A Narrative Report on

PHYSICAL ASSESMENT

In Partial Fulfillment of the

Requirements in NCM 207 – RLE

PRE- CLINICAL ROTATION

Submitted to:

MARIA TERESA FARALA, RN , MN

Clinical Instructor

Submitted by:

CHELSEY NOVIE C. MARTINEZ, ST.N.

BSN 2C – Group 1

August 30, 2021

 PHYSICAL ASSESSMENT

A. BIOGRAPHICAL DATA
Name of Client: Emelita C. Martinez Age: 54 Gender: Female
Home Address: Barangay 1, San Francisco, Agusan del Sur
Birthdate: April 9, 1967 Birthplace: Lupon, Davao Orriental Nationality:
Filipino Marital Status: Married Education Level: College Graduate
Occupation: Vendor Religion: Roman Catholic

B. ADMISSION HISTORY
- NO ADMISSION HISTORY
C. HISTORY OF PRESENT ILLNESS
- NO PRESENT ILLNESS
D. PAST HEALTH HISTORY
- Previously visited to a clinic with the attending physician Dr. Solde of San
Francisco Doctor’s Hospital. Reasons of seeking care is chest pain.
Approximate date is June 15, 2020. Examined with ECG, no abnormalities
detected, no medications were prescribed.
E. FAMILY HEALTH HISTORY.
- In the paternal side, grandfather cause of death old age, grandmother cause
of death is high blood. Father’s death caused by high blood and
hematemesis. In maternal side, grandfather passed away due to prostate
cancer and grandmother cause of death is high blood. Has a female sibling
passed away due to pneumonia and currently have a sister who has a
recent illness of high blood pressure.
F. GORDON’S FUNCTIONAL HEALTH PATTERN
a. Health Perception – Health Management Pattern- Caught cold last
month. Waking up early as her important things to do to keep health. No
accidents encountered this year.
b. Nutritional-Metabolic Pattern- Bread as breakfast and coffee as her fluid
intake, with 3 meals a day. Vitamin C every day. Weight maintained, has a
weight of 66 kg and height of 152 cm. Good appetite. No discomfort in
swallowing and no diet restriction. Heal well and no skin lesions. Has a
dental problems in last molar teeth covered with cavities. No changes in
skin color. Oral mucosa is normal. Has a missing 2 molar teeth’s.
Temperature is normal and no intravenous feeding.
c. Elimination – Bowel elimination twice a day with dark brown character and
no discomfort. Urine elimination approximately 7 times a day and has a
problem in control. Excessive perspiration and has an odor problem,
bromhidrosis a foul smelling body odor related to sweat as reported by
client. No body cavity drainage.
d. Activity- Exercise Pattern- Have a sufficient energy for desired activities,
exercise pattern is going up and down to a 13 steps stairs. Perceived ability
 for feeding, cooking, bathing, grooming, shopping, toileting, general mobility
and home maintenance. Has a good posture and no absent body parts.
e. Sleep- Rest Pattern – Has a 7-9 hours of sleeps, early awakening as the
sleep onset problem.
f. Cognitive-Perceptual Pattern –no hearing difficulty, reported that vision is
blurry sometimes. No change of memory lately. Can moderately learn things
if teach slowly. Client reported that having difficulty in making decision
recently.
g. Self- perception/ Self Concept Pattern – describes self as most of the
time is feeling good. Noticed something in part of her body is changing
(abdomen). Things that make her frequently angry is dog’s stool.
h. Roles/ Relationship Pattern – Lived with family, sometimes having
problem with partner. Sometimes having difficulty handling problems with
children but can manageably handle. Has a close friends.
i. Sexually / Reproductive Pattern – not sexually active with partner.
Menstruation starts on August 1, 2021, has a prediction of having a
menopause.
j. Coping/ Stress Tolerance Pattern- Encountered crisis since the start of
pandemic. Relaxed most of the time, only having a tense when children is
fighting. Doesn’t take any medication, drugs or alcohol. To pray is the
number one thing to handle big problems in life.
k. Values/ Beliefs Pattern – Client reported that religion is important to her
life that it helps when difficulty arise.

G. PHYSICAL ASSESEMENT
i. GENERAL SURVEY

We received our client seated on a chair at the time of assessment. Awake,

coherent, and sensitive to stimuli, with a sense of time, person, location, and tasks to do.
Her body type is endomorph. With a body weight of 66 kg and a height of 152 cm, he has
a body mass index of 28.6. Has a lordosis posture.
 The client looks to be comfortable and helpful during the evaluation. The verbal
answer is focused and well-groomed, and the attitude is suitable. Well-developed, well-
hydrated, and well-nourished. Following the evaluation, the client's vital signs are as
follows:

