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II.

NURSING ASSESSMENT

A. PERSONAL HISTORY

Mr. Juan dela Cruz is a 68 years old male Filipino, Catholic, who was born on
February 8, 1941 at Mabalacat, Pampanga. He is 5’5 ft in height and 59.09 kg in weight.
He is married and blessed with three children (two boys and a girl). He currently resides
at Balibago, Angeles City with his family. He was a high school graduate in Mabalacat,
Pampanga. He is a retired electrician. He was rushed on the emergency department
of a private tertiary hospital in Angeles City, last November 25, 2009 (Wednesday) at
9:00 pm with chief complaints of chest pain described as heartburn, dyspnea, cold
clammy skin, pallor and dry mouth. Assessments of the sign and symptoms were done
and standards of care procedure were given at the emergency department. After series
of initial laboratory and diagnostic exam the client was transferred to the Intensive Care
Unit of the said institution with an admitting diagnosis of: Acute Coronary Syndrome,
Non ST elevation Myocardial Infarction, Community Acquired Pneumonia, Hypertensive
Cardiovascular Disease (HCVD) and Diabetes Mellitus type 2. He stayed in the
Intensive Care Unit for 4 days from November 25 to 28, 2009 and was transferred to a
private room on the on the 28 th day of November the patient was discharged last
December 3, 2009 with a final diagnosis of Acute Coronary Syndrome, Non ST
elevation Myocardial Infarction, Community Acquired Pneumonia, Hypertensive
Cardiovascular Disease (HCVD) and Diabetes Mellitus type 2.

Mr. Juan dela Cruz He is a high school graduate in Mabalacat, Pampanga on the
year 1957. He started to work as an electrician when he was 20 years old approximately
by the year 1961; he started as a helper of his uncle. He stops working as an electrician
at the age of 50 years old approximately the year 1991. He got married on the age of 30
by the year 1971. Presently, together with his wife, they are running a small sari-sari
store built on the year. According to Mr. Juan Dela Cruz, they are earning an estimated
amount of PHP 3, 000 a month. With regards to the allocation of finances, Mr. & Mrs.
Dela Cruz works together in order to solve the problems or what decision to be made.
Some of their daily expenses are being paid off through the money being sent by his in-
laws and cousins amounting to PHP 30,000 a month. They spend a total of Php.

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20,620.00/mo for their monthly expenses such as foods: 7,500.00, water bill:
Php.800.00, electric bill: Php.3, 000.00, groceries: Php. 5, 000.00, gas tank: Php.
1,650.00, medical Supplies: Php. 2,000.00, Soap: Php.120.00, laundry soap: Php.
250.00, shampoo: Php. 200.00, toothpaste: Php. 100.00. Based from the breakdown of
expenses, the money is enough to support the family’s needs and according to the
National Economic and Development Authority (NEDA), for a family not to be
considered poor, each individual should be provided with at least Php 2,768.60 a
month. Dividing the sum of money among the 7 family members, each person is allotted
with Php 4,714.29 a month which indicates that the family is capable of providing for
their needs adequately and thus classifying them as not poor.

Mr.Juan dela Cruz used to wake up at around 4:00 am to have his breakfast
such as coffee with pandesal, fried hotdog, egg and rice after which, he will open and
clean the store. At 6:00 am, he will go to the market to buy groceries for their store. And
at 8:00 am, he would stay and sell at their store until 6:00 pm. He usually had his lunch
together with his family at 12:00 pm they usually as adobo, sinigang, caldereta and
piritong isda at manok, he usually takes a bath at 6:00 pm. And at 7:00 pm, he takes his
dinner; watch television at around 8:00 – 10:00 pm and sleeps at around 10:00 pm.
While during Sunday, the whole family will go to mall to have fun.

The family of Mr. Juan dela Cruz is purely pampangeños. They could speak
Capampangan, Tagalog and English. They have been residing in Angeles City for a
very long time now. They are affiliated to the Roman Catholic Church and seldom go to
church instead hear mass on television and according to them, they do not believe in
pamahiin and albularyos. They believe in images that would heal their sickness, wiping
handkerchief over it and pray for their health.

