CHINESE GENERAL HOSPITAL COLLEGE OF NUSING HISTORY AND PHYSICAL ASSESSMENT

Name: L.S. Age: 89 y/o Address: Hospicio de San Jose

Date Admitted: April 1985 Birth Date: July 19, 1925 Religion: R. Catholic

Unit/Bed no.: 7 Sex: Female Civil Status: Single

Medical diagnosis/clinical impression: Optic Neuropathy & Hip Fracture Operation done (if any): - exploratory laparotomy 2000 - Post Left Hip Pinning Surgery 2005 Chief complaint: N/A Past Health History: Patient received complete immunization. And cannot remember any childhood sickness. (-) HPN (-) DM (-) Asthma History of Present Illness during june 27, 2005 patient accidentally slipped on the floor hitting her bittocks, with loss of concousness. On the socong day hospitalization, hip pinning was done. Family Health History (-) HPN (-) Asthma (-) DM I. General Physical Assessment and Cranial Nerve Testing Vital Signs: T 36.2 0C P 84 R 20 BP 100/70

Physical appearance/ posture/ body movements/ hygiene/ nutritional status: Patient is wheelcahir bound in a proper sitting position. Has an appropriate expression of the face. The skin is pale and dry. Patient has limited body movements. No body odor upon assessment. Patient is taking a bath once a day every morning and is wearing a diaper. They eat cracker, fruit, vegetables, poultry and meat. Level of consciousness/ facial expression/ mood and affect/ speech/ gait: Upon interview, the patient is coherent and able to answer the questions asked to her. The patient cant stand up and walk. Skin: Clients skin is fair color. Skin is cold and dryn upon palpation. No presence of edema and lesion. Freckles is seen on the skin. Head: Head is round, no lesion and infestation. Hair is grayish to white in color. No palpable lymph nodes.

Neck & shoulders: Neck and shoulders are symmetrical. Lymph nodes are non palpable. No lesions and edema. Eyes: Eyes are symmetrical. Bilateral pupils constrict simultaneously. Pupil constricts simultaneously. The eyes are still with slight movement. Eyelids close symmetrically. Eyelashes are evenly distributed and are slightly curled outward. Sclera is white. Iris is dark brown. Iris of the left eye is grayish in color. Lens not inserted due to sudden change of pressure on the right eye. Client can no longer see objects. Ears: Position of ears are symmetrical, at eye level. Ears are equally aligned to each other upon inspection. No dryness and lesion upon assessment. The client is free from excessive cerumen, foreign body, and odorous discharges. Normal voice is heard at both ears. Nose: Alignment and symmetrical upon inspection. There is no tenderness of the maxillary sinuses. No difficulty in breathing. Mouth and throat: Lips are pink but dry. Buccal mucosa is moist with no presence of lesions and redness. Tongue has whitish to pink color with no lesion and any sign of inflammation. Client was able to move her tongue. Tonsils has no inflammation and any lesions seen. Has gag reflex. Uvula is at the center with no signs of inflammation and lesion. Chest: Breast are saggy. No tenderness when palpated with no other signs of inflammation. There were no retractions. The client does not use accessory muscles in breathing. There is no palpable crepitus. There is no adventitious sound heard upon auscultation. Abdomen: The abdomen was slightly protruded; scar was seen in the abdomen with no rashes and lesion. No tenderness when palpated. Genitalia and anus: The perineum has no rashes, lesions and signs of inflammation observed. Anus is intact, no tenderness and lesion. Cannot perform other assessment in the genitals because patients legs are difficult to move to the side. Extremities: Both upper and lower extremities were symmetrical in length and size. Number of fingers and toes are equally complete. Nail bed is pink and normal capillary refill. Extremities are slightly cold to touch with no lesion. Positive tenderness on the left leg when palpated. Other extremities has no tenderness and free from any signs of inflammation Spine: Clients spine is slightly curved outward. II. Other Significant health patterns Sleep Pattern: There is a sleeping schedule that is scheduled in the instituion. Client wakes up early in the morning at 6am. Takes a nap in between meals and feels asleep when client has no one to take to. Activity and Exercise: The client is wheelchair bound and has limited movements. Patients is routinely exercising every morning using active range of motion which the client can follow even without seeing the actual exercise. Physical therapist is also assigned to perform a range of motion. Activities also include prayers and novena.

Nutrition: Patients are receiving rice and different dishes composed of soups, meat, chicken, fish and vegetable. Crackers, biscuits and mamon are available for merienda. Client has lactose intolerance and was not able to eat milk or other dairy products. Work: The client is working with the nuns in school and heping children to have supplies. However, client was not able to work in present time because of the condition. Rest and recreation: According to the patient the only recreational activity she considers is that they attend masses and they pray novenas. She rest whenever she feels tired by sleeping. Elimination: The patient uses diapers for urinating and for defecating. Usually consumes 2 diapers per day and 1 diaper with stools. Diapers are changed by the care giver or the nurses on duty.