NURSE PATIENT INTERACTION:

Physical
Assessment
 Nurse-Patient Interaction
Transcribed by: Emily Anne R. San Pedro, student nurse
Date: January 24, 2011
Time start: 4pm
Time ends: 6pm

CLIENT: Mr. A. G.
GENDER: Male
AGE: 44

Our client arrived in a calm and subtle manner. I started off with introducing myself (and my co-
nurse) as his nurse for a day, it doesn’t seem to bother him. I asked for his name and he answered
it in a conventional manner. I explained our intention for the interaction. I told him that we’re
here to conduct his physical assessment to know the clients condition and asked for his full
cooperation, he just simply comply with our inquiry. We started our assessment by taking the
clients vital signs. He’s blood pressure is 90/70mmhg, pulse rate 75bpm, respiratory rate 18cpm
and temperature 36.6˚C. It was all normal. Next, we begin to check his physiological status. We
started at the head. His head is in normocephalic shape, we felt no lump or any tenderness. His
hair is gray in color, in a semi-bald cut. It was free of lice nits and dandruff There were no scars
and lesions noted. After we checked his head, we next assess his face. It was symmetrical. His
visual acuity is nearsighted. Then we checked the ears. We use the voice test because we don’t
have the paraphernalia’s to test the conduction and sensorineural of the ear. His hearing acuity
was normal. Next, we assess the nose. The nares were patent, symmetrical and no perforation,
also no tenderness were noted. Then we assess the thoracic region. We auscultate, palpate and
percuss it. It’s also normal. We also check the abdomen and other parts of the body. It was all
normal. The skin is warm. The capillary refill is also normal. We didn’t find any problem except
for hi nearsightedness. The client is healthy.
After the assessment, we started to talk with the client. We ask him how his day was, he said it
was just normal like any other day. At first he seems aloof but by the time passes by he started
opening up. As the conversation went on, we learned that the reason why the client looks bored
before is because the questions that we asked previously is already been asked to him before a
lot of times by other nursing students, so we change our topic that can cater his interest. We
talk about the client’s life. He is from project 4, Q.C. he is the youngest in their family. He was a
soldier in US army for years before he retired this year. He is aware of where he is and why he is
there. He is also aware of his surroundings and also knows the current event. We then talked
about his years in US army. He shared with us his experience about him being a trainee and also
how he felt when he was sent to fight in the war. As the client share his past experience, we
observed that the client might have a condition called Post Traumatic Stress Disorder (PTSD),
but we’re not entirely sure about it. As the conversation goes on, me and my co-nurse observes
that the client seems to have long accepted his condition. There is no remorse or compunction to
be heard in his narration. This shows a good sign of recovery but there is still a long way to go to
achieve that. The patients longs for his family and hoped that he will be release soon. The
patient’s physiological assessment is in normal conditions. Soon, the client bid goodbye and
return to his respected place. Overall, it was a productive work session. I and my co-nurse
documented the findings and the patient’s reaction to the interaction.