COLEGIO SAN AGUSTIN - BACOLOD

NURSING PROGRAM
B.S. Aquino Drive, Bacolod City
Contact Number: (034) 434 - 2471 Local 162
Email Address: csab.chap@gmail.com

SYSTEMIC ASSESSMENT

Nervous System ● Appears drowsy when spoken to in a loud voice.

● Opens his eyes but falls asleep back after a while.
● Was able to identify his name and birth date.
● Was not able to describe in detail what had happened in the last
few days.
● Manifests irritability and confusion.
● Experiences nausea and vomiting.
● Feels excruciating pain in the head.
● Disrupted sleep pattern.

EENT ● Eyebrows are asymmetrical. The right eyebrow appears higher

than the left eyebrow.
● Eyes are protruding and noted an unequal palpebral fissure.
● Both conjunctivas are pale in color.
● Sclerae has slight yellowish discoloration.
● Noted a slow corneal reflex and pupillary reaction to light.
● Pupils are unequal in size.
● Subconjunctival hemorrhage noted.
● Earlobes are bean shaped, parallel, and symmetrical.
● No lesions were noted on inspection.
● No discharges were noted at the ear canal.
● Nose in the midline.
● Both nares are patent.
● No tenderness was noted on palpation.
● Nasal mucosa is pinkish in color.
● Noted bleeding of gums.
● Tongue was pale with white taste buds on the surface.
● Weak gag reflex.
● Surface of the tongue is smooth.

Respiratory ● Shortness of breath noted.

System ● Retraction of the chest wall was noted.
● Deep and rapid breathing (RR: 23 CPM)
● Dry mucous membranes
● Pulmonary Leukostasis noted.
● Noted a wheezing sound in the lungs upon auscultation.

Cardiovascular ● Palpitation noted.

System ● Tachycardia was noted (HR: 120 bpm).
 ● Increase in blood pressure (140/100).
● Heart murmurs were noted (whooshing)

Alimentary ● Dry mouth

System ● Palpation of the abdomen revealed an enlarged spleen and
tenderness
● Normal bowel sounds were noted (borborygmi)
● On percussion, dullness was noted
● Tenderness of left hypochondriac was noted upon deep
palpation

Urinary System ● Yellow-colored urine approximately 6-7 times a day.

Musculoskeletal ● Malaise
System: ● Fatigue
● Body pain
● Decreased body reflexes with an abnormal range of motion of
the upper and lower extremities.
● Incapable of performing activities of daily living.

Integumentary ● Dry and pallor skin were noted

System ● Poor skin turgor was noted
● Petechiae and bruising were noted on the patient’s right lower
leg and ankle

Medical history

The patient experienced excruciating headaches that can be scale with 10/10 pain level;
malaise, and fatigue weeks before he was admitted. He also has intermittent fever that
goes on and off and the highest temperature recorded was 39.6. The patient also has
red little spots (petechiae) and bruises on his right lower leg and ankle.

Present

The patient is still experiencing an excruciating headache. He experienced nausea and

vomiting. Patient’s vital signs are as follows: Blood Pressure: 110/70mmHg, Heart Rate:
120 bpm, Respiratory Rate (at rest): 23 cpm. The patient experiences shortness of
breath and a Pulmonary Leukostasis was noted. The patient also experienced
palpitation and a whooshing sound or heart murmurs were noted. There is a decrease in
body reflex and the patient is incapable of performing activities of daily living.