The family gets their food from the market. They buy foods every other day and
cook meals that is enough for a day to prevent left over foods. But if in case there were
left-overs, they would store food in the refrigerator. The amount of food, however, is just
exact for the family and sometimes they got their food supply in their sari-sari store. The
wife of Mr. dela Cruz is the one who prepares the food. Regular hand washing and
proper food handling is being observed when preparing the food. They have a 2 gas

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range with stove and rice cooker for cooking. The entire household’s source of water is
supplied by the Angeles Water Works, which is paid monthly. The family uses the same
water for laundry, bathing and house chores but for their drinking water and for cooking
is form their water dispenser. The gallon is delivered by a Water Refilling Station near
them and spending an amount of Php. 200.00/month while the electricity if provided by
the Angeles electric corporation. The family uses 2 toilet facilities that are carriage type.
The toilet is generally clean. It has a shower, sink and a clothesline where they hang
towels and clothes during bathing. A trash can is also placed on one corner in which
they throw used shampoo sachets, soap cartons, tissue and used napkins. The
drainage system is closed. But generally water flows at the canal, especially whenever
they do laundry. The family has reported zero cases of flood in their area, which
indicates an effective drainage system. The family observed segregation of garbage and
it was collected by garbage collectors every week and being paid an amount of
Php.80.00 per month. They make sure it is properly tied in order not to attract flies,
rodents to invade and to avoid foul smell. The family’s means of communication is
through telephone. Some members of the family have cellular phones used for texting
and calling. They also have computer with internet connection for them to communicate
relatives form other countries. Their transportation needs are catered by a tricycle and
jeepney which they own.

B. FAMILY HEALTH - ILLNESS HISTORY

When the researchers interviewed Mr. Juan Dela Cruz regarding his parents, he
mentioned that both of his parents died of heart attack, when asked about the reason
regarding the real cause of his parents heart attack, Mr. Dela Cruz cannot give the
researchers a concrete answer, as according to him he was just two years old when he
lost both of his parents. For the researchers to confirm the claim of Mr. Dela Cruz, the
researchers have interviewed his third sister when she visited him in the hospital.
According to his sister, she mentioned that their mother died of heart attack when she
was giving birth to Mr. Dela Cruz due to severely increased high blood pressure during
the delivery, wherein their mother refused a cesarean section as an alternative due to
financial constraints. It was discussed to them that one of them either their mother or
Mr. Dela Cruz will not survived, but their mother chose to save Mr. Dela Cruz. Two

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years after his mother’s death, their father which has an existing hypertensive disease,
died also of heart attack. Since they lost their parents at a very young age, one of their
relatives on their paternal side adopted their two older sisters and lost their
communication with each other that is why when they are asked regarding the current
condition of their sisters, they do not really have an idea. On the other hand, Mr. Dela
Cruz and his third sister grew together. They were adopted by his uncle on their
maternal side. The researchers also asked Mr. Dela Cruz’ sister regarding the cause of
death of their grandparents on both paternal and maternal side. According to her, their
grandfather on their paternal side died of stroke and their grandmother died of Diabetes
Mellitus at a very advanced age. On the other hand, their grandfather on the maternal
side died of car accident and their grandmother died of advanced age, Rheumatoid
Arthritis, and Diabetes Mellitus. The researchers also interviewed his sister regarding
the health status of their uncles and aunties on both side. According to her, on the
paternal side, his father has three siblings composed of a 2 sisters and a brother, both
of her father’s sister died of hypertension, on the other hand her father’s brother, died of
diabetes mellitus. On the maternal side, her mother has 2 siblings, one male and one
female. Her mother’s sister died of stroke and his mother’s brother the one who adopted
them died of hypertension. The researchers also interviewed her regarding her current
health status and she said that currently she is suffering from Diabetes Mellitus Type 2.

