ASSESSMENT December 4, 2013

A. Digestive/Metabolic/Nutrition System
OBJECTIVE SUBJECTIVE
General Appearance:
Tenderness/pain
Fatigue and slight weakness
Guarded behavior
Facial grimace
Skin:
Dry
Warm
Jaundice
Itching
Poor turgor
Eyeball:
Icteric sclera
Moist
Mouth:
Number of teeth - Complete
Tongue:
Dry
Venous Filling:
3 seconds
Vital Signs:
BP 110/70mmHg
T 38.3C
P 112bpm
R 38cpm
Body Type:
Endomorph
50kg
Loss of Appetite
Nausea and vomiting
Difficulty in eating and swallowing:
Naa, mu-gahi akoang tiyan ug mu-sakit
dayun inig masobraan ko ug kaon busa
ginagmay ra gyud akong ma kaon
Usahay wa gyud koi gana ikaon
Pain:
P Mu-sakit inig masobraan ug kaon,
kung pisliton ug kung mu-lihok ko
Q Sakit kayo nga murag ga-kumoton
akong tiiyan
R Gikan dire sa tuo paingon saw ala
dayon ga-abot ang ka ngot-ngot sa likod
S 8/10
T Mawala dayon mubalik ra man dayon,
dili ko kaingon sa oras
Diet:
Kasagara jud namo ga kaonon didto utan,
isda, ug canned goods
Mu-kaon mi ika-tulo sa usa ka adlaw
Dili gyud limpyo ang ga kuhaan namo sa
tubig didto kay sa bomba ra man gud
Ga-hinulama ug ga-sagol lang mi ug mga
gamit didto sa akong kauban
Gipa-undang nakog kaon ug mangga
sakong mama, kay bsin daw maoy
hingtundan sa pagsakit sakong tiyan
Fluid Intake:
Dili ra gyud siguru mu-abot ug usa ka litro
nga tubig akong mainom busa permi ko
ga-uhawon
Limitado ra gyud akong mainom nga tubig
didto kay lisod man ang pangitaan ug
tubig
Ga-palit man mi ug mineral water, pero
kung wala gyud kwarta sa bomba ra
mukuha
Alcohol and Beverages:
Mu-inom pud pero panalagsa ra man
Undesired Weight Loss:
Oo, makaingon gyud ko nga nag niwang
ko. Sa wala pa ko nag sakit 60kg pa man ko
ato pagpatimbang nako didto
Elimination Pattern: Bowel Movement
Tulo ko ka adlaw sigeg kalibanga adtung
wa pa ko na admit

B. Cardiovascular/Circulatory System
OBJECTIVE SUBJECTIVE
Temperature:
38.3C
BP:
110/70mmHg
Pulses:
Carotid: Weak; (R) 110bpm; (L) 109bpm
Apical: Regular; 112bpm
Radial: Regular; Weak; (R) 117bpm; (L)
112bpm
Dorsalis Pedis: Regular; Weak; (R) 96bpm;
(L) 96bpm
Posterior Tibia: Regular; Weak; (R) 96bpm;
(L) 98bpm
Heart Rhythm:
Tachycardia
Jugular Vein Distention:
Negative
Nail bed Color:
Pale
Capillary Refill:
3 seconds
Edema and Varicosities:
None
Do you experience any of the following:
Abdominal discomfort
Joint and back pain
Light headedness
Fatigue and weakness
Family History:
Hypertension
Anemia
Physical Activity:
Type:
Frequency:
Duration:
Problem experience with usual activity and
exercise:
Dali rako hanguson ug sakit kayo akoang
tiyan inig maglihok-lihok
Factors affecting Activity Intolerance:
Ang kasakit nga akong gabation


C. Integumentary System
OBJECTIVE SUBJECTIVE
Temperature:
38.3C
Skin:
Dry
Warm
Jaundice
Itching
Poor turgor
Hair:
Normal distribution
Nail bed Color:
Pale
Capillary Refill:
Sigeg balik-balik akoang hilanat. Mawala,
dayon mubalik nasad
Dugay nako kabantay nga ga yellow
akoang panit, pero gipasagdaan ko ra tu.
Naa pud koi mga kauban nga na ingon ani
Oo, gapangatol ko