Vital Signs Actual Normal Values Significance

Temperature 36.4°C 35.5-37.5 °C Normal
(Axillary)
Cardiac Rate 77 60-100 bmp Normal
Pulse Rate 74 60-100 bmp Normal
Respiratory rate 16 12- 20 bpm Normal
Blood pressure 110/80 120-880 Normal

ii. SKIN

Skin has a rough texture and a uniform overall hue. Turgor is satisfactory, the skin
is warm, and the moisture is dry and unbroken, with no rashes. There were no lesions or
edema seen. There is no evidence of ulceration. The nails are well cut, and the nailbeds
are pink, with no cyanosis or clubbing. Capillaries refill in a fraction of a second. With a
diameter of 6mm, she has a mole in her left eye and upper lip.

iii. HEAD

The head is normcephalic, with a close fontanelles and a symmetrical skull. No

tenderness visible or palpable masses, depression or scarring and lesions. Hair is evenly
distributed and has normal texture. Scalp has dandruff.

iv. EYES

Eyebrows is symmetrically aligned with equal movements, hair is evenly

distributed. Eyelids is symmetrical with no edema, skin intact, no discharge. Lashes is
equally distributed and curled outward. Lacrimal duct is normal, no swelling and excessive
tearing. Cornea Lens is smooth, transparent shiny and details of the iris are visible.
Conjunctiva is pinkish and no lesions. Periorbital region has a discoloration. Sclera is
anicteric and pupil is isocoric, black in color, round, smooth border and iris is flat, left and
right eye has brisk reaction to light. EOM are intact, PERRLA and no signs of nystagmus.
Visual Acuity is normal and client able to see the counting fingers and hand movement.
Client has a left homonymous hemianopia which can only see one side.

v. EAR

The pinna is normal, with no discomfort. The external canal and ear canal are
non-tender, without swelling or discharge, and no bad odor. The tympanic membrane
seems normal, with typical landmarks. Hearing is normal, with high sensitivity to hushed
voices.

vi. NOSE

The nasolabial are symmetrical. The nasal mucosa is pink and moist. The nasal
septum is located at the midline. The color of the two nasal cavities was uniform and
symmetrical, and there was no flapping or perforation of the nasal wings, and no lesions
were seen. When the client breathes through the nostrils, the air flows freely. No masses
were observed in the maxillary sinus or the frontal sinus.

vii. MOUTH

Lips is symmetrical with a color of pale and moisture of crack and dry. Tongue is
in the midline no palpable nodules or lesions and has a whitish coating. Teeth is not
complete, 2 molar teeth are extracted. Gums is pinkish, no lesions. Buccal mucosa is
pink, moist, no ulcers notes. Palate is pink.

viii. PHARYNX

Uvula is in the midline. Mucosa is pink. The pharynx is normal in appearance

without tonsillar swelling or exudate. Gag reflex is negative.

ix. NECK.

Trachea is midline. Lymph nodes is non palpable. Thyroid gland is normal with no
masses. Head movement is coordinated and smooth with no discomfort. Jugular veins
is present and has a normal muscular strength. No muscle tremors or stiffness noted.
Carotid pulse is present.

x. THORAX

The chest wall is symmetrical, the spine is aligned, and there is no sign of mass,
trauma, or injury on palpation. The breathing mode is effortless and the skin is plumped.
There are no signs of respiratory distress.. Tactile Fremitus is symmetrical. Lung sounds
are clear in all lobes bilaterally without rales, ronchi, or wheezes. Resonance is normal
upon percussion of all lung fields.

xi. HEART

Precordium is normodynamic. Heart sounds: aortic, Pulmonic, tricuspid and

apical is distinct. No known heart disease or high blood pressure. No extra sounds like
murmurs, gallops or rubs are auscultated. S1 and S2 are heard and are of normal
intensity. Apical pulse is regular. Pulses are temporal which is strong same with carotid,
radial and popliteal. Some pulses are thready like dorsalis pedis and posterior tibia.

xii. BREAST

Size and symmetry is equal. No masses and dimpling noted. Skin is intact and
tender, no lesions noted. Nipple and areola is normal no discharge and swelling noted
and has a color of dark brown. 5 cm from the nipple keloid is noted.

xiii. ABDOMEN

Skin is intact. Contour is globular. Abdomen is soft, symmetric, and non-tender

without distention. There are no visible lesions or scars. Bowel sounds are present and
has a hyperactive sounds in left upper quadrant the rest is normoactive. No masses and
visible peristatic wave or any abnormalities. Umbilicus is midline.

xiv. GENETO- URINARY SYSTEM

Reported by client, pubic hair is normal. Labia is asymmetrical. Vagina has a

discharged of foul-smelling. No swelling, lumps and nodules reported.
xv. MUSCUKOSKELETAL AND NEUROGICAL ASSESEMENT
i. Muscles
- Muscles have all equal size, no contractures and tremors are noted.
Weakness in left deltoid and trapezius muscle. Client reported to have
numbness and tingling at left shoulder which is left deltoid and trapezius
muscles.
ii. Bones
- Bones is normal, have a symmetrical strength. No deformity and tenderness
noted,
iii. Joints
- Joints is symmetrical, crepitus sound is present no pain. No swelling,
redness and tenderness noted. Client perform a circular whole arm
movement in left arm and complained pain.
iv. Neurological Assessment
- Client have a spontaneous speech, no stuttering and hesitancy in speaking.
Client is oriented and no lapses in memory. Can remember what happen in
her birthday last year. Level of consciousness is oriented and alert.

