Bilateral Salpingooophorectomy due to an overgrowth on part of her
uterus and left ovary after a transvaginal ultrasound.
She stated that she has complete immunization and there are no known food and
medication allergies. She claimed that she takes over the counter medicines to treat simple colds
and minor aches and pains like Alaxan. During her hospitalization, she was given Mefenamic acid
as needed for pain and Cefuroxime every eight hours as an antibiotic.
F. FAMILY HISTORY
According to the family genogram, her grandparents, paternal side, are deceased and she
does not know her grandfather’s cause of death but her grandmother died due to old age. Patient’s
grandparents on the maternal side are already deceased and the patient does not recall the
causes of death. The patient’s father died due to a lung problem (patient does not know the exact
lung illness). Her mother has rheumatoid arthritis and also has hypertension. The genogram also
Grandfather,
unrecalledage and
cause of death
Grandmother, old
age
Grandfather,
unrecalledage and
cause of death
Grandmother,
unrecalledage and
cause of death
Father, 77
lung disease
Mother, 76, rheumatoid
arthritis and HTN
Patricio, 52,
rheumatoid
arthritis
Zenaida, 51,
had
hysterectomy
Anna,48, had
myoma;hyste
-rectomy
Eduardo,46,
healthy
Patient, 44,
adenomyosis
Priscilla, 38,
healthy

4. shows that two of her sisters also undergone hysterectomy before. The client is the fifth child of her
parents.
G. SOCIO-ECONOMIC
The client is a plain housewife and currently living with her husband and two daughters and
both of them are still students. The family’s source of income is from her husband who is a
supervisor in a resort. She claimed that her husband’s income is enough for them.
H. DEVELOPMENTAL HISTORY
Middle Adulthood: 35 to 55 or 65
Ego Development Outcome: Generativity vs. Self absorption or Stagnation
Basic Strengths: Production and Care
Now work is most crucial. Erikson observed that middle-age is when we tend to be
occupied with creative and meaningful work and with issues surrounding our family. Also, middle
adulthood is when we can expect to "be in charge," the role we've longer envied.
The significant task is to perpetuate culture and transmit values of the culture through the
family (taming the kids) and working to establish a stable environment. Strength comes through
care of others and production of something that contributes to the betterment of society, which
Erikson calls generativity, so when we're in this stage we often fear inactivity and
meaninglessness.
As our children leave home, or our relationships or goals change, we may be faced with
major life changes — the mid-life crisis — and struggle with finding new meanings and purposes. If
we don't get through this stage successfully, we can become self-absorbed and stagnate.
Significant relationships are within the workplace, the community and the family.
J.L.B. is worried about her children and the things to do at home since she is the one who
is in charge of them like household chores and taking care of her children’s needs. During the
interview, it showed that she gets her strength from her significant others especially her husband
and her daughters.
I. REVIEW OF SYSTEM AND PHYSICAL EXAMINATION
1. ROS AND PE
System ROS PE
a. General /overall health
status
“ok naman na ako pero malaki
ang ibinaba ng weight
ko..medyo hirap pa dn sa
paggalaw gawa ng tahi”
-awake, conscious and
coherent
-non ambulatory
-IVF on left metacarpal vein @
level 150 cc infusing well
-pt has IFC
-afebrile with a Temp= 36.5°C
-PR= 80bpm
-RR= 20 cpm,
-BP=130/90 mmHg
Wt=53 kg; significant weight
changes from 63 to 53 kg
b. Integument “wala naman akong nagising
sakit sa balat”
Skin :
- (-) hyperpigmentation, no
pallor and generalized
scaliness, nails without
clubbing or cyanosis
- incision site and dressing are
clean and intact; wound is
slightly moist with clear fluid
c. Head “wala naman” -symmetrical, smooth, firm
-(-)lesions on the scalp
-normocephalic
-tempomandibular joint felt
bilaterally with full ROM
d. Eyes “ayos naman” -symmetrical blinking
-bulbar conjunctiva clear with

