Name: NUDDIN, AL-QASARI C. AND PIOQUINTO, GIAN CARLO S.

Section: BSN 4A
Rotation: 8

CI: Jennifer C. Sampang RN, RM, MN

Date: February 27 – March 01, 2023
Area: CMZ Medical Ward

Assigned Patient
Patient’s Name: V.O.L Age: 70 y.o. Gender: Male Adm. Date: 02/23/23
Admission Diagnosis: Hemorrhoids Stage II, Anemia Secondary to Malignancy, Prostate
Cancer Stage IV
Other conditions: Bilateral Pneumonia, Atherosclerosis in Thoracic Aorta, Pleural
Effusion

CEPHALOCAUDAL ASSESSMENT

1. SKIN
Area/Feature to Assess Findings Analysis and Interpretation
Color Pale white skin NORMAL
Lesions Purplish lesions on the Purple Lesions are indicative
previous IV sites of purpura, this may be due to
the low low platelet levels
which can cause easy
bruising and bleeding.
Moisture Neither too dry nor too Moist NORMAL
Temperature Cold to touch, temperature is Cold and Clammy skin is
36°C indicative of Pulmonary
Edema where lungs are filled
with fluid (due to Pleural
Effusion) and is brought by
the lack of oxygen circulating
in the body due to the blood
not being able to properly
flow to the rest of the body.
Texture Wrinkled, smooth NORMAL
Mobility/Turgor Skin snaps back to its normal NORMAL
position in less than 2
seconds

2. HAIR
Area/Feature to Assess Findings Analysis and Interpretation
Color and Distribution Gray colored hair with black NORMAL
streaks and evenly distributed
Texture and Oiliness Soft and somewhat dry NORMAL
 Infestation
3. SCALP
Area/Feature to Assess
Tenderness, lesions, lumps,
masses
4. NAILS
Area/Feature to Assess
Color, shape, and texture
Capillary refill
Lesions
5. SKULL
Area/Feature to Assess
Shape and symmetry
Contour, masses, depression,
and tenderness
6. FACE
Area/Feature to Assess
Facial features
Edema and masses
7. EYES
Area/Feature to Assess
Visual Acuity
External Anatomical
Structures
8. EARS
Area/Feature to Assess
External Ear
There are no presence of lice NORMAL
Findings Analysis and Interpretation
Absence of redness, lesions, NORMAL
and lumps
Findings Analysis and Interpretation
Light pink colored, convex NORMAL
shaped, and firmly intact to
the skin
Immediately returns to its NORMAL
normal color
There are no presence of NORMAL
lesions
Findings Analysis and Interpretation
Rounded, symmetrical, and NORMAL
upright
Smooth, non-tender, there are NORMAL
no masses and depressions
Findings Analysis and Interpretation
Rounded face, slightly NORMAL
asymmetrical, and there are
no involuntary movements
No presence of edema or NORMAL
masses
Findings Analysis and Interpretation
Able to name and recognize NORMAL
objects and people well
There are no inflammation, NORMAL
edema, and masses
Findings Analysis and Interpretation
There are no discharge NORMAL
present, auricles are
symmetrical, and has the
same color as the facial skin
color
 Auditory Acuity Responds well to sounds NORMAL

9. NOSE AND SINUSES

Area/Feature to Assess Findings Analysis and Interpretation
Nose Unable to assess
Nasal cavity Unable to assess
Nasal sinuses Unable to assess

10. MOUTH
Area/Feature to Assess Findings Analysis and Interpretation
Breath Unable to assess
Lips Pale Pale lips are indicative of
poor oxygen circulation,
brought by pulmonary edema
Gums Unable to assess
Teeth Unable to assess
Tongue Unable to assess

11. NECK
Area/Feature to Assess Findings Analysis and Interpretation
Symmetry and musculature Symmetrical and moved NORMAL
smoothly
Lymph nodes Lymph nodes are non- NORMAL
palpable
Trachea Trachea is deviated away Tracheal deviated away from
from the right side of the the diseased side is indicative
patient of pleural effusion

