PATIENT PROFILE

DEMOGRAPHIC DATA

Patient Name :

Sex and Age :

Date of Birth :

Place of Birth :

Permanent Address :

Nationality :

Religion :

Educational Attainment :

Occupation :

Health :

Government Financing :

Spouse :

Father Mother

Name/Age

Address

Languages

Occupation

Marital Status

Educational Level

ADMISSION DATE & TIME :

CHIEF COMPLAINT :

ADMITTING DIAGNOSIS :

FINAL DIAGNOSIS :

NURSING HEALTH HISTORY

PAST MEDICAL HISTORY

FAMILY HISTORY

PSYCHOSOCIAL HISTORY
GORDONS TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS

HEALTH PERCEPTION AND HEALTH MANAGEMENT

NUTRITIONAL – METABOLIC PATTERN

ELIMINATION – EXCRETION PATTERN

ACTIVITY – EXERCISE PATTERN

SLEEP – REST PATTERN

COGNITIVE – PERCEPTUAL PATTERN

SELF-PERCEPTION – SELF-CONCEPT PATTERN

ROLE – RELATIONSHIP PATTERN

SEXUALITY – REPRODUCTIVE PATTERN

COPING AND STRESS TOLERANCE

VALUE AND BELIEF PATTERN

VITAL SIGNS MONITORING

DECEMBER 6, 2021 DECEMBER 7, 2021

Vital Signs
9:00AM 1:00PM 9:00AM 1:00PM
Temperature 36.5°C 36.6°C 36.4°C 36.3°C
Pule Rate 80 bpm 79 bpm 78 bpm 81 bpm
Respiratory Rate 16 cpm 17 cpm 16 cpm 15 cpm
Blood Pressure 100/70 100/80 90/70 90/70
Oxygen Saturation 96% 97% 97% 96%

REVIEW OF SYSTEMS

CATEGORY FINDINGS
General Appearance Conscious, coherent and aware of surroundings. Thin physique,
dressed appropriately. Facial grimace of abdominal pain.
Head, Eyes, Ears, Nose, Throat Symmetrical. No visual loss, trauma, inflammation. No deafness,
discharge or pain noted. No nasal obstruction nor epistaxis. No
oral sores, bleeding nor abnormal taste reported.
Neck No significant abnormalities noted.
 Chest & Lungs Clear airway, no dyspnea or other significant abnormalities.
Oxygen saturation at 96%.
Cardiovascular Blood pressure slightly lowered. Pulses are of equal strength and
rhythm. No other significant abnormalities noted.
Abdomen Soft abdomen, no tenderness. Slight distension noted.
Hypogastric bowel sounds.
Genitourinary No significant abnormalities noted.
Rectal Reported constipation and straining upon defecation. Presence of
rectal mass, 3-4cm from the anal verge.
Musculoskeletal No arthritis, arthralgia, joint stiffness, swelling nor pain noted. No
other significant abnormalities noted.
Lymph Nodes No swelling, node enlargement or tenderness observed.
Extremities/Skin No edema, no pallor, no pruritus, capillary refill time less than 2
seconds.
Neurological No neurological deficit noted.
Others No significant abnormalities noted.

LABORATORY AND DIAGNOSTIC EXAMS

DATE DIAGNOSTIC/ RESULT CLINICAL IMPLICATION

LABORATORY TEST

11/18/21 Abdominal X-ray  Presence Rectal mass causing obstruction of gastrointestinal

of Rectal tract. Diagnoses intestinal obstruction and acute
Mass abdominal pain of unknown origin.
 Hard,
11cm mass
 3-4cm
From the Anal
Verge
 80%
obstruction 



DRUG STUDY

DRUG NAME CLASSIFICATION MECHANISM OF INDICATIONS CONTRAINDICATION ADVERSE NURSING RESPINSIBILITIES

ACTION S EFFECTS
DRUGY STUDY

DRUG NAME CLASSIFICATION MECHANISM OF INDICATIONS CONTRAINDICATION ADVERSE NURSING RESPINSIBILITIES

ACTION S EFFECTS
DRUG STUDY

DRUG NAME CLASSIFICATION MECHANISM OF INDICATIONS CONTRAINDICATION ADVERSE NURSING RESPINSIBILITIES

ACTION S EFFECTS
DRUG STUDY

DRUG NAME CLASSIFICATION MECHANISM OF INDICATIONS CONTRAINDICATION ADVERSE NURSING RESPINSIBILITIES

ACTION S EFFECTS
NURSING CARE PLAN

CUES NSG DIAGNOSIS RATIONALE OBJECTIVES INTERVENTION RATIONALE EVALUATION

NURSING CARE PLAN

CUES NSG DIAGNOSIS RATIONALE OBJECTIVES INTERVENTION RATIONALE EVALUATION

NURSING CARE PLAN

CUES NSG DIAGNOSIS RATIONALE OBJECTIVES INTERVENTION RATIONALE EVALUATION

 JOURNAL RELATED TO CASE

1. DORON (POST OP: TOTAL THYROIDECTOMY)

2. APRON (POST OP: NEPHRECTOMY)

 DONA REMEDIOS TRINIDAD MEDICAL FOUNDATION

CALANIPAWAN ROAD, TACLOBAN CITY, LEYTE

1ST SEMESTER, S.Y. 2021-2022

DUTY
REQUIREMENTS
EVRMC, MAIN BUILDING,
SURGICAL WARD 2

SUBMITTED BY:
MIKAELLA SALDANA
CLINICAL GROUP B
BSN 4 -C

SUBMITTED TO:
MRS. EVELYN YU RANCES, MAN, RN
RTRMF-CN-CI