II. NURSING ASSESSMENT

A. PERSONAL HISTORY

Mr. Juan dela Cruz is a 68 years old male Filipino, Catholic, who was born on

February 8, 1941 at Mabalacat, Pampanga. He is 5’5 ft in height and 59.09 kg in weight.

He is married and blessed with three children (two boys and a girl). He currently resides

at Balibago, Angeles City with his family. He was a high school graduate in Mabalacat,

Pampanga. He is a retired electrician. He was rushed on the emergency department

of a private tertiary hospital in Angeles City, last November 25, 2009 (Wednesday) at

9:00 pm with chief complaints of chest pain described as heartburn, dyspnea, cold

clammy skin, pallor and dry mouth. Assessments of the sign and symptoms were done

and standards of care procedure were given at the emergency department. After series

of initial laboratory and diagnostic exam the client was transferred to the Intensive Care

Unit of the said institution with an admitting diagnosis of: Acute Coronary Syndrome,

Non ST elevation Myocardial Infarction, Community Acquired Pneumonia, Hypertensive

Cardiovascular Disease (HCVD) and Diabetes Mellitus type 2. He stayed in the

Intensive Care Unit for 4 days from November 25 to 28, 2009 and was transferred to a

private room on the on the 28th day of November the patient was discharged last

December 3, 2009 with a final diagnosis of Acute Coronary Syndrome, Non ST

elevation Myocardial Infarction, Community Acquired Pneumonia, Hypertensive

Cardiovascular Disease (HCVD) and Diabetes Mellitus type 2.

Mr. Juan dela Cruz He is a high school graduate in Mabalacat, Pampanga on the

year 1957. He started to work as an electrician when he was 20 years old approximately

by the year 1961; he started as a helper of his uncle. He stops working as an electrician

at the age of 50 years old approximately the year 1991. He got married on the age of 30

by the year 1971. Presently, together with his wife, they are running a small sari-sari

store built on the year. According to Mr. Juan Dela Cruz, they are earning an estimated

amount of PHP 3, 000 a month. With regards to the allocation of finances, Mr. & Mrs.

Dela Cruz works together in order to solve the problems or what decision to be made.

Some of their daily expenses are being paid off through the money being sent by his in-

laws and cousins amounting to PHP 30,000 a month. They spend a total of Php.

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20,620.00/mo for their monthly expenses such as foods: 7,500.00, water bill:

Php.800.00, electric bill: Php.3, 000.00, groceries: Php. 5, 000.00, gas tank: Php.

1,650.00, medical Supplies: Php. 2,000.00, Soap: Php.120.00, laundry soap: Php.

250.00, shampoo: Php. 200.00, toothpaste: Php. 100.00. Based from the breakdown of

expenses, the money is enough to support the family’s needs and according to the

National Economic and Development Authority (NEDA), for a family not to be

considered poor, each individual should be provided with at least Php 2,768.60 a

month. Dividing the sum of money among the 7 family members, each person is allotted

with Php 4,714.29 a month which indicates that the family is capable of providing for

their needs adequately and thus classifying them as not poor.

Mr.Juan dela Cruz used to wake up at around 4:00 am to have his breakfast

such as coffee with pandesal, fried hotdog, egg and rice after which, he will open and

clean the store. At 6:00 am, he will go to the market to buy groceries for their store. And

at 8:00 am, he would stay and sell at their store until 6:00 pm. He usually had his lunch

together with his family at 12:00 pm they usually as adobo, sinigang, caldereta and

piritong isda at manok, he usually takes a bath at 6:00 pm. And at 7:00 pm, he takes his

dinner; watch television at around 8:00 – 10:00 pm and sleeps at around 10:00 pm.

While during Sunday, the whole family will go to mall to have fun.

The family of Mr. Juan dela Cruz is purely pampangeños. They could speak

Capampangan, Tagalog and English. They have been residing in Angeles City for a

very long time now. They are affiliated to the Roman Catholic Church and seldom go to

church instead hear mass on television and according to them, they do not believe in

pamahiin and albularyos. They believe in images that would heal their sickness, wiping

handkerchief over it and pray for their health.

