Physical Assessment

In Partial Fulfillment of the

Requirements in NCM 204-RLE

PRE-CLINICAL ROTATION

Submitted to:

CLAUDETTE ADVINCULA, RN, MN

Submitted by:

CARMENA MARIE A. ALING, St.N

KEZIA D. APALISOC, St.N

KAYE MARNELLE R. JACOSALEM, St.N

RYSHER HANGELO S. NOLASCO, St.N

BSN2H – Group 1 Subgroup 1

August 31, 2019

A. BIOGRAPHICAL DATA

Name: E.S.R

Age: 80 years old

Gender: Female

Civil Status: Widowed

Number of Dependents: None

Religion: Roman Catholic

Address: Cabantian, Davao City

Ordinal Rank: 2nd of 9 siblings

Educational Attainment: Masters of Education Degree

Occupation: Retired Professor

B. ADMISSION HISTORY

Chief Complaint: Bradycardia

Admitting Diagnosis: Diarrhea

Admission Date/ Time: August 22, 2019, 2:00AM

Ward/ Room/ Bed Number: Sta. Rosa Ward/Room 232

Attending Physician: Dr. Guillermo

C. HISTORY OF PRESENT ILLNESS

Prior to admission, patient was experiencing abdominal pain with excessive loss of
watery stool, along with this, she was also experiencing weak joints and shaking knees.
She was admitted to San Pedro Hospital with her watcher, Lyra, under Dr. Guillermo
last August 22, 2019 at 2:00 in the morning.
D. PAST HEALTH HISTORY
The proponents’ patient was born in Davao Oriental on April 2, 1939. She is allergic
to crabs and shrimp paste. She completed her childhood immunizations, such as
Bacillus Calmette-Guerin Vaccine, Hepatitis B Vaccine, Diphtheria-Pertussis-Tetanus
Vaccine, Oral-Polio Vaccine, and Measles Vaccine.

The client is known to be hypertensive, with a history of three hospitalizations last

2018 due to hypertension. She is currently taking Boehringer Ingelheim, Carvedillol
Cavid, Alorvastatin, Calcium Avamax, and Aldazide Omega 3 as her maintenance, but
is subject to change every two years because of the development of side effects such
as vomiting and edema on the lower extremities.

In addition, she had a mild stroke last 1992, and she also fractured her ribs due to
car accident last 1998. She had also undergone an ECG procedure and was diagnosed
with stickiness of the vein.

E. FAMILY HISTORY

The patient’s mother had a cataract which caused her blindness. Her father had
diabetes and became blind. The patient has eight (8) siblings, three (3) died because of
 lung cancer. The fifth sibling of the patient had cancer of the esophagus, who has also
passed away. Both the patient and her eighth sibling have hypertension.

F.PHYSICAL ASSESSMENT

The proponents’ physical assessment was done last August 23, 2019, 6:34PM.

GENERAL SURVEY

When the proponents walked inside the room of the patient, they have observed
that she was slightly drowsy. However, the patient was responsive, answering the
questions asked to her in an organized manner using appropriate words, oriented to
time and place, and also having a Glasgow Coma Scale of 14/15. All throughout the
assessment, the patient was cooperative and was in an appropriate mood. Her body
built is endomorph. For her grooming, she wore a hospital gown, and socks were also
put on. An IV was infused into her right metacarpal vein, a mainline IV of Plain NSS 1
Liter running at 120cc/hour, with a side drip IV of D5H 20 and Dopamine. A cardiac
monitor was also attached to the patient. Halitosis and bromhidrosis were not noted
from the proponents’ patient.

VITAL SIGNS RESULT NORMAL RANGE

Temperature 36.6 C 35.6 – 36.7 C
Pulse Rate 49 80 – 90 beats per minute
Respiratory Rate 29 16 – 20 breaths per minute
Blood Pressure 100/60 mmHg 110/70 – 130/90 mmHg
Cardiac Rate 60 80 – 90 beats per minute

SKIN

The skin is moderately-light in color, but discolorations and swelling were seen on
her left hand due to the IV insertion complications, lesions and ulcerations were not
observed, and her nails were all well-trimmed. In addition, the patient’s skin has a
smooth texture, and feels dry and warm to touch. Fair skin turgor was also noticed.

HEAD

The patient’s head is normocephalic in configuration. Edema was noticed on both of

her periorbital. Her hair is thin and is cut at neck-length, and has natural dark black hair
with white strands which were well distributed along the scalp, with no infestations
present. Both of her fontanelles are closed, with a symmetrical skull. The patient’s jaw
muscle strength is normal.

EYES
 The eyebrows are aligned and are able to perform equal movements, with hair
evenly distributed. The upper and lower lids close easily and are symmetrical. The
lashes are curled outwards and are equally disseminated. The lacrimal ducts are slightly
normal secreting small amount of tears in the eye. The lens are smooth with a gray to
white ring on the corneal margin. The conjunctivas are pale in color. With edema on the
periorbital region. The pupils are equally round, reactive to light and accommodation.
She is able to perform smooth equal eye movements. Dependent to reading glasses.
She is able to read the headlines on the television from a semi-fowler position in bed.

EARS

The ears are equal in size bilaterally. The pinna is normoset. The canal walls are
pink and smooth. The tympanic membrane is pearly-gray. The patient had no hearing
problems throughout the assessment.

NOSE

Symmetrical facial features on nasolabial fold with its midline nasal septum.
Pinkish mucous membrane and non-tender sinuses were shown. No discharges,
patency and lesions depicted.

