CHAPTER I ASSESSMENT

A. NURSING HEALTH HISTORY

COMPREHENSIVE ADULT HEALTH HISTORY
I. Demographic Profile
Client CB is a married female Filipino Citizen, 80 years of age born on the year of 1936 at the
city of Pampanga. She is a Roman Catholic. The client only finished grade 3 and doesnt have
work due to her age. She is currently living with her family in Quezon City.
II. Admission Data
Client CB was accompanied by his son and daughter-in-law and was rushed in the hospital due
to Chief Complaint of Difficulty of Breathing at the Lung Center of the Philippines in Quezon
City on July 01, 2016. Other than difficulty of breathing, the patient is also experiencing fever,
sore throat, and cough. Her initial diagnosis was Pneumonia moderate risk, and her final
diagnosis is Post TB Bronchiectasis. She was confined on Medicine ward 2B, room 3010A.
III. History of Present Illness
As reported by the clients son, Mrs. CB has a 1-year history of a productive cough with whitish
scanty phlegm, positive low grade fever, weight loss, and experiencing anorexia. During
assessment the client also manifest difficulty of breathing, shortness of breath, and difficulty in
talking. Upon admission the client was also given salbutamol nebulization thrice a day and
Tuseran with partial relief.
IV. Past Medical History
Client BC has a history of Tuberculosis.
V. Family Health History
VI. Personal and Social History
VII. Review of Systems
PERSON GORDONS REVIEW OF SYSTEMS

B. PHYSICAL EXAMINATION
I. Physical Presence
The clients chronological age is congruent with the apparent age which is 80 years old. The
patient exhibits body symmetry, no obvious deformity, and has a well appearance. Client has a
humpbacked appearance with unsteady and slowed movement that might be due to her age.
There is no body or breath odor.
II. Psychological Presence
The client appears clean and was neatly dressed. Generally, the client is cooperative and pleasant.
The client responds to questions and command but not clear and understandable due to the
nasogastric tube attached to her. The patient appears awake and alert.
III. Distress
The client is experiencing difficulty of breathing and shortness of breath with labored speech and
cough as evidenced by high respiratory rate for up to 32 breaths per minute. The face is relaxed,
and the client is willing to move all body parts freely. The client does not perspire excessively
and doesnt show any signs of emotional distress such as nail biting or avoidance of eye contact.
IV. Skin
There are no any lesions observed. The clients skin color is brown in color and is uniform
throughout her whole body. Also, the clients skin temperature is equal in all extremities and has
no tenderness and edema. The client has slow skin turgor (3-4 seconds) due to her age.
V. Hair
The clients hair color is white/grayish in color. The hair is short, thick and curly in appearance.
Scalp hair, eyebrows, eyelashes, and body hair is well distributed.
VI. Nails
The client has pale to bluish nailbeds and has long nails. Upon observation, the patient has thick
nails has no splintering or brittle edges. Cyanosis is observed on nailbeds.
VII. Skull and Face

The head is normocephalic and symmetrical. There is no any visible lesions, masses, depressions
or lumps. Facial features are symmetrical. The shape of the face is oval, and has no
disproportionate structures or involuntary facial movements.
VIII. Eyebrows, Eyes, Eyelashes
The client has symmetrical and in line with each other eyebrows. It is black in color and is
evenly distributed. Eyes are evenly placed and in line with each other, non-protruding, and has
equal palpebral fissure. Eyelashes are black in color and is evenly distributed and turned
outward.
IX. Ears
The earlobes are bean shaped, parallel, and symmetrical. The upper connection of the earlobe is
parallel with the outer canthus of the eye. Skin is same in color as in complexion. No lesions
noted upon observation. The auricles appear firm. No discharge and lesions noted.
X. Nose and Paranasal Sinuses
Nose is at the midline. No discharges. No nasal flaring. Both nares are patent except that there is
a nasogastric tube attached on right nares. No bone and cartilage deviation noted. Nasal septum
is in the midline and is not perforated.
XI. Mouth and Oropharynx
Lips has visible margin, symmetrical in appearance, pinkish in color, and has no edema visible.
Gums has no bleeding and is pinkish in color. The patient has no teeth, and no any abnormal
breath odor. Tongue is pinkish in color with white taste buds on the surface. No lesions noted.
Able to move tongue freely.
XII. Neck
The neck is straight and has no visible mass or lumps. Symmetrical and has no jugular venous
distension.

XIII. Thorax and Lungs

The shape of the thorax is elliptical. The client uses accessory muscles upon breathing and has a
high respiratory rate for up to 32 breaths per minute. The client has also cough and crackles
might be heard upon auscultation due to phlegm.
XIV. Heart
The clients heart rate is 96 which is tachycardia. The client doesnt have any chest pain or
palpitations. The clients blood pressure is 130/70 mmHg.
XV. Breast
XVI. Abdomen
XVII. Extremities
extremities are equal in size. Have same contour with prominences of joints. No involuntary
movements. No edema. Color is even. temperature is warm and even.
XVIII. Genitourinary System