HYPERTENSION

A Case Study Presented to the

Faculty of the College of Nursing

In Partial Fulfillment
Of the Requirement in
NCM 101- Health Assessment RLE

Submitted to

Submitted by
BSN 1-F Group 5
April 29, 2021
 Table of Contents

Introduction 3

Objectives 4

Anatomy and Physiology 4

Nursing Health History 8

A. Biographical Data 8

B. Past Health History 9

C. Family Health History 13

D. Lifestyle and Health Practices 15

Review of Systems 18

References 30

Consent Form 32

Documentation 33

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 Introduction

Health assessment stands as an essential element in the grand scheme of a very dynamic

and cyclical nursing process. It is basically an evaluation of the health status of the client through

performing a physical examination after taking a health history (Health Science Journal, n.d).

Skills involved in health assessment serve as a decisive role in assessing and determining the

client’s health problems and caring needs, and consequently have a vital job in developing

clinical care programs and determining appropriate nursing treatments and interventions (NCBI,

2013). In addition, higher standards of health evaluation expertise enable nurses to help track

improvements in their client’s health, as well as make better decisions and nursing diagnoses.

The more detailed and accurate the assessment, the better the outcomes and in turn a higher level

of health is attained. Another aspect of health assessment being beneficial is that it assists nurses

in identifying and prioritizing patient health concerns and priorities. It allows nurses to engage

with clients about what matters to their well-being and eventually equip them in assisting clients

to understand their overall health condition and taking steps to change it.

Hypertension or commonly known as high blood pressure, is when blood pressure – the

force of blood pushing against the walls of blood vessels, is consistently too high. Blood pressure

is written as two numbers. Systolic, the first number represents the pressure in blood vessels

when the heart contracts or beats. Whereas diastolic, the second number represents the pressure

in the vessels when the heart rests between beats. Hypertension is a serious medical condition

and can increase the risk of heart, brain, kidney and other diseases (World Health Organization,

2019). In the Philippines, studies show that deaths and burden of disease associated with

hypertension has significantly increased over the last three decades. Hypertension death rate

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elevated from 11% in 1990 to 21 percent in 2017, while other related hypertension disabilities

and disorders rose from 4 to 11%. Hypertension is considered as a "silent killer" (Mayo Clinic,

2018). Based on the latest WHO data published in 2018, deaths in the Philippines caused by

hypertension reached 14,488 or 2.38% of total deaths. The estimated death rate every 100,000 of

the population is 23.44 ranking Philippines number 25 in the world. In addition, a study

conducted by the Philippine Heart Association for hospitalized patients in the Philippines,

considered hypertension as the leading cause of death with a percentage of 38.6 (Asian

Management of Hypertension, 2019). Furthermore, with the utilization of long-term historical

trends (1993 to 2015), prevalence of hypertension among Filipino adults is projected to remain

stagnant. Assuming the prevalence rate continues to persist, the projected number of Filipino

adults with hypertension is expected to grow almost double in the year 2050.

I. Objectives

The students of BSN1F will be:

● Able to define Hypertension and its epidemiology.

● Able to discuss the anatomy and physiology of specific organs of the body.

● Able to differentiate abnormalities from the normal using the IPPA.

● Able to recognize the limitations and difficulties in performing activities of daily living

for hypertensive patients.

II. Anatomy and Physiology

It all starts with the arteries, which are the blood vessels that are responsible for the

supply of oxygen-rich blood from the heart to the tissues of the body (National Cancer Institute,

n.d). Normally, healthy arterial blood vessels are flexible, strong, and elastic. Added to this, their

inner lining is smooth, which allows blood to flow freely, supplying all the vital organs and

