I.

Biographic Data

Name: Ms. Liwanag, Ligaya Magtoto

Address: Saint Joseph, Barax2, Caloocan City
Age: 43
Gender: Female
Religion: Roman Catholic
Marital Status: Single
Occupation: None
Room and Bed#: 343A
Chief Complaint: Abdominal Pain
Attending Physician: Dr. Edgardo Fajardo

II. Nursing History

A.Past Health history

- The patient is non-diabetic, non-hypertensive, and non-asthmatic.
Allergic to an unrecalled dye. She had undergone Myomectomy on De Los
Santos Hospital, no untoward reaction occurred and no blood transfusion
was made.

B. History of Present Illness

- The history of present illness started 1 day prior to admission when
the patient experience hypogastric pain, colicky in character with a pain
scale of 10/10, non-radiated associated with non projectile vomiting, non
bloody streaked, non bilous, more than 5 episodes, and loose watery stool
for more than five times. No associated signs and symptoms like fever,
dysuria, change of color, difficulty of breathing. The patient took
Metoclopramide (Plasil) unrecalled dosage and frequency and Loperamide
500mg with afforded no relief. Due to persistence of the above signs and
symptoms, the patient sought consult at our institution and was
subsequently admitted.

B.Family History
(+) Cardiovascular Disease
(+) Cancer
(+) Hypertension
(+) Stroke
(+) Thyroid Disease
(+)Asthma
(+) Renal Disease
(+) Diabetes
(-) Alcoholism
(-) Psychiatric Disease
(-) Arthritis
 III.Activities of daily Living
Gordon’s Before During Analysis
Functional Health Hospitalization Hospitalization
Patterns
Health perception- The patient was The patient started Acknowledges
health management unable to cope with to take responsibility
pattern her health condition for meeting her
basic health needs.
Nutritional- The patient is able The patient was in a
Metabolic Pattern to digest and absorb BRAT diet and 1 day
food. NPO for her
abdominal X-ray.
Still she can digest
and absorb food.
Elimination Pattern The patient always The patient is
urinates always nauseated
and can’t defecate
because of the
abdominal pain.
Activity –Exercise The patient was The patient is
pattern unable to maintain ambulatory
usual routines of
physical activity
Sleep-Rest pattern The patient sleeps The patient sleeps
normally well
Cognitive- The patient The patient lessens
Perceptual pattern experiences the pain in the
abdominal cramping abdomen
and pain
Self-Perception-Self- The patient is The patient is less
Concept Pattern anxious and anxious and more
worrisome. relaxed
Role-Relationship The patient has her The patient was able
Pattern niece and relatives to communicate her
beside her feelings with her
family members
Sexuality- The patient is The patient doesn’t
Reproductive inactive in sexual want to engage in
relations sexual intercourse
Coping-Stress The patient was able The patient was able
tolerance to seek help from to seek help from
her relatives her relatives and the
medical team
Value-Belief Pattern The patient prays The patient prays
occasionally more often
 IV.Physical Assessment

BODY PARTS METHOD FINDINGS INTERPRETATION

HEAD Inspection Normocephalic Normal

Hair Inspection Black in color Normal

Scalp Inspection No lesion and no Normal

deformities

Skull Inspection Round Normal

Face Inspection Symmetrical, brown Normal

in color
Palpation
Rough

EYES

Eyebrows Inspection Symmetrically alignedNormal

Eyeball Inspection Coordinate eye Normal

Movement

Ocular Muscles Inspection Eyes can follow Normal

movements

Pupil Inspection Constrict and equally Normal

round and reactive to
light accomodation

Sclera Inspection Whitish Normal

Vision Inspection Can see clearly Normal

EARS

Pinna and Ear Inspection Brown in color Normal

cannal
Palpation Recoils and return to Normal
original shape when
folded

External cannal Inspection Clear Normal

NOSE
External nose Inspection Symmetric Normal

Palpation Air equally pass in Normal

and out of the two
nasal openings

MOUTH

Lips Inspection Moist and pink in Normal

color

Tongue Inspection Pinkish Normal

Teeth Inspection Yellowish in color Normal

NECK Palpation No palpable mass Normal

Palpable Carotid Normal

Pulse

SKIN Inspection No lesion Normal

Palpation Dark brown in Normal

complexion

THORAX AND LUNGS Inspection Symmetrical Anterior Normal

and Posterior
Auscultation Normal
No cracles, no
Wheezes Normal

Clear lung field

ABDOMEN Inspection No scar or any Normal

Present of Rashes
Palpation Normal
(-) tenderness
Auscultation Normal
(-) abdominal pain
Normal
Active Bowel sounds

UPPER EXTREMITIES Inspection Length is appropriate Normal

to the body and are
symmetrical D/t Aging

Slightly wrinkled,
Saggy skin

LOWER Inspection Length are Normal

appropriate in the
EXTREMITIES body and symmetrical

NAIL Inspection Trimmed finger and Normal

toe Nails

NAIL BED Palpation Capillary refill is 3 Normal

seconds