3 seconds

D. Elimination System
OBJECTIVE SUBJECTIVE
Abdomen:
Firm
Bowel Sounds:
Hyperactive
Measurement:
Intake: 1000cc
Output: 800cc
Edema:
None
Present Urine:
Color: Dark yellow
Frequency: 4 x a day
Previous Surgery:
None
History of pain and discomfort:
None
Personal Elimination Habits:
Normal ra man pud akong paglibang sa
wa pa ko nag sakit; makalibang ko kaisa sa
usa ka adlaw
Elimination Problem:
Tulo ko ka adlaw sigeg kalibanga adtung
wa pa ko na admit
Medication taken:
Antibiotics
Fluid Intake:
Dili ra gyud siguru mu-abot ug usa ka litro
nga tubig akong mainom
Limitado ra gyud akong mainom nga tubig
didto kay lisod man ang pangitaan ug
tubig
Ga-palit man mi ug mineral water, pero
kung wala gyud kwarta sa bomba ra
mukuha
Physical Activity:
Type:
Frequency:
Duration:

E. Musculoskeletal System
OBJECTIVE SUBJECTIVE
Mobility:
Ambulatory
Muscle Strength:
Fatigue and slight weakness
Malaise
Lethargic
Restlessness
Guarded behavior
Do you experience any of the following:
Gapangluya pa gyud ko hantud karun,
hawoy akong tibuok lawas nga dili ko
kasabot



ASSESSMENT December 5, 2013
A. Digestive/Metabolic/Nutrition System
OBJECTIVE SUBJECTIVE
General Appearance:
Tenderness/pain
Fatigue and slight weakness
Guarded behavior
Facial grimace
Skin:
Dry
Jaundice
Itching
Poor turgor
Eyeball:
Icteric sclera
Moist
Mouth:
Number of teeth - Complete
Tongue:
Dry
Venous Filling:
3 seconds
Vital Signs:
BP 100/70mmHg
T 36.1C
P 84bpm
R 23cpm
Body Type:
Endomorph
50kg
Loss of Appetite
Nausea
Difficulty in eating and swallowing:
Wala pa gihapon koi gana ikaon
Pain:
P Mu-sakit inig masobraan ug kaon,
kung pisliton ug kung mu-lihok ko
Q Sakit kayo nga murag ga-kumoton
akong tiiyan
R Gikan dire sa tuo paingon saw ala
dayon ga-abot ang ka ngot-ngot sa likod
S 7/10
T Mawala dayon mubalik ra man dayon,
dili ko kaingon sa oras
Diet:
Kaon naman ko ginagmay; sabaw ug
utan
Fluid Intake:
500cc
Elimination Pattern: Bowel Movement
Wala pa ko nakalibang sukad gahapon

B. Cardiovascular/Circulatory System
OBJECTIVE SUBJECTIVE
Temperature:
36.1C
BP:
100/70mmHg
Pulses:
Carotid: Weak; (R) 80bpm; (L) 80bpm
Apical: Regular; 84bpm
Radial: Regular; Weak; (R) 83bpm; (L)
84bpm
Do you experience any of the following:
Abdominal discomfort
Joint and back pain
Fatigue and weakness
Dorsalis Pedis: Regular; Weak; (R) 78bpm;
(L) 80bpm
Posterior Tibia: Regular; Weak; (R) 80bpm;
(L) 80bpm
Heart Rhythm:
Normal
Jugular Vein Distention:
Negative
Nail bed Color:
Pale
Capillary Refill:
3 seconds
Edema and Varicosities:
None

C. Integumentary System
OBJECTIVE SUBJECTIVE
Temperature:
36.1C
Skin:
Dry
Jaundice
Itching
Poor turgor
Hair:
Normal distribution
Nail bed Color:
Pale
Capillary Refill:
3 seconds
Wala ko hilanti karun
Gapangatol pa gihapon ko


D. Elimination System
OBJECTIVE SUBJECTIVE
Abdomen:
Firm
Bowel Sounds:
Hyperactive
Measurement:
Intake: 1200cc
Output: 600cc
Edema:
None
Present Urine:
Color: Dark yellow
Elimination Problem:
Wala pa ko nakalibang sukad gahapon
Medication taken:
Antibiotics
Fluid Intake:
500cc
Frequency: 2 x a day