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tissues with enough nutrients and oxygen (Mayo Clinic, n.d). However, due to the increase of

blood pressure level, or hypertension, the pressure of blood flowing through the arteries

gradually increases. Thus resulting in the damage in the cells of the inner lining, wherein fats

enter the bloodstream and damage the arteries, which will eventually become less elastic, and

limits the blood flow throughout the body. In addition, the constant pressure of blood moving

through a weakened artery can cause an enlargement and a bulge formation on a section on its

wall, making it harder for the blood to circulate. Hence, it allows the development of several

systemic problems in the human body, which involves the heart, kidneys, and brain. First, is the

human heart, which is the organ responsible for the circulation of blood in the body. Primarily, it

provides oxygen and nutrients to tissues while removing carbon dioxide and other wastes. Added

to this, the heart is one of the organs in the body that is greatly affected when hypertension or

high blood pressure afflicts an individual. In relation to this, Hypertension occurs, when one's

blood pressure rises to dangerously high levels. This damages the arteries by making them less

elastic, which results in the decrease of blood flow and oxygen to the heart, thus leads to heart

disease, and causes chest pain, also referred to as angina. The narrowing of the heart's arteries

causes an increase in resistance, and the narrower the arteries become, the greater the blood

pressure levels. In addition, High blood pressure could also cause Coronary artery disease,

wherein the arteries are narrowed and is damaged by the high level of blood flowing through the

blood vessels, resulting in difficulties in the supply of blood in the heart. When this occurs, chest

pain, erratic heart rhythm, and, in the worst-case scenario, a heart attack may occur. Furthermore,

High blood pressure also forces the heart to work harder in pumping blood to the rest of the

body, which may cause the left ventricle of the heart to thicken, and this increases an individual’s

risk of heart failure, and cardiac death. Second, is the human kidneys, which are the two bean-

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shaped organs found in the renal system. These are the ones in charge of excreting waste

products, drugs, and toxins from the body through urine. Added to this, kidneys aid in filtering

blood until it is returned to the heart. It also performs various critical functions, including blood

pressure regulation. Moreover, blood flows into the kidneys through the renal arteries, which are

branches of blood vessels that carry blood to the kidneys from the aorta (National Institute of

Diabetes and Digestive and Kidney Diseases, n.d). The renal arteries supply oxygen and

nutrients to the kidneys. Hence, when clogged, kidneys will not be able to function normally,

which leads to the narrowing of renal arteries, also referred to as renal artery stenosis (RAS),

wherein it prevents normal amount of oxygen-rich blood from reaching the kidneys, thus will

injure the kidney tissues and increase blood pressure throughout the body (Mayo Clinic, n.d).

The increase in the blood pressure caused by RAS, is called Renovascular hypertension (RVH)

(National Kidney and Urologic Diseases Information Clearinghouse, n.d). Furthermore, damaged

kidneys will lose their ability to function normally, resulting in the inability to control blood

pressure because they are unable to develop aldosterone, a hormone that helps the body maintain

blood pressure levels. Lastly, is the human brain, which is a three-pound organ, composed of

cerebrum, cerebellum, and brainstem, that is found in the Nervous System. It is responsible for

the interpretation of information, and control of the functions of the body. Added to this, it

receives information through the five senses, namely, the sense of sight, smell, touch, taste, and

hearing, wherein it properly organizes the message to be able to be stored in the memory of an

individual. Moreover, for the brain to function properly, nourishing blood supply that is rich in

oxygen and nutrients is needed. The Blood flow in the brain is referred to as cerebral circulation,

which is vital for a healthy brain function. Additionally, blood provides oxygen and glucose to

the brain, and although the brain is only a small part of the body’s weight, it still requires a lot of

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energy to function and survive (Kinman, T., 2016). According to Davis Lab at the University of

Arizona, the brain needs about 15 percent of the heart’s cardiac output to get the oxygen and

glucose it needs, thus a lot of blood is needed for it to remain functional and healthy. However,

when the circulation is impaired and damaged, a variety of complications to the brain could

happen. In relation to this, high blood pressure could cause disruption of the blood circulation,

wherein it could cause several brain damage and neurological problems. First is the Transient

ischemic attack (TIA) or sometimes called a ministroke. It is a brief, temporary disruption of

blood supply to your brain, wherein the arteries are hardened, and blood clots occur. Second is

Stroke, wherein high blood pressure level damages the blood vessels causing it to narrow,

rupture, and leak. This as well deprives the brain of enough oxygen and nutrients, which causes

the brain cells to die. Third is Dementia, wherein arteries are blocked or narrowed which causes

a limited blood flow to the brain. Lastly, is mild cognitive impairment. It is a condition in which

a transition stage between the changes in understanding and memory that generally come with

aging and the more-serious problems caused by dementia (Mayo Clinic, n.d).

