IV.

Patients Profile
Personal Data

Patients Name

: Patient D

Age

: 32Y 11M 3D

Gender

: Female

Address
Mandaluyong City

: 309 M. D. De Leon St. Brgy. New Zaniga,

Educational Attainment

: College Graduate

Civil Status

: Married

Birthday

: Sept. 23, 1981

Religion

: Christian

Nationality

: Filipino

Occupation

: Customer Service

Husbands Name

: Mr. D

Occupation

: Graphic Artist

Medical Data

Chief Complaint

: Right Lower Abdominal Pain

Admitting Diagnosis

: T/c Acute Appendicitis

Finals Diagnosis

: Acute Appendicitis

Time and Date Admitted

: 12:25 pm/Aug. 26, 2014

OB Gynecologist

: Dr. Tirador

Attending Physician

: Dra. Merner Salas, M.D.

Operation

: Surgery Appendectomy

Surgeon

: Dra. Merner Salas M.D.

1st Assistant

: Dr. Pablo

2nd Assistant

: Dra. Montesa

Anesthesiologist

: Dr. Odevillas

Chief Complaint:
Biglang sumakit ang tiyan ko banda sa may ibabang kanan.
Sa sobrang sakit, hindi ko na kayang tumayo ng diretsyo.

History of Present Illness

1 day prior to admission, patient D had sudden-onset right lower
quadrant pain. Consult was done at Our Lady of Lourdes Hospital and Dr.
Tirador prescribed her Isoxilan 3x a day.
A few hours prior to admission, right lower quadrant pain recurred,
hence, consult and subsequently admitted.

Past Health History

The patient was born September 23, 1981. Patient D was completely
immunized. She was never admitted to a hospital but experienced common
illnesses such as cough and colds, fever. Whenever she have fever, cough
and colds, she just take Paracetamol (Biogesic/Bioflu) 500mg/tab and
Solmux. No history of allergies of any kind. She never had operations or
injuries. She said that it was her first time to get pregnant. Shes now on 18
weeks AOG. She always have her check-up every 4 weeks. She had
Seborrheic Dermatitis when she was 9 years old until today. Patient D said
that she is using Ketoconazole shampoo to treat the said condition. She also
said that she was diagnosed with Myoma Uteri early this year and she had
her check up again with her OB Gynecologist and it was seen and was
considered Left Ovarian Dermoid Cyst. Shes not taking any medications for
her Left Ovarian Dermoid Cyst.

Personal/Social History
Patient D is the youngest in their family. Her mother is still alive but her
father died when she was 23 years old due to enlargement of the heart
(Cardiomegaly) and hypertension. She has 3 brothers and 2 sisters. She is
married and is 18 weeks pregnant with their first child. She doesnt usually
drink liquors. In terms of her exercise, she doesnt have the time to exercise
regularly because shes busy with work but if she has time, she do jogging
and yoga. She doesnt have time to hang-out with her friends since she
started working. At the age of 21, she graduated from College and
immediately had a job which lasted only 2 years then she rested for 6
months and after found a new job and currently working as Customer Service
Representative.

Environmental History (Living/Neighborhood/Circumstances)

Patient D and her husband live with patient Ds family. Their house is
near the road where vehicles pass by. She also said that their house is made
of cement and wood which is enough for her family to live in. According to
her, cockroaches, flies and mosquitoes are present at their house. They also
own some appliances like television, radio, electric fan, and air conditioner.
They have an electric and water connection. They live in a place where
houses are near each other.

GENOGRAM

Maternal Side
Side

Legends:

Girl
Boy

Maternal:
Grandmother (died due to enlargement of the heart)
Grandfather (died due to aging)

Paternal

Mother of the patient (has vertigo and hypertension)

Paternal:
Grandmother (died due to aging)

Grandfather (died due to aging)

Father of the patient (died due to hypertension and

enlargement of the heart)

Auntie of the patient (has hypertension)

Uncle of the patient (has hypertension)

Siblings:
Sister of the patient (has asthma)

The patient (has Sebborrheic Dermatitis, Left Ovarian Dermoid

Cyst, Appendicitis/Appendectomy)

VI. Physical Assessment

General Appearance
Patient was received awake, responsive and coherent, with ongoing IVF
#2 D5W 500 + 2 amps Isoxilan at 40 cc/hr with 10-11 gtts/min, infusing well
at the left metacarpal vein. Patient has a mesomorphic type of body built and
weighs 66 kilograms and with a height of 157 centimeters. The patient was
certainly oriented to time, place and persons. The patient was seen wearing
corrective lenses/glasses. Still cannot walk straight because of the surgery
done but can already walk around. Hygiene and cleanliness are maintained.

