Episcopal Diocese of Southern Philippines

BRENT HOSPITAL AND COLLEGES INCORPORATE

R.T. Lim Blvd., San Jose, Zamboanga City
S.Y. 2023-2024

PHYSICAL ASSESSMENT
PEDIATRICS AND GERIATRICS

Submitted by:
Sulaiman,Fairuza B.

Submitted to:
Ron Danwen Dime RN, MAN
Clinical Instructor

2024
 Episcopal Diocese of Southern Philippines
BRENT HOSPITAL AND COLLEGES INCORPORATE
R.T. Lim Blvd., San Jose, Zamboanga City
S.Y. 2023-2024

PHYSICAL ASSESSMENT (GERIATRIC )

Biographic data

NAME: Rosalinda F. Capistrano

AGE: Seventy-three years old
SEX: Female
BIRTHDATE: August 26, 1950
CIVIL STATUS: Married
RELIGIOUS AFFILIATION: Islam
ETHNIC GROUP: Muslim
HOME ADDRESS: Luyahan Housing, Pasonanca Zamboanga City
NAME OF SPOUSE: Benedict Luna
NUMBER OF CHILDREN: Three
DATE HOME VISIT: May 26, 2024

I. Family Health History:

The client has a family history of hypertension and diabetes mellitus as mentioned.

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II. Past Medical History:
The client was admitted to Zamboanga City Medical Center for one week due to chest
pain and high blood pressure last 2020.

III: Present Health Condition:

Whenever she moves around, the customer reports of discomfort in her right ankle due to
she fells down in their upstairs six months ago. In addition, the client has elevated blood
pressure and is visually impaired.

A. PHYSICAL ASSESSMENT

General Appearance:
Throughout the examination, the client looked presentable in general. The client has a friendly
smile on their face. She was cooperative and provided a comprehensive response to the question
without hesitation. She showed no symptoms of distress.

Assessment of the head

The head is 50 centimeters in diameter, round, smooth-contoured, and shows symmetrical. There are no
lesions, edema, or swelling observed. The hair is straight, smooth, and colored black and white. Its
structure is also merely thin. The hair is uniformly spaced on both sides and is located in the center of the
scalp. Furthermore, it is free of dandruff and pediculosis. Upon inspection, the forehead appears to be
free of masses and abnormalities with few scars. When the forehead is lightly palpated, there is
no pain as stated by the client and wrinkles appear when the face displays emotion.

Assessment of the eyes

The structure and form of the eyelids are symmetrical in both eyes. Both eyes' upper eyelids are
normal. The eye movement is steady and regular. The sclera are white, the iris is pure brown,
and the pupils contract when light enters the eye. Wrinkles are present in the eyes, but there are
no lesions, masses, or inflammation. The customer maintains normal vision and can see the chart
from 20 feet away without the need for reading glasses. They can also recognize small items.
The eyebrows are shaped differently and asymmetrical. Although the hair is not evenly
distributed, no lesions or scars are visible upon a closer inspection

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Assessment of the ears

The client's auricle is symmetrical in size and position, with an olive tint that complements her
skin tone. There are no malignancies, anomalies, or tenderness and it is smooth texture. When
speaking in a normal voice, the client is completely alert and able to repeat the phrases during the
the whispers test.

Assessment of the nose

There are no discharges and the nose appears clean upon inspection. The client reports no pain
upon light palpation, and there are no malignancies, lesions, or masses in the nose. When one
nostril is occluded the patient is able to breathe in and out continuously.

Assessment of the mouth, lips and throat

The lips are dry and have a faint pale color. The lips are of normal size and are free of any sores,
lesions, or scars. The client wears dentures, accordingly her teeth are no longer complete and
clean. Her tongue and gums are both pink in color, and there are no lesions, edema, or bleeding
present. There are no anomalies or lesions visible in her throat and it is pink and smooth in color.
The client has no issue or pain when extending her tongue out.

Assessment of the neck

The neck does not have edema, scars, and lesions and is symmetrical in shape. The patient did
not experience any pain or struggles when the neck was lightly palpated.
.

Assessment of the chest

There are no abnormalities like scoliosis or barrel chest, the chest and back have a regular shape.
The client's respiratory pattern is normal upon auscultation. The client's apical pulse is within
normal limits and breathing is not difficult for her.

Assessment of the breast

The overall shape of the breast is symmetrical, and the areola has a dark brown contour. A light
circular palpation shows no lumps or soreness, There is no any discharges on the nipples.

Assessment of the axilla

The axilla has thin hair and, when lightly palpated, shows no lesions, scars, or lumps. The client's
skin tone and the axilla's shade match.

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Assessment of the abdomen
The abdomen's overall shape is flat, and scars are undetectable. Auscultation of the abdomen
reveals an ordinary bowel sound, which is low-pitched.

Assessment of the genitals

The client refused to be assessed and examine on these parts.

Assessment of the anus

The client has no perineal abscess, lesions, hemorrhoids and rashes.

Assessment of the lower extremities

The client's right ankle’s fracture makes it difficult for her to lift her legs, but when I touch
something on her lower extremity, she can describe its texture and temperature.

Assessment of the skin

The client's skin is olive, and upon inspection, I found no scars. She does have little hair on her
upper and lower limbs.

Assessment of the musculoskeletal

The client's right ankle’s fracture makes it difficult for her to walk rapidly, but she does have
strength when she squeezes the examiner's hand.

Assessment of the neurologic system

The customer is able to talk regularly and with clarity while indicating. The client is prepared for
the assessment and has a thorough awareness of the matters that need to be assessed.