III. Nursing Health History

A. Biographical Data

● Name: M.P.V

● Address:

o Antilla Subdivision, Silay City

● Gender:

o Female

● Provider of history (patient or other):

o Patient

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 ● Birth date:

o September 25, 1970

● Age:

o 50 y/o

● Place of Birth:

o Bacolod City

● Nationality:

o Filipino

● Marital Status:

o Married

● Religion:

o Roman Catholic

● Educational Level:

o College Graduate of BS in Mass Communication

● Occupation:

o Senior High School Teacher

B. Past Health History

● Problems at birth

o No problems experienced at birth.

● Childhood illnesses

o Rheumatoid Arthritis: The pain started during preschool until grade school. The

pain was moderate and bearable and was usually felt during walking. It radiates

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 from the knee down to the calves. The condition has affected the ability of the

patient to carry out activities of daily living, especially walking.

o Chronic Epistaxis: The condition began during the patient’s first year in high

school as caused by a physical trauma. Hot weather triggered the occurrence of

such conditions. And pain was not experienced alongside with the stated

condition.

o Tonsillitis: Condition first occurred when the client was in 3rd year in high school

and it lasted until she was already 2nd year in college. Initially, the client was not

able to feel the pain, but as soon as it did pain was felt every other week along

with fever and sore throat. After 2 to 3 years the condition worsened accompanied

by the presence of pus. The pain was characterized to be moderate but the client

could not attend her music class each time pain was felt. Around the time the

client experienced having inflamed lymph nodes.

● Immunizations to date

o HepB: Year 2003, the patient received her first immunization. While in 2005 was

the last time she received the immunization shot.

● Adult illnesses (physical, emotional, mental)

o Ureter stone (right side): The condition was diagnosed in 1997 while the patient

was unconscious about the pain brought about by the condition. It was discovered

as the client sought treatment due to a tea-like appearance of her urine and was

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 eventually diagnosed and got treated. From the time the pain was already felt--

usually due to minimal water intake--, it spreads from the anterior right lumbar

region to posterior right lumbar region. The pain was characterized to be ranging

from moderate to severe by the patient to the point that it makes the client feel

like vomiting.

o Kidney stone (left side): The condition was accompanied with pain and was

initially felt in 2003. The patient was diagnosed with the condition between 2004-

2005, diagnosis was initiated due to the severe pain felt by the patient. The patient

has experienced recurring pain in the lumbar area especially when water intake

was minimal. Lesser pain was felt when the patient was in a relaxed sitting

position or when she rested the area. The pain felt varies from mild, moderate to

severe and was characterized like a numbing pain and gradually turns into a sharp

pain over time. When the pain experienced is severe, it limits the ability of the

patient to carry out activities of daily living. In 2017, Lithotripsy was performed

for the patient due to a 3cm stone left inside, as the other was dissolved by

medications and treatment.

o Hypertension: The condition was experienced by the patient during her late 40’s

and was diagnosed last 2017. Age, lifestyle and family history were some of the

factors considered as a contributor to the patient’s condition. Due to high blood

pressure the patient has been experiencing headache and this usually happens

whenever the patient misses to take her maintenance. Her blood pressure mostly

is no lower than 130/80 and reaches up to 180/110. The pain affects the ability of

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 the patient to carry out daily activities. Medications being taken are a combination

of Losartan 50 and Amlodipine 5.

● Surgeries

o 1989: Client underwent tonsillectomy due to infected and inflamed tonsils.

o 1997: Client underwent hemorrhoidectomy due to swollen veins in the lower part

of the rectum and anus.

o 1995, 2001, 2013: Gave birth to all three living children through cesarean section.

o 2017: Underwent lithotripsy due to the presence of stones in the kidney and the

ureter.

● Pregnancies

o October 15, 1995: Gave birth to a healthy female with no complications during

birth.

o February 21, 2001: Gave birth to a healthy female with no complications during

birth.

o March 3, 2013: Gave birth to a healthy male with no complications during birth.

