DATA PATHOPHYSIOLOGICAL BASIS/

P ER (October 25, 2009)

RATIONALE

S Significant others: Girl friend ➢ Serves as support system during

crisis
Y Coping mechanism: none ➢ An individualized process wherein an

C individual find support

acceptance which can relieve her
and

anxiety
H Religion: Roman Catholic ➢ Can directly affect clients choice of
O Primary language: Iloco ➢
treatment
Facilitates communication with client
S which will help in getting the
appropriate assessment
O Primary source of health care:
O’ Brien medical clinic
➢ Important in cases of illness wherein
diagnosis or detection of certain
C illness will be achieved

I Financial resources: A monthly salary of P50,000 – P75,000

being the president of an advertising and publishing company
➢ Will determine the support system of
the patient with regards to the
A own by the family income of the family

L Occupation & education: College graduate with a degree in

Business Administration
➢ Determines the level
understanding of the patient
of

General appearance: the patient is wearing a tightly fitting
“sando” and boxers soaked with blood along the abdominal
region, fairly kempt, weak and pale in appearance, lethargic
Affect: inappropriate
Orientation: Not 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
➢

Memory: Not assessed because level of consciousness is ➢ Decreased circulating blood to

already decreased deliver enough amount of oxygen to
the brain

Speech: ➢ Assesses any discrepancies

Rhythm & fluency: staggering and in slow pace regarding speech
Volume and tone: soft but audible
Organization: Exhibits thought of association but does not
comprehend with complicated thinking and sequencing
Nonverbal communication: presence of grimace ➢ Aids in verbal communication
Stool: no defecation on this day
E Pattern: ➢ Irregular due to decreased intake of
Consistency: fluid
L Color:

I
M Urine: ➢ Necessary for the surgical procedure
I Quantity per voiding: drained approximately 20ml in the
urine bag
N Color: amber yellow

A
T Toileting ability: with indwelling folley catheter ➢ Assesses her capabilities and need
I of assistance

O
N
1
R Body frame: mesomorph ➢ With BMI (22.46)

E Posture: not assessed ( to ED via stretcher)

Gait: not assessed ( to ED via stretcher)
S Coordination: cannot repeatedly touch the nose and the
finger
➢ To assess for intact motor system

T Balance: not assessed ( to ED via stretcher)

Muscle strength: ➢ Determine clients muscle capabilities
Criteria: with or without gravity & resistance
5=100% of normal strength against full gravity and
A resistance
4=75% normal full movement against gravity and
➢ This will determine the clients ability
to perform ADL’s
N minimal resistance
3=50%normal movements against gravity
D 2=25% full muscle movement against gravity with full
support
1=10% no movement; contraction of muscle is palpable
0= 0% of normal strength with; complete paralysis
A
C
T 2/5 2/5 (biceps)
I
V 2/5 2/5 (iliopsaoas)
I
T
Y
Allergies: Any allergies can affect treatment
S Food: none
➢
regimen
Drugs: none
A Environment: none

F Eyes/ vision: There is no use of eye glasses/PERRLA

Ears/hearing: With symmetrical pinna: no discharges noted ➢ Good hearing abilities can help to
E and no complaint of hearing impairment, hence there is no
use of hearing aides ➢
patient’s safety
Can aid to proper nurse-patient
interaction
Skin integrity: With 2 gunshot wounds on the umbilical area Due to the disruption of the skin
E and the lower epigastric area; no exit points
➢
integrity from an abdominal trauma
Color: ruptured skin appears to be reddish in color
N Hair distribution: well distributed on the head

V Abdomen:
I INSPECTION: Skin color consistent, noted 2 gunshot wounds
on the umbilical area and the lower epigastric area; no exit
R points

O X-RAY: bullet lodged at the pre-pyloric area. Another

bullet lodged at the colon-transverse hitting also the
N duodenum

M Temperature: 36.7 oC(axillary) ➢ To determine the presence of

infection
E Mucous membrane: slightly dry ➢ Moderate dehydration

2
N Activity tolerance:
Perceived exertion rate of 7/10; needs somewhat stronger
➢ Due to muscle weakness

effort in performing tasks or ADL’s

T ➢

Criteria by Borg of 1982:

0= nothing at all
1= very weak effort
2= weak or light effort
3= moderate effort
4= somewhat stronger effort
5= strong effort
7= very strong effort
9= very, very strong effort
10= maximal effort
Airway: ➢ Due to blood pooling at the
Nose: with secretions; with difficulty of breathing noted peritoneum compressing the
Mouth: no lesions diaphragm
O Position of comfort: fetal position ➢ To ease the perceived pain from the
X Color: ➢
abdominal trauma
Due to decreased circulating blood
Y Skin: pale
Lips: pale
volume due to bleeding from
andomonal trauma
G Nail beds: pale in color
Capillary Refill: Poor, returns to its original condition within 2- ➢ To assess for blood circulation
E 3 seconds.
PR: Location-radial
N Rate- 115bpm
Rhythm-regular
A Strength-thready

T RR: 35cpm
Edema on extremities: none
I Oxygen therapy: 2-3 L/min

O
N
Diet: on NPO ➢ Nessesary for the surgiacal
procedure to be made
N OFI: Contraindicated on prescribed diet
IVF: ➢ Supplemental fluid
U 1. Solution: PNSS1L FD 500cc, then regulate to 30-31
gtts/min once BP= 110/80
T Site: left arm
Incorporation: none
R Height: 5’8”
Weight: 67 kgs
I BMI: ➢ Serves as basis for nutritional status
BMI= wt (kg)
T Ht2 (m)
= 67 kgs
I (1.7272)2
= 22.45 = normal
O criteria (mosby’s PDQ):
<20 = underweight
N 20-25= normal
25-30= over weight
30-40= obese
>40= severe obesity

Tissue turgor- Skin goes back to its original condition after 2

seconds

Gag reflex: intact ➢ There is no alteration

3
Ability to: ➢ There is no affectation in the
Chew: (+) esophageal muscles
Swallow: (+)
Tolerated food: (+)