DE LA SALLE LIPA

COLLEGE OF NURSING
1962 J.P. Laurel National Highway, Lipa City
Tel. (043)756-5555, 756-2491, 756-2391 loc 270

Date of Assessment: December 15, 2010

Patient History & General Information

Name of Patient: Patient SEMISTROKE Age: 65y/o Sex: Male
Marital Status: Married Religion: Catholic Date/Time Admitted: 12-14-10 2pm
Information Provided by: Client assisted by his wife

History of the Present Illness

Chief Complaint:
Elevated blood pressure (130/90) with left sided body paralysis
Summarized Current Illness Episode:
Prior to admission, the client complained of numbness and weakness
on the left side of his body in particular with moving his left shoulder and left leg.
According to the client, his check up was supposedly the next day but they had
decided to visit LMMC a day earlier than what is scheduled due to numbness
and hypertension. Hence, the client was admitted to LMMC 2 in the afternoon.

Initial Vital Signs: Temp: 36.4°C PR: 74 bpm RR: 26 breaths/min BP: 110/80
Height: 5’5 inches Weight: 78 kg.

Past Medical History

Family History: Mother side: Stroke Father side: Stroke, Hypertension
Past Medical & Surgical History:
According to the client as supported by the significant others, the client
has had a semi-stroke dated April 23, 2010 with paralysis on the left side of his
body and being unconscious for less than a day.

Food/Drug Allergies
No known allergies to foods and drugs

Biophysical, Psychosocial & Functional Assessment

SYSTEM FINDINGS
 • Observed conscious and coherent

Neurological Assessment • Responds to questions asked; displays no difficulty in speaking

• Oriented/perceptive to time, place and events
• GCS score of 14 points
• Pupils equally reactive to light and accommodation

• Radial pulse of 74 beats per minute

Cardiovascular Assessment • Heart rate of 74 beats per minute
• Skin temperature not excessively warm nor cold to touch
• Capillary refill test: color return less than 2 seconds

• Respiratory rate of 26 breaths per minute

Respiratory Assessment • Quiet, rhythmic and effortless respirations
• No intercostals retraction or use of accessory muscles
• Auscultated normal breath sounds: vesicular, broncho-vesicular
and bronchial breath sounds

• Symmetric movements caused by respiration upon inspection

• Audible bowel sounds (normoactive) 11/min upon auscultation
Gastrointestinal Assessment
• Tympany over the stomach and gas-filled bowels as percussed
• No tenderness, relaxed abdomen with smooth, consistent
tension upon palpation
Integumentary Assessment
• IV site @ the right dorsum of the hand
• Light brown skin color was inspected uniformly
• No edema; when pinched, skin springs back slowly to previous
state due to aging

• Equal size on both sides of the body

• With flaccidity/muscle weakness on the left shoulder and left leg
Musculoskeletal Assessment • With grade 2 muscle strength on the left side of body: 25% of
normal strength; full muscle movement against gravity but with
support

Genitourinary Assessment
• Urinates 3 times within the shift
• Yellowish-colored urine
• Do not have difficulty in urination

Reproductive/Sexuality Assessment
• The client refused his reproductive system to be assessed.
• In sexuality, the client is a father to his 3 children and sexually
identified himself as a man

• Has a good eye contact with the examiner

Psycho/Social Assessment • Communicates well and responds to the questions being asked
• Cooperates during assessment
• Attentive to the health teachings

Pain Assessment

Do you have pain now? NO

Have you had pain in the past weeks or months? NO

If yes,

a. Pain location

b. Pain description

c. Pain intensity-adult scale (NO PAIN) 0 1 2 3 4 5 6 7 8 9 10 (WORST PAIN)

d. Duration

e. What helps the pain?

_______________________________________________________________________________

f. What aggravates the pain?

_______________________________________________________________________________
_______________________________________________________________________________

Activities of Daily Living Assessment

ADL Needs
a. Hygiene & Grooming: do not take a bath regularly, body odor, brushes teeth 2x a day, poor groom
b. Activity: before admission: listening to radio, sleeping, upon admission: lying in bed, sleeping
c. Nutrition: ate three times a meal with rice, common viand: fish, vegetables, pork
d. Toileting: irregular bowel movement, 4 times a week
e. Sleep: 7-8 hours of sleep at night, do not take a nap every afternoon, irregular pattern of sleep

Sensory Deficits
a. Vision has no impaired vision,
b. Hearing experienced difficulty in hearing questions and asks to repeat some of the questions
c. Speech speaks clearly and in moderate tone
d. Other _________________________________________________________________________

Assistive Device/s Used

____________________________________________________________________________________

Cultural Spiritual Assessment

A. Are there any spiritual, traditional, ethnic or cultural practices that need to be part of your client care?
___No____
B. Is there any way the nurse can assist you with your religious / spiritual practices? Pray for the
betterment of client
C. Would you like to be visited by the hospital chaplain?
____No_________________________________________
Assessed by:
GATERA, Jad Paulo C.