A case presentation

This

case presentation aims to expand our knowledge about Appendicitis and have a thorough understanding about how to manage patients with such disease.

At the end of this case presentation, the audience should be able to: To define Appendicitis. To enumerate and explain the different signs and symptoms of a client with Appendicitis. To enumerate and explain the different diagnostic tests used to assess the presence of Appendicitis and the different nursing responsibilities of each test.

 To

enumerate and explain the surgical treatment used for the management of Appendicitis. To know the causes and occurrences of this disease such as its causative agents, predisposing and precipitating risk factors that contribute to its development. To identify the complications of the disease. To determine the ways on how to prevent the occurrence of such disease. To discuss the anatomy and physiology of the Digestive System.

 To

trace the pathophysiology of Appendicitis based from the signs and symptoms manifested by the patient. To discuss the nursing care plan for the management of the needs of our patient. To be familiar with the different medications given to our patient and be able to determine its function, indications, actions, and side effects and necessary nursing intervention for each drug. To formulate the discharge care plan for the continuity of care at home.

 By

choosing this case, it may help us, researchers, to better understand the clinical presentation of acute appendicitis, as we know remains one of the most common surgical diseases. It may manifest in its classical form yet it can present itself in many ways; atypical appendicitis. When the diagnosis is delayed the consequences may lead to perforation.

In the long run, this case definitely will provide a better understanding on disease of surgery; not just for acute appendicitis but also the other abdominal diseases such as cholecystitis, pancreatitis, intestinal obstruction, renal colic, etc. One of our purposes to study Appendicitis and choose it as our case presentation is to enable ourselves in developing our knowledge and understanding about the different factors affecting our patient with such condition. We all got interested about the disease so we decided to study and gathered relevant information about the disease. We also wanted to gain a sharpened understanding of why the disease happened to our patient as it did, and what might become important to look at more extensively in particular conditions that our client manifested.

 Appendicitis

is an inflammation of the vermiform appendix that develops most commonly in adolescents and young adults. It can most likely happen in males than in females. It can occur at any age but is rare in clients younger than 2 years and reaches a peak incidence in clients between 10 and 30 years. It is not common in older adults; however, when it occurs in such clients, rupture of the appendix is more common. Appendicitis affects 7% to 12% of the population.

Acute Form- it develops suddenly and rapidly in a previously undiseased appendix and it runs a relatively brief course. Signs: Stomach Ache Nausea Vomiting Increase of 1-2 degree temperature

Sub-acute Form- the onset is less abrupt and violent, or after initial onset of the acute type, the process partially subsides. Sign: Less severe pain
Chronic Form- this is the residual disease following in the wake of untreated but selfcontrolled acute or sub-acute appendicitis. Sign: Mild intermittent pain

 Simple-

the appendix is inflamed but still

intact. Gangrenous- there is tissue necrosis and microscopic perforation. Perforated- there is gross perforation and contamination of the peritoneal cavity.

Obstruction of the appendiceal lumen Appendicitis begins when the opening from the appendix into the cecum becomes blocked. The blockage may be due to a build-up of thick mucus within the appendix or to stool that enters the appendix from the cecum. The mucus or stool hardens, becomes rock-like, and blocks the opening. This rock is called a fecalith (a rock of stool). Swelling of the abdominal wall At other times, the lymphatic tissue in the appendix might swell and block the appendix. After the blockage occurs, bacteria which normally are found within the appendix begin to invade the wall of the appendix. Kinking of the appendix Infection, most probably from Yersinia enterocolitica (almost 30 %).

The classic manifestations of appendicitis begin with acute abdominal pain that comes in waves. At first, the pain may be perceived merely as discomfort that makes the client feel that passing flatus or having a bowel movement will bring relief. Unfortunately, many clients take a laxative during this period, which may lead to rupture of the appendix and peritonitis.

