PHYSICAL ASSESSMENT

In Partial Fulfillment of the Requirements in NCM 101 RLE Pre- Clinical Rotation

Submitted to: Mary Abigail Albiso, RN Clinical Instructor

Mr. Ralph Leo Garcia St. N. Ms. April Dream Cofreros St. N. Practicing Clinical Instructors

Submitted by: Mark John Mellejor Maria Carina Pilar Denosta BSN 2B- Group 1

July 13, 2010

A. BIOGRAPHICAL DATA Name: Patient X Ward/Unit: San Lorenzo Home Address: Tandag, Surigao del Sur Place of birth: Tandag, Surigao del Sur Marital Status: Single Occupation: Student Age: 12 Gender: Male

Room: 306 Bed #: 6 Birthday: November 27, 1997 Nationality: Filipino Educational: High School Religion: Catholic

B. ADMISSION HISTORY Patient X was admitted on June 23, 2010 via stretcher; with the chief complain of fever. With a signs and symptoms of behavioral changes and upward rolling of eyeballs his physician is Dr. Lagapat.

C. HISTORY OF PRESENT ILLNESS Patient X experienced on and off fever before he was admitted due to bicycle fall on June 19, 2010, he experienced pain on his right knee with a pain scale of 6 out of 10 but no injury at all.

D. PAST HEALTH HISTORY In the service of Dra. Juicy M. Bonifacio. Patient X was hospitalized 4 years ago (2006) due to high fever in Tandag Medical Clinic. According to mother, patient is fully immunized because his son receive 1 doze of CBG, 1 doze of measles vaccine,3 dozes of HepaB,3 dozes of OPV and 3 dozes of DPT before his son reached a year old after birth. His mother forgot when was the last immunization took place. Patient X also experienced asthma, with medications of Sabutamol, Ventolin, and Turgesep. Patient has no allergies in food and in medications, and also had not experience any common childhood illness like; chicken pox, measles, mumps, and tonsillitis, only cough and fever.

E. FAMILY HEALTH HISTORY i.GENOGRAM Paternal Side Maternal Side

Father

Moth er

Aunt

Brother 1

Chin Alden

Brother 2

Sister 1

Legend: Cardiac arrest Asthma Diabetes Mellitus Male Female

ii. The family Genogram of our patient shows that our patient may inherit Diabetes Mellitus but has no significant evidence because, both his parents doesnt have any symptoms that carry the disease. Mother confirmed that she and her husband dont have any Diabetes Mellitus. As you can see, in the genogram our Patient inherited the Asthma, but there is no significant connection because both his parents dont have Asthma. F. GORDONS FUNCTIONAL HEALTH PATTERNS *Health Perception/ Health Management Patient X generalize health has been good and keeping to stay fit, but was hospitalized due to bicycle fall. Patient X is overweight, but not obese, with a BMI of Basketball and jogging is his exercise to keep his body healthy. In a scale of 1 to 5 with

1 as the lowest and 5 as the highest, his motor sensory muscle strength has a rate of 5 except for his right knee; patient is oriented and obeying base on his NVS. *Nutritional- Metabolism Patient X daily food intake is more on pork and chicken, but less vegetable. Has vitamin supplement like Fern C, his fluid intake ranges from 5 to 9 glasses a day. Patient has a complete set of teeth and weighs 59 kg and has a height of 150.5 cm. *Elimination Patient X has normal bowel movement, and at least defecates once a day, frequent in urination, urine is aromatic and amber in color. Have no odor problems. *Activity-Exercise Patient X is energetic, plays basketball, when it comes to bathing, grooming, shopping, toileting, general mobility. Bed mobility and home maintenance, patient is full self-care. Patient has no absent body parts, has perfect handgrip. Has pulse rate of 93 beats per minute and has a respiration rate of 23, and has normal blood pressure of 110/70. *Sleep-Rest Patient is ready for any activities after sleep, has rest relaxation period after the activities. He can regain the energy after doing some rest. Patient verbalized that sometimes he has sleeping problems. usahay dugay ko makatulog pero sayo lang pud ko makamata. mga kaduha o kaupat lang sa sulod sa isa ka month, pero usahay wala jud. Patient has no nightmares and no early awakenings during dawn. *Cognitive-Perceptual No hearing difficulty, not wearing an eyeglasses and patient is forgetful or has recent memory loss sometime. Patient verbalized: usahay jud makalimot ko, importante pa jud akong makalimtan patient also stated some example like forgetting his assignments and baon sometimes. Patient is oriented and easily grasps ideas like, whenever his mother teaches him something like; cooking rice, and could easily learn it by just watching and listening to instructions. Has low level of attention span can be easily distracted by texting and Patient use Visayan and Tandaganon language.

