Professional Documents
Culture Documents
Assessment
A.
Biographical Profile
Name: AbBa
Address: Swa-on, Kapalong Davao Del Norte
Age: 53 years old
Date of Birth: January 01, 1960
Date of Place: Kapalong, Davao Del Norte
Gender: Male
Status: Single
Nationality: Filipino
Religion: Roman Catholic
Date of Admission: June 24, 2013
Time of Admission: 6:30 pm
Initial Diagnosis: Acute Appendicitis
Final Diagnosis: Acute Appendicitis
Attending Physician: Dr. Kharidz B. Macasayan, MD.
B.
CHIEF COMPLAINT
right lower quadrant. These prompted her to seek medical advice, thus confined in
Davao Regional Hospital last June 24, 2013 with the admitting diagnosis of Acute
Appendicitis under the service of Dr. Kharidz B. Macasayon, MD. Her medications were
Cefoxitin, Metronidazol. Paracetamol, Tramadol and Ranitidine.
D.
Normal Vagina Spontaneous Delivery. The patient was completely immunized. He was
never admitted to a hospital but he experienced common illness such as cough and
colds. She occasionally drinks liquors and used cigarettes. Her usual diet includes food
that are He prefers meat products in her meal than leafy vegetables.
E.
Personal History:
Smoker
( )
Alcohol drinker
( )
Family History
Smoker
() Fathers side
Alcohol Drinker
Asthma
()
Hypertension
() Mother side
DM
( )Father side
Malignancy
()
Tuberculosis
( )Grand-grandmother side
Heart problem
()
Social History
High School Level
F.
PHYSICAL ASSESSMENT
General Survey
Received lying on bed conscious, responsive and coherent. Fairly groomed. With
clean and intact top dressing at right lower quadrant. With IVF #4 PNSS 1L infusing
well at the right dorsal metacarpal vein regulated at 30 gtts/min. On NPO. Capillary
refill of 2 sec.
Genearal Appearance at First Sight
Received sitting on bed awake, responsive and coherent. With an IVF #3D5LR 1L
infusing well at the right dorsal metacarpal vein regulated at 80 cc/ . Patient has a
mesomorphic type of body built and weighs 54.5 kilograms and stands 54 tall. The
patient was certainly oriented to time, place and persons. She was able to deal with her
emotions appropriately as the interview went on. Wearing a cotton T-shirt and jogging
pants, patient looked neat and tidy..
Vital Signs
Date
Shift
Time
CR
PR
RR
BP
Temp.
06-26-13
7-3
8:00am
89
88
18
129/83
37.4
12:00pm 90
92
19
130/80
37.0
Skin
Brown skin generally uniform in color in areas except in areas exposed in the sun
No jaundice
Head
No infestations
Eyes
No discharges
When looking straight ahead, the client can see objects in the periphery
Ears
Symmetrically aligned
No lesions or discoloration
Nose
Neck
No tenderness
Symmetrical neck
Chest
Firm
No tenderness
Cardiovascular
BP 129/83
PR 88
Respiratory/Chest
Chest symmetric
Respiratory rate 18
Gastrointestinal/Abdomen
Globular
No splenomegaly
No hepatomegaly
Soft
Tympanic
No tenderness
GenitoUrinary
Musculoskeletal/Extremities
No tenderness
Neurologic
Oriented
Conscious
Coherent
Normal heart sound may heard upon auscultation and no chest pain noted; normal
rhythm
Capillary refill: Good capillary refill in 2sec.
Prenatal: N/A
Menarche: N/A
VII- Stimulation-Activity
Work: Farmer
Recreation/Pastime: Watching TV, Planting flowers in their backyard
Hobbies/vices:
Previous hobbies are smoking, drinking and planting
SAFETY-SECURITY NEED
Neuro V/S: Conscious, responsive and alive.
Mental Status
The patient is coherent, responsive and able to cooperate as we conduct the
assessment.
Emotional problem: Patient does not feel much safe and secure in terms of his
condition because of the complications that may arise, but he feels safe and secure in
terms of his expectations to his family who are taking care of him.
LOVE-BELONGING NEED
Children (living with ;) NONE
Husband (living with ;) NONE
SELF-ESTEEEM NEED
Patient was to socialized to his family members with confidence of functioning in his life.
Present medical condition affects the said role but compensation in many ways still
realized.
SELF-ACTUALIZATION NEED
He thinks positively and entrusted to God all his worries. He feels accepted by his
family.
Nurses
Nurses Intervention
Assessment
01-30 & 31/ 2013
Initial Assessment
(7-3)
Medical
Management
Doctors order
Poor hygiene
Administer antibiotic
to increase fluid
as ordered. Water
intake
therapy.
Encourage the
patient to have a
a day as ordered.
Provide health
ability to transmit
teaching
virus to others.
Elevated Blood
Place patient in
Administer
Pressure 140/70
MHBR
antihypertensive
drugs as ordered.