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C. HISTORY OF PAST ILLNESS

During the interview, Mr. Juan dela Cruz reported that he had no history of
serious childhood illnesses. He had chicken pox, measles and sometimes experience
simple cough, colds and fever. They do not believe in albularyos and manghihilot. They
used to buy over – the – counter (OTC) drugs when someone in the family is sick such
as paracetamol for fever, neozep for colds and Mefenamic acid for pain. They also
utilize herbal medicines such as: Oregano and Lagundi for colds and cough and
Ampalaya for proper blood circulation and this would be prepared by means of boiling.
But in serious health cases, they immediately consult a doctor or rush to a nearest
hospital. Mr. Dela Cruz told the researchers that he used to have a regular check up
every 6 months. It was through one of his check up approximately five years ago when
it was learned that he has a diabetes mellitus type 2 after series of laboratory and
diagnostic procedures. It was also found out that he is already experiencing
Hypertensive Cardiovascular disease secondary to dyslipidemia. When the researchers
asked him regarding the results of the said laboratory and diagnostic procedures, he
mentioned that he already misplaced those documents. He mentioned that so as to
manage his condition and prevent aggravation of his condition, his doctor advised him
to take metformin 1 tablet three times a day. Metformin is an oral hypoglycemic agent to
control his blood glucose level and maintain it on the normal range. He was also given
simvastatin 80 mg tablet to be taken once a day before he sleeps to manage his blood
cholesterol level and prevent complication that may be brought about such as Coronary
artery disease. He was also advised to have a well balanced diet, with limitations on
dietary sodium and fat contents and have an active lifestyle by exercising al least 3 to 5
times a week for 15 minutes.

When the researchers asked him about his compliance to the prescribed
management, Mr. Dela Cruz was honest to say that he did not really follow the said
management religiously, and as a matter of fact, a year after, he developed an eye
complication which resulted to blurring of his vision aggravated also of his advancing

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age. He was advised to wear eyeglasses, currently his eyeglasses has a lens power of
250 on the left lens and 240 on the right lens.

D. HISTORY OF PRESENT ILLNESS

When Mr. Juan Dela Cruz was asked if he has previous hospitalization, he
mentioned that he was never been hospitalized before and this is his first
hospitalization. The researchers asked Mr, Juan Dela Cruz what made him consult a
doctor when he was diagnosed with Diabetes Mellitus type 2 approximately five years
ago (2004), he said that he is used to have his check up every six months but he failed
to have his check up a year before he was diagnosed of DM Type 2, Hypertensive
Cardiovascular disease secondary to dyslipidemia. When asked about what he felt
during that specific span of time, he mentioned that he never expected that what he was
actually experiencing during those times are already sign and symptoms of his disease
as he thought that those are normal changes in line with aging. He mentioned that he
frequently goes to the comfort room to urinate; he also mentioned that suddenly he was
so eager to drink a lot of fluids which according to him, normally he seldom drink water
after he eats. He also mentioned that he began to crave more for food as he felt that he
was always hungry. There are also these scenarios when he will feel sudden chest
tightness while watching television or while staying on their sari – sari store. He also
observed that most of the time he cannot sustain an activity like walking because he
easily gets tired. The day before he went to see his doctor, he experienced dizziness
and headache. Since his doctor found out that he is experiencing Diabetes Mellitus type
2 and hypertensive cardiovascular disease secondary to dyslipidemia. His doctor gave
him some medication (simvastatin and metformin) and diet prescription (low salt, low fat
and well – balanced diet), but Mr. Dela Cruz failed to comply religiously with these
treatment regimens which may have contributed to his present condition.

It was on November 25, 2009 when Mr. Dela Cruz accompanied by his daughter
went to a tertiary hospital in Angeles City due to chest pain few hours after he had a
petty quarrel with his wife. Approximately 2 hours prior to admission he felt dizzy and

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intense headache so he took some paracetamol to relieve his headache but it was not
relieved. Then an hour prior to admission he felt abdominal discomfort but he just
ignored it; 45 minutes prior to admission he felt chest tightness, difficulty of breathing,
and excessive sweating. He became anxious and called his daughter. His daughter
panicked because he really looks so pale, they immediately asked for help and brought
him to the emergency department of the nearest private tertiary hospital.