E. Musculoskeletal System
OBJECTIVE SUBJECTIVE
Mobility:
Ambulatory
Muscle Strength:
Fatigue and slight weakness
Malaise
Lethargic
Restlessness
Guarded behavior
Do you experience any of the following:
Luya pa gihapon, kay inig lihok nako mu-
sakit man gud


ASSESSMENT December 6, 2013
A. Digestive/Metabolic/Nutrition System
OBJECTIVE SUBJECTIVE
General Appearance:
Tenderness/pain
Fatigue and slight weakness
Guarded behavior
Facial grimace
Skin:
Dry
Jaundice
Itching
Poor turgor
Eyeball:
Icteric sclera
Moist
Mouth:
Number of teeth - Complete
Tongue:
Moist
Venous Filling:
2 seconds
Vital Signs:
BP 100/80mmHg
T 37.6C
P 84bpm
R 20cpm
Body Type:
Endomorph
50kg
Difficulty in eating and swallowing:
None
Pain:
P Ayha na lang kung pisliton ug kung
mu-lihok ko
Q Sakit pa, pero dili na parehas atung
niagi nga murag gakumoton
R Gikan dire sa tuo paingon sa wala
dayon ga-abot ang ka ngot-ngot sa likod
S 5/10
T Mawala dayon mubalik ra man dayon,
dili ko kaingon sa oras
Diet:
Ginagmay nga pagkaon pero sige na
nakog sudlan akong tiyan
Fluid Intake:
750cc
Elimination Pattern: Bowel Movement
Nakalibang nako kaisa
Improved Appetite

B. Cardiovascular/Circulatory System
OBJECTIVE SUBJECTIVE
Temperature:
37.6C
BP:
100/80mmHg
Pulses:
Carotid: Weak; (R) 81bpm; (L) 80bpm
Apical: Regular; 84bpm
Radial: Regular; Weak; (R) 86bpm; (L)
84bpm
Dorsalis Pedis: Regular; Weak; (R) 80bpm;
(L) 80bpm
Posterior Tibia: Regular; Weak; (R) 82bpm;
(L) 81bpm
Heart Rhythm:
Normal
Jugular Vein Distention:
Negative
Nail bed Color:
Pale
Capillary Refill:
2 seconds
Edema and Varicosities:
None
Do you experience any of the following:
Abdominal discomfort
Fatigue and weakness

C. Integumentary System
OBJECTIVE SUBJECTIVE
Temperature:
37.6C
Skin:
Dry
Jaundice
Itching
Poor turgor
Hair:
Normal distribution
Nail bed Color:
Pale
Capillary Refill:
2 seconds
Gabalik-balik akoang hilanat, gabie
gihilantan napud ko
Naa pa gihapon ang katol


D. Elimination System
OBJECTIVE SUBJECTIVE
Abdomen:
Firm
Bowel Sounds:
Normoactive
Measurement:
Intake: 1450cc
Output: 800cc
Edema:
None
Present Urine:
Color: Dark yellow
Frequency: 3 x a day
Elimination Problem:
Wala pa ko nakalibang sukad gahapon
Medication taken:
Antibiotics
Fluid Intake:
750cc

E. Musculoskeletal System
OBJECTIVE SUBJECTIVE
Mobility:
Ambulatory
Muscle Strength:
Fatigue and slight weakness
Guarded behavior
Do you experience any of the following:
Luya pa gihapon, kay inig lihok nako mu-
sakit man gud


ASSESSMENT December 13, 2013
A. Digestive/Metabolic/Nutrition System
OBJECTIVE SUBJECTIVE
General Appearance:
Alert
Skin:
Moist
Jaundice improved
Good turgor
Eyeball:
Icteric sclera improved
Moist
Mouth:
Number of teeth - Complete
Tongue:
Moist
Venous Filling:
2 seconds
Vital Signs:
Difficulty in eating and swallowing:
None
Pain:
P Usahay inig lihok na lang, pero okay
naman
Q Wala na gasakit
R Dili na gaka apil ang sa wala
S 2/10
T Dili nako matagna ang oras
Diet:
Prutas akoang sigeg kaonon karun
Fluid Intake:
1600cc
Elimination Pattern: Bowel Movement
Makalibang nako kaisa sa usa ka adlaw
parehas adtung una
BP 110/80mmHg
T 36.6C
P 86bpm
R 20cpm
Body Type:
Endomorph
53.5kg
Improved Appetite

