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    Oncology Health Assessment

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    Himani Patel
    This document provides a health assessment of a 40-year-old male patient diagnosed with oral cancer. It includes information on the patient's family history, environmental history, socioeconomic status, nutrition, personal history, history of illness, physical examination findings, diagnostic evaluation, and medical management. The physical examination found abnormalities in the mouth including lesions and the diagnostic evaluation showed abnormalities in blood work. The patient is being treated with medications including Bleomycin.

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    Oncology Health Assessment

    Uploaded by

    Himani Patel
    1K views12 pages
    This document provides a health assessment of a 40-year-old male patient diagnosed with oral cancer. It includes information on the patient's family history, environmental history, socioeconomic status, nutrition, personal history, history of illness, physical examination findings, diagnostic evaluation, and medical management. The physical examination found abnormalities in the mouth including lesions and the diagnostic evaluation showed abnormalities in blood work. The patient is being treated with medications including Bleomycin.

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    This document provides a health assessment of a 40-year-old male patient diagnosed with oral cancer. It includes information on the patient's family history, environmental history, socioeconomic status, nutrition, personal history, history of illness, physical examination findings, diagnostic evaluation, and medical management. The physical examination found abnormalities in the mouth including lesions and the diagnostic evaluation showed abnormalities in blood work. The patient is being treated with medications including Bleomycin.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    1K views12 pages

    Oncology Health Assessment

    Uploaded by

    Himani Patel
    This document provides a health assessment of a 40-year-old male patient diagnosed with oral cancer. It includes information on the patient's family history, environmental history, socioeconomic status, nutrition, personal history, history of illness, physical examination findings, diagnostic evaluation, and medical management. The physical examination found abnormalities in the mouth including lesions and the diagnostic evaluation showed abnormalities in blood work. The patient is being treated with medications including Bleomycin.

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    of 12

    NOOTAN COLLEGE OF NURSING

    VISNAGER

    sub : CLINICAL SPECIALITY-1


    MEDICAL SURGICAL
    NURSING
    Topic: HEALTH ASSESSMENT on oncology

    SUBMITTED TO:- SUBMITTED


    BY:-
    Ms. Srushti Contractor Mr.Dharmendra Patel
    Assistant Proffecer F.Y M.Sc Nursing
    NCN , Visnager NCN, Visnager
    INDEX

    SR.NO CONTENT PAGE NO


    1 PATIENT PROFILE 3

    2 FAMILY HISTORY 4

    3 ENVIRONMENTAL HISTORY 5

    4 SOCIOECONOMIC HISTORY 5

    5 NUTRITIONAL HISTORY 6

    6 PERSONAL HISTORY 7

    7 HISTORY OF ILLNESS 8

    8 PHYSICAL EXAMINATION 10-11

    9 DIAGNOSTIC EVALUATION 12

    10 MEDICAL MANAGEMENT 12

    HISTORY OF THE PATIENT

    IDENTIFICATION DATA:-
    Name of the Patient: Patel Hiteshkumar Rameshbhai

    Age : 40 years

    Sex : Male

    Address : Ahemedabad

    Bed No. : 6

    Doctor’s Unit : Dr. sailesh patel

    Ward : Surgical Unit

    I.P.D. No. : I1110223987

    Date of Admission : 15/2/2018

    Educational Status : 12th std.

    Occupation : Farmer

    Monthly Income : 10,000/-

    Religion : Hindu

    Mother Tongue : Gujarati

    Marital Status : Married

    Diagnosis : ‘ORAL CANCER’

    FAMILY HISTORY :
    Sr Name of Relationshi Age/sex Occupation Marital Educatio Health
    no family p status n status
    . member With
    patients

    1. Hiteshkuma Head of 35year/male Farmer Married 12th pass Unhealthy


    r Family
    member
    2. Artiben Wife 32 House wife Married 10th pass Healthy
    year/Female

    3. Vrushti Daughter 8 year Student Un 2nd pass Healthy


    married

    ENVIRONMENTAL HISTORY:
     HOUSE: He having owns house .
     LOCALITY: He lives in town.
     TYPE OF HOUSE: His house is pucca type.
     VENTILATION: There is proper ventilation in the house.
     NUMBER OF DOORS AND WINDOWS: DOORS:- 1
    WINDOWS:- 3
     BATHROOM: There is a separate bathroom in the house.
     LATRINE: There is a latrine in the home.
     WATER SUPPLY: There is a tape water supply in the house.
     KITCHEN: Kitchen is attached in the house.
     GARBAGE DISPOSAL FACILITY: There is adequate garbage disposal facility.
     DRAINAGE: Drainage is proper.
     CLEANLINESS HOUSE:- House tends to be kept clean.
     SURROUNDING:- Surroundings are clean

    SOCIOECONOMIC HISTORY:-
    Client Belongs from medium socioeconomic class. Their family income is above 10,000
    rupees per month. They follow their role and responsibilities well. They have good
    relationship with their neighbours and society

    NUTRITIONAL HISTORY:
    He is vegetarian. He likes to eat house made foods . He is taking vegetarian diet. He is
    taking sabaji- roti in afternoon because he is taking Tiffin at his working area. In dinner also
    taking full diet, including Sabaji- roti, rice-dal, salad & milk curd
    MARITAL HISTORY
     YEARS OF MARRIAGE: He has been 10 years of marriage life with her wife.
     MARITAL RELATIONSHIP: The marital relationship is satisfactory
     STAYING TOGETHER: They stay together.
     ANY MARITAL DISCORD: There is no marital discord.
     NUMBER OF CHILDREN: He has 1 children.
     HEALTH OF SPOUSE: Spouse is healthy.
     HEALTH OF CHILDREN: Good.
     ANY CONGENITAL DISEASE IN CHILDREN: There is no children to them.