Note: All pregnancies were through cesarean section

● Accidents

o Has not been involved in any accident ever since.

● Prolonged pain or pain patterns

o Knee Joint Pain (Kinder – Grade School Days)

o Pain in the lumbar area due to ureter stone

o Post birth cramps after cesarean sections (pain felt after giving birth to all

children)

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 ● Allergies

o No history of any allergies.

● Physical, emotional, social or spiritual weaknesses or strength

Strength Weakness
Physical ● Very energetic ● Occasional body pain
Emotional ● Emotionally strong and /

has a good coping

mechanism
Social ● Can adjust with the ● Gets nervous during

people around her very supervised talks

well

● Likes talking to other

people
Spiritual ● Strong faith to God /

C. Family Health History

● Age of parents (Living or deceased? date?)

o Mother: ZGP– 81 years old; alive

o Father: EDP – 81 years old; deceased – February 8, 2021

● Parents' illnesses and longevity

o Mother (February 5, 1940 – present)

▪ Hypertension – discovered when she was 30 years old; after giving birth

▪ Uterus Cancer (2009) – went through Total Abdominal Hysterectomy with

Bilateral Salpingo-Oophorectomy (TAH-BSO) upon discovery

▪ Diabetes (2009 – present)

▪ Urinary Tract Infection (2010 – present) – recurring

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 o Father (December 29, 1939 – February 8, 2021)

▪ Tuberculosis (1 year) – treated

▪ Kidney stone (1 year) – treated the same together with his TB

▪ Hemorrhoid (started when he was 25 years old)

● Recurring

● Underwent hemorrhoidectomy once

▪ Hypertension – discovered when he was 65 years old

▪ Mild Stroke (2011)

▪ Stroke (October 2020 – February 2021) – cause of death

● Grandparents' illnesses and longevity

o Maternal Grandmother; deceased with unknown longevity

▪ Diabetes – cause of death

▪ Hypertension

o Maternal Grandfather; deceased with unknown longevity

▪ Malaria – cause of death

o Paternal Grandmother; deceased with unknown longevity

▪ Hypertension – cause of death

▪ Acid Reflux

o Paternal Grandfather; deceased with unknown longevity

▪ Died due to old age

● Aunts' and uncles' age and illnesses and longevity

o Aunt: LGM (1936 – 2015); 79 years old

▪ Hypertension (10 years)

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 ▪ Heart Ailment (5 years) – cause of death

▪ Diabetes

o Aunt: OGB (1938 – 2016); 78 years old

▪ Colon Cancer (6 years) – cause of death

Note: Aunt’s on the mother side

● Children's ages and illnesses or handicaps and longevity

o MMPV – 25 years old

▪ Polycystic Ovary Syndrome (2017 – present)

o MMEPV – 20 years old

o MJMP – 8 years old

D. Lifestyle and Health Practices

● Description of a typical day (AM to PM): upon waking in the morning and until bedtime

o Client usually starts her day at 5 am to get ready for work. She drinks coffee daily

after she eats her breakfast. At work, she would usually prepare her work for the

day and clean and decorate her office. She eats her lunch with her colleagues at

around 12 P.M. After work, the client usually heads home or stops by the market

to buy dinner. She eats upon getting home at around 3-4 PM. After eating, the

client rests or naps for a while before washing up. She eats dinner at around 7-8

PM and starts to work on her laptop or help her youngest child with his

assignment afterwards. If there’s no work or assignments to do, she watches

movies while lying down on the bed. The client normally sleeps at around 12-1

AM.

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● Nutrition and weight management: 24-hour dietary intake (foods and fluids), who

purchases and prepares meals

o The client eats 3 meals a day. The meals would mostly contain meat and the

served breakfast is usually processed food and eggs. Lunch and dinner, however,

are home cooked meals prepared by the household help. The client or the

household help are the ones who purchase the ingredients for the meals. They try

to purchase healthy and easy to cook foods as much as possible.

● Activities on a typical day: Exercise habits and patterns

o The client does not engage in any activities but is planning to start once she gets a

break from work. She also plans to incorporate it in her daily activities. The most

that she currently does is going up and down her work place’s stairs.

