Physical Assessment

In Partial Fulfillment
of the Requirements on NCM 203 RLE

Submitted to:

Mrs. Kristine Monica Reyes, RN

Clinical Instructor

Submitted By:

Tuansi, Al-Khusairy A.

BSN-1F

September 1, 2021
 A. BIOGRAPHICAL DATA

Name of Client: Aleezahran A. Tuansi

Age: 16

Gender: M

Ward/Unit: A/Medical

Bed No: C

Examiner: Al-Khusairy A. Tuansi

Home/Address: 9600, 121 Jose Lim Sr. St, Cotabato City, Maguindanao

Birth Date: October 21, 2021

Place of Birth: Cotabato City

Nationality: Filipino

Marital Status: Single

Educational Level: High School

Occupation: Student

No. of Dependents: 2

Religion: Islam

B. ADMISSION HISTORY

Chief Complaint: “My stomach is aching”

Admitting Diagnosis: Constipation

Admission Date: September 1, 2021

Ward/Room/Bed Number: A/303/C

Attending Physician: Al-Khusairy A. Tuansi

 C. HISTORY OF PRESENT ILLNESS

Symptoms experienced were fewer than three bowel movements a week, dry, hard,
and lumpy stool, and stomach ache. The onset of the constipation was that the
bowel movements became less frequent and stools became difficult to pass. The
duration of the pain and reaction towards the sickness happens at least three times a
day. The frequency can be stated as three bowel movements per day to one
movement every three days. It‟s not too severe but fewer than three bowel
movements per week occur. The region of the pain can be located at the lower right
abdomen. It hurt really badly all the way round to the back with pain on the right
shoulder. Some related symptoms are bloating and nausea. Precipitating and
palliative factors are dehydration and little to no activity. Some remedies or given
initial treatment before consultation are consumption of fibre, drinking a lot of water,
and taking over-the-counter prescription. Consultation was made when there was no
passing of stool for 4 days already at a nearby local clinic with the family doctor.

Notes:

It is important to consume foods rich in fibre such as fruits, vegetables, and whole
grains. Fibre promotes bowel movements and prevents constipation. Foods that are
low in fibre include high-fat foods, such as cheese, meat, and eggs.

D. PAST HEALTH HISTORY

Personal Medical History

- Gastritis, diagnosed July 2021. Patient was diagnosed when he presented to the
emergency room with stomach pain, loss of appetite, and heaviness of breathing. He
was treated with an antacid and histamine. The patient reported that the antacid
helped his symptoms significantly. He only continued on the histamine for 2 weeks,
as he did not feel it helped with his symptoms.

Others/ remarks:
Gastritis has many symptoms which effects the nutritional vitamin absorption in the
body. The PH acidity gastric juices are effected which results in poor absorption
values. If you had this disease for long time you see effect in the vision (Blurry
Vision) and Hair and skin. Poor Vision and Hair loss is aftereffect of having the
disease for prolong periods of time.

E. FAMILY HEALTH HISTORY

The genogram displays medical facts of each individual with medical genogram
symbols. What's more, an annotation frame is offered below the diagram so that
readers can understand this genogram with no confusion. For instance, heart
disease, diabetes and language problem are genetic illness. From the following
template you see clearly whether a person is disease gene carrier, dominance
patient or healthy .

F. GORDON’S FUNCTIONAL HEALTH PATTERNS

I.HEALTH PERCEPTION- HEALTH MANAGEMENT PATTERN

  Alee perceives his health to be reasonably good, not 100%, but fairly good for
his age. He stated he has always strived to live a healthy lifestyle and
believes that his performance as a student keeps his joy as he walks around
their home library countless times throughout the day where he attends online
classes. Although Alee takes medication for the management of chronic
gastritis, diagnosed in 2020, he feels that it is well controlled and does not
impact on his ability to perform his role at school, undertake housework or
participate is recreational activities with his family on weekends. When not
controlled, Chronic gastritis puts strain on the upper center abdomen,
damages lining in the stomach and damages the upper left abdomen,
resulting in a loss of blood if untreated. As Alee already suffers breathing
problems it is imperative his uric acid level is regularly monitored. Alee
regularly attends his doctor and believes it is important to adhere to any
recommendation or treatment administered by the doctor. He advised he
would be too scared not to do so in case something bad happened to him so
he complies implicitly. Although Alee would like to have private health
insurance they feel that it is too expensive. He is satisfied with the Medicare
system and believes it meets his needs adequately. The necessity of installing
aids or changing any aspect of their home to increase safety or prevent
accidents has not been necessary. He believes he is far from this stage of life
just yet and feels confident in his ability to manage his situation as is.

