A. Nursing History (Based on the Functional Health Pattern by Gordon) 1. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN 1.

1 Clients description of his/her health: The patient stated that she was never been hospitalized before for any reason thus this is her first hospitalization. She describes herself as a healthy individual not until she found out about her pregnancy. She started feeling nauseated, and feels like vomiting during the first few weeks, she admits a feeling of discomfort and she often gets sick and has fever at times. Patient said that she didnt experience any vaginal spotting even after she took the pamparegla meds that she has. 1.2 Health Management: When asked if the patient had a pre-natal checkup upon learning that she is pregnant, she said that she didnt. Whenever she feels sick or is sick, she just take whatever medication is available and applicable for her condition, like paracetamol if she experiences fever. 1.3 History of present illness 8 weeks prior to admission, patient was amennorheic for 5 weeks and was found herself to be (+) for pregnancy test. No vaginal spotting, no urinary symptoms, no hypogastric pain and no prenatal check up were done by the patient. Few hours prior to admission, patient started to have sudden severe sharp right lower quadrant pain, non-radiating and anorexia. With persistence of this abdominal pain, patient consulted and was subsequently admitted. 1.4 Past illnesses: The patient stated that other than cough and colds and fever, she had no other serious illness/condition before current hospitalization. 1.5 History of hospitalization: The patient admits that she has never been hospitalized before. 1.6 History of illness in the family: (+) Ovarian Cancer (Mother) (+) Hypertension (Father) 2. NUTRITION AND METABOLIC PATTERN 2.1 Usual food intake (before consultation) Breakfast Bread and sandwich spread plus coffee Lunch 1 cup of rice and soup with meat Supper 1 cup of rice and vegetables with meat Snacks biscuits or bread Preferences: Rice and meat 2.2 Usual fluid intake (type, amounts): - Water (approximately 2-5 glasses per day) - Coffee (approximately 1 cup per day)

2.3 Any food restrictions: Patient was put on NPO upon further assessment during admission because of possible appendectomy. 2.4 Any problems with ability to eat: None

2.5 Any supplements (vitamins, feeding): Vitamin C 3. ELIMINATION PATTERN 3.1 Bladder: Usual frequency/day: 6-10 times a day Color: light yellow Complaints the usual pattern of urination: None 3.2 Bowel: Usual pattern/day (time, frequency, color and consistency): Every morning and night, twice a day, brown, and semi-solid Complaints of usual pattern of bowel movement: None Home remedies: None 3.3 Any assertive device: None 3.4 Skin (condition): The patients skin is slightly dry and warm to touch. It has a good skin turgor.

4. ACTIVITY EXERCISE PATTERN 4.1 Usual daily/weekly activities Leisure: watching television and cooking sometimes Exercise: walking and running everyday if shes not feeling dizzy 4.2 Any limitations of physical ability: None 4.3 History of dyspnea or fatigue: The patient reports no history of Dyspnea or fatigue. 5. SLEEP-REST PATTERN 5.1 Usual sleep pattern: Bedtime 10 pm Hours slept 8-9 hours No. of pillow/s 3 pillows Sleep routines 2 hours siesta in the afternoon 5.2 Any problems regarding sleep: The patient said that she sometimes cannot sleep at night well especially during the night before her admission to ER because of unbearable abdominal pain.

6. COGNITIVE-PERCEPTUAL PATTERN 6.1 Any deficits in sensory perception (hearing, sight, touch): The patients said that the child has no deficit in hearing, seeing, and touching. 6.2 Ability to read and write. Any difficulty in learning?

The patient is able to read and write and has no difficulty in learning. She is working as a full time accounting clerk in her hometown in Ilocos Norte. 6.3 Any complaints? (e.g. pain): The patient complaints of unbearable abdominal pain the night prior to admission and had a pain scale of 10/10 when assessed. As a remedy, she said that she took some revicon forte at first.

7. SELF-PERCEPTION 7.1 What the client is most concerned about: The patient is most concern about the reaction of her brother and other family member because they didnt know that she was pregnant and they knew it just now because of her current hospitalization. She is also concern about her boyfriend who was still at Ilocos Norte during the time of assessment and has not been contact yet about her present condition. 7.2 Present health goal: When asked about her present health goal, she said that she wants to get well as soon as possible so that she could resume her usual activities and be productive like she used to. 7.3 Effect of present illness to self: The patient is anxious about so many things including the revelation of her pregnancy to her family and during the time of assessment, the patient seems to be restless because of too much pain.

8. ROLE RELATIONSHIP PATTERN 8.1 Language spoken: The patient speaks Filipino and can speak Ilocano. 8.2 Manner of speaking: The patient speaks in a medium-pitched tone. 8.3 Significant person to client: The significant persons to client are her whole family and her boyfriend. 8.4 Complaints regarding family: When asked about this matter, the patient was silent at first and said that she has no complaints regarding her family especially to her brother who is the one currently taking care of her now. 8.5 Living with (members of family): The patient, originally lives with her relatives at Ilocos Norte and is just on vacation to her brothers residence in Cavite. 9. SEXUALITY AND SEXUAL FUNCTION 9.1 Anticipated change in sexual relations because of illness - According to patient, her boyfriend is away from her and she anticipates because of her present illness, their sexual relations would be changed and they might consider abstinence for some time. 9.2 Knowledge of sexual functioning - Patient is aware of her sexual functioning as a woman. 10. COPING STRESS MANAGEMENT PATTERN

10.1 Decision making ability The patient said that at 23, she is now capable of making her own decision with regards to the things about herself like settling her own family with her boyfriend soon. 10.3 Management of stress: When it comes to being stressed, the patient often thinks and re-thinks of all the things that stresses her and has always seem to come up with a solution for it. She also prefers to have a silent walk every time she feels confused about certain matters and circumstances regarding herself. 10.4 Expectations from nurses to provide comfort and security during hospitalization: Since it is her first hospitalization, the patient expects that this would not be so traumatic to her. She admits that shes scared of injection or its any form and expects the doctors and nurses to understand the way she might react and respond to it. 11. VALUE BELIEF SYSTEM 11.1 Source of strength and meaning: The patient mentioned that right now God is her source of strength and meaning. 11.2 Importance of God to client: The patient said that relationship with God is very essential and with her present condition and with the previous decisions that she made, she feels like she did not consulted and communicated well to God thats why shes considering that she might have made a mistake that lead her to be hospitalized and be in this illness state. 11.3 Religious practices (type and frequency) When it comes to attending masses, the patient said that she attends to it irregularly especially now that shes staying with her brother in Cavite. 11.4 Request for religious person/practice: None