5. tiny vessels visible
-nontender lacrimal apparatus
e. Ears “wala naman” -(-)discharges on external ear
-(-)tenderness
“ok naman,bihira naman
magkasipon”
-(-)nasal discharges
-pink and moist mucosa with
no lesions
-(-)nontender nasal sinuses
-sinuses clear upon
illumination
g. Mouth and Throat “wala naman akong problema
sa lalamunan”
-(-)hoarseness
-dry lips
-(+) gag reflex
-tonsils not enlarged
-left first molar tooth decay
h. Neck “wala” -(+) full ROM
-smooth, firm and nontender
thyroid
-(-)cervical lymph nodes
enlargements
i. Breast and Axillary “wala,nagb-BSE ako kaya lang
nakakalimutan ko sya kung
minsan kaya hindi din
consecutive yung exams”
-(-)skin lesions, no dimpling;
non-tender on palpation, no
palpable masses or lumps. No
discharge.
-flat pale brown areola
-inverted nipples
-(-) axillary lymph nodes
enlargment
j. Respiratory “wala” -resonant on percussion,
vesicular breath sounds, no
crackles, no wheezes, no
rhonchi.
k. Cardiovascular “wala naman” -(+) apical pulse felt at fifth ICS
LMC line
-identical apical and radial
pulse @80 bpm
-normal heart sounds
-regular rate,normal rhythm
l. Urinary “yun lang, yung nagkaroon nga
ako ng UTI nung pinagbubuntis
ko ang bunso namin”
-urine output of >30 cc/hr
-urine color amber yellow
(seen from the urine bag
connected to the cath.)
-(-) bladder distention
-normal kidney punch test
m. Genitalia “dose ako nung unang
nagkaron ng mens..huling
regla ko nung June 10”
The patient refused to be
examined on her genital part
n. Musculoskeletal “hindi pa ako nakakalakad,
pabangon bangon
lang,ganyan..uupo.. minsan
sumasakit ang likod ko,sa
bandang kaliwang taas”
-patient wasn’t able to
ambulate due to catheter
-full ROM of upper extremities
-less lower extremity
functioning due to incision site
pain
o. Neurologic “wala naman” -responds to questions and
statements appropriately
-oriented to time,place, and
person
-CN I:able to smell odor
correctly
-CN II: Snellen chart result
20/20
-CN III,IV,VI: good EOM
-CN V: (+)sensation to light
touch and pain
-CN VII: (-) drooping of the
corner of the mouth while head

6. -CN VIII: passed whisper and
Romberg test
-CN IX: (+) gag reflex, able to
identify taste
-CN X: (+) symmetrical
elevation of the palate, uvula
rises while swallowing
-CN XI: able to shrug
shoulders, able to move neck
with ease
-CN XII: (-) limitation of tongue
movements
p. Hematologic “wala, di naman ako pasain” -(-) bleeding
-(-) bruising
q. Endocrine “wala” -no excessive sweating
-heat and cold tolerance
J.FUNCTIONAL ASSESSMENT
A. Health-Perception-Health Management Pattern
Patient still feels that her body is weak since she just had an operation. Her diet is more
on vegetables and fish and the patient thinks that these things nurses or doctors would suggest. In
the past, it has been also easy for her to find ways to follow things nurses or doctors suggest
The patient does not know the exact cause of her illness and she consulted a doctor
after having heavy, prolonged and painful period. That decision was important for her because if
she did not decide to go to a doctor, she would not have known the cause of those symptoms.
B. Self-esteem, Self-concept/Self-perception Pattern –
The patient would describe herself as a very patient person. Most of the time, she feels
good about herself but since the illness started, the patient felt that her body became weak.
There is nothing that frequently makes her angry and annoyed. The only thing that
makes her anxious and fearful is when she gets bad news about her mother’s health.
C. Activity-Exercise Pattern –
She has sufficient energy for completing required activities like the household chores but
has no regular exercise; considers her everyday chores as her informal exercise. She watches
television and sings on the karaoke whenever she has spare time. Below are the different activities
and its corresponding functional level. Level 0=full self care; level 1=requires use of requirements
or device;level 2=requires assistance or supervision from another person; level 3= requires
assistance or supervision from another person or device; level 4= is independent and does not
participate
Perceived abilityfor
Feeding – level 0 Grooming – level 2
Bathing – level 4 Gen. Mobility – level 3
Toileting – level 4 Cooking – level 4
Bed mobility – level 2 Home Maintenance – level 4
Dressing – level 2 Shopping – level 4
D. Sleep-Rest Pattern
The patient would have eight hours of sleep and feels good after waking up. She sleeps
right away when she goes to bed and always have a good night sleep; goes to the bathroom once
in a while then goes back to sleep. She does not take daytime naps and does not use sleeping
aids.
E. Nutritional/Elimination
Typical daily food intake would be fish and vegetables for lunch and dinner. She prefers
pinangat and eats a lot especially during lunch time. She claimed that she lose weight by ten
kilograms: from 63-53 kg