The family gets their food from the market. They buy foods every other day and

cook meals that is enough for a day to prevent left over foods. But if in case there were

left-overs, they would store food in the refrigerator. The amount of food, however, is just

exact for the family and sometimes they got their food supply in their sari-sari store. The

wife of Mr. dela Cruz is the one who prepares the food. Regular hand washing and

proper food handling is being observed when preparing the food. They have a 2 gas

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range with stove and rice cooker for cooking. The entire household’s source of water is

supplied by the Angeles Water Works, which is paid monthly. The family uses the same

water for laundry, bathing and house chores but for their drinking water and for cooking

is form their water dispenser. The gallon is delivered by a Water Refilling Station near

them and spending an amount of Php. 200.00/month while the electricity if provided by

the Angeles electric corporation. The family uses 2 toilet facilities that are carriage type.

The toilet is generally clean. It has a shower, sink and a clothesline where they hang

towels and clothes during bathing. A trash can is also placed on one corner in which

they throw used shampoo sachets, soap cartons, tissue and used napkins. The

drainage system is closed. But generally water flows at the canal, especially whenever

they do laundry. The family has reported zero cases of flood in their area, which

indicates an effective drainage system. The family observed segregation of garbage and

it was collected by garbage collectors every week and being paid an amount of

Php.80.00 per month. They make sure it is properly tied in order not to attract flies,

rodents to invade and to avoid foul smell. The family’s means of communication is

through telephone. Some members of the family have cellular phones used for texting

and calling. They also have computer with internet connection for them to communicate

relatives form other countries. Their transportation needs are catered by a tricycle and

jeepney which they own.

B.FAMILY HEALTH - ILLNESS HISTORY

When the researchers interviewed Mr. Juan Dela Cruz regarding his parents, he

mentioned that both of his parents died of heart attack, when asked about the reason

regarding the real cause of his parents heart attack, Mr. Dela Cruz cannot give the

researchers a concrete answer, as according to him he was just two years old when he

lost both of his parents. For the researchers to confirm the claim of Mr. Dela Cruz, the

researchers have interviewed his third sister when she visited him in the hospital.

According to his sister, she mentioned that their mother died of heart attack when she

was giving birth to Mr. Dela Cruz due to severely increased high blood pressure during

the delivery, wherein their mother refused a cesarean section as an alternative due to

financial constraints. It was discussed to them that one of them either their mother or

Mr. Dela Cruz will not survived, but their mother chose to save Mr. Dela Cruz. Two

9

years after his mother’s death, their father which has an existing hypertensive disease,

died also of heart attack. Since they lost their parents at a very young age, one of their

relatives on their paternal side adopted their two older sisters and lost their

communication with each other that is why when they are asked regarding the current

condition of their sisters, they do not really have an idea. On the other hand, Mr. Dela

Cruz and his third sister grew together. They were adopted by his uncle on their

maternal side. The researchers also asked Mr. Dela Cruz’ sister regarding the cause of

death of their grandparents on both paternal and maternal side. According to her, their

grandfather on their paternal side died of stroke and their grandmother died of Diabetes

Mellitus at a very advanced age. On the other hand, their grandfather on the maternal

side died of car accident and their grandmother died of advanced age, Rheumatoid

Arthritis, and Diabetes Mellitus. The researchers also interviewed his sister regarding

the health status of their uncles and aunties on both side. According to her, on the

paternal side, his father has three siblings composed of a 2 sisters and a brother, both

of her father’s sister died of hypertension, on the other hand her father’s brother, died of

diabetes mellitus. On the maternal side, her mother has 2 siblings, one male and one

female. Her mother’s sister died of stroke and his mother’s brother the one who adopted

them died of hypertension. The researchers also interviewed her regarding her current

health status and she said that currently she is suffering from Diabetes Mellitus Type 2.

10

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C. HISTORY OF PAST ILLNESS

During the interview, Mr. Juan dela Cruz reported that he had no history of

serious childhood illnesses. He had chicken pox, measles and sometimes experience

simple cough, colds and fever. They do not believe in albularyos and manghihilot. They

used to buy over – the – counter (OTC) drugs when someone in the family is sick such

as paracetamol for fever, neozep for colds and Mefenamic acid for pain. They also

utilize herbal medicines such as: Oregano and Lagundi for colds and cough and

Ampalaya for proper blood circulation and this would be prepared by means of boiling.

