Group 5 RLE of BN1D with Client JRS

UNIVERSITY OF SAINT LA SALLE

COLLEGE OF NURSING

NCM 101 Health Assessment

RLE Skills Lab
nd
2 Sem, AY 2018-2019

Contents of Case Presentation

Introduction
Common cold , known simply as a cold, is a viral infectious disease of the upper
respiratory tract that affects the nose,throat, sinuses, and larynx. It may be caused by several
different viruses, the most common of which are rhinoviruses. Rhinovirus is spread through viral
particles entering the nose or the eye, and spreading to the nose and throat. These viruses cause the
symptoms of cold that include coughing, sore throat, runny nose, sneezing, headache, and
fever.This common cold virus can reproduce itself more efficiently in the cooler temperatures (33–
35 °C (91–95 °F) found inside the nose.These viruses are released when the sick person sneezes,
coughs, or blows their nose which is considered symptoms of cold. In addition to symptoms these
viruses caused sore throat, headache, and fever. Common cold is a contagious infection and it can be
easily passed from one person to another. You may able to acquire cold through direct contact and
indirect contact. Direct contact is when the sick person sneeze or cough, tiny droplets of fluid
containing the cold virus then launched into the air and be breathed in by others. However, indirect
contact is when the sick person sneezes while covering the mouth then hold on to something and
someone else touches it then they may catch the cold virus if they then touch their mouth or nose.
According to research ,adults experience two to four colds a year while children experience three to
eight. The risk of having common cold is when you have a chronic illness or otherwise weak
immune system.That is why compared to adult’s body-defense ,children are more susceptible to
acquire infection due to their underdeveloped immune system. Furthermore, since women are more
likely to come into close contact with children ,they get more colds than men. Common cold is a
self-limiting infection, which means it gets better by itself without the need for treatment or will
most likely go away on their own. So there is no cure for the common cold instead it is possible to
relieve symptoms by taking over-the-counter medication such as paracetamol and drinking plenty of
fluids.
 I. Objectives

After 20 minutes of Health Assessment Presentation, the students of BSN-1D will be able to:

1.Review the anatomy and physiology of the upper respiratory system.

2.Collect subjective and objective data through inspection, palpation, percussion, and
auscultation.

3. Differentiate the normal from abnormal findings from the client

II. Anatomy and Physiology

The upper respiratory system is the body system primary involved with our case where our
client has ¨common colds¨ . The organs of the upper respiratory system include the mainly the
nose,pharynx, and the larynx. The nose is the only externally visible part of the respiratory system. Its
openings are called nostrils or nares ,which are the passageway of air that enters the nose during
breathing. The nasal cavity is the interior of the nose while the nasal septum is the midline that divides the
nasal cavity. Olfactory Receptors are responsible for the sense of smell. The Respiratory Mucosa lines the
nasal cavity and is rested on thin walled veins that warms air, and produces sticky mucus that moistens the
air and traps incoming bacteria and other foreign debris.Ciliated Cells create a gentle current that moves
the sheet of contaminated mucus posteriorly toward the throat. This ciliary action occurs when the
temperature is extremely cold it and these cilia become sluggish,allowing mucus to accumulate in the
nasal cavity and to dribble outward through the nostrils; this explains what we call ¨runny nose. Conchae
is a mucosa-covered projections or lobes, it gently increase the surface area of the mucosa exposed to the
air and increases the air turbulence in the nasal cavity. Mucus-coated surfaces trap and prevent inhaled
particles from reaching the lungs. Palate is a partition that separates the nasal cavity from the oral cavity .
It has two types the hard palate, which supports anteriorly , and the soft palate, the unsupported posterior
part.Paranasal Sinuses surround the nasal cavity and are located in the frontal, sphenoid, ethmoid, and
maxillary bones; they lighten the skull and act as resonance chambers for speech and produce mucus
which drains into the nasal cavities. Nasolacrimal Duct drains tears from the eyes; also empty into the
nasal cavities. Pharynx or the throat, is a musculomembranous tube that serves as a common passageway
for food and air. It has three divisions : nasopharynx ,oropharynx, and the laryngophraynx. Larynx or
“voice box”, routes air and food into the proper channels and contains vocal cords to produce sound.