7. She has a good appetite, loves to eat and no food or diet discomforts, food
allergies/intolerance. Over the last 24 hours she’s been eating and taking crackers and water since
her GI is not yet fully recovered. She also claims that she heals well and there are no skin
problems other than her wound incision.
She admits that she is afraid to go to the dentist before that’s why she is experiencing
tooth decay now on her left first molar.
Her usual bowel elimination would be once a day and with no discomfort. Urinary
elimination would be about six times a day, with a light yellow urine and no discomfort.
F. Sexuality-Reproductive Pattern
a-b. The patient requested to skip this part of the interview since she is not comfortable
to talk about sexual relations with other people she is not very familiar with.
Her first menstruation started when she was 12 years old. LMP June 10,2013 with
dysmenorrheal and prolonged, painful period
G. Interpersonal Relationships/Resources
She considers her social role as raising kids with good morals and bright future ahead of
them which will contribute to the society’s well-being. When it comes to her role in the family, she
is a good wife to her husband and a mother to her children. She is very close with her family and
has a strong support system (especially her husband) which she would go for counseling when
there is a personal problem
H. Coping and Stress Management/Tolerance Pattern
Kinds of stress in life – about health and when there is a family emergency. Her current
stress now would be her hospitalization since she is worried about her kids being at home without
her. Methods to relieve stress would be just talking with her husband or with her friends, and she
says that these have been very helpful. She is not tense most of the time. The only thing that
makes her tense is whenever she gets bad news about her mother’s health.
According to her, her husband is the most helpful when taking things over.
Having a grandchild is the big change in her life in the last year. When there is a big
problem in her life, she seeks her husband’s help and they both think about the solutions to that
problem. She says that sharing the burden really helps. Most of the time, this way is successful.
I. Personal Habits
The patient does not have personal habits
J. Environmental Hazards
The client said that their neighborhood is safe and have adequate utilities. They have
access for transportation.

