ASSESSMENT

Name: Mrs. Luzviminda Baptista

Age: 42 years old
Address: Cabaruan, Sta. Catalina, Ilocos Sur
Gender: F
Civil Status: Married
Religion: Catholic
Date and time of Admission: July 4, 2010 @ 11:00 AM
Chief Complaint: dizziness, chest pain and body weakness

July 5, 2010

Vital Signs taken as follows:

Body Temperature: 36.4°C,
Pulse Rate: 83BPM,
Respiratory Rate: 18 CPM
Blood Pressure: 120/80 mmHg

A. General Appearance:
Anti Luzviminda was seen lying on her bed in a supine position, she was awake however
weak in appearance. She sits on her bed at times. She has an IV fluid of D5NM 1 liter inserted on
the right hand at 980 cc level. She was wearing a red sleeveless shirt with shorts.

B. Head to Toe Assessment

1. Skin
-fair complexion
-skin is dry with a minimum perspiration
-body temperature of 36.4° C
2. Head
-slightly square in shape
-proportional to body size
-able to move to its desired position/direction w/out difficulty

3. Hair @ Scalp
-Black hair strands
-smooth in strands, thick and curly
-hair equally distributed
-no dandruffs noted
4. Eyes
-both eyes are symmetrically aligned
-with good vision-able to recognize finger counts at a distance of 5 meters
-can move eyeballs to any direction
-with white sclera & brown iris
-with slightly pinkish palpebral conjuntiva
5. Eyebrows
-black in color
-equally distributed
-symmetrically aligned
6. Ears
-with attached earlobes with well formed cartilage.
- symmetrically aligned with the outer cantus of the eyes.
-with good hearing acuity cable to hear and
answer what the student nurse ask
from a distance of 4-6 ft. with a voice volume during normal conversation.
-with small amount of cerumen noted.
7. Mouth
- with pale mucous membrane
- with slightly pale lips
- with pinkish and moist tongue that can move freely to any direction
- with pinkish gum
8. Neck
- proportional to the body size
- coordinated smooth movements, able to move to its desired direction.

9. Pulmonary
- symmetrical chest expansion
- with respiratory rate of 18 cpm

10. Abdomen
- with visible movements during respiration
- round shaped abdomen

11. Upper Extremities

- right and left arms are symmetrically aligned
- proportional to body size
- with slightly long nails, slightly dirty
- with pale nail bed
- with no rashes, cuts or breaks noted
- with an intact IV fluid of D5NM 1 L, inserted at the right hand

12. Lower Extremities

- right and left legs are symmetrically aligned
- proportional to body size
- can move but slowly
- with pale nail beds
- with no rashes, cuts or breaks noted