PERSONAL DATA

Name: Mr.Constantino H. Maliwat Age: 66y/o Sex: Male Civil Status: Married
Address: Lawak, Tayug, Pangasinan
Occupation: Tricycle driver
Date of Admission: January 7, 2015 @ 7:45pm
CHIEF COMPLAINTS: flank pain @ RLQ
DIAGNOSIS: Admitting diagnosis- Renal Abscess. Final diagnosis- Sigmoid Polyps, Internal
Hemorrhoids; Nephrolithiasis, non-surgical abdomen

HEALTH HISTORY
A. History of present illness
Mr. Maliwat was diagnosed to have Sigmoid Polyps, Internal Hemorrhoids
B. History of past illness/Surgeries
Mr. Maliwat was diagnosed before with Nephrolithiasis and Hypertension
C. Family health history
Mr. Maliwat has a history of Hypertension in the family, because his father and
grandparents has Hypertension
DEVELOPMENTAL DATA
Based on Havighursts age periods and developmental tasks, the patient is at the period of
middle age and the developmental tasks include:
1.
2.
3.
4.
5.
6.
7.

Achieving adult civic and social responsibility

Establishing and maintaining an economic standard of living
Assisting teenage children to become responsible and happy adults
Developing adult leisure-time activities
Relating oneself to ones spouse as a person
Accepting and adjusting to the physiologic changes of middle age
Adjusting to aging parents

Based on Erik Ericksons stages of development, the patient belongs to maturity stage, where the
central task is integrity versus despair. He accepts the worth and uniqueness of ones own life and give
importance of his own.
ASSESSMENT
PATHOPHYSIOLOGY OF PRESENT ILLNESS
Sigmoid Polyps
MEDICAL TREATMENT AND MANAGEMENT INCLUDING PROCEDURES AND ITS
IMPLICATION TO NURSING
Radiologic/Ultrasound Report
Conclusion: Nephrolithiasis, right, with perinephric fluid collection probably abscess
CBC result
WBC: 3.02 Normal: 5.0-10.0 x 109 /L
RBC: 2.56 Normal: 4.69-6.13 x 1012 /L
Lower GI Endoscopy
Anus

ENGORGED VESSELS ABOVE THE DENTATE LINE WITH NO

Sigmoid
Ascending colon

ACTIVE BLEEDING
A 5MM POLYP WAS SEEN 20 CMS FAV, REMOVED BY COLD BIOPSY
FORCEPS
COPIOUS FECAL MATERIAL SEEN OBSCURING ADEQUATE VIEW
OF MUCOSA UNDERNEATH

EVALUATION AND IMPLICATION OF THIS STUDY to:

A. Nursing Practice
This case study will help other health care provider when it comes to management, treatment
and different interventions. This will give an additional knowledge in dealing with patient.
B. Nursing Education
This study will provide the needed information, health educators can share his/her patient and
to other people in the community or hospital. This can also serve as a guide and basis of other
health care provider during intervention.
C. Nursing Research
It is used as a basis knowing the different things related to patients condition like
pathophysiology of such, how it is acquired, procedures and surgeries to be done, and the
different management used.
REFERRAL AND FOLLOW-UP
Mr. Maliwat was discharged last January 20,2015, and he was instructed to come back for followup check up on January 28,2015.

PINES CITY COLLEGES

Magsaysay Avenue, Baguio City
College of Nursing

Case study
(SIGMOID POLYPS)

Pacheco, Charmaine T.
BSN VI 1
Group A

Mr. Vincent Gattud

Clinical Instructor