● Sleep and rest habits and patterns: how many hours a night the person sleeps,

interruptions, whether the client feels rested, problems sleeping (e.g., insomnia), rituals

the client uses to promote sleep, and concerns the client may have regarding sleep habits

o The client sleeps well, having no trouble sleeping. However, she only sleeps for

about 4-5 hours at night. The only concern she has with sleeping is forcing herself

not to – especially when she has a lot of work to be finished.

● Use of medications and other substances (caffeine, nicotine, alcohol, recreational drugs)

o Aside from the medications prescribed by the doctor, the client drinks coffee. She

also used to smoke.

● Self-concept and self-care responsibilities: health care checkups (i.e., dental, visual,

medical); breast/testicular self- examination; and accident prevention and hazard

protection (e.g., seat belts, smoke alarms, and sunscreens)

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 o The client goes to a cardiologist for a check-up once a year, and to a nephrologist

once in a while for her kidney stone. She puts sunscreen on before leaving the

house, and prioritizes her safety and her family.

● Social activities for fun and relaxation: social activities contributing to society

o The client likes travelling and going on a road trip. She also goes out with her

friends to support local businesses. The client watches a lot of movies during her

free time.

● Relationships with family, significant others, and pets: composition of the family into,

which they were born and about past and current relationships with family members

o The client has a healthy relationship with her family and friends. She has a dog

that loves getting her attention. She was also brought up well by her parents

despite being occasionally separated from them when she was little.

● Values, religious affiliation, spirituality: philosophical, religious, and spiritual beliefs

o The client highly values respect and humility. She is anchored in faith, grace, and

love. She believes in God who can do all things.

● Past, current, and future plans for education: type of work, level of job satisfaction, work

stressors, finances

o The client used to work as a secretary at a non-governmental organization before

she studied nursing and worked as a volunteer nurse in the dialysis department at

Doctors Hospital Bacolod. She also worked as a freelance massage trainer under

TESDA. Due to financial situations, she had to switch into a lot of different

careers. Currently, the client works as a senior high school teacher and is fine with

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 her current job. She only stresses about having a lot of paperwork and reports but

overall she is fine with it.

● Stressors in life, coping strategies used

o The client only stresses about finances occasionally. However, she gets through it

with courage, determination, coffee, and friends.

● Residency , type of environment, neighborhood, environmental risks

o The client lives at a non-gated subdivision. She describes her neighborhood as

very peaceful and friendly. There are, however, some neighbors who smoke and

burn piles of dried leaves. The location of her house is near a creek so there are

times when the rain is heavy, the creek overflows and floods the area.

IV. Review of Systems for Current Health Problems

● General Appearance

⮚ Assessment Findings: Client is chubby and stands at an approximate of five feet,

with head well-proportioned to the body, hair is short with dye and facial features

bilaterally equal.

● Skin, hair, and nails (Integumentary)

⮚ Client’s History: Light brown birthmarks present on both shoulders; Presence

of warts along cervical to thoracic area was observe;

Skin:

⮚ Assessment Findings: skin is brown to fair skin; no odors emanating from the

skin; due to sun exposure upper limbs appear darker than the rest of the body;

discolorations was not detected; skin is intact with no redness present; skin is

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 warm, smooth and moisturized; elastic and mobile; no presence of lesions;

temperature is within normal; no signs of edema;

Hair:

⮚ Assessment Findings: dyed mahogany red hair, above shoulder, and thin and

dry; evenly distributed hair on scalp and perineum; thin and shiny; moderate

oiliness; evenly distributed to the rest of the body; no signs of infection and

infestation on the scalp; dandruff is found on some parts of the scalp; hair in the

axilla has been removed;

Nails:

⮚ Assessment Findings: clean and well-groomed nails; nails form about 160

degree angle from base; no detachment of nail plate; nail bed is pinkish; hard,

smooth, and immobile;

● Head and neck

Head

⮚ Client’s History: Hair was dyed a few months ago with occasional appearance
of dandruff and experiences dizziness or headaches once in a while.

⮚ Assessment Findings: head is symmetrically, round, hard, and smooth; no

visible lesions; facial features are symmetrical; no lesions or lumps; temporal

lobe artery are non-tender and elastic

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 Neck

⮚ Client’s History: No observed history which concerned the neck.