 Pain

in the abdomen - it first starts in the epigastrium or periumbilical area then shifts to the Lower Right Quadrant where there is an inflammatory process that may involve the parietal peritoneum and can come in contact with the peritoneum.

Loss

of appetite Nausea Vomiting- follows after pain starts Constipation or diarrhea- laxative or cathartic should never be given while the person has fever, nausea, or pain. Inability to pass gas

 Low

fever that begins after other symptoms Abdominal swelling Localized rebound tenderness at Mcburneys point Rovsings sign may be elicited by palpating the left lower quadrant; this paradoxically causes pain to be felt in the right lower quadrant

*If the appendix curls around behind the cecum, pain and tenderness may be felt in the lumbar region. If its tip is in the pelvis, these signs may be elicited only on rectal examination.
*Pain and Local tenderness may be less acute in older adults wherein acute appendicitis is more virulent and complications develop sooner. *Pregnant women may develop pain in the lower right quadrant, periumbilical or right subcostal area (under the rib cage), this may be due to the displacement of the appendix by the distended uterus.

Rovsing's sign >Continuous deep palpation starting from the left iliac fossa upwards (anti clockwise along the colon) may cause pain in the right iliac fossa, by pushing bowel contents towards the ileocaecal valve and thus increasing pressure around the appendix. Laughing too hard can result in great pain when dealing with appendicitis. Psoas Sign > Psoas sign or "Obraztsova's sign" is right lowerquadrant pain that is produced with the patient extending the hip due to inflammation of the peritoneum overlying the iliopsoas muscles and inflammation of the psoas muscles themselves. Straightening out the leg causes the pain because it stretches the muscles, and flexing the hip into the "fetal position" relieves the pain.

Obturator sign >If an inflamed appendix is in contact with the obturator internus, spasm of the muscle can be demonstrated by flexing and internal rotation of the hip. This maneuver will cause pain in the hypogastrium. Dumphy's sign >Increased pain in the right lower quadrant with coughing. Blumberg sign >Also referred as rebound tenderness. Deep palpation of the viscera over the suspected inflamed appendix followed by sudden release of the pressure causes the severe pain on the site indicating positive Blumberg's sign and peritonitis.

Age: Appendicitis can occur in all age groups but it is more common between the ages of 10 and 30 Gender: A male dominance exists, with a male to female ratio (1.4: 1) and the overall lifetime risk is 8.6% for males and 6.7% for females. Diet: People whose diet is low in fiber and rich in refined carbohydrates have an increased risk of getting appendicitis.

 Hereditary:

A particular position of the appendix, which predisposes it to infection, runs in certain families. Having a family history of appendicitis may increase a child's risk for the illness.
variation: Most cases of appendicitis occur in the winter months - between the months of October and May in countries that have winter season. In the Philippines, it may vary because of weather changes. Gastrointestinal infections such as Amebiasis, Bacterial Gastroenteritis, mumps, Yersiniasis, Coxsackievirus B and Adenovirus can predispose an individual to Appendicitis.

Seasonal

Infections:

1.Meckel's diverticulitis. A Meckel's diverticulum is a small outpouching of the small intestine which usually is located in the right lower abdomen near the appendix. The diverticulum may become inflamed or even perforate. If inflamed and/or perforated, it usually is removed surgically. 2.Pelvic inflammatory disease The right Fallopian tube and ovary lie near the appendix. Sexually active women may contract infectious diseases that involve the tube and ovary. Usually, antibiotic therapy is sufficient treatment, and surgical removal of the tube and ovary are not necessary.

3.Inflammatory diseases of the right upper abdomen. Fluids from the right upper abdomen may drain into the lower abdomen where they stimulate inflammation and mimic appendicitis. Such fluids may come from a perforated duodenal ulcer, gallbladder disease, or inflammatory diseases of the liver, for example, a liver abscess. 4.Right-sided diverticulitis. Although most diverticuli are located on the left side of the colon, they occasionally occur on the right side. When a right-sided diverticulum ruptures it can provoke inflammation they mimics appendicitis. 5.Kidney diseases. The right kidney is close enough to the appendix that inflammatory problems in the kidney-for example, an abscess-can mimic appendicitis.