B. Cardiovascular/Circulatory System
OBJECTIVE SUBJECTIVE
Temperature:
36.6C
BP:
110/80mmHg
Pulses:
Carotid: Strong; (R) 84bpm; (L) 85bpm
Apical: Regular; 86bpm
Radial: Regular; Strong; (R) 86bpm; (L)
86bpm
Dorsalis Pedis: Regular; Strong; (R) 84bpm;
(L) 84bpm
Posterior Tibia: Regular; Strong; (R)
85bpm; (L) 84bpm
Heart Rhythm:
Normal
Jugular Vein Distention:
Negative
Nail bed Color:
Pink
Capillary Refill:
1 second
Edema and Varicosities:
None
Do you experience any of the following:
None

C. Integumentary System
OBJECTIVE SUBJECTIVE
Temperature:
36.6C
Skin:
Moist
Jaundice improved
Good turgor
Hair:
Wala naman ko hilantani mga pila ka
adlaw
Dili naman ko gapangatol

Normal distribution
Nail bed Color:
Pink
Capillary Refill:
2 seconds

D. Elimination System
OBJECTIVE SUBJECTIVE
Abdomen:
Firm
Bowel Sounds:
Normoactive
Measurement:
Intake: 1500cc
Output: 800cc
Edema:
None
Present Urine:
Color: Yellow
Frequency: 4 x a day
Elimination Problem:
None
Medication taken:
Antibiotics
Fluid Intake:
750cc

E. Musculoskeletal System
OBJECTIVE SUBJECTIVE
Mobility:
Ambulatory
Muscle Strength:
Normal
Do you experience any of the following:
None


ASSESSMENT January 8, 2013
A. Digestive/Metabolic/Nutrition System
OBJECTIVE SUBJECTIVE
General Appearance:
Alert
Skin:
Moist
Jaundice wala na
Good turgor
Eyeball:
Icteric sclera wala na
Moist
Mouth:
Difficulty in eating and swallowing:
None
Pain:
None
Diet:
Balik nako sa normal, makakaon nakog
dinaghan kay wala nay sakit
Fluid Intake:
1600cc
Elimination Pattern: Bowel Movement
Number of teeth - Complete
Tongue:
Moist
Venous Filling:
2 seconds
Vital Signs:
BP 110/80mmHg
T 36.4C
P 86bpm
R 22cpm
Body Type:
Endomorph
55kg
Improved Appetite
Normal

B. Cardiovascular/Circulatory System
OBJECTIVE SUBJECTIVE
Temperature:
36.4C
BP:
110/80mmHg
Pulses:
Carotid: Strong; (R) 86bpm; (L) 85bpm
Apical: Regular; 88bpm
Radial: Regular; Strong; (R) 86bpm; (L)
86bpm
Dorsalis Pedis: Regular; Strong; (R) 84bpm;
(L) 82bpm
Posterior Tibia: Regular; Strong; (R)
85bpm; (L) 85bpm
Heart Rhythm:
Normal
Jugular Vein Distention:
Negative
Nail bed Color:
Pink
Capillary Refill:
1 second
Edema and Varicosities:
None
Do you experience any of the following:
None

C. Integumentary System
OBJECTIVE SUBJECTIVE
Temperature: Dili nako ga yellow ug dili nako
36.4C
Skin:
Moist
Jaundice wala na
Good turgor
Hair:
Normal distribution
Nail bed Color:
Pink
Capillary Refill:
2 seconds
gapangatol

D. Elimination System
OBJECTIVE SUBJECTIVE
Abdomen:
Firm
Bowel Sounds:
Normoactive
Measurement:
Intake: 1600cc
Output: 750cc
Edema:
None
Present Urine:
Color: Yellow
Frequency: 4 x a day
Elimination Problem:
None
Medication taken:
None
Fluid Intake:
750cc

E. Musculoskeletal System
OBJECTIVE SUBJECTIVE
Mobility:
Ambulatory
Muscle Strength:
Normal
Do you experience any of the following:
None