Upon their arrival to the emergency department at around 9:00 pm, they were
interviewed regarding the chief complaints of Mr. Dela Cruz and obtained his vital signs;
his actual vital signs are as follows: T= 36.8°C, P= 105bpm, R= 25cpm and BP=
190/130mmHg, after which, the resident on duty on the emergency room immediately
ordered an ECG reading of the client and it revealed that the patient has marked ST
segment depression. This made them suspect that the patient is suffering from
myocardial infarction, as part of the standard of care in patient experiencing myocardial
infarction, the resident on duty placed him on O2 inhalation at 2LPM, he was attached to
cardiac monitor to continuously monitor the activity of his heart. An IV infusion of 1 liter
of PNSS was started and regulated KVO to initiate a route for drug administration. He
was also given morphine sulfate and Isosorbide Dinitrate (Isoket) drip for his chest pain.
Furosemide, metoprolol, and captopril were also given to the patient to control his high
blood pressure. Enoxaparin Sodium was also given to the patient to prevent further
thrombus formation. Serum Na, K, Mg, Ca, Creatinine, HGT, FBS, CBC with platelet
count together with Chest x- ray PA view were ordered for risk stratification, blood
specimen was immediately obtained. In line with this, to confirm the diagnosis of
myocardial infarction the physician ordered Serum Troponin T determination and blood
specimen was also immediately obtained. PT and aPTT were also ordered to have a
baseline data regarding the clotting ability of the patient.

Few minutes after, the client’s pulse rate suddenly became thready and weak
dropped to 60bpm, to prevent further decrease in the pulse rate of the patient, he was
given Atropine Sulfate. Few minutes after the administration of the drug, the patient’s
pulse rate became normal then became excessively high (200 bpm); ECG reading was

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automatically printed through his cardiac monitor and revealed atrial fibrillation with
rapid ventricular response. As a management, lidocaine drip was initiated. With all the
management done, the patient was diagnosed to have Acute Coronary Syndrome, Non
ST elevation Myocardial Infarction, Community Acquired Pneumonia, Hypertensive
Cardiovascular Disease (HCVD) and Diabetes Mellitus type 2.

E. PHYSICAL ASSESSMENT

Lifted from the ER Notes


November 25, 2009 9:00 pm

Vital signs:

T- 36.8°C
P- 105 bpm 9:30 pm = 60 bpm
R- 25 cpm
BP- 190/130 mmHg
GCS: 15 (E4V5M6)

• (+) DM
• (+)HPN
• (+) dyslipidemia
• (-) Allergy
• Anicteric sclera
• Pale conjunctiva
• Symmetrical chest expansion with no retraction
• Bibasal crackles
• Heart is adynamic proportion,normal rate and rhyhtm, (-) murmur
• Abdomen is flat and normal bowel sound, non globular not tender
• Symmetrical extremities, full and equal pulses

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• (-) edema
• Good skin turgor
Initial Doctor’s order:
• O2 Inhalation via nasal cannula @ 2LPM
• Start PNSS 1L x KVO
• Morphine Sulfate (Avinza) 4mg IV PRN
• Isosorbide Dinitrate (Isoket) D5W 90 cc +10g Isoket/soluset 1.5mg/hr
• Furosemide (Lasix) 1 ampule now, then 40 mg/tab 1 tab for 3 days
• Metoprolol (lopressor) 50 mg/tab ½ tab BID
• Captopril (Capoten) 25 mg/tab ¼ tab q 12
• Enoxaparin Sodium (Clexane) 0.4 cc SQ now then q 12
• Chest X- ray PA view, CBC with platelet count, PT, aPTT, Troponin T.
• Serum Na, K, Ca, Creatinine, FBS, HGT

November 26, 2009

Vital signs:
T- 35.8°C
P- 76 bpm
R- 18 cpm
BP- 100/70 mmHg
GCS: 15 (E4V5M6)

General Appearance and Mental Status:


During the assessment, Mr. Dela Cruz was wearing a hospital gown. He is
cooperative, coherent and oriented to person, place and time. He easily gets
tired even just for a couple of minutes of talking. He also exhibits thought
association and has a sense of reality. He has no difficulty recalling past and
present events. He is hooked to Oxygen via nasal cannula regulated at 2LPM, on
continuous cardiac monitoring, and with condom catheter attached to urine bag.