    PRESENTING CHIEF COMPLAIN :


    Mr. Hiteshbhai having a oral cancer and he is suffering for oral pain , swelling , thinking,
    rough sports and unexplained Bleeding in the mouth also Ear pain.

    PAST MEDICAL HISTORY:


    Mr. Hiteshkumar having No any past medical history

    PAST SURGICAL HISTORY :


    Mr. Hitesh kumar having no any past surgical History
    Habits:
    Mr. Hitesh kumar having of daily reced the needs proper and tobacco chewing.

    PERSONAL HYGIENE:
     Hygiene : My patient is unable to maintain proper Hygiene.
     Activity: Activity is abnormal , He is not well and not work in properly.
     Rest & Sleep : Not proper Rest / sleep because he has suffering from Bleeding in
    mouth and leukoplania.

    PHYSICAL EXAMINATION
     General Appearance
    - Nourishment:-Well nourishment - Dull nourished
    - Body build:- Balance - Imbalance
    - Health :- Healthy - Unhealthy
    - Activity:- Normal - Dull
    - Conciousness:- conscious - Conscious
    - Look:- Normal - Dull

     Posture
    - Body area :-Normal
    - Mvovement:- Normal
    - Weight :- 55 kg
    - Height:- 5’5

     Skin condition
    - Colour :- Black colour
    - Lesion:- Normal
    - Body Temperature
     Vital sign
    1.Temperature – 98’ F 2. Pulse – 74 b/m. 3. Respiration – 26 b/m.
    4. Blood Pressure – 110/64 mm of hg.

     Head and Face


    - Shape:- Normal
    - Scalp:- Normal
    - Face:- Normal
    - Eyes:- Normal
    - Ear:- Normal
    - Nose:- Normal

     Mouth & phyrynx


    - Lips - Normal
    - Colour:- Normal
    - Teeth:- Normal
    - Mucus membrane:- Normal
    - Tongue:- Normal
    - Throat:- Normal
    - Pharynx:- Normal

     Neck
    - Lymph node:- Normal
    - Thyroid gland:-Normal
    - Range of motion:-Normal
    - Chest:- Normal

     Abdomen
    -Observation:-No any leasion
    -Auscaltation;-Normal
    -Palpation:-Palpable
    - Percussion:-Normal

     Extrimities
    - Joint movement ;-

     Back
    - Back
    - Kyphosis
    - Scolloosis
    - Lordosis

     Ganital & Rectal


    - Swelling
    - Discharge

     Neurological test
    - CO- ordination test:-Well oriented
    - Equillbrium test:-

     Reflexes
    - Biceps:- Normal
    - Triceps:- Normal
    - Pateller:- Normal
    - Achilles:- Normal
    - Gluteal:- Normal
    - Test of sensation

    INVESTIGATUION:-

    Test name Pateints test value Normal value


    Hb 15gl 13-18M
    CBC 3500/cumm 4000-10000Kumm
    Neutrophil 45% 40-75%
    Lymphocyte 15% 20-45%
    Platelet count 15-45
    Monocyte 3% 2-10%
    Eosinophil 2% 1-6%

    GENERAL INVESTIGATION:-
    Book picture Patients picture
    Hb Male:-15 to 18 √
    WBC √
    RBC √
    Neutrophil √
    Lymphocyte √
    Urine test √
    Eosinophil
    Special investigation
    Chest x-ray √
    CT – scan √
    MRI √
    Tissue biopsy(Tongue or other oral tissue) √

    MEDICATION HISTORY:
    NAME OF DOSE MODE OF INDICATION CONTRAINDI SIDE NURSING
    DRUG &ROUTE ACTION CATION EFFECT RESPONSIBILITY

    Bleomycin IM/IV/Subcu Antibiotic Cancer of -Pregancy -pain in -Assess the


    t 2 unit for Head ,Neck , tumor pulmonary
    first 2 doses Antineopl Cervix, panis - toxicity
    followed by astic Breastfeeding -Headache
    24 hr of -Hemolytic -Therapautic
    - responce
    observation uremic
    Hypersensitiv syndrome
    ity -To report any
    -Nausea complain side
    effect to nurse
    prescriber.
    Metrotrexa -PO/IM/IV - -Breast, - -Dizziness -Hepatic studies
    te 3.3mg/day Antineopl lung,head , Hypersensitiv -Headache
    and 4-6 astic neck,carcino ity -confusion -Bleeding time
    week. ma -HIV -Nausea
    -PO/2m 15- - - -Sever renal -Anorexia -Therapeautic
    30 mg/days Antimetab Osteosarcom disease responce
    olite a -
    - Thromobocyt -To report any
    Lymphocytic openia. complains.
    leukemia
    NAME OF DOSE MODE OF INDICATION CONTRAINDICATION
    DRUG &ROUTE ACTION

    Bleomycin IM/IV/Subcut Antibiotic Cancer of -Pregancy


    2 unit for first Head ,Neck ,
    2 doses Antineoplastic Cervix, panis -Breastfeeding
    followed by -Hypersensitivity
    24 hr of
    observation

    Metrotrexat -PO/IM/IV - -Breast, -Hypersensitivity


    e 3.3mg/day Antineoplastic lung,head , -HIV
    and 4-6 neck,carcinom -Sever renal disease
    week. - a -Thromobocytopenia.
    -PO/2m 15- Antimetabolite -Osteosarcoma
    30 mg/days -Lymphocytic
    leukemia

    Carboplatin IV 300mg on Antineoplasine Carcinoma -pregnancy


    e day cancer on
    head . Neck, -Breast feeding
    Breast
    -Hypersensitivity

    -Significant bleeding

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