This action might not be possible to undo. Are you sure you want to continue?
E is a 25 year old male, born on April 27, 1986 via NSVD by a “hilot”. He is the youngest of the 3 siblings. The family resides in Igbaras, Iloilo. He is still studying at University of Iloilo PHINMA taking up Bachelor of Science in Nursing.
Socio-Economic Factor Mr. E belongs in a nuclear family, Roman Catholic and a student. His father is a retired employee of Universal Distillery Company and his mother is a housewife with a family income of 20,000 pesos per month which according to Mr. E is enough to meet their basic needs. He has a sister and a brother which have a family already.
Environmental Factor Mr. E resides in a 2 storey medium size house with a 5 stairs going up to the second floor without railings, made up of concrete with 4 rooms and 1 bathroom with good ventilation. The house is located in a residential area. According to Mr. E they are buying their water for drinking and motor pump is their source of water for washing, bathing and laundry purposes. Their excreta disposal is water sealed. The family of Mr. E owns a pet dog with a regular vaccination of anti-rabies.
Erick Erickson’s Psychosocial Theory Based on Erickson’s psychosocial theory Mr. E a young adult is classified under intimacy vs. isolation which explains that most important event are love relationships no matter how successful a person are. He is not developmentally complete until he is capable of intimacy on the other hand, an individual who has not yet developed a sense of identity usually will fear a committed relationship and may repeat to isolation. In Mr. E’s case, he had 3 relationships but now he chooses to be single and focus himself with his family and his studies.
II. Mental Status Mr. E is conscious and coherent, oriented to person, place and time. He is a college student, able to maintain eye to eye contact. He is open and approachable and is able to converse with the student nurse.
E is close with his family and if ever he has a problem he opens it to his parents and siblings. Mr. Before the next procedure. he is very cheerful. funny and has a sense of humour. using a peeled apple and the skin of an orange. IV. E was able to share past experiences about his childhood and past relationship showing that his long term memories are still intact. Smell Client’s nose has no deviation in terms of shape and size. nose is pointed and no discharges were seen during assessment. patient is instructed to look straight to observe the general appearance of his eyes. E. according to the patient. Eyes are almond in shape.Emotional Status According to Mr. rises are black in color. and scleras are whitish in color. III.During Assessment Mr. he went to church and attend the mass every Sunday this implies to him that he have faith in God and trust his life to Him. Test shows that there are no abnormalities or obstructions were identified in the sense of smell. The patient does not use eyeglasses or contact lenses. His conjunctiva is pale and moist. Hearing 2 . After smelling he correctly identified the two fruits. With the use of a penlight pupils are assessed. E is a Roman Catholic. eyebrows and eyelashes are equally distributed. Mr. he doesn’t have any history of sinus infection or epistaxis. Pupils are equally round and reactive to light accommodation. Patient is also instructed to follow the direction of a finger with his eyes following six cardinal positions. permission was asked to the patient to do another test. He is friendly and has lots of friends in their place. Visual acuity is assessed by asking the patient to read the word written in a piece of paper with a font size of 12 about 3 feet away from him using the right eye first then left eye and then both eyes. I ask him to identify the two samples by smelling. without the patient’s knowledge. Sensory Perception Vision In assessing the vision. and his eyes were able to move in full range of motion and in all directions.
then using another cotton ball. the patient is asked to touch the two materials and ask the texture while blindfolded. Taste Mr. V. He was asked to raise both his arms. no dentures and has 4 teeth loss. E’s lips were moist and symmetrical in shape. He performed it with ease and freely moves without any difficulty. E’s sense of touch. He can bend and straightened her elbows and extend and spread fingers. bean shaped. but there is a presence of tooth cavities. Mr. patient is asked to do some test. tenderness and deformity upon palpation of joints. then right ear after the test. he correctly identified the difference of two materials. Touch In assessing Mr. After the test Mr. In assessing the hearing acuity of the patient. no presence of tooth decay. Using the case of BP apparatus which is rough in texture and the medical kit which is smooth in texture. I poured an alcohol on it and rubbed it on the same area. he was able to repeat the whispered words. tongue in pinkish color. E identified the two samples correctly. a cotton ball was stroke to the back of her neck. No inflammation. he was asked to close his eyes.M. Motor Ability Patient is asked to perform R. exercises on the upper and lower extremities. He performed it with ease with the muscle grade of 5+ which is normal. another test by the use of the beeping sound of our electronic thermometer at a distance of 4 feet away and still he was able to hear the sound. 2 at the upper portion and 2 at the lower portion of the teeth. Temperature Date Time Temperature Location 3 . He was asked to taste a pinch of sugar and a pinch of iodized salt without knowing the two samples are. I assess using a tongue depressor. To assess her sense of taste. E’s ears were parallel. and he stated that he felt a sensation of wet and cold on his skin. firm cartilage and with a presence of cerumen. no signs of gingivitis. E he was able to exercise such as jogging and weight lifting if there is no class and if he has time.O. buccal area are moist. After the test. E is instructed to repeat the words that will be whispered at a distance of two feet away on the left ear first.General appearance of Mr. VI. symmetrically proportional to the size of head. According to Mr.
