I. ASSESSMENT

A. General Data

Name: Ms. X

Sex: Female

Address: Bacoor Cavite

Civil Status: Married

Age: 45

No. of Days in this Hospital: ER

Date of Admission: Aug 9, 2010

B. Chief Complaints

The client experience chest pain which she described as radiating from her

sternum area towards her xyphoid process lasting approximately for about

10-15 minutes which provoked her to go to the hospital.

C. History of present illness

A week prior to admission, client experienced generalized body weakness

and occasional radiating chest pain related to stress and fatigue. A day prior

to admission she claimed of same symptoms.

D. Past Medical History

Client was diagnosed about 10 years ago (year 2000) of Hypertension.

Client has a childhood illness of allergic rhinitis related to dust that is still

presently manifested.

Client hadn’t encountered any form of accident or serious injuries at the

moment.

E. Family History

Client claimed with familial history of hypertension (maternal side) and she

stated a link in the genealogy that manifested diabetes on her paternal side.

F. Physical Assessment

Date: August 9, 2010 Clinical Area: St. Dominic Medical Center

Initial vital signs:

T = 36˚C

CR = 120bpm

RR = 20cpm

BP = 130/90 mmHg

General Appearance

The patient is conscious, coherent and is not in distress. She looks

according to age and is calm and engaging. One can see that she is well

nourished and practices good hygiene.

Body Part

Assessed

Technique Used Actual Finding Interpretation

Skin

Head

Eyes

Inspection

Palpation

Inspection

Palpation

Inspection

Skin color is fair and even

Skin is smooth with fair skin turgor

Normocephalic

Evenly distributed hair, no dandruff,

lesions nor infection

Sinuses non-tender

Symmetrical eyelids

Pinkish conjuctiva

Anicteric sclera

Cornea and lens slighty cloudy

PERRLA

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Signs of Aging

Normal

Body Part

Assessed

Technique Used Actual Finding Interpretation

Ears

Nose

Inspection

Palpation

Inspection

Palpation

Normoset

No discharge

Non tender

No presence of mass or nodules

Symmetrical nasal folds

Nasal septum at midline

Mucosa is moist, pinkish, intact and

no discharge

Airways patent on both nares

Non tender sinuses

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Mouth

Pharynx

Neck

Inspection

Inspection

Inspection

Palpation

Lips pinkish and dry

Tongue at midline

Gums and mucosa pink

Presence of dentures

Uvula at midline

Tonsils not inflamed

Neck symmetrical with full ROM

Trachea at midline

Lymph nodes non tender

Thyroid gland non palpable

Normal

Normal

Normal

Aging

(decalcification)

Normal

Normal

Normal

Normal

Normal

Normal

Pulmonary Inspection

Auscultation

Symmetric

Clear lung sounds

No adventitious breath sounds

Normal

Normal

Normal

Body Part

Assessed

Technique Used Actual Finding Interpretation

Cardiovascular

Abdomen

Auscultation

Inspection

Palpation

Presence of palpitation

Flat and symmetrical

No lesions

No tenderness

Due to cardiac

compensation

Normal

Normal

Normal

Extremities Inspection

Palpation

Skin smooth

Skin intact

Nails convex curved

Pink nail beds

Normal capillary refill

Skin cool to touch

Bounding pulses

Muscles with slight atrophy

light muscle strength

Full active ROM

Normal

Normal

Normal

Normal

<3 sec.

Decreased

perfusion

Cardiac

compensation

Aging process

Normal

Normal

Motor

Sensory

Inspection 100% intact

12 cranial nerves responsive

Normal

Normal

Cardiovascular Disease

1.Decreased Cardiac Output

2.Ineffective Tissue

Perfusion

3.Impaired Gas Exchange

4.Acute Pain

II. OTHER SOURCES OF INFORMATION

A. Drug Study

NAME OF DRUG

(GENERIC AND BRAND

NAME)

CLASSIFICATION ROUTE MECHANISM OF ACTION

INDICATION NURSING RESPONSIBILITY

Nitroglycerin Vasodilator, Antianginal

Patch Decreases oxygen demand by decreasing preload and after load

To prevent or minimize anginal attacks before stressful events

1. Closely monitor V/S especially BP.

2. Applied to any non hairy parts of the skin except distal parts of the arms and legs.

III. Concept Map