DATA

P 10-28-09 PATHOPHYSIOLOGICAL BASIS/ RATIONALE

S Significant others: Mother

Coping Mechanism: Conversing with the significant
➢ Serves as support system during crisis
➢ An individualized process wherein an individual

Y others find support and acceptance which can relieve

her anxiety
Religion: Roman Catholic ➢ Can directly affect clients choice of treatment
C Primary Language: Iloco ➢ Facilitates communication with client which will
help in getting the appropriate assessment
H Primary Source of Health Care: Doctor O’brien
Medical Clinic
➢ Important in cases of illness wherein diagnosis
or detection of certain illness will be achieved

O Financial Resources: A monthly salary of P50,000- ➢ Will determine the support system of the
S P75,000 being the president of an advertising and
publishing company owned by their family
patient with regards to the income of the family

O Occupation and Education: Businessman; College

graduate with a degree of Business management
C General appearance: Appropriately dressed with a
hospital gown, lying on bed, appropriately groomed
I with coordinated movements; weak as seen and pale in
appearance
A Affect: Appropriate
➢ Determines the level of understanding of the
patient
➢ Assess any self care neglect and to determine
what the patient looks like
➢ Discrepancies in the affect or mood of the
client will affect correct assessment

L Orientation: Oriented to time, place and person

Memory: intact
➢

➢
Rules out any neurologic alterations

Also rules out neurologic alterations

Immediate: Remembers the questions asked by
the nurse
Recent: Remembers the incidence last night
Remote: Remembers his birthday last year
Speech: ➢ Assesses any discrepancies regarding speech
Rhythm & fluency: Understandable; moderate
pace with unclear articulations of words in a smooth
manner
Volume and tone: Audible, slow soft speech
Organization: Exhibits taught of association with
logical sequence and make sense
Nonverbal communication: ➢ Aids in verbal communication
Grimaces such as nodding, frowning and raising
eyebrow when in doubt
Stool:
E ➢ No defecation on this day ➢ On NPO

L Urine:
Quantity per voiding:
➢ Decreased due to increased metabolism from
infection and due to fluid shifting from

I Approximately 20ml per hour; 480ml in a 24 hour

basis
Color: dark yellow
intravascular to interstitial spaces

M Toileting ability:
➢ On Indwelling Folley Catheter
➢ Assesses his capabilities and need of
assistance
I Abdomen:
N ➢ INSPECTION: Skin color consistent, with surgical
suture noted from epigastric region just below the

A xyphoid process until the Hypogastric region,

approximately 8-9 cm in length, 2 minor suture on

T the umbilical area and the lower epigastric area at

approximately 1 inch in length
➢ Erythema on the surgical procedure ➢ Inflammatory response due to surgical

I ➢ Noted yellowish to reddish purulent wound
discharge, may be thicker than usual, stronger
O unusual odor
➢ Respiratory movements, slightly pulsation noted in
N epigastric region and no peristaltic waves
➢ AUSCULTATION:
➢ Hypoactive bowel sounds or hypoperistalsis (3
clicks/min)
➢ Absence of flatus
➢ PERCUSSION: dull sound
➢ PALPATION: Noted tenderness, guarding and
rigidity
➢ Positive rebound tenderness upon palpation
ADL’s: Able to perform activities of daily living with
R maximal assistance
procedure
➢ Signs of presence of infection
➢ Due to the alteration in the normal structure of
the GI tract
➢ Due to anesthesia
➢ Due to blood or fluid accumulation in the
peritoneum
➢ Abdominal pain is aggravated by stretching or
moving of the parietal layer of the peritoneal
membrane and the overlying muscle contract
to protect peritoneum upon palpation
➢ Due to muscle weakness and due to pain upon
movement

E Sleep pattern: 5-6 hours at night with intermittent naps

of 1-2 hours at day time.
➢ Due to hospitalization and change in the
environment and pain

S Body frame: Mesomorph

Posture: Stooping slightly forward
➢ With BMI (22.38)
➢ Due to pain upon movement