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He stands 5 feet and 5 inches and weighs 59.09 kg with an ectomorph body
built.

HEAD AND FACE


Head
His hair is grayish in color. It is evenly distributed and no presence of
dandruff was noted. No presence of infestations was noted.

Skull and Face


He has normocephalic skull and with smooth skull contour. No nodules and
masses were noted upon palpation. His face is symmetrical in shape and there is
no abnormal elevation or depression on the face.

Eyes
His eyebrows are symmetrically aligned with hair evenly distributed.
Eyelashes are also evenly distributed. Skin is intact, no discharges and no
discolorations are present at the surface of eyelids. Lids close symmetrically. He
has pink palpebral conjunctiva. His pupils constrict when looking at near objects
while they dilate when looking at far objects. According to the patient, he uses
eye glasses so he can read well. It was prescribed by his ophthalmologist 2
years ago. According to him, his eyeglass has a magnification grade of 250 on
the left eye and 240 on the right eye.

Ears
His auricles are same as facial color and it is aligned with the outer canthus
of the eye. They are firm and not tender upon palpation. Pinna recoils after it is
folded. There is no presence of impacted cerumen. He can hear and respond
when he is asked.

Nose

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His nose is straight and his septum is located in the midline. No deviations
have been observed in the shape, size and color of the external nose. No
discharges were noted and there is the absence of nasal flaring. Also, no
nodules and masses were noted upon palpation.
Lips and Teeth
Outer lips are symmetrical. He exhibits ability to move his lips. Inner lips and
buccal mucosa are uniform in color. He loss his 3 molars on the upper right and 2
molars on the lower left and 1 pre molar on the lower left. His tongue is in central
position and he can move it freely.

NECK

Neck Muscle
Neck muscles are equal in size. No masses and nodules were noted upon
palpation. Head movements are coordinated and he can move his head freely.

Lymph Nodes and Thyroid gland


Lymph nodes are not palpable and there is no enlargement noted upon
observation and palpation. Thyroid gland is not inflamed.

THORAX AND LUNGS


Lungs
There is full and symmetrical chest expansion. There is an effortless and
rhythmic respiration and bibasal crackles sounds were heard upon auscultation
of the lungs.

Heart
Regular rhythm of apical pulse was noted upon auscultation point of maximal
impulse is located on the 6th intercostals space.
Abdomen

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No distention and presence of lesions and masses were observed. He has
normoactive bowel sounds.

Skin
He has brown-colored skin which is generally uniform except in areas of
lighter pigmentation such as the palms, lips and nail beds. No abrasions and
edema have been noted. He has good skin turgor, which turned back to previous
state in less than 2 seconds when pinched.

Extremities
Peripheral pulses are in full pulsations. Limbs are not tender and no edema is
present at extremities.

Fingernails
His nail plates are colorless and have concave curves. They are slightly long
and untrimmed. His nail beds returned to previous state in less than two seconds
after pressure was applied.

Neurological Assessment
Cranial Nerve I
Name: Olfactory
Type: Sensory
Function: Smell
Actual Findings: the patient was able to identify the odor of the alcohol and
perfume.
Cranial Nerve II
Name: Optic
Type: Sensory
Function: Vision and visual fields

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Actual Findings: as observed by the student nurse and assessed, the patient
has difficulty in reading the newsprint since the patient is not wearing his
eyeglasses.
Cranial Nerve III
Name: Oculomotor
Type: Motor
Function: Extra ocular eye movement, movement of sphincter of pupil,
movement of ciliary muscles of lens.
Actual Findings: Pupils are round and black in color; pupils’ constricted upon
light accommodation and dilated upon removal of light and when looking at near
objects and dilates when not illuminated and when looking at far objects.
Cranial Nerve IV
Name: Trochlear
Type: Motor
Function: Extra ocular eye movement, specifically, movement of eyeballs
downward and laterally.
Actual Findings: Mr. Dela Cruz can move his eyes downward and laterally
without difficulty.
Cranial Nerve V
Name: Trigeminal
Type: Sensory and Motor
Function: Sensation of the cornea, skin of the face, nasal mucosa, anterior oral
cavity and muscles of mastication.
Actual Findings: the student nurse was not able to test for blink reflex. There
are no difficulties in chewing observed. The patient can feel or respond to deep
touch.
Cranial Nerve VI
Name: Abducens
Type: Motor
Function: Moves eyeball laterally
Actual Findings: Mr. Dela Cruz can follow the movement of penlight laterally.

