VII.

PHYSICAL ASSESSMENT
Assessment Findings

General Appearance The client is awake, conscious, and oriented

Integumentary
 Skin The client skin is uniform in color, unblemished and no presence of any
foul odor. The client skin is dry and pale and no presence of edema.
 Hair Hair is black, thin, oily and evenly distributed and dandruff is seen. There
is also no sign of infection
 Nails Client’s nail plate is concave and has a smooth texture, with pale nail
beds and capillary refill of 3.
 Head The client’s head is proportionate to his body size and has a smooth
texture. The scalp is non tender and white.
 Face The face of the client appeared smooth and has a uniform consistency
and with no presence of nodules or masses.

Eyes and Vision

 Eyebrows Hair is evenly distributed. The client’s eyebrows are symmetrical aligned
and showed equal movement when asked to raise and lower eyebrows.
  Eyelashes Eyelashes appeared to be equally distributed and curled slightly
outward.
 Eyelids There were no presence of discharges, no discoloration and lids close
symmetrically with involuntary blinks approximately 15-20 times per
time.
 Bulbar conjunctiva Bulbar conjunctiva appeared transparent with few capillaries evident.
 Palpebral conjunctiva Palpebral conjunctiva appeared shiny, smooth and pale in color.
 Pupils The pupil of the eyes are black and equal in size.
 Iris The iris is flat and round. PERRLA (pupil equally round and respond to
light accommodation.)
Ear and Hearing
 Auricles The auricles is symmetrical and has the same color with his facial skin.
The auricles are aligned with the outer cantus of eye. When palpating for
the texture, the auricles are firm and not tender.
Nose and Sinuses
 Internal and External Nose The nose appeared symmetric, straight, and uniform in color. There is no
presence of discharge or flaring. When lightly palpated, there is no
tenderness and lesions.
Mouth and Oropharynx
 Teeth and Gums There is no discoloration of the enamels, no retraction of gums, pale in
color of gums.
 Tongue and floor of the mouth The tongue of the client is centrally positioned. It is pale in color, moist
and slightly rough. There is a presence of thin whitish coating.
 Uvula The uvula of the client is positioned in the midline of the soft palate.
 Neck The neck muscles are equal in size. The client showed coordinated,
smooth head movement with no discomfort.
Abdomen The abdomen of the client has an unblemished skin and uniform in color.
The abdomen has a symmetric contour.
Abdominal movement There were symmetrical movements caused associated with client’s
respiration.
DRUG DATA CLASSIFICATION MECHANISM OF INDICATION ADVERSE EFFECTS NURSING
ACTION /CONTRAINDICATION RESPONSIBILITIES
Generic name : Therapeutic The B-complex - to treat and CNS: headache, - Verify doctors
Vitamin B. complex. antiamemics food vitamins act prevent dizziness, insomnia, order.
supplements. ascoenxyme and are vitamin fatigue tiredness, - Know the
Brand name : essential for the deficiency rash. reason for
Aduvit metabolism of giving the drug
PHARMACOLOGICAL: protiens, CONTRAINDICATION - Chech for
multivatamins carbohydrates and - Sensitivity to contraindication
Patient dose: fatty acids. any of the - Prepare drug on
1 tab OD ingredients time.
included in
the
medication.

DRUGSTUDY
Vitamin c.

MECHANISM OF INDICATION/ NURSING

NAME OF DRUG Classification ACTION. CONTRAINDICATION SIDE EFFECT RESPONSIBILITIES
- Dietary - Nausea - secure doctor’s
Increase protection supplement - Vomiting order.
Generic name: vitamins mechanism of the - To prevent vit C - Heartburn
Ascorbic acid immune system, thus in patients with - Diarrhea - Do hand washing
supporting wounds poor nutritional
BRAND NAME: healing. habits - Assess
Vit.c - To acidify urine. condition
CONTRAINDICATION
Route: - use to sodium - Give
Per oral ascorbate in medication on
patient on time.
Timing sodium - Instruct
OD restriction. patient to be
- Use of calcium cautiousns of
asscorbate on the drugs
patient receiving
digitalis.

NURSING CARE PLAN

 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Following 1 day of - Assess sleep - High Following 1 day of

SUB: Sleeping patern r/t nursing intervention pattern percentage of nursing intervention
” paputolputol yung emotional or physical the patient will be disturbances sleep the patient was able
tulog ko” as verbalized discomport. able to achive optimal that are disturbances to achive optimal
by the patient. amount of sleep as associated with can affect the amount of sleep as
evidenced by improve the recovery of the evidenced by improve
OBJECTIVE: of sleeping pattern. environment patient. of sleeping pattern.
- Presence of - Observe abd - To dermine
eye bags. obtain usual sleeping
feedbacks pattern and to
- Taking napp regarding on compare if
when there is a the usual there are any
chance or if sleeping improvments
there is a free pattern on the sleeping
time bedtime pattern of the
routine and the patient
usual sleep and
rest.
- Tell patient to - Allows the
write a journal patient to set
regarding aside problems
pronblems or any mental
before retiring. activities just
before going to
sleep.
ASSESSMENT Diagnosis Planning Nursing Intervention RATIONALE Evaluation
ASSESSMENT DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTION