MCN Form 003

Lyceum of the Philippines University

College of Nursing

Name Mrs. Y. E Age 43

Diagnosis Pain on Posterior Right Lower Hospital No.
Quadrant
Ward/RM ED

CLINICAL APPRAISAL

History of
Present Health Patient had a sudden onset of pain on the posterior right lower quadrant of
Concern the abdomen. Patient prior to admission reported to have indicated a pain
scale of 10/10 but has receded to 5/10. Wound now has pus secretion and is
foul smelling in odor.

Past Health Patient stated that she had a prior case of questionable UTI back in early
History September. It was not confirmed, and patient is waiting on laboratory results
to determine possible relevance or clarification relating to current condition

Family History Upon interview, patient had not stated any persistent health history that may
relate to current condition.

Lifestyle and
Health
Practices

Lyceum of the Philippines University

 MCN Form 003

College of Nursing

Name Mrs. Y.E Age 43

Diagnosis Pain on Posterior Right Lower Quadrant Hospital No.
Ward/RM ED

CLINICAL APPRAISAL
Review of > Experienced posterior right lower quadrant pain
Systems for > Redness and swelling on wound site, with foul odor
Current Health > Abdomen is distended due to inflammation from initial wound site
Problem > Vital signs:
T: 35.8
BP:80/70 mmhg
O2 Sat.: 91 – 95%
CR: 107 bpm
RR: 27 bpm
> Patient’s lips are dry and dehydrated
> Patient with weak disposition
> Urine dark yellow in color

Developmental  Client is 43 years of age, at stage 7 of Erik Erickson’s model, under

Level Generativity-Stagnation. Patient has a relatively diminishing role in
society and functions more of in the household
MCN Form 003