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IX.

PHYSICAL ASSESSMENT
A. General Appearance

HEENT

Essentially normal

CHEST/LUNGS

Essentially normal

HEART

Essentially normal

ABDOMEN

Essentially normal

HEIGHT & WEIGHT

Ht. 165cm., Wt.50 = 18.37 THIN

EXTREMITIES

Essentially normal

B. Head to Toe Assessment


AREA ASSESSED
Head and Face

Skin

FINDINGS

NORMAL FINDINGS

Presence of scar on the


left upper eyebrow.

Skull is proportionate to
body, no tenderness, hair
evenly distributed. Face
is symmetrical with
symmetrical facial
movement.

Skin of patient uniform in


color, skin intact.

Uniform in color, hair


evenly distributed.

Pale
Capillary refill >3 secs.
Not normal

Clean, pinkish nail bed.


Capillary refill 2-3
seconds.

Normal

Client has straight


normal eye condition.
Pupil is black on color
and equal in size.

Nails

Eyes

Nose

Normal

Nasal septum is in the


midline, mucosa in
moist.

Lips are pale and dry,


pale mucosa. Not normal

Symmetrical, tongue is
in midline, lips pinkish
and symmetrical

Normal

Skin is uniform in color

4 bowel sounds/min. Not


normal

Uniform in color, flat and


symmetric contour, skin
intact. Symmetric
movements caused by
respiration. Normal
active bowel sounds

Musculoskeletal System

ROM grading of 2.
Cannot resist strength
due to the pain she felt.

Able to move and


control without any
resistance.

Upper & Lower extremities

No deformities
No lesions

No deformities
No lesions

Mouth

Neck
Abdomen

GORDONS 11 HEALTH PATTERN

Health Perception/ Health Management Pattern

At the moment, patient perceives his health as poor. Before hospitalization, he has a
sedentary lifestyle and is not concerned about his diet. He was not eating properly
and frequently starves himself. He also was not able to attend his needs in times he
felt sick or ill, unless it becomes severe.

Nutritional/Metabolic Pattern

Patients intake is 3-4 meals per day and 5-8 glasses of fluid intake per day. She
also has a sedentary lifestyle and shows no concern on gaining weight. Does not
have food restrictions or allergies and likes to eat meat, fish, and poultry rather than
fruits and vegetables.

Elimination Pattern

Bowel movement 1x a day with a brownish-black, occasionally hard stool. No history


of constipation, diarrhea, and incontinence. Voids at least 4-6x a day with yellowishcolored urine. Delays urination at times and has an amount of about of a glass
(180ml).

Activity- Exercise Pattern

Patient frequently experiences fatigue and weakness and practices poor methods to
provide self care. Uses only one pillow when sleeping and doesnt have occupation
at the moment. Leisure time is watching television and taking care of her kids.

Sleep- Rest Pattern

Sleeps for 6-8 hrs a day without any difficulty in sleeping or insomnia. Methods to
promote sleep include watching television. Occasionally awakens at night.

Cognitive- Perceptual Pattern

Present pain experienced on her flank or lower back with a punching quality, usually
with a severity of 8/10. Patients decision-making is fair, with knowledge level of quite
fair as well.

Role/ Relationship Pattern

The patient is married. She is happy with his family and friends.

Sexuality- Reproductive Pattern

Patient is sexually active and does not have any problems in sexual life. She is not
using any contraceptives. Patient has 3 children.

Coping Stress Tolerance


Patient is always talking to her husband whenever there is a problem. She is
afraid of her condition at the moment but seems satisfied with the care hes
presently receiving with her husband giving her a positive outlook towards her
condition.

Value- Belief Pattern

Seems satisfied with the way of her life. She is hoping and praying that her condition
would be better. She had much faith in God and goes to church every Sunday with
her family.

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