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 hadnt 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 = 36C
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

Technique

Actual Finding

Interpretation

Assessed
Skin

Used
Inspection

Skin color is fair and even

Normal

Palpation

Skin is smooth with fair skin

Normal

turgor
Head

Inspection

Normal
Normocephalic

Normal

Evenly distributed hair, no

Eyes

Palpation

dandruff, lesions nor infection

Normal

Sinuses non-tender
Inspection

Normal
Symmetrical eyelids

Normal

Pinkish conjuctiva

Normal

Anicteric sclera
Cornea and lens slighty cloudy

Signs of Aging
Normal

PERRLA

Body Part

Technique

Assessed

Used

Actual Finding

Interpretation

Ears

Inspection
Palpation

Nose

Inspection

Normoset

Normal

No discharge

Normal

Non tender

Normal

No presence of mass or nodules

Normal

Symmetrical nasal folds

Normal

Nasal septum at midline

Normal

Mucosa is moist, pinkish, intact

Normal

and no discharge

Mouth

Palpation
Inspection

Airways patent on both nares

Normal

Non tender sinuses

Lips pinkish and dry

Normal
Normal

Tongue at midline

Normal

Gums and mucosa pink

Normal

Presence of dentures

Aging
(decalcification)

Pharynx

Neck

Inspection

Uvula at midline

Normal

Tonsils not inflamed

Normal

Inspection

Neck symmetrical with full ROM

Normal

Palpation

Trachea at midline

Normal

Lymph nodes non tender

Normal

Thyroid gland non palpable

Symmetric

Normal
Normal

Clear lung sounds

Normal

No adventitious breath sounds

Normal

Pulmonar

Inspection

Auscultation

Body Part

Technique

Assessed

Used

Actual Finding

Interpretation

Cardiovasc

Auscultation Presence of palpitation

ular

Due to cardiac
compensation

Inspection

Flat and symmetrical

Normal

No lesions

Normal

Palpation

No tenderness

Normal

Inspection

Skin smooth

Normal

Skin intact

Normal

Nails convex curved

Normal

Pink nail beds

Normal

Normal capillary refill

<3 sec.

Abdomen

Extremities

Palpation

Skin cool to touch

Decreased

Bounding pulses

perfusion

Muscles with slight atrophy

Cardiac

light muscle strength

compensation

Full active ROM

Aging process
Normal

Motor

Inspection

Sensory

II.

100% intact

Normal
Normal

12 cranial nerves responsive

Normal

OTHER SOURCES OF INFORMATION

A. Drug Study

NAME OF CLASSIFICATI ROUT MECHANIS INDICATIO

DRUG
ON
E
M OF
N
(GENERIC
ACTION
AND
BRAND
NAME)
Nitroglyce Vasodilator,
Patch Decreases To prevent
rin
Antianginal
oxygen
or minimize
demand by anginal
decreasing attacks
preload and before
after load
stressful
events

III.

NURSING
RESPONSIBILITY

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.

Concept Map

1.Decreased
Cardiac
Output

Cardiovascular
Disease

2.Ineffective
Tissue
Perfusion

3.Impaired
Gas Exchange

4.Acute Pain