POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC.

MacArthur Highway, Digos City

NURSING ASSESSMENT TOOL
PERSONAL DATA
Name: Editha balboa
Date:11/15/16
Address: Bangong lupa Magallanes, Davao city
Time: 10:00 am
Age: 70 yrs old
Gender: female Civil Status: Widow
Occupation: none
Nationality: filipino
Religion: catholic
Whom to notify in case of emergency:
Date of Admission: November 15, 2016
Reason for Admission: Anterior neck mass
Diagnosis: Cutaneous squamous cell carcinoma, left check ST.III CT3N0M0.
HISTORY OF PRESENT ILLNESS:
Patient suffer anterior neck mass for 5 years when suddenly there is a blood in his neck mass
they rush to hospital for treatment purposes.
PAST HISTORY:
Patient suffer malaria when she is 8 years old and she was admitted at that time.
Medication Taken: Paracetamol, clindamycin, omeprazole 40mg IVTT, celecoxid 200g.
Physician: Dr. salansang/ Dr. caballero
FAMILY HISTORY
Hereditary Illness: diabetes mellitus
Family Members
Name
Margarita B. Pardillo
Michael Ryan B. Pardillo

Age
40y/o
21y/o

Health
Alive
Alive

Occupation
Midwife
unemployed

REVIEW OF SYSTEMS:
NEUROLOGICAL
Patient appears conscious and responsive. He is oriented to time, place and person. He
also doesnt appear to have any mental disabilities and is generally mentally well.
EYE/VISION
The patients both eyes can see but she cannot distinguish far objects. The peripheral
conjunctiva appears pinkish and both eyes do not appear red and dry. Eyes and eyebrows are
parallel to each other and symmetrical. Pupils equally round and react to light and
accommodation.

EARS/HEARING
Both ears appear normal without the presence of discharges, and no impacted cerumen
and foreign objects upon thorough inspection using a pen light. The patient can hear normally
without any difficulty.
NOSE
Nose is patent and appears normal. Nasal mucosa is pink, moist and intact. Nostrils are
patent with no signs of nasal flaring. No discharges and foreign objects observed. patient suffer
colds.
MOUTH/TONGUE/TEETH/SPEECH
The buccal mucosa is pink and has no evident signs of infection. No lesions present on
lips, gums and tongue. lips appear normal. Teeth are complete with no dentition although there
are small signs of tooth decay. The patient has also no difficulty in speaking and pronounces
words correctly.
THROAT/NECK
The throat is pink with normal tonsils and adenoids. Patient can swallow without any
problems and has no signs of infection. However the neck has wound on the left area due to
surgical operation.
RESPIRATORY SYSTEM
The patient breathes at ease with no signs of respiratory distress. There were also no
adventitious breath sounds upon auscultation. The patients respiratory rate is also within normal
range with a rate of 22 cycles per minute.

MUSCULOSKELETAL SYSTEM
The extremities have decreased normal range of motion due to body weakness. The
patient still needs some assistance in doing activities of daily living such as taking a bath. No
tremors or spasms observed on the muscles.
INTEGUMENTARY SYSTEM
The patients skin is patent with good turgor which indicates that the patient is hydrated.
No lesions or rashes were noted on the skin although it appeared to be a bit oily.
CIRCULATORYSYSTEM

The patient has no signs of cyanosis as evidenced by pinkish conjunctiva and mucosa.
Upon pressing the nails, redness goes back within 3 seconds which indicates that capillary refill
is good. The patient has also no signs of cardiovascular diseases with a pulse rate within normal
range beats per minute.
GASTROINTESTINAL
Bowel sounds were heard indicative of normal peristalsis. The patient has not
experienced any loose bowel movement and has no signs of indigestion. Upon palpation, no pain
was noted. Percussion of the abdomen yielded a resonant sound.
GENITOURINARY
The patient has a normal urinary frequency of about 3 every 8 hours. He also has no
difficulty in urinating. No pain was noted and has no signs of infection.
PRESENT BEHAVIOR
The patient is very responsive and is in a good mood. He answers the groups questions
immediately and appropriately. He is also cooperative and open minded to several nursing
interventions that the group administered.
SOCIO-ECONOMIC STATUS
The patients are already senior citizen and have business of boarding houses that cost of
15 thousand amounts and she already.
FAMILY CONCERN
The patient is confident that his family will take care of them even the grandson is
always at his side cause his other family member are working.
LATEST VITAL SIGNS:
BP-140/80
PR-79
RR-20
Temp-36.0