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B. NURSING PATIENT INTERACTION
PERSON TYPE OF
DIALOGUE COMMUNICATION RATIONALE
INTRODUCTORY
PHASE
SN: Hello po, Broad opening This technique
ma’am! is designed to
Magandang facilitate
araw po. I am communication
Fairuza and build
Sulaiman po na rapport,
nag-aaral sa allowing
Brent Hospital patients to share
and Colleges more
Incorporated. information
about their
GP: Hello Ma’am! condition,
experiences,
Ma’am maaari and needs.
SN: ko po bang Broad-opening
hingin ang oras
nyo at mayroon
po akong
konting
katanungan
tungkol po sa types of
health nyo at questions create
pwede ko po ba a supportive
kayong i-assess environment
from head to toe where patients
po? feel heard and
understood,
Ah. Sige which can
GP: Ma’am! improve the
overall quality
of care and
patient
satisfaction.
WORKING

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PHASE
SN: Kamusta po Open-ended question These questions
kayo ngayon are designed to
ma’am? Pwede encourage
po bang patients to
malaman kung elaborate on
may their feelings,
nararamdamang experiences,
sakit po kayo sa and concerns,
katawan? promoting a
more in-depth
GP: Ayos naman, and meaningful
eto may mga dialogue.
araw na mataas
yung blood
pressure tapos
di ako
masyadong
nakakagawa ng
mga gawaing
bahay dahil sa
sakit ng
kaliwang paa ko
SN: at mabilis
mangalay.
Ganun po ba
nakapag-check
up na po ba
kayo?

GP: Mga limang

buwan na ang
huli kong
pagpunta sa
hospital at
magpacheck-up
nun dahil sa
mataas na blood
pressure ko.

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SN: Ah ganun po ba.
Pwedeng i-
assess ko na po
kayo?

GP: Sige ma’am

SN: Information Information in
Ang vital signs the context of
niyo po ay nurse-patient
interactions
RR:17
refers to the
breaths/min
exchange of
PR: 75 relevant details
pulse/min between the
nurse and the
Body patient that aids
Temperature: in
35.5 °C understanding
the patient's
BP: 130/90 health status,
needs, and
Mataas po ang
concerns. This
blood pressure
exchange is
nyo ngayon.
critical for
Ganun ba, accurate
medyo mababa assessment,
po ngayon dahil diagnosis, and
GP: minsan po nasa treatment.
140/90

Ah ganun po ba.

SN:
TERMINATING
PHASE
SN: So, sa sinabi mo Summarizing Summarizing in
po kanina ay nurse-patient
uulitin ko po, interactions
masakit po yung involves the
kaliwang paa at nurse restating

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 hindi po kayo the main points
nakakakilos of the
nang maayos conversation to
tapos sa ensure mutual
assessment understanding
naman po natin and clarity.
ay normal lang
naman po ang
iba maliban sa
blood pressure
nyo po na hindi
normal.

GP: Salamat at
nacheck mo.

C. GORDON’S 11 FUNCTIONAL HEALTH PATTERN

1. Health Perception and Health Management

The customer believes that her age and certain genetic factors have impacted her health. In
the morning, she works out to keep her right ankle’s pain away from getting worse, and she
believes that this is helping. She always eats nutritious foods and vegetables that are
beneficial to her bones.

2. Nutritional and Metabolic Pattern

The client mentioned taking multivitamins on a daily basis. She hasn't noticed any weight
increase or loss. She typically enjoys eating veggies and avoids from undesirable foods,
particularly those that are readymade to be eaten. She also doesn't have any skin issues and
dental problems.

3. Elimination Pattern
The client typically has considerably of bowel motions right before bed and in the morning.
There are no anomalies in the stools that she has noticed. Five to seven times a day is the
frequency of urination, the urine has a yellowish color and no unpleasant smell.

4. Activity Exercise Pattern

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The customer can still perform some household chores like cooking and sweeping, but she
finds it difficult to carry out daily routines. She has joint problems, particularly with her right
ankle fracture. This problem has been impacting her activity pattern. She spends her free time
spending time containing and keeping an eye on her grandchildren. During certain activities,
she needs help from someone else, like getting up stairs.

5. Cognitive Perceptual Pattern

The patient is receptive, spatially aware, and capable of providing precise responses to
questions. The patient claims that despite she is aware of her condition, she frequently forgets
to take her medications as prescribed and to get rest. The patient wears eyeglasses but does
not have any hearing issues.

6. Sleep and Rest Pattern

The client does not have trouble falling asleep. She goes to bed around 8 p.m. and gets up at
6 a.m. She naps for ten hours each day. She claimed she had not been having any difficulties
with her sleep.

7. Role Relationship Pattern

Mrs. Capistrano currently lives with her husband and one of her daughters with their family, as
described by the client. She claims that they get along well with each other. In addition, her daughter
helps her, particularly when she is unwell or needs medical attention .

8. Sexually reproductive Pattern

Mrs. Capistrano is experiencing menopause already. The client claims there are no problems
with reproductive health.

9. Self Perception Self Concept Pattern

The client demonstrated body dysmorphia and other negative self-perceptions as a result of
her diminished physical capacities. Because of her inability to walk normally, the client is
now hesitant to go anywhere by herself in public. The customer mentioned that she is still
satisfied with her life despite her challenges, whereas the noise in the area is what irritates
her.

10. Coping stress tolerance

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The client experiences stress because of her illnesses. She emphasizes that stress is
something that contributes to her health issues. As a result, the client's coping method when
she feels anxious is to cook, particularly bake, and to perform household duties. To better
handle these pressures, the client also requires ways to deal and a helping hand.

11. Value Belief pattern

Mrs. Capistrano is Muslim and prays five times a day. Her religious views influence her
health-related ideals and decisions.

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