INITIAL DATABASE FOR CAYLALUAD FAMILY

A. Family Structure, Characteristics, and Dynamics The family structure is nuclear. According to Mrs. Maritess, they are happily in love with each other even if they are not legally married. Their civil status is single but they consider their relationship as live in partners. They have been living in San Juan City for six years now. According to Mrs. Maritess, they formerly lived in Maypajo, Malabon but they just transferred at #104 A. Lake, San Juan City because her husbands work is located near the area. Her husbands boss allowed them to live in the house for free so that he could easily communicate with Mr. Caylaluad during emergencies. The primary dialect they use is Tagalog. Mrs. Maritess mentioned that they sometimes speak Waray when they are talking to people who also speak the same dialect. In terms of making decisions, every member of the family has the right to speak and air their side but the final decision still comes from Mrs. Maritess husband. Her primary role is to take care of the children and budget the money for every day expenses. She mentioned that she disciplines the children by nagging them since it is what she is already accustomed with. She also said that even if she does that, she still loves her children very much. She only does that so that her children could listen. Mrs. Maritess verbalized, Makukulit kasi masyado. Mga bata pa kasi. When it comes to her relationship with her husband, she mentioned they are both happy. When she was asked of the usual things that they are having problems with, she mentioned, Wala naman. Kapag walang pera siguro. Pagkatapos nun, okay na kami. According to Mrs. Maritess, when the salary is insufficient for them, she borrows money from her neighbor whose business is lending money. This action is her primary solution to her problem. When asked if borrowing money causes problems to them, she said, Hindi naman. Nasosolve nga nun yung problema namin eh.

B. Socio-economic and Cultural Characteristics The familys monthly income is approximately P8000/month. The head of the family, Danilo Caylaluad, is their source of income. He has been a jeepney driver for almost 3 years now. He usually makes decisions about the money and how it is being spent. The familys expenditures are food, electricity, water, education, and medications. They spend P200 a day for their food and P100 a day for the expenses of their children in school. Every month, her wife, Mrs. Maritess Caylaluad, pays P1000 for the electricity and another P1000 for their water bill. Most of the time, their children acquires cough and colds so they spend P200 a month for the medications of the children. When asked about the prioritization of their monthly expenditures, Mrs. Maritess answered, Siyempre pagkain muna. Yun ang pinakaimportante tapos yung gamut ng mga anak ko kasi palagi silang nagkakasakit. Pangatlo yung tubig tapos kuryente at panghuli

yung mga baon ng anak ko sa eskuwelahan. For her, their monthly income is not adequate to meet their basic necessities because of their family size. Danilo Caylaluad is a high school graduate. Mrs. Maritess finished until Grade 3 Two of their children are in the elementary level. Danica is currently in Grade 4 and Danilyn is in Grade 2. The family belongs to an ethnic group which is Waray and their religious orientation is Roman Catholic. Mrs. Maritess is the one who takes care of their children. She prepares her children for school, does the household chores and also washes their clothes. We often notice that she washes their clothes and do their household chores. She also fetches her children from school. This is her daily routine while her husband is the one who earns their money and their source of living. She can also recognize some leaders such as the Barangay Captain, Mr. Gorayeb and Lilia Rosario, the officer in charge in DSWD. She mentioned that the barangay captain is not an effective leader because he is only active in their barangay when the election is near. She also mentioned that Lilia Rosario is an effective leader. Mrs. Maritess Caylaluad belongs to an organization in their barangay called the Pink Lady. She knows about the feeding program but when asked if it is effective, she verbalized, Minsan hind. Wala kasi sila tsaka busy sila. The barangay communication system is effective according to her and information dissemination is done through house to house basis.

C. Home and Environment The size of their house is not adequate for their family. The measurement of their house is approximately 5 meters in width and almost 9 meters in length. Although their children are still young and small, their house is still insufficient for them to feel comfortable. Their house is located at A. Lake Street. They are residing in a one big 2-storey house which consists of 19 families upstairs and 9 families in the ground area. They do not pay for the rent because of her husbands work plus they do not own the land as well. Their room is the fifth from the main door adjacent to the comfort room. The house is made of mixed materials. The flooring and the wall is made of cement while the ceiling is made of wood. They use tarpaulin as the cover of their door. Before entering the house, we have noticed that the flooring is inclined and slippery. They do not have any window inside the house which makes it poorly ventilated. The house is also smelly and the smell is very unpredictable. We did not ask them if they can smell it since they might be offended. When asked as to why there are no windows inside the house, Mrs. Maritess answered, Wala na kasi malalagyan at saka dulo na kami. Pag naglagay kami ng bintana, mabubutas ang dingding ng tabing bahay namin They have one electric fan in their living room and one inside their bedroom. Their source of lighting is via electricity. Their comfort room is shared by all other families living there and the excreta disposal is pail system. The sewage system is a blind drainage type. Mrs. Maritess mentioned, May mga tubo diyan sa

ilalim niyan. The house is tightly spaced. When you enter the house, the kitchen will already be visible. They dont have a dining room and only has one bedroom. Mrs. Maritess verbalized, Tabi-tabi kaming natutulog ng limang anak ko tsaka ng asawa ko. Komportable naman kami. Siksikan pero ganun talaga. When asked if she considers it a problem, she said, Oo kaso wala naman kaming magagawa. Pinatira lang kami dito kaya pwede na rin. She sleeps at around 8:00 p.m. in the evening and wakes up at 5:00 a.m. When it comes to vectors like cockroaches, rats, mosquitoes and flies inside the house, she mentioned, Nagkakaroon ng ipis kasi may pagkain at makalat ang bahay. Marami ring pumapasok na langaw dito lalo na kapag baha sa labas. They do preventive measures such as spraying inside but she verbalized, Minsan hindi mo talaga maiiwasang lumabas yang mga ipis na yan. May panahon talaga na bigla silang naglalabasan. There are breeding sites inside the house as well. Their things are disorganized the laundry is sometimes done inside the house which can cause stagnant water to accumulate. This is another source of breeding site for mosquitoes. Another cause is because the house is adjacent to the comfort room and excess water flows from the comfort room to the house. They use plastic as their trash can which is located inside their house. They do not segregate the trash. Mrs. Maritess verbalized, Mas madali kasi kapag sa plastic lang para diretso na sa trak yung basura. Their source of drinking water is from a covered container which is commercially prepared. When she was still bottle-feeding her youngest child, she heats the water until it boils. She verbalized, Ilang buwan lang yung pagpapagatas ko sa bote. Mas gusto ko kasi na sa akin siya dumidede. The foods they usually eat are meat and fish. She said, Bumibili lang kami ng lutong pagkain sa karinderya. Mrs. Maritess also mentioned, Wala ng natitirang pagkain sa amin kapag binibili namin sa karinderya. Kakainin na namin tapos ubos na agad. When asked where she places the excess food, she replied, Sa lamesa lang tapos tatakpan para hindi madapuan ng langaw. The house itself is congested because they are more than 20 families living in a big house which is only divided into smaller rooms to house all of them in. BEDROOM 9 METERS

5 METERS

KITCHEN

CABINET

TABLE

D. Health Status of each Family Member Presently the family is in good condition. The family members undergone complete immunization when they are still young. They dont have the habit of smoking and drinking liquors. Mr. Danilo the head of the family has asthma and migraine which he inherited. The disease that had been in their family last year until present was chicken pox, fever, cough and colds. Four members in the family specifically the children got chicken pox and Danilyn second child in the family has asthma. Whenever one member of the family got cough and colds they drink calamansi juice to recover it. When there was illness in the family they usually take paracetamol. The family also goes to the health center when needs arises. They eat three times a day and they usually eat fish dish. Usually there is no left or wasted food when they eat because sometimes the food they eat is not enough for them said by the mother. The children looks thin, the nails are long and they often play outdoors when their mother is busy washing their clothes. Anthropometric data: Danilo (head of the family) 34 years old was 70 kg of weight., Mrs. Marites 34 years old has 64 kg, Danica 9 years old eldest daughter was 27 kg, second is Danilyn 8 years 24 kg, third is Maricar 6 years old which is 16.7 kg, fourth is Marlon 4 years old 15 kg, and fifth is Diane 2 years old 11.9 kg of weight. E. Values, Habits, Practices on Health Promotion, Maintenance of Health and Disease Prevention

The five children had completed vaccination. Aling Marites assures that her five children had completed their vaccine namely, BCG, DPT, OPV, HepB, Measles. When there is someone who is sick, they go to the center for check-up. The family dont do exercise. Aling Marites verbalized, wala na akong time sa pag eehersisyo, sa pag aalaga pa lang ng bata wala na akong oras. But she do considers walking, doing household chores, and laundry as an exercise. When aling Marites gets tired, she only sits and take a rest. She doesnt take any medicine. The family does not have any recreational activity. They dont have time for bonding moments. Aling Marites added, kapag ganitong oras, ganito lang ginagawa naming nakaupo sa labas, minsan pag araw ng laba, naglalaba ako tapos yung mga bata nandyan sa labas nakikipaglaro sa mga pinsan nila. Pero minsan natutulog sila kapag pagdating galling ng eskwela. The whole family takes a bath once a day but if one of the member in the family is sick, he/she will not take a bath. Tulad nung may bulutong siya di ko siya pinapaliguan kapag may lagnat sila pero pag wala pinapaliguan ko nay an kasi Makati yung katawan nila she added. They do wear slippers outside but Diane and Marlon do not wear slippers. They dont wear slippers inside the house which is not proper and hygienic. They are in touch with the microorganisms on the floor and may cause them to have flat worms on their stomach

FIRST LEVEL ASSESSMENT HEALTH PROBLEM Inadequate living space as a health threat CUES Subjective: Aling Marites verbalized, tabi tabi kaming natutulog ng limang anak ko tsaka ng asawa ko. Komportable naman kami. Siksikan pero ganun talaga Objective: I noticed that the space of their home is not adequate for them because it should be 6 square meters per individual but they are 4 individuals living there and they only have 12 square meters. Subjective: I asked them why they dont have any window, aling Marites verbalized, Wala na kasing malalagyan e, tsaka sa dulo na kami pa, pag naglagay kami ng bintana mabubutas yung dingding ng tabing bahay namin. Objective: They do not have any window inside their house which made it poorly ventilated. The house was smelly, I cant predict what the smell was, but it is so awkward. I didnt ask them if they can smell it because they might be offended. They only have one electric fan in their living room and one in their bedroom. Subjective: I asked aling Marites why they do not segregate their trash, she answered, Mas madali kasi kapag sa plastic lang para diretso na sa trak. Objective: When it comes to garbage disposal, they use plastic as their trash can located inside their house and without cover. Objective: Before you enter their house, the flooring was slippery and inclined. Subjective : I asked her what does she think is the possible reason why there are pests in their house like cockroaches, rats, flies, and mosquitoes, she verbalized Nagkakaron ng ipis kasi may pagkain at makalat ang bahay atsaka marami ring pumapasok na langaw rito lalo na kapag baha sa labas. They do preventive measures such as spraying insecticides. Hindi mo talaga maiiwasang lumabasa yang mga ipis nay an e. May panahon talaga na bigla silang naglalabasan. Aling Marites

Poor ventilation as a health threat

Improper garbage disposal as a health threat

Fall hazard as a health threat

Presence of breeding sites of vectors of diseases

added. Objectives: There are breeding sites inside their house. Their things are disorganized. Sometimes she does her laundry inside their house which can cause of having stagnant water that might become a breeding site of mosquitoes. Another problem is that their room is adjacent to the comfort room, excess water flowing from there might be another breeding site.

