Manuel S.

Enverga University Foundation

Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES

I. CLINICAL SUMMARY
A. GENERAL DATA PROFILE

NAME: PATIENT RKD

ADDRESS: CANDELARIA, QUEZON
BIRTHDAY: SEPTEMBER 14, 1990
BIRTH PLACE: CANDELARIA, QUEZON
SPOUSE NAME: JUDY ANN ABEL
NATIONALITY: FILIPINO
RELIGION: ROMAN CATHOLIC
OCCUPATIONS: FISH VENDOR
DATE OF ADMISSION: MARCH 6, 2019
ADMITTING DIAGNOSIS: ANEMIA SECONDARY TO BLEEDING
PEPTIC ULCER DISEASE
ADMITTING PHYSICIAN: DR. PATRICIO, JAN MORRIS MISOLAS

B. CHIEF COMPLAINT:
-Prior to admission the patient experienced abdominal pain, nausea and vomiting at Brgy,
Pahingahan Candelaria, Quezon. March 5, 2019 he admitted at Nursery Road, Masin Norte
Candelaria,Quezon then he transferred at Quezon Medical Center in Lucena, City on March 6 , 2019 at
around 8:22 in the morning for laboratory purposes.

C. NURSING HISTORY
a. HISTORY OF PRESENT ILLNESS:

-Prior to admission the patient experienced abdominal pain, nausea and vomiting on her home
at Pahingahan Candelaria, Quezon, semi consciously he brought to Quezon Medical Center Lucena City,
accompanied with her relatives. The doctor in charge ordered to have an Laboratory test to find the
possible cause of her present illness.

-Physical assessment, Chest x-ray and other laboratory test was done. He was diagnosed
anemia secondary to bleeding peptic ulcer disease.

PEPTIC ULCER
 Manuel S. Enverga University Foundation
Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES

a. Childhood Illness:
- Fever
b. Immunization:
- Hepatitis B, BCG, MMR
c. Allergies:
- No known allergies to food and drugs
d. Incidents:
- Motor accident
e. Hospitalization:
- First time to Hospitalized
f. Medication currently taking:
-Tranexamic Acid 500mg
g. Domestic travel:
- The usual route of travel is within Candelaria, Quezon up to Batangas City to Lucena
City

D. FAMILY HISTORY:
(Refer to the Genogram)

PEPTIC ULCER
 Manuel S. Enverga University Foundation
Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES

E. SOCIAL HISTORY
ACCORDING TO ERIK ERIKSON
STAGE AGE CENTRAL INDICATORS INDICATORS
TASK OF NEGATIVE

POSITIVE OF
RESOLUTION RESOLUTION

YOUNG 18-40 YEARS INTEMACY VS Ability to give Persistent

ADULTHOOD OLD ISOLATION and receive love, aloneness/
commitments isolation,
and mutuality emotional distance
with others, in all relationship,
collaboration in prejudices against
work and others, lack of
affiliations established
sacrificing for vocation, and
others and seeking intimacy
responsible through causal
sexual behaviors. sexual encounter.

When it comes to Erickson’s theory, intimacy vs. isolation is stage six. This stage happens in young

adulthood and may trail off by middle age. This makes sense. When you’re at this age, you’re probably

starting college or thinking about your future. You’re no longer in a high school where you can interact

with people, so you want to have relationship that can last. You’re no longer looking for a lovey-dovey

romantic relationship, but instead, one that you can be more intimate with. When it comes to

friendships, you want people you can spend a lifetime with and not just acquaintances. You want to

build connection to help your career.

PEPTIC ULCER
 Manuel S. Enverga University Foundation
Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES

F. ENVIRONMENT/ LIVING CONDITION

Patient RKD is currently living in Brgy. Pahingahan Norte, Candelaria Quezon, together
with her family. They are living in a wood and cement, near school, away from main road near at
Peter Paul Medical Center. The patient claimed that there is no difficulty in seeking healthcare.
Patient RKD no problems with going to church and to the market which is near to their house.

