I.

ASSESSMENT
A. General Data
• Name: Ms. X
• Sex: Female
• Address: Bacoor Cavite
• Civil Status: Married
• Age: 45
• No. of Days in this Hospital: ER
• Date of Admission: Aug 9, 2010

B. Chief Complaints
• The client experience chest pain which she described as
radiating from her sternum area towards her xyphoid process
lasting approximately for about 10-15 minutes which
provoked her to go to the hospital.

C. History of present illness

• A week prior to admission, client experienced generalized
body weakness and occasional radiating chest pain related to
stress and fatigue. A day prior to admission she claimed of
same symptoms.

D. Past Medical History

• Client was diagnosed about 10 years ago (year 2000) of
Hypertension.

• Client has a childhood illness of allergic rhinitis related to

dust that is still presently manifested.

• Client hadn’t encountered any form of accident or serious

injuries at the moment.
 E. Family History

• Client claimed with familial history of hypertension

(maternal side) and she stated a link in the genealogy that
manifested diabetes on her paternal side.

F. Physical Assessment
Date: August 9, 2010 Clinical Area: St. Dominic Medical Center
Initial vital signs:
T = 36˚C
CR = 120bpm
RR = 20cpm
BP = 130/90 mmHg

• General Appearance
The patient is conscious, coherent and is not in distress.
She looks according to age and is calm and engaging. One can
see that she is well nourished and practices good hygiene.

Body Part Technique Actual Finding Interpretation

Assessed Used
Skin Inspection Skin color is fair and even Normal
Palpation Skin is smooth with fair skin Normal
turgor
Inspection Normal
Head
Normocephalic Normal
Evenly distributed hair, no
Eyes Palpation dandruff, lesions nor infection Normal
Sinuses non-tender
Inspection Normal
Symmetrical eyelids Normal
Pinkish conjuctiva Normal
 Anicteric sclera Signs of Aging
Cornea and lens slighty cloudy Normal
PERRLA

Body Part Technique Actual Finding Interpretation

Assessed Used
Ears Inspection Normoset Normal

Palpation No discharge Normal

Non tender Normal
Nose Inspection No presence of mass or nodules Normal
Symmetrical nasal folds Normal
Nasal septum at midline Normal
Mucosa is moist, pinkish, intact Normal
and no discharge
Airways patent on both nares Normal
Palpation Non tender sinuses Normal
Mouth Inspection Lips pinkish and dry Normal
Tongue at midline Normal
Gums and mucosa pink Normal
Presence of dentures Aging
(decalcification)
Pharynx Inspection Uvula at midline Normal
Tonsils not inflamed Normal

Neck Inspection Neck symmetrical with full ROM Normal

Palpation Trachea at midline Normal
Lymph nodes non tender Normal
Thyroid gland non palpable Normal
Pulmonar Inspection Symmetric Normal
y Auscultation Clear lung sounds Normal
No adventitious breath sounds Normal

Body Part Technique Actual Finding Interpretation

Assessed Used
Cardiovasc Auscultation Presence of palpitation Due to cardiac
ular compensation

Inspection Flat and symmetrical Normal

Abdomen No lesions Normal
Palpation No tenderness Normal

Extremities Inspection Skin smooth Normal

Skin intact Normal
Nails convex curved Normal
Pink nail beds Normal

Palpation Normal capillary refill <3 sec.

Skin cool to touch Decreased
Bounding pulses perfusion
Muscles with slight atrophy Cardiac
light muscle strength compensation
Full active ROM Aging process
Normal
Normal
Motor Inspection 100% intact Normal
Sensory 12 cranial nerves responsive Normal
 II. OTHER SOURCES OF INFORMATION

A. Drug Study

NAME OF CLASSIFICAT ROUT MECHANIS INDICATIO NURSING

DRUG ION E M OF N RESPONSIBILITY
(GENERIC ACTION
AND
BRAND
NAME)
Nitroglyce Vasodilator, Patch Decreases To prevent 1. Closely monitor
rin Antianginal oxygen or minimize V/S especially
demand by anginal BP.
decreasing attacks
preload and before 2. Applied to any
after load stressful non hairy parts
events of the skin
except distal
parts of the
arms and legs.

III.Concept Map

1.Decreased
Cardiovascular
Cardiac 4.Acute Pain
Disease
Output

2.Ineffective 3.Impaired
Tissue Gas Exchange
Perfusion