1.Chronic Appendicitis There is chronic abdominal pain and recurrent acute attacks at intervals of several months. This may be attributed to inflammatory bowel diseases and renal disorders. 2.Perforation This happens when appendicitis is not properly diagnosed and when appendectomy is not done 24-48 hours after the diagnosis. In general, the longer the delay between diagnosis and surgery, the more likely is perforation. 3.Peritonitis This is identified by the spreading of the tenderness from a localized area to the entire abdomen. The abdomen becomes distended, the fever becomes more elevated and the patient appears extremely ill.

4.Development of an intraperitoneal abscess This is the bodys method of localizing the products of perforation into a confined area, thereby avoiding infection of the entire peritoneum. If the abscess does not respond to intensive antibiotic treatment, an operation must be performed to drain it. 5.Septic Pyelophlebitis This results from the spread of infection from the appendix to the veins that drains the organs. This infection results in abscesses of the liver. These abscesses often do not respond to antibiotic therapy and in many cases terminate fatally.

Diagnosis is based on results of a complete physical examination and on laboratory and x-ray findings. 1.WHITE BLOOD CELL COUNT WITH DIFFERENTIAL COUNT The WBC count determines the number of leukocytes per cubic millimeter of whole blood. The counting is performed very rapidly by electronic devices. The WBC may be performed as part of a CBC, alone, or with differential WBC count. - The white blood cell count in the blood usually becomes elevated which can be manifested by person who have infections(e.g. 10,000-20,000/mm3). This is called Leukocytosis which is accompanied by a shift to the left, or increase in the percentage of immature band neutrophils to mature segmented neutrophils.

 Inform

client that he/she may feel slight discomfort on tourniquet and needle puncture. Instruct patient to avoid strenuous exercises 24 hours before the test. There are no food, fluid, or medication restrictions unless by medical direction. Inform the patient that specimen collection takes approximately 5 to 10 minute.

2.Urinalysis This is the microscopic examination of the urine that detects red blood cells, white blood cells and bacteria in the urine. Urinalysis usually is abnormal when there is inflammation or stones in the kidneys or bladder. -This is done to rule out Urinary tract infections and other urologic causes. This is compulsory in women, to rule out pregnancy in appendicitis, as well to help ensure that the abdominal pain felt and thought to be acute appendicitis is not in fact, due to ectopic pregnancy.

 Provide

for client privacy. Instruct patient to obtain urine midstream clean catch. Review the procedure with the patient. If a catheterized specimen is to be collected, explain this procedure to the patient, and obtain a catheterization tray. Inform the patient that specimen collection takes approximately 5 to 10 minutes.

3.Abdominal Ultrasound This is a non-invasive procedure wherein high frequency sound waves are reflected back to a Doppler device that produces a computer generated image. This procedure takes less than 30 minutes and it is also useful for atypical symptoms which can most likely to happen in older adults. -This can be used to identify an enlarged appendix or an abscess and is helpful in women because it can exclude the presence of conditions involving the ovaries, Fallopian tubes and uterus that can mimic appendicitis. Instruct patient to lie still. Instruct patient not to eat 6 hours prior to the test.

4.Abdominal X-rays This can done with a barium enema contrast to diagnose appendicitis. The patient is in a flat and upright position. In normal appendix, the lumen will be present and the barium fills it up and is seen when the x-ray film is shot. In appendicitis, the lumen of the appendix will not be visible on the barium film. - Fecalith or calculus can be noted in the lower right quadrant, a local ileus may also be noted. Provide for client privacy. Instruct client to remain motionless as much as possible while the procedure is going on.