8. III. LABORATORY STUDIES AND DIAGNOSTICS
Procedure/ Date Indications Normal Values/Findings Actual Findings and
Interpretation
Nursing Responsibilities (pre,intra,post)
Transvaginal
UTZ
May 18, 2013
Gynaecologic
Cytology
May 29,2013
Clinical Lab
Hematology
June 12,2013
-To confirm enlargement of the
uterus
-To assess endometrial lining
-To assess the ovaries
To know the microscopic
appearance of reproductive cells
that would further confirm the
diagnosis of abnormalities and
malignancies of the reproductive
organs
To determine if the cells and their
values are within normal range;if
there are presence of infections;
There should be no abnormal
pelvic growths
There should be no abnormalities
that reflect any lesions that may
indicate malignancy
Hgb=123-153G/L
Hct=0.36-0.45
WBC=5-10x10^g/L
Right ovary measures
2.16x2.30x1.24 cm;
Left ovary measures 7.51x5.91x5.30
cm
*Abnormalities noted that the left
ovary is cystic as measured. It’s
unilocular, thin-walled containing
echogneic stippling and lines
The uterus anterior wall=2.39cm;
posterior wall=2.65 cm and
demonstrate a coarse echopattern.
*Posterior adenomyosis
General Categorization:
(-) for intraepithelial malignancy
*The growth is benign
Other non-neoplastic findings:
Reactive cellular changes
associated with inflammation.
*There is cell differentiation and
overgrowth.
Hgb=109
Hct=0.33
WBC=9.2;
*Results are in normal range
Pre:
-Explaintheproceduretothepatient–what it is for and
how it is done
-Informthepatientwhowillperformthetest and where
andwhenitwillbeperformed
-Informthepatientthatsheneeds toemptybladderbefore
theprocedure
-Informthepatientthattherewillbeminimaldiscomfort
duringthetest.
Intra:
-Accompanypatienttotheultrasoundroom
-Provideprivacy
Post:
-Informthepatientthatawrittenreportoftheultrasound
resultswillbeforwardedtothereferringphysicianandthe
physicianwilldiscussthetestresults
Pre:
-Explain what the procedure is all about-how it
is taken and what it is for;includes smears
Intra:
-Provide privacy
Post:
- Informthepatientthat theresultsofthecytologywillbe
forwardedtothereferringphysicianandthephysicianwill
discussthetestresults
Pre:
-Explaintheproceduretothepatient
-Informthepatientthatthetestrequiresbloodsample
-Informthepatientwhowillperformthetestandwhenitwill
beperformed

9. -Informthepatientthattherewillbediscomfortfromneedle
punctureandpressurefromthetourniquet
Intra:
-Instructthepatienttoapplymanualpressureanddressing
orcottonballoverpuncturesiteonremovaluponremoval
Post:
-Monitorthepuncturesiteforoozingorhematoma
formation

10. II. PROBLEM LIST
A. ACTUAL or Active
Problem No. Problem Date Identified Date
Resolved/Remarks
1 Acute pain in the
incision site
June 26, 2013
2 Weight loss June 26, 2013
3 Upper back pain June 26, 2013
B. HIGH RISK or Potential
Problem No. Problem Date Identified
1 Risk for deep vein thrombosis June 26, 2013
2 Risk for slow wound healing June 26, 2013
3 Risk for musculoskeletal weakness June 26, 2013

11. III. NURSING CARE PLAN
CUES NURSING
DIAGNOSIS
BACKGROUND
KNOWLEDGE
LONG TERM SHORT TERM INTERVENTION RATIONALE EXPECTED OUTCOME
S: “masakit ang tahi
ko pag gumagalaw
O:
-Received patient
lying on bed,
awake, conscious,
coherent, oriented
to time and person
place with an IVF
on LBV D5IMB x12°
level of 4800 cc @
3 pm infusing well;
rate of 41-
42ugtts/min
-Pain scale of 6/10;
facial grimace upon
moving
-Impaired physical
mobility
S:
“eto medyo mahina
pa ang katawan”
O:
-Impaired physical
ND: Acute pain
related to
surgical incision
ND: Poor
physical
condition
secondary to
TAHBSO= incision
on her abdomen to
remove the
diseased
organsimpaired
skin/woundpain
Surgical
procedure body
insist demands of
nutrition and
The patient will be
able to move and do
exercises and
activities of daily
living independently
after six to eight
weeks.
The patient will
perform activities of
daily living
independently and
After nursing
interventions within
the shift, the client
will manifest a
decrease in pain
scale from 6/10 to
2/10 or lower.
After nursing
intervention, the
patient will
demonstrate an
DIAGNOSTIC
Assess the client’s
perception, level of
understanding and
needs.
THERAPEUTIC
Obtain client’s VS
including the pain scale
and help with
administering analgesics
as indicated
Encourage deep
breathing
EDUCATIVE
Encourage verbal report
during and after each
nursing intervention
Teach client diversional
activities
DIAGNOSTIC
Evaluate the need for
individual assistance and
discuss lifestyle changes
imposed by fatigue state
>To identify and
assess the
different nursing
interventions to
be done
>To assess the
effectiveness of
nursing
interventions
and obtain
baseline for
future
comparison; to
alleviate pain.
>To inhibit pain
>Because pain
is highly
subjective
>To divert
attention from
pain
>To determine
degree of
fatigue
Short term:The patient’s pain scale
will decrease from 6/10 to 2/10 or
lower
Long term: The patient will perform
ADL independently after six to eight
weeks
Short term: The patient will
demonstrate an increase in energy
output with presence of fatigue
Long term: The patient will perform

