II.

Assessment
A.

Biographical Profile

Name: AbBa
Address: Swa-on, Kapalong Davao Del Norte
Age: 53 years old
Date of Birth: January 01, 1960
Date of Place: Kapalong, Davao Del Norte
Gender: Male
Status: Single
Nationality: Filipino
Religion: Roman Catholic
Date of Admission: June 24, 2013
Time of Admission: 6:30 pm
Initial Diagnosis: Acute Appendicitis
Final Diagnosis: Acute Appendicitis
Attending Physician: Dr. Kharidz B. Macasayan, MD.
B.

CHIEF COMPLAINT

Right Lower Quadrant Pain

C.

HISTORY OF PRESENT ILLNESS

Several days prior to admission the patient experienced an abdominal pain at the

right lower quadrant. These prompted her to seek medical advice, thus confined in
Davao Regional Hospital last June 24, 2013 with the admitting diagnosis of Acute

Appendicitis under the service of Dr. Kharidz B. Macasayon, MD. Her medications were
Cefoxitin, Metronidazol. Paracetamol, Tramadol and Ranitidine.
D.

PAST MEDICAL AND NURSING HISTORY

The patient was born on January 01, 1960. He was delivered full term through

Normal Vagina Spontaneous Delivery. The patient was completely immunized. He was
never admitted to a hospital but he experienced common illness such as cough and
colds. She occasionally drinks liquors and used cigarettes. Her usual diet includes food
that are He prefers meat products in her meal than leafy vegetables.
E.

PERSONAL, FAMILY AND SOCIO-ECONOMIC HISTORY

Personal History:
Smoker

( )

Alcohol drinker

( )

Family History
Smoker

() Fathers side

Alcohol Drinker

() Mothers and Fathers side

Asthma

()

Hypertension

() Mother side

DM

( )Father side

Malignancy

()

Tuberculosis

( )Grand-grandmother side

Heart problem

()

Social History
High School Level

Smoker, alcoholic drinker for 20 years

Socialized with other people
Urban Residence

F.

PATIENT NEED ASSESSMENT (Based on Maslow, Henderson, Abdellah,

Gordon, and Growth Development Theories)

II. Assessment

PHYSICAL ASSESSMENT

General Survey
Received lying on bed conscious, responsive and coherent. Fairly groomed. With
clean and intact top dressing at right lower quadrant. With IVF #4 PNSS 1L infusing
well at the right dorsal metacarpal vein regulated at 30 gtts/min. On NPO. Capillary
refill of 2 sec.
Genearal Appearance at First Sight
Received sitting on bed awake, responsive and coherent. With an IVF #3D5LR 1L
infusing well at the right dorsal metacarpal vein regulated at 80 cc/ . Patient has a
mesomorphic type of body built and weighs 54.5 kilograms and stands 54 tall. The
patient was certainly oriented to time, place and persons. She was able to deal with her
emotions appropriately as the interview went on. Wearing a cotton T-shirt and jogging
pants, patient looked neat and tidy..

Vital Signs
Date

Shift

Time

CR

PR

RR

BP

Temp.

06-26-13

7-3

8:00am

89

88

18

129/83

37.4

12:00pm 90

92

19

130/80

37.0

Skin

Brown skin generally uniform in color in areas except in areas exposed in the sun

No jaundice

Normal capillary refill time 2sec.

