Our Lady of the Pillar College-Cauayan

Cauayan City, Isabela

College HEALTH
of Nursing and Midwifery
ASSESSMENT

PHYSICAL ASSESSMENT

Name of Patient: Chelsea May Bal-ut Age: 19 Gender: Female Birthday: May 1, 2004
Address: Cabaritan San Manuel Isabela Occupation: Student Status: Single Civil Status: Single
Chief Complaints: Cough

Assessment PA Technique Used Actual Findings Analysis/ Interpretation

GENERAL APPEARANCE Inspection  Color is even without obvious lesions: light Normal
 Skin appearance to dark beige pink in light skinned client

 Dress and Grooming Inspection  Wears appropriate clothing; clean and Normal
neat. Hair is well

 Hygiene Inspection  There is no indistinct odor, and client is Normal

clean

 Posture Inspection  Posture is erect and comfortable for age. Normal

The same when standing, sitting and
walking
 Body build Inspection  Weight within range for height, age, body Normal
size. Firm and well - developed muscles.
Mesomorph body built. Body built
proportionate to height and weight. Firm
 and equal distribution of fat and muscle
mass.
 Level of Consciousness Inspection  Conscious and coherent Normal
 Response immediately
 Maintain eye contact

 Level of Comfort Inspection  Very comfortable Normal;

 Facial Expression Inspection  Patient is calm and expresses ideas and Normal
feelings clearly and concisely.

 Speech Inspection  Understandable, moderate pace; exhibits Normal

thoughts association

VITAL SIGNS Adult: 36.4 Degree Celsius Normal

 Body Temperature
36.5 to 37.5 Degree
Celsius
 Pulse Rate Adult: 60 bpm Normal

70 (60-100)
 Respiratory Rate 16-20/min 17 bpm Normal

 Blood Pressure Older Adult 100/60 mmHg Normal

120/80 mmHg
 Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: “Hindi ako Activity intolerance related After 4 hours of nursing Independent: •Establishes patient’sAfter 4 hours of nursing
makatulog dahil sa ubo to exhaustion associated intervention, the patient capabilities or needs interventions, the patient
ko” as verbalized by the with interruption in usual will demonstrate a • Evaluate patient’s and facilitates choice was able to demonstrate a
response to activity. of interventions
patient. sleep pattern because of measurable increase in measurable increase in
discomfort, excessive tolerance in activity with • Provide a quiet • Reduces stress and tolerance in activity with
Objective: coughing and dyspnea. absence of dyspnea and environment and excess stimulation, absence of dyspnea and
• Fatigue. excessive fatigue limit visitors during promoting rest. excessive fatigue.
acute phase.
• Dyspnea. • These measures
• Elevate head and promote maximal
• Vital Signs encourage frequent inspiration, enhance
T: 36.4 position changes, expectoration n of
deep breathing and secretions to
P: 60 effective coughing. improve ventilation.
R: 17 •Encourage • Facilitates healing
adequate rest process and
BP: 100/60
balanced with enhances natural
moderate activity. resistance.
Promote adequate
nutritional intake.

Force fluids to at
least 3000 ml per
day and offer warm,
rather than cold
fluids.
Collaborative:

•Administer
medications as
prescribe:
mucolytics or
expectorants.
 Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: “nahihirapan Ineffective Airway STG: After 6 hours of 1. Monitor VS every 2 hrs. 1. To assess baseline data. STG: After 6 hours
ako huminga dahil sa Clearance related to nursing intervention, 2.promotes maximal lung of nursing
ubo ko”, as verbalized thick tenacious the client will be able to 2. Encourage patient to position function. 3.Repositioning intervention, the
in high Fowler’s or semi
by the patient. secretions and airway cough effectively and promotes drainage of client had been able
obstruction as clear own secretions. Fowler’s positon. pulmonary secretions and to cough effectively
Objective: manifested by shallow 3. Turn patient every 2 hrs and enhances ventilation to and clear own
LTG: After 5 days of
>inability to cough respiration, tachypnea nursing intervention, prn. decrease potential of secretions. Goal was
effectively and fever. atelectasis. met.
the client will maintain 4.Teach client to maintain
>shallow respirations patency of airway and adequate hydration by drinking 4.To help thin secretions. LTG: After 5 days of
>febrile will have clear breath at least 8- 10 glasses of nursing
sounds. 5.To conserve energy and intervention, the
fluid/day (if not to reduce airway collapse. client
>anxiety contraindicated). maintained
6.CPT techniques utilizes patency of airway
>restlessness forces of gravity and and had clear breath
5. Teach and supervise effective
>adventitious breath coughing techniques. .6. motion to facilitate sounds. Goal was
sounds secretion removal.
perform Chest Physical therapy. met
>tachypnea

>use of accessory
muscle while breathing