Physical Assessment

● Gastrointestinal
○ Abdominal girth: 32”
○ Tenderness: Present
● Integumentary
○ Skin
■ Color: Brown
■ Odor: No foul odor
■ Skin turgor: < 3 seconds
■ Skin temp: Within normal range
○ Hair
■ Thick
■ Sign of infection: No sign of infection

○ Nails
■ Color: Slight pale
■ Cuved: < 180 degrees
■ Capillary refill: < 3 seconds
● Head
○ Skull
■ Rounded
■ Normocephalic
■ Symmetrical
■ Nodules: None
■ Masses: None
■ Depressions: None
○ Face
■ With few wrinkles
■ Nodule: None
 ■ Masses: None
○ Eyes
■ Eyebrows: With adequate amount of hair
■ Eyelashes: With adequate amount of hair
■ Eyelids: Present
■ Bulbar Conjunctiva: Yellowish
■ Sclera: Yellowish
■ Palpebral Conjunctiva: Slight pale
■ Tearing: None
■ Cornea: Clear
■ Pupil: Normal
■ Iris: Dark brown
■ Peripheral visual field: Far Peripheral vision
■ Extraocular muscle: Normal
■ Able to read 14 inches distance
○ Ears
■ Symmetrical
■ Color: Same with facial color
■ Height: Same both sides
■ Firm: Normal
■ Pinna recoil: Normal
■ Watch tick test: Positive
○ Nose
■ Symmetrical
■ Straight
■ Color: Same with facial color
■ Discharge: None
■ Flaring: None
■ Lesions: None
 ○ Mouth
■ Lips: Dark pink
■ Moist
■ Symmetrical
■ Smooth
■ Able to whistle
○ Teeth
■ Discoloration: Yellowish
■ Gums: Pinkish pale
● Neck
○ Muscle
■ Symmetrical
■ Coordinated
■ With smooth head movement
■ Lymph Nodes: None
■ Trachea: In the midline

● Lungs and Chest

○ Chest
■ Intact
■ Tenderness: No sign of tenderness
■ Masses: None
○ Expansion
■ Symmetrical
■ Quiet
■ Rhythmic
■ Effortless respiration
■ Thumb separate: 1cm
● Spine
 ■ Aligned
● Shoulder
■ Height: Same height both sides
■ Right shoulder: No masses
■ Left shoulder: With visible lump
● Heart
○ Aortic: Present with no visible pulsation
○ Pulmonic: Present with no visible pulsation

I. Gordon’s Functional Health Pattern

Date: March 11, 2019
Temperature : 36.5 ˚C
Pulse Rate : 74beats per minute
Respiratory Rate : 21breaths per minute
Blood Pressure : 110/80 mm Hg
Weight : 54 kilograms
Height : 5 feet 2 inches

Before Hospitalization During Hospitalization

● Patient verbalized Health Perception/Health ● Patient verbalized

that his viands are Management that he stopped
often the following: eating
- Processed food preservatives and
(hotdog, longganisa, continued eating
etc.) more vegetables,
- Vegetables fish, and
- Fish sometimes meat as
well
● Relative of patient ● Patient stopped
verbalized that the smoking and
patient used to drinking alcohol
smoke and drink ● Patient stopped
alcohol 5 years ago exercising due to
● Patient verbalized liver ascites
that he used to jog ● Patient is
twice a week hospitalized
● Patient stated that
he goes on regular
check-ups every
Saturday at a
government hospital

● Patient verbalized Nutritional/Metabolism ● Patient continued

that he eats to eat vegetables
vegetables and fish; and fish; seldom
seldom meat meat
● Patient verbalized ● Patient verbalized
that he drinks 8-12 that he drinks 8-12
glasses of water per glasses of water
day per day
● Patient’s weight is ● Patient’s weight
within normal range decreased from 54
kilograms down to
50 kilograms
● Patient verbalized Elimination ● Patient verbalized
that he would that he has
urinate after drinking difficulty in
fluids urinating

● Patient verbalized Activity/Exercise ● Patient verbalized

that his previous that he no longer
work is a form of exercises due to
exercise his ascites
● Patient verbalized
that he used to jog
twice a week

● Patient is married Sexuality/Reproductive ● Patient is

● Patient has 3 hospitalized
children
● He verbalized that
they do not have
problems with
intimacy

● Patient has a hearing Cognitive/Perceptual ● Patient has a

problem on his left current hearing
ear for 10 years now problem on his left
● Patient has no eye ear
problem ● Patient has not had
● Patient verbalized an eye
that he is a examination
kinaesthetic learner

● Patient is married Role/Relationship ● Currently plays the

● Patient has 3 role of patriarchal,
 children despite the
● Lives under one roof condition
with his family

● Patient would have Self-perception ● Patient verbalized

regular check-ups that he believes he
with his family will recover from
● Patient immediately his illness
consulted the doctor
when he noticed that
his abdominal girth
was slowly increasing
in size

● Patient is a Catholic Value/Belief ● Patient has a

● Patient verbalized strong faith in God
that he goes to ● Patient believes
Church with his that he will recover
family every Sunday from his illness
and special masses with divine
● Patient reads the interventions
Bible

● Patient verbalized Coping/Stress ● Patient verbalized

that his child’s that his child’s
academic achievements
achievements reduce reduce his anxiety
his anxiety level level

● Patient used to be Sleep/Rest ● Patient verbalized

well-rested all the that he
 time experiences
● Patient verbalized fatigue
that he is able to do ● Patient verbalized
daily activities that it takes at
without pain and least 3 hours
discomfort before he falls
● Patient verbalized asleep.
that it would take at
least 3 hours before
he fell asleep

● Patient used to take Medication History ● Patient is in proper

medications compliance of
(Quadtab) with medication
multivitamins regimen