St.

Anthony’s College
San Jose, Antique
Nursing Department

I. VITAL INFORMATION
Name: E.F.Y
Age: 72 years old
Address: Arangote st., Pojo, Bugasong
Civil Status: Married
Sex: Female
Religious Affiliation: Roman Catholic
Date and Time Admitted: July 3, 2018
Chief Complaint: Headache, vomiting
Date of Interview: July 11, 2018

II. CLINICAL ASSESSMENT

II.A: NURSING HISTORY

1. History of present illness

Prior to
2. Past Health Problems/ Status
a. Childhood Illness: experienced Chickenpox
b. Childhood immunizations: Complete
c. Allergies: None

3. Family history illness

(+) Hypertension
(-) Cancer
(-) Diabetic
 4. Patient’s expectations
Patients expect that during hospitalization there will be more medications to take and also
Nurses and will help one another in order to help their patients to be fine. Also patient
expects that the quality of the nursing care is in the highest quality.

5. Patterns of Functioning
a. Breathing Patterns
RR: 20
Breathes through the mouth
b. Circulation
Usual blood pressure: 110/80
(+) History of High Blood Pressure
c. Sleeping Patterns
Usual bedtime: 10-11 PM
Number of pillows: 2
Bedtime rituals: Praying
Problems regarding sleeping: none

d. Drinking patterns
Kinds of fluid intake in 24 hours

Morning Evening Weekends

Water 2-4 glasses 2-3 glasses 3-4 glasses
Coffee 1 glass (Occasionally) 1 glass (Occasionally) 1 glass (Occasionally)
Cola 1 bottle (Occasionally) 1 bottle (Occasionally) 1-2 bottle (Occasionally)

e. Eating Patterns

Usual Food Taken Time

Breakfast Rice, Vegetables, Meat 7 or 8 AM
Lunch Rice, Chicken, Vegetables 11 or 12 Noon
Dinner Rice, Vegetable 7 or 8 PM
Snacks Bread, Juice 3 PM

Food Likes: Vegetables, Fruits, Biscuits

Food Dislikes: Canned goods, Fatty foods, frozen foods
f. Elimination Patterns
1. Bowel Movement
Frequency: 1-2 times a day
Problems or difficulty: none
Usual Remedy: drinking plenty of water
2. Urination
Frequency: 3-4 times a day
Problems or difficulties: none
Usual Remedy: drinking plenty of water

g. Exercise
Walking
Stretching (every morning)
Doing household chores

h. Personal hygiene
1. Bath
Type: full bath
Frequency: once a day
Time: Every morning
2. Oral Care
Frequency: 3 times a day
Care of dentures: none

i. Recreation
Watching Television, bonding with family, Store managing
B. PSYCHOSOCIAL ASSESSMENT
1. Psychosocial Nursing Assessment
Lifestyle information: Normal
Normal Coping Patterns: Task management and relaxation
Personality Style: Normal
Recent Life Changes or Stressor: None
Major issues raised by current illness: None

2. Mental status Examination

Appearance:
Clean

Behavior:
Calm
Unusual actions: None

Speech:
Slurring with speech

Mood/Affect
Appropriate

Thoughts:
Appropriate

Memory:
Impaired recent memory: No
Impaired remote memory: No
 Concentration:

 Listens and can follow discussions

 Can follow instructions and responds appropriately

General appearance:
 The patient has no Physical deformities or abnormalities.
 The patient showed no sign or potential sign of distress.
 Patient’s nutritional status and body built is appropriate to her age.
 The patient is relaxed, no involuntary movements.
 Patient’s mood is appropriate to the situation, comfortable and calm
 Patient is physically looks clean and neat.
 Patient is asleep most of the time

CEPHALOCAUDAL PHYSICAL ASSESSMENT

INTEGUMENT
Skin
 The client is uniform in color, unblemished and no presence of foul odor.
 Has good skin turgor and skin’s temperature is within normal limit.

Scalp
 Lighter color than the complexion
 Moist
 No scars noted
 Free form lice, nits and dandruff
 No lesions noted
 No tenderness or masses on palpation
HEAD
Hair
 Black in color with presence of white hair
 Evenly distributed, covers the whole scalp
 No evidence of alopecia
 Thick and smooth

Skull
 Generally round, with prominence in the frontal and occipital area (normocephalic)
 No tenderness noted upon palpation.

Face
 Shape is rounded
 Face is symmetrical
 No involuntary muscle movements
 Can’t move facial muscle at will

Eyebrows
 Symmetrical and in line with each other
 Black in color
 Evenly distributed

Neck
 Neck is straight
 No visible mass or lumps
 Symmetrical
 No jugular venous distension
EYES and VISION
Eyes
 Evenly placed and in line with each other
 None protruding
 Equal palpebral fissure

Eyelashes
 Black in color
 Evenly distributed
 Turned outward

Eyelids
 Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes are open
 Meets completely when ayes are closed
 Symmetrical

Sclera
 White in color
 No yellowish discoloration
 Some capillaries is visible

Cornea
 No irregularities in the surface
 Looks smooth
 Cornea is transparent

Pupil
 Black
 Equal in size
 Equally rounded and reactive to light
EARS and HEARING
Ears
 Earlobes are bean shaped, parallel, and symmetrical
 The upper connection of the earlobe is parallel with the outer canthus of the eye
 Color is same with the complexion
 No lesions noted
 The auricle are has firm cartilage on palpation
 Pinna recoils when folded
 There is no pain or tenderness on the palpation of the auricles and mastoid process
 No discharges noted at the ear canal

Nose and Sinuses

 Nose in the midline
 No discharges
 Both nares are patent
 Np tenderness noted upon palpation

Mouth and oropharynx lips

 With visible margin
 Symmetrical in appearance and movement
 Pinkish in color
 No edema

Gums
 Pinkish in color
 No gum bleeding
 No receding gums

Teeth
 White to yellowish color
 No halitosis
Tongue
 Pinkish with white buds on the surface
 No lesions noted
 Able to move tongue freely and with strength
 Surface of the tongue is rough

Uvula
 Positioned in the midline
 Pinkish to red in color
 No swelling or lesions noted

Thorax and Lungs

 Moves symmetrically ion breathing with no obvious masses
 Spine is straight, with slightly curvature in the thoracic area
 Breathing is soundless and effortless
 Exhalation is longer than the inhalation

Abdomen
 Skin color is uniform, no lesions
 No venous engorgement
 It is soft and non-tender

Musculoskeletal system
 Good range of motion in all joints
 No evidence of swelling or deformity

Mental status
 Alert
 Cooperative
 Relaxed