12. THORAX AND LUNGS

Area/Feature to Assess Findings
Lesions Lung expansion is decreased
on the right side, tactile
fremitus is decreased
Sounds Decreased breath sounds
heard upon auscultation,
bronchial sounds heard over
the left side, dull percussion,
vocal fremitus is decreased
Analysis and Interpretation
A change in the elastic
equilibrium volumes of the
lung and chest wall indicates
an accumulation of
air/fluid/pus/blood in the
area, restricting its
movement. Decreased tactile
fremitus indicates a
significant separation of the
pleura from the parenchyma
which can be fluid/pus/blood.
Decreased breath sounds
indicate a decreased air
movement in the lungs. Dull
percussion indicates
abnormal lung density,

Appearance Use of accessory muscles was
noted. Ability to speak was
impaired.
13. CARDIOVASCULAR
Area/Feature to Assess Findings
Arterial pulse Arterial pulse (radial) is at 85
beats per minute.
Heart Point of maximal impulse is
below the 5th intercostal
space, lateral to the
midclavicular line
14. ABDOMEN
Area/Feature to Assess Findings
Generalized appearance of Abdominal distention,
the abdomen tenderness, and pain was
noted in the left lower
abdominal quadrant.
Bowel sounds Decreased bowel sounds over
the ileocecal valve was heard.
Abdominal Quadrants Dullness was noted on the
lower left quadrant with
scattered dullness heard in all
other quadrants.
15. VASCULAR SYSTEM
Area/Feature to Assess Findings
Arms Edema was noted on both
arms with a pale skin tone
and was cold to touch.
Legs Legs are pale and cold to
meaning, air does not occupy
the lungs. Decreased vocal
fremitus indicates a decrease
in lung tissue density due to
fluid or air accumulation
which decreases the
transmission of low
frequency sound vibrations.
The use of accessory muscles
indicates increased breathing
effort. Impaired ability to
speak entails worsened
pulmonary function or
reserve.
Analysis and Interpretation
NORMAL
A displacement in the PMI
laterally and downward is
indicative of cardiomegaly
Analysis and Interpretation
NORMAL
Decreased bowel sounds
indicates constipation as
peristalsis is not present.
Dullness in left lower
quadrant indicates that the
intestines are filled with some
sort of mass (stool).
Analysis and Interpretation
Edema in the upper
extremities indicates
problems with blood vessel
permeability. Pale and cold
skin indicates poor perfusion.
NORMAL
 touch with no lesions, edema,
or absent pulses.

16. MUSCULOSKELETAL SYSTEM

Area/Feature to Assess Findings Analysis and Interpretation
Gait Unable to assess
Temporomandibular Joint Unable to assess
Sternoclavicular Joint There was no noted NORMAL
deviations in location, color,
swelling, masses, tenderness,
or pain.
Cervical, thoracic, and Noted deviations in thoracic Right-leaning spine indicates
lumbar spine spine to the right dextroscoliosis.
Shoulders, arms, elbows Noted edema on arms, client Unable to perform full ROM
was unable to have full range indicates restrictions in
of motion and perform movement.
flexion properly.
Hands, wrist, fingers No tenderness no changes in NORMAL
shape and symmetry. Skin
was pale, patient was able to
have full ROM of the fingers
and wrist.
Hips Noted flexion of the knee but Unable to perform full ROM
was unable to bring into the indicates restrictions in
chest. Leg extension was movement.
moved far away from the
body as possible.

17. NEUROLOGIC SYSTEM

Area/Feature to Assess Findings Analysis and Interpretation
Neurological Status Glasgow coma scale score is NORMAL
at 14. Noted tense behavior
but with no abnormalities on
mood, thought processes, and
cognitive abilities.