MOUTH

The lips are symmetrical, pale in color and shows signs of dryness. The tongue is
located at the midline and no abnormalities where observed. The patient is currently
using dentures for the upper teeth. The gums, buccal mucosa, and palate show
paleness.

PHARYNX

The uvula is located at the midline. The mucosa is pale, there were no swelling or
ulcerations observed. The tonsils are not inflamed and the patient’s gag reflex is
present.

NECK

The trachea is located at the midline. The lymph nodes and thyroid are non-
palpable and not tender. The range of motion is normal. The jugular vein is not
distended and the muscle strength is normal.

THORAX

The patient’s thorax is symmetrical in shape, and her spine is in normal alignment.
Bulges, tenderness, and lesions were not observed. Her breathing pattern is effortless,
 and also has good chest skin turgor. Symmetrical respiratory excursion was observed.
There were no adventitious breath sounds that were heard.

HEART

Inspected pulses with no precordium abnormalities. Heart sounds were distinct

without extra murmurs. Pulses indications such as temporal, carotid, brachial, popliteal,
dorsalis pedis, posterior tibia was weak, regular apical rate with strong radial. Negative
result on calf tenderness or Homan’s sign from either left and right part.

BREAST

The breasts are symmetric and nontender. Both nipples and areola are brown.

ABDOMEN

The skin is intact and uniform in color and has a distended contour making it look
like it is swollen. No verbalization was said by the patient upon the assessment. No
abnormalities were found and the umbilicus is midline at lateral line. During auscultation
for bowel sounds, hyperactive bowel sounds can be heard at a rate of 5-35 sounds per
minute. The bladder is palpable, there were no ascites found and muscle guarding
occurred during the palpation.

G. CONCLUSION

Lifestyle serves as an indication of various health abilities. As indicated on the

patient, pertinent findings were having edema, weak pulses and in lower extremities
causes the patient minimized movement and distended abdomen with low bowel
sounds reported. These are few assessments among those abnormalities have shown.
Upon conducting physical assessments, planned monitoring distributions were made
among the group to easily evaluate the patient with its own current state.

Assigned members were initiating the assessment, one of them conducted and
interview among the watcher which provide an informed consent copy as the subject for
the case study. Approved consent is needed to further proceed to an actual physical
assessment were the two members take hold. Patient and watcher both agreed and
aware for the said procedures and are open to possible health assessment provided
questions. In line with the chronological assessment, the patient lies on bed at all times
and responsive upper extremities able to locate some findings when asked. In relation
to that first assessment, careful assurances were made among the group with the
attempt to must conduct and recheck properly prior for gathering data’s efficiently and
factual.
 Patient exposed to Acute Diarrhea and Bradycardia. Signs and symptoms were
reflected and on patients concrete condition. Admitted to these chief complaints was
definite to lab results pertaining to increase potassium in the body. Acute diarrhea is
fairly common among children and elders. It is characterized by loose, watery stools or
a frequent need to have a bowel movement. Patient undergoes treatment with high
blood medicinal maintenance. These result of a viral or bacterial infection. Number of
conditions or circumstances on a potential cause of diarrhea includes: a food
intolerance or food allergies as evident by the patient’s health history. Meanwhile
Bradycardia can cause dizziness, weakness, lack of energy or fainting spells. Existing
additional symptoms such as dry skin and thinning of hair were presented. A very high
blood potassium level in the diet can also contribute especially if your kidneys don’t
work well or you take certain medicines. It is relevant for slow heart rate of the patient.
Since potassium is one of the most necessary minerals in the body. Consuming optimal
health of right electrolytes to help regulate fluid balance, muscle contractions and nerve
signals. Poor fluid balance can lead to dehydration, which in turn affects the heart and
kidneys.

Prevention is better than cure. The totality of this outcome interprets to be more
protective and aware of one’s health reacted to environmental and communicable
bacterial contaminations. A serious condition among all ages that needs proper
provisions on adequate balance diet and health education for a normal functional
stability of energy use on our body systems. These entails to practice a just sanitary
care manner starting from our body to how we prepare the foods we eat. Students need
elevated knowledge on the vitamins and minerals intake in our body. Keeping ourselves
on guard from any harmful diseases. Disturbing diseases might lead to low academic
performances and emotional distress. What’s more, a high-potassium diet may help
reduce blood pressure and water retention, protect against stroke and prevent
osteoporosis and kidney stones. Young as we are, to become equipped on health was a
key to preserve life.

Nursing profession plays a great role in modifying benefits on health. Variations of

care plans must be instilled to anyone even in the simplest form. It contains, exercises
on handwashing, proper hygiene and suitable health care management. Treatments
and medication must follow a standard precautionary measure to enhanced accurate
expected results. Impaired manipulation may affect the lives of many as people were
dependent on their medical professional guidance. To strengthen and boost immunity
must not settle for less but to expand one’s capabilities and responsibility to address
health problems immediately. Failed to apply these consumptions may increase
mortality and untreated severity of diseases. Lack of resources must be observed.
 Providing helpful medical organizations or programs related to Diarrhea and
bradycardia were strongly be useful so that the public must be informed by the new
breakthroughs and value more security on the welfare of the majority.

H. REFERENCES

Herdman, T., & Kamitsuru, S. (2019). Nursing diagnoses: definitions and classification.
NANDA International, Inc, 2018 – 2010. 11 th edition. Thiems publishing.