NURSING HEALTH HISTORY:

A. BIOGRAPHICAL DATA:
This is the case of Mr.A , 23 yrs/old single, a Roman Catholic born march, 31, 1987 and
currently residing at Pajo, Meycauyan, Bulacan this is his first admission in Bulacan Medical
Hospital/BMC .

B. CHIEF COMPLAINT:
According to pt. 12 hrs prior to admission he experienced epigastric pain @ RLQ of his
abdomen.

C. HISTORY OF PRESENT ILLNESS:

12 Hours PTA client experienced , (+) epigastric pain @ LRQ of the abdomen, (+) Anorexia,
(+)vomiting, (+) fever and (+) Dysuria. And consult at a nearly clinic in meycauyan and was
referred to BMC.

D. PAST HEALTH HISTORY:

According to his mother he completed his vaccinations such as BCG,OPV, HEPA V ETC…
And had a childhood illness such as chicken pox, cough and colds, fever has no any allergies in
any foods and medications.

E. FAMILY HEALTH HISTORY:

Mother Father
(-) DM (-)DM
(-)HPN (-) HPN
(-) ASTHMA (-) ASTHMA

F. LIFESTYLE:
According to client they eat 3x a day he loves to eat seafoods , meat and chicken and eat
vegetables always. He is occasional drinker he does not smoke.

G. SOCIAL HISTORY:

Pt. is a roman catholic, he has an intimate relationship with his family. He work as a factory
worker in meycauyan, he eats 3x a day, he also helps his father in their every day expenses . client
sleep at 9pm and wakes up at 5am and start his work at 7am till 5pm.
 PHYSICAL EXAMINATION

I. General Appearance

The pt has small body frame with V/S of T= 36.6°C, RR = 22cpm, PR= 84 bpm, and

BP = 120/80. Has no body odor, was properly groomed and appropriately dressed. The

pt was conscious, oriented and cooperative.

Interpretation:

Findings are normal.

II. Skin:

The pt. has a brown skin color and smooth texture. Skin turgor is elasctic and

mobile, skin moisture is dry pt. has a impaired skin integrity on his abdomen due to

appendectomy.

Interpretation:

Findings are abnormal due to his operation.

III. Nails:

Nail plate curvature is convex 160°, smooth in texture, and a prompt return of

color as blanch test was performed.

Interpretation:

Normal

IV. Head:

Skull shape is normocephalic, proportionate to the body and has no lesions, and

masses upon palpation, facial movements are symmetrical, and facial features are

proportionate.

Interpretation:

Normal
V. Eyes:

Eyebrow is evenly distributed, eyelids close bilateraly. Eyelashes curled outward,

conjubctiva are moist, palpebral is pinkish while bulbar is white, eyes are symmetrical

and coordinated in movement.

Interpretation:

Findings are normal.

VI. Nose:

Nose color is proportion to her racial tone, septum is at the midline, both nares

have patent airways, and has no tenderness upon palpation of the sinuses.

Interpretation:

Normal

VII. Ears:

Color is proportion to her racial tone, auricles are symmetrical, has no hearing

difficulty and no discharges were present.

Interpretation:

Normal

VIII. Neck:

Lymph nodes are not palpable, neck size is proportionate to head and body, and

neck muscles are in good condition.

Interpretation:

Normal
IX. Chest and Lungs:

Thorax shape is AP lateral 1:2, lung expansion is normal, and vesicular sounds are

heard during auscultation of the lungs.

Interpretation:

Normal

X. Abdomen:

Abdomen is not distended, has a skin integrity due to operation, and color

is similar to the racial tone.

Interpretation:

Abnormal

XI. Upper and Lower extremities:

Arms and legs are symmetrical, movable, and no pain felt during movements.

Interpretation:

Normal

PERSON GORDON:
PSYCHOLOGICAL: ANALYSIS:

-The pt stated that he is just a simple -Self concept is one mental image of
person, happy and kind person. He dressed and oneself a positive self steam accdg to kozier
groomed himself properly the pt. lives with his self steam is ones judgment of one’s person
family they consider themselves as a nuclear perceive the size, appearance at functioning
family. Him and his father is the one who at the body parts
works for the family, and accrdg to him their
income is enough for the family -A family structure of parents and
their offspring’s is known as nuclear family but
in life style can also called. Fatigue there must
be a sufficient income to meet all the needs of
the family.
ELIMINATING:

-Before admission the client urinates -Patterns of defecation vary in

for 3x a day and defecates for 2 times a day but frequency quantity and consistency some
now during admission the client urinates once drugs have side effect that can interfere w/
a day and sometimes he has difficulty in bowel normal eliminating.
elimination.
REST AND ACTIVITY:

-Client stated that walking and playing -Rest implies calmness relaxation and
basketball before the occurrence of pain he without emotional stress (KOZIER)
felt, this is the exercise every morning of the -Physiological needs such as air, food,
client. Client sleeps at 9pm and wake up at water, shelter, rest, sleep, activity and
5am during week days. temperature maintenance is crucial for
survival (PILLITERI)
SAFE AND ENVIRONMENT:

-pt. has no allergies in any medications -Allergy is an immunologic response

and foods he has surgical incision at the when the pt. is exposed to foreign substance
abdomen. the body will react by producing antibodies.
(KOZIER P.769)
OXIGINATION:

-The pt. stated that he doesn’t have -Physiologic needs such as air, food,
any difficulty in breathing he doesn’t have water, shelter, rest, sleep, activity and
cough and colds that’s why he can breathe temperature maintenance are crucial for
easily. survival (PILLITERI)
NUTRITION:

-Pt. loves to eat seafood’s and meats -Physiologic needs such as air, food,
and vegetables sometimes eat fruits. water, shelter, rest, sleep, activity and
temperature maintenance are crucial for
24hours dietary recalled: survival (PILLITERI)

B: lugaw, milk, water

L: lugaw, juice, water

D: cup noodles, Gatorade, water

DESCRIPTION OF PROCEDURE:

-CBC is a series of test used to evaluate the composition and concentration of the cellular
components of blood it consists of the fallowing test RBC, WBC count and platelet count etc.