⮚ Assessment Findings: neck is erect and in midline; no visible lumps and

masses; neck is non-tender; no masses upon palpation; C rings are palpable;

thyroid is non-palpable

Palpation of the Lymph Nodes

Palpation of the Lymph Nodes

Location of the Nodes Palpable Non-palpable
Submandibular ✔
Superficial Cervical ✔
Submental ✔
Tonsillar ✔
Posterior Cervical ✔
Supraclavicular ✔
Occipital ✔
Deep Cervical ✔
Preauricular ✔
Postauricular ✔

● Ears

⮚ Client’s History: Family history present with the client’s father experienced

noise-induced hearing loss.

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 ⮚ Assessment Findings: ears equal in size bilaterally; color, position and size of

the auricles are normal and symmetrical; mobile and firm; pinna recoils after it

was folded; small amount of cerumen present in the ear canal; ears are smooth

with no signs of lumps and lesions; texture, and elasticity of the auricles are

normal; no discharge; responds to normal voice tones well

● Eyes

⮚ Client’s History: No listed history related to the eyes.

⮚ Assessment Findings: Acuity by Snellen Chart – OD 20/63, OS 20/50, OU

20/63; movements of extraocular muscles are smooth and symmetrical; color

and eyelids’ position is normal; conjunctive and sclera looks moist and smooth;

no signs of lesion or redness on the sclera; cornea is transparent with little to no

opacities; both irises are round, flat and evenly colored; pupils are equal in size;

both pupils respond normally with light and accommodation

● Mouth, throat, nose, and sinuses

Mouth

⮚ Client’s History: Had braces and underwent root canal procedure.

⮚ Assessment Findings: lips are pinkish to brown, fairly hydrated, and no visible

lesions; teeth are properly aligned; one central incisor is discolored due to root

canal; mucosa and gums are pinkish, well hydrated, and no visible lesion

found;

Throat

⮚ Client’s History: No tonsils due to tonsillectomy.

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 ⮚ Assessment Findings: hard and soft palates are in normal shape and color.

Mucosa is pink with a ridged hard palate and good condition uvula. No

exudates or enlargements found.

Nose and Sinuses

⮚ Client’s History: No listed history associated with the nose and sinuses.

⮚ Assessment Findings: normal in size, shape, and color; symmetrical; no

flaring and discharge; mucosa is pink; nasal septum is intact and in position; no

displaced bone or cartilage; no lesions observed; frontal and maxillary sinuses

are non-tender upon palpation and percussion; can breathe through both nares;

Olfactory nerve (CNI) functioning well as patient can identify odors

satisfactorily

● Thorax and lungs

⮚ Client’s History: Client’s father had tuberculosis; Client used to smoke and

stopped during her 30’s;

⮚ Assessment Findings:

in a sitting position the client is relaxed, unlabored breathing; face, lips, chest are

normal in terms of color (pinkish); sternum is in midline and straight both in

anterior or lateral view; thorax is symmetrical and anterior-posterior diameter is less

than the transverse diameter; respiration is normal within 15 breaths per minute,

with normal rhythm and symmetrical expansion

Posterior and Lateral Thorax: thorax is symmetrical; during inspiration expansion

is symmetrical; no masses and unusual movements in the posterior chest wall,

costal spaces, and ICS; Client is able to perform deep-breathing exercises;

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 movement of the chest wall is symmetrical; normal vocal fremitus; thorax is normal

upon percussion; excursion is equal bilaterally and measures at 3.8 cm; breath

sounds are all normal; voice transmission is normal with indistinct and soft

generated sounds

Anterior Thorax: breathing pattern is symmetrical and passive; breathing did not

require much effort from the muscles; tactile fremitus is normal; no lumps, no

masses, no tenderness, and unusual movements felt; excursion is equal bilaterally;

normal upon percussion; no abnormal sounds detected

● Breast and regional lymphatics

⮚ Client’s History: No family history of breast cancer; Breast fed her first 2

children

Breast

⮚ Assessment Findings: breast are not symmetrical-- left breast is bigger than

the other; breast are large in size and asymmetrical with looser breast tissue; no

discoloration or hyper-pigmentation; nipples are visible; no dimples or bulges

on the skin; no redness, itchiness nor discharges found; no hard lump felt; no

rashes and infection in the axilla; ; thickened muscle at the lower inner

quadrant of the left breast-- no pain felt

Note: Wedged pattern technique was used and palpation was performed by the

Client.