T Gait: Unsteady gait

Coordination: Can repeated touch the nose and the
➢
➢
Due to weakness
To assess for intact motor system
fingers
Balance: (+) Rhomberg’s test: Unable to stand on one ➢ Due to weakness

a foot and arms perpendicular to the body and cannot

maintain his balance when eyes are closed
Muscle strength: Determine clients muscle capabilities with or
n
➢
Criteria: without gravity & resistance
5=100% of normal strength against full gravity
d and resistance
4=75% normal full movement against gravity and
➢ This will determine the clients ability to perform
ADL’s
minimal resistance
3=50%normal movements against gravity
2=25% full muscle movement against gravity with
A full support
1=10% no movement; contraction of muscle is

C palpable
0= 0% of normal strength with; complete paralysis

T
I 3/5 3/5 (biceps)

V 2/5 2/5 (iliopsoas)

I PAIN: ➢ Due compression of the nerve endings

T P= movement, coughing, sneezing
Q= stabbing

Y R= radiates to sides of the abdomen

S= rated pain 6/10, 10 as severe pain and 0 as
none
T= sudden, insidious
 Allergies: Any allergies can affect treatment regimen
S
➢
Food: none
Drugs: none
A Environment: none
Eyes/ vision: There is no use of eye glasses ➢ Good eye sight can aid to patient in any undue

F injuries

Ears/hearing: With symmetrical pinna: no discharges
E
noted and no complaint of hearing impairment, hence
there is no use of hearing aides
Skin integrity: Surgical suture noted from epigastric
Good hearing abilities can help to patient’s
➢
safety
➢ Can aid to proper nurse-patient interaction
➢ Due to the disruption of the skin integrity from

E region just below the xyphoid process until the

Hypogastric region, approximately 8-9 cm in length, 2
minor suture on the umbilical area and the lower
an abdominal trauma

N epigastric area at approximately 1 inch in length

V Color: with evidence of redness,

induration on the incision site.
warmth and
➢ Inflammatory response from infection

I Hair distribution: well distributed on the head, with fair

distribution all over the body
R Temperature: 38.5o C (axillary)
Mucous membrane: Dry
➢
➢
Due to infection
On NPO and due to fever

O Activity tolerance:
Perceived exertion rate of 7/10; needs very strong
➢ Due to muscle weakness and pain

N effort in performing tasks or ADL’s

M Criteria by Borg of 1982:

0= nothing at all
1= very weak effort
E 2= weak or light effort
3= moderate effort
N 4= somewhat stronger effort
5= strong effort

T 7= very strong effort

9= very, very strong effort
10= maximal effort
Airway: ➢ No affectation on the organs of the respiratory
Nose: without secretions; with no difficulty of system
breathing noted
O Mouth: no lesions
Position of comfort: Side lying and slightly flexed ➢ Position of comfort due to pain

X Color:
Skin: Pale
➢ Due to decreased haemoglobin level and
bleeding from the trauma and from the pain
Lips: Pale surgical management
Y Nail beds: Pale
Capillary Refill: Returns to its original condition within ➢ To assess for blood circulation, decreased
G 2-3 seconds.
PR: ➢
circulating blood volume
Decrease circulating blood volume

E Location-radial
Rate-120bpm
Rhythm-regular
N Strength-thready

A RR: 33cpm
Edema on extremities: none
Oxygen therapy: 2-3 L/min Aids in breathing difficulty of the patient and
T
➢
supply oxygen demand of the body

I
O
N
Diet: NPO ➢ Hypoactive bowel sounds and absence of
flatulence
N OFI: On NPO
IVF: ➢ Serves as supplemental fluid
U 1. Solution: D5NM
Site: left arm
T Regulation: 31-32gtts/min
Incorporation: 1amp of Biomix
R Height: 5’8”
Weight: 66.7 kgs

I BMI: 22.38
BMI= wt (kg)
➢ Serves as basis for nutritional status needs
Ht2 (m)
T = 67kgs
(1.7272)2
I = 22.38= normal
criteria (Mosby’s PDQ):

