1

III. PATIENT’S DATA

Patient Code Name: Patient B

Age: 18 yrs. Old

Nationality: Filipino

Civil Status: Single

Occupation: Student

Sex: Male

Religion: Roman Catholic

Ward and Room Number: Nursing Station 1

Date of Admission: November 28, 2023

Vital Signs During Admission:

Blood Pressure: 110/80 mmHg Temperature: 36.2℃

Pulse Rate: 120 bpm Respiratory Rate: 30 bpm

O2Sat: 89% Weight: 48 kg

Height: 5’6

Date of Discharge: December 2, 2023

Chief Complaint: Ineffective breathing pattern, redness skin and itching

Admitting Diagnosis: Allergic Reaction to foods

Attending Physician(s): Dr. Torres

 2

IV. FAMILY BACKGROUND

Grandmother
(Mother side)
Grandfather - with hypertension
(Father side) and food allergy
- with hypertension

Patient Father Patient Mother

- with hypertension - with allergic
food reaction

Patient Brother
- with allergic
PATIENT food reaction

- with allergic food reaction

Family health history

As we all asset the patient all the information, data, and sources that we used to assess
the patient’s condition were directly received from the patient’s own health history and
the health histories of his family members.
Patient b verbalized when he was 16 years old he used to eat a lot of different foods
especially those chocolates and carbonated drinks as teenager he is very active in
playing outside games one day when he got invited by his friend to a birthday party he
got fascinated of a large amount of foods and one dish got his attention that was his first
encountered of creamy garlic shrimp he ate a lot and that was his first food allergic
reaction triggered he suffered from mouth and throat itching, lip swelling and skin
reactions, such as hives, puffy eyes and skin redness, difficulty of breathing he said he
 3

almost died when that happened he was carried to the emergency department where he
injected epinephrin. As he getting to puberty according to patient B he avoided eating
shrimps and other certain foods that can make his allergy trigger as well as by advised
of his doctor to prevent such life threatening experience. According to patient b his
family members has also allergies his grandparents has hypertension where his
grandmother on his mother’s side has an allergy on peanut and other certain foods
patient B knows that his family members including his mother and siblings has an food
allergy history, he said that his mother used to be strict when it comes to cleaning the
house and preparing of foods he also stated that his mother was so over protective on
them, she was a house wife patient b said that his mother has an allergy to certain
foods he can still fathom the moment when his mother accidently eat a peanut butter
she was suffered that time from skin reactions, nausea and vomiting he remembered
that his mother has prescribed medication which is palforzia where she used to intake
every time her food allergy triggers. Patient’s other siblings his older sister has also
allergy like his mother and his younger brother who still in elementary can be seen also
of allergies his father was the only member of the family that has no allergy his father
job was engineer.
Patient B knows that he is allergy on a certain food when he got invited to a
thanksgiving party because they are just graduated from senior high where he
graduated with a flying color, he was smart and sporty he loves playing football and
online games. When the foods has been served there was a certain dish where he has
a trauma but his intrusive thoughts to try again the foods because according to him he
cannot remember the taste so at first he gets one of shrimp and then he enjoyed until
he cannot notice that he has been eating too much and then his allergy trigger abruptly
he was sent to er department where he suffered from mouth and throat itching, difficulty
of breathing, lip swelling and skin reactions, such as hives, puffy eyes and skin redness.

Effects/Expectations of Illness to self/family:

The patient was identified as having an Allergic reaction in eating shrimp. Which
resulted in signs and symptoms of difficulty of breathing and skin redness sudden
 4

itching, lip swelling, watery eye, skin reaction, such as hives, and skin redness The
patient's rushes caused her to become itching. The patient needs continuing medical
care, including expensive and time-consuming procedures, medication, and regular
checks for breathing pattern and redness of skin. The patient also experienced
psychological and emotional effects such as distress, and anxiety because, according to
the patient, he’s afraid if his condition can be treated or not. According to the patient, his
family is concerned about his health condition, which is why they monitor his condition
from time to time for them to know if it is normal or above normal.