Vital Signs
T 36.5o C
P 76 bpm
R 20 bpm
BP 120/80 mmHg

Head
Head was normocephalic and had a smooth skull contour. Hair was
smooth, and evenly distributed. The hair was black in color and silky. The
scalp was clean. No swelling or tenderness noted upon palpation.

Ears
Both ears were symmetrical; auricle aligned with outer canthus of the
eye. The color of the outer ear was homogenous with that of the skin color.
The external pinna was firm, and non-tender. No discharges, tenderness,
masses, or swelling were noted upon inspection and palpation.

Eyes
Both eyes were symmetrical. Eyelashes equally distributed, curled
slightly outward. Pupil size in 3mm in diameter for both eyes. Reaction to

light was brisk. There was a uniform reaction to accommodation. The pupil
was black in color with pinkish conjunctiva. Lids closed symmetrically, skin
intact, no discharges and no discoloration. Blinking reflex was functional. No
ulceration or lesions noted on the area.

Nose
The external was symmetrical. Nasal mucosa was intact and pinkish in
color and was free of purulent discharges. No nasal flaring noted.

Mouth and Throat

The lips were dry and light pink in color. The gums were pinkish in
color. Her teeth were still intact, with orthodontic braces and complete set of
teeth. Uvula was at the middle. Mucosa was pinkish. Tonsils were uninflamed.
No further abnormalities noted.

Neck
The neck was symmetrical and was proportion to head and shoulder.
The thyroid were smooth as palpated. She was able to turn her head in
upward, sideward and downward position with movement. The carotid artery
has mild pulsation. No sign of lesion or tenderness noted.

Chest and Lungs

Size , shape and symmetry were normal, chest movement is bilateral
equal, respiratory rate is normal, dyspnea, cough, hemoptysis, cyanosis were
absent, resonant sound found all over the lungs are and no any dull sound on
percussion, wheezing, crept sounds were absent, normal breathing sound is
present on auscultation and no any abnormality found.

Abdomen
The abdomen was soft, globular and non-tympanitic. Upon palpation,
the right lower quadrant is still painful and still covered with sterile gauze.
Bowel sounds were still monitored.

Lower/Upper Extremities
Both upper and lower extremities were normal. No signs of lesions,
deformity and tenderness. Skin is uniform with the skin color of the body.
Cardiovascular System
Patients blood pressure was monitored every hour when she was
under our care. Blood pressure ranges from 100/80 mmHg to 12/80 mmHg.
Her pulse from 76bpm to 85bpm. Capillary refill within 3-5 sec.

Musculoskeletal System
Muscle weakness is absent, joint pain or stiffness is absent, edema on
joints or ankles are absent and any other fracture or deformity is not found.

Skin/Skin Appendages
Patients skin was warm to touch with fair complexion; fingernails were
trimmed and tidy. Hair was distributed evenly no clubbing of fingers noted.

Genitourinary System
Negative from spotting, discharge and contractions. Has good fetal
movement. Fetal Heart tone was 140-150. Last Menstrual period was last
April 17, 2014. She is now on 18 weeks AOG.

V. Gordons Health Pattern

Health Pattern
1.Health
Perception/Health
Management
Pattern

2.Nutritionla/Meta
bolic Pattern

Before
Hospitalization
She perceived
health as being
able to work,
fulfill her
responsibilities as
a wife. She works
hard and still do
some household
chores. She
enjoys cooking
specifically fatty
foods.

During
Hospitalization
Still have the same
perception of what
health is. However,
patient realized
that its difficult to
be sick because of
the physical and
financial
constraints. Patient
during
hospitalization is
conscious, calm
and normal.
Though there is an
obvious sign of
weakness.

Analysis and
Interpretation
Many people
define and
describe health
as: Being free
from symptoms
of disease and
pain as much as
possible, being
able to be active
and to do what
they want or
must, and being
good in spirits
most of the
time.
(Kozier.
Fundamentals of
Nursing, 8th ed.)