But in serious health cases, they immediately consult a doctor or rush to a nearest

hospital. Mr. Dela Cruz told the researchers that he used to have a regular check up

every 6 months. It was through one of his check up approximately five years ago when

it was learned that he has a diabetes mellitus type 2 after series of laboratory and

diagnostic procedures. It was also found out that he is already experiencing

Hypertensive Cardiovascular disease secondary to dyslipidemia. When the researchers

asked him regarding the results of the said laboratory and diagnostic procedures, he

mentioned that he already misplaced those documents. He mentioned that so as to

manage his condition and prevent aggravation of his condition, his doctor advised him

to take metformin 1 tablet three times a day. Metformin is an oral hypoglycemic agent to

control his blood glucose level and maintain it on the normal range. He was also given

simvastatin 80 mg tablet to be taken once a day before he sleeps to manage his blood

cholesterol level and prevent complication that may be brought about such as Coronary

artery disease. He was also advised to have a well balanced diet, with limitations on

dietary sodium and fat contents and have an active lifestyle by exercising al least 3 to 5

times a week for 15 minutes.

When the researchers asked him about his compliance to the prescribed

management, Mr. Dela Cruz was honest to say that he did not really follow the said

management religiously, and as a matter of fact, a year after, he developed an eye

complication which resulted to blurring of his vision aggravated also of his advancing

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age. He was advised to wear eyeglasses, currently his eyeglasses has a lens power of

250 on the left lens and 240 on the right lens.

D. HISTORY OF PRESENT ILLNESS

When Mr. Juan Dela Cruz was asked if he has previous hospitalization, he

mentioned that he was never been hospitalized before and this is his first

hospitalization. The researchers asked Mr, Juan Dela Cruz what made him consult a

doctor when he was diagnosed with Diabetes Mellitus type 2 approximately five years

ago (2004), he said that he is used to have his check up every six months but he failed

to have his check up a year before he was diagnosed of DM Type 2, Hypertensive

Cardiovascular disease secondary to dyslipidemia. When asked about what he felt

during that specific span of time, he mentioned that he never expected that what he was

actually experiencing during those times are already sign and symptoms of his disease

as he thought that those are normal changes in line with aging. He mentioned that he

frequently goes to the comfort room to urinate; he also mentioned that suddenly he was

so eager to drink a lot of fluids which according to him, normally he seldom drink water

after he eats. He also mentioned that he began to crave more for food as he felt that he

was always hungry. There are also these scenarios when he will feel sudden chest

tightness while watching television or while staying on their sari – sari store. He also

observed that most of the time he cannot sustain an activity like walking because he

easily gets tired. The day before he went to see his doctor, he experienced dizziness

and headache. Since his doctor found out that he is experiencing Diabetes Mellitus type

2 and hypertensive cardiovascular disease secondary to dyslipidemia. His doctor gave

him some medication (simvastatin and metformin) and diet prescription (low salt, low fat

and well – balanced diet), but Mr. Dela Cruz failed to comply religiously with these

treatment regimens which may have contributed to his present condition.

It was on November 25, 2009 when Mr. Dela Cruz accompanied by his daughter

went to a tertiary hospital in Angeles City due to chest pain few hours after he had a

petty quarrel with his wife. Approximately 2 hours prior to admission he felt dizzy and

13

intense headache so he took some paracetamol to relieve his headache but it was not

relieved. Then an hour prior to admission he felt abdominal discomfort but he just

ignored it; 45 minutes prior to admission he felt chest tightness, difficulty of breathing,

and excessive sweating. He became anxious and called his daughter. His daughter

panicked because he really looks so pale, they immediately asked for help and brought

him to the emergency department of the nearest private tertiary hospital.

