Chapter III

Physical Assessment
Patient’s Name: C.L Age: 57 years old
Date of Assessment: August 30,2020 Time of Assessment: 10:00am -11:00 am
General Survey Receive patient lying on bed, conscious & coherent, restless, with # 1 PNSS 1L x KVO with side drip of
D5W + 1 amp nicardipine regulated at 10 mcgtts/min, infusing well at right arm/ metacarpal vein, (-) for
phlebitis or infiltration, in respiratory distress, not well-groomed and has foul body odor, with vital signs as
follow: BP: 180/110 mmHg (Hypertensive); RR= 28 (labored); PR= 108 (irregular rate & rhythm); T= 37.9
(febrile); O2 Sat: 98%

Body Parts History Inspection Palpation Percussion Auscultation Interpretation

SKIN Had a Has brown skin Skin is Not applicable Not applicable Gangrene on the
history of complexion, warm, and right foot is not
chicken pox right foot dry, poor getting sufficient
when she gangrene on skin turgor blood circulation
was 14 heel and sole and poor causing the tissue to
years old noted, affected blanching. die due to prolonged
and German area of hyperglycemia which
measles but gangrene is result to damage of
couldn’t black in color the blood vessel and
recall the and red, moist it is possible of blood
date and with foul circulation to be cut
 year smelling cottage off which lead to
cheese delayed wound
discharges healing.
(Diabetes.co.uk,
2019)

HAIR & SCALP No Hair is short and Scalp is Not applicable Not applicable
significant black in color, nontender
history of thin, unkempt and no
hair related and evenly masses
problems distributed, no present
dandruff noted
NAILS No untrimmed Nails are Not applicable Not applicable Poor capillary refill
significant fingernails & firm, thick due to poor blood
history of toenails, convex and poor flow ,
nail related in shape, capillary
problems nailbeds are refill (<3 Nailbed are slightly
 slightly pinkish sec.) pinkish due to
and pale on the
right foot and no
clubbing noted
HEAD & FACE Had history Normocephalic, no areas of Not applicable Not applicable
of headache eyebrows are masses
last for 3 thin and black and
days last tenderness
July, 19,
2020
EYES Had history Sclera is slightly Eyeballs Not applicable Not applicable
of blurry white Iris is are firm,
vision last brown, eyelid smooth and
august 3, dropping noted, nontender,
2020 conjunctiva is no
pale, pupils are tenderness
equally round on lacrimal
and reactive to gland &
light and ducts
accommodation,
no swelling of
lacrimal glands
& ducts, (+)
 Blink reflex, able
to close both
eyes with
resistance

EARS No Symmetrical, Pinna is Not applicable Not applicable

significant helix of ear is pliable &
history of aligned; yellow soft, no
ear related cerumen is tenderness,
problem noted in both masses &
ears swelling, no
palpable
nodules
NOSE Had history Nasal septum is No Not Assessed Not applicable
of colds last midline, nasal tenderness
May 5, 2020 mucosa is on frontal
pinkish, and no and
nasal maxillary
discharges sinuses.
noted, has fine
nose hair,
Mouth & throat Had a Lips are slightly Lips are Not applicable Not applicable
history of pale, intact and soft and
 mouth ulcer in midline, oral free from
last April 6, mucosa and tenderness
2020 & tongue are and
tonsilitis last slightly pale, masses
2018 teeth are
yellowish, 16
teeth with 9
dental caries,
(+) swallowing
reflex, no dental
prosthesis noted
NECK No Neck is intact, Trachea is Not applicable Not applicable
significant no jugular in midline;
neck related distention noted. cervical
problem lymph
nodes are
non-
palpable
THORAX & BACK Had a Clavicles are Nontender Not Assessed PR: 108bpm
(cardio - history of symmetrical, and no (irregular rate &
pulmonary) hypertension chest is intact, masses Rhythm), (+)
RR: 28 cpm, noted minimal crackles
use of sound at right
 accessory lower lobe.
muscles while
breathing
Peripheral No no varicose vein Non pitting Not Applicable Not Assessed
Vascular significant on both lower edema
history of extremities grade 1 at
any vascular noted, left lower
disease extremity,
pulses are
present
BREAST No Refused Refused Not applicable Not applicable
significant
history
related to
breast
ABDOMEN Had a umbilicus is in tenderness
history of midline and on
constipation inverted, striae hypogastric
but cannot gravidarum area, no
recall the noted, protruded masses on
year and abdomen four
date quadrants
GENITO- Menarch at Not assessed Not Not applicable Not applicable
URINARY age of 11 Assessed
 and
menopause
d at age of
50
MUSCULO- No spinal Not Assessed Not Applicable
SKELETA deformities,
no pain
sensation
on right
foot and
decrease
sensation
on the left
foot

GORDON’S TYPOLOGY OF NURSING

HEALTH PRIOR TO ADMISSION DURING ADMISSION IDENTIFIED

 PATTERN NURSING PRIORITIZATION JUSTIFICATION
PROBLEM
HEALTH Patient verbalizes “ Kinahanglan gid gali No problem
PERCEPTION - ambot lang gid mam mag pati sa doctor Identified
HEALTH kung kumpleto ko sa mam no kay kung
MANAGEMEN bakuna di ko na abe magsakit mas maayo
T matandaan kay dugay na gid ng mag pa doctor
pero akong mga bata para di na mag lala
complete sila sa bakuna.” ang sakit.” Patient
Whenever the family emphasize the need
experiences illness they for medication
don’t directly went to the compliance to promote
hospital instead they visit good healing and fast
a manghihilot first.” “hina recovering. She
man gud ang pamaligya verbalizes “mao tung
maam maong pag sa una kay wala ko
magsakit di dayun mapa nag pati og nag pa
doktor ba kay mahal ang doctor ug gipa
bayad maong mag adto sagdahan nako maong
sa me didto sa nag lala akong samad
manghihilot.” she added. sa tiil maong karun
The patient has irregular mag pati na gid ako sa
treatments on her DM, doctor para dali ko ma
 “isa sad ka rason ayo”.
nganong di nako kaayo
matuman ang mga gi
adbays sa akoa sang
doctor nako dati kay
gamay ang kita namo sa
among baligya, igo lang
pang palit og sud an og
bayad sa mga gastoson
sa balay”
NUTRITIONAL The patient loves to eat During admission the Impaired skin
- METABOLIC sweet foods and usually patient’s diet are low integrity related to
drinks soft drinks salt, low fat and low gangrene on the
especially cola. She purine diet. The patient right foot
usually eats three times is now strictly following
more in a day with the diabetic diet, 1,800
snacks in between. She kcal in 4 servings/day. Imbalance
doesn’t like eating Parenteral fluid is nutrition: greater
vegetables and always given, than body
had fish, pork and Weight of 70kgs with a requirements
chicken meat. She also BMI of 28.22 related to erratic
liked eating fried food (overweight),” feel ko eating
paired with cola. The tambok og nagbug at
patient verbalizes, “kung na gani kaayo ko
nagatinda ko gulay sige mam, overweight man
ko ug kaon-kaon, tingala daw ko kay kusog Hyperthermia
lang ko may samad na kaayo ko mukaon sa related to illness
akon tiil, wala ako una pero karon gina related symptoms
kabatyag, pila ka adlaw control ko na hinay
daw nag lala nagid siya, hinay, lisod ning
naga sugod nag itom tambok ta kay damo ta
akon samad maong mabatyagan.” as
nabalaka akon bana kag verbalized by the
mga anak, gi updan patient. “murag ge
dayun ko sa akong bata lagnat ko mam/sir ba
mag adto sa ospital” maong murag wala
koy gana magkaon,
murag na bag uhan ko
sa diabetic diet og
basig tungod ini sa
akong samad na wala
pa na ayo, nalata
najud akong tiil unya
ga nana og baho pajud
siya” she added.
 Patient temperature is
37.9 degrees Celsius
ELIMINATION She defecates every Patient has difficulty No problem
other day, with stool color defecating but stills Identified
of yellow and light brown. defecate every other
Patient voids several day, stool is yellow and
times a day, brown in color. Patient
approximately 7-10 times void less compared to
a day. She verbalizes pre admission. She
“pag gabie sige kog mata voids 220 ml for 8
kay mangihi.” She hours with urine color
described her urine as a of yellow.
yellow in colors and
presence of small
bubbles. “gina amigas
sad akong ihi” she added.
ACTIVITY - Prior to Admission, the During admission, the Impaired physical
EXERCISE patient stated that “tong patient is needing an mobility related to
naa ko sa balay medyo assistance. “giubanan underlying
makalakaw man ko, ko sa akong bata na condition
galuto og ga limpyo sad mag adtog ospital,
ko pero gina punggan ko tong dri nako sa ospital
sa akong bana og bata limitado na kaayo
 kay basig maglala akong akong mga lihok, di
samad sa tiil, usahay ga nasad ko makalakaw
patabang sad ko nila lakaw, og naa rako sa
kung mag adtog Cr kay akong higdaan, kung
basig maslide ako”. Tong mag adto man kog Cr,
wala ni akong samad sa gapauban ko sa akong
tiil ga lakat gid ako sa bata kay di na kaayo