Patient has no
known food
allergies and eats
foods such as
meat, vegetables
and fruits.
Though she like
fatty and oily
foods. She eat 3
meals a day but
usually forgets to
eat lunch because
her work is in the
evening and go

The patients diet

is nothing per orem
because
shes
post-surgery
and
havent had flatus
yet but she can sip
water and with an
IV fluid of D5W
500.

Health status
greatly affects
ones eating
habits and
nutritional
status. Disease
process can
disrupt
metabolism and
caloric needs of
a middle-aged
adult.
Alterations in
the clients diet

home early in the

morning so she
likes to sleep than
eating lunch. She
occasionally drink
alcohol and drinks
7-8 glasses of
water every day.

3.Elimination
Pattern

Patient reported
that she voids
and defecates
regularly. Patient
said that she
urinates
frequently. She
passes out stool
once a day; she
said her stool is
usually formed
and brown in
color. Patient did
not have any
difficulty urinating
or defecating.

Patient verbalized
that she has
difficulty going to
the bathroom and
urinate because
her surgery is still
painful but she can
tolerate it. There
was negative flatus
yet.

are often
needed to treat
a disease
process, to
increase or
decrease
weight, or to
allow an organ
to rest and
promote
healing. (Kozier.
Fundamentals of
Nursing, 8th ed.)
The healthy
body maintains
a balance
between the
amount of fluid
ingested and
the amount of
fluid eliminated.
The excretory
function of the
kidney
diminishes with
age, but usually
not significantly
below normal
levels unless a
disease process
intervenes. The
frequency of
defecation is
highly
individual, the
amount also
varies from
person to
person. Many
older people

believe that
regularity
means a bowel
movement
everyday.
(Kozier.
Fundamentals of
Nursing, 8th ed.)
4.Activity/Exercise
Pattern

Patient is a
Customer Service
Representative
and her work is at
night time so she
doesnt have time
to do exercises
but if she has
time, she do
jogging and yoga.

Patient cant do
her usual activity
because there is
still pain in the
right lower
quadrant due to
the surgery done.
She was advised
not to perform any
strenuous activity
to avoid abdominal
pressure and to
avoid pain.

People often
define their
health and
physical fitness
by their activity
because mental
well-being and
the
effectiveness of
body functioning
depend largely
on their mobility
status. People
with mobility
impairments
may feel
helpless and
burdensome to
others. (Kozier.
Fundamentals of
Nursing, 8th ed.)

5.Sleep/Rest
Pattern

Patient said she

was able to sleep
for at least 7-8
hours a day
before
hospitalization.
Patient usually
sleeps in the
morning and

During
hospitalization,
patient verbalized
that she cant
sleep at night
properly because
of her condition.
There were times
when he was not

People require
sleep in order to
cope with daily
stresses, to
prevent fatigue,
to conserve
energy, to
restore the mind
and body, and

6.Cognitive/Conce
ptual Pattern

wakes up in the
evening because
her work is at
night. She usually
wakes up 9:20 in
the evening and
sleeps 9 in the
morning then
wake up again
2pm to eat lunch
with her husband
and sleeps again
and wakes up at
6pm to eat dinner
but usually she
doesnt eat
dinner. She eats
her dinner in the
office. She did not
have any
difficulty sleeping
even if faced with
stress in work and
in home.
Patient did not
experience any
sensory deficits,
she did not use
hearing aid,
except eye
glasses for
reading. She
speaks Tagalog
and English

able to sleep/rest
aside from her
condition, another
factor is the
visitation of the
nurses who takes
her vital signs,
medicines, etc.

to enjoy life
more fully.
Illness that
causes pain,
physical distress
personal
problems and
stress can result
in sleep
problems.
(Kozier.
Fundamentals of
Nursing, 8th ed.)

Patient
speaks
Filipino. He did not
have any difficulty
reading,
writing
and
communicating.
Answered
questions correctly
and was able to
recall information
about
herself.
Patient
is
also
oriented to person,
time and place.

The middle-aged
adults cognitive
and intellectual
abilities change
very little.
Cognitive
process include
reaction time,
memory,
perception,
learning.
Problem solving
and creativity.
(Kozier.
Fundamentals of
Nursing, 8th ed.)

