II. Patients Profile A.

Biographical Data Name: Gender: Status: Date of Birth: Place of Birth: Age: Religion: Nationality: Ethnicity: Date admitted Chief complaint: Admitting Diagnosis: Patient XY Female Single(with live in partner) July 17, 1994 Tuding slide Itogon ,Benguet 17 Roman Catholic Filipino Kankana-ey July 28, 2011 11:10 PM

Breast tenderness Mastitis; right breast

B. Patients

History

B.1 Present Medical History

5 months prior to admission, patient palpated a small mass on her right breast, characterized as soft with associated occasional on and off breast pain, pricking in character, 5/10 in severity ,non-radiating,

no associated fever, difficulty of breathing and vomiting. Sought consult at private doctor,patient were given antibiotics however no relief of the above symptoms noted. Patient tolerated the above condition until 1 month prior to admission, there was persistence of breast pain and noted erythema and swelling of the right breast however no consult was done until 1 day prior to admission, the condition progressed w/ increasing severity of pain to 10/10 which prompted consult @ with an impression of cellulitis with abscess formation at the right breast and has advised for surgical intervention however patient opted to be transferred in this institution hence the admission. B.2 Past Medical History Patient gave birth to a healthy baby boy last December 18, 2011 in a normal delivery. She only received one shot of tetanus toxoid. Client also suffered from UTI and was admitted at Abatan Hospital. She consult to the local health center within their community for check-up when shes Sick.

B.3 Family History There is a history of mastitis in the family, her sister was diagnose with mastitis. Also there is a history of hereditary disease such as hypertension in the family. B.4 Socio-Environmental History Client lives in a rural area. The family only rented their house with only one room. It is walking distance from the jeepney terminal. Their water source is from the local water supply that they use in their everyday water needs such as washing clothes and dishes and taking a bath. Client lives with his live in partner for more than a year together with their 7 months baby. They are both Roman Catholic by religion. They both work as a fish vendor and its their main source of their income RECOMMENDATION

TO PATIENT AND SIGNIFICANT FAMILY MEMBERS

1. Encouraged the patient to verbalize feeling of discomfort. 2. Do not rely on instinct or beliefs of others. 3. Their family should be responsible of maintaining healthy habits to prevent occurrence of disease.

TO THE HOSPITAL AND STAFF

1. Continue guiding the students in the wards, for in the ward the student can learn more. 2. Maintain good treatment and the way of care they are giving to the patient. 3. Take time to listen to each patient regarding their concerns and feelings. 4. Follow strictly the administration of prescribed medication 5. It is important to give their best in performing interventions to all patient be strictly monitoring the condition of their client

TO UNIVERSITY OF BAGUIO Since cholecystitis is a disease that needs to be managed intensively and properly. The school should conduct seminars and trainings so that the student nurses who will be handling such cases during their duty will have an edge with regards to proper management and for them to have the full knowledge with regards to the disease. TO OUR FELLOW STUDENTS We would like to recommend that they continue doing their job as learning nursing students with passion and

dedication until fate maybe the hindrance in doing so. Always refer for any abnormality observed they should always check the doctors order to know if there are any changes in medication and for other procedures to be done; also respect and obedience to our superiors like our clinical instructors must one of our great courage and attributes.

Conclusion Our patient X has a chief complaint of upper right quadrant pain. She was admitted in Notre Dame de Chartres and she was diagnosed of having Acute Cholecystitis (cholelithiasis).After the surgery the patient verbalized feelings of pain on the operation site.Since cholecystitis is the inflammation of the gallbladder which is usually accompanied by gallstones or cholelithiasis ,these

gallstones may block the way of toxic substances that really needs to go out, but due to this blockage this toxic substances are not being expelled and are just being stored in the bladder for a period of time. The treatment usually done is the cholecystectomy. In order to lower the risk of having this kind of condition each and every one of us must be conscious in our diet. We should try to avoid foods which are rich in salt and fats, especially those foods which contains many seasonings. We should be conscious on our health especially if we want to avoid life threatening diseases that will shorten our life span. If we are diagnosed of having a disease then we should seek, medical attention, advice and follow the physicians order like when to take the medications, is it before or after meals for the medication to take its effect.