I.

DEMOGRAPHIC DATA

Name of the Patient :RGA

Age :49 years old

Gender :Female

Home Address :Brgy. Cabawa, Dapa, Surigao del Norte

Birthdate :August 21, 1968

Birthplace :Dapa, Surigao del Norte

Civil Status :Married

Religion :Catholic

Nationality :Filipino

Chief Complaint :Hypogastric Pain, Vaginal Bleeding

Admitting Diagnosis :Ovarian New Growth

Post-Operation Diagnosis :Primary Peritonitis, Ascites

Admission Date and Time :October 26, 2017 / 10:13am

Attending Physician :Dra. Christia Lyn Mantilla

PHYSICAL ASSESSMENT

APPEARANCE AND MENTAL STATUS

REMARKS/
PART NORMAL OBSERVATION SIGNIFICANCE
Body build, height, Proportionate, varies with Height:5’3 Normal
and weight, in lifestyle Weight:50 kg
relation to clients Age:49 years old
age, lifestyle and
health
Posture and gait, Relaxed ; erect posture; Cannot sit and stand Abnormal
standing, sitting and coordinated movement erect ; cannot walks in
walking coordinated movement
(need assistance)
Overall hygiene and Clean; neat Has a overall hygiene and Normal
grooming grooming, neat and clean

Body and breath No body odor or minor No breath and body odor Normal
odor in relation to body odor relative to work
activity level or exercise, no breath
odor

Distress in posture No distress noted No distress observed in Normal

or facial expression both posture and facial
expression
Obvious signs of Healthy appearance Unhealthy appearance Abnormal
health or illness

Client’s attitude Cooperative, able to Can follow all instructions Normal

follow instructions
Client’s affect/ Appropriate to situation Client seemed happy and Normal
mood, in a good mood
appropriateness of
responses
Quantity of speech, Understandable, Client’s words are Normal
quality and moderate pace; clear tone understandable, clear,
organization and inflection; exhibits and in moderate pace
thought association
Listen for relevance Logical sequence; makes Client make sense Normal
and organization of sense; has sense of reality
thoughts

SKIN
Skin color Varies from light to deep Skin color is light brown Normal
brown; from ruddy pink to
light pink; from yellow
overtones to olive
Uniformity of skin Generally uniform except Uniform skin color Normal
color in areas exposed to the
sun
Edema, if present No edema Edema on both legs (left Abnormal
and right +3)
Skin lesions Freckles, some No birthmark, some Normal
birthmarks, some flat and patches on her right leg
raised nevi; no abrasions
or other lesions
Skin moisture Moisture in skin folds and Client has a dry skin (not Abnormal
the axillae well hydrated)

Skin temperature Uniform; with normal Temp:

range

Skin turgor When pinched, skin Springs back to normal Normal

springs back to previous state in less than 1
state; may be slower in second
elders
HAIR
Hair on scalp Evenly distributed hair Evenly distributed Normal

Thickness or Thick hair Thick Normal

thinness

Texture and oiliness Silky, resilient hair Silky, resilient Normal

Presence of No infection or infestation No infection or Normal

infections or infestation
infestations
Amount of body hair Variable Varies upon inspection Normal

NAILS
Fingernail and Highly vascular and pink in Normal
toenail bed color light-skinned clients; dark-
skinned clients may have
brown or black
pigmentation in longitudal
streaks
Tissues surrounding Intact epidermis Intact Normal
nails
Capillary refill Prompt return of pink or Capillary refill less than 1 Normal
usual color (generally less second
than 4 seconds)

SKULL AND FACE

Size, shape and Rounded; smooth skull Normocephalic, Normal
symmetry of the contour symmetric and smooth
skull skull contour
Skull nodules or Absence of nodules or No nodules or masses Normal
masses and masses
depression of the
skull
Facial features Symmetric or slightly Symmetric facial features Normal
asymmetric facial
features; palpebral
features equal in size;
symmetric nasolabial folds
Symmetry of facial Symmetric facial Client can raise both Normal
movements movements eyebrows, can close both
eyelids, can open both
sides of her lips
EYE STRUCTURES AND VISUAL ACUITY
Eyebrows Hair evenly distributed; Evenly distributed Normal
skin intact

Eyelashes Equally distributed; curled Eyelashes evenly Normal

slight outward
Eyelids Skin intact; no discharge;
no discoloration
Bulbar conjunctiva Transparent; capillaries
sometimes evident; sclera
appears white
distributed, curled
upward
Skin are intact, no Normal
discharge, no
discoloration noted
Filled with capillaries Normal