O
<20 = underweight
20-25= normal
25-30= over weight
N 30-40= obese
>40= severe obesity

Tissue turgor: Skin goes back to its original condition

after 1-2 second
Gag reflex: intact ➢ There is no alteration
Ability to: ➢ There is no affectation in the esophageal
Chew: (+) muscles
Swallow: (+)
Tolerated food: (+)

P 11-07-09
S Significant others: Mother
Coping mechanism: Conversing with the
DATA
PATHOPHYSIOLOGICAL BASIS/ RATIONALE
➢ Serves as support system during crisis
➢ An individualized process wherein an individual find

Y significant others and other people around him

Religion: Roman Catholic
support and acceptance which can relieve her anxiety
➢ Can directly affect clients choice of treatment
Primary Language: Iloco ➢ Facilitates communication with client which will help in
C Primary Source of Health Care: Doctor O’brien
getting the appropriate assessment
➢ Important in cases of illness wherein diagnosis or
Clinic detection of certain illness will be achieved
 Financial Resource: A monthly salary of Will determine the support system of the patient with
H
➢
P50,000-P75,000 being the president of an regards to the income of the family
advertising and publishing company owned by
O the family
Occupation and Educational Attainment: ➢ Determines the level of understanding of the patient
S Businessman; College graduate with a degree of
Business management

O General appearance: Appropriately groomed

with coordinated movements; ambulatory,
slightly and alert
C Affect: Appropriate
I Orientation: Oriented to time, place and person
➢ Assess any self care neglect and to determine what the
patient looks like
➢ Discrepancies in the affect or mood of the client will
affect correct assessment
➢ Alterations on orientation may signify an affectation/
damage in the brain

A Memory: Intact ➢ Also rules out neurologic alterations

Immediate: Remembers the questions
L asked by the nurse
Recent: Remembers his last meal
Remote: Remembers his first
Speech:
Rhythm & fluency: Understandable; ➢ Assesses any discrepancies regarding speech
moderate pace with clear articulations of
words
Volume and tone: Audible with good voice
modulation
Organization: Exhibits good association of
thoughts and words with logical sequence and
make sense
Nonverbal communication: ➢ Aids in verbal communication
Absence of grimaces, nodding, frowning and
raising eyebrow when in doubt
Stool:
E Pattern: regular (twice a day)
Consistency: semi formed
➢ Normal bowel functioning is recovered

L Color: yellowish to brownish

Urine:

I Quantity per voiding:

Approximately 30-40ml per hour; 720-2160ml ➢ No affectation on the normal renal functioning
in a 24 hour basis
M Color: yellow- amber
Toileting ability:
I Able to perform toileting with minimal assistance ➢ Assesses his capabilities and need of assistance

N Abdomen:
➢ INSPECTION: Skin color consistent, with

A surgical suture noted from epigastric region

just below the xyphoid process until the

T Hypogastric region, approximately 8-9 cm in

length, 2 minor suture on the umbilical area

I
and the lower epigastric area at
approximately 1 inch in length ➢ Indicates that incision complete its healing process
➢ Absence of discharges
O
➢ Absence infection
➢ Respiratory movements, slightly pulsation
noted in epigastric region and no peristaltic
N waves
➢ AUSCULTATION: ➢ Gastro- intestinal functioning recovers from trauma and
➢ Normoactive bowel sounds (7clicks/min) able to resume its normal functioning
➢ Presence of flatus
 ➢ PERCUSSION: dull sound on the right
upper quadrant
➢ PALPATION: Absence of tenderness
➢ Negative rebound tenderness upon
palpation
ADL’s: Able to perform activities of daily living Due to improved muscle strength
R
➢
with minimal assistance
Sleep pattern: 6-7hours at night with ➢ Due to decreased pain perception, able to adapt to the
E intermittent naps of 1-2 hours at day time.
Body frame: mesomorph ➢
new environment
With BMI (21.96)

