Chapter V

Health Assessment

General Assessment:

Client 74 years old, female was admitted to surgical ward due to fall injury. Upon

entering in the client room, client is unresponsive, unconscious and asleep with GCS 5. Bruises

are present in both lower and upper extremities due to fall injury that happened twice in a

standing position which results to fluid accumulation the brain. Nasogastric tube was attached in

her left nostril for her enteral feeding and for her oral medications; with foley catheter attached to

urobag patent and intact with urine output of 350 cc . Client positioned semi fowler to prevent

intracranial pressure.

Digestive/ Metabolic/ Nutrition

The client exhibits an endomorph body type, characterized by a soft, round and slim

build. Prior to admission, her weight is 45 kilogram, with a subsequent weight loss of 5

kilograms. However, upon admission, her weight was recorded at 40 kilograms, and her height is

was measured 154 centimeters resulting in a calculated BMI of 16.44 which is underweight.

Patient is unresponsive and unconscious and she cannot even swallow food that is why the

Attending Physician ordered to put client in Nasogastric Tube for feedings and also for oral

medications, during the shift we administered 120 cc for her enteral feeding and 10 cc for her

oral medication which is Potassium Chloride and for her Intavenous fluids is PNSS 1L to run for

60cc per hour. According to the family members the client doesn’t have any food allergy even

medications she eats all she wants and always drinks coke and can consumed 2 liters of coke

everyday and drink alcoholic beverages occasionally. Her vital signs are as follows: Temperature
(T) of 36.4 degrees Celsius, Heart rate (HR) 71 beats per minute, Respiratory rate (RR) of 16

breaths per minute, Blood pressure (BP) reading of 140/80 mmHg which is elevated, and oxygen

saturation (SPO2) level of 98%.

Respiratory System:

The patient exhibited a respiratory rate of 20 breaths per minute; she is having difficulty

of breathing upon admission that is why oxygen 2L/min was administered, but after few days’

oxygen was detached due to family refusal since they signed already the DNR and DNI form.

Additionally, during the hospital stay client was positioned semi fowler position for lung

capacity and promoting respiratory well being. Upon auscultation crackles sound was noted in

both lungs of the patient, and her oxygen saturation was drop from 95% to 85% which leads to

difficulty in breathing. According to the final diagnosis client was diagnosed with lung mass and

she didn’t have any medication in relation to this.

Cardiovacular/Circulatory System

During the assessment an elevated blood pressure was recorded with a reading of 140/80

mmHg, he was not taking any medication like antihypertensive medications. An examination of

the client nails indicated abnormal with dry and round nail edges, no trimmed nails and poor

circulation of blood in the nail bed. Capillary refill testing, a rapid assessment of peripheral

tissue blood flow, demonstrated a refill time of less than 4 seconds, indicative of poor

circulation. Family members stated that client experience Transient ischemic attack or also know

as mild stroke last March but it resolves immediately in a span of 24 hours.

Integumentary System

The client present, afebrile with a body temperature of 36. 4 degrees Celsius. Her skin is

dry and warm to touch and upon inspection bruises were observed both upper and lower

extremities since patient has history of falls injury prior to admission, she has fair-colored skin.

Upon assessment, her skin turgor is noted to be less than 4 seconds, her eyes and tongue are

moist, and her hair distribution is even, though there is a thin volume of hair with some white

strands observed. The distribution of hair on her upper and lower extremities is not even. The

condition of the client nails on both her hands and feet is dirty.

Elimination

The client had a urinary catheter in place during hospitalization since client is

unconscious and unresponsive. Upon abdominal assessment, the abdomen appeared soft and non

tender, displaying a normal size and shape with no palpable masses observed during inspection.

Hypoactive bowel sounds were noted during auscultation, indicating decreased bowel activity

within the abdomen. In contrast, the client had a relatively normal urinary pattern with a urine

color ranging from yellow to dark yellow urine. There was also slightly foul odor noted. Her oral

intake amounted to 120 cc while intravenous (IV) fluid intake was 900 cc, resulting in a total

intake of 1200 cc. In the same timeframe, her urine output was measured at 350cc, reflecting a

different between input and output.

Musculoskeletal System

Client is non ambulatory, wherein she cannot do her activities of daily living (ADL)

general weakness in muscle tone was observed, since client is unconscious and unresponsive.
Client was not able to follow instructions and cannot move her body. Weakness was observed in

both lower and upper extremities where there is decreased in ROM.

Cognitive and Perceptual/Neurologic Exam

The client is unconscious and unresponsive with GCS 5, not oriented to time, place or

even person. The client cannot obey commands when instructed and cannot respond to any

questions when being asked, but client can recognized pain. Family members was signed the

DNR and DNI since client considered as terminally ill.