Palpebral Shiny, smooth, and pink Pink in color Normal

conjunctiva and red

Lacrimal gland No edema or tenderness No edema or tenderness Normal

over lacrimal gland
Lacrimal sac and No edema or tearing
nasolacrimal duct
Cornea Transparent, shiny and
smooth; iris are visible
No edema, no tearing Normal
Transparent, shiny and Normal
smooth, iris are visible
Corneal sensitivity Client blinks when the Using cotton applicator, Normal
cornea is touched client blink when her
cornea was touched

Pupils Black in color; equal in Pupils about 4mm; equal Normal

size, normally 3 to 7 mm size
in diameter; round,
smooth border, iris flat
and round
Pupils reaction to Illuminated pupil Constricts when the Normal
light constricts penlight was pointed on
her eyes
Pupils reaction to Pupils constrict when Constricts when the Normal
accommodation looking at near object; object is near
pupils dilate when looking
at far object; pupils
converge when near
object is moved toward
nose
Visual acuity Able to read newsprint Client can read newsprint Normal
without aid of eyeglasses

EARS AND HEARING

Auricles Color same as facial skin, Color is the same as Normal
symmetrical, auricle facial hair, symmetrical,
aligned with outer mobile and firm, not
canthus of eye, mobile, tender
firm, and not tender;
pinna recoils after it is
folded
External Ear Canal Dry cerumen, grayish-tan Grayish cerumen Normal
color, or sticky, wet
cerumen in various shades
of brown
Client’s response to Normal voice tones Client can hear normal Normal
normal voice tones audible voice tones
NOSE AND SINUSES
External nose Symmetric and straight, Symmetric, no Normal
not tender, no lesions tenderness, no lesions

Patency of both Air moves freely as the Air moves in and out for Normal
nasal cavities client breaths through the both nasal activities
nares
Nasal septum Nasal septum intact and in Intact and positioned in Normal
midline midline
Maxillary and frontal Not tender Not tender Normal
sinuses
MOUTH AND OROPHARYNX
Outer lips Uniform pink color, soft, Slightly pink in color, soft, Normal
moist, smooth texture, moist and smooth
symmetry of contour, texture,symmetrical, can
ability to purse lips purse lips
Inner lips Uniform pink color, moist, Uniform in color, moist, Normal
smooth, soft, glistening, smooth, soft and elastic
and elastic texture

Teeth and gums 32 adult teeth, smooth, Upper: 15 Abnormal

white, shiny tooth Lower: 14
enamel, pink gums, moist, White and shiny enamel,
firm texture to gums, no no gum retraction, some
retraction of gums tartar present
Tongue Central position, pink Central position, pinkish- Normal
color, moist, slightly red in color, smooth,
rough, thin whitish lateral
coating, smooth, lateral
margins, no lesions
Tongue movement Moves freely, no Tongue can move freely Normal
tenderness
Base of the tongue Smooth tongue base with Veins present Normal
prominent veins
Hard and soft palate Light pink, smooth, soft Light pink, smooth soft Normal
palate, lighter pink hard palate, color of the the
palate, more irregular hard palate is the same
texture as soft palate

Uvula Positioned in midline of Positioned in midline Normal

soft palate

Tonsils Pink and smooth, no Not inflamed, nor visible Normal

discharge, of normal size,
not visible
Gag reflex Present Gag reflex present Normal
NECK
Neck muscles Muscles equal in size; Muscles equal in size Normal
head centered
Head movement Coordinated, smooth No problem in head Normal
movements with no movement, no
discomfort discomfort noted

Neck muscle Equal strength Equal in strength Normal

strength
Lymph nodes Not palpable Lymph nodes are Abnormal
palpable
Trachea Central placement in Positioned in the center Normal
midline of neck, spaces
are equalon both sides

Thyroid gland Not visible on inspection Not visible Normal

THORAX AND LUNGS

Posterior Thorax
Shape and Chest symmetric Symmetric chest Normal
symmetry of the
thorax
Spinal alignment Spine vertically aligned Spine is vertically aligned Normal
Temperature and Skin intact; uniform in Intact skin, uniform Normal
integrity of chest temperature temperature
skin
Respiratory Full and symmetric chest Chest expansion is full Normal
excursion expansion and symmetric

Anterior thorax
Breathing patterns Quiet, rhythmic and Respiratory rate: 20cpm; Normal
effortless respirations effortless respirations

Respiratory Full symmetric excursions Full and symmetric Normal

excursion excursions
Trachea Bronchovesicular and No crackles, no wheezes, Normal
(auscultation) vesicular breath sounds no ronchi

Anterior chest Bronchovesicular and No crackles, no wheezes, Normal

(auscultation) vesicular breath sounds no ronchi

HEART AND CENTRAL VESSELS

Carotid artery Symmetric pulse volumes; Symmetric pulse; full Normal
full pulsations, thrusting pulsations; pulse rate:
quality 83bpm; blood pressure:
120/90mmHg

