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Nursing Health History And Physical Assessment

Ramos, Art Christian M. BSN 3-3 Medical Surgical Ward Proffesor Maricel Chua, R.N. September 3, 2012

I.

Demographic Data:

Name: Patient A Address: Amelia Street, Sampaloc, Manila Age: 64 years old Gender: Male Nationality: Filipino Marital status: Married Occupation: None Religion: Roman Catholic CC: PTR @ Right Upper Lobe Date of Admission: August 20, 2012 Admitting Diagnosis: COPD, Prob. Emphysema, IAE CAP Date Received: August 27, 2012

II.

History of Present Illness: 1 week prior to admission, patient A stated that he had cough with thick yellow sputum. Upon admission of patient, he had developed difficulty of breathing.

III.

Past medical Health History: Upon prior assessment of his records, patient had (+) bronchial asthma. Patient A does not have (-) hypertension, (-) heart diseases, (-) diabetes, (-) cancer, (-) PTB.

IV.

Physical Assessment:

Performed: August 27, 2012 Vital Signs: T = 36.6C ; PR= 87 bpm RR= 25 cpm; BP= 110/50 mmHG General Appearance: Patient received lying in bed, sleeping, unconscious. He was seen lying in bed with a fetus like position with an IV of PNSS 1 L regulated at 5gtts/min at 800cc level located at his right hand and a profuse amount of oxygen supply via nasal canula. There were signs of distress and episodes of difficulty of breathing. Patients body built is skinny. Patient A was accompanied by one of his fellow neighbor. Skin: Patient A has brown skin color with poor skin turgor. Patient A does not have any lesions, pressure sores, open wounds or edema noted but skin was very dry, scaly and warm. Hair: Upon inspection, patient A has blackish grey, thin, and coarsed hair that is evenly distributed. No infestations were noted. No evidences of alopecia were noted. Head: Upon Inspection, patient A has normocephalic. Closed fontanelles. No signs of lesions noted. Ears: The patients auricle is properly aligned with the outer canthus of the eye while his pinna recoils after it is folded. There are no lesions, nor masses noted; nor obstruction of the cerumen in the ear canal. Eyes: Upon inspection, patient A has symmetrically aligned eyebrows, eyelashes and eye lids. Conjucntiva is pink without any discharged. Sclera is anicteric. Cornea and lens are smooth, without lesions and discharges. Pupil size is equal with

measurement of 5mm to the right and left eye. Reactions to light in both eyes are brisk and uniform constriction. Visual acuity is grossly normal.

Nose: Upon inspection, the patients nose was uniform in color with the face. There were no nasal flaring and lesions noted. Both nares are patent. No discharges or any obstructions were seen and assessed. Mouth: Upon inspection, patients lip is pinkish in color, no pallor and dryness evident in the outer lip. Patient A has dentures. Gums are pinkish in color. Buccal mucosa is pinkish. Speech is intact. No mouth pains, bleeding gums, neither difficulty swallowing, lesions nor dysphagia were noted. Neck: Neck muscles and head movement were intact. No nodules were evident and non palpable. Breast: Upon palpation, no masses and tenderness were present. Heart: Upon taking of vital signs, patient garnered the following vital signs for his cardiac rate: 25 cpm, blood pressure of 110/50 mmHg, pulse pressure of 87 bpm. Stated of concurrent chest pain and DOB. No edema and distended veins were noted as well as lesions or masses on the chest. Capillary refill of 2 seconds and a pinkish nail bed. Thorax and Lungs: Chest expansion was symmetrical. Breathing pattern was tachypnea with the use of accessory muscles to breath. Shape of chest was barrel chested. Patient also has difficulty of breathing as manifested by 27 cpm with adventitious breath sound (wheezes) on both lung fields upon auscultation. Patient was assessed with (+) productive coughing, chest pain, and difficulty of breathing.

Abdomen: Upon inspection, abdomen was uniform in color, no lesions, masses, or scars present. Symmetrical abdominal movements caused by respirations were noted. No tenderness and no guarding reflex upon light palpation. Patient stated that he has no recent bowel changes and abdominal pain. Extremities: Patient refused to be assessed because of the reason he wants to rest and sleep and not to be disturbed anymore, but patient stated that he has no back problems, has weakness because of his conditions. No joint problems were stated as said by the patient. External Genitalia: Patient refused to be assessed but stated he has no problems within genitalia. Neurological: Patient was drowsy, slightly responsive because of the reason he wants to sleep but was able to state his full name, and where he was and what time of the day. No numbness, or tingling or burning sensation reported.