H. CONCLUSION

Health assessment is to collect information about the patient's health. Effective health
screening is a comprehensive assessment that provides a holistic approach and provides
interventions. Intervention must consider the patient's spiritual, cultural, socio-economic
and socio-psychological preferences. As stated by Bickley in the year 2017 the health
assessment only surrounds with client and physician centered this is to work together to
form a successful relationship.

1. What are the pertinent finding?

A 54 year old woman who has no admission history and present illness but had
past visit of clinic last year seeking care for chest-pain attending finds no
abnormalities and no medications prescribed. Upon the assessment the findings
are as follows:
 W: 66 kgs and H: 152 cm
 Scalp has a dandruff
 Periorbital has discoloration
 Left homonymous hemianopia which can only see one side
 2 molar teeth are extracted both left and right
 5 cm from the nipple keloid
 Client reported to have numbness and tingling at left shoulder which is left deltoid
and trapezius muscles.
 Client perform a circular whole arm movement in left arm and complained pain.

2. Summarize the over-all health condition of the client.

Base on the Gordon’s Functional Pattern client caught cold last month but
just got rid of it in three days. Has a good health management pattern. No problems
nutritional and metabolic pattern. Urine elimination approximately 7 times a day
and has a problem in control. Excessive perspiration and has an odor problem,
bromhidrosis a foul smelling body odor related to sweat as reported by client. Has
good activity and exercise pattern including the sleep and rest pattern. No hearing
difficulty but sometimes have blurry vision. Describes self as most of the time is
feeling good. Sometimes having difficulty handling problems with children but can
manageably handle. Not sexually active with partner.
Vital signs are in good condition. Client is well developed and has a good
orientation. Good is appropriate. No problem with skin, has a mole of 6mm in
diameter in left eye and left upper lip. Visual Acuity is normal and client able to see
the counting fingers and hand movement. Client has a left homonymous
hemianopia which can only see one side. No problem in ear, nose, mouth and
pharynx, no lesions were noted in the site that mentioned. No discomfort in thorax
and heart reported. No known heart disease or high blood pressure. 5 cm from the
nipple keloid was noted. Abdomen has a contour of globular, no lesions inspected.
Genitals area was reported as normal by the client. Client reported to have
numbness and tingling at left shoulder which is left deltoid and trapezius muscles.
 No deformities and tenderness noted in bones. Client is alert has oriented in the
assessment.
Lastly, I conclude that our client is in good condition and living healthy.

3. How did you find doing the assessment? Feeling? Insight.

Everyone should get their health evaluated. It is a test in which we judge a

person's mental and physical health. This is a plan of care that specifies the person's
unique requirements and how the healthcare system will meet those needs. Doing the
evaluation helped me understand how essential it is to do health assessment before
providing the client a final diagnosis. Because in real-life circumstances, you can't just
sit and stare at your client and then give them a nursing diagnosis without first
evaluating them.

Honestly, at first I was so nervous because my mother is my acting patient in

this assessment. I was so afraid that I might find something abnormalities in her body.
But as I examined her starting from her head up to her toes, gladly that she doesn’t
has any abnormalities around her body which makes me happy even though she
slightly complained that her left arm are having pain sometimes which she make it a
secret to us. Although this work appeared to be daunting at first, I recognized that
mixing some of the strategies I learned in this session into the way I normally assess
patients might give a more holistic approach. I typically had discussions with my clients
while assessing them, and I discovered that by asking them about their lives while I
went through the physical aspects of the test, I could learn a lot about how they were
feeling and what support networks they had available to them.

It is a wonderful joy to participate in this type of activity, and even if we are in

an online class, we are still able to carry out one of the most essential processes that
will benefit us in the future. When assessing a patient's health, it is critical to consider
the entire picture; it is critical to have assessment skills improved to the fullest extent
since, in the hospital, as stated by Jarvis that the nurse is the only health care worker
who is constantly present at the bedside. I find this idea to be true to my practice. As
much as I like learning about the individuals I care for that knowledge is useless if I
 am unable to provide appropriate treatment based on my initial physical examination
of the patient.

4. Significance to you as a student nurse and a professional nurse someday.

Someday as a professional nurse, and most recently as a second-year student

nurse. The most essential duty is to be a competent and caring professional nurse who
genuinely makes a difference in the lives of patients by delivering holistic nursing care.
To assist people in a Christ-like manner by integrating critical thinking expertise with the
nursing practice. To be a competent and lifelong learning nurse who provides empathic
and compassionate care while preserving honesty and integrity and respecting all
cultures and individual choices.

I. REFERENCES:

Jarvis, C. (2008). Physical examination & health assessment (5th ed.). St. Louis:
Saunders Elsevier.

L, Bickely. P, Szilagyi (2013). Bates' Pocket Guide to Physical Examination and

History Taking. Seventh Edition. J. B. Lippincott Company.

S. Jensen (2011). Pocket Guide for Nursing Health Assessment. A Best Practice
Approach Lippincott Williams & Williams.