Head

No head and scalp lessions

Symmetric facial features and movements

Symmetric nasolabial folds

Evenly distributed black hair

No infestations

Eyes

Eyebrows symmetrical with equal movement

Eyelashes equally distributed and curled slightly outward

Skin of eyelids intact with no discoloration

Eyelids close symmetrically

Bilateral blinking exhibited

No discharges

Slightly in pale palpebral conjunctiva

Iris black in color

Pupils equals in size with smooth borders

Illuminated pupils constricts

Pupils converge when near object is moved toward the nose

When looking straight ahead, the client can see objects in the periphery

Both eyes coordinated, move in unison with parallel alignment

Ears

Color same as facial skin

Symmetrically aligned

Pinna immediately recoils after it is folded

Pinna is not tender

No lesions or discoloration

Normal voice tones audible

Able to hear ticking of a watch in both ears

Nose

Symmetric and straight

Nasal septum intact and in the midline

Mouth and throat

Outer lips uniform slightly pale in color with symmetric contour

Buccal mucosa is of uniform slightly pale in color

Gums are slightly pale

Tongue slightly pinkish, not so moist, at central position

Neck

No tenderness

Symmetrical neck

Chest

Firm

No tenderness

Generally symmetric in size

Cardiovascular

BP 129/83

PR 88

Symmetric pulse strength

Respiratory/Chest

Chest symmetric

Chest wall intact, no tenderness, no masses

Symmetric chest expansion and excursion

Endothelin-converting Enzyme ECE, (+) crackles, (+) wheezes

Respiratory rate 18

Gastrointestinal/Abdomen

Globular

Normoactive bowel sounds

No splenomegaly

No hepatomegaly

Soft

Tympanic

No tenderness

GenitoUrinary

No tenderness when urinating

Musculoskeletal/Extremities

Muscle equal size on both sides of the body

No tenderness

Smooth coordinated movements

Neurologic

Can respond to verbal commands

Oriented

Conscious

Coherent

PATIENT NEED ASSESSMENT

Name: AbBa
Admitting Medical Diagnosis: Acute Appendicitis
Arrive on unit by: Ambulance (from Kapalong to Hospital)
Accompanied by: Health Staff and Brother
Admitting weight: 66kg.
Clients Perception of Reason for Admission: Pila na kaadlaw nakong antos sakong
sakit sa tiyan sa may baba banda too kog butod lang pero mas ni samot mao nag
paadmit nalang ko
How has the problem been managed at home: Agwanta-agwanta lang unya giobserbahan
Allergies: None
Medication: Furosemide, KaliumDurule
PHYSIOLOGICAL NEEDS
II- Oxygenation
*BP: 110/90mmHg *PR/CR: 85BPM

*RR:33CPM (character) regular in rhythm

Lungs (per auscultation: character; lung sound; symmetry of chest expansion;

breathing character pattern)
Vesicular breath sounds heard, with normal rhythm, symmetry upon chest expansion
Cardiac status (per auscultation

(sound, character, chest pain)

Normal heart sound may heard upon auscultation and no chest pain noted; normal
rhythm
Capillary refill: Good capillary refill in 2sec.

Skin character and color:

Skin is dry and has some lesions in some areas, brownish in color, senile and warm to
touch
Life-supporting Apparatus: O2 prior to admission
II- Temperature Maintenance
Temperature: 36.5 C
Skin Character: Senile skin warm to touch and dry
III- Nutritional Fluids
Height/Weight: 162cm66/kg.
*Amount of food consumed: on NPO
Prescribe diet: on NPO
*Problem(Nausea, Vomiting: no. of times and frequency, amount and character):
Nausea and vomiting as adverse effects of anesthesia
Eating Pattern: no eating pattern since still on NPO order
Intake (IVF: Fluid/Water): IVF in PNSS prior to admission
IV- Elimination
Last Bowel Movement (frequency, Amount, character): Wasnt able to defecate.
Normal Pattern: No exact pattern
Urination (frequency, amount, character, sensation)
In moderate amount; amber in color; seldom
V- Rest-Sleep
Bedtime: 9-10 pm

Waking Up: 4-5 am

Sleep (Pattern, amount, of sleep): 6-7 hours of sleep

Problems(as verbalized): Sakit akong tahi ug mulihok ko

Other Observations (related): She suffered pain in his incision site.
VI- Pain Avoidance
Rate Pain:rate 7(scale 1-10)

Time Started: Every time he moves.

Bedtime: No exact time

Location: Right Lower Quadrant in abdominal area
Frequency: Intermittent, Every time he moves.
Behavior (Restless, Facial expression, Irritable, Diaphoretic)
Diaphoretic and Grimace face noted
Character: phantom pain, moderate pain and guarding behaviour noted
VII- Sexuality-Reproductive
LMP: N/A
Gravida/Parity: N/A

Prenatal: N/A

Menstrual cycle: N/A

Gynecologic problems: N/A
EDC:N/A
Family planning method used: N/A
Children: N/A

Menarche: N/A

VII- Stimulation-Activity
Work: Farmer
Recreation/Pastime: Watching TV, Planting flowers in their backyard
Hobbies/vices:
Previous hobbies are smoking, drinking and planting

SAFETY-SECURITY NEED
Neuro V/S: Conscious, responsive and alive.
Mental Status
The patient is coherent, responsive and able to cooperate as we conduct the
assessment.
Emotional problem: Patient does not feel much safe and secure in terms of his
condition because of the complications that may arise, but he feels safe and secure in
terms of his expectations to his family who are taking care of him.
LOVE-BELONGING NEED
Children (living with ;) NONE
Husband (living with ;) NONE
SELF-ESTEEEM NEED
Patient was to socialized to his family members with confidence of functioning in his life.
Present medical condition affects the said role but compensation in many ways still
realized.
SELF-ACTUALIZATION NEED
He thinks positively and entrusted to God all his worries. He feels accepted by his
family.

G. COURSE IN THE WARD

Date/ Shift

Nurses

Nurses Intervention

Assessment
01-30 & 31/ 2013

Initial Assessment

(7-3)

Medical
Management

Monitor the patient

Doctors order

by taking vital signs

in every 4 hours
Persistent Cough

Poor hygiene

Instruct the patient

Administer antibiotic

to increase fluid

as ordered. Water

intake

therapy.

Encourage the

perineal care twice

patient to have a

a day as ordered.

proper hygiene and

provide thorough
teachings
Knowledge deficit in

Provide health

ability to transmit

teaching

virus to others.
Elevated Blood

Place patient in

Administer

Pressure 140/70

MHBR

antihypertensive
drugs as ordered.