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Overview of The Case

The patient presented with a right periumbilical mass. She has a history of obesity and pregnancy which are modifiable risk factors for umbilical hernia. The physical exam found a reducible mass in the right periumbilical area. The objectives are to understand factors that impact patient health and safety, identify signs and symptoms of umbilical hernia, and learn about disease process, risk factors, manifestations and management through a nursing care plan.

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52 views3 pages

Overview of The Case

The patient presented with a right periumbilical mass. She has a history of obesity and pregnancy which are modifiable risk factors for umbilical hernia. The physical exam found a reducible mass in the right periumbilical area. The objectives are to understand factors that impact patient health and safety, identify signs and symptoms of umbilical hernia, and learn about disease process, risk factors, manifestations and management through a nursing care plan.

Uploaded by

Yessamin
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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OVERVIEW OF THE CASE

Present History of the Disease: Right periumbilical mass

Modifiable Factors: Non-modifiable factors:


Pregnancy Gender (Female)
Obesity Congenital defect
Strenous Activity

OBJECTIVES

1. To acquire an in depth understanding by determining factors that compromise health and safety
of patient with umbilical hernia
2. To identify different sign and symptoms that may be manifested by the patient with umbilical
hernia
3. To gain knowledge about the disease process, pre-disposing factors, clinical manifestation and
the disease management.
4. To demonstrate the use of systemic approach based on nursing care plan.
5. To share/ impart knowledge to the class about the patient’s condition and treatment.

HISTORY OF PRESENT ILLNESS


The patient complains of abdominal mass on the right side of the umbilicus which she first
noticed few months prior to surgical admission. The patient has no history of abdominal pain, vomiting
and loose stools. The bowel, bladder habits are normal, sleep is normal and the appetite is good. There is
no loss of weight. On February 1, 2020 at 10: 15 am patient was admitted at La Consolacion University
General Hospital with the chief complaint of abdominal mass related to umbilical hernia and after
necessary investigation, she has been prepare for herniorrhaphy/ abdominoplasty the next day.

HISTORY OF PAST ILLNESS


The patient does not have any history of pediatric illness neither injuries nor accident. The patient
has no history of respiratory problems such as asthma, cardiac ailments, tuberculosis, diabetes,
hypertension, malaria or any surgical history in the past.
FAMILY HISTORY
There is no history of the same condition. But has a family history of Hypertension and Diabetes
Mellitus.

SOCIAL HISTORY:

The patient is non-smoker and non-alcoholic

DRUG AND ALLERGY HISTORY


There is no routine consumption of any drug. The patient doesn’t have any known allergies of
any kind.

IMMUNISATION HISTORY
The patient could not specify her immunization history.

VITAL SIGNS

 BP : 100/70 mmHg
 HR : 74 bpm
 RR : 20 cpm
 Temp : 36.0 C
PHYSICAL ASSESSMENT

 HEENT - anicteric sclera, peak palpebral, no cerebral leak adenopathy


 NAILS: Short, capillary filled less than 2 seconds
 SKULL: Skull size and shape is symmetrical and appropriate to body size
 NECK: Positioned at midline, no masses
 CHEST/LUNGS:  Clear breath sounds
 CVS: Adynamic precordium, normal rate, regular rhythm
 ABDOMEN: soft, non-tender abdomen, reducible mass on right periumbilical area
 MENTAL STATUS
 Language: Can express speech clearly
 Orientation: Well oriented to time, place and person
 Attention span: The client maintains eye contact and has the appropriate expression to
situation.
 Level of Consciousness: The patient is alert and conscious
 Walking Gait: The patient is able to walk

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