Name Kaycelyn A.

Jimenez Date March 3, 2021

Group BSN 3B-2A Name of CI Christopher Ian Gaerlan

I. Patient Profile
Name Patient X
Age 43
Gender Female
Address Manila City
Civil Status Married
Nationality Filipino
Occupation Not applicable
Religion Iglesia ni Cristo
Date of Admission October 18, 2020
Time of Admission 8:00 am
Ward Surgery Ward
Bed No. 5
Admitting Dx Acute cholecystitis with cholelithiasis
Chief Complaints Abdominal pain, fever

II. Mental and Emotional Status

Patient X is conscious, coherent, febrile, and not in cardiopulmonary distress. Upon
assessment, she is responsive to verbal, noise, light, touch and pain stimuli. She specifically
complains of abdominal pain for the past 3 days. She recalls a past history of similar pain, but has
never had any diagnostic workup. She has a Glasgow coma scale score of GCS15(E4V5M6). She
speaks and acts according to her age. The patient is at the Formal Operational Stage or the final
stage of cognitive development of an individual according to Jean Piaget’s Four Developmental
Stages. She is able to use symbols to relate to abstract concepts.
III. Psychological Status
Patient X is a 43-year old, female, married and a Filipina. She is living from Manical City
and unemployed. She neither drinks alcohol nor smokes, or even using of drugs. She is Iglesia ni
Cristo and has no practices or beliefs which might affect in providing health care. She has a past
medical history of significant hypertension and hypercholesterolemia. She is status post a total
abdominal hysterectomy 1 year ago. She is under the seventh stage of Erik Erikson’s Theory of
Psychosocial Development; Generativity versus Stagnation. This stage takes place during middle
adulthood between the ages of approximately 40 and 65 years old.
IV. Environmental Status
Mrs. X is admitted at Bed no. 5- Surgery ward. The area is clean, well ventilated, quiet
environment, and has proper lighting. The bedside table is located on the left side of the bed and is
easily accessible within hands reach. The side rails of the bed are pulled up and the level of the bed
is lowered down.

V. Nutritional Status
Prior to hospitalization, Mrs. X notes that her last meal last night was causing her epigastric
pain that was markedly became worse. Her physical exam reveals an overweight woman and has no
known food allergies. During her hospitalization, she is currently on DAT. The food of Mrs. X is
being served in the hospital. Food serve are usually vegetables, fish, and sometimes meat. She eats
her meals on time. She was able to swallow her food and medications as well and can eat by
herself. There is no culture or religious dietary restrictions reported by the patient herself.

VI. Integumentary Status

 Patient X’s skin is warm to touch, no pallor, no cyanosis, jaundice and no rashes upon
inspection. No edema was noted. Eyes assessment revealed anicteric sclerae, and pink palpebral
conjunctivae. Nose inspection shows no nasoaural discharge, no sinus tenderness, pink nasal
turbinate, and patient has moist lips and oral mucosa is intact. Supple neck, no cervical
lymphadenopathies, and no neck vein engorgement were noted upon neck assessment.

VII. Temperature
Baseline data prior to admission was T: 100.6. During shift endorsement her temperature
was 38.5oC. Her ROS is positive for abdominal pain, nausea, one episode of vomiting, and has
subjective fever.

VIII. Fluids and Electrolytes

PNSS 1L x 12 hours was being infused to patient X. The current level was at 450ml. She
has moist lips and oral mucosal. She is currently on Diet as Tolerated and with four medications
namely Metronidazole 500mg IV q 6 o, Ceftriaxone 2g IV OD, Ketorolac 30mg IV q 60 RTC, and
Tramadol 50mg IV q 80 RTC.

IX. Circulatory Status

Her Baseline Vital Signs are BP 155/90, HR 110. Her chest and cardiovascular exams are
normal except for mild tachycardia. Upon endorsement her BP was 140/90, and PR was 85 bpm
which significantly lowered down but still considered elevated. Upon assessment, pulse rate is
normal rate, regular rhythm. Auscultation of the heart reveals PMI at 5th ICL MCL, no heaves, no
thrills, no murmurs, and tachycardic.

X. Respiratory Status
Baseline data of patient X’s RR is14, SpO2 98%. Patient was hooked to O2 at 2L/min via
Nasal Cannula. During the endorsement shift her latest vital signs were RR – 24 cpm, SpO2 – 90%
in room air. Symmetrical chest wall expansion, no retractions, no wheezes was noted. Basal rales
heard over the left lung more than the right upon auscultation.

XI. Elimination Status

Urinalysis came out with yellow appearance, slightly turbid, pH reaction of 6.6, and 1.025
in specific gravity. Microscopic examination of the urine showed 7-10/HPF in WBC, 0-2/HPF in
RBC, Mucous treads showed in moderate/LPF, and with significantly many bacteria was found.

XII. Motor Status

GCS: 15(E4V5M6), Upon assessment of the Cranial Nerves, the findings revealed alert and
oriented to 3 spheres, (-) dysarthria, (-) aphasia, able to smell, no visual field defects, pupils equally
reactive to light, intact EOM, no preferential gaze, (+) corneal reflex, (+) sensation over the face,
(+) facial asymmetry, (+)intact muscle facial expression, able to hear sounds, (+) gag reflex, moves
head side to side against resistance, tongue at midline. Her motor grade is 5/5 right upper extremity.

XIII. Sensory Status

Her abdominal exam is significant for tenderness to palpation to her epigastric and right
upper quadrants without rebound tenderness. Bowel sounds are normal. Flabby, non-distended,
normoactive bowel sounds, no abdominal aortic bruits, tympanic, non-tender on all
quadrants, for tenderness to palpation to her epigastric and right upper quadrants without
rebound tenderness

XIV. Comfort and Rest Status

Patient claims that normally she sleeps six to eight hours a day. However, she has difficulty
on sleeping due to the pain on her abdomen that localizes to her epigastric area and states that it
radiates to her right upper quadrant. She only sleeps four to five during hospitalization due to her
condition and for medication administration. Pain scale of 9/10 is documented as verbalized by the
patient.