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NURSING TOOLS:
Date of Assessment: February 17, 2011Informants: Patient, Folks and Patient Chart
I - BIOGRAPHICAL DATA:
NAME: P.A,BAGE: 16 years oldCIVIL STATUS: SingleADDRESS: Salang, Balasan, IloiloRACE: BrownRELIGION: Seventh Day AdventistOCCUPATION: StudentDATE OF ADMISSION: February 15, 2011TIME OF ADMISSION: 5 amROOM: Surgical Ward DepartmentPHYSICIAN’S: Dr. N. O
II – CLIENT HEALTH HISTORY:
A. Chief Complaint:* Right Lower Quadrant PainB. Admitting Impression:* T/C Ruptured AppendicitisC. History of Present Illness:* 2 days before the client was admitted he had fever and experiencing pain at Right Lower Quadrant Pain.D. Post Health History:* Patient had a complete immunization when he was a child, but he had experienced mumps and measleswhen he was a child.E. Family History:
Heredofamilial Disease Paternal Maternal
AsthmaDiabetes MellitusHypertensionCancer Others (specify)F. Socio – Cultural History:* The patient interacted to others with a good attitude. He is also friendly and had his own group friends attheir school. He socializes with their neighbors at their place.
 
G. Environmental History:* Patient P,A.B lived at Salang, Balasan, Ilo-ilo. Their house was near the road, and made up of concretematerials and they are maintaining their surroundings clean.H. Medical Substance Use:* Eteroxib (Arcoxia) 120 mg ODI. Assessment:Vital Signs: T- 36.9, P- 78, R- 20, BP- 110/70 mmHgWeight: 53 kgHeight: 5’2’’Speech: Clear Mental Status: ResponsiveEmotional Status: Sometimes happy, sometimes silent
III – PATTERN AND FUNCTIONING:HOME HOSPITALA. FLUID AND NUTRITION
Eat 3x a day, sometimes withsnacks. Drinks water 8-10 glassesa day.DAT
B. REST AND SLEEP
He slept at around 10:30 pm andwakes up at 5:30 am.Patient slept at around 9 pm andwakes up at 6 am and had a napfrequently.
C. ELIMINATION
Normally eliminates his bowelabout 2x a day and urinatesnormally.Eliminates bowel once a day andurinates a lot.
D. ACTIVITY ANDEXERCISE
Sometimes he plays basketballevery afternoon after his class.Walking in the hospital’s corridor from surgical ward to O.R.
E. PERSONAL HYGIENE
Takes a bath every morning andalso after playing basketball andhalf bath in the evening.Sponge bath by his mother in themorning.
IV – TYPE OF EXAMINATION:
Date: 2-15-11
Laboratory Test Result Normal Values
Sodium 139 mmol/L 135-148 mmol/LPotassium 3.7 mmol/L 3.7-5.3 mmol/L
URINALYSIS Results
Color Straw HazyReaction pH 7.0Specific Gravity 1.015Protein Albumin NegativeSugar Negative
 
HEMATOLOGY
Result Normal Values
Hemoglobin Mass Concentration 149 gms/L Male: 130-170 gms/LErythrocyte Volume Fraction 0.44 Male: .40-.50Erythrocyte Number Concentration 4.7 Male: 4.5-5.5Leukocyte Number Concentration 6.3 5.0-10.10
V – PHYSICAL ASSESSMENT:CEPHALOCAUDAL INSPECTION PALPATION PERCUSSION AUSCULTATIONSKIN
Brown in color,slightly dry skinSlightly rough,warm to touchN/A N/A
HAIR 
Short, black, curlyhair Dry to touch N/A N/A
HEAD
Round in shape,no lesions found,no birth marksSkull can easilypalpated and alsomandibleN/A N/A
FACE &LYMPHATICS
Round face,brown in color, nolesionsSoft cheek, shortnoseN/A N/A
EYES
Long lashes,pupils equallyroundRound eyes andeasily palpatedN/A N/A
NOSE
No lesions, shortnoseNot easy to pinch,warm to touchN/A N/A
MOUTH &THROAT
Lips symmetrical,light red in color Trachea easilypalpatedN/A N/A
NECK 
No lesions, nonodules noted,mandible andclavicle easilyseenWarm to touch N/A N/A
CHEST
Movement of chest easily seenevery time heinhale and exhaleRib cage easilypalpated but nopalpable massesN/A N/A
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