The patient's family claims that they are concerned about their patient's health
because food allergic reaction is easy to treat because as in the mother side of the
patient they have a food allergies as they inherited to their grandparents as a result,
they have concentrated treatment to the breathing pattern of the patient as they
verbalized it doesn't matter if they spend a lot of time and money as long as they can
guarantee that their patient will recover from this illness. The patient, on the other hand,
believes that he will be able to beat this sickness if he listens to his doctor's advice and
takes his family's support. The patient believes that he can recover because she is
taking medication, lessen what nurse advice and that various therapies are being
offered to treat his allergies. The patient adds that he will maintain a healthy lifestyle
and refuse to eat allergies food to ensure a full recovery.

Family members also have confidence in their patient's ability to heal because
they have seen them follow instructions, and they also have a genuine belief that their
loved one will be able to do so because he is making efforts to fully recover on her own.
To supply the patient with all they require, all they as a family need to do is continue to
assist them. This support can take the form of helping with everyday tasks, providing
prescriptions, and the doctor's needed medication.

Client’s Health History

Past Health History

 5

The patient had been identified as having an allergic reaction to food when he
was 16 years old, back in 2021. The doctor then gave him advice on how to treat on
food allergic live a healthy lifestyle, including eating healthier meals, avoid allergic food,
and cutting back on restricted seafoods. Despite having these problems diagnosed, the
patient chose to disregard the results and carry on with his unhealthy lifestyle habits,
continuing to work because she wasn't experiencing any strange symptoms at the time.
Even though the patient had signs of allergies, such as eating a lot of allergic food and
restricted favorite see food. The patient was unable to keep track of his trigger on
craving allergic food at the same time, and he wasn't taking any medications to keep it
there.

Present Illness/es

The patient's chief complains ineffective breathing pattern, redness skin and
itching which has become unbearable and prompted the decision to seek medical
attention at the hospital. Patient experiences the signs and symptoms of allergic
reaction such as difficulty of breathing, readiness, and swelling where from time to time
she feels the itching in her entire part of his body. Every time he has difficulty in
breathing his mother assisted her because of the worries situation he has now. The
patient also manifested that he experienced scratching from time to time, wherein his
mother, who is the watcher, sustains him by refusing to scratching the inching body and
the mother are there to make the patient irritated and calm as the patient has a watery
eye on her face. The patient also pointed out that he did not experience any difficulty of
breathing before prior from his allergy reaction he was not aware that his condition has
gotten worse.
 6

VII. PHYSICAL ASSESSMENT

Personal Data

Patient B is 18 years old male admitted on November 28, 2023 with a chief
complaint of Ineffective breathing pattern, redness skin and itching

General Survey

Received patient on bed coherence with ongoing IVF PLNSS 1L 100cc/hr on

right metacarpal vein infusing well not in respiratory distress (+) redness

Vital signs

-Temperature: 36.2℃ -RR: 30 cpm

-B/P: 110/80 mmHg -O2Sat: 89 %

-PR: 120 bpm -Weight: 48 kg -Height: 4’11

Appearance of the patient: Patient appeared weak due to classical manifestations

such as difficulty of breathing

Skin: The patient's entire body has a reediness, dry skin and pallor was noted.

Hair: His hair appears to be in black and curly. No signs of redness

Face: The patient's face is round with asymmetrical, and grimace noted.

Eyes and Vision: Eyebrows are symmetrically aligned. Upon inspection corrective
lenses, pupils are equal, reactive to light and in accommodation. Patient’s visual acuity
appeared weak due to his state.
 7

Ears and hearing: Upon inspection, ears are symmetrically aligned with each other,
and are aligned with the outer canthus of each eye. No unusual discharge noted.
Patient is cooperative when hearing questions.

Nose: Upon inspection, the patient’s nose is refined shaped.

Mouth: The patient's outer lips were noted to be dry.

Neck: (-) lymphadenopathy (LAD). No masses, lesions or any unusuality were noted.
Shoulder muscles had symmetry from an anatomical perspective.

Chest: Clear to auscultation

Nails: The fingertips and toe of the patient appears pink. Epidermis surrounding the
nails was intact and trimmed no lesion were noted.

Abdomen: The abdomen is gentle, non-tender, and uncongested. No scars or lesions

can be seen.

Extremities: Extremities appeared without tenderness or deformity and no swelling or

edema. Full range of motion is noted to all joints.