bagsakan kay ko makalakaw tarong
magbaligya sang mga tungod sa samad sa
gulay” akong tiil”. As
verbalized by the
patient.
SLEEP AND Patient usually more than The patient had on and Disturbed Sleeping
REST 8 hours a day. Earliest off sleeping pattern Pattern related to
time in going to bed is at when admitted due to environmental
7 pm and usually wakes nurse’s care. She barrier and
up at 5:30 am or 6 am in usually sleeps at 8 in insufficient privacy
the morning. She usually the evening, “ maka
took a nap for about 1 to mata ko sa ka init dri
2 hours in the afternoon. og di kaayo ko katulog.
Sometimes, she wakes Putol putol sad akong
up in the middle of the tulog kay maka mata
night and had a hard time ko ug nay nurse mo
 going back to sleep. adto mag Bp og
muhatag tambal” as
verbalized by the
patient. She wakes up
at 5:30-6:00 in the
morning.
COGNITIVE Patient is oriented to The patient verbalizes Deficient
PERCEPTION time, place and people. “mainitidhan nako ang knowledge
Able to focus well and gi ingon ni doc na regarding disease
communicate well. She is kailangan tangalon process and
also able to identify ang akong isa ka tiil treatment
events, differentiate and para sa akong
identify changes in kaayohan og dili na
environment. maglala akong
situasiyon”. “wala gid Impaired comfort
abe ko kabalo kung related to illness-
ano ina ang diabetes related symptoms
kay abe ko simple ra
na sakit.” “dili ko
comportable og di ko
makapakali dri mam,
gamay sad dri ang
higdaan dili ko
 makalihok tarong
samot naa koy samad
sa tiil, init pajud dri”
she added.
SELF Prior to admission, the During admission, she Fear related to
PERCEPTION patient is able to express was very vocal about surgical procedure
her feelings through small the fear she felt She
talks with her family. She stated, “tong nag ingon
stated, “tung naga lain na si doc na kailangan
akong paminaw maam tanggalon akong mga
kay gina ingon jud nako tudlo sa tiil nahadlok
nako sa akong pamilya na ginakulbaan ko sa
wala nako gina tago- operasyon kay halin pa
tago.” She added, “pero gid sa una wala pako
ug kaya pa nako maam di ka agi opera,
ko gusto eingon para dili mahadlok jud ko sa
sila ma balaka”. “ tong maging resulta ani ug
naa nani akong samad, ma putol ni akong
abe nakog simple lang tudlo, mahadlok sad ko
samad lang na dali lang kay basig dugay mayo
mayo” akong tiil or di najud
mayo kay diabetic
baya ko unsaon
 nalang akong
pamaligya ani.”
ROLE The patient is a mother to During the admission, No problem
RELATIONSHI her 5 children and a wife the patient stated, Identified
P to her husband. She “karon kauban nako
stated, “ako or akong akong isa ka bata siya
bana ang ga desisyon gabantay nako
maam, pero ga samtang akong bana
pamangkot man kami sa gapaningkamot na
gusto sang mga bata makakwarta pang
namon”. As verbalized by bayad sa akong pag
the patient. “ okay raman ospital og palit sa
me og close ko nila” as akong tambal. As
she added. verbalized by the
patient.
SEXUALITY the patient and her Patient verbalized No problem
husband no longer sleep “wala jud me ka tapad Identified
together. They are man lang sa akong
sleeping in a separate bana kay akong anak
room, the patient sleeps man ang ga bantay
with her younger nako dri sa ospital,
daughter. The client is muuli man siya dayun
already menopause since paghuman bisita, wala
 she was 50 years old. naman sad jud me ga
tapad tulog mam.”
Patient emphasizes
that she and her
husband are no longer
have sexual
intercourse for about a
year now.
VALUES - The patient is a Roman “sa akong ginabatyag No problem
BELIEF Catholic. “ nagasimba karon, wala gid nako Identified
gid ako taga domingo, gina sisi sa ginoo kay
naga pasalamat ako sa kabalo ako palangga
mga blessings na gihatag kita sa diyos, padayon
niya sa akong pamilya gihapon akong
bisag naa koy pagsalig og pagsamba
ginabatyag, kung naga niya bisag naa ko dri
pangadi ako, mawala sa ospital kay kabalo
akong problema og ako na di ko niya
ginabatyag” as verbalized pabay an” as
by the patient. verbalized by the
patient.