I PATIENT ASSESSMENT DATA BASE
A. GENERAL DATA
1. Name: MR. G.
2. Address: O’ Donnell Capas, Tarlac
3. Age: 39 yrs old
4. Sex: Male
5. Birth date: oct. 17, 1970
6. Rank in the family: 3rd
7. Nationality: Filipino
8. Civil Status: Married
9. Date of admission: Feb.2, 2010
10. Order of admission:
11. Attending Physician: Dr. Cardinez Jeffery
B. CHIEF COMPLAINT: Abdominal pain
C. HISTORY OF PRESENT ILLNESS:
1 day prior to admission, patient experienced right lower quadrant pain, with no other accompanying signs and symptoms noted, due to resistance of the above
patient was bought few hours prior to admission.
D. PAST HEALTH HISTORY/ STATUS:
1. Childhood Illness: Measles (3years old), common colds (once a year), cough occurs when she have common colds.
2. Immunization: Complete
3. Major Illness: HPN, Cardiomyopathy
4. Allergy: To allergies to drug and foods
E. FAMILY ASSESSMENT
NAME RELATION AGE SEX OCCUPATION EDUC’L ATTAINMENT
Evangeline Wife 37 Female Housewife College Graduate
Marilyn Daughter 17 Female student High School
Jimmy Son 15 Male student High School
F. SYSTEM REVIEW - Gordon’s 11 Functional Health Patterns Assessment
1. HEALTH PERCEPTION - HEALTH MANAGEMENT PATTERN
Patient’s family uses herbal medicines (garlic, oregano, guyabano leaves, malunggay and anonas) as a treatment for some diseases that they encounter such
as fever, stomachache, toothache, etc. they consult first to “magtatawas” or “albularyos” and even “hilots” if they experiences some diseases.
2. NUTRITIONAL – METABOLIC PATTERN
They prefer to eat vegetables rather than meat. The patient usually takes 8 to 10 glasses of water per day. Their source of drinking water is hand pump. The
patient take alcohol occasionally, only cola and water for his beverages.
3. ELIMINATION PATTERN
Bowel habits: 1 to 2 times defecation every day
Color: light brown
Odor: foul
Consistency: water
Bladder habits: 2 to 3 times each time
Color: yellow
Odor: normal
4. ACTIVITY – EXERCISE PATTERN
Self care ability - 2
Feeding-2 Dressing-2 Grooming-2
Bathing-0 Toileting-2 Cooking-2
Bed Movility-2 Home Maintenance-4
Legend:
0-full care
I-requires use of equipment
II-requires assistance or supervision from others
III-requires assistance or supervision from other, and equipment and a device
IV-dependent: doesn’t participate
5. COGNITIVE – PERCEPTION PATTERN
GEA can’t perceive sounds clearly and accurately. He has no visual impairment but has a decrease appetite. He’s anxious about her situation that’s why he
has an impaired strategy in decision-making.
6. SLEEEP – REST PATTERN
GEA suffer from disturbances of sleep. He’s unable to sleep well at night. He consumes only 5-6 hours of sleep. He just nap at the afternoon to compensate
to his sleeping alterations.
7. SELF-PERCEPTION AND SELF-CONCEPT PATTERN
He feels like dying anytime. He’s very anxious of his condition that he can’t find his self worth.
8. ROLE RELATIONSHIP PATTERN
Being a father, he plays his role in the family without any
9. SEXUALITY-REPRODUCTIVE PATTERN
10. COPING-STRESS TOLERANCE PATTERN
11. VALUE-BELIEF PATTERN
G. HEREDO-FAMILIAL ILLNESS
(+) HPN
(+) Asthma
II. PHYSICAL ASSESSMEMT
A. General Survey
Pale and weak appearance
Poor hygiene noted
Conscious and coherent
B. Vital Signs
BP- 120/70
Temp-36.7C
PR-74
RR-24
C. Regional Exam
1. HEENT: Pink palfebral conjunctiva, no discharge, no tonsillopharyngeal congestion
2. Neck and Lymph nodes: no palpable lymph nodes
3. Skin: Warm moist
4. Chest and Lungs: Symmetrical chest expansion, no retraction, clear breath sound
5. Cardiovascular: Pulse palpitation
6. Breast and axilla: N/A
7. Abdomen: Flat, tender, (+)rebound tenderness
8. Genitals: N/A
9. Rectum and Anus: N/A
10. Neurological/Cranial nerves: N/A
III. PERSONAL / SOCIAL HISTORY
A. Habits/Vices
1. Caffeine-1cup/day
2. Smoking-1pack/day
3. Alcohol-occasionally
4. Tea-none
5. Drugs-none
B. Social Affiliation: none
C. Rank in the family: 4th
D. Travel: none
E. Educational Attainment: Elementary Graduate
IV. ENVIRONMENTAL HISTORY
GEA lives with his family in a barrio near the farm. They are prone to fire hazard because of their stock of hay at the backyard. Their source of water is hand pump.
V. INTRODUCTION
Appendicitis is inflammation of the vermiform appendix caused by an obstruction of the intestinal lumen from infection, stricture, fecal mass, foreign body or tumor.