Upon their arrival to the emergency department at around 9:00 pm, they were

interviewed regarding the chief complaints of Mr. Dela Cruz and obtained his vital signs;

his actual vital signs are as follows: T= 36.8°C, P= 105bpm, R= 25cpm and BP=

190/130mmHg, after which, the resident on duty on the emergency room immediately

ordered an ECG reading of the client and it revealed that the patient has marked ST

segment depression. This made them suspect that the patient is suffering from

myocardial infarction, as part of the standard of care in patient experiencing myocardial

infarction, the resident on duty placed him on O2 inhalation at 2LPM, he was attached to

cardiac monitor to continuously monitor the activity of his heart. An IV infusion of 1 liter

of PNSS was started and regulated KVO to initiate a route for drug administration. He

was also given morphine sulfate and Isosorbide Dinitrate (Isoket) drip for his chest pain.

Furosemide, metoprolol, and captopril were also given to the patient to control his high

blood pressure. Enoxaparin Sodium was also given to the patient to prevent further

thrombus formation. Serum Na, K, Mg, Ca, Creatinine, HGT, FBS, CBC with platelet

count together with Chest x- ray PA view were ordered for risk stratification, blood

specimen was immediately obtained. In line with this, to confirm the diagnosis of

myocardial infarction the physician ordered Serum Troponin T determination and blood

specimen was also immediately obtained. PT and aPTT were also ordered to have a

baseline data regarding the clotting ability of the patient.

Few minutes after, the client’s pulse rate suddenly became thready and weak

dropped to 60bpm, to prevent further decrease in the pulse rate of the patient, he was

given Atropine Sulfate. Few minutes after the administration of the drug, the patient’s

pulse rate became normal then became excessively high (200 bpm); ECG reading was

14

automatically printed through his cardiac monitor and revealed atrial fibrillation with

rapid ventricular response. As a management, lidocaine drip was initiated. With all the

management done, the patient was diagnosed to have Acute Coronary Syndrome, Non

ST elevation Myocardial Infarction, Community Acquired Pneumonia, Hypertensive

Cardiovascular Disease (HCVD) and Diabetes Mellitus type 2.

E. PHYSICAL ASSESSMENT

Lifted from the ER Notes

November 25, 2009 9:00 pm

Vital signs:

   T- 36.8°C

   P- 105 bpm 9:30 pm = 60 bpm

   R- 25 cpm

   BP- 190/130 mmHg 

GCS: 15 (E4V5M6)

(+) DM

(+)HPN

(+) dyslipidemia

(-) Allergy

Anicteric sclera

Pale conjunctiva

Symmetrical chest expansion with no retraction

Bibasal crackles

Heart is adynamic proportion,normal rate and rhyhtm, (-) murmur

Abdomen is flat and normal bowel sound, non globular not tender

Symmetrical extremities, full and equal pulses

(-) edema

15

Good skin turgor

Initial Doctor’s order:

O2 Inhalation via nasal cannula @ 2LPM

Start PNSS 1L x KVO

Morphine Sulfate (Avinza) 4mg IV PRN

Isosorbide Dinitrate (Isoket) D5W 90 cc +10g Isoket/soluset 1.5mg/hr

Furosemide (Lasix) 1 ampule now, then 40 mg/tab 1 tab for 3 days

Metoprolol (lopressor) 50 mg/tab ½ tab BID

Captopril (Capoten) 25 mg/tab ¼ tab q 12

Enoxaparin Sodium (Clexane) 0.4 cc SQ now then q 12

Chest X- ray PA view, CBC with platelet count, PT, aPTT, Troponin T.

Serum Na, K, Ca, Creatinine, FBS, HGT

November 26, 2009

Vital signs:

   T- 35.8°C

   P- 76 bpm

   R- 18 cpm

   BP- 100/70 mmHg 

GCS: 15 (E4V5M6)

General Appearance and Mental Status:

      During the assessment, Mr. Dela Cruz was wearing a hospital gown. He is

cooperative, coherent and oriented to person, place and time. He easily gets

tired even just for a couple of minutes of talking. He also exhibits thought

association and has a sense of reality. He has no difficulty recalling past and

present events. He is hooked to Oxygen via nasal cannula regulated at 2LPM, on

continuous cardiac monitoring, and with condom catheter attached to urine bag.

He stands 5 feet and 5 inches and weighs 59.09 kg with an ectomorph body

built. 

