PHYSICAL ASSESSMENT

In Partial Fulfillment of the Requirement in NCM 207

PRE-CLINICAL ROTATION

Submitted to:

JINGKY FRANCO, RN

Clinical Instructor

Submitted by:

Avila, Josephine L.
Balonda, Karylle Sydney A.
Bantilan, Marc Joshua P.
Chua, Thea Jana T.
Cubarrubia, Phoebe Hyacinth P.
Cudis, Chlizly Noween C.
Derla, Alfonso Luis T.
Econar, July Jane B.

BSN-2H – Group 2

August 29, 2022

 a. Biographical Data
Name: A.L.D Age: 19 Gender: Male
Ward/Unit: Sta. Rosa Ward Room#: 302 Examiner:Josephine L. Avila, St. N
Address: ___Panabo City, Davao del Norte ________________________
Birthdate: Dec 18, 2002 Place of Birth: Tagum city
Nationality: Filipino Marital Status: Single Educational Level: College
Blood type: A Occupation: N/A Religion: Roman Catholic

b. Admission History
• Chief Complaint: Difficulty of breathing with coughing episodes
• Admitting Diagnosis: Abnormal vital signs results
• Admission Date: August 26, 2022 @ 7 AM
• Ward/Room/Bed Number: Sta. Rosa Ward, 302-2
• Physician: Dr. Joy Milan

c. History of Present Illness

Patient A.L.D., male, 19 years old, is a persistent student nurse in a higher
educational institution in Davao City, Davao del Sur. He was immersed in completing his
laboratory tests within the day as a pre-requisite for the face-to-face classes. Upon
walking up the hospital stairs, he suddenly experienced difficulty breathing
accompanied by coughing episodes. Fortunately, he ran into a nurse, who then assisted
and assessed his vital signs. Upon assessment, the nurse was able to record the
following data: blood pressure = 135/75C, respiration rate = 25 breaths/minute, pulse
rate = 90 beats/minute, cardiac rate = 90 beats/minute, and temperature = 36C. On top
of this, the patient also verbalized, “Maglisod ko ug ginhawa pirmi”. Upon obtaining the
results, the nurse referred the patient to a pulmonologist, Dr. Joy Milan, who then
ordered admission. Due to this pre-existing condition, the patient has reported trouble
sleeping, which often happens five times a week. He would suddenly wake up at around
3 in the morning and it would take another 2 hours for him to get back to sleep.
Consequently, he has a hard time compensating for a normal sleeping pattern since he
has academic responsibilities from morning to evening. With regards to the latter, he
has difficulty establishing good communication with his friends and family as he has
been very irritable and impatient lately. Thus, no one would have the courage to speak
to him unless he sets the conversation.

d. Past Health History

To put it into context, the patient has a history of asthma and was admitted 5
years ago due to a severe asthma attack. Traced to his family background, his mother is
also asthmatic and there are a few more relatives from both the mother’s and father’s
side who have acquired such a condition.

e. Family Health History

i. Genogram
The genogram above depicts the family history from both sides of patient A.L.D’s
parents - starting from his grandparents, to his parent’s siblings, and down to his brother
and sister. Furthermore, this describes that both of his parents’ sides had a history of
asthma condition; however, it appears that he acquired most of his condition from his
mother's side which indicates the relevance of the condition that passes from generation
to generation.

f. Gordon's Functional Health Patterns

• Health Perception – Health Management Pattern
Patient A.L.D is well-aware and well-equipped with the health services he ought
to have in case his asthma arises suddenly. He goes directly to Dr. Joy Milan, his
pulmonologist, whose clinic is located within a 5-minute walking distance from his
house. Apart from this, he is currently taking his maintenance medication.

• Nutritional – Metabolic Pattern

As for the patient’s food preferences, he prefers to consume healthy foods rather
than those that contain saturated or hydrogenated fat since this can trigger his asthma.
Examples of these healthy foods are the following: broccoli, skinless chicken, and
almonds. On the other hand, the following are the ones the patient avoids: bacon,
canned goods, and junk foods.

