PHYSICAL ASSESSMENT

HEENT
Head.

Observed as normocephalic and symmetrical. The hair is evenly

distributed with some traces of gray hair. The scalp is damped with perspiration but
in good condition and there were no lesions, depressions nor deformity. Also, no
tenderness was apparent upon palpation.
Face. Patients face appeared symmetrical and smooth with even skin tone.
Senile skin was observed with some wrinkling which was also moist from
perspiration. There were no lesions or deformity noticed and patient was able to do
different facial expressions with ease. Palpation revealed no nodules and masses.
Eyes. These are seen to be aligned and symmetrical in shape. The scleras
are anicteric, the conjuctivas are pale, and the pupils are round, reactive to light and
accommodation. The eye movements are synchronous and patient was able to
follow the 6 directions smoothly and with ease. There was no abnormal drainage
observed. Upon giving some newsprint, patient had some difficulty reading small
fonts. There were no enlargements or nodules palpated around the eye area.
Ears. The auricles are equal in size and shape bilaterally and there was no
deformity noted. There was some cerumen present but no abnormal drainage
coming from the ear canal. There is some hearing difficulty and patient usually asks
the nurse to repeat the statement for clarification. Tenderness was not elicited upon
palpation of the auricles and the area near it.
Nose. Located at the midline with no drainage or congestion. No nasal flaring
noted and sense of smell intact. When lightly palpated there was no pain or
tenderness complained.
Mouth and Throat. The lips are dry and pale, the tongue is at midline, and
the oral cavity contains no lesions. There were some plaques present on teeth but
no foul odor noted. She was able to chew and swallow without difficulty. The trachea

is at midline, the thyroid gland is unremarkable and no masses were palpated.

Superficial lymph nodes palpated to be non-tender.
THORACIC REGION
The chest is proportional on both sides with no deformity involved. It can be
seen that the patient has senile skin which is warm to touch and free from lesions,
both on the anterior and posterior chest walls. Respiratory rate is around 20-22cpm,
with normal depth and rhythm. There was no exertion on both inspiration and
expiration during rest but some dyspnea was elicited once complicated movements
were assumed. Accessory muscles and paradoxical movements of the chest wall
were not observed and there was no tenderness on palpation of the rib and sternum
area. Resonance was heard on percussion while on auscultation, there were no
adventitious breath sounds and the apical pulse is regular in rhythm with a rate of 73
beats per minute with no murmurs involved. Both the patients breasts are noted to
be sagging but with no masses prominent on palpation. The right breast is observed
to be bigger in size and a bit lower from the other.

ABDOMEN
On inspection the abdomen is free of lesions and has a uniform skin color.
There is a noticeable surgical scar in the midline from a previous procedure. There
was no venous engorgement observed or any obvious deformity. Upon auscultation
of bowel sounds, it revealed as hypoactive with just about 5 clicks per minute. And
when percussed, distention was confirmed and a dull sound was produced mostly on
the umbilical region. Also, a tender solid mass was palpated in this area.

GENITOURINARY
The skin in this area is uniform in color to the rest of the body with no
noticeable lesions and abrasions. There is no abnormal foul odor coming from the
organs involve. Also, no complaints of dysuria, nocturia or urinary retention
mentioned. There were no abnormal placements of organs on palpation. Upon,
percussion, bladder was not distended and flank pain was negative.

EXTREMITIES
Both the upper and lower extremities have senile skin, warm to touch, and
with no lesions and deformity. Also, it is remarkable that dry skin can be noticed
mostly on the lower extremities. There were no inflammation of the joints but
decreased strength can be observed and patient cannot tolerate to stand alone
without the help of a person or an assistive device. Capillary refill was checked to be
2 seconds and peripheral pulses are patent and strong bilaterally. Patient was able
to do passive ROM activities on both sides with aide. Tremors were markedly noticed
throughout the assessment on both hands.

