Nursing Assessment

Name: Rachel Mabaylan Date: August 12, 2010

Vital Signs:
Pulse: 73 BP: 100/60 mmHg Temp: 36 C Resp.rate: 22cpm Height: 5’2’’ Weight: 49kg

EENT:
[ ] impaired vision [ ] blind
[ ] pain [ ] reddened [ ] drainage
[ ] gums [ ] hard of hearing [ ] deaf Breast
[ ] burning [ ] edema [ ] lesion [ ] teeth tenderness
Assess eyes, ears, nose, throat
For abnormality [x] no problem
RESPIRATORY
] ] asymmetric [ ] tachypnea Linea nigra
[ ] apnea [ ] rales [ ] cough [ ] barrel chest
[ ] bradypnea [ ] shallow [ ] bronchi
[ ] sputum [ ] diminished [ ] dyspnea
[ ] orthopenea [ ] labored [ ] wheezing
[ ] pain [] cyanotic
Assess resp.rate, rhythm, depth, pattern
Breath sounds, comfort [x] no problem
CARDIOVASCULAR
[ ] arrhythmia [ ] tachycardia [ ] numbness
[ ] diminished pulses [ ] edema [ ] fatigue
[ ] irregular [ ] bradycardia [ ] murmur
[ ] tingling [ ] absent pulses [ ] pain
[ ]assess heart sounds, rate, rhythm, pulse, bp,
Circulation, fluid retention, comfort
[x] no problem
GASTRO INTESTINAL TRACT
[ ] pain [ ] urine color [ ] vaginal bleeding
[ ] hematuria [ ] discharge [ ] noctoria [ ]olyguria
[x]Assess urine freq., control, color, odor,[ ] comfort
[ ]Gyn-bleeding, discharge [ ] no problem
NEURO
[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures
[] lethargic [ ] comatose [ ] vertigo [ ] tremors
[] confused [ ] vision [ ] grip
[x]Assess motor function, sensation, LOC, strength,
Grip, gait, coordination, orientation, speech [x]no problem
MUSCULOSKELETAL and SKIN Edema
[ ] appliance [ ] stiffness [ ] itching [ ] petechiae
[ ] hot [ ] drainage [ ] prosthesis [] swelling
[ ] lesion [ ] poor turgor [ ] cool [ ] deformity
[ ] wound [ ] rash [ ] skin color [ ] flushed
[ ] atrophy [x ] pain [ ] ecchymosis
[ ] diaphoretic [ ] moist
Assess mobility, motion, gait, alignment, joint function/
Skin color, texture, turgor, integrity [x] no problem
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 Nursing System Review Chart II

SUBJECTIVE OBJECTIVE

COMMUNICATION:
( ) Glasses ( ) Languages
( ) Hearing Loss Comments: ( ) Contact Lenses ( ) Hearing Aide
( ) Visual Changes “wala man ko problema sa
Pupil size 3 mm ( ) Speech Difficulties
( x ) Denied ako panan aw ug pandungog”
As verbalized by patient. Reaction: PERRLA( Pupil Equally Round and
Reactive to Light and accommodation)

OXYGENATION:
( x) Dyspnea Comments: “Galisod kog
( ) Smoking History ginhawa” as Resp. ( x ) Regular ( ) Irregular
verbalized by patient Describe:
_NONE_
( ) Cough R symmetrical to the left lung with
( ) Sputum expansion
( ) Denied
L symmetrical to the right lung with
expansion
CIRCULATION

( ) Chest Pain Comments: “Gasakit ako legs Heart Rhythm ( x) Regular ( ) Irregular
Usahay” as
Ankle Edema: Absent
verbalized by patient
(x ) leg pain present at both feet_and upper extremities
( ) Numbness of
extremities Pulse Car Rad DP Fem
( ) Denied
R_ + +_ + +

L_ + + + +

NUTRITION

Diet: Balance diet ( ) Dentures (X) None

( ) N ( )V Comments: “kusog ko
Full Partial With Patient

Upper () () ()
(x) recent change in mokaon karun” as
verbalized by patient Lower () () ()
Weight, appetite
( ) Swallowing Difficulty
( ) Denied

Elimination:

Usual Bowel pattern Urinary frequency Comments: Bowel sounds:

“wala man normoactive
__once a day 6x a day
Abdominal Distention
( )constipation remedy ( ) Urgency
( ) yes (x) No
No constipation Urine(color,
( ) Dysuria consistency,odor)
Date of Last BM ( ) Hematuria yellowish , aromatic
_July 6,2008 ( ) Incontinence
Diarrhea (character) ( ) Polyuria
__none__ _ ( ) Foley in place
( ) Denied
MNGT OF HEALTH & ILLNESS Briefly describe patient’s ability to follow
treatments
( ) Alcohol (X) Denied
(diet, meds, etc)
(amount and frequency)
Client is eager to follow the medications
“dili man ko gapanigarilyo ug gainom” prescribed to her.
( ) SBE none

Last Pap Smear : none

16

SUBJECTIVE OBJECTIVE

SKIN INTEGRITY: ( ) Dry ( ) Cold ( )Pale

( ) Dry Comments: “wala man pud koy ( ) Flushed ( ) Warm
( ) Itching problema sa akong panit, ( ) Moist ( ) Cyanotic
(X) Denied kanang murag talomtom Rashes, Ulcers, decubitus (describe size, location,
drainage, color and odor)
 dugay naman na” as none
verbalized by patient
ACTIVITY/SAFETY LOC and Orientation
( ) Convulsion Comment: “ usahay gakalipong Patient is oriented to time and place
(x ) Dizziness ko kanang kapoy kayo Gait: ( ) Walker ( ) Cane
( ) Limited motion cge ug lihok lihok.” As ( ) Steady ( ) Unsteady
Of joints verbalized by patient ( ) Sensory and Motor Losses in face or extremities:
The patient has no sensory and motor losses
Limitation in ability to ( ) ROM Limitation:
( ) Ambulate No limited ROM
( ) Bathe Self
(x ) Denied
COMFORT/SLEEP/AWAKE
( ) Pain Comments: “sa diri lang ko
(Location, frequency) maglisud ug tulog kay ( ) Facial Grimace
naa may mga bata, ( ) Guarding
( ) Nocturia usahay ga ihi-ihi ko” as ( x) No other signs of pain
( ) Sleep difficulty verbalized by patient
(x ) Denied ( ) siderail release from signed ( 60 + years )
_______________________________
_______________________________

COPING: Observe non verbal behavior

The patient is participative.
Occupation: housewife
Members of Household: 10 Person and phone number that can be reached at any
Most Supportive Person: husband time: none

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DIAGNOSTIC TEST

HEMATOLOGY REPORT
Date started: 6/30/10

Time started: 3:00 PM

Test Results Unit Reference

White blood cells 12.4 X 1000/uL 5.0-10.0
Red blood cells 3.71 X 100 000/ uL 4.2-5.4
Hemoglobin 10.1 g/dL 12.0-16.0
Hematocrit 30.8 % 37-47
Mean corpuscular 83.0 fL 80-96
volume (MCV)
Mean corpuscular 27.2 pg 27-31
Monoglobin (MCH)
Mean corpuscular 32.8 g/dL 32-36
monoglobin
contraction (MCHC)

Differential count
Lymphocyte 34 % 20-48
Neutrophil 62 % 40-75
Monocyte 2 % 4.0-9.0
Eosinophils 2 % 0.0-7.0
Basophils % 0.0-2.0
Bands/stabs % 0.0-2.0
Platelet 318 X 1000/L 150-450