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Cranial Nerve VII
Name: Facial
Type: Motor and Sensory
Function: Facial expression, taste (anterior 2/3 of the tongue)
Actual Findings: Mr. Dela Cruz does not have difficulty in doing facial
expression. He does not have difficulty in his taste sensation.
Cranial Nerve VIII
Name: Acoustics
Type: Sensory
Function: Hearing
Actual Findings: He does not have difficulty in hearing and he also was able to
respond to some questions asked.
Cranial Nerve IX
Name: Glossopharyngeal
Type: Motor and Sensory
Function: Swallowing ability, tongue movement, taste (posterior tongue)
Actual Findings: He does not have difficulty in swallowing although He does not
have difficulty in taste sensation. He does not have any difficulty in speaking.
Cranial Nerve X
Name: Vagus
Type: Motor and Sensory
Function: Sensation of pharynx and larynx, swallowing and vocal cord
movement.
Actual Findings: No hoarseness of voice when speaking. The student nurse
was not able to test for gag reflex.
Cranial Nerve XI
Name: Accessory
Type: Motor
Function: Head movement and shrugging of the shoulders.
Actual Findings: He can turn his head on each side and can elicit elevation of
shoulders.

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Cranial Nerve XII
Name: Hypoglossal
Type: Motor
Function: Protrusion of tongue, movement of the tongue upward, downward and
laterally.
Actual Findings: Mr. Dela Cruz can move his tongue freely.

November 28, 2009


Vital signs:
T- 36°C
P- 77 bpm
R- 20 cpm
BP- 100/70 mmHg

GCS: 15 (E4V5M6)
General Appearance and Mental Status:
During the assessment, Mr. Dela Cruz was wearing a hospital gown. He is
cooperative, coherent and oriented to person, place and time. He easily gets
tired even just for a couple of minutes of talking. He also exhibits thought
association and has a sense of reality. He has no difficulty recalling past and
present events. He is hooked to Oxygen via nasal cannula regulated at 2LPM, on
continuous cardiac monitoring, and with condom catheter attached to urine bag.

HEAD AND FACE


Head
His hair is grayish in color. It is evenly distributed and no presence of
dandruff was noted. No presence of infestations was noted.

Skull and Face

22
He has normocephalic skull and with smooth skull contour. No nodules and
masses were noted upon palpation. His face is symmetrical in shape and there is
no abnormal elevation or depression on the face.

Eyes
His eyebrows are symmetrically aligned with hair evenly distributed.
Eyelashes are also evenly distributed. Skin is intact, no discharges and no
discolorations are present at the surface of eyelids. Lids close symmetrically. He
has pink palpebral conjunctiva. His pupils constrict when looking at near objects
while they dilate when looking at far objects. According to the patient, he uses
eye glasses so he can read well. It was prescribed by his ophthalmologist 2
years ago. According to him, his eyeglass has a magnification grade of 250 on
the left eye and 240 on the right eye.

Ears
His auricles are same as facial color and it is aligned with the outer canthus
of the eye. They are firm and not tender upon palpation. Pinna recoils after it is
folded. There is no presence of impacted cerumen. He can hear and respond
when he is asked.

Nose
His nose is straight and his septum is located in the midline. No deviations
have been observed in the shape, size and color of the external nose. No
discharges were noted and there is the absence of nasal flaring. Also, no
nodules and masses were noted upon palpation.

Lips and Teeth


Outer lips are symmetrical. He exhibits ability to move his lips. Inner lips and
buccal mucosa are uniform in color. He loss his 3 molars on the upper right and 2
molars on the lower left and 1 pre molar on the lower left. His tongue is in central
position and he can move it freely.

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NECK

Neck Muscle
Neck muscles are equal in size. No masses and nodules were noted upon
palpation. Head movements are coordinated and he can move his head freely.

