Nursing History

Review of Systems
Physical Assessment
Nursing Care Plan

CHUA, Joan Elizabeth A.

IV – F3
Mrs. Ma. Lourdes Uysison, DVM, RN, MAN
6B PM
Date of Exposure: July 12 – 15, 2010
 BIOGRAPHIC DATA

ROOM 629
Name: Charles Tiu
Age / Sex: 43 / M
Date of Birth: May 20, 1967
Place of Birth: Philippines
Civil Status: Married
Religion: Catholic
Nationality: Filipino
Address: 1572 Yakal St., Sta. Cruz, Manila
Admission No.: 105616-0001
Admission Date: July 8, 2010
AMD: Dr. Evan Ong
Diagnosis: Hepatitis A
Chief Complaint:
The client sought medical help at the institution presenting with abdominal pain (pain
scale of 6) and jaundice.
History of Present Illness:

Past health History:

REVIEW OF SYSTEMS
 System Verbalization
General Health/ “Okay naman iyong pakiramdam ko ngayon. Kaso kung
Appearance titignan mo medyo madilaw pa iyong kulay ng katawan at
mata ko.”

Integumentary System “..kung titignan mo medyo madilaw pa iyong kulay ng

katawan at mata ko.”

Musculoskeletal System “Hindi naman masakit ang anumang parte ng katawan ko..
at naglalakad ako papunta at pabalik ng CR.”

Neurologic System “Monday ngayon, July 12.”

(when asked to state the day today.)

Respiratory System “Hindi ako nahihirapan huminga..”

Cardiovascular System “Nadiagnose ako na may hypertension April this year..

Pinainom ako ng Norvasc for 14 days.”

Digestive System “Mahilig ako sa seafoods. Hindi naman ako mapili sa

pagkain.”

Genito-urinary System “Wala naman akong problema pagdating sa pag-ihi, ok

naman.”

Excretory System “Normal naman ang pagdumi ko. Madalas every other day
okaya araw araw.”

PHYSICAL ASSESSMENT
GENERAL APPERANCE and BEHAVIOR

JULY 12, 2010 : The client was seen on bed sitting, while watching TV. He was talking to her
wife when we entered. He has no IVF or other contraptions. Is ambulatory, and coherent
when we started conducting the interview.

VITAL SIGNS
Temperature 36. 5degrees Celcius
Respiratory rate 16 breaths / min
Pulse rate 72 bpm
Cardiac rate 75 bpm
Blood Pressure 120 / 80 mmHg

Part of the Technique Findings Analysis

body
Normal Actual
Skin Inspection No lesion, color is No lesion, uniform skin Abnormal skin
uniform color is light yellow. color due to
Warm skin Skin is warm to touch liver problem.
Jaundice is
manifested
when client has
liver disorder.
a. skull Inspection Normochepalic Normal Normal
and No tenderness noted
palpation upon palpation
b. scalp Inspection Lighter in color than
and the complexion
palpation
c. hair Inspection Can be black or brown Black hair, Smooth. Normal
and or burgundy
palpation depending on the face
Maybe thick or thin,
coarse is smooth
Face Inspection Face is symmetrical Smymmetrical Normal
a. Eyebrows Inspection Symmetrical in line Symmetrical Normal
with each other
b. eyes Inspection Symmetrical in face Symmetrical Eyes, Abnormal due to
Sclera of eyes has liver problem.
yellow discoloration
c. eyelashes Inspection Color dependent on Normal Normal
race
Turned outward
d. eyelids Inspection No ptosis noted Normal Normal
Symmetrical
Ears Inspection Ear lobe are bean Ear lobe are bean Normal
shaped and parallel shaped and parallel
and symmetrical and symmetrical
Parallel with the upper Parallel with the upper
cantus of the eye cantus of the eye
No lesions noted No lesions noted
Nose Inspection Symmetrical in Symmetrical in Normal
Sinuses appearance appearance
Pinkish-red in color Pinkish-red in color
Mouth Inspection Visible margin Visible margin
Lips Symmetrical in Symmetrical in Normal
appearance appearance
Pinkish in color Pinkish in color
Gums Inspection Pinkish color Pinkish color Normal
Teeth Inspection White to yellowish White to yellowish Normal
 No halitosis No halitosis
Thorax Inspection, Elliptical in adult, the Elliptical in adult, the Normal
auscultation anteroposterior anteroposterior
and diameter is less than diameter is less than
palpation the transverse the transverse
diameter a ratio of diameter a ratio of 1:2
1:2 Moves symmetrically
Moves symmetrically on breathing with no
on breathing with no obvious masses;
obvious masses Respiratory Rate is 16
breaths per minute
Heart Inspection No visible pulsation Normal Cardiac rate of Normal
and No murmurs 75bpm
palpation

Auscultation
Abdomen Inspection Skin color is uniform No masses palpated Normal
no lesions and masses
Upper Inspection Both L. extremities are Both L. extremities are Abnormal due to
Extremities equal in size and have equal in size and have liver problem
the same contour the same contour that causes
Smooth Smooth jaundice.
No involuntary No involuntary
movements movements
Uniform in color Slight yellow skin color
Lower Inspection Both L. extremities are Both L. extremities are Abnormal due to
Extremities equal in size and have equal in size and have liver problem
the same contour the same contour that causes
Smooth Smooth jaundice.
No involuntary No involuntary
movements movements
Uniform in color slight yellow skin color

5 IDENTIFIED PROBLEMS
1.
2.
3.
4.
5.

PRIORITIZED :
NURSING CARE PLAN

ASSESSME NURSING RATIONALE PLAN OF NURSING RATIONALE EVALUATION

NT DIAGNOSIS CARE INTERVENTION