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HEAD AND FACE

Head

      His hair is grayish in color. It is evenly distributed and no presence of

dandruff was noted. No presence of infestations was noted. 

Skull and Face

      He has normocephalic skull and with smooth skull contour. No nodules and

masses were noted upon palpation. His face is symmetrical in shape and there is

no abnormal elevation or depression on the face. 

Eyes

      His eyebrows are symmetrically aligned with hair evenly distributed.

Eyelashes are also evenly distributed. Skin is intact, no discharges and no

discolorations are present at the surface of eyelids. Lids close symmetrically. He

has pink palpebral conjunctiva. His pupils constrict when looking at near objects

while they dilate when looking at far objects. According to the patient, he uses

eye glasses so he can read well. It was prescribed by his ophthalmologist 2

years ago. According to him, his eyeglass has a magnification grade of 250 on

the left eye and 240 on the right eye.

Ears

      His auricles are same as facial color and it is aligned with the outer canthus

of the eye. They are firm and not tender upon palpation. Pinna recoils after it is

folded. There is no presence of impacted cerumen. He can hear and respond

when he is asked. 

Nose

      His nose is straight and his septum is located in the midline. No deviations

have been observed in the shape, size and color of the external nose. No

17

discharges were noted and there is the absence of nasal flaring. Also, no

nodules and masses were noted upon palpation. 

Lips and Teeth

      Outer lips are symmetrical. He exhibits ability to move his lips. Inner lips and

buccal mucosa are uniform in color. He loss his 3 molars on the upper right and 2

molars on the lower left and 1 pre molar on the lower left. His tongue is in central

position and he can move it freely. 

 

NECK

Neck Muscle

      Neck muscles are equal in size. No masses and nodules were noted upon

palpation. Head movements are coordinated and he can move his head freely. 

Lymph Nodes and Thyroid gland

      Lymph nodes are not palpable and there is no enlargement noted upon

observation and palpation. Thyroid gland is not inflamed. 

THORAX AND LUNGS

Lungs

      There is full and symmetrical chest expansion. There is an effortless and

rhythmic respiration and bibasal crackles sounds were heard upon auscultation

of the lungs. 

Heart

      Regular rhythm of apical pulse was noted upon auscultation point of maximal

impulse is located on the 6th intercostals space. 

Abdomen

      No distention and presence of lesions and masses were observed. He has

normoactive bowel sounds. 

18

Skin

      He has brown-colored skin which is generally uniform except in areas of

lighter pigmentation such as the palms, lips and nail beds. No abrasions and

edema have been noted. He has good skin turgor, which turned back to previous

state in less than 2 seconds when pinched.  

Extremities

      Peripheral pulses are in full pulsations. Limbs are not tender and no edema is

present at extremities. 

Fingernails

      His nail plates are colorless and have concave curves. They are slightly long

and untrimmed. His nail beds returned to previous state in less than two seconds

after pressure was applied. 

Neurological Assessment

Cranial Nerve I

Name: Olfactory

Type: Sensory

Function: Smell

Actual Findings: the patient was able to identify the odor of the alcohol and

perfume.

Cranial Nerve II

Name: Optic

Type: Sensory

Function: Vision and visual fields

Actual Findings: as observed by the student nurse and assessed, the patient

has difficulty in reading the newsprint since the patient is not wearing his

eyeglasses.

Cranial Nerve III

Name: Oculomotor

19

Type: Motor

Function: Extra ocular eye movement, movement of sphincter of pupil,

movement of ciliary muscles of lens.

Actual Findings: Pupils are round and black in color; pupils’ constricted upon

light accommodation and dilated upon removal of light and when looking at near

objects and dilates when not illuminated and when looking at far objects.

Cranial Nerve IV

Name: Trochlear

Type: Motor

Function: Extra ocular eye movement, specifically, movement of eyeballs

downward and laterally.

Actual Findings: Mr. Dela Cruz can move his eyes downward and laterally

without difficulty.

Cranial Nerve V

Name: Trigeminal

Type:  Sensory and Motor

Function: Sensation of the cornea, skin of the face, nasal mucosa, anterior oral

cavity and muscles of mastication.

