Nursing assessment tool

Cardiac
1. health history

A Biographical data

Name of client - Darwin Del santoz

Address – Julliville, Buhangin Davao City
Age – 56 Date of birth march 3 1942 tel no. – 241 5528
Sex – male Martial status – married occupation – none

B. Chief complaints. Reasons for seeking health care :

Chest pain
C. History if Present Illness
- Patient was diagnosed to have CHF on year 2004 and maintains medications to avoid the occurrence of the
attack. One week prior to admission, the patient is experiencing chest pain, but did not seek any medical
assistance, instead, he just rely on the medications being taken. 3 days prior to admission, the condition recurred
and persisted, but still did not seek for assistance. One day prior to admission, patient experienced severe chest
pain which prompted her daughter to bring her at BIHMI.
D. Past medical History
- Admitted at CHDC due to hypertension.
E. Present health:
- Patient is responsive, coherent and cooperative to the procedures.
F. Past Health History:

Childhood Illness:
- Chickenpox, mumps, measles, colds, cough, fever.
Accident/Injuries
- no known accident
Serious or Chronic Disease
- Hypertension and CHF
Hospitalization
- Admitted at CHDC due to Hypertension
Obstetric History
-
Immunizations
- he had a complete immunization or vaccination in her childhood
Last Exam date (Dental,Vision,Hearing,EKG,Chest x-ray)
-Last November 2008
Allergies
-allergic in sea foods
Current medications
-Prozinc drops 2ml O.D, Metronidazole 250 mg / 5 ml q6, Tempra 80 mg q 1 PRN for fever
Habits
-Play basketball
Family History of illness
-Hes grandmother has an hypertension stage 2
Personal and social History
-

Family memvers at home

Shiela 50 Y/O Wife
Marcela 24 Y/O Daugther

Economic History
- Patient relies to her daughter

II. Review of systems

1. Integument
- Darkish Brown in color, and has poor skin turgor
2.Head
-he had dandruff during adolescent and now her hair becomes thinner and grey white in color
3.Eye structures and visual acuity
- he had a difficulty in viewing small particles, and has a difficulty in reading
4.Ears and hearing.
-he had difficulty in hearing in her right ear.
5,Nose and sinuses.
-he was able to smell different kind of food.
6.Mouth and oropharynx.
-he had only 4 teeth, she never used any dentures due to lack of financial resources. She did not experience any
difficulties.
7.Neck
-he did not suffer any neck pains recently she never had felt any enlargement but she able to palpate some small
masses in her neck.
8.Thorax and lungs.
-he she recently experience difficulty in breathing, chest pain and cough w/ yellow colored sputum
9. heart and central vessels
-he didn’t experienced any heart attacks,, but she never experience any signs of cyanosis.
10. Peripheral vascular systems
-he noticed her veins where getting bigger on her upper and lower extremeties, sometimes she experience cramps.
And numbness.
11. Breast and axillae.
Breast are in symmetric position and the axillae has no masses or tenderness noted
12. Abdomen
- good in contour, symmetrical and no scars or abnormalities noted
13.Musculuskeltal system
- he cannot move hes arm well due to old age.
14.Neurological system.
-he can remember where he is. And he is oriented

15. Genitals and inguinal area

-no masses or abnormal skin deformities in he genitals and inguinal area.
16.Rectum and anus.
-he defecates at least once or twice a day, varying from salt to hard stool.

III. Physical Examination.

1. General appearance and mental status.

-he was responsive, awake and oriented, weak and irritable.
2. Vital signs. Measurements
- T-36.2, PR-86, RR – 32
3. Integument
A. Skin
-w/ poor skin turgor skin turgor, no rashes , eythma, lumps, sore or itching noted.
B. Hair
-w/ evenly thin hair, silky, whitish no signs of infection.
C. Nails
-Slightly, rough texture, with bluish that reflexes cyanosis.
4. Head
A. Skull
Round – normocephalic
B. Face
- with some wrinkles in hes face due to old age.
5. Eye structures and visual acuity
- Near vision
A. External eye structures
- upper eyelid normally covers one half of upper iris, palpebral fissures symmetrical. Eyelids in contact eyeball.
No lesions noted
B. Visual Fields.
- Peripheral vison intact in both eyes and all fiels
C. Extrocular Muscle
- Has a symmetrical corneal light reflex
D. Visual Acuity
- 14/14
6. Ears and hearing
- Ability to hear anything
A. Auricles
-Symmetrical and aligned w/ order canthus of eye, firm and non tender.
B. External Ear canal and tympanic membrane
Increase coarse and wine like hair.
C, Gross Hearing and Acuity.
-