PERIPHERAL VASCULAR SYSTEM

Peripheral pulses Symmetric pulse volumes; Symmetric pulses; full Normal
full pulsations pulsations
Peripheral leg veins Limbs not tender; Not tender, symmetric in Normal
symmetric in size size
Skin of the hands Skin pink color; skin Skin temperature is Normal
temperature not normal; moist; slightly
excessively warm or cold; pale
no edema; skin texture
resilient and moist
Capillary refill Immediate return of color Capillary refill return less Normal
than 1 second

BREAST AND AXILLAE

Breast Females: rounded shape; Round in shape; Normal
generally symmetric symmetrical

Skin of the breast Skin uniform in color; skin Uniform in color; smooth Normal
smooth and intact and intact skin

Areola Round or oval and Rounded; dark in color Normal

bilaterally the same; color
varies widely, from light
pink to dark brown

Nipples Rounded, everted and Rounded; equal in size; Normal

equal in size, similar in pointed forward
color, soft and smooth;
both nipples point the
same direction
ABDOMEN

Skin integrity of Unblemished skin; Surgical incision (22cm) Abnormal

abdomen uniform color with JP drain on lower
right quadrant
Contour and Concave or convex; no Concave; no evidence of Normal
symmetry evidence of liver or spleen liver or spleen
enlargement enlargement

Abdominal Symmetric contour Symmetric Normal

movements
Palpation of liver May not be palpable; Not palpable Normal
border feels smooth
Palpation of bladder Not palpable Not palpable Normal
MUSCULOSKELETAL SYSTEM
Size Equal size on both sides of Equal on both sides of Normal
body the body
Muscle tendons No contractures No contractures Normal
Muscle tremors Normally firm No tremors Normal
Muscle strength Equal strength on each Equal strength Normal
body side
Bones No deformities No deformities Normal
Bones for edema or no tenderness or swelling No tenderness; no Normal
tenderness swelling
Range of motion Varies to some degree in Normal ROM Normal
accordance with person’s
genetic makeup and
degree of physical activity

FEMALE GENITALS AND INGUINAL AREA

Pubic hair Distributed in the shape of Distributed in inverse Normal
an inverse triangle triangular manner

Pubic area Pubic skin intact; no Intact; no lesion Normal

lesions
RECTUM AND ANUS
Anus Patent, has good tone Patent, good tone Normal

DISCHARGE PLAN

Medication:

 Take home medication as prescribed by the physician

 Report any side effects and adverse reactions as indicated by the healthcare

provider
Environment/ Exercise

 Instruct patient to stay calm, quiet environment.

 Home environment must be free from slipping or accident hazards.

 Reinforce the need to continue exercises at home.active ROM exercises increase

muscle mass, tone and strength pressure joint mobility and improve cardiac and

respiratory function.

 Encourage /advise patient to use/ wear a clean cotton t-shirt to prevent contact

between the skin and shoulder harness and to promote absorption of perspiration.

Treatment

 Teach and instruct patient to perform proper wound care and advise to wear binder

(provides support for abdominal muscles and help to promote healing at the incision

site)

 Inform patient to follow referrals and follow-up check ups.

Nutrition

 Encourage patient to maintain proper nutrition, healthy diet and avoid unhealthy

habits such as smoking and alcoholic drinks.

 TABLE OF CONTENTS

PAGE NO.

I. Demographic Data 1

II. History of Present Illness

III. History of Past Illnes

IV. Family Health History

V. Human Anatomy and Physiology

VI. Pathophysiology

VII. Physical Assessment

VIII. Gordon’s Typology of 11 Functional Patterns

IX. Medical Management

X. Surgical Management

XI. Nursing Management

XII. Diagnostic/ Laboratory Exam

XIII. Drug Study

XIV. Nursing Care Plan

XV. Discharge Plan

ST. PAUL UNIVERSITY SURIGAO

COLLEGE OF HEALTH SCIENCES

LEVEL III

NURSING CASE STUDY:

PRIMARY PERITONITIS, ASCITES

SUBMITTED BY:

LIWAGON, KRIZZA LEEN F.

CEDRO, PRESCELA MARIZ C.

JIMENEZ, APPLE GRACE S.

RUAYANA, LARA JEAN A.

 SUBMITTED TO:

MRS. KRISTAL LIZA C. BESARIO, RN, MAN

FAMILY HISTORY

Grandfather Grandmother Grandfather Grandmother

(Hypertension) (Diabetes Type II) (Arthritis) (Hypertension)

Mother Father
(Arthritis) (Arthritis)

Brother Patient Brother Brother Sister

(Hypertension) (Primary (Appendicitis) (none) (none)
Peritonitis,Ascites
)