G. PHYSICAL ASSESMENT

PHYSICAL NORMAL ACTUAL INTERPRETATION

ASSESMENT FINDINGS FINDINGS

GENERAL - clear in appearance - weak in appearance - Patient loss weight

APPEARANCE and well groomed and well groomed due to decrease
appetite
-cooperative -in distress
- Approximately 52
- cooperative kg

SKIN - with good skin - with poor skin

turgor turgor

HAIR - evenly distributed - evenly distributed - poor hygiene due to

hair hair his condition

- thick hair - thick hair

- with hair color

- with no dandruff

NAILS -with good capillary - Capillary refill 3 - Risk for fluid and
refill of 1-2 seconds seconds electrolyte imbalance

-with pinkish nail - With pallor nail

beds beds

PEPTIC ULCER
 Manuel S. Enverga University Foundation
Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES

-with clean and short - With clean and

short nails at normal
Nails angle curvature

- Surrounding tissue
were intact and no
lesions noted

SKULL AND FACE -mouth uniform -mouth uniform

consistency absence consistency absence
of nodules and masses of nodules and masses

-rounded and smooth -rounded and smooth

skull contour skull contour

-symmetrical facial
movement

EYES -no eye discharges -no eye discharges -fluid and electrolyte
imbalance
-with pinkish -with pale conjunctiva
conjunctiva
-eyebrows hair evenly
-eyebrows hair evenly distributed/skin intact
distributed/skin intact
-with sunken eyeballs
-symmetrical facial
movement

EARS -Auricle color same -Auricle color same

as facial skin as facial skin

-Auricle are mobile -Auricle are mobile

firm and not tender firm and not tender

-Able to hear both -Able to hear both

ears ears

-no edema and -no edema and

discharges discharges

PEPTIC ULCER
 Manuel S. Enverga University Foundation
Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES

MOUTH -pinkish lips -pale lips

-without missing teeth -with false teeth -risk for aspiration

(upper)
-with pink gums - sign of respiratory
-with pink gums infection
-no foul odor
-with slightly foul
-with symmetrical odor
contour
-with symmetrical
contour

MUSCULOSKETAL -symmetrical -symmetrical -relatively weak

unable to perform
(UPPER AND -no athrophy -limited range of activity of daily living
LOWER motion o upper and (ADL)
-with full range of lower extremities
EXTREMETIES)
motion

- Symmetrical - Normal chest

- With normal expansion
sound - Use intercostal
- Normal chest muscles during
expansion breathing
CHEST

-No abdominal -with tenderness in the

distension epigastric area

-Flat rounded
abdomen
ABDOMEN -Symmetrical contour

-No surgical incision

PEPTIC ULCER
 Manuel S. Enverga University Foundation
Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES

H. PATTERNS OF FUNCTIONING

FUNCTIONAL HEALTH BEFORE DURING INTERPRETATION

PATTERN HOSPITALIZATION HOSPITALIZATION

Health management pattern  Not hospitalized  First time The patient and the
hospital family was aware about
admission the condition of the
patient due to the first
time admission because
anemia secondary to
bleeding peptic ulcer
disease.

Nutritional / Metabolic

 Number of meals  3x a day  3x a day May at risk for

per day  Poor appetite  with good electrolyte imbalance
 Appetite appetite and malnutrition
 Glass of water per
day  4x a day
 Height and weight  1 glass a day
 5’2
 5’2
 55kgs
 Approximately
52kgs
Elimination

 Frequency of  5-6 x a day  3x a day Due to decreased intake,

urination output also decreased.
 Amount of urine
per day  1300 per day  800ml /day
 Frequency of
bowel movement
 Everyday  Every other day
Activity and exercise The patient gets easily
fatigue before and during
 Exercise  Walking  Walking confinement.
 Fatigability  Not easily  Easily fatigue
 Activities of Daily fatigue
Living  Walking /
cleaning the
house
Cognitive/ Perceptual  The patient is
 Oriented to time  Oriented oriented and
 Orientation place and person responds
 Responsiveness appropriately.

PEPTIC ULCER
 Manuel S. Enverga University Foundation
Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES

 Responds
appropriately to  Responds
verbal and appropriately
physical stimuli
Roles/ Relationship

 A good son  Became aloof to  Due to her sickness

 As a son  Kind his family the patient became
 As brother  Caring aloof may be because
of the financial burden
she have caused.

Values/Beliefs  Patient believes  Same as before  Patient is

in god and religious and
always pray. worships god.

Self Perception / Self  Have a high  Have a high self  Patient still has
Concept self worth / worth / high self worth
importance importance in spite of his
incident he still
think that life is
important that
should be lived
purposely.

Coping / stress  He seek for some  Patient is always  He has good

advice to her talking to her coping
family and family to lessen techniques.
friends the stress

PEPTIC ULCER