Lymph Nodes and Thyroid gland


Lymph nodes are not palpable and there is no enlargement noted upon
observation and palpation. Thyroid gland is not inflamed.

THORAX AND LUNGS


Lungs
There is full and symmetrical chest expansion. There is an effortless and
rhythmic respiration and bibasal crackles sounds were heard upon auscultation
of the lungs.

Heart
Regular rhythm of apical pulse was noted upon auscultation point of maximal
impulse is located on the 6th intercostals space.

Abdomen
No distention and presence of lesions and masses were observed. He has
normoactive bowel sounds.

Skin
He has brown-colored skin which is generally uniform except in areas of
lighter pigmentation such as the palms, lips and nail beds. No abrasions and
edema have been noted. He has good skin turgor, which turned back to previous
state in less than 2 seconds when pinched.

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Extremities
Peripheral pulses are in full pulsations. Limbs are not tender and no edema is
present at extremities.

Fingernails
His nail plates are colorless and have concave curves. They are slightly long
and untrimmed. His nail beds returned to previous state in less than two seconds
after pressure was applied.

Neurological Assessment
Cranial Nerve I
Name: Olfactory
Type: Sensory
Function: Smell
Actual Findings: the patient was able to identify the odor of the alcohol and
perfume.
Cranial Nerve II
Name: Optic
Type: Sensory
Function: Vision and visual fields
Actual Findings: as observed by the student nurse and assessed, the patient
has difficulty in reading the newsprint since the patient is not wearing his
eyeglasses.
Cranial Nerve III
Name: Oculomotor
Type: Motor
Function: Extra ocular eye movement, movement of sphincter of pupil,
movement of ciliary muscles of lens.
Actual Findings: Pupils are round and black in color; pupils’ constricted upon
light accommodation and dilated upon removal of light and when looking at near
objects and dilates when not illuminated and when looking at far objects.

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Cranial Nerve IV
Name: Trochlear
Type: Motor
Function: Extra ocular eye movement, specifically, movement of eyeballs
downward and laterally.
Actual Findings: Mr. Dela Cruz can move his eyes downward and laterally
without difficulty.
Cranial Nerve V
Name: Trigeminal
Type: Sensory and Motor
Function: Sensation of the cornea, skin of the face, nasal mucosa, anterior oral
cavity and muscles of mastication.
Actual Findings: the student nurse was not able to test for blink reflex. There
are no difficulties in chewing observed. The patient can feel or respond to deep
touch.
Cranial Nerve VI
Name: Abducens
Type: Motor
Function: Moves eyeball laterally
Actual Findings: Mr. Dela Cruz can follow the movement of penlight laterally.
Cranial Nerve VII
Name: Facial
Type: Motor and Sensory
Function: Facial expression, taste (anterior 2/3 of the tongue)
Actual Findings: Mr. Dela Cruz does not have difficulty in doing facial
expression. He does not have difficulty in his taste sensation.

Cranial Nerve VIII


Name: Acoustics
Type: Sensory

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Function: Hearing
Actual Findings: He does not have difficulty in hearing and he also was able to
respond to some questions asked.
Cranial Nerve IX
Name: Glossopharyngeal
Type: Motor and Sensory
Function: Swallowing ability, tongue movement, taste (posterior tongue)
Actual Findings: He does not have difficulty in swallowing although He does not
have difficulty in taste sensation. He does not have any difficulty in speaking.
Cranial Nerve X
Name: Vagus
Type: Motor and Sensory
Function: Sensation of pharynx and larynx, swallowing and vocal cord
movement.
Actual Findings: No hoarseness of voice when speaking. The student nurse
was not able to test for gag reflex.
Cranial Nerve XI
Name: Accessory
Type: Motor
Function: Head movement and shrugging of the shoulders.
Actual Findings: He can turn his head on each side and can elicit elevation of
shoulders.
Cranial Nerve XII
Name: Hypoglossal
Type: Motor
Function: Protrusion of tongue, movement of the tongue upward, downward and
laterally.
Actual Findings: Mr. Dela Cruz can move his tongue freely.

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