II.NUTRITIONAL METABOLIC PATTERN

 During a 24 hour period Alee usually consumes three main meals and rarely
has snacks during the day when working. He believes his studies influences
his eating pattern during the week as he only has a 30 minute lunch break
which leaves little time for large or extended meals. In the 24 hours prior to
the interview Alee consumed cereal, milk, water, yoghurt, orange juice, fruit,
vegetables and muffins. During the week he feels his diet to be balanced and
more than adequate. Alee is a Vegetarian, he has no food allergies but does
modify his diet regularly based on his body image and weight fluctuations.
Research suggests people who potentially suffer from a binge-eating disorder
have a history of weight fluctuations and obesity. On the weekend when he
spends a lot of time with his family and he admits he consumes more snacks,
fast food and foods considered to be empty of nutritional value such as potato
chips, lollies, ice cream and soft drink. Alee laughingly classes himself as a
“weekend social eater”. In an article, indicated, „people tend to eat more when
they are around friends and family than when eating with strangers‟. „Tooth
decay is primarily caused by circulatory changes, poor dietary habits and poor
mouth or dental hygiene, and as a result Alee has top dentures although they
do not inhibit his ability to eat nor restrict the types of food choices available to
him. There have been no significant changes to his diet as he has wanted due
 to the vegetarian menu he eats for his main meals, however he stressed that
he does overeat „rubbish food‟ with family. However, when questioned if this
overeating has primarily occurred since school, he sheepishly admitted it was
probably a lifelong habit. Sometimes he has noticed significantly lower energy
levels particularly in the afternoon but Alee believes this to be based on the
expectations of his studies rather than indications his nutritional intake is a
contributing factor. When queried if his Iron and Vitamin intake were sufficient
based on the fact he doesn‟t eat red meat Alee stated hr didn‟t think it caused
him a problem, nor had his Doctor ever mentioned any need for additional
supplements. Research has shown that people on a vegetarian diet get all the
iron they need by eating iron rich foods, including legumes, green leafy
vegetables and fortified breads/cereals although iron will be less available for
absorption than in diets which include meat. Hunt suggests, „vegetarians
should consider consuming vitamin C, or citrus fruits to improve absorption
ratios in order to balance out nutritional requirements‟. No issues were
identified in terms of hair loss, increased facial hair growth, skin disorders or
nail growth. Alee maintains a regular skin regime to promote health, elasticity
and prevent wrinkles. His skin appears well hydrated. Alee‟s hair and nails
were similarly maintained.

III. ELIMINATION PATTERN

 When reflecting on his voiding pattern Alee stated he voided approximately

three times per day dependent on his daily schedule and his fluid intake, and
about the same amount at home in the evening. Alee experiences problems
with bowel elimination and has utilised suppositories, supplements or other
medication for either constipation or diarrhoea. He uses his bowels twice a
day and believes the amount of fruit and vegetables consumed within his diet
coupled with his fibre based cereal every morning sufficiently meets his
needs. Alteration in elimination patterns can sometimes indicate signs or
symptoms of issues within the gastrointestinal system.

IV. ACTIVITY- EXERCISE PATTERN

 Exercise which keeps the heart pumping and working steadily for about 20
minutes per day improves fitness, reduces the risks of heart disease, obesity
and maintains mobility. As discussed in the health perception/health
management pattern Alee walks reasonable distances during the day at
around place of studying. In addition to the walking he attends gentle Exercise
Classes virtually twice a week. He feels he has sufficient energy to participate
in these classes and they form the basis of his regular exercise pattern.
V. SLEEP-REST PATTERN

 Alee says he thoroughly enjoys sleeping and will generally achieve 8-9 hours
per night which he thinks provides him with ample rest and recuperation from
his daily activities. The amount and quality of sleep decreases, however Alee
has neither noticed nor experienced any significant change to his sleep
pattern in many years. When Alee was approximately 10 years old he used to
sleep-walk but has since outgrown this problem. He states he awakens at 3
every morning „regular as clockwork‟ to go to the bathroom but experiences
little difficulty returning to sleep.

VI. COGNITIVE-PERCEPTUAL PATTERN

 The average brain shrinks approximately 5-10% in weight between the ages
of 20 and 90 resulting in a decrease in working memory, however, the brain
can adapt and grow new cells, but this is dependant on physical activity,
stimulation and learning (Santrock 2006). Alee believes the constant mental
and physical stimulation of his studies keeps his brain active as evidenced by
the successful completion of recent study. He is a keen crossword puzzler
and novel reader which he feels supports his cognitive functions. Of the five
sensors the most significant change has been to Alee‟s vision as he has more
computer exposure. Alee wears glasses for reading, computer work and
magnification for everyday activities. He has his vision tested every three
years and upgrades his eyewear as recommended by the Optometrist. Alee
has not noticed any change in his ability to smell, hear, or touch but admits to
a taste change from sweet to savoury flavours.