VI. ANATOMY AND PHYSIOLOGY
Digestion takes place almost continuously in a watery, slushy environment. The large intestine absorbs water from its inner contents and stores the rest until it is
convenient to dispose of it. Attached to the first portion of the large intestine is a troublesome pouch called the (veriform) appendix. The appendix has no function in
modern humans, however it is believed to have been part of the digestive system in our primitive ancestors.
VII. PATHOPHYSIOLOGY
Infammation
Increase Intraluminal Pressure
Clot formation-blockage of blood vessel
Lymphoid Swelling bacterian, protozoan, fungal, invasion of body tissue
Decreased Venous drainage
Thrombosis
Bacterial Invasion
Abscess
Gangrene
Perforation (24 to 36 hrs)
Peritonitis
VIII. LABORATORY AND DIAGNOSTIC EXAMINATIONS
DATE:02-05-10
TYPE OF EXAM:HEMATOLOGY
TEST RESULT NORMAL VALUE SIGNIFICANCE
HEMOGLOBIN 126.0 gL 123-153 gL Normal
RBC 4.30 gL 4.1-10.9 gL Normal
WBC 11.5 gL 4.1-10.9 Increase white blood
cell
POLYS 11.8 0.55-0.63 Increase poly
LYMPHO 0.884 gL 0.23-0.35gL Increase lympho
Urinalysis
COLOR RESULT
Transparency [Link]
Reaction 5.0
Specific gravity 1.015
Glucose Trace
Albumin Trace
WBC 2-5/HPF
RBC 1-2/HPF
Epithelial cell Rare
\
IX. DRUG STUDY
Generic Name: CEFOXITIN
Brand Name: MEFOXIN
Dosage: 1 gram IVP q 8hour
Indication:
Mechanism of Side Effects Contraindication Nursing Consideration
Action
Broad-spectrum Cardiovascular Is contraindicated >Document indication
cephalosporin that Hypotension in patients who for therapy,
is penicillinase and Gastrointestinal have shown characteristics of
cephalosporinase- Diarrhea hypersensitivity to symptoms and culture
resistant and is Neuromuscular cefoxitin and the result.
stable in the Possible exacerbation of cephalosporin >Monitor I&O and renal
presence of B- myasthenia gravis group of function; reduce dose
lactamase. Blood antibiotics. with dysfunction.
Eosinophilia, leukopenia >Assess infusion site for
including granulocytopenia, pain and redness; may
neutropenia cause thrombophlebitis.
Liver Function
Transient elevations in SGOT,
SGPT, serum LDH, and serum
alkaline phosphatase
Renal Function
Elevations in serum creatinine
and/or blood urea nitrogen
levels have been observed.
Generic Name: KETOROLAC
Brand Name: ACULAR
Dosage:
Indication: Ophthalmic; treatment of allergic conjunctivitis, and for prophylaxis and reduction of inflammation and associated
symptoms
Mechanism of Action Side Effects Contraindication Nursing Contraindication
Analgesic, anti- Ophthalmic; active peptic ulcer Assess patient pain before and
inflammatory and transient Stinging desease,recent 1 hour after treatment
anti pyretic. and burning on gastrointestinal (GI) Assess for hypersensitivity
instillation, bleeding or perforation, reaction.
ocular irritation, moderate to severe renal monitor for possible adverse
allergic reaction impairment ,hypovolemia or reaction
GI; dehydration Assess for blood dyscrasias
ulceration, and signs of
bleeding and bleeding,bruising,fatigue or
perforation, post- poor healing
operative bleeding,
acute renal
failure.
X. NURSING CARE PLAN
ASSESSMENT NSG. DIAGNOSIS GOALS INTERVENTION RATIONALE EVALUATION
Subjective: Pain related to After 3 hours >Vital signs taken >serve as a Goal met, after 3
“Medyo masakit ruptured of tissue rendering the and recorded. baseline data. hours of rendering
ang sugat ko”, as secondary to proper nursing >Placed patient to >help reduce the the proper
vervalized by the appendectomy. intervention the comfortable pain nursing
patient. Rated patient’s pain will position. intervention the
pain of 6/10. lessen to 4/10. >Deep breathing >lessen patient’s pain was
exercise perception of lessen to 4/10.
Objective: instructed pain.
>warm skin >Administered >to relieve pain.
>weak in analgesic as
appearance prescribed.
>pale looking
>guarding the
abdominal area
when moving
>Viatl signs
BP-90/60
Temp- 36.7C
PR-78
RR-26
XI. ONGOING APPRAISAL
XII. DISCHAGE PLAN
1. Teached medications, brand name and generic name , expected effects, adverse reaction and dosage.
2. Demonstrate medication administration.
3. Provide guidelines for when to seek medical help.
4. Make sure that follow up visit with the careproviders is schedule.
PANPACIFIC UNIVERSITY NORTH PHILIPPINES
URDANETA CITY, PANGASINAN
CASE STUDY
OF
APPENDICITIS
SUBMITTED BY:
Mark Joffrey Desiar
SUBMITTED TO:
MRS. RUBY PASCUAL RN.
