Assessment Tool:

PAIN AND DISCOMFORT

Client verbalized the presence of pain. Pain was characterized as sharp,
intermittent, localized aggravated by movement and relieved by rest and rated as
7/10. No pharmacologic interventions were done for pain. Client seen with tophi on
left elbow characterized as firm, non-movable approximately 3-4cm in diameter.
Nursing Diagnoses:
Acute Pain
HEENT
No abnormal facial discoloration was noted however, patient complained of
headache and dizziness with associated increase in blood pressure (200/90 mmHg).
No infestations and significant abnormalities were noted in hair and scalp. Client
verbalized ability to see objects but noted a decrease in acuity due to age-related
reasons. Ears were intact and with no discharges and hearing problems. No
complaints of nasal congestion, bleeding or problems regarding the nose were
noted. Lips are intact and pinkish. Client with moist mucus membranes. Client also
verbalized presence of occasional nape pain together with a high blood pressure. No
medications or interventions were done during episodes of pain associated with
high blood pressure

NEURO
Patient is oriented to all aspects with a GCS score of 15. Clients speech is normal.
Pupils are equal, round and reactive to light and accommodation. No abnormal
findings were noted in the cranial nerves. Client is able to swallow ingested food or
water without difficulty. Client is calm during the interview and does not exhibit
misbehaviors. Client experiences headache and nape pain usually when with high
blood pressure. Client did not seek any consult and did not use any medication.

MUSCULO-SKELETAL
Client able to do full ROMs and is able to move without restrictions or difficulty.
Client with adequate muscle mass and does not require the use aids or assistive
devices. Client has a tophi found in the left elbow where pain is felt at times.
Clients posture, gait and coordination is normal. Client does not make use of
medications and has not sought any consult regarding tophi.

RESPIRATORY
Client reported absence of respiratory difficulty. Client manifests a respiratory rate
of 21 with regular rhythm, depth and quality. With symmetrical expansion of chest
during respiration. Client does not complain of DOB or cough. Client is pinkish with
no signs of cyanosis or pallor.

CARDIOVASCULAR
Client reported previous problems regarding hypertension. Client did not verbalize
presence of palpitations or chest pains but complained of nape pain, headache and
dizziness/ with a capillary refill of less than 2 seconds. Clients BP was 200/90 and
HR was 65bpm. No other abnormalities were noted. Peripheral pulses were strong
and bounding. No edema was noted. Client has not sought consult regarding
problem and did not take any medications for HPN.
Nursing diagnoses:
Ineffective peripheral tissue perfusion
Decreased Cardiac Output
GIT AND GUT
Client is able to swallow and ingest food normally. Client eats three times a day
consuming 75-100% of foods served. Clients diet is composed of a variety of meat,
vegetable, rice and water. Client usually eats and prefers eating organ meats and
occasionally eats beans and legumes. Client does not appear to be too large for
age. Client did not report any GI problems and problems regarding GI were not
noted. Patient verbalized daily bowel movement and normal voiding patterns. No
medications affecting the GIT and GUT were used.

REPRODUCTIVE SYSTEM
No significant data regarding current condition

INTEGUMENTARY SYSTEM
Clients temperature within normal limits during days of interview and home visit.
With good skin turgor andwith moist skin. Client seen with tophi on left elbow. No
ulcerations and other wounds were noted.

PSYCHOSOCIAL ASSESSMENT

Client verbalized inability to consult physician regarding hypertension and tophi on

elbow. Client also resisted advice regarding seeking consult at the nearest health
clinic. Reasons were due to distance and laziness. Client appears to be in a calm
state however is usually hesitant in allowing the taking of his blood pressure. Patient
verbalized ability to sleep however pain may affect sleep. Client is the breadwinner
and head of the family. He currently resides with his family.