VII. SELF-PERCEPTION---SELF-CONCEPT PATTERN

 Of the most interest and focus, and highlighted throughout this assessment,
was Alee‟s image of himself. Although he states he is reasonably satisfied
with his current status in life and what he has achieved for himself and his
family, his perception of how he looks demonstrates issues around physical
dissatisfaction, possible low self-esteem and a lack of confidence in social
situations. Maintaining a positive self-image and feelings of self-worth is
essential in order to achieve successful transitions despite changing abilities
and limitations‟. He clearly states he doesn‟t feel too insecure however he
believes his weight issues affect his ability to feel confident when he pursues
recreational and social activities. Physical ideals and social stigma value a
thin body, which society symbolises as „people‟s ability to discipline their
appetite and restrain themselves from overeating‟. Alee states when he is
doing school and performing tasks which he perceives are within his
 capabilities he feels competent and happy within himself. It is only when he is
required to enter the social arena he is faced with unhappiness and dilemma
about his body image. Those who are overweight are subject to stigmatism for
being different and falling outside of the social norm. On occasion he will
refuse to go out with friends or feels upset about his selection of clothing and
fit, negatively believing he will be an embarrassment to friends and family due
to his size. When he does socialize outside of his immediate family circle he
tends to sit quietly and not draw attention to himself especially if the social
event has a number of well-dressed and slim people in attendance, and
particularly if he sees them as being of a similar age bracket to himself. A thin
body is viewed by society as the essence of beauty, sexual attractiveness,
social status, health and occasionally moral worth. In recent years Alee states
although he does not perceive himself as tired he admits to using his age as
an excuse to decline invitations to attend social functions based purely on the
fact that he is not comfortable with his body image.

VIII. ROLES-RELATIONSHIPS PATTERN

 Alee is a brother, son, and student. He enjoys close relationships with his
parents. Alee has a select group of friends but feels as a result of his studies
commitments during the week, coupled with family commitments, he has little
spare time to socialise with friends. He does not belong to any social groups
and mentioned that he thought social groups were a waste of his time. Some
factors may inhibit older people from pursuing recreational activities based on
a perceived poor usage of time, conditioning to appear busy, fears about the
future and the lack of previous opportunities to pursue a hobby or new
interest.

IX. SEXUALITY-REPRODUCTIVE PATTERN

 Alee has experienced little interest in being sexually active and cites a definite
loss of interest however he did indicate his sexual needs were „abundantly‟
met. Sexual desires fluctuate over the years with highs and lows, commonly
coinciding with major life changes. Alee says he has no problems, pain or
issues during sexual intercourse. He experiences no embarrassment when
openly discussing issues of a sexual nature, nor did he find it difficult to talk
about sex education. Alee believes due to it being a taboo subject with his
parents when growing up it has influenced him to be very. A good health
maintenance plan includes regular health screenings and examination. Alee
states he consciously adheres to preventative health measures.
X. COPING-STRESS TOLERANCE PATTERN

 The stress Alee feels when he is at school relates to his supervisor who Alee
states is not as the best as he would like. He does however have other
colleagues at school with whom he can debrief as required. He cites his family
as being his primary support and states they have always talked through as a
family any issues which may impact on his coping mechanisms. A recent
significant stressful event was grades and the subsequent fight with siblings
which occurred between him, his brother, and sister. Again his brother and
sisters were his primary means of support during this time although he did
consider accessing professional counselling. Being aware of what causes
stress, how you react and having a network of support are all strategies which
can help you to manage and control stressful events. Alee feels he has
accepted the outcomes from this event and moved forward. Alee does not
drink alcohol, use medication or take drugs to relieve stress but will comfort
eat and compensate with food on occasion resulting in weight gain and
subsequently poor body image and what he terms „mild undiagnosed
depression‟ which he says never lasts for very long.

XI. VALUES-BELIEFS PATTERN

 An individual‟s sense of spirituality can be influenced by culture, life

experiences and religious beliefs. Alee is a practicing Muslim and spiritual
person. His family and faith have always been the most important part of his
life. He has been muslim ever since and values his relationship with it. Recent
goals have included good grades on graduation and resettling into a newly
purchased family home which he feels have all been guided by his faith and
spiritual beliefs. He believes he has enjoyed a rewarding life and has always
been a „big, happy, bubbly person‟. As indicated in previous patterns Alee‟s
body image pervades all patterns of his life suggesting a lowered perception
of self.