• Elimination Pattern
On average, the patient urinates eight times and defecates at least once or twice
daily. His urine volume ranges from 1000-2000 mL daily and is pale yellow in terms of
color. On the other hand, his fecal matter is brown in color and soft in consistency. No
other abnormalities, such as constipation, diarrhea, and the presence of intestinal
parasites have been denoted.

• Activity – Exercise Pattern

As a result of his condition, the patient has to prevent from performing strenuous
activities. With that being said, his daily activities primarily revolve around effortless
walking and controlled breathing exercises. On top of that, the patient is observed to
have an increased cardiac output when performing heavy exercises as his body is trying
to compensate for energy.

• Cognitive – Perceptual Pattern

Upon assessment, patient A.L.D is capable of communicating effectively for the
reason that he responds to the questions in an organized and systematic manner. His
stimuli respond both physically and verbally as well. No other sensory deficits have
been identified.

• Sleep – Rest Pattern

Due to his pre-existing condition, the patient has reported trouble sleeping, which
often happens five times a week. He would suddenly wake up at around 3 in the
morning with his chest feeling heavy. Normally, it would take another 2 hours for him to
get back to sleep. Consequently, he has a hard time following a normal sleeping pattern
since he has academic responsibilities from morning to evening.

• Self-perception – Self-concept Pattern

The patient is a warm-hearted, affectionate and kind person. Though weak, he
still shows a strong sense of enthusiasm and hopes to be relieved and treated.
However, due to his condition, he loses self-confidence for his incapacity to engage in
physical activities. Since his last admission, he wanted to make sure to be better.

• Role – Relationship Pattern

He is a persistent student nurse. A lovable son, and is a protective brother to his
sisters. He lives together with his family and his favorite bonding with them is watching
movies and playing chess. Due to his condition, however, he has difficulty establishing
good communication with his friends and family as he has been very irritable and
impatient lately. Thus, no one would have the courage to speak to him unless he sets
the conversation.
 • Sexuality – Reproductive Pattern
The patient has no difficulties with sexual functioning. No history of sexually
transmitted disease or any disease affecting his genitals was denoted.

• Coping – Stress Tolerance Pattern

No big changes within the past two years, yet he was immersed in completing his
laboratory tests in order to complete his requirements for the face-to-face classes. With
regards to the patient's coping mechanism, he distresses himself by performing
household chores and by taking a nap or sleeping. No traumatic events were
experienced before. Just recently, he has been experiencing stress and anxiety since
compared to other teens, he frequently falls behind them and has a lower tolerance for
engaging in such activities. If the stress is too much or hysterical, crying is his way of
releasing emotions.

• Value – Belief Pattern

The patient is a Christian who values kindness, love, and purity. He is a religious
man throughout his life and he always brings with him the rosary when praying at night.
Moreso, he goes to church with his family to attend mass every Sunday.

g. Physical Assessment
Vital Signs Pt’s Vital Signs Normal Values Indication
Temperature 36.0 °C 35.6 – 36.7°C Normal
Blood Pressure 135/75 110/70 - 130/90 Abnormal
mmHg (Hypertension)
Cardiac rate 90 bpm 70 – 80 bpm Abnormal
(Bradycardia)
Pulse Rate 90 bpm 70 – 80 bpm Abnormal
(Bradycardia)
Respiratory Rate 25 bpm 16 – 20 bpm Abnormal
(Tachypnea)
 I. Skin
The client's skin is equal in color, undamaged, and there is no odor. His skin
turgor is normal, and his skin temperature is normal as well.

II. Head
The client's face seemed smooth and homogeneous in consistency, with no
nodules or lumps. Hair is spread equally. When asked to raise and lower his brows, the
brows were symmetrically aligned and moved equally. Furthermore, the client's hair is
thick, smooth, and equally distributed, with a varying amount of body hair. There are no
indicators of illness or infestation either. When palpated, there are no nodules, lumps, or
depressions.

