Physical Assessment

A. General Appearance
Ms. CB is a medium frame and stooped in posture. Her gait is staggering. She is
appropriately dressed and well groomed and no body odor. Her height is 4 ft and
9 inches , her weight is 46 kg, her vital signs are; BP 90/50; RR 25; PR 75; Temp
36.6

B. Mental Status
She is conscious and can remember time, place and person. She is cooperative
and she uses simple words as I talk to her.

C. Skin
Her skin color is normal skin brown color and warm to touch. She has dry and
rough skin. Her skin turgor has wrinkles and loss of elasticity. The hair of her skin
is evenly distributed.

D. Nails
Her nail plate shape is concave 180’ and rough nail condition. Her nail bed color
is pink and capillary refill is within 2-3 seconds.

E. Head and Face

Her head is proportionate to body size and white scalp. Her hair condition are
evenly distributed. Her face is symmetric and easy movement of the muscles in
the muscle.

F. Eyes
Her eye condition is straight normal and thick eyebrows. Her blink response is
frequent and her eyeballs are symmetric. Her bulbar is clear and palpebral is
pink. Her sclera is white and pupils are equal. Her pupils reacted 3-4 mm light
and accommodation. Her lacrimal apparatus is moist.

G. Ears
Her auricle is normal racial tone, symmetrical and elastic. Her pinna recoils when
folded. In external canal has some cerumen. And hearing acuity responds to
normal voice.

H. Nose
Her external nose is normal racial tone and his septum is on the midline, mucosa
is pink and both patent. Nasal cavity is dry and sinuses are non-tender.

I. Mouth
 Her lips are dry, mucosa is pink and tongue is in the midline, smooth, pink and
movable.

J. Phaynx
Her uvula is on the midline and mucosa is pink. Her tonsils are not inflamed and
gag reflex are present.
K. Neck
Her neck muscles are equal in size and lymph nodes are not palpable. Trachea
is on the midline and thyroid gland is not palpable.

L. Breast and Axilla

Her breast is symmetrical, round, smooth and nipples are everted. Lymph
noodes in the axilla is not palpable.

M. Chest and Lungs

Her chest shape is AP to lateral ratio 1:2. Lung expansion is symmetrical. Her
breathing pattern is irregular with the presence of crackles in breath sounds.

N. Abdomen
The skin intergrity is normal raical tone and rounded. Symmetrical in movement
with normal bowel sounds.

O. Lower extremities
Passive Exercise.

Nursing Health History

Personal data
 Ms. CB is a 42 years old client, live at Alabang Muntinlupa. July 19, 1960 is her
birthday. She lives with her siblings. Her vital signs are; BP 90/50; RR 25; PR 75; Temp
36.6, her weight is 46 kg and her height is 4ft. and 9 inches.
Chief complaint
“hindi ako masyadong makahinga ng malalim” as verbalized by the client.
History of Present Illness.
1st day prior to admission: she complained of difficulty of breathing and she took
up furosemide tab. 20 mg once a day.
2nd day of hospitalization: complain of easy fatigability and apnea, both lower
extremities positive of bipedal edema.
Diagnostic exam: CBC, U/A, BUN, Na, K, PT/PTT, ECG, CXR done.
PLRS 1L x 8’ started as venoclysis.
Fluid intake limited to 1-2 L/day.
Medication:
Furesemide 20 mg OD
Kalium Derule TID
Salbutamol Neb q 8’
Lanoxin 0.25 gm tab. OD
Ipatropium Neb q 8’
Aldactone 25 g tab OD
Paracetamol 500 mg tab q 4’

Diagnose: CHF: t/c RHD FC II-III

CAP- MR Pulmonary conjestion

Family Health History.

– The client verbalizes that they don’t have any hereditary disease.
 Legend:
Decease

Female

Male

Social History.
She has good communication with his family, friends and also her relatives.