III. Nursing Health History

A. Biographical Data
Name: JRS
Address: Sharina Heights, Bacolod City
Gender: Male
Provider of History: Client
Birthdate: August 8,1999
Age: 19 years old
Nationality: Filipino
Marital Status: Single
Religion:Roman Catholic
Educational Level: 1st year College
Occupation:None
Weight: 42kgs

B. Past Health History

Based on the information collected by the student nurse from interviewing the client, the
client was born through the Cs method due to this mother vaginal hole was small. At birth, he was
immunized with BCG vaccine and Hepatitis B vaccine (HBV) ,then later on in his childhood, with
DTwP-Hib-Hep B vaccine, polio vaccine, pneumococcal conjugate vaccine (PCV) , Measles-Mumps-
Rubella vaccine (MMR), andTetanus-Diptheria vaccine (Td). Moreover, our client was involved in a
vehicular accident last 2016 that resulted into an open fracture on his left tibia bone and required a
 surgery; an external fixator was used by the doctor to stabilized the injured part. 4-6 months the
external fixator was attached on his fracture bone and he experienced stabbing pain caused by the
attachment of the external fixator but as time goes by the pain fade aways. His recovery time is 9
months. He has no known allergies and is physically active.

C. Family Health History

Regarding his family´s health history, the client stated that his mother is 50 years old while
his father is 54. According to him, his parents do not have any known illness ,but 3 out of his mother´s
siblings has hypertension. In addition to this, his mother´s father died due to renal failure and also had a
history of hypertension.

D. Lifestyle and Health Practices

On a typical day, the client wakes up at around 7 o’clock in the morning to attend his
classes. On weekends, he proceeds to his normal routine which includes doing some household chores and
doing his school works. He observes normal sleeping habits in which he usually sleeps for 8 hours straight
and does not experience insomnia or any other sleeping problems. After a long day, he sleeps at around 11
in the evening. The client maintains his nutrition and weight by observing a well-balanced diet prepared
by his mother, and takes multivitamins such iron, calcium, and ferrous sulfate. He doesn’t drink coffee nor
use recreational drugs but he drinks alcoholic beverages occasionally. According to the patient, he hasn’t
undergone any check-ups regarding his genitourinary system and doesn’t usually visit the doctor for any
check-ups unless he has a severe illness. For his social activities, he would hang out and catch up with his
friends. He also participates in the Amity Youth Volunteer Organization to offer basic first aid service in
school events and disaster drills. He is a Roman Catholic that upholds the values and virtues of his church
such as respect, compassion, and faith. He has a good relationship with his family and they would usually
hold gatherings during the holidays. He is a first year college student and aims to graduate and be a
professional engineer someday. The client experiences stress caused by academics ,and financial and
family problems and copes up through excessive eating and sleeping the client lives in a environment
where sari sari stores are meters away from his house,the client also stated that there is a presence of stray
dogs and cats and surrounded by trees.

IV. Review of Systems for Current Health Problems

In assessing the client´s current health condition, student nurses are able to assess the following systems:

Assessing the General Appearance

Upon first meeting the client, his voice is muffled and he keeps on sniffing.The client is
well groomed, with beautiful teeth, and bright eyes and fair skin. We noticed a problem with his
posture and observed that the client’s left shoulder is lower than right shoulder. Client is shy type of
person. Client can speak well, and able to walk normally.

Assessing the Skin, Hair, and Nails

Client´s skin color is fair, with a body temperature of 36.7 degree celsius. The
client has no rashes, lesions, hair loss, dandruff and excessive sweating. The clientś condition is
normal and his nails are pinkish in colour with 160 degree angle.

Assessing the Head and Neck

On our first assessment, the client has sore throat is unable to taste light flavors like viands
but can taste strong flavors. On our follow up assessment, he has become well and he did not
experience headache , stiffness, difficulty of swallowing, nor enlarged nodes in both of our
assessment.
 Assessing the Ears
The patient experienced no pain, no ringing or buzzing in the ears nor was there difficulty in
hearing or dizziness.

Assessing the Eye

On first assessment, client has reddish eyes and watery eyes. On our follow up assessment, his
eyes were no longer reddish nor watery. In both of our assessment, client sees no halos, no pain,
infections, blurring, black spots, flashes or double vision.

Assessment of Mouth, Throat, Nose, and Sinuses

On our first assessment, the client was sneezing, coughing and sore throat.Upon assessing him
2 days later, he is not experiencing these symptoms anymore.However, there was no mouth pain,
no lesions ,hoarseness, nasal obstruction, snoring or nosebleed on either first or follow up
assessment.