7. Nose and Sinuses.

A. Nose
- Nose is in midline placemaent. Shape symmetrical and consistent.

B. Facial Sinuses.
- No preorbital edema or discoloration in sinuses

8. Mouth and oropharynx

A Lips and buccal Mucosa
-lips are midline symmetrical, skin intact, pink and moist. No unusual odor
B. Teeth And Gums
- Teeth are white, not loose, with good occlusion, and in good repair
C tongue/ floor of the mouth
- Pink and moist, papillae intact. Tongue is freely and symmetrically mobile
D. Salivary Glands
- Both ducts with moist and pink mucosa, no lesion, swelling, or modules
E Palate and Uvula
- uvula are in midline, pink, moist, without lesion.
F. Oropharunx and tonsils
- No lesions, Erythema, swelling, exudates, or dis-charge

Neck
A. Neck muscles
- are mobile, no signs of stiff neck
B. Lymph Nodes
- Lymph nodes normally not palpable especially the deep and clavicular nodes.
C. Trachea
- is midline placement.
D. Thyroid Gland
- consistency is firm, smooth, and meaty, with no nodularity, enlargement, or tenderness.

10. Thorax and Lungs

A Posterior Thorax

Inspection
- Skin is intact, no scars
Palpation
- nontender. No deformities or crepitus
Percussion
- Resonance to second intercostals space on left; slight dullness over third through fifth intercostals space over
heart.
Auscultation
-. With no adventitious sounds, lungs are clear to auscultation. No crackles, wheezes or rubs

B. Anterior Thorax

Inspection
- Skin is intact, no scars
Palpation
- nontender. No deformities or crepitus
Percussion
- Resonance to second intercostals space on left; slight dullness over third through fifth intercostals space over
heart.
Auscultation
-. With no adventitious sounds, lungs are clear to auscultation. No crackles, wheezes or rubs

11. Heart and central vessels

A, Precordium, Aortic and pulmonic areas, Tricuspud Area, Apical Area, Epigastric Area.
- positive pulsation at apex
B. carotid Arteries
- Positive carotid palpations
C. Jugular Veins
- jugular venous wave undulated, easily obliterated, varies with position change and respirations.

12. Peripheral Vascular system

A. Peripheral pulses
-positive
B peripheral Veins
- are intact
C. Peripheral Perfussion
-

13. Breast and axillae inspection

- No dimpling or retraction,
Palpation
- no mass or tenderness during palpation
14. Abdomen Inspection
- abdominal skin intact with no lesions or masses. Umbilicus inverted and midline, Abdomen symmetrical
bilaterally from costal margin to iliac crest with umbilicus in center, no abdominal distension.
Auscultation
- Bowel sounds are present., no bruits, no venous bums.
Percussion
- tympany to dullness,

Palpation
- Abdomen soft and nontender. No organomaly or masses, nontender.

15. Musculoskeletal System

A. Muscles
- Muscles soft, pliable, and nontender in relaxed state; firm and nontender in contracted state. No abnormal
movements
B. Bones.
- bones are palpable, and no signs of fractured bones
C. Joints
- Joints midline with no visible bony overgrowth, swellings, or redness, nontender.

16. Neurological System

A. Language
- can speak clearly and ligible
B. Orientation
- the patient are oriented on what he is doing.
C. Memory
- the patient can still recognize everything around him
D. Attention span and circulation
-
E. Level of consciousness
-
F. Cranial Nerves

Olfactory Nerve
- Patient is able to identify substances.
Optic Nerve
- EOM intact
Oculomotor Nerve
- brisk constriction of pupils in reaction to light, followed by dilation and constriction
Trochlear Nerve
- Eyes deviate to side opposite from way head is turned
Trigeminal Nerve
- Full range of motion in jaw,, patient perceive light touch and superficial pain bilaterally
Abducens Nerve
-
Facial Nerve
- facial nerve intact; able to make faces. Taste sensation on anterior tongue intact
Auditory
- can hear clearly
Glossopharyngeal Nerve
- Swallow nad cough reflex intact. Speech clear.
Vagus Nerve
- Taste on posterior intact.

Accesory Nerve
-Movement symmetrical, with patient moving against resistance without pain.
Hypoglossal Nerve
- can protrude tongue medially. No atrophy, tumors, or lesions.

G. Reflexes
Biceps Reflex
- +2
Triceps Reflex
- +2
Brachioradialis Reflex
- +2
Patellar Reflex
- +2
Achilles reflex
- +2
Plantar reflex
- flexion of all toes

H. Motor Function

Gross motor and balance

-
Fince motor
Doctors order

March 5, 2009

 Please admit to General ward

 Secure consent
 Labs – CBC, UA,
 Check vital signs q 4
 Refer to Dr. Gamalo
 IVTT : D5 PNss 1L 45cc/hr
 Meds : Prozinc drops 2ml O.D, Metronidazole 250 mg / 5 ml q6, Tempra 80 mg q 1 PRN for
fever
 Refer for any unusualities
 Will inform AP of admission aware
 Refer accordingly

Laboratory