Regional Lymphatics

⮚ Assessment Findings: lateral, posterior, and pectoral nodes are not felt ( due to

recent menstrual cycle)

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● Heart and neck vessels

⮚ Client’s History: Food intake is unhealthy; Engage in exercises seldom to

never; Bad sleeping patterns

Heart

⮚ Assessment Findings: precordium is symmetrical; abdominal aorta is normal;

precordium is normal-- the heart is normal in size and is symmetrical; no

bulges and no exaggerated pulsations; pulsations were felt in PMI; no abnormal

pulsations; no abnormal sounds detected; S1 is heard loudest at the apex; S2 is

heard loudest at the base; 67 beats per minute; average interval between S1 and

S2 is 0.40 seconds

Neck Vessels

⮚ Assessment Findings: pulsations were detected but veins are not visible; no

bruits heard in the carotid arteries: both pulses in the carotid arteries are equally

strong

● Peripheral vascular

⮚ Client’s History: With no listed history related to the peripheral vascular.

⮚ Assessment Findings: skin color of the lower extremities are the same; the

skin is dry and pain is not felt; minimal and evenly distributed hair; nails are

firm; venous pattern is normal; no signs of edema, scars or impaired skin

integrity upon inspection and palpation; skin color remains the same despite the

change of position; capillary refill is normal-- color returns in less than 2

seconds; no pain or tenderness felt after checking for Homan’s sign

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 Palpation of Peripheral Arteries

Palpation of the Peripheral Arteries

Location of Pulse Beats per minute Pulse grade
Radial 71 2+
Brachial 59 2+
Dorsal 63 2+
Posterior tibial 61 2+
Popliteal 45 2+
Inguinal -- --

● Abdomen

⮚ Client’s History: Experienced pain in the lumbar area due to kidney and ureter

stone; Experienced birth cramps post cesarean section

⮚ Assessment Findings: skin in the abdomen is unblemished and no

discolorations detected; abdomen is round; visible signs of striae due to

pregnancies; no abdominal herniation; movements are symmetric; peristalsis

and aortic pulsations are not visible; no visible vascular pattern; bowel and

vascular sounds are audible upon eating last meal 1 hour before the assessment;

no arterial bruits; no tenderness; no negative reactions from the client; abdomen

is relaxed and has consistent tension; scarring in the abdomen is present due to

cesarean sections

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● Female genitalia

⮚ Client’s History: Age of onset menstruation-- 12; last menstrual period-- April

5, 2021; regularity of the cycle-- 3 days and every 28th or 30th day cycle; at least

3-4 pads are used per day; menstruation is painful on the 1st and 2nd day; no

vaginal discharge; had 3 pregnancies; urinates frequently at night

⮚ Assessment Findings: hair in the perineum is evenly distributed-- no signs of

infestations; no lesions, swelling and excoriation in the labia majora and

perineum

Note: The inspection was done by the client herself.

● Anus and rectum

⮚ Client’s History: Client undergone hemorrhoidectomy once

⮚ Assessment Findings: perianal and sacrococcygeal areas are normal; no

lesions; no external hemorrhoids; no inflammation; no rashes nor excoriation;

scars are present due to hemorrhoidectomy

● Musculoskeletal

⮚ Client’s History: With history of joint pain at the knee

⮚ Assessment Findings: lower and upper extremities are symmetrical; no visible

deformities and bony enlargements; body alignment is normal; hips are aligned

with the shoulders; normal gait; muscles on both side are equal but have slight

differences in terms of measurements; no contractures in the muscles and

tendons; no tremors; no deformities and swelling in the bones and joints; no

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 heat or tenderness felt; no heat, tenderness in bones and joints upon palpation;

movement is smooth; no crepitation; no palpable nodules

Assessment of Joint ROM: most joint move smoothly; knee joint is slightly weak

Assessment for Muscle Strength

Test for Muscle Strength

Muscle Left Right
Sternocleidomastoid 4 4
Trapezius 3 3
Deltoid 3 3
Biceps 4 4
Triceps 3 3
Wrist and Finger Muscles 2 2
Grip Strength 3 3
Hip Muscles 3 3
Hip Adduction 4 4
Hip Abduction 3 3
Hamstrings 4 4
Quadriceps 3 3
Muscles of the ankles and feet 3 3