III. Eyes
The eyelashes looked to be evenly distributed and slightly curled outward. There
were no discharges or discoloration, and the lids closed symmetrically with 15-20
involuntary blinks per minute. The bulbar conjunctiva was translucent, with only a few
capillaries visible while the palpebral conjunctiva was pink, shiny, and smooth. Moreso,
the sclera was white. There was no edema or lacrimal gland tearing. The cornea was
clear, smooth, and glossy, and the iris features were also evident. When the cornea was
touched, the client blinked.
The pupils of the eyes were all the same size and color. The iris is round and flat.
PERRLA (pupils equally round response to light accommodation), pupils constrict both
lit and unilluminated. When staring at a close object, the pupils constrict and dilate.
When the object is pushed closer to the nose, the pupils congregate. When looking
straight ahead, the client can detect items in the periphery when examining the
peripheral visual field. When testing for the extraocular muscle, the client's eyes moved
in sync with parallel alignment. Lastly, the client was able to read the Snellen chart held
14 inches away.
 IV. Ears
The auricles are symmetrical and have the same hue as the skin on his face. As
such, they are aligned with the eye's outer canthus. The auricles are movable, firm, and
not painful when palpated for texture as well. Finally, the pinna recoils when folded.
During the assessment of the watch tick test, the client was able to hear ticking in both
ears.

V. Mouth
The client's lips are uniformly pink, moist, symmetric, and smooth in texture.
When asked to whistle, the customer was able to contract his lips. Teeth and Gums:
There is no yellowing of the enamels, no retraction of the gums, and the gums are
pinkish in color. On the other hand, the buccal mucosa of the client was equally pink;
moist, soft, shiny, and elastic in texture. The client's tongue is centrally located as well -
it is pink, wet, and somewhat scratchy. There is a thin yellowish covering present.
Moving on, silky palates are pale pink and smooth, whereas hard palates are more
uneven in texture. Lastly, the client's uvula is located in the soft palate's midline.

VI. Pharynx
While assessing the client's pharynx at a time to avoid the gag reflex by exposing
one side of the oropharynx, the examiner found out that it was good - with no signs of
tenderness, swelling, or lesions.

VII. Nose
The nose seemed symmetric, straight, and consistent in terms of color. On the
same note, there were no discharges or flaring present. Finally, there was no pain or
lesions when softly palpated.

VIII. Neck
Check the client's neck muscles by asking him to hold his neck erect and
observing his head movement. As he moves his neck, the examiner found out that there
were no signs of swelling or masses and the muscles were equal in size. As his head
moved, the examiner observed that it had a smooth movement without discomfort.
Furthermore, the head flexes at 45 degrees, his head hyperextends at 60 degrees, the
head laterally flexes at 40 degrees, and the head laterally rotates at 70 degrees. Lastly,
patient A.L.D also moved against resistance with equal muscle strength when asked to
shrug his shoulders against the examiner’s hands.

IX. Thorax
Client’s thorax is oval, and the overall form is elliptical, more expansive, and
deep, with an anteroposterior to transverse ratio is 1:2, which is normal. His spinal
alignment is also vertically aligned. Upon assessment, the thorax showed no masses or
tenderness. The client's chest expansion is full and symmetric, which is normal as well.
While comparing the fremitus on both lungs and between the apex and base of each
lung, it was deemed that the fremitus decreased as he has a history of asthma.
The client's lungs are symmetrical as the examiner compares one side of the
lung with the other. His diaphragm is 6cm, which is normal, and the diaphragm is slightly
elevated on the right side. The last part of checking the patient's posterior thorax is
auscultating the chest using the systematic zigzag procedure. For this part, adventitious
breath sounds for the client's corresponding moment on the opposite side of the chest
were heard. The breathing patterns of the anterior thorax of our client are not typical.
Patient A.L.D has shortness of breath and dramatically decreased tidal volume or
respiratory rate. The patient's costal angle at which the ribs enter the spine is about less
than a 90-degree angle, showing no masses or tenderness. It shows the decreased
chest excursion as the client takes a deep breath when the examiner palpates the
anterior chest for the respiratory excursion.
Lastly, the tactile fremitus of the client shows bilateral symmetry, and the anterior
chest of the client resonates until the 6th rib at the diaphragm level but is flat over areas
of heavy muscle and bone, heart, liver, and tympany over the stomach. The trachea and
the anterior chest produce adventitious breath sounds (crackles).
 X. Heart
The examiner inspected and palpated the client's precordium for abnormal
pulsations, lifts, or heaves. Upon assessment, pulsations at the apex than at the base
were observed because the apex is more active and the bottom is a quieter area.
Moreso, the client's cardiac rate is 90 bpm, denoting a regular rhythm and absence of
abnormal beats, murmurs, and pulse. His carotid artery has symmetric pulse volumes,
full pulsations, and thrusting quality. Quality remains the same when the client breathes,
turns his head, elastic arterial wall, and there is no presence of bruit.
The client has a positive carotid pulsation, JVP of 2 cm at 45 degrees angle. His
peripheral pulse on both sides is symmetric and full pulsation is observed as well. On
another note, his peripheral leg veins are symmetric in size and his limbs are not tender.
In Buerger's Test, the patient's skin color on the hands and feet is pink, his temperature
is not excessively warm/cold, there are no signs of edema, and his skin texture is
resilient and moist. As the client raises his leg slowly to a maximum angle of 90°, his
limb is still pinkish. The client is negative for Allen's Test and the Capillary Refill Test
since the original color of the skin surface returns after 2 seconds.

