Minalang,Haaron G.

Group 15-level4 section 6

Physical assessment

Vital signs:

Temperature-36.5

Pulse rate: 78

RR: 19

BP: 120/70

General appearance: the client was conscious and coherent, cooperative. He is 82

years old. He is moderately groomed. He is dressed with proper attire. Always
wanted to be termed as “gwapo”

Body parts Technique used Findings analysis

Head Inspection Symmetrical, Normal

Hair inspection White in color, ,no White hair is

flaking and no lice normal due to the
or infection. It is aging process
evenly distributed

eyes inspection Symmetrical to normal

each other
,eyebrows and
eyelashes are
evenly distributed,
pinkish conjunctiva
Ears inspection Symmetrical, not Patients hearing
tender, sound is ability is
heard on both ears decreasing
but should be in a
loud tone

nose inspection Symmetrical, there The patient

are some mucus experiences runny
discharge nose most of the
time in the
afternoon

Mouth inspection Light pink in color, Normal due to

moist, has aging process
dentures in upper
and lower gum
area

neck Inspection No nodules, not Normal

tender,
palpation
Upper extremities inspection Uniform skin color, Normal due to
symmetrical aging process
muscle mass but
floppy

Lower extremities inspection Even skin color and Normal due to

texture, aging process
symmetrical
muscle mass but
floppy

skin inspection Medium brown to Normal due to

whitish skin tone, aging process
dry ,wrinkled and
scaly,

Nails inspection Smooth, intact The patient

epidermis, with complained that his
untrimmed nails manicurist has not
arrived to clean his
nails

Chest inspection Symmetrical chest normal

expansion

Abdomen inspection Flabby and Bulgy Related to a

looking lifestyle of no
exercise
Nursing care plan 1

Assessment Diagnosis Planning Intervention rationale Evaluation

Subjective: Wandering After 2-3 >provide a >decreases After 3

in the nursing structured wandering nursing
“papunta ako sa afternoon shifts of daily behavior shift the
baba”……..”san na related to nursing routine client was
nga ba papunta”as separation intervention >to able to be
verbalized by the from the patient >Provide a accommoda free of
patient familiar will be able safe place te safe injury; or
environment to be free of for client to wandering unexplain
Objective: wander
as observed injury; or ed exits
>Frequent/continu in the unexplained > provide a
ous movement objective exits 24 hour
from place to reality
place, often
revisiting the same orientation
destination

>unable to
recognize/rememb
er the place where
he is going

Nursing care plan 2

Assessment Diagnosis Planning Intervention rationale Evaluation

Subjective: Risk for fall After 2-3 >Observe >noticing After 3

related to nursing shifts individuals factors that nursing
No subjective the behavior of nursing general health might affect shifts of
was of sleeping in intervention status safety nursing
appropriate a bench the patient interventio
for a risk without side will be able >consider >identifyin n and
rails demonstrate environmental g practice
Objective: hazards in the needs/defici
lifestyle the client
>82 years old change to care setting ts provides was able
>difficulty reduce the environment opportuniti to
with gait risk factors es for demonstra
>Encouraging intervention
and protect and practicing te lifestyle
>Preferred to self from change
sleep in a patient to >to prevent
injury sleep in the fall while that
bench without
side rails bed with side sleeping reduces
rails the risk
factors