Cross Infection from a communicable disease as a health threat

Most of the times her children get cough and colds. So she spends P200 a month for their medication.

Family size beyond what family resources can adequately provide

Their monthly income is not enough to meet their basic necessities and also because of their family size. Usually there is no wasted food when they eat because its just enough for them. According to her, when her salary is insufficient, she would borrow from her neighbor.

Illness state as health deficit

Mr. Danilo, the head of the family has asthma and migraine. According to aling Marites, it was an inherited illness. Children in the family got chicken pox and Danilyn has asthma.

SECOND LEVEL ASSESSMENT Health problem Inadequate living space as a health threat Inability to make decisions with respect to taking appropriate health action due to: Failure to comprehend the nature/magnitude of the problems. Poor Ventilation as a health threat Inability to provide a home environment conducive to health maintenance and personal Cues Subjective: tabi tabi kaming natutulog ng limang anak ko tska ng asawa ko. Komportable naman kami, siksikan pero ganun talaga. When I asked her if she considers it as a problem she said Oo, kaso wala naman kaming magagawa, pinatira lang naman kami ditto kaya pwede na rin. Subjective: I asked them why they dont have any window, aling Marites verbalized, Wala na kasing

due to: Inadequate family resources, specifically limited physical resources.

malalagyan e, tsaka sa dulo na kami pa, pag naglagay kami ng bintana mabubutas yung dingding ng tabing bahay namin.

Improper garbage disposal as a health threat Inability to recognize the presence of the condition due to: Inadequate knowledge Attitude in life which hinders recognition of a problem. Fall hazard as a health threat Inability to make decisions with respect to making appropriate health action due to: Inadequate manpower resources Presence of breeding sites of vectors of diseases Inability to make decisions with respect to taking appropriate health action due to: Inadequate manpower resources

Subjective: I asked aling Marites why they do not segregate their trash, she answered, Mas madali kasi kapag sa plastic lang para diretso na sa trak. Every other day, garbage truck collects their trash.Hindi naman mahirap magtapon, ilalagay lang naming sa kanto yung basura naming tapos dadaanan nang truck yung basura. Objective: Before you enter their house, the flooring was slippery and inclined.

Objectives: There are breeding sites inside their house. Their things are disorganized. Sometimes she does her laundry inside their house which can cause of having stagnant water that might become a breeding site of mosquitoes. Another problem is that their room is adjacent to the comfort room, excess water flowing from there might be another breeding site.

Cross infection from a communicable disease as a health threat Inability to make decisions with respect to taking appropriate health action due to: Failure to comprehend the nature of the problem Low salience of the problem Inadequate knowledge to as to alternative courses of action. Lack of trust/confidence to the health personnel. Inability to provide adequate nursing care to the sick due to: Inadequate knowledge about child development and care. Inadequate knowledge of the nature and extent of nursing care needed. Lack of necessary facilities, equipment and supplies for care.

Most of the times her children get cough and colds. So she spends P200 a month for their medication.

Lack of knowledge and skills in carrying out the necessary interventions. Inadequate family resources for care specifically financial constraints.

Inability to provide a home environment conducive to health maintenance and personal equipment due to: Inadequate family resources specifically financial constraints. Inadequate knowledge about hygiene and sanitation. Inadequate knowledge of preventive measures. Lack of skill in carrying out measures to improve home environment.

Failure to utilize community resources for health due to: Lack of trust/confidence to the health personnel. Unavailability of required care/service. Lack of family resources specifically financial resources. Their monthly income is not enough to meet their basic necessities and also because of their family size. Usually there is no wasted food when they eat because its just enough for them. According to her, when her salary is insufficient, she would borrow from her neighbor.

Family size beyond what family resources can adequately provide Inability to recognize the presence of the condition due to: Lack of knowledge Inability to make decisions with respect to taking appropriate health action due to: Low salience of the problem Lack of knowledge as to alternative courses of action open to them. Lack of knowledge about the community resources about care

Illness state as health deficit

Inability to recognize the presence of the condition due to: Lack of knowledge

Inability to make decisions with respect to taking appropriate health action due to: Low salience of the problem Lack of knowledge as to alternative courses of action open to them. Inadequate knowledge about community resources for care. Inability to decide which action to take from among the list of alternatives. Fear of consequences of action specifically: economic, physical, emotional and psychological consequences. Inability to provide adequate care to the sick, disabled, dependent, or at risk member of the family due to: Lack of knowledge about disease or health condition Lack of knowledge about the nature and extent of nursing care needed Lack of necessary facilities, equipment and supplies for care. Lack of knowledge and skills in carrying out the necessary interventions.

Family 3-DAY DIET RECALL

Breakfast

Friday 8 cups of rice 8 pieces of hotdog 4 pieces of egg Water Nilagang Baboy 7 cups of rice Water 10 pieces of bread 6 glasses of juice Adobong Sitaw 6 cups of rice water

Saturday 4 packs of Chicken noodles Water

Sunday 15 pieces of pandesal Margarine Water Coffee Pinakbet 6 cups of rice Water 3 pack of Pancit Canton Water Tinolang Manok 6 cups of rice water

Lunch

Snack

6 Pritong Tilapia 6 cups of rice Water 5 pieces of Banana cue Water Ginisang Patola 6 cups of rice water

Dinner

CAYLALUAD FAMILY

Celso

Teresita

Roberto

Maria

Danilo

Maritess

Legend: X Deceased - Male - Female

Danica

Danilyn

Maricar

Marlon

Diane

Problem Prioritization Family size beyond what family resources can adequately provide as health threats Criteria 1. Nature of the problem 2. Modifiability of the problem Computation 2/3x1 Actual score 2/3 Justification A health threat that doesnt demand immediate action The family has an inadequate knowledge about the existence of the problem and the interventions to solve it There is a possibility of further increasing the family size due to unrecognized problem The family doesnt recognize the problem

1/2x1

3. Preventive potential 4. Salience of the problem Total score

1/3x1

1/3

0/2x1

0 2

Cross contamination of communicable diseases as a health threat Criteria 5. Nature of the problem 6. Modifiability of the problem Computation 2/3x1 Actual score 2/3 Justification A health threat that doesnt demand immediate action

1/2x1

The family has an insufficient living space which is important on the management of cross contamination of communicable diseases.

7. Preventive potential

3/3x1

Prevention for cross contamination is can be reduce by adequate hygiene and space isolation.

0/2x1 8. Salience of the problem Total score

1/2

The family does recognize the problem but perceived not needing immediate action

3 1/6

Case of asthma for some of the family members as a health deficit Criteria 1. Nature of the problem 2. Modifiability of the problem 3. Preventive potential 4. Salience of the problem Total score Computation 3/3x1 Actual score 1 Justification A health threat that demands immediate action The family has available resources but inadequate knowledge about the solution of the case.

1/2x1

2/3x1

2/3

Though asthma is a hereditary disease, proper interventions are readily available for the management. The family recognize the problem to be in need immediate attention

2/2x1

3 2/3

Chicken fox of a member for health deficit and health threat for other member Criteria 1. Nature of the problem 2. Modifiability of the problem 3. Preventive potential 4. Salience of the problem Total score Computation 3/3x1 Actual score 1 Justification A health deficit that demands immediate action to prevent cross contamination. The family has limited resources to modify the problem like living space and hygiene Isolation is needed to prevent cross infection to other family members The family recognize the problem to be in need immediate attention

1/2x1

3/3x1

2/2x1

1 4

Inadequate living space as a health threat Criteria 1. Nature of the problem 2. Modifiability of the problem 3. Preventive potential Computation 1/3x1 Actual score 2/3 Justification A health threat that doesnt demand immediate action The family has limited financial resources to modify the problem. Increasing the living space of the family will allow health appraisal and prevent transferability of the current infection. The family recognize the problem as not requiring immediate attention

1/2x1

3/3x1

4. Salience of the problem Total score

1/2x1

1/2 3 1/6

Poor ventilation as a health threat Criteria 1. Nature of the problem 2. Modifiability of the problem 3. Preventive potential 4. Salience of the problem Total score Computation 2/3x1 Actual score 2/3 Justification A health deficit that doesnt demands immediate action. The family has limited resources to modify the problem. Good ventilation is easily achievable if resources are available. Good ventilation also increases health status. The family doesnt recognize the problem to be in need immediate attention 3 1/6

2/2x2

3/3x1

1/2x1

1/2

Improper garbage disposal as a health threat Criteria 1. Nature of the problem 2. Modifiability of the problem 3. Preventive potential 4. Salience of the problem Total score Computation 2/3x1 Actual score 2/3 Justification A health deficit that doesnt demand immediate action. The family has available resources but inadequate knowledge about problem solving Proper garbage disposal can be done on many ways and can eliminate vectors infestation The family doesnt recognize the problem to be in need immediate attention

2/2x1

3/3x1

1/2x1

1/2 3 1/6

Fall hazard as a health threat Criteria 1. Nature of the problem 2. Modifiability of the problem 3. Preventive potential 4. Salience of the problem Total score Computation 2/3x1 Actual score 2/3 Justification A health deficit that doesnt demands immediate action. The family has available resources but inadequate knowledge about problem solving Fall injury can be avoided with proper reconstruction.