FUNCTIONAL HEALTH PATTERNS

Health perception and Management
The patient verbalized that she puts high value to health and sees it as very
significant. As she said, as much as she can do activities that will preserve her
health, she would do it. She also added that she automatically seeks medical consult
whenever she feels that there is something wrong about her system. And whenever
she is given a therapeutic regimen to follow, she always makes sure she is able to
comply, even if it requires a huge amount of money. However, as interviewed, there
was really a time where she needed to quit a therapeutic session because of the
side effects it brought. Also, she claimed to be guilty of having an inactive lifestyle
ever since, but she mentioned that she compensates it with good nutrition instead.
Nutritional/Metabolic
There were no food restrictions imposed to the patient during the time of her
illness. Her typical daily food intake includes Rice, Pork and a couple of Fruits. The
patient had no swallowing difficulties and she eats the amount of food she feels her
stomach can accommodate. Usually she demands whatever food she likes but
almost always she cannot completely consume the entire amount because she
easily feels full. As noted, her hydration status was adequate. Patient weighs 85kg
and stands 5 feet 4 inches.

Elimination
The patients bowel movement has significantly changed throughout the
course of her illness. She often experiences constipation and able to move her bowel
only once in a week. On the other hand, her urination was not compromised and she
usually urinates about 5 times in a day, however, there were episodes of urinary tract
infection during her chemotherapy sessions before admission.

Activity/Exercise
The patient sometimes needs an assistive device when transferring from one
place to another and passive ROM exercises can hardly be tolerated without
assistance. Although patient usually insists to do solely her activities of daily living,
she easily gets exhausted and cannot manage to finish the task without aid. Aside
from that, dyspnea can also be observed when exerting effort on heavy activities
such as when walking long distances and she often feels pelvic discomfort also
during certain movements. Though breathing is non-exaggerated and pulse rate is
non-tachypneic during rest, patient still prefers to take more breaks in bed than do
passive exercises.

Cognitive-Perceptual
The patients cognitive functions such as language, memory, and decision
making are intact. In fact, she was the one who really decided to undergo the
operation after understanding its risks and benefits. Also through reading, she has
become knowledgeable about the procedure to be done and what preparations she
would undergo. However, she has a hard time picking up conversations due to some
hearing loss and needs to have the speaker repeat his statement twice. Aside from
that, the patients peripheral vision and acuity has already declined, and patient
cannot tolerate too much glare. All other senses though are intact and normal but
patient seems to be more sensitive to light touches and pain.

Sleep-Rest
The sleeping pattern of the patient has been disturbed since the time her
illness has brought discomfort. She has a harder time falling asleep, and usually
rests only for a few hours in a day. Also, the patient stated that she doesnt feel the
same satisfaction on the quality and quantity of sleep she gets especially in the
hospital due to disturbances of some health care routines.

Self-perception/ Self-concept
Patient feels bad about the situation and sometimes feel self-pity. Despite this,
patient still has a positive feeling about her recovery and as she verbalized would be
her, third life. Furthermore, she revealed that sometimes she cannot help her self
on being in a state of depression because of everything that happened to her and
her life.

Role/Relationship
P

Coping/Stress
The patient has revealed that previously she had an onset of depression
when she knew about her illness. She stated that crying and being numb was her
means of channeling the frustrations she feel about her condition. Also, she added
that she could have not recovered from that state, if not for her daughter who
provided her with emotional support and brought her for psychiatric help. From then
on, she has confide with her daughter, though at times she would still burst to tears,
but still she noted that having someone to vent out her feelings really helped.
Besides that, the patient would also do religious activities to release inner tensions
for she believes that faith and family support will aid in combating stress.

Sexuality-Reproductive
Patient has already reached the menopausal stage. She said that she is still
living with her husband; however, she did not give information regarding her sexual
health.

Value Belief
Patient greatly believes in God and she entrusts her life to Him. She was very
hopeful on her operation to be successful and believes that this would be another life
God will give her. Also, the patient refers to her family as the most important people
and she said that she will help herself surpass the surgical procedure for them. The
patient was as well seen praying the rosary before sleeping.