PURPOSE:
-The CBC provides valuable information about the blood and to some extent the bone marrow
w/c is the blood forming tissue. It used for the ff. purpose to identify persons who may have
infection.

-NURSING RESPONSIBILITIES:
-CBC requires a sample of blood collected from vein clean first the skin w/ a cotton ball moisten
w/ alcohol and the use of tourniquet and should be removed from the arm as soon blood flows.

HEMATOLOGY:

WBC: 14.4 11 10 9/L <3.5 – 10.0>

RBC: 4.66 10 12/L <3.80 – 5.80>
HGB: 132gl 1 <110 – 165>
HCT: .386 l/L <.350 - .500>
PLT: 292 10 9/L <150 – 390>
PCT: .219 10 -21/L <.100 - .500>

MCR: 83 +1 <80 – 97>

MCH: 28.4pg <26.5 – 33.5>
MCHC: 342 g/L <315 – 350>
KDW: 13.0 m/n <10.0 – 18.0>
MPV: 7.5 +1 <6.5 – 11.0>
PDW: 12.7 – 1 <10.0 – 18.0>

WBC FLAGS: 6 . t2
Ditti:
LYM: 17.3 l/0 <17.0 – 48.0>
MON: 5.2 l/0 <4.0 – 16.0>
GRA: 77.5 lt l/0 <43.0 – 76.0>

# LYM: 2.4 10 9/l <1.2 – 3.2>

#MON: 0.7 10 9/l <0.3 – 0.8>
#GRA: 11.3 + 1 10 <1.2 – 6.8>
 PATHOPHISIOLOGY

PRE DISPOSING FACTORS PRECIPITATING FACTOR

-AGE -DIET
-SEX

OCCULATION OF FECALITH, TUMOR OR FOREIGNBODY

AND BACTERIAL INVASION

INTRA LUMINAR OBSTRUCTION

VASCULAR CONSTRUCTION AND I INTRALUMINAL PRESSURE

INCREASED BACTERIAL GROWTH

INFLAMMATION
PRIORITIZE NURSING PROBLEMS:

CUES NURSING DX. JUSTIFICATIONS

S: “sumasakit ang tahi ko sa tyan”
as stated by the client  Acute pain R/T surgical  This is nsg. Dx should be
incision. given a high priority bec.
O: pain scale of 7 out of 10 It can affect the normal
 With Facial grimace. activity of pt. and can
 With muscle guards. became a precipitating
 With limited range of factors can lead to other
motion. complications.

S: O  Risk for infection R/T  This actual problem

O: surgical incision. needs an immediate
 Presence of surgical attention bec. These is a
incision. risk of infection any time
 Unchanged dressing. in the skin natural barrier
to infection because it is
open.

S:
 “Medyo masakit yung  Impaired skin integrity 
tahi ko” as stated by the R/T non intact skin.
client.
O:
 Incision on the abdomen
RLQ.
 Disruption of skin surface.
 With facial grimace.
 With intact dressing.
 Guarding behavior.
M:
 CEFUROXIME 750mg / CAP q8 PO X 7days
 METRONIDAZOLE 500mg / tab T.I.D X 7days
 CELECOXIB 250mg / CAP Bid

E:
 RELAXATION TECHNIQUES
 BRISK WALKING

T:

H:
 PROPER WOUND CARE/DRESSING
 HAND WASHING
 DEEP BREATHING

O:
 FEB.23, 2011 @ OPD

D:
 SOFT DIET INSTRUCTED
D5LR

INDICATIONS NURSING RESPONSIBILITIES

 TO STABLISH A LIFE LINE FOR RAPIDLY  IDENTIFY THE PT.

NEEDED.

 ASSESS FOR REDNESS AND

INFLAMMATION.
 TO PROVIDE WATER SOLUBLE VITAMINS
AND MEDICATIONS.

 CHECK FOR INFLAMMATION AND

PLEBITIS.

 TO PROVIDE SALTS NEEDED TO MAINTAIN

ELECTROLYTE BALANCE.
 DURING IV INFUSION THE NURSE SHOULD
SEE TO IT IS BEING ADMINISTERED THE
PROPER RATE OR FLOW.

 TOPROVIDE WATERSOLUBLE GLUCOSE

MAIN FOOD FOR METABOLISM.
 STRICT ASEPTIC TECHNIQUES BE
OBSERVED LIKE HAND WASHING.

 TO SUPPLY FLUIDS WHEN CLIENTS ARE

UNABLE TO TAKE IN AN ADEQUATE
VOLUME OF FLUIDS BY MOUTH.