2/2x1

3/3x1

1/2x1

1/2 3 1/6

The family doesnt recognize the presence of the problem

Presence of breeding site for vectors as a health threat Criteria 1. Nature of the problem 2. Modifiability of the problem 3. Preventive potential 4. Salience of the problem Total score Computation 2/3x1 Actual score 2/3 Justification A health deficit with ineffective intervention The family has available resources but has inadequate knowledge about problem solving

2/2x1

3/3x1

Cleanliness can deter the presence of vectors and their breeding sites. The family recognize the presence of the problem but only do ineffective action

1/2x1

1/2 3 1/6

Prioritized Problem Family size beyond what family resources can adequately provide as health threats Cross contamination of communicable diseases as a health threat Case of asthma for some of the family members as a health deficit Chicken fox of a member for health deficit and health threat for other member Inadequate living space as a health threat Poor ventilation as a health threat Improper garbage disposal as a health threat Fall hazard as a health threat Presence of breeding site for vectors as a health threat 2 4 3 2/3 3 1/6 3 1/6 3 1/6 3 1/6 3 1/6 3 1/6

Health problem

FAMILY NURSING PROBLEMS

GOAL OF CARE

OBJECTIVES OF CARE

INTERVENTION MEASURES

RATIONALE

Chickenpox as a health deficit to four family members and health threat to others

After nursing intervention the family will take necessary measures to prevent or properly manage Chickenpox 1. Inability to recognize the possibility of cross infection of chickenpox to the other members due to lack of knowledge

After nursing intervention the family will be able to:

METHOD OF NURSEFAMILY CONTACT Home visit and Review on health condition of the clients through medical report

RESOURCES REQUIRED

EVALUATIO N

Material resources: Visual aids and materials needed for teaching

1. Correct wrong 1. Discuss with the actions about family the nature, chickenpox causes, signs and symptoms of Chickenpox and the consequences of failure to take appropriate action on the problem

2. Inability to provide adequate nursing care to the sick, dependent or vulnerable member of the family due to: a. Lack of

2. Apply therapeutic measures, including skin care to manage adequately the chickenpox of the four

2. Discuss with the family the possible ways of providing adequate treatment of chickenpox utilizing less expensive drugs and supplies and emphasize the importance of personal hygiene and proper washing of clothes and

Lecture can be defined as highly structured method by which the teacher verbally transmits information directly to groups of learners for the purpose of instruction. (Nurse as Educator Principles of Teaching and Learning for Nursing Practice 3rd

Time and effort of the nurse and the family

*ANGE L IKAW NA BAHAL A DITO HINDI KO MAKIT AE HEHEH E

knowledge about the disease (nature, severity, complications, prognosis and management) b. Lack of knowledge on the nature and extent of nursing care needed. 3. Inability to utilize the health resources available in the community.

members and to improve personal hygiene.

beddings in the management of chickenpox and in the prevention of transfer to other members.

edition p.431)

3. Illustrate ways on how to use health resources in the health center.

3. Discuss with the family the importance of maximizing the health resources in the community.

FAR EASTERN UNIVERSITY

INSTITUTE OF NURSING

HEALTH TEACHING PLAN Barangay Balong Bato, San Juan, City

SPECIFIC OBJECTIVES TOPIC/CONTENT METHODOLOGY/TEACHING STRATEGY TIME FRAME RESOURCE PERSON/ MATERIALS EVALUATION

After nursing intervention the family will be able to: 1. Correct wrong actions about chickenpox Chickenpox - Ito ay isang nakakahawang sakit galing sa varicella-zoster virus. Symptoms: Bago lumabas ang mga pantal o paltos - Lagnat - Pananakit ng ulo - Pananakit ng tiyan 10-21 days after contact with a person that has a chickenpox - Paltos (blisters) sa buong katawan - Langib (scab) Causes: One to one instruction - Involves delivering information specifically designed to meet the needs of an individual learner. - It can be tailored to meet objectives in all three domains of learning. (Bastable, Susan, Nurse as Educator, p.438) 5 minutes Flip chart

*ANGEL IKAW NA BAHALA DITO HINDI KO MAKITA E HEHEHE

Direktang pakikisalamuha skin-to-skin contact Paghina ng resistensya ng katawan Varicella-zoster virus Demonstration >Effective in learning in the psychomotor domain. It actively engages the learner through stimulation of visual, auditory and tactile senses. (Bastable, Susan, Nurse as Educator, p.443)

Nutrition: 2. Apply therapeutic -gulay measures, including -isda skin care to mage -karne adequately the -kanin chickenpox of four -prutas members and to improve personal Physical activities: hygiene -huwag makipaglaro o makisalamuha sa taong may chicken pox. Hygiene: -maligo araw-araw -mag toothbrush araw-araw -maghugas ng kamay >bago kumain >bago maghanda ng pagkain >pagkatapos gumamit ng palikuran Handwashing: Bago maghugas ng kamay -gupitin ang mga kuko -tanggalin ang sensing at relos -bigyang pansin ang mga parte ng kamay na madalas marumihan. -buksan ang gripo at basain ang kamay -hugasan ang mga kamay, sabunin ng sabon at kuskusin ng mabuti.

15 minutes

Flip chart

-ibuka ang mga daliri at kuskusin ang likod ng kamay. -mag-ingat na kuskusin ang pagitan ng mga kukohugasan ang pagitan ng mga daliri -mag-ingat na kuskusin ang dulo ng mga daliri at kuko sa iyong palad. -banlawan ang kamay at hugasan ng isa-isa ang mga daliri. -pagkatapos maghugas ng kamay, ounasan ng malinis na tuwalya at patuyuing maigi. Source: http://doh.dc.gov/page/handwashingfact-sheet

3. Illustrate ways on how to use health resources in the health center.

Seek immediate medical care: -alamin ang lokasyon ng pinakamalapit na health center sa iyong lugar. -ipaalam sa mga health workers o sa health center kung mayroong tao na maaaring maykarong sintomas ng chicken pox upang mabigyan ito ng aksyon. Source: http://chd1.doh.go.ph/index.php/healt h-advisories/key-health-messagesforemergencies/134

One to one instruction Involves delivering information specifically designed to meet the needs of an individual learner. It can be tailored to meet objectives in all three domains of learning. (Bastable, Susan, Nurse as Educator, p.438)

5 minutes

Flip chart

PHYSICAL ASSESSMENT DEMOGRAPHICS Clients Initials: Maritess Caylaluad Gender: Female Age: 34years old

VITAL SIGNS Pulse Rate: 68 bpm Respiratory Rate: 18 cpm Temperature: 36.2C Blood Pressure : 100/90 Body Weight: 11.9 Kg Body Height: 90 cm.

Areas of Assessment Height and weight, body build GENERAL SURVEY Posture and gait;

Normal Findings Proportionate, varies with lifestyle (Fundamentals of Nursing, Kozier pp 473) Relaxed, erect posture, coordinated movement when walking.

Actual Findings Weight and height were taken. The clients body build is an endomorph.

Interpretation Normal

The client had a normal, coordinated gait. Posture was slightly slouched. Could stand, sit and walk with

Normal

standing, sitting and walking

(Fundamentals of Nursing, Kozier pp 473)

no difficulty, although movement was slower than of an adult. Clients manner of walking was elicited with slow and careful steps. Client appeared tidy in her clothing. Normal

Hygiene and grooming (in relation to persons activities prior to assessment)

Clean and neat. (Fundamentals of Nursing, Kozier pp 473)

Body and breath odor

No body odor or minor body odor; no breath odor (Fundamentals of Nursing, Kozier pp 473) No distress noted. (Fundamentals of Nursing, Kozier pp 473) Healthy appearance

No body odor or minor body odor

Normal

Signs of distress in posture, facial relaxation

There was no distress noted from the clients posture. Facial muscles appeared to be relaxed and non-tense. Client had a healthy appearance.

Normal

Normal

Signs of health and illness

(Fundamentals of Nursing, Kozier pp 473) Cooperative Client is cooperative during the assessment. Normal

Clients attitude

(Fundamentals of Nursing, Kozier pp 473) Appropriate to the situation N/A N/A

Clients affect or mood, appropriateness of the response Quantity of speech (amount and pace); quality (loudness, clarity, inflection) and

(Fundamentals of Nursing, Kozier pp 473) Understandable, moderate pace, exhibits thought association (Fundamentals of Nursing, Kozier pp N/A N/A

organization (coherence of 473) thought, over generalization, vagueness) Logical sequence, make sense, has sense of reality. Relevance and organization of thoughts (Fundamentals of Nursing, Kozier pp 473) Varies from light deep brown; from ruddy pink to light pink; from yellow overtones to olive, generally uniform except in areas exposed to sun; areas of lighter pigmentation (Fundamentals of Nursing, Kozier pp 475- 476) Moist skin folds and axillae. Skin moisture (Fundamentals of Nursing, Kozier pp 475- 476) Temperature is uniform within normal range, warm temperature (Fundamentals of Nursing, Kozier pp 475- 476) When pinched, skin brings back to its normal state (skin is tuck hydration) (Fundamentals of Nursing, Kozier pp The clients skin retracted to former state in few seconds when pinched. Normal The clients skin had a mildly dark-brown complexion, parts exposed to the sun were quite darker than of the unexposed parts, corresponding parts shows uniformity of color. Except for the periphery of lesions A, B, and C, (below) the skin on other areas were not reddened. Normal N/A N/A

SKIN Uniformity of color

Skin folds and axillae were not moist. Skin is dry. Abrasions from dry skin were noted after client was observed to scratch some areas. The clients skin temperature was warm and was uniform throughout the body.

Normal

Normal

Skin temperature

Skin turgor

475- 476) Presence of edema (e.g. Location, color, temperature, shape, and the degree to which the skin remains indented or pitted when pressed by a finger) Presence of skin lesions according to location, distribution, color configuration, size, shape, type or structure NAILS Finger nail plate shape to determine its curvature and angle No edema (Fundamentals of Nursing, Kozier pp 475- 476) No edema noted. The clients upper and lower extremities and abdominal areas were nonedematous. Normal

Freckles, some birthmarks, some flat and raised nevi, no abrasions or other lesions (Fundamentals of Nursing, Kozier pp 475- 476) Convex curvature; angle of nail plate about 160 degree (Fundamentals of Nursing, Kozier p 479) Highly vascular and pink in lightskinned client, dark-skinned clients may have brown or black pigmentation in longitudinal streaks (Fundamentals of Nursing, Kozier p 479) Smooth texture

Lesions observed on clients skin. Patient is recovering from chicken pox

Not normal

Clients fingernails and toenails had a convex curvature, angle of nails were approximately of 160 angle.

Normal

Clients fingernails and toenails were light pink in fingers and toes.

Normal

Fingernail and toenail bed color

Fingernail and toenail texture

(Fundamentals of Nursing, Kozier p 479)

Clients fingernails and toenails were somewhat smooth in texture.

Normal

Intact epidermis Tissues surrounding nails (Fundamentals of Nursing, Kozier p 479) Prompt return of pink or usual color (generally less than 4 seconds Blanch test of capillary refill (Fundamentals of Nursing, Kozier p 479)

Intact epidermis in tissue surrounding the clients fingernails and toenails.

Normal

Color of the clients fingernail returned to pink for 3 seconds after pinching.

Normal

SKULL Inspect skull for size, shape or symmetry SCALP Inspect for color, and appearance HAIR Inspect for evenness of growth, thickness or thinness Inspect hair texture and oiliness FACE Inspect facial feature

The clients head shape is symmetric and Skull shape is normocephalic and symmetrical. (Fundamentals of Nursing, normocephalic. Kozier pp 481) No tenderness; lighter than skin color. (Fundamentals of Nursing, Kozier pp 481) The clients scalp color was light brown and was lighter than skin color. No notable tenderness noted upon palpation. The clients hair color was black and it was thin.

Normal

Normal

Evenly distributed hair, thick hair. (Fundamentals of Nursing, Kozier pp 478) Springing curls in some ethnic group (Fundamentals of Nursing, Kozier pp 478) Symmetric features and movement. (Fundamentals of Nursing, Kozier pp 481)

Normal

The clients hair was smooth and straight-stranded.

Normal

The clients face is symmetric, features of the face were in place, and notable movements of the facial muscles were symmetrical per expression.

Normal

Observe the shape of the face EYES Assess eyebrows

Round. (Fundamentals of Nursing, Kozier pp 481) Symmetric structure with equal movement. (Fundamentals of Nursing, Kozier pp 481-490) Skin intact: no discharge; no discoloration; lids close symmetrically; approximately 15-20 involuntary blinks per minute; bilateral blinking; when lids are open no visible sclera above corneas, and upper and lower borders of cornea are slightly covered. (Fundamentals of Nursing, Kozier pp 481-490) Eyelashes curl outward. (Fundamentals of Nursing, Kozier pp 481-490) Palpebral conjunctiva is clear, moist and smooth. White. (Fundamentals of Nursing, Kozier pp 481-490) Transparent, shiny, and smooth; detail of the iris are visible. (Fundamentals of Nursing, Kozier pp 481-490) Color varies, oval and flat. (Fundamentals of Nursing, Kozier pp

The clients face was round with a near-square semblance.

Normal

The clients eyebrows were present, equally distributed, and were moving symmetrically.

Normal

Assess eyelids

The clients eyelids were intact, no discharge or discolorations noted. Lids close symmetrically. Involuntary blinks were observed although blinks were not counted. Sclera was not seen as lids were open. Upper and lower borders of the cornea are slightly covered.

Normal

Assess eyelashes

The clients eyelashes curl outward.

Normal

Assess conjunctiva

The clients palpebral conjunctiva appeared clear, smooth and clear with visible structures underneath. The clients sclera was white.

Normal

Assess sclera

Normal

Assess cornea

The clients cornea was transparent, shiny and smooth. The clients iris was visible.

Normal

Assess the iris

The clients irises were black in color, round and flat.

Normal

481-490) Black in color; equal in size; normally 37 mm in diameter; round. (Fundamentals of Nursing, Kozier pp 481-490) Pupils equally round, shrink suddenly to bright light and elicit accommodation. (Fundamentals of Nursing, Kozier pp 481-490) Able to read news print; 20/20 vision of Snellens chart. (Fundamentals of Nursing, Kozier pp 481-490) No edema or tenderness over lacrimal glands. (Fundamentals of Nursing, Kozier pp 481-490) Both eyes coordinated, move in unison, with parallel alignment. (Fundamentals of Nursing, Kozier pp 481-490) When looking straight ahead, client can see object in the periphery. (Fundamentals of Nursing, Kozier pp 481-490) Color same as facial skin; symmetrical; auricle aligned with outer canthus of eyes. (Fundamentals of Nursing, Kozier pp 492-495) The clients pupils were black, round and equal in size on both eyes with approximately 3-4 mm diameter. Normal

Assess pupil color, shape, and symmetry of size

Pupillary reaction

The clients pupil reacts to sudden bright light. The clients pupils also elicited accommodation.

Normal

Assess visual acuity. Test near vision and distance vision Inspect and palpate the lacrimal gland Test each eye for alignment and coordination

Test using Snellens chart was not performed.

N/A

No notable enlargement or edema in the lacrimal apparatus. Lacrimal glands were nontender.

Normal

Eyes move in cardinal gazes with unison.

Normal

Client can see objects in the periphery.

Normal

Test peripheral Fields

EARS Inspect the auricle for color, symmetry, and

The clients ear color was the same as skin color, although slightly lighter. Auricles aligned with each other and are somewhat aligned with the outer canthus of the eyes.

Normal

position Palpate for texture, elasticity, and areas for tenderness Inspect ear canal for cerumen, skin lesions, pus and blood Mobile, firm, and no tenderness; pinna recoils after it is folded. (Fundamentals of Nursing, Kozier pp 492-495) Dry cerumen, grayish tan color; or sticky, wet cerumen in various shades of brown. (Fundamentals of Nursing, Kozier pp 492-495) Normal voice tones audible. (Fundamentals of Nursing, Kozier pp 492-495) Able to hear ticking in both ears. (Fundamentals of Nursing, Kozier pp 492-495) Sound is heard in both ears; localized at the center of the head (Weber negative). (Fundamentals of Nursing, Kozier pp 492-495) Air-conducted (AC) hearing is greater than bone-conducted (BC) hearing. (Fundamentals of Nursing, Kozier pp 492-495) Symmetric and straight; No discharge, or flaring; uniform color. (Fundamentals of Nursing, Kozier pp 497-498) The clients ears were firm and nontender. Pinna recoils after it was folded. Normal

The clients ear canal was clear. Cerumen was moist and light brown in color. No notable lesions, pus or blood in the canal.

Normal

Test hearing acuity. Assess normal voice tones

The clients audition to normal voice tones were normal, client can respond to commands with a normal voice tone. The client was able to hear ticking in both ears.

Normal

n/a

Perform watch tick test

Webers test was not performed.

n/a

Perform Webers test

Rinnes test was not performed.

n/a

Perform Rinnes test

NOSE Inspect any deviations shape, size, or color and

The clients nose was symmetric and straight. Nasogastric tube present, inserted in the right nares. Parts of the tubes were taped in the right nose and right cheek. Nasal flaring was not present. Nose had

Not normal

flaring or discharge Inspect nasal cavities for the presence of redness, swelling, growth, and discharge Inspect nasal septum between nasal chambers Test patency of both nasal cavities Palpate any tenderness, masses, displacement of bone and cartilage SINUSES Palpate the sinuses for tenderness No tenderness. (Fundamentals of Nursing, Kozier pp 497-498) Uniform pink color; soft, moist, smooth texture; symmetry of contour; ability to purse mouth. (Fundamentals of Nursing, Kozier pp 499-502) Mucosa pink; clear, watery discharge; no lesions. (Fundamentals of Nursing, Kozier pp 497-498)

uniform color. The clients nares were pink and moist. No watery discharges or lesions noted. Normal

Nasal septum intact and in midline Air moves freely, as the client breathes through the nares. (Fundamentals of Nursing, Kozier pp 497-498) No tenderness; no lesions, masses. (Fundamentals of Nursing, Kozier pp 492-495)

The clients nasal septum was in midline and was intact. Patency of both nasal cavities were not noted, right nasal cavity is blocked with an NGT.

Normal

Not normal

No lesions and masses noted on the left nose. Palpation in areas of NGT was not performed to avoid manipulation and deviation of NGT. No tenderness noted on the sinuses.

Normal

Normal

MOUTH Inspect lips for symmetry, color, and texture

The clients visible lips were pink. Normal symmetry and contour was noted. Ability to purse mouth was observed. Discharges were noted, as clear colorless copious saliva, especially when coughing.

Not normal

Inspect buccal mucosa for color, moisture, texture, and presence of lesions

Uniform pink color (freckled brown pigmentation in dark- skinned client). (Fundamentals of Nursing, Kozier pp

Buccal mucosa was moist and pink in color.

Normal

499-502) Inspect teeth for color number and conditions 32 adult teeth; smooth, white, shiny tooth enamel. (Fundamentals of Nursing, Kozier pp 499-502) Pink gums; moist, firm texture to gums; no restriction of gums. (Fundamentals of Nursing, Kozier pp 499-502) Central position; pink color moist; slightly rough; thin whitish coating color); smooth lateral margin; no lesions. (Fundamentals of Nursing, Kozier pp 499-502) Smooth with no palpable nodules. (Fundamentals of Nursing, Kozier pp 499-502) Light pink, smooth, soft palate Lighter pink hard palate, more irregular texture. (Fundamentals of Nursing, Kozier pp 499-502) Positioned in midline of soft palate. (Fundamentals of Nursing, Kozier pp 499-502) Pink and smooth posterior wall. (Fundamentals of Nursing, Kozier pp Uvula was in midline Normal Teeth were white and smooth. Normal

Inspect gums for color and conditions TONGUE/FLOOR OF THE MOUTH Inspect for color and texture of the mouth floor and frenulum Palpate for any nodules, lumps or excoriated areas PALATES AND UVULA Inspect and palpate for color, shape, texture, and the presence of bony prominences Inspect for position of the uvula and mobility while examining the palates OROPHARYNX AND

Gums were pink, moist and firm.

Normal

Tongue was in center, was pink in color, visible lateral margin. No lesions noted.

Normal

Tongue was smooth and has no palpable nodules. Client reported no tenderness.

Normal

Soft and hard palates were pink in color. Both palates are moist. No tenderness noted.

Normal

Oropharynx was pink and smooth. No lesions or

Normal

TONSILS Inspect and palpate for color, and texture

499-502)

discharges noted.

Pink and smooth Inspect tonsils for size, color, and discharge No discharge. (Fundamentals of Nursing, Kozier pp 499-502) Not palpable; no tenderness. (Fundamentals of Nursing, Kozier pp 505) Central placement in midline of neck; spaces are equal on both sides. (Fundamentals of Nursing, Kozier pp 506) Not visible on inspection THYROID GLAND Inspect symmetry and visible masses Gland ascends during swallowing but not visible. (Fundamentals of Nursing, Kozier pp 506-507)

Tonsils were pink and smooth. No lesions or discharges noted. No enlargement noted

Normal

NECK AND LYMPH NODES Locate /palpate/identify lymph nodes and note for tenderness TRACHEA Inspect and palpate for placement

Not palpable; no tenderness.

n/a

Central placement in midline of neck; spaces are equal on both sides

Normal

Gland ascends during swallowing but not visible.

Normal

Palpate for smoothness and areas of enlargement, masses or nodules

Lobe may not be palpable If palpated, lobe are small centrally located, painless, and rise freely with swallowing. (Fundamentals of Nursing,

Lobe are small centrally located, painless, and rise freely with swallowing.

Normal

Kozier pp 506-507 POSTERIOR THORAX Inspect the size, shape, symmetry and compare the diameter of anteroposterior thorax to transverse diameter Inspect the spinal alignment Anteroposterior to transverse diameter in ration of 1: 2; chest symmetry The clients thorax is cylindrical and symmetrical. Anteroposterior to transverse diameter was not performed as to avoid manipulation of the lesion inferior to the nipple, but AP diameter is approximately twice larger than of transverse diameter. Spine vertically aligned. Shoulders and hips are on the same length. Spinal column is straight. Normal

Spine vertically aligned; spinal column is straight, right and left shoulders and hips are at the same length Uniform temperature, no tenderness and masses

Normal

Palpate for temperature tenderness and masses Assess respiratory excursion

The clients skin temperature in the thorax was slightly warmer than of the extremities. Further palpation was not performed. Symmetric chest expansion was noted.

Normal

Full and symmetric chest expansion Bilateral symmetry of vocal fremitus. It is heard most clearly at the apex of the lungs; low pitched voices of males are more readily palpable than higher pitched voices of females

Normal

Palpate vocal fremitus

Vocal fremitus was not noted, with client unable to produce vocal sounds.

Not normal

Percuss the posterior thorax

Percussion notes resonate; except over Percussion elicited resonance on lung fields. scapula; lower pt. of resonance is at the diaphragm Vesicular and bronchovesicular sounds Upon auscultation, there were noted vesicular and bronchovesicular sounds. Clear breath sounds. No

Normal

Auscultate the posterior

Normal

thorax ANTERIOR THORAX Inspect breathing patterns Palpate for temperature, tenderness, and masses Assess respiratory excursion Palpate vocal fremitus Quiet, rhythmic and effortless respirations Skin intact, uniform temp chest-wall intact; no tenderness / masses Full symmetric excursion; thumb normally separates 3 to 5 cm Percussion notes resonate down to the 6th rib at the level of the diaphragm but are flat over areas of heavy muscle and bone, dull Bronchial and lobular breath sounds Bronchovesicular and vesicular breath sounds

adventitious sounds noted. The clients manner of breathing was quiet, rhythmic and effortless The clients skin temperature in the thorax was slightly warmer than of the extremities. No tenderness was noted on areas in the chest. The chest elicited full symmetric excursion. Separation of 3 cm was noted. Percussion notes resonate down to the 6th rib at the level of the diaphragm but are flat over areas of heavy muscle and bone, dull Normal

Normal

Normal

Not normal

Auscultate the trachea Auscultate the anterior thorax HEART

Bronchial sounds noted on auscultated area. Upon auscultation, there were noted vesicular and bronchovesicular sounds. No adventitious sounds noted. No pulsations, lifts or heaves noted.

Normal Normal

Normal

No pulsations Aortic and pulmonic area Tricuspid area Apical area No pulsations; no lifts or heaves With pulsations and very visible in thin persons. Pulsations visible in 50% of adults and No pulsations, lifts or heaves noted. No observable pulsations as for the gauze on the apical area, lifts noted. Auscultation of the chest was performed as the area Normal Normal

Auscultate the aortic,

Normal

pulmonic, tricuspid and apical valves

palpable in most PMI in 5th LICS at or medial to MCI; diameter of 1-2cm; no lift or heave

is the site of lesion C.

CAROTID ARTERIES

Symmetric pulse volumes; full pulsations; thrusting quality; quality Palpate carotid artery with remains same when client breathes, extreme caution turns head; and charges from sitting to supine pos.; elastic arterial wall Auscultate the carotid arteries JUGULAR VEINS Inspect jugular veins BREAST AND AXILLAE Inspect breast for size, symmetry, contour, or shape while the client is in sitting position Inspect the skin of the breast for localized discoloration or hyper pigmentation, retraction, dimpling, localized hypervascular areas, swelling or edema

Carotid arteries were not palpated to prevent manipulation and trauma to the stoma and organs of the neck.

n/a

No sound heard on auscultation

Carotid arteries were not auscultated to prevent manipulation and trauma to the stoma and organs of the neck. The clients jugular veins were not visible.

n/a

Veins not visible indicating right of head is functioning normally Females; rounded shape; slightly unequal in size; generally symmetric. Males; breast even w/ the chest wall; of obese, may be similar in shape to female breast

Normal

The clients breasts are even with the chest wall.

Normal

Skin uniform in color; smooth and intact; diffuse Skin uniform in color; smooth and symmetric horizontal or vertical vascular pattern in intact; diffuse symmetric horizontal or light skinned people vertical vascular pattern in light skinned people; striae, moles and nevi

Normal

Inspect the areola for size, shape, symmetry, color surface characteristics and any mass or lesions Inspect the nipples for size, shape, position, color, discharge and lesions Palpate the axillary, subclavicular and supraclavicular lymph nodes Palpate for breast for masses, tenderness Palpate nipples for tenderness and discharges

Round or oval and bilaterally the same; light pink to dark brown in color; Irregular placement of sebaceous gland Round, everted, and equal in size

The clients areola is round. Color is dark brown and was the same color on the other areola. Some raised sebaceous glands were present in the periphery of the areola. The clients nipples were round, everted. The size was the same for the other nipple.

Normal

Normal

No tenderness, masses or nodules

No tenderness, masses or nodules noted on the said areas.

Normal

No tenderness, masses, nodules or nipple discharge No tenderness, masses, nodules or nipple discharge

Left breast was partially palpated. No tenderness and masses noted on the right and left breasts. No tenderness, masses, nodes or discharges noted in both nipples.

Normal

Normal

ABDOMEN Inspect the abdomen for skin integrity Inspect the abdominal contour while standing at the clients side while the client is in dorsal Unblemished skin , uniform color; silver white stria or surgical scars Flat rounded (convex) or scaphoid (concave)

The clients abdominal skin was dry, is dark brown but had a lighter tone than of the exposed areas. Skin was wrinkled on prominent skin folds. Contour was flat-round

Normal

Normal

recumbent position Inspect for an enlarged liver or spleen Assess the symmetry of contour while standing at the foot of the bed Inspect the abdominal movements associated w/ respirations, peristalsis, or aortic pulsations Observe vascular patterns Auscultate the abdomen for bowel sounds, vascular sounds, and peritoneal friction rubs No evidence of enlargement of liver or spleen Symmetric contour No notable evidence of liver or spleen enlargement. Normal

Skin fold contour was symmetric.

Normal

Symmetric movements caused by respiration; visible peristalsis in very lean people; Aortic pulsation in thin persons at epigastic area No visible vascular pattern

Symmetric movement of the abdomen and chest upon respirations. Peristalsis was not visible. Aortic pulsations were not seen.

Normal

No visible vascular patterns noted on the clients abdominal area. Auscultation of abdomen for NGT placement was elicited. NGT was in the gastric area. Acquisition of other sounds for auscultation like bowel sounds, arterial bruits, and friction rub was not performed. Percussion of the abdomen elicited tympany on the stomach and some areas in the large bowel. Dullness in liver and spleen was noted. Clients abdomen is was relaxed. No tenderness noted upon light palpation. Deep palpation was not performed.

Normal

Normal

Audible bowel sounds; absence of arterial bruits; absence of friction rub

Tympany over the stomach and gasPercuss several areas in filled bowels; dullness specially over each of the four quadrants the liver and spleen; or a full bladder Perform light palpation followed by deep palpation of all four quadrants SKELETAL MUSCLES Inspect the muscles for No tenderness, relaxed abdomen with smooth, consistent tension

Normal

Normal

Equal size on both sides of the body

The clients muscles in the extremities (arm, forearm, thigh, calf) were of equal size on both sides.

Normal

size. Compare the muscles on one side of the body ( arm, thigh, calf ) to the same muscle on the other side Inspect the muscle and tendons for contractures (shortening ) Inspect the muscles for fasciculation and tremors. Inspect any tremors of the hands and arms out in front of the body Palpate muscle tonicity Test for strength (neck) Test for strength (upper extremities) Test for strength (lower extremities) BONES Inspect the skeleton for normal structures and deformities No deformities No contractures No contractures noted on the muscles of the trunk and appendages. Normal

No muscular fasciculation or tremors noted. No fasciculation or tremors

Normal

Normally firm Equal strength

Muscle tone was firm on movable muscle groups. Neck muscle strength was symmetrical. Strength was not tested. Upper limb muscle strength was symmetrical on both sides with fairly strong strength. Lower limb muscle strength was symmetrical on both sides with fairly strong strength. No gross deformities on the prominent bones noted.

Normal Normal

Equal strength on each body side

Normal

Equal strength on each body side

Normal

Normal

Palpate the bone to locate any areas of edema or tenderness JOINTS Inspect the joint for swelling Palpate each joint for tenderness, smoothness of movement, swelling, crepitation and presence of nodule RANGE OF MOTION Upper extremities (shoulder and scapula) Upper extremities (elbows) Upper extremities (hands) Lower extremities (accetabulum /inguinal area) Lower extremities (popliteal) Lower extremities (ankles

No tenderness or swelling

No tenderness was noted on palpation. No gross deformities or edema noted on the palpated areas.

Normal

No swelling

No visible joint swelling or enlargement on the upper and lower limbs noted.

Normal

No tenderness, swelling, crepitation or nodules

The clients joints elicited no tenderness upon palpation, along with no nodules noted. No swelling, redness, enlargement or edema seen. No crepitation or rubbing sounds heard upon movement.

Normal

No limitation of motion

No reports of limitation of motion noted on moving and rotating the arm.

Normal

No limitation of motion

No reports of limitation of motion noted on moving and rotating the forearm. No reports of limitation of motion noted on moving the wrist and hands. No reports of limitation of motion noted on moving the thigh.

Normal

No limitation of motion

Normal

Normal

No limitation of motion

No limitation of motion No limitation of motion

No reports of limitation of motion noted on moving the legs. No reports of limitation of motion noted on moving

Normal

Normal

the feet.

Physical Assessment Name: Danilyn Caylaluad BMI: Weight: 24 kg Vital Signs: Temperature:36.4 Degree Celsius Pulse Rate: 69 bpm Respiratory Rate: 19 cpm Age: 8 years Old Height:124 cm

AREA/BODY PART ASSESSED Describe the clients body built, height and weight in relation to clients age, lifestyle and behavior Observe clients posture, gait, and standing, sitting and walking Describe the clients overall hygiene and grooming

NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS

GENERAL SURVEY Proportionate, varies The clients body built is with lifestyle proportionate (Fundamentals of nursing, 8th edition Kozier. Pge 572) Relaxed, erect posture, The client is relaxed, coordinated movement has an erect posture; ((Fundamentals of and coordinated nursing, 8th edition movement Kozier. Pge 572) Clean, Neat The client is clean and (Fundamentals of neat in appearance and nursing, 8th edition is groomed Kozier. Pge 572) approproiately for the occasion

Normal

Normal

Normal

Note body odor in relation to activity level

Observe signs of distress in posture or facial expression Note obvious signs or health illness

Asses the clients attitude

Note the clients affect/mood assess the appropriateness of the clients response Listen for quantity of speech (amount and pace) quality (loudness, clarity, inflection) and organization (coherence of thought, overgeneralization, vagueness) Inspect for relevance and organization of thoughts

No body odor or minor odor relative to work or exercise, no breath odor (Fundamentals of nursing, 8th edition Kozier. Pge 572) No distress noted (Fundamentals of nursing, 8th edition Kozier. Pge 572) Healthy appearance (Fundamentals of nursing, 8th edition Kozier. Pge 572) Cooperative, able to follow instructions (Fundamentals of nursing, 8th edition Kozier. Pge 572) Appropriate to situation (Fundamentals of nursing, 8th edition Kozier. Pge 572) Understandable, moderate pace, clear tone and inlection; exhibits thought association (Fundamentals of nursing, 8th edition Kozier. Pge 572) Logical sequence; make sense; has sense of reality (Fundamentals of nursing, 8th edition

The client has no body odor and no breath odor

Normal

The client has no observable signs of distress in posture or facial expression The client has a healthy appearance

Normal

Normal

The client cooperates and able to follow instructions

Normal

The clients response is appropriate to situation

Normal

The client has an understandable, moderate speech; has a clear tone of voice; and exhibits thought association

Normal

The client has logical sequence of thought; makes sense and ahs sense of reality

Normal

Inspect the skin color

Inspect the uniformity of skin color

Assess the edema, if present (i,e location, color, temperature, shape, and the degree to which the skin remains indented or pitted when pressed by finger.) Inspect, palpate and describe skin lesions according to location, distribution, color, configuration, size, shape, type or structure. Observe and palpate

Kozier. Pge 572) INTEGUMENTARY SKIN Varies from light to deep The patients skin color brown; from nuddy pink is brown to light pink; from yellow overtones to olive (Fundamentals of nursing, 8th edition Kozier. Pge 579) Generally uniform The patients skin is except in areas exposed uniform in color; areas to sun; areas of lighter that are not exposed in pigmentation (palms, sunlight are lighter lips, nail beds) in dark skinned people (Fundamentals of nursing, 8th edition Kozier. Pge 579) No edema No edema (Fundamentals of nursing, 8th edition Kozier. Pge 579)

Normal

Normal

Normal

Freckles, some birthmarks, some flat and raised nevi; no abrasions or other lesions (Fundamentals of nursing, 8th edition Kozier. Pge 579) Moisture in skin folds

The patient has no lesions

Normal

The client has moisture

Normal

skin moisture

Palpate skin temperature, compare the feet and two hands, using the back of your fingers Note skin turgor(fullness or elasticity) by lifting and pinching the skin on an extremity

and the axillae (varies with environment temperature, and activity) (Fundamentals of nursing, 8th edition Kozier. Pge 579) Uniform; within normal range (Fundamentals of nursing, 8th edition Kozier. Pge 579)

on skin folds

The patients skin is warm to touch and has a uniform temperature

Normal

Inspect fingernail plate shape to determine its curvature and angle

Inspect fingernail and toenail texture

Inspect fingernail and bed color

When pinched, skin The patients skin springs back to previous pinches easily and state; may be slower in springs back to previous elders (Fundamentals of state nursing, 8th edition Kozier. Pge 580) NAILS Convex, curvature; angle The patients nail has a of nail plate is about 160 convex curvature. (Fundamentals of nursing, 8th edition Kozier. Pge 583) Smooth texture The patients nail has a (Fundamentals of convex curvature nursing, 8th edition Kozier. Pge 583) Highly vascular and pink The client has light in light-skinned clients; brown toned fingernails dark-skinned clients may and toenails have brown or black pigmentation in longitudinal streaks (Fundamentals of nursing, 8th edition

Normal

Normal

Normal

Normal

Inspct tissues surrounding nails

Perform Blanch test capillary refil

Inspect the skull for size, shape and symmetry

Palpate for presence of mass/nodules, depressions and tenderness

Inspect for the color of the scalp, presence of dandruff infection, odor and lesions Inspect for the color of the hair , length

Kozier. Pge 584) Intact The client has an intact epidermis(Fundamentals epidermis of nursing, 8th edition Kozier. Pge 584) Prompt return of pink or The capillary refill usual color (generally return of usual color in less than 4 seconds) 3 seconds (Fundamentals of nursing, 8th edition Kozier. Pge 584) HEAD TO TOE ASSESSMENT SKULL Rounded The patients skull is (normocephalic), and round and symmetric with the normocephalic and is frontal, parietal and symmetrical occipital prominences (Fundamentals of nursing, 8th edition Kozier. Pge 583) Smooth, uniform The patients skull is consistency; absence of hard and smooth nodules or masses absence of nodules or (Fundamentals of masses nursing, 8th edition Kozier. Pge 585) HAND AND SCALP No presence of dandruff The patients scalp is infection, odor and whitish in color, there is lesions (Fundamentals no presence of th of nursing, 8 edition dandruff; there are no Kozier. Pge 585) lesions Evenly distributed The client has a short, hair.thick, silky, and evenly distributed,

Normal

Normal

Normal

Normal

Normal

Normal

distribution, texture, oiliness, presence of lice, nits and split ends

Inspect for color of skin,symmetry, texture,shape/contour and facial movements

resilient, no infection or thick, silky and resilient infestation and no infection (Fundamentals of nursing, 8th edition Kozier. Pge 582) FACE Symmetric or slightly The clients face is asymmetric slightly asymmetric facialfeatures with with a round symmetrical facial appearance; has a movements smooth and soft skin (Fundamentals of nursing, 8th edition Kozier. Pge 585)

normal

EYES Visual acuity Distant vision 20/20 vision left and right eye Equally distributed; slightly curled outward (Fundamentals of nursing, 8th edition Kozier. Pge 588) Skin intact; no discharge; no discoloration; lids close symmetrically; bilateral blinking with approximately 15-20 blinks per minute 20/20 vision on snellens chart The patients eyelashes are evenly distributed and is slightly curled outward Normal

Eyelashes Inspect the eyelashes for distribution and direction of curl Eyelids Inspect the eyelids for surfaces characteristics, position in relation to corner, ability to blink and frequency amd lower lids when eyes closed

Normal

The clients eyelids has no discharge or discoloration; lids close symmetrically; bilateral blinking approximately 15 blinks per minute

Normal

(Fundamentals of nursing, 8th edition Kozier. Pge 588) Conjunctiva Inspect the bulbar conjunctiva for color, texture, lesions and foreign bodies Transparent; capillaries sometimes evident; sclera appears white (Fundamentals of nursing, 8th edition Kozier. Pge 588) Shiny, smooth, and pink or red (Fundamentals of nursing, 8th edition Kozier. Pge 588) The patients bulbar conjunctiva is clear, moist, and smooth; underlying structures are clearly visible and the sclera appears white The lower and upper palpebral conjunctiva of the patient are clear and free of swelling or lesions The cornea of the patient is transparent with no opacities and shows smooth and overall moist surface with details of iris visible No swelling or redness over the areas of lacrimal gland; there is draining noted upon palpating the nasolacrimal duct Normal

Inspect the palpebral conjunctiva

Normal

Cornea Inspect the cornea for clarity, texture, transparency and depth

Transparent, shiny, and smooth; details of the iris are visible; has a depth of about 3 mm (Fundamentals of nursing, 8th edition Kozier. Pge 589) Lacrimal gland, sac and nasolacrimal duct Palpate the lacrimal No edema or tenderness gland, lacrimal sac and over lacrimal gland; no nasolacrimal duct for edema or tearing on edema and evidence or lacrimal sac and tearing nasolacrimal duct (Fundamentals of nursing, 8th edition Kozier. Pge 589) Pupils Inspect the pupils for Black in color, equal in

Normal

Normal

The color of the pupil is

Normal

color, shape, symmetry

Test each pupil for direct and consensual reaction to light

Test the pupils for reaction and accommodation (PERRLA)

size ; normally 3-7 mm in diameter; round, smooth border, iris flat and round (Fundamentals of nursing, 8th edition Kozier. Pge 590) Illumitaed pupil constricts( direct response); non illuminates pupil constricts (consensual response) (Fundamentals of nursing, 8th edition Kozier. Pge 590) Pupils constrict when looking at near object; pupils dilate when looking at far object; pupils converge when near object is move toward nose (Fundamentals of nursing, 8th edition Kozier. Pge 590)

black but there is no presence of cloudness; right pupil 3mm in size and left pupil 3mm in size

Direct reaction to light is present

Normal

Pupils constricts when looking at near objects; pupils dilate when looking at far far object; pupils converge when near object is move toward nose

Normal

Peripheral vision Assess the peripheral When looking straight The client can see visual fields (one at a ahad, client can see objects in the periphery time) objects in the periphery (Fundamentals of Temporal nursing, 8th edition Central Kozier. Pge 591) Nasal Ears Auricles

Normal

Inspect auricles for color, symmetry of size and position.

Palpates for texture elasticity and areas of tenderness.

Inspect the external ear canal form cerumen, skin lesion, pus, and blood.

Assess for the clients response to normal voice tones. Perform Watch tick test

Perform Webers test

Color same as facial Ears are equal in size skin, symmetrical, bilaterally and the auricle aligned with auricle aligns with the outer canthus of eye corner of each eye and about 10 from vertical within a 10 angle of (Fundamentals of the vertical position. Nursing, 8th Edition, Color is consistent with Kozier; pg.596) facial color. Mobile,firm, and tender pinna recoils after it is The skin is smooth with folded (Fundamentals no lesions or nodules. th of Nursing , 8 Edition, Kozier; pg.596) External ear canal Dry cerumen, grayishtan color; or sticky, wet A small amount of cerumen in various odorless cerumen is the shades of brown only discharge present. (Fundamentals of Nursing, 8th Edition, Kozier; pg. 596) Hearing Acuity Test Normal voice tones audible ( Fundamentals Audible voice tunes of Nirsing, 8th Edition, Kozier; P.597) Able to hear ticking in both ears Able to hear and (Fundamentals of identify the ticking in Nursing , 8th Edition, both ears. Kozier; pg.597) Sound is heard in both ears or is localized at Sound is heard in both the center of the head ear for about 20 (Fundamentals of seconds

Normal

Normal

Normal

Normal

Normal

Normal

Conduct Rinnes Test

Inspect the external nose for shape,size,color, flaring and sicharges.

Papates for areas of tenderness and masses.

Determine the patency of nasal cavities

Inspect the lining of the nares, nasal septum and if there is any redness or swelling.

Palpate the maxillary and frontal sinuses for tenderness

Nursing, 8th Edtion,Kozier; pg.597) Air-conducted hearing Air-conducted hearing is greater than boneis greater than boneconducted hearing conducted hearing (Fundamentals of Nursing, 8th Edition, Kozier; pg.597) NOSE AND SINUSES Symmetric and Color is the same as the straight,no discharge or rest of the face and flaring,uniform in color nasal sructure is (Fundamentals of symmetric.There are no Nursing, 8th discharges and flaring. Edition,Kozier,pg.600) Not tender,no lesions (Fundamentals of No tenderness Nursing, 8th Edition,Kozier pg 600) Air moves freely as the client breathes through Air moves freey as the the nares client breathes through (Fundamentals of the nares. th Nursing, 8 Edition, Kozier,pg.600) Mucosa pink; clear,watery discharge, Nasal mucosa is no lesions and nasal pink,watery discharge, septum intact and in no lesions and nasal midline (Fundamentals septum is intact and in of Nursing, 8th Edition, midline Kozier pg.600) Not tender (Fundamentals of The sinuses are not Nursing , 8th Edition, tender upon palpation

Normal

Normal

Normal

Normal

Normal

Normal

Kozier, pg.600) MOUTH AND OROPHARYNX Lips Inspect and palpate lips and buccal mucosa for color, moisture,texture and presence of lesions Unifrom pink color; moist, smooth,soft,glistening, and elastic texture (Fundamentals of Nursing,8th Edition, Kozier pg.602)

Lips are smooth, and moist without lesions or swelling.

Normal

Teeth and Gums Inspect the teeth and 32 adult teeth; smooth, gums for white, shiny, tooth condition,number , and enamel; pink moist,firm color, presence of texture of gums dental caries,odor and (Fundamentals of texture of gums. Nursing, 8th Edition,Kozier pg.602) Tongue and Mouth Floor/ Roof Inspect the tongue for Central position, pink in surface, position, color, moist,slightly texture and movement rough, thin whitish coating;smooth,lateral margins, no lesions; moves freely with no tenderness (Fundamentals of Nursing, 8th Edition, Kozier; pg.603) Inspect the mouth floor Smooth tongue base and roof for color and with prominent veins texture. (Fundamentals of

The patient has 21 yellowish teeth and 3 teeth have dental carries

Deviated from normal

The clients tongie surface is smooth, shiny, and pink and is slightly pale with visible veins and lesions Normal

Smooth tongue base with prominent veins

Normal

Palpate the tongue for nodules, and lumps on excoriated areas

Nursing, 8th Edition, Kozier,pg.603) Smooth with no palpable nodules (Fundamentals of Nursing, 8th Edition, Kozier,pg.604)

The cleints tongue does not have nodules or lesions upon palpation

Normal

Palates and Uvula Inspect hard and soft Light pink, smooth, soft The hard palate is pale palate for color, shape palate; lighter pink hard or pinkish with firm, and texture. palate,more irregular wrinkle folds; soft texture (Fundmentals of palate is light pink, soft Nursing, 8th Edition, and smooth. Kozier; pg.604) Inspect the uvula for Positioned in midline of postion and mobility. palate (Fundamentals Uvula hangs freely in of Nursing, 8th Edition, the midline. Kozier pg.604) Tonsils and Orophrynx Inspect the tonsils and Pink and smooth oropharynx for color, posterior wall of Pink and smooth size, discharge and the opopharynx; pink and tonsils. presence of gag reflex. smooth tonsils with no discharge and of normal size or not visible; gag reflex is present (Fundamentals of Nursing, 8th Edition, Kozier; pg.604) NECK AND LYMPH NODES Inspect the neck Muscles equal in size, Neck is symmetric with muscles for swelling or head centered; head centered and masses, head coordinated, smooth without bulging masses; movement and muscle movements with no neck movement is strength. discomfort; neck smooth and has equal

Normal

Normal

Normal

Normal

Inspect the thyroid gland for visible masses.

muscle has equal strength strength (Fundamentals of Nursing, 8th Edition, Kozier; 607) Not visible on inspection Landmarks are (Fundamentals of positioned midline. Nursing, 8th Edition, Kozier pg.608) THORAX Quiet, rhythmic and effortless respirations (Fundamentals of Nursing, 8th Edition, Kozier; pg.617) Bronchial and tubular breath sound (Fundamentals of Nursing, 8th Edition, Kozier; pg.617) Bronchivesicular and vesicular breath sound (Fundamentals of Nursing, 8th Edition, Kozier; p.617) Anteroposterior diameter in ratio of 1:2; chest is syemmteric (Fundamentals of Nursing, 8th Edition, Kozier; pg.614)

Normal

Anterior Thorax Inspect breathing patterns

The patient has quiet, rhythmic, and effortless respirations

Normal

Auscultate the trachea

Brochial and tubular breath sounds was heard

Normal

Auscultate the anterior chest.

Bronchovesicular and vesicular breath sounds were heard

Normal

Posterior Thorax Inspect the shape and symmetry of the thorax from posterior and lateral views. Comapre the anteposterior diameter to the transverse diameter.

Scapulae are symmetric and nonprotuding.Shoulders and scapulae are at horizontal position. The ratio of anteposterior thorax to transverse diameter is 1:2

Normal

Spine vertically aligned; Spinal column Spinal column appears is straight, right and straight and thorax left shoulder and hips appears symmetric with are at same height ribs sloping downward. (Fundamentals of Nursing , 8th Edition, Kozier; pg.614) Palpatefor temperature, Skin intact,uniform Skin ios intact and tenderness,and masses. temperature;no uniform temperature; tenderness ; no no tenderness and no masses. masses (Fundamentals of Nursing, 8th Edition, Kozier; pg.614) Auscultate the chest Vesicular and bronchovesicular Bronchovesicular and breath sounds vesicular breath sounds (Fundamentals of were heard th Nursing, 8 Edition, Kozier; pg.616) HEART AND CENTRAL VESSELS Inspect and palpate the No pulsations; no lift or pericardium for the heave (Fundamentals of No pulsations; no heave presence of abnormal Nursing, 8th Edition, present on the pulsations,lifts, or Kozier; pg.621) pericardium heaves. Inspect and palpate No pulsations; no lift or aortic, pulmonic , heave (Fundamentals of No pulsations; no heave tricuspid,apical area. Nursing, 8th Edition, present Kozier; pg.622) Inspect and palpate Aortic palpations epigastric area. (Fundamentals of There is an aortic Nursing, 8th Edition, pulsation Kozier ;pg.622)

Inspect the spinal alignment for deformities.

Normal

Normal

Normal

Normal

Normal

Normal

Auscultate the heart in all four sites: aortic, pulmonic, tricuspid, apical(mitral)

Palpate the carotid artery

Inspect the abdomen for skin integrity, shape/contour, symmetry and abdominal movements in relation with respirations.