Actual Findings: the student nurse was not able to test for blink reflex. There

are no difficulties in chewing observed. The patient can feel or respond to deep

touch. 

Cranial Nerve VI

Name: Abducens

Type: Motor

Function: Moves eyeball laterally

Actual Findings: Mr. Dela Cruz can follow the movement of penlight laterally.

Cranial Nerve VII

Name: Facial

Type: Motor and Sensory

Function: Facial expression, taste (anterior 2/3 of the tongue)

20

Actual Findings: Mr. Dela Cruz does not have difficulty in doing facial

expression. He does not have difficulty in his taste sensation.

Cranial Nerve VIII

Name: Acoustics

Type: Sensory

Function: Hearing

Actual Findings:  He does not have difficulty in hearing and he also was able to

respond to some questions asked.

Cranial Nerve IX

Name: Glossopharyngeal

Type: Motor and Sensory

Function: Swallowing ability, tongue movement, taste (posterior tongue)

Actual Findings: He does not have difficulty in swallowing although He does not

have difficulty in taste sensation. He does not have any difficulty in speaking.

Cranial Nerve X

Name: Vagus

Type: Motor and Sensory

Function: Sensation of pharynx and larynx, swallowing and vocal cord

movement.

Actual Findings: No hoarseness of voice when speaking. The student nurse

was not able to test for gag reflex.

Cranial Nerve XI

Name: Accessory

Type: Motor

Function: Head movement and shrugging of the shoulders.

Actual Findings: He can turn his head on each side and can elicit elevation of

shoulders.

Cranial Nerve XII

Name: Hypoglossal

Type: Motor

21

Function: Protrusion of tongue, movement of the tongue upward, downward and

laterally.

Actual Findings: Mr. Dela Cruz can move his tongue freely.

November 28, 2009 

Vital signs:

   T- 36°C

   P- 77 bpm

   R- 20 cpm

   BP- 100/70 mmHg 

GCS: 15 (E4V5M6)

General Appearance and Mental Status:

      During the assessment, Mr. Dela Cruz was wearing a hospital gown. He is

cooperative, coherent and oriented to person, place and time. He easily gets

tired even just for a couple of minutes of talking. He also exhibits thought

association and has a sense of reality. He has no difficulty recalling past and

present events. He is hooked to Oxygen via nasal cannula regulated at 2LPM, on

continuous cardiac monitoring, and with condom catheter attached to urine bag.

HEAD AND FACE

Head

      His hair is grayish in color. It is evenly distributed and no presence of

dandruff was noted. No presence of infestations was noted. 

Skull and Face

      He has normocephalic skull and with smooth skull contour. No nodules and

masses were noted upon palpation. His face is symmetrical in shape and there is

no abnormal elevation or depression on the face. 

22

Eyes

      His eyebrows are symmetrically aligned with hair evenly distributed.

Eyelashes are also evenly distributed. Skin is intact, no discharges and no

discolorations are present at the surface of eyelids. Lids close symmetrically. He

has pink palpebral conjunctiva. His pupils constrict when looking at near objects

while they dilate when looking at far objects. According to the patient, he uses

eye glasses so he can read well. It was prescribed by his ophthalmologist 2

years ago. According to him, his eyeglass has a magnification grade of 250 on

the left eye and 240 on the right eye.

Ears

      His auricles are same as facial color and it is aligned with the outer canthus

of the eye. They are firm and not tender upon palpation. Pinna recoils after it is

folded. There is no presence of impacted cerumen. He can hear and respond

when he is asked. 

Nose

      His nose is straight and his septum is located in the midline. No deviations

have been observed in the shape, size and color of the external nose. No

discharges were noted and there is the absence of nasal flaring. Also, no

nodules and masses were noted upon palpation. 

Lips and Teeth

      Outer lips are symmetrical. He exhibits ability to move his lips. Inner lips and

buccal mucosa are uniform in color. He loss his 3 molars on the upper right and 2

molars on the lower left and 1 pre molar on the lower left. His tongue is in central

position and he can move it freely. 

 

NECK

23

Neck Muscle

      Neck muscles are equal in size. No masses and nodules were noted upon

palpation. Head movements are coordinated and he can move his head freely. 

