CASE PRESENTATION
Prepared By: Group 5
PHYSICAL ASSESSMENT
AREA ASSESSMENT
[Link] Survey
with good hygiene and properly dressed
A. General Appearance
Active and displaying appropriate affect
B. Mental Status
[Link]
Normal skin color; no signs of edema and lesions; no
A. Skin
noted bruises; warm and with slight poor skin turgor
B. Hair Some white hair and artificial color (blonde) ; No
enough distribution and texture.
Rough nails; tissues are intact around the nails; slightly
C. Nails pale nail bed color; Capillary Refill Time: less than 2
seconds
[Link] and Neck
Head Circumference: head and face are proportion to
A. Skull
each other and symmetric; no verbal pain.
B. Eyes Parallel to each other; pink conjunctiva; normal color of
sclera; dark brown iris; pupils equally reacted to light
(dilated when reacted to light; constrict when reacted to
light);normal visual aquity, extra ocular movements and
peripheral vision
C. Ears No signs of serumen, lesions, pus or blood
D. Nose and Sinuses No signs of obstruction on each nostrils
No tenderness nor pain on the maxillary and frontal
sinuses when palpated
E. Mouth and Oropharynx Pinkish oral mucosa; no signs of bleeding on the
gingivae; pinkish colored tonsils, not enlarged and no
discharge
F. Neck Swellings, masses noted; lymph nodes are found.
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No lesions and bruises; normal symmetry of
A. Posterior Thorax
expansion and spinal alignment
Normal respiratory excursion and tactile fremitus
Dull sound during percussion and no adventitious
breath sounds during auscultation
B. Anterior Thorax No lesions and bruises; normal symmetry of
expansion
Sudden breathing difficulty (sometimes).; no
adventitious breath sounds during auscultation
Normal apical pulse: 64 bpm; no abnormal
pulsations, lifts or heaves
No localized discoloration, swelling or edema; No
C. Breast masses, tenderness or discharge
V. ABDOMEN Normal contour; No lesions or skin breakdown on
all four quadrants; Normal bowel sounds, gurgling
sound every 5-20 seconds interval; Tympanitic
sound heard during percussion; No pain or
tenderness during palpation;
Have pain when urinating on the L Lower
quadrant.
VI. EXTREMITIES No lesions; with presence of bruises on right and
left; Symmetrical muscle size; No tremors;
Normal tonicity and strength; no tenderness and
swelling, crepitating and presence of nodules.
Verbal weakness on the bone and joint.
[Link] STATUS
Scored 15 on the Glasgow Coma Scale (Eyes Response: 4, Spontaneous; Motor
A. Level of Consciousness
Response: 6, Responds to verbal command; Verbal Response: 5, Oriented and talks)
B. Cranial Nerves Client was able to identify the smell of her cologne and the smell of coffee as
I. Olfactory verbalized.
II. Optic She was able to identify letters with a distance of 50/20.
III. Oculomotor Normal extra ocular movements; pupils equally reacted to light
IV. Trochlear Normal extra ocular movements
V. Trigeminal Manifested blink reflex; Was able to clench teeth upon verbal command
VI. Abducens Normal extra ocular movements
VII. Facial Client was able to smile, raise eyebrows, puff out cheeks, and close eyes; She was
able to identify the taste of sugar and coffee
VIII. Auditory She was able to clearly hear and repeat the spoken words
IX. Glossopharyngeal Manifested gag reflex; Tongue was able to move from side to side and up and down.
X. Vagus Manifested gag reflex; Tongue was able to move from side to side and up and down.
XI. Accessory She was able to shrug shoulders against resistance
XII. Hypoglossal Tongue was able to move from side to side
A. Reflexes Biceps, Triceps, Patellar, Achilles and Plantar Reflexes all graded +2, which means a
normal response
B. Motor Function Client was able to walk across the room and back while hands are moving; slightly
curvature posture and balance.
C. Sensory Function The client was able to feel the cotton touching her skin; patient was also able to
determine the “sharp” and “dull” ends of the reflex hammer.
VIII. No redness and swelling; No noted
GENITALIA/INGUINAL discharge,
AREA Verbal pain of 7/10 during urination
asverbalized by the patient.
IX. RECTUM/ANUS Normal color and integrity; No signs of
rectal prolapsed, fissures, polyps or
hemorrhoids
Normal sphincter tone; no nodules, masses
or tenderness as verbalized by the patient.
NCP
Assessment Diagnosis Planning Intervention Evaluation
Subjective: Impaired gas After 8 hours of >Monitor Vital Signs The patient
"Nahihirapan ako exchange r/t altered implementing the and cardiac rhythm demonstrate
huminga kanina." as oxygen supply nursing interventions >Elevate head of improved ventilation
verbalized by the the patient will bed/position client and relieved
patient demonstrate appropriately difficulty of
Objective: (+) improved ventilation >Encourage patient breathing.
restlessness and relief of difficulty to have adequate
(+) DOB of breathing. rest
(+) generalized >Advise patient to
weakness limit activities
Vital signs taken as: >Provide patient
T: 36.8 with oxygen as
P: 88 prescribed by the
R: 42 physician
BP: 130/90 >Administer
medications as
prescribed by the
physician
Assessment Diagnosis Planning Intervention Evaluation
Subjective: Activity After 8 hours of >Monitor vital >Patient
"Nanghihina pa intolerance r/t implementing the signs verbalized
ako" as generalize nursing >Advise patient relieved from
verbalized by the weakness interventions he to have adequate being restless
patient patient will rest
Objective: (+) demonstrate in >Assist patient
restlessness physiological with activities
(+)generalized signs of >Provide patient
weakness intolerance such with quiet and
Vital signs taken as pulse, peaceful
as: respiration and environment.
T: 36.8 BP will remain >Advise patient
P: 88 within normal to avoid food and
R: 42 range drinks with
BP: 130/90 caffeine content