S Posture: upright
Gait: steady gait with hands swaying on sides ➢ Body gains its normal functioning
T alternately
Coordination: Can repeatedly touch the nose ➢ To assess for intact motor system
and the fingers
Balance: (-) Rhomberg’s test: able to stand on ➢ Improved muscle strength
one foot and arms perpendicular to the body and
a can maintain his balance when eyes are closed
Muscle strength: ➢ Determine clients muscle capabilities with or without

n Criteria:
5=100% of normal strength against full
gravity & resistance

gravity and resistance ➢ This will determine the clients ability to perform ADL’s
d 4=75% normal full movement against
gravity and minimal resistance
3=50%normal movements against gravity
2=25% full muscle movement against

A gravity with full support

1=10% no movement; contraction of
muscle is palpable
C 0= 0% of normal strength with; complete
paralysis

T
I 4/5 4/5 (biceps)

V 4/5 4/5 (iliopsaoas)

I PAIN: none
T
Y
Allergies: Any allergies can affect treatment regimen
S
➢
Food: none
Drugs: none
A Environment: none
Eyes/ vision: There is no use of eye glasses/ ➢ Good eye sight prevents the risk of other injury to client

F PERRLA
Ears/hearing: With symmetrical pinna: no ➢ Good hearing ability can contribute to safe environment
discharges noted and no complaint of hearing
E
➢ Can aid to proper nurse-patient interaction
impairment, hence there is no use of hearing
aides

Skin integrity: Surgical suture noted from

E epigastric region just below the xyphoid process

until the Hypogastric region, approximately 8-9
cm in length, 2 minor suture on the umbilical
N area and the lower epigastric area at
approximately 1 inch in length
 Healing process completed
V
➢
Color: no evidence of redness, warmth and
induration on the incision site.
I Hair distribution: well distributed on the head,

R with fair distribution all over the body

Temperature: 37.4 o C (axillary)
Mucous membrane: moist
O Activity tolerance:
N Perceived exertion rate of 3/10; needs
moderate effort in performing tasks or ADL’s
➢ No signs of infection
➢ Adequate fluid in the body
➢ Improved muscle strength

M
➢
Criteria by Borg of 1982:
0= nothing at all
E 1= very weak effort
2= weak or light effort

N 3= moderate effort
4= somewhat stronger effort
5= strong effort
T 7= very strong effort
9= very, very strong effort
10= maximal effort
Airway: ➢ No affectation on the organs of the respiratory system
Nose: without secretions; with no difficulty of
O breathing noted
Mouth: no lesions
X Position of comfort: semi- fowler’s position
Color:
➢ Position of comfort
➢ Due to adequate hemoglobin level to carry enough
Y Skin: pinkish
Lips pinkish
oxygen to the body

Nail beds: pinkish

G Capillary Refill: Returns to its original condition
within 1-2 seconds.
➢ To assess for blood circulation, normal circulating blood
volume
E PR:
Location-radial
➢ Increase circulating blood volume

N Rate-72 bpm
Rhythm-regular
Strength-
A RR: 14cpm ➢ Normal breathing pattern due to adequate oxygenation
T Edema on extremities: none
Oxygen therapy: no use of oxygen therapy Able to breath with no difficulty
I
➢

O
N
Diet: Soft diet ➢ Can tolerate any type of food with no containdications
OFI: approximately 1800 cc per day ➢ No fluid restrictions ordered

N IVF:
1. Solution: PNSS 1L
➢ Serves as supplemental fluid

U Site: left arm

Regulation: 20-21 gtts/min

T Height: 5’8”
Weight: 65.5 kgs
BMI: 21.96 ➢ Serves as basis for nutritional status needs of the
R BMI= wt (kg)
Ht2 (m)
patient
 = 67kgs
I (1.7272)2
= 21.96= normal
T criteria (mosby’s PDQ):
<20 = underweight

I 20-25= normal
25-30= over weight
30-40= obese
O >40= severe obesity

N Tissue turgor- Skin goes back to its original

condition after 1-2 second
➢ Adequate amount of blood circulates in the body

Gag reflex: intact ➢ There is no alteration

Ability to: ➢ There is no affectation in the esophageal muscles
Chew: (+)
Swallow: (+)
Tolerated food: (+)