PHYSICAL ASSESSMENT

GENERAL SURVEY: Patient is lying on bed awake and coherent, feeling of

fatiguability, palpitations, severe headache, nausea and vomiting, tremors and moist
hands. She claimed that the she has been experiencing since yesterday of having a
feeling of nervousness and dyspnea upon exertion.

Hair The patient’s Patchy hair loss is noted.

Skin The patient’s skin observed to be warm, shiny and moist with the temperature of
36.5°C.
Eyes The patient’s eyes appear to be slightly bulging, periorbital edema noted.
Hands The patient is checking on the nail beds, the distal separation of the nail plate is
observed, cold tremors moist hands are also noted.
Throat The patient’s Thyroid gland is smoothly palpable diffused enlarged. Patient’s
body built appears to be thin.
Lungs The patients are lungs clear, the tracheal air column is at midline and the heart
is enlarged. HR: 150bpm, RR: 22cpm, O2 Sat 94%.
Neck The patient’s neck was a little bit big with slight neck vein distensions noted and
the trachea was located midline.
Breast The patient’s left breast is slightly bigger than the right, his nipples and areola
are light brown in color. He appears to have gynecomastia and no palpable
masses were noted.

Respiratory The patient has a fruity odor on his breath; he is having difficulty breathing with
shortness of breath, nasal flaring and uses her accessory muscles in breathing.
His RR is 28cpm.
Cardiovascular The patient breath sounds are heard in all areas of the lungs. He sometimes
complains of chest pain he states that the pain is 8/10 and shows guarding
behavior with his chest with a grimace facial expression. His heart rate is
120bpm with a blood pressure of 160/100mmHg, no murmurs or gallops were
heard.
Urinary The patient states that he experiences increase in urination. His urine output is
350 ml/hour
Genital The patient didn’t want you to assess his genitals, but he stated that it looks
normal.
Peripheral/ The patient’s pulses on her extremities are strong and bounding. He has a CRT
Vascular of 4 seconds
Musculoskeletal The patient’s feels weak and needs assistance in doing activities of daily living
he easily gets fatigue
Neurologic The patient’s GCS is 15/15 Conscious, awake and coherent.

Psychiatric The patient looked anxious and displayed signs of depression.h hx

Vital signs checked, BP:160/100, Temp:37.9, HR: 150bpm, RR:22cpm, O2 Sat 94%, pain scale of severe
headache as claimed was 8/10.

Upon conducting a physical examination, the patient’s eyes appear to be slightly bulging, periorbital
edema noted. Patchy hair loss noted. Skin observed to be warm, shiny and moist. Checking on the nail
beds, distal separation of the nail plate observed, cold tremors moist hands are also noted. Thyroid
gland is smoothly palpable diffused enlarged. Patient’s body built appears to be thin.

The physician was asking the patient’s family history, she said “Sa among family Doc kay Diabetes,
Asthma man ang common nga sakit sa side sa akong Mama, actually asthmatic sya, lolo nako namatay sa
asthma, akong lola kay namatay sa diabetes. Pero naa koy isa ka Auntie, igsoon sako akong Mama
naoperahan sa US sa iyang thyroid kay nadiagnose siya dati ug Hyperthyroidism bata-bata pa daw sya
ato. Sa akong mama na side, tubuan ug mga cysts maskin asa pero dili man nuon cancerous. Sa tinuod
lang, nagka DENGUE FEVER pod ko tong 4th yr highschool ko, naadmit ko diri. Sa akong Papa pod na side
wala koy idea sa ilang mga sakit kay bulag na sila akong mama dugay na.”

GENOGRAM

Assessment Nursing

Diagnosis

Planning Intervention Rationale Evaluation

Subjective:

“ madali nga ako

mapagod” as

verbalized by the

patient

Objective:

- Restless

- Irritability

- fatigue

Vital Signs:
- BP: 140/90

mmHg

- PR: 120 bpm

- RR: 27 cpm

Increased

cardiac

workload

related to

hypermetabolic

as evidenced by

increase blood

pressure, pulse

rate and

respiratory rate

At 4 hours

of nursing

intervention

the patient

will be able

to maintain

adequate

cardiac

output as

evidence by

stable vital
signs as

follows

blood

pressure

(from

140/90 to

120/80) ,

pulse rate

(120- 60-

100 bpm)

and

respiratory

rate (27-

20bpm).

Independent:

• Monitor vital signs

especially blood

pressure

• Place the client in

semi-Fowler’s

position or position

of comfort

• Provide restful

environment

Dependent:
• Maintain adequate

nutrition and fluid

balance as ordered

by the physician

( low iodine and low

root crops foods)

Collaborative:

• Administer Beta

Blockers

(Propanolol) Inderal

as ordered).

• May indicate

compensatory

changes in stroke

volume

• Elevating the head

may decrease

cardiac work load

• Rest periods

decrease oxygen

consumption

• To provide proper

nourishment to

the patient

• Decreases heart
rate/ cardiac work

by blocking

conversion of T3

to T4.

After 4 hours of

rendering nursing

intervention the

patient was able

to maintain

adequate cardiac

output as

evidence by

stable vital signs

as follows blood

pressure (120/80)

, pulse rate (110

bpm) and

respiratory rate

(24bpm)