XI. Breast
The client's breasts are even with the chest wall and his skin is uniform in color,
smooth, and intact. The size and shape of the areola are round/oval, dark brown in
color, and bilaterally the same. Furthermore, there is an irregular placement of
sebaceous glands on the surface of the areola, with no masses and discharges
recorded. The client's nipple size and shape are round, everted, and equal in length.
Finally, the axillary, subclavicular, and supraclavicular lymph nodes show no tenderness,
swelling, or discomfort.

XII. Abdomen
In assessing the client's abdomen, the examiner performs the IAPP (inspection,
auscultation, percussion, palpation). Upon assessment, the client's skin is intact and
unblemished, and the abdomen is round with no evidence of liver or spleen
enlargement or symmetric contour. As such, his abdomen produces audible bowel
sounds, an absence of arterial bruits, and a lack of friction rub.
The client's liver size at the midclavicular line is 10 cm and 7 cm at the central
sternal line. There is no tenderness or muscle guarding and consistency in its tension.
Deep palpation in all four quadrants is performed and tenderness is present near or
over the xiphoid process, cecum, and sigmoid colon. Lastly, the liver is not palpable and
is in a smooth border, while the upper part of the pubic symphysis is not palpable.

XIII. Genito-Urinary
The client's distribution, amount, and characteristics of pubic hair are triangular
and spread up to the abdomen. The urethral meatus has a pink, slit-like appearance at
the tip of the penis and no discharge. His penile shaft and glans penis skin are intact,
slightly wrinkled, and the color is light brown like his body skin; foreskin is easily
retractable (from glans penis) and a small amount of thick white smegma between glans
and foreskin is denoted.
Furthermore, the penis is smooth, semi-firm, and slightly moveable. The patient's
scrotal skin is loose and darker than the rest of the body, and size varies with
temperature changes. Both testes are rubbery, smooth with no nodules or masses, and
about 2x4 cm. On the other hand, the epididymis is resilient, typically tender, and softer
than the spermatic cord. Both inguinal areas have no swelling or bulges, and there is no
palpable bulge in the hernias as well.
Finally, the client's anus and surrounding tissue are slightly darker than the
surrounding skin and are intact. Digital Rectal Exam was also performed by the
examiner to palpate the rectum for anal sphincter tonicity, nodules, masses, and
tenderness - no nodules, masses, and tenderness record; thus, indicating good
sphincter tonicity. Upon withdrawing the finger from the rectum and anus, brown color
feces is observed.

XIV. Musculoskeletal
The client's muscle size is equal and manifests a good muscle tone, with no
contractures, tremors, or fasciculations. As such, his muscle is passive for flaccidity and
spasticity, has coordinated movements, and has equal muscle strength on each
laterality. There are no deformities in the client's skeleton, tenderness, and swelling
along areas of long bones and his joints. Lastly, the client's range of motion is smooth
and movements are coordinated with no complaints of tenderness observed.
XV. Neurological
1-Alert 5-Decorticate
2-Drowsy 6-Decerebrate
3-Very Drowsy 7-Comatose
4-Localizing
Note that, before meeting the patient, the examiner introduced herself, asked his
name, and how his day was. Upon assessment, the patient was well-attentive and alert.
Scored 1.