5.Computerized tomography (CT) Scan This is a noninvasive procedure used to enhance certain anatomic views of the abdominal structures, but it becomes invasive when a contrast medium is used. The patient lies on a table and is moved in and out of a doughnut-like device called a gantry, which houses the x-ray tube and associated electronics. The scanner uses multiple x-ray beams and a series of detectors that rotate around the patient to produce cross-sectional views in a threedimensional fashion by detecting and recording differences in tissue density after having an xray beam passed through bone and tissue.

-In patients who are not pregnant, this is useful in diagnosing appendicitis and periappendiceal abscesses as well as in excluding other diseases inside the abdomen and pelvis that can mimic appendicitis. The inflammation caused by appendicitis in the surrounding peritoneal fat (so called "fat stranding") can also be observed on CT, providing a mechanism to detect early appendicitis and a clue that appendicitis may be present even when the appendix is not well seen. Thus, diagnosis of appendicitis by CT is made more difficult in very thin patients and in children, both of whom tend to lack significant fat within the abdomen.

 Ensure

for clients cooperation. Provide for clients privacy. Instruct client to remain motionless. NPO 24 hours before the test. Instruct client to void unless CT scan is on the pelvic area.

6. Pelvic Examination This is done on females who are of childbearing age to rule out gynecologic disorders, tubal pregnancy or pelvic inflammatory diseases.
Provide

for client privacy. Instruct that the client may feel slight discomfort during the procedure.

7.Intravenous Pyelogram This is the most commonly performed test to determine urinary tract dysfunction or renal disease. IVP uses IV radiopaque contrast medium to visualize the kidneys, ureters, bladder, and renal pelvis. The contrast medium concentrates in the blood and is filtered out by the glomeruli; it passes out through the renal tubules and is concentrated in the urine. -this is done to differentiate appendicitis from possible urinary tract diseases

 Inform

the patient that the procedure assesses the kidneys, ureters, and bladder. Inform the patient that the procedure is performed in a radiology department by a technologist and a physician and takes approximately 30 minutes. Ask the patient to lie still during the procedure because movement produces unclear images; the patient may be asked to hold his or her breath for short periods.

*Prior to Surgery* Intravenous Fluids- to restore/ maintain vascular volume and prevent electrolyte imbalance Antibiotic Therapy- 3rd Generation cephalosporins against gram-negative bacteria (e.g. Cefoperazone, Ceftazidime, Cefotaxime, Ceftriaxone) -This is repeated during surgery and continued 48 hours post operatively. *Note that antibiotic therapy ALONE is not generally used to treat acute appendicitis.

Appendectomy This is the surgical removal of the appendix which is performed as soon as possible to decrease the risk of perforation. It may be performed under a general or spinal anesthetic with a low abdominal incision or by laparoscopy. Laparotomy This is the traditional type of surgery used for treating appendicitis. This procedure consists in the removal of the infected appendix through a single larger incision in the lower right area of the abdomen. The incision in a laparotomy is usually 2-3 inches long. This type of surgery is used also for visualizing and examining structures inside the abdominal cavity and it is called exploratory laparotomy.

 Laparoscopic

Approach

This surgical procedure consists of making three to four incisions in the abdomen, each 0.25 inches to 0.5 inches long. This type of appendectomy is made by inserting a special surgical tool called laparoscope into one of the incisions. The laparoscope is connected to a monitor outside the patient's body and it is designed to help the surgeon to inspect the infected area in the abdomen. The other two incisions are made for the specific removal of the appendix by using surgical instruments. Laparoscopic surgery also requires general anesthesia and it can last up to two hours.

 NOTES

appendectomy

This means Natural Orifice Transluminal Endoscopic Surgery method. This type of appendectomy was first pioneered in Coimbatore, India on March 2008. This is done without a single incision on the external skin.
SILS

Which means Single incision laparoscopic Surgery, where a single 2.5 cm incision is made to perform the surgery.

