CHAPTER I ASSESSMENT

A. NURSING HEALTH HISTORY

COMPREHENSIVE ADULT HEALTH HISTORY
I. Demographic Profile
Mr. AMC is a 47 years old Filipino male client, born on the 22 nd day of December 1966 in
Pangasinan. He is currently living in 659 Geronimo Street Sampaloc, Manila. He is currently
married to Mrs. DC with 7 children. His current occupation is Pedicab Driver. He is also a
Roman Catholic. The client only finished high school.
II. Admission Data
Patient AMC was rushed in the Emergency Room of OSpital ng Sampaloc due to chief complain
of defecating stools with blood and vomiting with blood stain on the afternoon of the 8 th day of
August 2016. His initial diagnosis by the physician is Upper Gastro Intestinal Bleeding
secondary to Benign Peptic Ulcer.
III. History of Present Illness
Prior to clients Admission, the patient was said to be defecating stools with blood and vomiting
blood for the past 2 days. He is also complaining of epigastric pain with pain scale of 6. The
client lay down and in side lying position to alleviate the pain.
IV. Past Medical History
Other than his current condition, the client has a Psoriasis that starts to appear when he was 37
years old. He said that it started from his nails and then spread out after sometime throughout his
whole body.
V. Family Health History
The client has no any known family members that also has Psoriasis. He doesnt take any
medications prior to his current illness and doesnt apply anything on it. He doesnt undergo any
previous surgery or any psychiatric procedures yet. The patient was said to be the 7 th child on
their family. His mother is still alive without any known illness or disease but his father died
already due to having an edema. He has 9 other siblings and everyone is still alive and has no

any known disease or illness. The patient has also 7 children, 6 are male and 1 is female who are
all disease free also.
VI. Personal and Social History
The patient is a Pedicab driver, he financially supports his family through driving a Pedicab. The
client doesnt smoke but occasionally drinks alcohol with his friends.
VII. Review of Systems
The clients health in general is currently not in good condition. He was chronically ill for a long
time and now he is experiencing epigastric pain. The client has rashes, dryness and color changes
in skin and nails. The client is also currently experiencing headache and dizziness. The client
also has vision problem but is not wearing any glasses. the client has also difficulty in hearing.
The client is also experiencing frequent colds. He has no any problem in throat. The client also
experiences prolonged cough. The client doesnt have any known Cardiovascular problem. The
client is currently experiencing vomiting and blood in stools. The client has also no genitourinary
or genial problems. The client has also no problem in peripheral, musculoskeletal and psychiatric
problem. He also doesnt have Neurologic, hematologic, endocrine and immunologic problems.

PERSON GORDONS REVIEW OF SYSTEMS

B. PHYSICAL EXAMINATION
I. Physical Presence
The clients chronological age is congruent with the apparent age which is 47 years old. The
patient exhibits body symmetry, no obvious deformity, and but doesnt have a well appearance
due to his chronic illness which is Psoriasis. Client doesnt have a humpbacked appearance with
unsteady and slowed movement that might be due to her the pain he is currently having. There
has a relevant body due to his current condition which signifies that he doesnt have a good
hygienic ritual.

II. Psychological Presence

The client appears not properly groomed. Generally, the client is cooperative and pleasant. The
client responds to questions and command but not clear and understandable due to the pain he is
currently experiencing. The patient appears sleepy.
III. Distress
The client is experiencing epigastric pain. The face is not relaxed which shows the pain he is
currently experiencing; the client is not that much 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
The client has erythematous skin upon observation. The clients skin color is pinkish to reddish
in color and is uniform throughout his whole body as a manifestation of Psoriasis. 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).
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 brownish to black nailbeds. Upon observation, the patient has a brittle nails which
is also caused by his Chronic Illness. Cyanosis is not 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. Trachea is also at the midline.
XIII. Thorax and Lungs
The shape of the thorax is elliptical. The client doesnt use accessory muscles upon breathing and
has a normal respiratory rate for up to 20 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 80 which is normal. The client doesnt have any chest pain or
palpitations. The clients blood pressure is 120/70 mmHg.

XV. Breast
Breast has no any visible lumps, depression, or lesions visible. It is also equal in shape and
size.
XVI. Abdomen
The clients abdomen is round in shape with erythematous skin. It is also painful due to his
current condition which is UGIB.
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
The client has no problem in Genitourinary system.