12. mobility
-Weakness
-Limited ROM on
lower extremities
surgery oxygen post
opfatigue
participate in desired
activities at level of
ability six to eight
weeks post op
increase energy
output with presence
of fatigue within the
shift
THERAPEUTIC
Establish realistic activity
goals with client
EDUCATIVE
Instruct client in ways to
monitor responses to
activity and significant
signs and symptoms
>Enhance
commitment in
promoting
optimal
outcomes
>To indicate the
need to alter
activity level
activities of daily living
independently and participate in
desired activities at level of ability

13. IV. ANATOMY AND PHYSIOLOGY
Uterus
The uterus is located inside the pelvis immediately dorsal (and usually somewhat rostral) to
the urinary bladder and ventral to the rectum. The human uterus is pear-shaped and about 3 in.
(7.6 cm) long. The uterus can be divided anatomically into four segments: The fundus, corpus,
cervix and the internal os. The Uterus is the organ of pregnancy as this is where implantation and
development of the fetus occurs.
Fallopian tube
The fallopian tubes stretch from the uterus to the ovaries and measure about 8 to 10 cm (4
to 6 inches) in length. The ends of the fallopian tubes lying next to the ovaries feather into ends
called fimbria (Latin for "fringes" or "fingers"). Millions of tiny hair-like cilia line the fimbria and
interior of the fallopian tubes. The cilia beat in waves hundreds of times a second catching the egg
at ovulation and moving it through the tube to the uterine cavity. Other cells in the tube's inner
lining or endothelium nourish the egg and lubricate it's path during its stay inside the fallopian tube.
Once inside the fallopian tube, the egg and sperm meet and the egg is fertilized.
Ovaries
The ovary (for a given side) is located in the lateral wall of the pelvis in a region called
the ovarian fossa. The fossa usually lies beneath the external iliac artery and in front of
the ureter and the internal iliac artery.
The ovaries are not attached to the fallopian tubes but to the outer layer of the uterus via
the ovarian ligaments. Usually each ovary takes turns releasing eggs every month; however, if
there was a case where one ovary was absent or dysfunctional then the other ovary would
continue providing eggs to be released.
FALLOPIANTUBES

14. V. PATHOPHYSIOLOGY
Endometrial glands
and tissue present in
endometrium
Surrounding myometrium
hypertrophy and
hyperplasia
Prevents uterine
contractions Bleeding arterioles
won’t stop
menorrha
gia
dysmenor
rhea
Prolonged
period
TAHBSO
Uterus enlargement
Pelvic
pain
Agent
Altered cell differentiation and
growth
Transvaginal utz
Posterior
adenomyosis
with dermoid
cyst of left ovary
Ovarian
enlargement
Cyst in the ovary
Stomach
compression
Loss of appetite
Fatigue
Significant weight
loss
Gynaecologic
cytology
Cell
differentiation
and overgrowth