*Self Perception-Self-Concept Patient describe him self as friendly, handsome, and chubby and shy. Most of the time he feels good about himself but sometimes feels bad because he is forgetful. The thing that makes him annoyed is misplacing his things. *Role-Relationship Patient lives with his family and has lots of friends, has good relationship with his schoolmates and classmates, likes interaction with family members and others. For him, things go well in school. *Sexually-Reproductive N.A. (not applicable) *Coping-Stress Tolerance Patient is relaxed most of the time, sleeping is his way to cope with stress. If he has big problems, he always pray and ask help from his parents, like; problems in school, his grades and sometimes with others. *Values and Beliefs Since they are four siblings in the family, he cannot always get what he wants but still he understands the situation. Patient X wants to be a singer and a computer technician someday. For him religion is very important because for him God is his best friend. The patient is very devoted about what he believes.

G. PHYSICAL ASSESSMENT General Survey Patent X has a body built of ectomorph, with a height of 150.5 cm and has a weight of 59 kilograms. Patient is overweight but not obese and has a BMI of 26. He is alert and oriented, well groomed and has appropriate mood for physical assessment. His vital signs were: temperature of 36.4, cardiac rate of 95, pulse rate of 92, respiratory rate of 20 and blood pressure of 110/80.

Skin Patient has uniform skin color with a rough texture. Skin is uniformly warm and has good skin turgor. No lesion noted and has no edema and ulceration. His nails are well trimmed. Has a capillary refill of 2 seconds. Head Patient has a normocephalic head, with fontanelles closed. Skull is symmetrical; his scalp is clean, and has normal distribution of hair; fine, and dry. Has symmetrical face movements and with normal muscle strength of jaw. Eyes Patients eye structure is symmetrical as well as with his eyelids. Eyebrows are aligned with symmetrical movements. His lashes are curled upward, lacriminal duct is normal; cornea and lens are smooth with pinkish conjunctiva. Both pupils are isocoric and brisk, with uniform reaction to accommodation with both pupil sizes of 2, with a normal EOM and uniform convergence. And patient has 20/20 vision; we assessed it through giving him a reading material that is 14 to 20 inches away from him and checked if he could read it loud and clear. Ears Patient has symmetrical ears and has normal hearing acuity; we assessed it by letting him repeat the 3 words that we whispered in his ears and let him repeat it. Nose Nasolabial fold are symmetrical with midline septum and have pinkish mucosa, both patent, can inhale with one nare closed and has non tender sinuses. Mouth Lips are symmetrical with moist texture and pinkish in color. Tongue is located in midline portion. With teeth complete, yellowish in color. Have pinkish gums, mucosa and palate. Pharynx Uvula is located in the midline portion of the pharynx, has pinkish mucosa, and tonsils not inflamed and has positive gag reflex.

Neck Trachea is located at the midline portion of the neck, with lymph nodes non palpable. Has normal range of motion. Has absent jugular vein distention and has normal muscle strength. Thorax Thorax has symmetrical shape with a normal spinal alignment has an effortless breathing pattern and has good chest skin turgor. Has symmetrical respiratory excursion of 3 and has symmetrical tactile fremitus. And with bronchial breath sounds. No wheezes, crackles, ronchi, friction rub present. Heart Patient has distinct heart sounds, aortic, pulmonic, tricuspid, apical pulse are present. Pulses in the temporal, carotid, apical, brachial, radial, popliteal and posterior tibia and dorsalis pedis are strong. Breast His Breast size and symmetry is equal and non tender. No masses and edema present. Abdomen His abdominal skin is intact. Has globular contour; no abnormalities noted. His bowel sounds are normoactive and has bruit vascular sound. Tympanic percussion, and has a bladder size of 5 cm in MCL and 3 cm on MSL. Bladder is non palpable because patient emptied his bladder before the assessment. Has negative result on Ascities. And palpation is tender.