Assessing the Thorax and Lungs

In both of our first and follow up assessment, there client did not experience any
pain,orthopnea,nor hemoptysis.During our first assessment, client has difficulty in breathing and
sputum was present but was diminished on our follow up assessment. The costal angle is
asymmetrical and there is a depression on the left costal margin.

Assessment of Breast and Regional Lymphatic

Client experienced no pain, no lumps, no discharges from nipples, no dimpling or change
in breast size, any swollen and tender lymph nodes in axilla.

Assessing Heart and Neck Vessel

There were no chest pain or pressure; there were no palpitations during assessment.
Patient’s blood pressure was 155/80 mmHg, with pulse rate of 82 bpm, 96 %SpO2.

Assessing Peripheral vascular

There is no pain, swelling, redness, stiff joints, and sores on feet or legs. The color of feet
and legs are normal corresponds with overall body skin color as well as the palms and hands. There
were also no changes of strength in his muscles as well as his ability to care for himself

Assessing Abdomen
Client stated that he did not experience pain, nausea, vomiting, indigestion, difficulty of
swallowing, nor presence of gas. There is no jaundice on patients abdomen skin color even hernia
was not present.

Assessment of Male Genitalia

The client stated that he experience no pain during urination, client´s urination is in normal
frequency and there is not difficulty in urinating. There is no blood in the urine, penile pain, or scrotal
swelling.

Assessment of Anus, Rectum, and Prostate

There is no pain in defecating, no haemorrhoids, no blood in stool, diarrhea nor
constipation.Thus, bowel habit is normal stated by the client

Assessment Musculoskeletal
Pain, swelling, redness, or stiffness in joints was not experienced. Strength of extremities was
normal ,and client was able to care for self and work. There is a curvature if the vertebral column
and shoulders are asymmetrical;left shoulder is lower than right shoulder. In assessing the knee
jerk reflex, left leg was more sensitive than right leg .He is 161 cm in height. Upon assessing our
client we found out that he has a scars on his lower leg due to the external fixator that was
attached during his recovery stage. The scars are 13 inches long
 Assessment Neurological
Client´s mood, behaviour, and anger is well balance. There is no headache, concussions, loss
of strength or sensation, coordination, difficulty with speech, memory problems, strange thoughts
or actions, and difficulty reading or learning.

V. REFERENCES

Marieb, E., & Keller, S. (2018). Essentials of Human Anatomy and Physiology (12th ed., pp. 463-475).
Pearson.

Mckinley,M., O´Loughlin,V., O´Brien, E., Harris, R.(2015). Human Anatomy (4th edition). McGraw-
Hill
Education.

Hebderson,L.,Gower, L., Bays , H.(2016).Physical Examination & Health Assessment Seventh Edition.
Elsevier Inc

Runny nose: Get relief. (2018). Retrieved from

https://www.mayoclinic.org/symptoms/runny-nose/basics/causes/sym-20050640

How do cold and flu affect the body?| Cold and Flu.(2018) Retrieved from
https://www.sharecare.com/health/cold-and-flu/how-cold-flu-affect-the-body
 Table of Contents

I. Introduction 1

II. Objectives 2

III. Anatomy and Physiology 2-4

IV. Nursing Health History. 4-8

Biographical Data…………………………………………………………....4-5

Past Health History……………………………………………………….….5-6

Family Health History…………………………………………………….…...6

Lifestyle and Health Practices……………………………………………….6-8

V. Review of the Systems………………………….………………………………8-17

VI. Documentation………………………………………………………………..18-20

VII. References……………………………………………………………………….21
 UNIVERSITY OF SAINT LA SALLE
COLLEGE OF NURSING
2nd Sem, AY 2018-2019

COMMON COLD
A Health Assessment Presentation

In Partial Fulfilment
For the requirements in NCM 101 Health Assessment
Skills Lab

Submitted to:
Jasmin R. Uy , RN.,MN
Health Assessment RLE -Clinical Instructor

Submitted by:
Jerthemier Vence Occena
Mitzie Lorraine Pescuela
Kennsia Cherese Reynaldo
Cris Kristine Treyes
Danielle Ross Tubal
Kaiser Dhan Tuhao
Ferdinand Tupaz
Patricia Mae Vaflor
Nicole Aubrey Villacencio