● Neurological

⮚ Client’s History: No neurological associated history

⮚ Assessment Findings:

Assessment the LOC: client is responsive to the questions asked; normal level of

consciousness

Assessment of the Cranial Nerves: (refer to the next page)

Assessment of Extremities for Sensation: client is reactive to pain and light touch

symmetrically in all areas; sensitive to position

Assessment of Motor and Cerebral Function: normal gait; client is well-balanced

Assessment of the Deep Tendon Reflex: was not assessed due to unavailability of

equipment

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 Assessment of the Superficial Reflexes: umbilicus move towards the areas

touched; toe curls in response to the light scratch on her plantar; equal elevation of

the uvula

Assessment of the Cranial Nerves

Assessment of the Cranial Nerves

Olfactory Both nostrils can identify different kind of odors
Optic Client finds it difficult to read the newspaper without her reading glasses;

Snellen chart visual acuity test

OD: 20/63

OD: 20/50

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 OU: 20/63

Note: The visual acuity test was done without the use of reading glasses
Oculomotor Movements of extraocular muscles are smooth and symmetrical; both

Trochlear pupils respond normally with light and accommodation

Abducens
Trigeminal Temporal and masseter muscles are normal; client feels a sharp sensation

in her forehead, cheeks, and chin when sharp in contact with the sharp

end of the paper clip and feels dull when touched by the paper clip’s dull

end
Facial Facial movements are symmetrical
Vestibulocochlear /
Glossopharyngeal Normal motor function; client is able to swallow normally

Vagus
Spinal Accessory Normal trapezius and sternocleidomastoid function
Hypoglossal Tongue is strong and mobile

References

American Heart Association (2016). How High Blood Pressure Can Lead to Kidney Damage or

Failure. Retrieved from https://www.heart.org/en/health-topics/high-blood-

pressure/health-threats-from-high-blood-pressure/how-high-blood-pressure-can-lead-

to-kidney-damage-or-failure

Davis Lab (n.d). Blood Supply Brain. Retrieved from

https://davislab.med.arizona.edu/content/blood-supply-brain

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Kinman, T. (2016). Cerebral Circulation. Rterieved from

https://www.healthline.com/health/cerebral-circulation

Mayo Clinic (n.d). High blood pressure dangers: Hypertension’s effects on your body. Retrieved

from https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-

depth/high-blood-pressure/art-20045868#:~:text=High%20blood%20pressure%20can

%20also,of%20dementia%20(vascular%20dementia).

Mayo Clinic (n.d). Renal artery stenosis. Retrieved from https://www.mayoclinic.org/diseases-

conditions/renal-artery-stenosis/symptoms-causes/syc-20352777

National Cancer Institute (n.d). Classification & Structure of Blood Vessels. Retrieved from

https://training.seer.cancer.gov/anatomy/cardiovascular/blood/classification.html

National Institute of Diabetes and Digestive and Kidney Diseases (n.d). Your Kidneys &b How

They Work. Retrieved from https://www.niddk.nih.gov/health-information/kidney-

disease/kidneys-how-they-work#:~:text=Each%20of%20your%20kidneys%20is,your

%20blood%20and%20removes%20wastes.

National Kidney and Urologic Diseases Information Clearinghouse (n.d). Renal Artery Stenosis.

Retrieved from https://www.niddk.nih.gov/health-information/kidney-disease/renal-

artery-stenosis

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30
Consent Form

31
Documentation

Interview with the Client

Inspecting for Gait by instructing the client to walk

32
Palpating supraclavicular nodes

Percussing the abdomen

33
Auscultating breath sounds

34