7.Self-Perception
Pattern

Patient verbalized
that she felt good
about herself
before the
hospitalization
even before the
surgery because
she was able to
work and fulfill his
responsibilities.
She also reported
that she is patient
about things and
makes it a point
to resolve all
matters that
annoys her. She
does not have
any negative
feelings about
herself or people
around him. She
has a positive
outlook in his life
because he felt
fulfilled.

Patient verbalized
that during
hospitalization and
during treatment,
she felt like losing
hope because she
thinks her baby is
going to be
aborted. She felt
bad about herself
because of the
limitations that she
experience.
However, the
support of the
family is one of the
reason why she is
she still happy.

A positive selfconcept is
essential to a
persons mental
and physical
health. Selfconcept also
extends to the
choices people
make and
perceptions they
have about their
health. People
respond to
stressors such
as illness and
alterations in
function related
to aging in
variety of ways.
Individuals with
poor selfconcept may
express feelings
of
worthlessness,
self-dislike or
even self-hatred.
They may feel
sad, or
hopeless, and
may state they
lack energy to
perform even
the simplest of
tasks. (Kozier.
Fundamentals of
Nursing, 8th ed.)

8.Role/Relationshi
p Pattern

Patient lives with

her husband and
with the patients
family. Patient
also said that she
has good
relationship with
his friends and
family

During
hospitalization, the
family of the
patient stays with
her in the hospital.
Her relative visits
her and is taking
care of her. She
felt grateful by
their presence
even though her
situation is odd.

Throughout life,
people undergo
numerous role
changes. Each
person usually
has several
roles. Failure to
master a role
creates
frustrations and
feelings of
inadequacy,
often with
consequent
lowered selfesteem. (Kozier.
Fundamentals of
Nursing, 8th ed.)

9.Sexuality/Reprod Patient is married

uctive Pattern
and has a good
marital
relationship with
her husband.
They dont have
children yet but
the patient is
currently
pregnant. She is
sexually active.
She said that she
and her husband
usually have sex
twice a week
before she got
pregnant. When
she got pregnant
they only have
sex once a week

During her
hospitalization, her
sexual life is
altered because of
the surgery done
to her and she
thinks its
inappropriate to
have sex in a
hospital and lately
she doesnt like to
have sex because,
like what she said,
its uncomfortable
for her and the
husband
understands it.

Regardless of
gender, age,
race,
socioeconomic
status, religious
beliefs, physical
and mental
health, or other
demographic
factors, people
express their
secuality in a
variety of ways
throughout their
lives. Sexual
health is the
integration of
the somatic,
emotional,
intellectual and

or sometimes
none because its
uncomfortable for
the patient
because of her
growing belly.

10.Coping/Stress
Tolerance Pattern

When faced with

problems,
she
talks
to
the
person
involved
to resolve it as
verbalized by the
son
of
the
patient.

social aspects of
sexual being, in
ways that are
positively
enriching and
that enhance
personality,
communication
and love.
(Kozier.
Fundamentals of
Nursing, 8th ed.)
During
hospitalization, it is
very obvious that
the patient just
sleeps and pray
whenever
she
experiences
and
encounters
unwanted situation
and
lately
she
doesnt encounter
stress.

Coping
strategies vary
among
individuals and
are often related
to the
individual\s
perception of
the stressful
event. A
persons coping
strategies often
change with a
reappraisal of a
situation. If the
duration of the
stressors is
extended
beyond the
coping powers
of the individual,
that person
becomes
exhausted and
may develop
increased
susceptibility to

health problems.
(Kozier.
Fundamentals of
Nursing, 8th ed.)

11.Value/Belief
Pattern

She felt contended

with her life. She is a
Christian and goes to
prayer meetings every
Wednesday and mass
every Saturday.

Because
of the
patients condition,
the chaplain of the
hospital does his
rounds and thats
the only time, the
patient
receives
holy
sacrament.
Plus the holy mass
that
was
being
played all over the
hospital rooms.

Spiritual health
as defined by
the Nursing
Outcomes
Classification
progect
(Moorhead,
Johnson, &
Maas, 2004
p.519), is the
Connectedness
with self, others,
higher power, all
life, nature and
the universe
that transcends
and empowers
the self.
(Kozier.
Fundamentals of
Nursing, 8th ed.)
After the
diagnosis of his
disease, patient
now has a
stronger and
deeper
relationship with
God.