Neuromuscular and Neurological For his muscles; his sternocleidomastoid, trapezius, biceps, triceps, fingers/wrist, hip muscles (both in raising and abduction/adduction) and as well as his hamstrings and feet has a grade of 5 (active movement against full resistance). His right quadriceps has a grade of 4(active movement against some resistance), because during the time that he fell from his bicycle, his right knee was the one that has been hit by the big rock. His left quadriceps has a grade of 5(active movement against full resistance). Skeletal structure and joints are symmetrical in length and as well as his joints.

He responds to questions appropriately and spontaneously and without hesitations. Lapses in memory present and verbalized makalimot ko usahay, pero usahay ra pud. Patient is oriented. Hes very willing to share but can easily be distracted through texting. And has no definite eye contact. Cranial Nerves I. - Olfactory Nerve: patient has a normal sense of smell. II.- Optic Nerve: patient is able to read newsprint. And has 20/20 vision, was able to determine colors. III.- Oculomotor Nerve: patient has equal movement of pupils both brisk and equal to light accommodation. IV.- Trochlear Nerve: eyeballs was has normal EOM. V.-Trigeminal Nerve: patient felt the touch of the hand VI.- Abducens Nerve: present eye lateral movements. VII.- Facial Nerve: has symmetrical face movements, was able to puff cheeks, smile, frown, show his teeth and wink. He was able to determine taste of the candy offered. VIII.- Acoustic Nerve- was able to hear snap of fingers and able to hear whispers in the ear. IX.- Glossopharyngeal Nerve- was able to swallow while saying AH. X.- Vagus Nerve: present Gag reflex. XI.- Spinal Accessory Nerve: was able to shrug shoulders and able to resist force during the assessment. XII.-Hypoglossal Nerve: Patient was able to swallow food with out any difficulties.

H. CONCLUSION The patients over all health condition is good. Patient is cooperative and willing to help himself in improving his health condition and wellness through listening to our advises on how to lessen his weight and how to have a proper diet. Upon doing the assessment we discovered that our patient is shy at first but as time passes, he learned on how to reach out to us and open his concerns regarding his health. He became cooperative, especially in the assessment. We realized that it is very

important to build rapport to our clients and gain their trust. So that they can open up to us and share more about themselves. On our overall assessment our patient has stable vital signs and has no missing body parts and has normal result on our physical assessment, but overweight. To sum up, patient has good posture and gait, has normal vision and hearing acuity, has good skin turgor, obeying and alert, has good muscle strength and is perfectly in good health condition, our patient has asthma and is not positive in diabetes mellitus. This activity helped us develop our skills and as well as gain self confidence and trust in our selves. This experience also helped us to exercise our patience and understanding. We are able to render health teachings and provide care to our patients like real nurses does.

I. REFERENCES Doenges, M.E., Moorhouse, M.F. Murr, A.(2006) Nursing Care Plans; Guidelines For Individualizing Client Care Across The Life Span (7th Ed), F.A. Davis company, Philadelphia Kozire, Erb, et. al.(2002) Fundamentals of Nursing; Concepts, Process, and Practice (5th Ed) Pearson Education Asia Pte Ltd 23-25 First Lok Yang Road, Singapore 629733 Lemone, P. Burke, K. (2004) Medical-Surgical Nursing; Critical thinking in Client Care (3rd Ed) Pearson Education, Inc., Upper Saddle River, New Jersey 07458

July 13, 2010 DR. VICTOR C. BONGAR Director, Office of Student Affairs San Pedro College Dear Sir Bongar: Good day! In line with the SPC-YFC Campus Based General Assembly this coming July 16, 2010, we would like to ask permission from your good office to allow the following people listed below to enter our school premises. They will be there to help facilitate the said activity. Also some of them will be our speaker during the activity. Here is the list of persons expected to come on the said date: 1. Philip John Aquino 2. Vincent Saplot 3. Ivan Paster 4. Matthew Bentinganan 5. Karl Mosqueda 6. Michael Rivera 7. Hentzie Ong 8. Jorie Joy Fronda 9. Landel Mae Pascua 10. Katrina Bernasor 11. James Batoon 12. Jen Nacario 13. Jonaf Ortojan 14. Jeaune Gail Villaceran 15. Jinno Go We are hoping for your consideration regarding this matter. Thank you and God bless! In Christ, BEN YVES GASCO YFC President Noted by: MRS. MARIVIC PLASENCIA Club Moderator Approved by: DR. VICTOR C. BONGAR

OSA Director