A.

BIOGRAPHICAL INFORMATION
Artemio Dona Pagador, 75 years old, male, married, Filipino, Artemio born on December
07, 1972, presently residing at Alaminos, Pangasinan. Artemio was the informant and he was
admitted for the first time in this institution on April 16, 2018.

B. HEALTH HISTORY
1. History of present illness
Patient has a history of enlarging mass at nape area for 2 years. Characterized as soft,
non-tender, non-moveable. Due to persistence of mass with increasing size, patient sought
consult 1 month prior to admission in this constitution. Excision biopsy was done revealing
consistent with an atypical lipomatous tumor, well differentiate liposarcoma. Patient was the
advised surgical intervention hence admitted.

2. Past Medical History

There were no previous hospitalizations. There is no occurrence of hypertension, asthma,
diabetes mellitus, goiter, heart disease and without allergy.

3. Heredofamilial History
His father was deceased. Family history of diabetes mellitus

4. Social profile
His primary care giver was his wife since the day he was admitted in this institution. He
is the breadwinner of his family and he is also a seaman for almost 18 years. He lives with his
wife and with his four children.

5. Environment
Patient lives along non-congested neighborhood in a four story building with 4 rooms and
4 window per room. Their house is clean, each of every one of them especially his children had a
specific household chore. Garbage is being segregated. They have 4 cats inside their house.
E. NURSING DIAGNOSIS
PRIORITIZATION
PRIORITIZATION
1. Impaired skin integrity related to tissue
trauma secondary to status post excision of
nape mass.
2. Acute pain related to tissue trauma
secondary to surgical procedure.
RATIONALE:
NURSIN DIAGNOSIS
1. Impaired skin integrity related to tissue
trauma secondary to status post excision of
nape mass.
2. Acute pain related to tissue trauma
secondary to surgical procedure.
ACTUAL or POTENTIAL
Actual
Potential
RATIONALE
Based on OFFTERAS, since there is no
problem on oxygen and fluid, food must be
prioritized to this situation. And this is an
actual problem of the client
The patient does not experience pain during
our shift, a medications for pain was given to
for occurrence of pain or to alleviate pain.
Pain is not present but it may happen due to
biological injury agents.