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PamantasanngLungsodngMaynila

(University of the City of Manila)


Intramuros,Manila

COLLEGE OF NURSING

Requirements in Surgery Ward: Physical Assessment with Patient History

Submitted by:

Panti, Renzie Rex P.

BSN 3-1

Prof. Chua
I. DEMOGRAPHIC PROFILE

The patient’s name is NDL. She is currently living in Sampaloc, Manila. She was born
on November 27, 1964. She is now 54 years old. She is a sewer. The patient is married
and has two children. She is a Filipino. Her religion is Roman Catholic. She weighs 59
kg and his height is 5’4ft. The patient was seen on August 14, 2018. The primary source
of information is the patient herself.

II. NURSING HISTORY


CHIEF COMPLAINT

“Nandito ako kasi yung pigsa ko ang sakit na tapos pumutok.” As verbalized by the
patient.

HISTORY OF PRESENT ILLNESS

The patient complains of pain and itchiness due to boil in her right arm. She also said
that the boil is already bust. The patient said that she can no longer manage the pain
and she’s scared on what will happen if she will not go to the nearest hospital which is
Ospital ng Sampaloc.

CURRENT MEDICAL HISTORY

Patient was admitted to Emergency Ward to have her checked her boil and wants to
know what will happen. As further assessment of the doctor, the diagnosis is Abscess
forearm in right part. The doctor gave admitted her at the surgery ward and did incised
the boil so that all of the pus will be out from the affected site and further healing will be
monitored when admitted to Medical and Surgical Ward.

PAST MEDICAL HISTORY

The patient stated that the childhood illnesses she had was Chicken Pox, and
Mumps. She also stated that she didn’t have any severe illness before. Also, there is no
history noted for accidents and injuries. Patient said he has allergy but don’t know what’s
the primary cause. The patient also stated that she was hospitalized before because she
gave birth.
PSYCHOSOCIAL HISTORY

The patient is 54 years old. She finished high school and had a relationship at the
age of 25. The patient is now living with her children. She is a sewer as means of
livelihood. The patient stated that she acquires inadequate sleep of 5-6 hours a day. The
patient didn’t denies of drinking soft drinks. She also denies smoking and taking
prohibited drugs. Patient said that she doesn’t get an exercise daily. She usually spent
her day in work and taking care her house at night.

FAMILY HEALTH HISTORY

The patient stated that there was no other illness that runs in the family. There was
no history of Bronchial Asthma, Diabetes Mellitus, AURI, Cancer and anything else.

SPIRITUAL HISTORY

The patient’s religion is a Roman Catholic. She maintains her spiritual being by
attending church weekly.

VITAL SIGNS

The patient’s pulse rate is 90 bpm. Her blood pressure is 120/80 mmHg. The
temperature is 36.5 C which is within normal limits. Her respiratory rate is 18 cpm with
pulse rate of 86 bpm.
PHYSICAL ASSESSMENT:

HEENT

Head: Configuration- normocephalic


Hair- normal texture and fine distribution of hair
Scalp- no lesions, no tenderness

Eyes: Sclera- white


Conjunctiva- pink

Ears: External Ear- no lesions, masses, tenderness were seen

Nose: Color- no discharge was seen


Septum- midline

Throat and Teeth: Present and in good dentition


Mouth Tongue: has no lesions
Gums and Mucosa: no swelling, bleeding, infection was seen
NECK

Active ROM: normal flexion, extension, lateral rotation and tilting


Trachea: is in midline, mobile
Thyroid: non-palpable or palpable, normal size & consistency, has no lesions

BREASTS

Inspection (Breasts and Nipples)- normal size for her age, didn’t inspect on her breast but
the patient said that there are no nodules when you inspect.
Palpation (Breasts and Nipples)- no masses as the patient herself said.

THORAX & BACK

Observation: symmetrical expansion with respiration

LUNGS

Percussion and Palpation of Lung Fields- normal resonant percussion


Auscultation- clear, normal vesicular breath sounds
HEART

Auscultation: normal beats per minute

ABDOMEN

Observation: there are scars due to incision when she gave birth.
Auscultation: normal bowel sounds are heard

EXTREMITIES

Upper: Nails- not cyanotic, no clubbing


Palms- normal color, rough in texture, with scars and lesions in her
right palm
Muscles- normal size for her age

Lower: Nails- not cyanotic, no clubbing


Muscles- normal size for her age

SKIN: skin is dry, with scars and lesions present in her palm

LYMPH NODES

Neck: not palpable, no lesions, no masses


Axillary: not palpable, no lesions, has a lot of fats, no nodules.

NEUROLOGIC

Mental Status: Awake & Alert; oriented to person, place & time
Cranial II: Visual Acuity- 120/80 eyesight, using an eyeglass
II and III: Pupillary Reaction to Light- direct & consensual which is
normal
Accommodation- normal
VII: Wrinkle Forehead, Close Eyes, Show Teeth-
normal
VIII: Hearing- normal through discussion
X: Cough- can cough, normal
XI: Shrug Shoulders and check sternocleidomastoid muscles -
normal

XII: Protrude Tongue- midline protrusion


Motor System: Normal tone
5 / 5 strength in all extremities
Sensory: Light Touch- nomal
Position Sense- normal
Vibration- normal
Sharp- normal
Coordination: Gait and Balance- patient states that somehow she can’t balance herself
when standing.
Finger to Nose- normal
Rapid finger movements- normal