 Most

appendicitis patients recover easily with surgical treatment, but complications can occur if treatment is delayed or if peritonitis occurs. Recovery time depends on age, condition, complications, and other circumstances, including the amount of alcohol consumption, but usually is between 10 and 28 days. For young children (around 10 years old), the recovery takes three weeks.

As the primary health care provider, we must take into consideration the pain the patients feels and must do our interventions with utmost care and gentleness. We must also conform with the certain management to be done in association with the disease and the various therapies that it may incur. We in likewise manner, must act as a support to the patient in accordance with our responsibilities as the primary health care provider.

*To assist in evaluating child for clinical manifestations and prepare the child for surgery as indicated
Maintain

child NPO until otherwise indicated Maintain bed rest in position of comfort Do not apply heat to the abdomen; cold application may provide relief No palpations- palpating the area increases the pain No enemas- it may aggravate the clients condition and might cause rupture of the appendix

*To prevent abdominal distention and assess bowel function postoperative abdominal laparotomy:
Remain

NPO Gastric decompression by nasogastric tubemaintain patency and suction Assess peristaltic activity Evaluate and record character of bowel movement

*To decrease infection and promote healing postoperative abdominal laparotomy:

Place the client in Semi-Fowlers Position- to localize the infection and prevent spread of infection and development of sub diaphragmatic abscess. Antibiotics- Intravenously 7-10 days then switch to oral preparations Check for response to antibiotic and as well as status of IV infusion site. Vital Signs frequently (2-4 hours) Provide appropriate wound care- evaluate drainage from abdominal penrose drains and incisional areas.

*To maintain adequate hydration and nutrition, and promote comfort postoperative abdominal laparotomy:
IV

infusion Check for tolerance to PO liquids when NGT is removed Give Clear PO liquids when peristalsis returns Progress diet as tolerated Analgesics as indicated

Name: W.M.C.L Age: 18 years old Gender: Female Birthday: November 4, 1992 Civil Status: Single Occupation: None Place of birth: Tuguegarao City Address: Tuguegarao City Nationality: Filipino Dialect: Tagalog Religion: Catholic

Date of admission: January 19, 2011 Time admitted: 11:30 pm Admitting institution: Clinica De Leon Chief complaint: right lower quadrant pain, vomiting Attending Physician: Dr. Narciso Chan, Jr. Principal Diagnosis: AGE r/o acute appendicitis Final diagnosis: Acute appendicitis Source of information: Patient, S.Os, Patient's chart Date of Operation: January 20, 2011 Time of Operation: 12:00 am Initial Vital Signs: BP=110/70 mmHg Temperature=37 C PR=73 bpm RR=18 cpm Date of operation: January 20,2011 Time of operation: 12:00AM

 HISTORY

OF PRESENT ILLNESS Eleven hours PTC, patient W.L suffered from abdominal pain in the epigastric region with a pain scale of 5/10 but did not take any medication. She thought that it was just a sign of peptic ulcer, so her sister managed this by providing hot compress that subsided the pain and made it tolerable. The pain subsided for a few minutes but still has not completely disappeared. The patient then experienced an even greater pain hours later with the pain scale of 6/10 associated with nausea.

The patient then vomited and suffered from fever accompanied by chills. Her sister tried to do tepid sponge bath but she refused, instead she took Paracetamol to relieve the fever and brought her to the hospital. Upon admission, the patient manifested severe right lower abdominal pain with a pain scale of 8/10. She also experienced nausea and vomiting.

HISTORY OF PAST ILLNESS She does not have any allergy from foods and medicines. She also experienced having mumps, measles and chicken pox. She has completed all her immunizations, she had her check-up last May 2010 because she experienced pain in urination 3 days PTC but did not take any medications. She was diagnosed with UTI. She took Ciprofloxacin 500 mg thrice a day for one week that subsided the pain. On January 17, 2011, she again had her check-up because she again experienced pain in urination 1 week PTC but did not take any medication. She was prescribed Ciprofloxacin 500 mg thrice a week for 1 week but she only took it for 2 days because the pain disappeared on the 3rd day.