Eye opening Verbal response Motor response

4 Spontaneous 5 Oriented 6 Obeying

3 Responsive to verbal 4 Confused 5 Localizing

2 Responsive to pain 3 Disoriented 4 Withdrawing

1 No eye opening 2 Inappropriate 3 Decorticate

1 No response 2 Decerebrate

1 Comatose

Eye opening – 4 When I entered the room, the client was on alert.

Verbal Response – 4 The patient can respond, but their responses don't appear

quite correct; this is classified as confused communication.

Motor Response – 5 The patient tries to reach the area where I applied painful stimuli.

Total RLS/GCS Score : SCORE 13/15

 Cranial Nerves Assessment

CRANIAL NERVE ASSESSMENT REMARKS

I. OLFACTORY The examiner asked the Present

patient to identify the smell of
the coffee, alcohol, and vanilla.

II. OPTIC The examiner asked the Present

patient to read with each eye
and both eyes.

III. OCULOMOTOR PERRLA (pupils equally round Present

and reactive to light and
accommodation)

IV. TROCHLEAR Both eyes are able to move as Present

necessary.

V. TRIGEMINAL Client was able to elicit corneal Present

reflex, sensitive to pain stimuli,
and distinguish hot from cold.

VI. ABDUCENS Both eyes move in Present

coordination.

VII. Facial Client performed various facial Present

expressions without any
difficulty and was able to
distinguish varied tastes

VIII. AUDITORY During the watch tick test, the Present

client was able to hear ticking
sounds in both ears.
IX. GLOSSOPHARYNGEAL Client was able to elicit gag Present
reflex and was able to swallow
without difficulty. As such,
tongue movement was
well-performed

X. VAGUS Positive sensation for pharynx Present

and larynx was assessed
through swallow reflex

XI. SPINAL ACCESSORY Client was able to shrug his Present

shoulders and turn his head
from one side to the other

XII. HYPOGLOSSAL The client was able to protrude Present

his tongue in different
directions.

CONCLUSION:
As reflected in the results above, all of the vital sign results are abnormal except
for the temperature (T = 36.0 °C). Upon assessment, the examiner was able to note that
abnormal pertinent findings occurred primarily in the thorax. To elaborate on this, patient
A.L.D’s thorax manifests some unusualities in the vocal fremitus, adventitious breath
sounds, and shortness of breath with decreased respiratory rate. On the same note, the
trachea and anterior chest were able to produce adventitious or crackling sounds. Due
to his pre-existing condition, the patient exhibited an abnormal sleeping pattern as well.
As student nurses, we can relate to this matter as we too have friends, relatives,
and even family members who may be suffering from such a condition. It is definitely
hard for them to move or perform activities due to their physical limitations. With such a
premise, not being able to breathe normally and perform as many activities as possible
are some of the worst scenarios they could be feeling.
Moreover, as the examiner goes through the assessment, it was inferred that all
of those abnormal findings must be given immediate attention and referral to the
physician as asthma is considered life-threatening. Certainly, the nursing profession
plays a vital role in monitoring, evaluating, educating, and maintaining the optimal health
of the patient. For this reason, we must be vigilant at all times so as to perform an
intensive assessment, care, and intervention for the clients in hopes of alleviating their
health complications.

REFERENCE:
RNlessons. (2021). Ineffective Breathing Pattern Nursing Diagnosis & Care Plan.
RNlessons.
https://rnlessons.com/ineffective-breathing-pattern-nursing-diagnosis-care-plan/
Wagner, M. (2021). Ineffective Breathing Pattern Nursing Diagnosis & Care Plan. Nurse
Together.
https://www.nursetogether.com/ineffective-breathing-pattern-nursing-diagnosis-ca
re-plan/
Wayne, G. (2022). Ineffective Breathing Pattern Nursing Care Plan. Nurselabs.
https://nurseslabs.com/ineffective-breathing-pattern