15. VI. MEDICAL-SURGICAL MANAGEMENT (Curative)
1. Procedure
Procedure/Date Indication/Analysis Nursing Responsibilites
(PRE, INTRA, POST)
Total Abdominal Hysterectomy
Bilateral Salpingo
Oophorectomy – June 25,
2013
Adenomyosis with dermoid
cyst of the left ovary
Pre:
- Reduce the anxiety of the
patient and their relatives by
orientation of the environment.
- Informed consent
- Check results of lab
- Monitor VS
- Assess I and O
- Examine level of anxiety
- Teach relaxation techniques
- Bowel preparation
-Light dinner, NPO
-Cleansing enema
- Prophylactic antibiotics
- IV fluids
Intra:
-Total Abdominal
Hysterectomy Bilateral
Salpingo Oophorectomy
Post:
-Vital signs monitoring q15
-IV fluids
-NPO to clear to soft diet
-Assess the scale of pain:
characteristics, scale, location
-Assess the state of the wound
-Assess nutritional status
-Auscultation of bowel sounds
-Give wound care information
and disease.
-Analgesics
-Health teachings to prevent
complications
–Pneumonia (DBE)
–DVT (turning exercise)
–Bedsores (turning
exercise)
2. Pharmacotherapeutics/Medicines
GN (BN)
CLASSIFICATION
STOCK
Indication (client-specific)
Dosage and Frequency
Nursing
Responsibilities/Implication
(PRE, INTRA, POST)
Cefuroxime (Ceftin)
Second
generation cephalosporin
antibiotic
500 mg/tab
Mefenamic acid (Ponstel)
NSAID
500 mg/cap
Prevents infections caused by
bacteria
500 mg/tab; q8° x 7 days
Treats pain (since the client
undergone surgery)
500 mg/cap; q6° as needed
Pre:
-Read orders carefully
-Correct procedure and route
for administration
-Give information about the
drug’s indication to the client
Intra:
-Introduce self and identify
patient
-Ask and assist patient to sit
-Inform patient to notify health
care providers if there are

16. allergic reactions to the
medications
Post:
-Document after administration
of medications and health
teaching
VII. DISCHARGE HEALTH TEACHING PLANS
Content Strategy
1. Compliance
Medication
Exercise
Treatment
Health teaching
Diet
Activity/Lifestyle Changes
Cefuroxime 500 mg/tab; q8° x
7 days
Mefenamic acid 500 mg/cap;
q6° as needed
Importance of having a regular
exercise
Wound care and dressing
Treatment plan
Encourage patient on intake of
fruits, vegetables and protein
Explain to the client that his or
her activity is limited
temporarily; bad habits
Give verbal and written
instructions to the patient and
family about adherence to the
prescribed medications.
Give verbal and written
instructions on how to do
simple exercises and remind
him to avoid lifting objects.
Give verbal and written
instructions on proper wound
care and changing wound
dressing
Teaches the patient and family
about the treatment plan
including the need to avoid all
alcohol intakes, take
medications as prescribe and
check with the physician before
taking any new medications.
Patient and family teaching
addresses skin and wound
care and to watch for and
report signs and symptoms of
complications.
Give pamphlet about foods that
are rich in protein and other
foods that help with wound
healing.
Give pamphlet with information
on the benefits of healthy
lifestyle. Encourage patient to
deviate from the old habits that
might hinder with the recovery
and also change lifestyle if too
sedentary
2. Follow up/Check-up Explain the significance of a
follow check up in the full
recovery and healing from the
illness
Giver verbal instructions and
also the schedule for the follow
up checkup. Contact the
patient prior to his appointment
to remind him of his check up.

17. VIII. SUMMARY OF CLIENT’S STATUS OR CONDITION AS OF LAST DAY OF CONTACT
(Narrative form)
As of last day of contact, the condition of the patient is better. She can sit up with
assistance but still cannot walk on her own since she just underwent surgery and still has a
catheter. She is practicing deep breathing and turning exercise to prevent venous stasis and
respiratory complications. She is still not able to pass flatus that’s why she is just taking crackers
and water to eat but she follows the doctor’s and the nurses’ advise to sit once in a while and also
turn. Her incision wound and its dressing are clean and intact. The wound itself is slightly moist,
with clear little discharge. She is looking forward to be discharged in the hospital and go home to
be with her family and the newest addition to their brood.