She has also experienced coughs, colds and fever during her childhood and her mother gave her over-the-counter drugs like Paracetamol (Biogesic) for fever, Phenylpropanolamine (Neozep) for colds and Bronchodilator (Salbutamol) for cough. She was also given vitamin supplements like Ceelin, Appebon and Growee. During her menstruation, she experiences dysmenorrhea and takes Midol or Buscopan for treatment.

 FAMILY

HISTORY According to the significant other, patient W.L has a family history of diabetes mellitus and hypertension on her mothers side and her father was also diagnosed with hypertension. Her mother has verbalized that they do not know whether or not they have a specific history for appendicitis because W.L was the first in their family that was diagnosed with acute appendicitis.

 SOCIAL

HISTORY Patient W.L is the second in the family of 5 and has close family ties. Her family is very supportive in terms of health and important decisions in her life. She belongs to the middle class and her parents are still the ones supporting her, financially. They experience family problems that are unavoidable such as death, hospitalizations and common family problems. She is a second year college student at the Cagayan State University taking Hospitality and Industry management. She has the habit of listening to music whenever she reviews, she says that the music helps her remember things.

She have a casual relationship with their neighbors and they sometimes have small talks with them. She have that certain sense of security within their neighborhood and services in their barangay are very accessible. She is fond of hanging out with her friends and sometimes goes to clubs with her mother. She also drinks alcoholic beverages occasionally. In terms of drinking, she can consume 2 glasses of wine, 4-6 glasses of mild liquor like Tanduay Ice and 2-3 glasses of hard liquor like Tequila. She is also fond of surfing the internet and social networking sites. In terms of her relationship with the opposite sex, she has hesitations in talking about it. She is an extrovert in a way that she can express herself easily with the other.

Date of Collection: January 20, 2011

FUNCTIONAL PATTERN Health PerceptionHealth Management Pattern

BEFORE HOSPITALIZATION She considers her health to be very important. She rates her health as 9 out of 10. Having a healthy body and mind enables her to do certain things especially dancing. She does not smoke. She experienced having cough, colds and fever and manages this by taking over the counter drugs like Paracetamol (Biogesic), Phenylpropanolamine (Neozep) and Bronchodilator (Salbutamol) as advised

DURING HOSPITALIZATION She perceives herself as an unhealthy person due to her present condition. She cooperates in her medical regimen and is very participative in all interventions done. She obeys all the doctors orders and takes medications on time.

older sister . But in terms of managing UTI as her past illness, she already seeks the advice of the physician at Peoples General Hospital. And she has a complete immunization during her childhood.

Nutritional-Metabolic Pattern

She has no allergy to foods and eats three meals a day with snacks in between. She eats bread or biscuits and drinks milk during her midnight snack but she eats junk foods and drinks juice or sodas when she is at school. But she usually eats low fiber foods such as chicharon and junk foods. She dislikes dried fishes like tuyo and tangi. She had just started drinking alcohol last 2010 on rare occasions like birthdays. She drinks 2 glasses of wine, 4-6 glasses of mild alcohol drink and 2-3 glasses of hard liquor. She doesnt have difficulty in swallowing and chewing.

When she was admitted the doctor ordered for NPO until she had undergone her appendectomy. 9-10 hours after the surgery the doctor had assessed her bowel sound to monitor if it is already normal. She has IVF of D5LRS regulated at 31-32 drops per minute.

Sleep-Rest Pattern

She usually sleeps at 11pm and wakes up early in the morning at about 5am6am during classes days. But during weekends she sleeps 1am and wakes up only at about 8am-9am. She usually watches television as a routine before going to sleep. She also takes 10 to 15 minutes of nap to take some rest. She reports no difficulty in falling asleep but do have sleep disturbances due to thirst, micturation and noise.

