PHYSICAL ASESSMENT

Temperature: 37.8*C
BP (Blood Pressure): 130/80 mmHg
RR : (Respiratory Rate) 27bpm
PR : (Pulse Rate) 90 bpm

APPEARANCE : Pt. is well groomed, wearing proper clothes/attire with out body
odor. With a height of 5’ 4” and weight of 55 kgs. Body built is medium.

MENTAL STATUS : Pt. is cooperative, appropriate to situation, exhibits thought

association. logical sequence of thoughts, and is oriented with time and place.

SKIN : Skin color is light brown and generally uniform except in areas exposed to
the sun; temperature is uniform; within normal range. Without any lesions and
edema. Skin turgor when pinched springs back to previous state immediately.

HAIR : Thin and evenly distributed, without any lesions, infection and infestation
on scalp.

NAIL : Convex curvature, angle between nail and nail bed of about 160 degree,
smooth texture, nail bed color is highly vascular and pink, tissue surrounding nails
are intact, blanch test capillary refill was done; prompt return of nail bed color to
pink < 2 – 3 sec.

HEAD ; Rounded (normocephalic and symmetric) facial features are also

symmetric. Absence of nodules or masses with symmetric facial movement.

EYES : Pt. eyebrow hair evenly distributed, symmetry aligned with equal
movement, eyelashes equally distributed; curled slightly outward. Eyelids intact; no
discharge , no discoloration. Lids close symmetrically. Bulbar conjunctiva is
transparent , sclera appears white. Palpebral conjunctiva is shiny, smooth and pink
in color. Lacrianl gland has no edema or tenderness. Pupil equal in size perrla
(pupils equally round and react to light and accommodation. Both eyes
coordinated, move in and unison with parallel alignment, not able to read
newsprint without using his reading glass.

EAR : pt. auricle color same as facial skin, symmetric position line drawn from
lateral angle of eye to point where top part of auricle joins head is horizontal
mobile , firm and not tender, pinna recoils after it is folded. There is presence of
dry verumen without ear discharge . Normal voice tones audible. Able to hear
tickingh of clock on both ears.

NOSE : Pt. external nose is symmetrical , straight, no discharge or flowing and

uniform in color, not tender, no lesion, no masses is palpated. Air moves freely as
the client breathes through the noses. Nasal mucosa is pink, no lesions. Nasal
septim intact and in the midline.

MOUTH : Pt. outer lies is uniform dark pink in color, soft, moist and able to purse
lips.

INNER LIPS : Uniform color, moist, smooth without any lesions. Pt. has no
ventures, has adult teeth which is yellowish in color, has dark pinkish gums tounge
is in central position, smooth, no lesions, moves freely, no tenderness. Base of
tongue has no prominent veins. Pt. tounge is smooth and no palpable nodules.
Tonsils is and are not inflammed and swollen. There is present of gag reflex.

NECK : pt. neck muscle equal in size, head centered, Coordinate, smooth
movements with no discomfort. Lymphnodes not palpable, trachmen in central
placement, in midline of neck. Thyroid gland is palpated and rise timely with
swallowing. There is also absent of bruit upon auscultation.

THORAX AND LUNGS : Chest is symmetric; anterior posterior to lateral

diameter in ratio of 1 : 2. posterior chest, skin intact; uniform in temperature.
Thoracic expansion full and symmetric chest expansion with no lag in movement.
There is no presence of any adventitious breath sounds. Anterior chest full
symmetric excursion percussion notes resonance down to sixth rib but but flat over
areas of heavy muscle. With presence of wheeze on inspiration. Client has 27
respiratory rate per minute which is a sign of difficulty of breathing.

HEART & CENTRAL VESSELS : Aortic and pulmonic areas has no pulsation.
heart was auscitated at four anatomic sites with S1 and S2; both heart at all sites.
Peripheral pulses has pull pulsation and it symmetric. Carotid artery was
auscultated, no sound heard. Jugular veins not distended. Peripheral leg veins has
no signs of phlebitis. Skin, hands and feet color are dark pinkish.

ABDOMEN : Pt. skin is uniform in color brownish without any presence of lesion,
no evidence of enlightment of liver or splee, abdominal movements are symmetric.
audible bowel sounds . No tenderness on abdominal skin.

MUSKULOSKELETAL SYSTEM : pt. has equal muscle size on both side of body.
no contractions, no tremors, bones has no deformities, has equal muscle strength
on even body side and is normally firm. Without any presence of lesions and edema.
Joints are non swelling and has good range of motion.

