POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC.

MacArthur Highway, Digos City

NURSING ASSESSMENT TOOL

PERSONAL DATA

Name: Josephine Natinga Date: Dec 8, 2016

Address: Vincent Heights Subd., Lanang, Davao City Time: 9:00 am
Age: 46 Gender: Female Civil Status: Married Occupation: Housewife
Nationality: Filipino Religion: Roman Catholic
Whom to notify in case of emergency: Crispino Natinga
Date of Admission: 12/6/2016 Reason for Admission: Referral from MDMRC
Diagnosis: Multinodular nontoxic goiter t/c anaplastic carcinoma

HISTORY OF PRESENT ILLNESS

The patient stated that seven years ago, she started to notice a mass growing in her neck but just ignored
it. The mass continued to grow throughout the years and she became more anxious. On November 13, she had
her checkup at MCDC in Digos City and was diagnosed with multinodular nontoxic goiter. On November 16, she
had her CT scan performed at MDMRC in Davao City. She was then referred to SPMC and decided to be admitted
last December 6, 2016.

PAST HISTORY
The patient said that this was her first hospitalization in his life. She had also complete vaccinations from
their local barangay health center. She already had chickenpox when she was 6 years old but was treated only
at their home. She also had experienced some fever, cough and colds but did not require hospital admission.
The patient said that she only resulted to herbal medicines to treat her diseases.

Medication Taken: None

Physician: Dr. Xirxiz Parilla

FAMILY HISTORY: Apparently, the patient said that her grandmother had goiter but did not treat it. She said
that her grandmother was just doing fine with the mass on her neck and died not because of it.

Hereditary Illness: Since there is a familial history of goiter, chances are the patient got the gene responsible
for goiter.

REVIEW OF SYSTEMS:
NEUROLOGICAL
The patient appears conscious and responsive. She is oriented to time, place and person. The patient
has good affect and answers the student nurse’s questions accurately.
EYE/VISION
Pupils and eyebrows are parallel and symmetrical. Pupils are equally round and reactive to light and
accommodation. The pupils have a scale of 3 in size and reacts to light briskly.

EARS/HEARING
Both ears appear normal and there are no signs of impacted cerumen and discharges. The patient can
hear clearly from both ears and has good hearing acuity.

NOSE
Nasal mucosa is pink, moist and intact. Nostrils are patent with no signs of nasal flaring. No discharges
and foreign objects observed.

MOUTH/TONGUE/TEETH/SPEECH
The buccal mucosa is pink and has no evident signs of infection. No lesions present on tongue and buccal
mucosa. Teeth are complete with no dentition although there are small signs of tooth decay. The patient
however has some difficulty in speaking because of the large mass on her neck.

THROAT/NECK
The throat is pink with normal tonsils and adenoids. A mass on the right side of the anterior neck is
noted. The patient does not complain any pain when palpating the mass. The patient has difficulty in swallowing
because of the mass.

RESPIRATORY SYSTEM
The patient breathes at ease with no signs of respiratory distress. There were also no adventitious breath
sounds upon auscultation. The patient’s respiratory rate is also within normal range at a rate of 22 cycles per
minute.

CIRCULATORY/CARDIOVASCULAR
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 of 88 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 urinates frequently at about once an hour with the urine being clear yellow in appearance.
MUSCULOSKELETAL
The patient has good range of motion. She can move at ease and can do both active and passive range
of motion exercises. The patient also has good muscle strength.

ACTIVITIES OF DAILY LIVING

The patient can easily do her activities of daily living such as eating, going to the bathroom and taking a
bath. She is independent and can do them without any assistance.

PRESENT BEHAVIOR
The patient is alert and responsive. She answers the student nurse’s questions immediately and
appropriately. She is also cooperative and open minded to several nursing interventions that the student nurse
had advised and done.

SOCIO-ECONOMIC STATUS
The patient currently stays at home and relies on her husband who works as a laborer and earns about
Php 4,000 a month. They have two children both are female and the eldest is working as a domestic helper and
earns around Php 25,000 a month. The youngest stays at home and doesn’t go to school. The patient said that
their eldest sends money to them monthly which is sufficient for the family

FAMILY CONCERN
The family is concerned to the patient’s condition and the surgical procedure to be done. They are
worried since it is the first time the patient undergoes a surgical procedure. The patient is anxious for the result
of the surgery.

LATEST VITAL SIGNS:

BP- 130/80 mmHg
PR- 88 bpm
RR- 22 cpm
Temp- 36.8°C

Submitted to: Lourdes Abecia, RN

Submitted to: Pryll John O. Colita
Date of submission: 12/9/2016
Rating: