A.

Demographic Data Name: Patient VM Address: San Jose Del Monte, Bulacan Age: 67 years old Birthdate: May 1, 1944 Sex: Female Marital Status: Single Religion: Roman Catholic Educational Level: High School Graduate B. Chief Complaint or Reason for Visit

Mabigat ang kaliwang paa at binti ko. as verbalized by the client.

C. History of Present Illness

The client stated that she couldnt remember how her illness started. She just said that her friend brought her to Emmaus in 2003 and by that time, she could barely walk. When she first consulted the doctor, she said that she couldnt feel anything into her leg. Another doctor said that she had a mild stroke. After few months, she consulted again the doctor and she was given maintenance medications for arthritis which she is still taking as of the moment. D. Past History of Illness

Patient VM has not been able to recall whether she completed the immunization when she was young. She doesnt have any allergies to food, medications and animals. She asks for medications to the volunteers whenever she feels sick.

E. Family History of Illness

As shown in the Genogram below, her mother died from cardiovascular disease. Her father died during a war when she was still young. She could not recall her grandparents because they were long gone. Some of her mothers siblings died because of heart attack. GENOGRAM

Father Side UR

Mother Side UR

UR

UR

LEGEND MALE FEMALE DECEASED CVD PATIENT UR UNRECALLED

JM DS

NS

WE

FS

MM = ++

LD

VM 67

Functional Health Pattern

The clients perception to her health has not been very good. On a scale of 1-10, she rated her health as 7/10. Ang bigat ng kanang paa ko kaya nahihirapan talaga akong kumilos. Ang bagal kong maglakad as verbalized by Patient VM. She said that there are times when she feels that she is too weak because of her foot and leg. It causes her pain at times too. She said that it is important that she eats healthy foods as well as she always tries to walk each morning to exercise her legs. 2. Nutritional and Metabolic Pattern Date January 4, 2012 January 5, 2012 January 6, 2012 Breakfast Lunch Dinner

Patient OD has a good appetite. She said that she consumes a large amount of water most especially when the weather is hot. She doesnt like to eat beans and monggo because it causes her pain in the legs. She doesnt have any food or eating discomforts and doesnt take any food supplement as well. 3. Elimination Pattern

The client urinates approximately 5 times a day. She said that at times, when she drinks a lot, she urinates more often. Her urine is usually clear, amber colored and is pungent. She has irregular bowel pattern. Sometimes, she defecates once a day but at times, it takes 2-3 days before she does. Her bowel is usually dark brown, formed and is aromatic. She doesnt perspire a lot and doesnt have odor problems.

4. Activity-Exercise Pattern She said that she has limitations in everything that she does. Because she couldnt walk without her walker, it takes time for her to move and to do things. Every morning, she goes out of the room and walks as she can to exercise her foot and leg. Most of the time she stays inside the room and shares stories with her room mates. 0- feeding 0- bathing 0- toileting 0- Bed mobility 0- grooming 0- ambulation 0- Dressing

*Level 0- Full self care Level 1- Requires the use of equipment or device Level 2- Requires assistance or supervision from another person Level 3- Requires assistance or supervision from another person or device Level 4- Dependent and does not participate 5. Sleep - Rest Pattern Day Time of Sleep Time awake Length of sleep

January 4 January 5 January 6 January 7 January 8 January 9 January 10

9:00 pm 9:00 pm 8:30 pm 9:00 pm 8:30 pm 9:00 pm 9:00 pm

3:30 am 3:30 am 3:30 am 4:00 am 4:00 am 4:00 am 3:30 am

6 hours 6 hours 7 hours 7 hours 7 hours 7 hours 6 hours

Hirap ako sa pagtulog minsan sa gabi dahil kay Lola Bonifacia. Maingay kasi siya minsan. as verbalized by the patient. She said that sometimes she has trouble with sleeping everytime Lola Bonifacia talks aloud in the evening. Nevertheless, whenever lola Boni is quiet, she has a continuous sleep in the evening. She sleeps at around 9 in the evening and wakes up at around 4 in the morning. At times, she takes naps in the afternoon for about 1-2 hours. 6. Cognitive Perceptual Pattern

Because of the aging process, patient VM has a slight hearing difficulty. She wears eyeglasses every time. She said that she experiences headache whenever she doesnt put her glasses on. Sometimes, she has trouble remembering things. She feels a little pain into her left leg at times. 7. Self Perception and Self Concept Pattern

When asked about how she would describe herself, patient VM said that she is just a simple person. Oftentimes, she feels good about herself. Her only problem is her left leg and foot. Also, she added that due to aging, she gets tired too easily. She needs time to rest after walking around the vicinity. She doesnt get angry or mad about things although Lola Bonis tantrums make her feel a little irritable whenever her sleep is disturbed. 8. Role Relationship Pattern

Patient VM lives alone in San Jose Del Monte Bulacan before being admitted to Emmaus. She doesnt have any siblings although she has good friends with her. Since she doesnt live with any family member, she solves her problems on her own. She had a good friend before, whom she shares everything with her but then she was fooled by her friend. Eventually, she was brought to Emmaus and was never visited again after few years. 9. Sexuality Reproductive Pattern

The client couldnt remember her first menstrual period. Also, she doesnt have a spouse and wasnt sexually active before.

10. Coping- Stress Pattern

She said that she doesnt feel tensed or stressed out oftentimes. She has good friends at Emmaus whom she can talk with or share her problems with. She feels lonely at times, but then she always makes sure that it doesnt affect her everyday life. 11. Value Belief Pattern Patient VM is a Roman Catholic. She makes sure that she gets out of her room every time a mass is held in the chapel. She was transferred at St. Francis form P. Daniel because she wanted to pray and attend the ceremonies in the chapel.

PHYSICAL ASSESSMENT
Clients Name: Patient VM Height: Weight: BMI = Vital Signs: Temperature: 36.2C Pulse rate: 78bpm Respiratory Rate: 23cpm Blood Pressure: 120/80 mmHg Date of Performance: January 5, 2012 Time of Performance: 4:00 pm

Parts to be Examined 1. GENERAL SURVEY Body built, height & weight in relation to clients age, lifestyle and health Clients posture and gait, standing, sitting and walking Clients overall hygiene and grooming Body and breath odor BEHAVIOR Signs of distress, in posture or facial expression Signs of health or illness Clients attitude Clients affect/mood; appropriateness of clients response Quantity of speech, quality Relevance and organization of thoughts 2. INTEGUMENTARY A. SKIN Color and uniformity of color

Technique Inspection Inspection

Normal Findings Proportionate, varies with lifestyle Relaxed, erect posture; coordinated movement Clean, neat No body odor or minor body odor relative to work or exercise; no breath odor No distress noted Healthy appearance Cooperative, able to follow instructions Appropriate to situation Understandable, moderate pace; clear tone and inflection; exhibit thought association Logical sequence; makes sense; has sense of reality Varies from light to deep brown; ruddy pink to light pink; from yellow overtones to olive

Actual Findings Proportionate. Curved posture, difficulty in walking

Interpretation Normal Deviation from normal due to aging and condition of the foot and leg Normal Normal

Inspection Inspection

She dresses cleanly, neatly and appropriately. No body odor or minor body odor relative to work or exercise; no breath odor No distress noted Healthy appearance She is very cooperative and able to follow instructions She responds appropriately and accordingly to every situation. Her speech is understandable, clear and has association of thoughts. Logical sequence; makes sense; has sense of reality Light Brown, Uniform in color

Inspection Inspection Inspection Inspection Inspection Inspection

Normal Normal Normal Normal Normal Normal

Inspection

Normal

Presence of edema Presence of lesion according to location, distribution, color, configuration, size, shape, type or structure Skin moisture

Inspection Inspection

Generally uniform except in areas exposed to the sun; areas of lighter pigmentation in darkskinned people No edema Freckles, some birthmarks, some flat and raised nevi; no abrasions or other lesions Moisture in skin folds and axillae (varies with environmental temperature and humidity and activity) Uniform; within normal range Skin springs back to previous state; has a good skin turgor Convex curvature; angle of nail plate about 160 No visible lines and cracks Smooth texture Highly vascular and pink in lightskinned people; dark-skinned may have brown or black pigmentation in longitudinal streaks Intact epidermis Prompt return of pink or usual color

Has no edema No lesion, birthmarks and freckles noted, Moisture in skin folds and axillae

Normal Normal

Inspection

Normal

Skin temperature Skin turgor B. NAILS Fingernails shape, curvature and angle Fingernail and toenail texture Fingernail and toenail bed color

Inspection Inspection Inspection Inspection Inspection

Her skin temperature is warm and uniform but within normal range. She has a good skin turgor. Her nail has a convex curvature approximately 160. She has a smooth nails without any damages. Pink color

Normal Normal Normal Normal Normal

Tissues surrounding nails Blanch test of capillary refill 3. HEAD A. SKULL

Inspection Palpation

She has an intact epidermis with no hangnails. Prompt return of usual color

Normal Normal

Size, shape and symmetry Presence of nodules, masses and depressions B. SCALP Color and appearance Areas of tenderness C. HAIR Evenness of growth, thickness and thinness Texture, oiliness over the scalp D. FACE Facial features, symmetry of facial movements 4. EYES A. EYEBROWS Evenness of distribution and direction of curl B. EYELASHES Evenness of distribution and direction of curl C. EYELIDS Surface characteristics, position in relation to the cornea, ability to blink and frequency of blinking D. CONJUNCTIVA Bulbar Conjunctiva for color, texture and presence of lesions Palpebral Conjunctiva for color, texture and presence of lesions

Inspection Palpation Inspection Palpation Inspection Palpation Inspection

Rounded (normocephalic); smooth skull contour Smooth, uniform consistency; absence of nodules and masses Usually white but it also depends on dark-skinned people No tenderness Evenly distributed thick hair Smooth texture; no oiliness Symmetrical facial features and movements Hair evenly distributed and the curl is outward Equally distributed; curls slightly outward Skin intact; no discharge or discoloration; Lids closed symmetrically approximately 1520 involuntary blinks per minute Transparent; capillaries sometimes evident; Shiny, smooth and pink or red

Skull is rounded and has a smooth skull contour. Have no nodules and masses. The scalp is lighter than the color of her facial skin and has no dandruff. No tenderness Hair not evenly distributed Smooth texture; no oiliness Has a symmetrical facial feature which has symmetrical movements. Has evenly distributed hair in her eyebrow and they are aligned with equal movement. Her eyelashes are equally distributed and curled outward She has smooth eyelids with no discharge; lids closed symmetrically

Normal Normal Normal Normal Deviation from normal due to aging Normal Normal

Inspection

Normal

Inspection Inspection

Normal Normal

Inspection Inspection

Her Bulbar Conjunctiva is transparent and has some visible small capillaries. Has shiny, smooth and pink palpebral conjunctiva.

Normal Normal

E. SCLERA Color and clarity F. CORNEA Clarity and texture G. IRIS Shape and color

Inspection Inspection Inspection

Sclera appears white Transparent, shiny and smooth; the details of iris are visible Rounded shape which are the same in each eye; color varies depending on the race and the color is evenly distributed Brown in color, equal in size and smooth border Able to read newsprints Illuminated pupils constricts Pupils also constricts when looking at near objects, dilate when looking at far objects and converge when near object is moved toward the nose

Has white sclera. Has a transparent, shiny and smooth cornea. Has a dark brown iris which is uniform and they are both rounded.

Normal Normal Normal

H. PUPILS Color, shape and symmetry of size I. VISUAL ACUITY Near Vision J. PUPILS Light reaction and accommodation

Inspection Inspection Inspection

Her pupils are brown, equal in size and have smooth borders. Has been able to read newsprints with eyeglasses on. Pupils constrict when light passes and it also converge when near object is moved toward her nose.

Normal Deviation from Normal due to aging Normal

5. LACRIMAL GLAND / SAC & NASOLACRIMAL DUCT Lacrimal Gland A. EXTRAOCULAR MUSCLES Alignment and coordination B. VISUAL FIELD Peripheral visual fields

Inspection and palpation Inspection Inspection

No edema, tenderness or tearing Both eyes coordinated, move in unison, with parallel alignment When looking straight ahead,

There is no edema, tenderness and tearing noted from the client. Her both eyes are coordinated; move in unison with parallel alignment. She can see objects in the periphery.

Normal Normal Normal

client can see objects in the periphery 6. EARS A. AURICLES Color, symmetry of size and position Inspection Color same as facial skin; symmetrical; auricle aligned with outer canthus of eye about 10 vertical Mobile, firm and not tender; pinna recoils after being folded Dry cerumen, grayish-tan color, sticky or wet cerumen in various shades of brown Normal voice tones audible Able to hear ticking sound in both ears Symmetric and straight; no discharge or flaring; uniform color Mucosa pink; clear watery discharge; no lesions Nasal septum intact and in midline Air moves freely as the client breathes through the nares Not tender Her ears skin color is same as the surrounding skin and both are symmetrical; the auricles are aligned in the outer canthus of each eye. Her auricles are mobile, firm and not tender; her pinna recoils when folded. She had no visible cerumen, has a grayish color. Can respond to normal voice tones. Can hear ticking sound in both ears. Nose is uniform in color same as with the surrounding skin; there are no discharge and flaring. Has no apparent lesions. Her nasal septum is in the middle. Her nasal cavities are patent. There is no tenderness, masses or displacement of bones and cartilage. Normal

Texture, elasticity and areas of tenderness B. EXTERNAL EAR CANAL Cerumen, skin lesions, pus and blood C. HEARING ACUITY TESTS Clients response to normal voice tone Watch tick test 7. NOSE Deviations in shape, size or color and flaring or discharge Nasal cavities for presence of redness, swelling, growths and discharge Nasal septum between the nasal chambers Patency of both nasal cavities Tenderness, masses and displacement of bones and cartilage SINUSES

Palpation Inspection

Normal Normal

Inspection Inspection Inspection Inspection Inspection Inspection Palpation

Normal Normal Normal Normal Normal Normal Normal

Tenderness 8. MOUTH A. LIPS Symmetry of contour, color and texture B. BUCCAL MUCOSA Color, moisture, texture and presence of lesions C. TEETH Color, number, condition and presence of dentures D. GUMS Color and condition E. TONGUE/ FLOOR OF MOUTH Color and texture of the mouth and frenulum Position, color and texture, movement and base of tongue Presence of nodules, lumps or excoriated areas F. PALATES AND UVULA Color, shape, texture, and presence of bony preminences Position of uvula and mobility while examining the palates. G. OROPHARYNX AND

Palpation Inspection

Not tender Uniform pink color, soft, moist, smooth texture, symmetry of contour, ability to purse lips Moist, smooth, soft, glistening and elastic texture 32 adult teeth; smooth, white and shiny tooth enamel Pink gums; moist and firm texture to gums; no retractions Central position; Pink color, moist, slightly rough; thin whitish coating, lateral margins; no lesions; raised papillae Moves freely; no tenderness; smooth tongue base with prominent veins Smooth with no palpable nodules Light pink, smooth, soft palate Lighter pink hard palate, more irregular Positioned in midline of soft palate

Her sinuses are not tender. Uniform pink color, soft, symmetry of contour, ability to purse lips She has a moist, soft, elastic texture of her buccal mucosa. She has false teeth. Pink gums; moist and firm texture to gums; no retractions Her tongue is in the center, pink in color, it is moist, slightly rough without lesions; it has a thin whitish coating and lateral margins. Her tongue moves freely without tenderness. It has no nodules. Has a light pink and smooth soft palate while lighter pink and irregular hard palate. The uvula is in the middle.

Normal Normal

Inspection Inspection Inspection

Normal Deviation from normal Normal

Inspection

Normal

Inspection and palpation Palpation Inspection Inspection

Normal Normal Normal Normal

TONSILS Color and texture Size of tonsils, color and discharge Presence of Gag reflex 9. NECK A. LYMPH NODES Lymph Nodes and tenderness B. TRACHEA Placement C. THYROID GLAND Symmetry and visible masses Smoothness, enlargement and nodules 10. THORAX A. POSTERIOR Shape, symmetry, compare the diameter of anteroposterior to transverse diameter Spinal alignment Temperature, tenderness and masses B. ANTERIOR Breathing patterns Temperature, tenderness and masses 11. CARDIOVASCULAR Aortic and pulmonic areas Tricuspid area

Inspection Inspection Inspection Inspection and palpation Inspection and palpation

Pink and smooth posterior walls Pink and smooth; no discharge; of normal size Gag reflex is present Not palpable Central placement in midline of neck; spaces are equal in both sides Not visible on inspection Glands ascends during swallowing; painless, centrally located and smooth Chest symmetric; anteroposterior to transverse diameter in ratio of 1:2 Spine vertically aligned Skin intact; uniform temperature Quiet, rhythmic and effortless respiration Skin intact; uniform temperature No pulsation No pulsation; no lift or heave

Pink and smooth posterior walls Pink and smooth; no discharge; of normal size She elicit gag reflex. Lymph nodes are not palpable Trachea is in the middle with spaces on both sides. It is not visible. Thyroid glands rise when swallowing; it is smooth and painless.

