Our Lady of the Pillar College-Cauayan

Cauayan City, Isabela

College of Nursing
HEALTH and Midwifery
ASSESSMENT RLE
ACTIVITY 1

PHYSICAL ASSESSMENT

Name of Patient: Patient K Age: 19 Gender: Female Birthday: November 9, 2003

Address: Sillawit Cauayan City, Isabela Occupation: None Status: Single Civil Status: Single
Chief Complaints: Patient K has complaining pain in her wisdom tooth since yesterday and not properly trimmed nails since today.

Assessment PA Technique Used Actual Findings Analysis/ Interpretation

GENERAL APPEARANCE Inspection and Inspection: NORMAL
 Skin appearance Palpation  The patient's natural skin tone is described as
having a porcelain-like appearance.
 The patient also has a patch on her knee light
brown 1 cm and on her left fist light brown .5
cm.
 The color of the patient's scalp does not appear
to be abnormal in any way.

 Dress and Grooming
Palpation:
 The skin of the patient appears very fine and
very silky.
 On the surface of the patient's skin, there are
no indications of the presence of lumps,
lesions, or discomfort.
Inspection  The vellus hairs on the patient are extremely NORMAL
fine and have a texture that is rather smooth.
 The patient's hair has a natural texture, and
 there is no sign of any kind of coloring
treatment on it. Negatively affected by
parasites such as nits, lice and even dandruff.
 The patient dressed appropriately in her white
uniform.
 The patient has neat and clean hair.
 Hygiene Inspection  The patient takes a bath 3 times a day and Risk for infection because her nails
there is no presence of unusual odor. are not properly trimmed and she
 The patient usually brush her teeth two times a has pain in her wisdom tooth.
day, but she has pain in her wisdom tooth.
 The patient skin care, she is doing it routinely
twice a day morning and evening.
 Nails are not properly trimmed.
 Posture Inspection  Her arms are at her sides, with her elbows in NORMAL
close proximity to her sides. Her shoulders are
relaxed. The angle formed by the elbows, hips,
and knees is approximately equal to ninety
degrees.
 The shoulders of the patient are aligned with
the hips, and the ears of the patient are aligned
with the shoulders.
 Body build Inspection  The patient has a form similar to a rectangle NORMAL
(for women). There is a slight difference
between the hips and the waistline in this
view. Her hip and shoulder widths are
comparable, and her build generally has a
balanced proportion of different parts.
Height: 162.56 CM
Weight: 52 kg
BMI: 19.7 (Normal)
 Level of Consciousness Inspection  On the Glasgow Coma Scale, the patient is NORMAL
currently rated as having a score of 15. It
appears like he is paying attention, is aware of
my presence, and is not getting annoyed by the
questions that I am asking.
  Level of Comfort Inspection  How would you grade this circumstance from NORMAL
one to ten, with one being the most
uncomfortable and ten being the most
pleasant, given the choice? The patient
provided the number 10 as their response.
 Facial Expression Inspection  During the time that patients are answering my NORMAL
questions, she maintains a cheerful and
relaxed tone.
 Speech Inspection  When he was responding to my inquiries, he NORMAL
did so in a manner that was cool and peaceful,
and there was not the slightest indication that
he was anxious in his voice.
VITAL SIGNS Inspection  After taking it at the site of her axillae, the NORMAL
 Body Temperature patient's body temperature was determined to
be 36.7 degrees Celsius.

 Pulse Rate Palpation  An evaluation of the patient's pulse rate in her NORMAL
radial pulse was performed for one minute,
and a result of 65 beats per minute was
recorded afterward; this indicated that the
patient had a normal pulse.

 Respiratory Rate Inspection  A normal respiration rate of 15 breaths per NORMAL

minute was identified after evaluating the
patient's chest movement for one minute. This
indicates that the patient has a healthy
respiratory rate.

 Blood Pressure Inspection  The patient's blood pressure was measured NORMAL
with a sphygmomanometer, and the results
Palpation showed that the patient has normal blood
pressure. The blood pressure reading was
120/80 mmHg.