lumps and tenderness.9°C May 17. No masses. IX. During auscultation 15 bowel sounds per minute were heard this implies audible and normal bowel sounds. No scars. He is a non-smoker and occasional alcoholic drinker maximum of two bottles of beer.”He drinks about 2 liters of water a day and a cup of cereal drink for breakfast. E is afebrile and temperature is at 37. No supraclavicular or suprasternal retractions were seen during inspiration. after auscultation. pulse scale is 2+ which is easily palpable. 2011 Time 3pm PR in Beats per minute 84 Pulse is regular in rate and rhythm taken at radial pulse.36. lesions and masses upon inspection and palpation of the abdomen. E stated “Kung sa school karne gid sud-an ko pirme. Lungs were auscultated for adventitious breath sounds. 2011 3pm Axilla Mr.1°C taken at right axilla. 4 . Circulatory Status Date May 17. negative for peripheral edema. pero sa balay gulay kag sabaw. VII. Rhythm and respiration pattern are regular. Blood Pressure Date May 17. He has a good appetite and don’t have any special diet. his capillary refill is within 1 to 2 seconds taken at right forefinger. Nutritional Status Mr. VIII. He has an effective airway clearance and effective breathing pattern which provide adequate gas exchange and results to a good level of consciousness. Nailbeds and palms are pinkish in color and no presence of edema. 2011 Time 3pm RR in Cycle per minute 18 His chest expansion was symmetrical with ease during respiration. 2011 Time 3pm BP 120/80 mmHg Taken at her brachial artery. Respiratory Status Date May 17. no adventitious breath sounds were heard.
Nail During assessment nails are pinkish in color. E has good skin turgor. no bed sore. He uses 5 pillows. XIII. 5 . he also undergone appendectomy which leaves a 5 stitches scar within the right iliac region according to the patient. no signs of clubbing. Urine is sometimes amber or straw in color. and no skin lesions. Physical Rest and Comfort Mr.Patient’s BMI 57. He takes a bath everyday he uses shampoo and soap for bathing. urine output of 480cc a day.57m2 = 23. XI. Elimination Status Mr. patient has short straight hair.5 kg 1. Patient has history of skin allergy which effect from his past medication which is cefazolin this can cause to him itchiness all over the body and narrowing of airways. E’s statement. no presence of tattoo. He sleeps at around 9pm during weekdays and 11pm during weekends. sleeps 8 hours a day before going to sleep he take a sponge bath and never fails to always say a prayer before going to sleep. one at his head and 2 on each side.37 (normal) X. State of Skin and Appendages Hair During assessment there was no dandruff seen. Skin Mr. after bathing he apply lotion in his skin and uses deodorant. He urinates 8 times a day approximately 60cc per urination according to Mr. no lice and ticks. E stated that he defecates once a day every morning before taking a bath with a semi-solid consistency without difficulty. XII. E he had his circumcision when he was 11 years old. Reproductive System According to Mr. Patient has a dark complexion. Patient has good capillary refill which is 1 to 2 seconds. E.
the patient was asked to do self breast examination. Extremities The patient was assessed for Homan’s Signs. drape was provided for the patient privacy. According to the patient he doesn’t feel any masses and lumps in his breast. his legs were dorsiflexed. Lymph nodes and axillary lymph nodes are not palpable. During inspection breast is flesh colored. During auscultation no sound heard in the thyroid gland area same with carotid arteries no swishing heard upon auscultation. Pain No pain during assessment. patient did not feel any calf pain and he don’t have any signs of thrombophebitis and edema in the lower extremities. masses and tenderness and no enlargement of thyroid gland.Breast In assessing the breast. Neck Patient has no enlargement of lymph nodes nor pain or stiffness. after the test. 6 . nipples and areola is brownish in color.
This action might not be possible to undo. Are you sure you want to continue?