Normal Normal Normal Normal Normal

Inspection Palpation

Normal Normal

Inspection Inspection Palpation Inspection Palpation Inspection and palpation Inspection and palpation

Her chest is symmetric spine vertically aligned skin is intact and has uniform warm temperature Quiet, rhythmic and effortless respiration Her skin is intact and has uniform warm temperature. No pulsation No pulsations or lift and heave.

Normal Normal Normal Normal Normal Normal Normal

Apical area Epigastric area Auscultate aortic, pulmonic, apical, tricuspid and epigastric area 12. CAROTID ARTERIES Palpate with extreme caution Auscultate the carotid arteries 13. JUGULAR VEINS Presence of veins 14. ABDOMEN Skin integrity Abdominal contour Enlarged liver or spleen Symmetry of contour Abdominal movements Vascular patterns Bowel sounds, vascular sounds and peritoneal friction rubs Percuss in each quadrants Light palpation of quadrants 15. MUSCULOSKELETAL A. MUSCLES

Inspection and palpation Inspection and palpation Auscultation

Some pulsations visible; no lift or heave Aortic pulsations S1-usually heard at all sites but louder at the apical area S2-usually heard at all sites but louder at the base of heart Symmetric pulse volumes; full pulsations No sounds heard Veins not visible

There are some pulsations felt but there are no lifts or heave. Aortic pulsations present There are heart sounds heard in all sites.

Normal Normal Normal

Palpation Auscultation Inspection Inspection Inspection Inspection Inspection Inspection Inspection Auscultation Percussion Palpation

His carotid artery has a full symmetric pulse volumes and pulsations. No sound heard Veins not visible

Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal

Unblemished skin, uniform color Unblemished skin, uniform color Flat, rounded or scaphoid Has flat abdomen. No evidence of enlarged liver and There are no evidence of enlarged liver spleen and spleen. Symmetric contour Has a symmetric contour. Symmetric movements caused by Has symmetric movements because of respiration respiration. No visible vascular patterns There are no vascular patterns seen. Audible bowel sounds; absence Audible bowel sounds; absence of of arterial bruits and friction rub arterial bruits and friction rub Tympany over stomach and gasThere is tympany over her stomach filled bowels; dullness over the and dull sound over her liver and liver and spleen or full bladder spleen. No tenderness, relaxed abdomen There is no tenderness; she has a with smooth, consistent tension relaxed abdomen with consistent tension.

Size, comparison on one side to other side Contractures Fasciculation and tremors Muscle tonicity Muscle strength B. BONES Normal structure and deformities Edema and tenderness C. JOINTS Swelling Tenderness, smoothness of movements, crepitation and nodules D. RANGE OF MOTION Upper Extremities Lower Extremities

Inspection Inspection Inspection Palpation Inspection and Palpation

Equal size on both sides of the body No contractures No tremors Normally firm Smooth coordinated movements

Has equal muscle size on both sides of the body. Have no contractures. Have tremors. has soft muscle Has greater muscle strength in the right side of the body Have no deformities. Have no edema, swelling at the left foot and leg There is no swelling. There is no tenderness, swelling, crepitation or nodules. Joints move smoothly She has difficulty in moving her joints

Normal Normal Deviation from normal due to aging Deviation from normal due to aging Deviation from normal due to condition of the left leg and foot Normal Deviation from normal due to condition of the left leg and foot Normal Normal Normal Deviation from normal due to condition of the left lower exteremity

Inspection Palpation

No deformities No tenderness or swelling

Inspection Palpation Inspection Inspection

No swelling No swelling, tenderness, crepitation or nodules Joints move smoothly Joints move smoothly