Lymph Nodes and Thyroid gland

      Lymph nodes are not palpable and there is no enlargement noted upon

observation and palpation. Thyroid gland is not inflamed. 

THORAX AND LUNGS

Lungs

      There is full and symmetrical chest expansion. There is an effortless and

rhythmic respiration and bibasal crackles sounds were heard upon auscultation

of the lungs.  

Heart

      Regular rhythm of apical pulse was noted upon auscultation point of maximal

impulse is located on the 6th intercostals space. 

Abdomen

      No distention and presence of lesions and masses were observed. He has

normoactive bowel sounds. 

Skin

      He has brown-colored skin which is generally uniform except in areas of

lighter pigmentation such as the palms, lips and nail beds. No abrasions and

edema have been noted. He has good skin turgor, which turned back to previous

state in less than 2 seconds when pinched.  

Extremities

      Peripheral pulses are in full pulsations. Limbs are not tender and no edema is

present at extremities. 

24

Fingernails

      His nail plates are colorless and have concave curves. They are slightly long

and untrimmed. His nail beds returned to previous state in less than two seconds

after pressure was applied. 

Neurological Assessment

Cranial Nerve I

Name: Olfactory

Type: Sensory

Function: Smell

Actual Findings: the patient was able to identify the odor of the alcohol and

perfume.

Cranial Nerve II

Name: Optic

Type: Sensory

Function: Vision and visual fields

Actual Findings: as observed by the student nurse and assessed, the patient

has difficulty in reading the newsprint since the patient is not wearing his

eyeglasses.

Cranial Nerve III

Name: Oculomotor

Type: Motor

Function: Extra ocular eye movement, movement of sphincter of pupil,

movement of ciliary muscles of lens.

Actual Findings: Pupils are round and black in color; pupils’ constricted upon

light accommodation and dilated upon removal of light and when looking at near

objects and dilates when not illuminated and when looking at far objects.

Cranial Nerve IV

Name: Trochlear

Type: Motor

25

Function: Extra ocular eye movement, specifically, movement of eyeballs

downward and laterally.

Actual Findings: Mr. Dela Cruz can move his eyes downward and laterally

without difficulty.

Cranial Nerve V

Name: Trigeminal

Type:  Sensory and Motor

Function: Sensation of the cornea, skin of the face, nasal mucosa, anterior oral

cavity and muscles of mastication.

Actual Findings: the student nurse was not able to test for blink reflex. There

are no difficulties in chewing observed. The patient can feel or respond to deep

touch. 

Cranial Nerve VI

Name: Abducens

Type: Motor

Function: Moves eyeball laterally

Actual Findings: Mr. Dela Cruz can follow the movement of penlight laterally.

Cranial Nerve VII

Name: Facial

Type: Motor and Sensory

Function: Facial expression, taste (anterior 2/3 of the tongue)

Actual Findings: Mr. Dela Cruz does not have difficulty in doing facial

expression. He does not have difficulty in his taste sensation.

Cranial Nerve VIII

Name: Acoustics

Type: Sensory

Function: Hearing

Actual Findings:  He does not have difficulty in hearing and he also was able to

respond to some questions asked.

26

Cranial Nerve IX

Name: Glossopharyngeal

Type: Motor and Sensory

Function: Swallowing ability, tongue movement, taste (posterior tongue)

Actual Findings: He does not have difficulty in swallowing although He does not

have difficulty in taste sensation. He does not have any difficulty in speaking.

Cranial Nerve X

Name: Vagus

Type: Motor and Sensory

Function: Sensation of pharynx and larynx, swallowing and vocal cord

movement.

Actual Findings: No hoarseness of voice when speaking. The student nurse

was not able to test for gag reflex.

Cranial Nerve XI

Name: Accessory

Type: Motor

Function: Head movement and shrugging of the shoulders.

Actual Findings: He can turn his head on each side and can elicit elevation of

shoulders.

Cranial Nerve XII

Name: Hypoglossal

Type: Motor

Function: Protrusion of tongue, movement of the tongue upward, downward and

laterally.

Actual Findings: Mr. Dela Cruz can move his tongue freely.

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