I.

VITAL INFORMATION

Name: B.,M Date of Interview: July 2, 2018

Age: 65 Informant: Atty. J.A.
Address: Badiang, San Jose, Antique Relationship to patient: Daughter
Civil Status: Married
Date and Time Admitted: July 10, 2018 8:40am
Chief Complaint: Neck and head pain

Ward: St. Paul Unit Room 5001

Bed No.: 1
Allergies: none
Religious Affiliation: Roman Catholic
Physician’s Initials: Dr. E.
Impression/Diagnosis: Tetanus

II. CLINICAL ASSESMENT

II.A NURSING HISTORY
1. HISTORY OF PRESENT ILLNESS
A. USUAL HEALTH STATUS
Patient has history of high cholesterol and hypertension
B. CHRONOLOGICAL STORY
1.Patient started feeling the symptoms 3 weeks ago
2. gradual
3. not available
4. two to three times a year
5. neck
6. cut from spring of the bed matress
7. acute pain on the neck
8. gardening at home
9.bacterial infection
10.medication alleviates the onset of symptoms, taken for 2weeks.
C. Relevant Family History
none
D. Disability Assessment
Impaired neck mobility

2. PAST HEALTH PROBLEM/STATUS

A. Childhood illness
 Common childhood illnesses includes having cough, cold and flu were
treated by medication over the counter
 B. Immunization
 Complete immunizations were given to her accordingly.
C. Allergies
 No known allergies whatsoever.
D. Accidents and injuries
E. Hospitalization for serious illnesses
 No previous record of hospitalization
F. Medications
 Gapbentin 300 mg 1 tab OD
 CBG pre meals TID
 Basagine 20 “4” OD
 Losartan 50 mg 1 tab OD
 Bisoprolol 5 mg 1 tab OD
 Mayonal 50 mg 1 tab TID
 Mefenamic acid(dolfenal) 500 mg 1 tab
 Clopidegrel 75 mg 1 tab OD

3. FAMILY HISTORY OF ILLNESS

Hypertension, from the mother side
4. PATIENT’S EXPECTATIONS
a) “Daad ma ayad rn ko pra maka uli rn ko”, as verbalized by the patient

5. PATTERNS OF FUNCTIONING
a. Breathing Patterns
 Crackles noted.
b. Circulation
 Patients’s usual blood pressure is 110/80. Has normal blood pressure.
c. Sleeping Patterns
 Patient sleeps at around 8pm at night.
 Number of pillows: 3
 Bedtime rituals: praying
 Problems regarding sleep: no problem in sleeping
 Usual remedy:
d. Drinking Patterns

e. Eating Patterns

Usual food taken Time

Breakfast 1 egg 7am
2 cups rice
 coffee
Lunch 2 cup rice 11:30
1 serving of vegetable
1 serving of meat

Dinner 1 ½ cup rice 7pm

1cup soup
1 serving of meat
Fruit
Snacks bread 3pm

f. Elimination Patterns
1. Bowel Movement
 Regular, everyday
 No difficulties in bowel movement
2. Urination
 Regular
g. Exercise
h. Patient does exercise by walking early morning
i. Personal Hygiene
1. Bath
 Type: faucet
 Frequency: once a day
 Time of Day: in the morning 8am
2. Oral Care
 Frequency: 1x a day
 Care of Dentures: patient has dentures
3. Shaving
 Frequency: none
j. Recreation
Patient enjoys gardening.
k. Health Supervision
 Patient is looked after by her children.

II.B PSYCHOSOCIAL ASSESSMENT

1. Psychosocial Nursing Assessment
 Lifestyle Information:
Patient is a stay home mom.

 Normal Coping Pattern:

 Going to her garden and pick some vegetables
 Understanding Of Current Illness:
Patient is aware of his medical condition
 Personality Style:
Patient has an easy and outgoing personality.
 History of Psychiatric Disorder:
Patient has no known history
 Recent Life Changes or Stressors:
Family
 Major Issues Raised by Current Illness:
Safety issues

2. Mental Status Examination

 Appearance
Neat and clean
 Speech
Moderate
 Mood/Affect
Happy
 Thoughts
Appropriate
Description: Patient is a positive thinker
 Ability to Abstract
Impaired: YES
 Memory
Impaired recent memory: NO
Impaired remote memory: NO

Description: patient has a good memorization

 Concentration
Able to focus
 Judgment
Realistic Decision making: YES
 Insight
Fair

II.C: CLINICAL INSPECTION

Date and Time Taken: July 2, 2018

II.B.1. Vital Signs T= 36.2 PR= 68 bpm

BP= 110/80 RR= 20 cpm

II.B.2. Height 5ft 3in

II.B.3. Weight 69 kgs
 II.B.4. Review of Systems

CEPHALOCAUDAL PHYSICAL ASSESSMENT

SKIN
 The patient’s skin is uniformly dark brown in color, has no lesions, edema or abrasions, is not moist
because of the air ventilated environment, has uniform temperature. The tissues surrounding the nails of
the patient are intact. And when blanched test performed, color of the nail of the client returns into pink in
less than 3 seconds.
HEAD AND FACE
 The patient’s scalp is lighter than the color of his skin and has no areas of tenderness. The hair is evenly
distributed and is thick. The patient has symmetric facial movements.
EYE
 The patient’s eyebrows have evenly distributed hair, has intact skin, symmetrically aligned, and has equal
movement. The conjunctiva is transparent, capillaries sometimes evident, and sclera appears white and
clear. The cornea is transparent, shiny and smooth, details of iris are visible. The iris is brown, flat and round.
The patient’s visual acuity is normal.

EAR
 The patient’s external ear canal is dry, has presence of hair follicles, no pus or blood. Patient has trouble
hearing on his right ear. Sound is heard clearly on both ears. Ear is without masses.

NOSE
 The patient has no tenderness on sinuses. The nose is in the midline, has no discharges, no nasal flaring,
both nares are patent, and no bone and cartilage deviation noted on palpation.
MOUTH AND THROAT
 The patient’s buccal mucosa is uniformly pink in color, moist, smooth, soft, glistening and elastic in texture,
and has no lesions. Teeth are white to yellowish in color, gums are pink, moist, firm, has no retraction and
bleeding of gums. Tongue is pink, has thin whitish color. Uvula is positioned in the midline of soft palate.
The tonsils are pink in color, and have no discharges
NECK
 Positioned at the midline without tenderness and flexes easily. No masses palpated.
ANTERIOR THORAX
 Quiet, rhythmic and effortless respiration
POSTERIOR THORAX
 Chest symmetrical
SPINAL ALIGNMENT
 Spine vertically aligned, spinal column is straight, left and right shoulders and hips are at
the same height.
BREATH SOUNDS
 Abnormal breath sounds with shortness of breath
LUNGS / CHEST
 The chest wall is intact with no tenderness and masses. There’s a full and symmetric
expansion and the thumbs separate 2-3 cm during deep inspiration when assessing for the
respiratory excursion.
HEART
 There were no visible pulsations on the aortic and pulmonic areas. There is no presence of
heaves or lifts.
ABDOMEN
 The abdomen of the client has an unblemished skin and is uniform in color. When nails
pressed between the fingers (Blanch Test), the nails return to usual color in less than 3
seconds.
UPPER EXTREMITIES
 Without scars and lesions on both extremities.
LOWER EXTREMITIES
 With painful swelling and redness on the site of the infection