NEUROLOGIC : Pt. has upright posture, walks unaided, maintaining balance,

maintain stance for at least 5 sec. While standing on one foot with eye closed,
maintains heel – toe walking along a straight line repeatedly and rhythmically
touches nose upon finger to nose test.
Rapidly touches each finger to thumb with each hand. Pt. able to discriminate hot
and cold sensation, able to feel sharps through stimulation. Client able to recognize
specific object, able to identify numbers or letters.

GORDON’S FUNCTIONAL HEALTH PATTERN

HEALTH PERCEPTION - HEALTH MANAGEMENT :

Pt. said that he believe and go to albularyo or quack doctors when he has an illness.
pt. also verbalized that eventhough he believe in albularyo he always consider it as
last option for he always consult first to the hospital.

NUTRITIONAL METABOLIC PATTERN :

My patient said that he likes to eat fish and vegetables and less on pork. Client
drinks 8 glasses of water per day. He has no problem in his appetite.

ELIMINATION PATTERN :

Client said that he frequently go to comfort room because of urination. He

said almost 15 times a day which is scanty in volume. Has no blood on urine,
yellowish in color. Client has no pain urination. Client defecates once every 3 days
or sometimes twice a day without discomfort.

ACTIVITY AND EXERCISE ;

Client verbalized that he is active even though he has. He woke up at 4 am in

the morning and some jogging for an hour for 3 times a week. Aside from that
client activity involves texting and listening to music. Client ables to perform his
activity of daily living.

SLLEPING – REST PATTERN :

My client rest commonly at 9 in the evening. He has difficulty in sleeping

sometimes because of difficulty of breathing. He also had difficulty of sleeping when
he already woke up from a past sleep or nap.

COGNITIVE/PERCEPTAUL PATTERN :

Pt. verbalized he does feel difficulty of breathing especially when it is cold. He has
no problem in memory, able to read and write. able to verbalize his thought and
feeling in a rationalize way.
SELF-PERCEPTION/CONCEPT PATTERN :

He doesn’t have any problem with the financial expenses on the hospital so
he doesn’t took this as a problem.

ROLE RELATIONSHIP PATTERN :

My client said that he is the bread winner in the family. But he wants to be
healthy again to be able to do his normal life as a father, husband and citizen.

SEXUALITY – REPRODUCTIVE :

Client verbalized he had 4 siblings the youngest is 11 years old. But yet he is
sexuality active with his wife and doesn’t use any kind of family planning method.

COPING-STREAA TOLERANCE TEST :

Client said he has no problem on coping with stress for he has his family to
lean on. He also doesn’t took problem seriously rather tries to solve it together with
his family.

VALUE-BELIEF PATTERN :

Pt. believe in GOD, he is a Roman Catholic, go to church with his family, he believe
though to some superstitious beliefs.
 NURSING HISTORY

NAME ; Donato Rolando

AGE ; 46 yrs old
C. S. : Married
OCCUPATION : Government Employee
RACE : Brown Race
ADDRESS : Libertad Kausuagan, Lanao del Norte
WIFE : Virginia M. Renato
BIRTHDAY : 02 Sep. 1962
Chief Complaint: Difficulty of Breathing

History of Present Illness:

Patient is known to have asthma since birth.

3 hours Prior to Consultation--------- Patient was playing basketball and took a bath.
He then begin to have difficulty of breathing.

PH : (+ ) HPN, father BEKE ( -)

(-) DM Bulutong ( -)
( -) CA

PHX : (- ) dm ( -) rpn
No social , 30 packs --- 17 yrs old /pack 1 day
occasional alcohol drinker

1996 ---UTI/Gastritis 2 ambobag

2007 Bulacan (Stones)

Bonifacio Hospital

NAME ; SGT. EDEN, JOSE ALTAGUIRE OCCUPATION : Soldier

AGE : 47 yrs old Gender : Male Children : 2
Date Admitted : April 13, 2010 Maulungbu, Samar
ADDRESS : Camp Mailog Artbal
CC : Masakit RLQ Ward : 4C MU/IP : category
 MSGT
HPT : Oct 2009 Pain/ Renal stores, middle pole of
the R reading with Pehticerisia
normal L breathing and bladder
WD

H of Pt. : (-) muscles (_)

( _ ) berke (- )

FIM : ( +) HPN father side ( _) CN

(-_ DM

LMP : Hospital

Nutrition : kinilaw, isda, mongo,

( -) mutart, (+ ) drink (-) cigarette
mactang
gabi 2x

( - ) DIFFICULTY YELLOWISH

(- ) NORMAL 1 X