Republic of the Philippines

WESTERN MINDANAO STATE UNIVERSITY

COLLEGE OF NURSING
Zamboanga City

Related Learning Experience

ROTATION 5: MEDICAL WARD

PEQUIT, Coleen T.
BSN – 4C
Date of Clinical Rotation: September 19-21, 2022
Submitted to: Winielyn D. Santuza, R.N., M.A.N.

CEPHALOCAUDAL ASSESSMENT
GENERAL APPEARANCE
 The patient is conscious, well-oriented of his present condition and showed interest with the
interview by answering every question instantaneously.
 The patient’s Vital Signs are normal with a temperature of 36.8 degree Celsius, pulse rate of 93
beats per minute, respiration rate of 18 breaths per minute and blood pressure of 110/80 mmHg.
 Upon receiving the patient, the patient was awake with PNSS 1L at 500 cc fluid level regulated at
12 gtts/min hooked in the right metacarpal vein.
 The patient has no obvious physical deformities or abnormalities.
 The patient showed no sign or potential signs of distress.
 Physically, the patient’s nutritional status and body built/stature is appropriate to his age.
 The patient is relaxed, has an erect posture and coordinated by body movements, can freely move,
flex and extend his extremities, doesn’t use any assistive device and can voluntarily move.
 The patient has a good facial expression without grimacing.
 The patient’s mood is appropriate to the situation, has appropriate response, comfortable and
calm.
 The patient is understandable, and moderate in pace.
 The patient physically looks clean and neat.

SKIN
The patient’s skin is uniformly brown in color except in areas exposed to the sun, has no lesions,
edema or abrasions, is not moist because of the air ventilated environment, has uniform temperature, and
when pinched, the skin springs back to the previous state. The tissues surrounding the nails of the patient
are intact. And when blanched test performed, color of the nail of the client returns into pink in less than
seconds.

HEAD AND FACE

The hair and scalp of the client was not assessed because she was wearing her hijab and refused
to be checked. The patient has symmetric facial movements.

EYE
The patient’s eyebrows have evenly distributed hair, has intact skin, symmetrically aligned, and
has equal movement. The conjunctiva is transparent, capillaries sometimes evident, and sclera appears
white and clear. The cornea is transparent, shiny and smooth, details of iris are visible. The iris is brown,
flat and round. The patient’s visual acuity is not normal and is wearing her prescribed glasses.
EAR
The patient’s external ear canal is dry, has presence of hair follicles, no pus or blood. Normal
voice tones are audible to patient. Sound is heard on both or localized at the center of the head. Ear is
without masses.

NOSE
The patient has no tenderness on sinuses. The nose is in the midline, has no discharges, no nasal
flaring, both nares are patent, and no bone and cartilage deviation noted on palpation.

MOUTH AND THROAT

The patient’s buccal mucosa is uniformly pink in color, moist, smooth, soft, glistening and elastic
in texture, and has no lesions. Teeth are white to yellowish in color, gums are pink, moist, firm, has no
retraction and bleeding of gums. Tongue is pink, has thin whitish color. Uvula is positioned in the midline
of soft palate. The tonsils are pink in color and have no discharges.

NECK
The trachea is on central placement in the midline of the neck, spaces are equal on both sides. The
thyroid gland is not visible in inspection, gland ascends during swallowing, no masses palpated.

CHEST (POSTERIOR AND LATERAL)

Equal chest expansion, decreased breath sounds of the right lung field, have no murmurs.

HEART
The patient’s heart has no palpable pulsation over the aortic, pulmonic, and mitral valves, no
noted abnormal heaves, and thrills felt over the apex, and no abnormal heart sounds is heard like
murmurs.

UPPER EXTREMITIES
Both extremities are equal in size, have the same contour with prominences of joints, no
involuntary movements, no edema, color is even, temperature is warm and even, has equal contraction
and even, can perform complete range of motion, no crepitus noted on joints, and can counter act gravity
and resistance on ROM.

ABDOMEN
The patient’s abdomen skin color is uniform, no lesions, have scar, flat, rounded, no tenderness
noted, with smooth and consistent tension, and has no muscle guarding.

LOWER EXTREMITIES
Both extremities are equal in size, have the same contour with prominences of joints, no
involuntary movements, no edema, color is even, temperature is warm and even, has equal contraction
and even, can perform complete range of motion, no crepitus noted on joints, and can counter act gravity
and resistance on ROM.

MUSCULOSKELETAL
The patient’s muscles are bilaterally symmetric, has no contractures and tremors, normal muscle
tension, adequate strength of the muscle. The bones are uniform in structure, no deformities, tenderness or
edema. Joints are not tender, has smooth movement and no nodules.

ANUS, RECTUM AND VAGINA

This was not assessed.