She sleeps at 11pm and wakes up 6am. She experienced difficulty of sleeping sometimes because of pain but able to take naps occasionally for about 15-30 minutes. The patient also is disturbed when sleeping because of the hospital routines like taking vital signs and giving medications.

Elimination Pattern

She urinates approximately 8x or more everyday. The urine was yellow amber in color with a foul smell. The patient also defecates 1-2 times a day with a stool having brown to dark brown color, slightly soft and semi formed. She expresses that sometimes she doesnt have any difficulty in defecating. However, due to her past condition (UTI), she sometimes experiences pain while urinating.

She has not yet defecated. She frequently urinates but scanty. The urine also has normal characteristics but the odor is slightly foul with yellow amber in color. She does void with the assistance of her mother or grandmother. After the surgery she has not yet defecated nor micturated.

Activity-Exercise Pattern

She considers doing house hold chores such as sweeping the floor and washing of dishes as a form of exercise. She enjoys leisure activities such as dancing together with her friends. The patient also loves surfing the internet as her pass time.

She cannot perform her usual activities of daily living due to her present condition. The patient also is unable to walk due to pain. She also needs the assistance of her mother or grandmother whenever she likes to change her position.

Cognitive-Perceptual Pattern

She is currently second year college. She has no sensory deficits. She is oriented to time, place and person. According to the patient the best way for her to learn new things is by reading books and through watching television that provides educational matters. Listening to music is a way for her to easily memorize her lessons. She can understand and speak in Itawes, Filipino and English.

She has a minimal eye contact with the student nurse when questions are raised and she closes her eyes whenever she feels any pain. She does not have difficulty in her senses. She can easily grasp ideas, is responsive to any questions and answers appropriately. And she is still oriented to time, place and person.

SelfPerception Pattern

She describes herself as a kind, loving, intelligent and friendly person. She also feels energetic and can do whatever she wants. She considers her parents and grandmother as her strength. She feels conscious with her appearance outside or inside their house.

According to the patient her illness greatly affects her physical capabilities as well as her emotional stability. She considers her current condition as a contributing factor to her weaknesses. According to the patient she is not capable of taking care of herself due to her current health condition.

Role-Relationship

She belongs to a family of 5 being the 2nd of the 3 siblings. She do have close family tie and her parents are very supportive to her decisions. Her elder sister serves as their consultant with regards to their health. In their home, she helps in doing house hold chores especially in washing dishes. She is an extrovert in a way that she can express herself easily with others.

Her relationship with her family became stronger. She perceives her condition as a burden to their family and she is not capable of doing the things she usually do in their house. She wishes to get well as soon as possible for her to be able to study again.

Sexuality-Sexual Pattern

She recognized herself as a simple person when it comes to expressing her femininity, of which is through wearing clothes appropriate with her gender. She had her menarche when she was fifteen years old and she had regular menstruation which last for 34 days. She can consume 2-3 pads per day. She has discomforts during menstruation and that it usually occurs late at night. The pain usually takes place in her 1st and 2nd day of menstruation and she treats it by taking analgesics like Midol. Her OB score is G0P0.

She still expresses her femininity by wearing appropriate clothes. Shes not having her menstruation during hospitalization.

Coping-Stress Management

According to the patient, whenever she got problems she just prays to God and takes enough rest. She doesnt usually share her problem to her parents even to her friends. Instead she stays in their house and watch television or in her room and think of some solutions to her problem.

She still prays to God to help her in her problems. According to her she follows whatever the doctor orders. And she already tells her problems to her parents especially when she feels any pain. Whenever she feels the pain she only watches television to manage the pain.

Spiritual-Belief Pattern

She considers her parents as a factor that helps her make decisions. God is the major source of her hope and strength in life. She doesnt have certain health practices that she need to follow when she is ill or hospitalized. But she still practices praying to strengthen her. She usually goes to mass every Sunday.

She has still the same spiritual and belief pattern. But her hope to overcome her disease is strengthen because of her family and through her prayers.