Auscultate abdomen for bowel sounds, vascular sounds, friction rubs

S1 is usually heard in 4 sites; usually louder at S1 was heard at apical apical area; S2 is usually area and S2 was heard heard in 4 sites; louder in the base of the heart at the base of the heart. (Fundamentals of Nursing, 8th Edition, Kozier; pg.622) Symmetric pubic volumes, full pulsation, Full thrusting pulsations thrusting quality (Fundamentals of Nursing, 8th Edition, Kozier, pg.622) ABDOMEN Unblemished skin, uniform in color; flat It is uniform in color round or scaphoid; no and no evidence of evidence of enlargement enlargement of liver of liver or spleen; or spleen syemmteric contour (Fundamentals of Nursing, 8th Edition, Kozier; pg.633) Audible bowel sounds 3- Audible bowel sound, 35times/min; absence of 18 times/min; No arterial bruits; absence of friction rub is present friction rub. in the spleen or liver (Fundamentals of Nursing, 8th Edition, Kozier; pg.634)

Normal

Normal

Normal

Normal

Physical Assessment

DEMOGRAPHICS Clients Initials: D.C Gender: Female Age: 9

VITAL SIGNS Temperature: 35.6C Pulse Rate: 64 bpm Respiratory Rate: 18 cpm

Body Weight: 27kg Body Height: --BMI: ---DBW: ----

Areas of Assessment Height and weight, body build

Normal Findings Proportionate, varies with lifestyle (Fundamentals of Nursing, Kozier pp 473)

Actual Findings The clients body build is proportionate

Interpretation Normal

Relaxed, erect posture, coordinated movement when walking. Posture and gait; standing, (Fundamentals of Nursing, Kozier pp sitting and walking 473) GENERAL SURVEY Hygiene and grooming (in relation to persons activities prior to assessment)

The client had a normal, coordinated gait. Posture was slightly slouched. Could stand, sit and walk with no difficulty, although movement was slower than of an adult. Clients manner of walking was elicited with slow and careful steps. Client appeared tidy in his clothing. Bloody discharges in the dressing, but were replaced after assessment per routine.

Normal

Normal

Clean and neat. (Fundamentals of Nursing, Kozier pp 473)

Body and breath odor

No body odor or minor body odor; no breath odor (Fundamentals of Nursing, Kozier pp 473) No distress noted. (Fundamentals of Nursing, Kozier pp 473) Healthy appearance

No body odor or minor body odor; no breath odor

Normal

Signs of distress in posture, facial relaxation

Aside from a slightly slouched posture, there was no distress noted from the clients posture. Facial muscles appeared to be relaxed and non-tense. Client had a sickly appearance.

Normal

Not normal

Signs of health and illness

(Fundamentals of Nursing, Kozier pp 473)

Cooperative Clients attitude (Fundamentals of Nursing, Kozier pp 473) Appropriate to the situation Clients affect or mood, appropriateness of the response Quantity of speech (amount and pace); quality (loudness, clarity, inflection) and organization (coherence of thought, over generalization, vagueness) (Fundamentals of Nursing, Kozier pp 473) Understandable, moderate pace, exhibits thought association (Fundamentals of Nursing, Kozier pp 473) Logical sequence, make sense, has sense of reality. Relevance and organization of thoughts (Fundamentals of Nursing, Kozier pp 473) Varies from light deep brown; from ruddy pink to light pink; from yellow overtones to olive, generally uniform except in areas exposed to sun; areas of lighter pigmentation (Fundamentals of Nursing, Kozier pp 475- 476)

Client is cooperative during the assessment.

Normal

Clients affect and mood was appropriate to the situation in each response.

Normal

Clients speech is not observable due to his stoma and NGT in place. Communication was elicited by written output, which was appropriate in each response and the output had coherence of thought and exhibited thought association. Quantity of words in writing were few but ample. The clients written output has a logical sequence and apt relevance according to the questions asked; has sense of reality.

Normal

Normal

SKIN Uniformity of color

The clients skin had a mildly dark-brown complexion, parts exposed to the sun were quite darker than of the unexposed parts, corresponding parts shows uniformity of color. Except for the periphery of lesions A, B, and C, (below) the skin on other areas were not reddened.

Normal

Moist skin folds and axillae. Skin moisture (Fundamentals of Nursing, Kozier pp 475- 476) Temperature is uniform within normal range, warm temperature (Fundamentals of Nursing, Kozier pp 475- 476) When pinched, skin brings back to its normal state (skin is tuck hydration) Skin turgor (Fundamentals of Nursing, Kozier pp 475- 476) No edema (Fundamentals of Nursing, Kozier pp 475- 476)

Skin folds and axillae were not moist. Skin is dry. Abrasions from dry skin were noted after client was observed to scratch some areas. The clients skin temperature was warm and was uniform throughout the body.

Normal

Normal

Skin temperature

The clients skin retracted to former state in few seconds when pinched.

Normal

Presence of edema (e.g. Location, color, temperature, shape, and the degree to which the skin remains indented or pitted when pressed by a finger) Presence of skin lesions according to location, distribution, color configuration, size, shape, type or structure NAILS

No edema noted. The clients upper and lower extremities and abdominal areas were nonedematous.

Normal

Freckles, some birthmarks, some flat and raised nevi, no abrasions or other lesions (Fundamentals of Nursing, Kozier pp 475- 476) Convex curvature; angle of nail plate about 160 degree

Freckles, some birthmarks, some flat and raised nevi, no abrasions or other lesions

Normal

Clients fingernails and toenails had a convex curvature, angle of nails were approximately of 160

Normal

Finger nail plate shape to

determine its curvature and angle

(Fundamentals of Nursing, Kozier p 479) Highly vascular and pink in lightskinned client, dark-skinned clients may have brown or black pigmentation in longitudinal streaks (Fundamentals of Nursing, Kozier p 479) Smooth texture

angle.

Clients fingernails and toenails were light pink in fingers and toes.

Normal

Fingernail and toenail bed color

Fingernail and toenail texture

(Fundamentals of Nursing, Kozier p 479) Intact epidermis

Clients fingernails and toenails were somewhat smooth in texture.

Normal

Tissues surrounding nails

(Fundamentals of Nursing, Kozier p 479) Prompt return of pink or usual color (generally less than 4 seconds

Intact epidermis in tissue surrounding the clients fingernails and toenails.

Normal

Color of the clients fingernail returned to pink for 3 seconds after pinching.

Normal

Blanch test of capillary refill

(Fundamentals of Nursing, Kozier p 479) Skull shape is normocephalic and symmetrical. (Fundamentals of Nursing, Kozier pp 481) No tenderness; lighter than skin color. The clients head shape is symmetric and normocephalic. Normal

SKULL Inspect skull for size, shape or symmetry SCALP

The clients scalp color was light brown and was

Normal

Inspect for color, and appearance HAIR Inspect for evenness of growth, thickness or thinness Inspect hair texture and oiliness FACE Inspect facial feature

(Fundamentals of Nursing, Kozier pp 481) Evenly distributed hair, thick hair. (Fundamentals of Nursing, Kozier pp 478) Springing curls in some ethnic group (Fundamentals of Nursing, Kozier pp 478) Symmetric features and movement. (Fundamentals of Nursing, Kozier pp 481) Round. (Fundamentals of Nursing, Kozier pp 481)

lighter than skin color. No notable tenderness noted upon palpation. The clients hair color was black with notable areas of gray-stranded hair. Centrally-distributed bald patches were noted. Thinning of hair density was also noted, starting from the center. The clients hair was smooth and straight-stranded. Normal

Normal

The clients face is symmetric, features of the face were in place, and notable movements of the facial muscles were symmetrical per expression. The clients face was round with a near-square semblance.

Normal

Normal

Observe the shape of the face EYES Assess eyebrows

Symmetric structure with equal movement. (Fundamentals of Nursing, Kozier pp 481-490) Skin intact: no discharge; no discoloration; lids close symmetrically; approximately 15-20 involuntary blinks per minute; bilateral blinking; when lids are open no visible sclera above corneas, and upper and lower borders

The clients eyebrows were present, equally distributed, and were moving symmetrically.

Normal

Assess eyelids

The clients eyelids were intact, no discharge or discolorations noted. Lids close symmetrically. Involuntary blinks were observed although blinks were not counted. Sclera was not seen as lids were open. Upper and lower borders of the cornea are slightly covered.

Normal

of cornea are slightly covered. (Fundamentals of Nursing, Kozier pp 481-490) Assess eyelashes Eyelashes curl outward. (Fundamentals of Nursing, Kozier pp 481-490) Palpebral conjunctiva is clear, moist and smooth. White. (Fundamentals of Nursing, Kozier pp 481-490) Transparent, shiny, and smooth; detail of the iris are visible. (Fundamentals of Nursing, Kozier pp 481-490) Color varies, oval and flat. (Fundamentals of Nursing, Kozier pp 481-490) Black in color; equal in size; normally 37 mm in diameter; round. (Fundamentals of Nursing, Kozier pp 481-490) The clients eyelashes curl outward. Normal

Assess conjunctiva

The clients palpebral conjunctiva appeared clear, smooth and clear with visible structures underneath. The clients sclera was white.

Normal

Assess sclera

Normal

Assess cornea

The clients cornea was transparent, shiny and smooth. The clients iris was visible.

Normal

The clients irises were black in color, round and flat.

Normal

Assess the iris

Assess pupil color, shape, and symmetry of size

The clients pupils were black, round and equal in size on both eyes with approximately 3-4 mm diameter.

Normal

Pupillary reaction

Pupils equally round, shrink suddenly to The clients pupil reacts to sudden bright light. The bright light and elicit accommodation. clients pupils also elicited accommodation. (Fundamentals of Nursing, Kozier pp 481-490) Able to read news print; 20/20 vision of The client was able to read news print if the client

Normal

Assess visual acuity. Test

Normal

near vision and distance vision Inspect and palpate the lacrimal gland Test each eye for alignment and coordination

Snellens chart. (Fundamentals of Nursing, Kozier pp 481-490) No edema or tenderness over lacrimal glands. (Fundamentals of Nursing, Kozier pp 481-490) Both eyes coordinated, move in unison, with parallel alignment. (Fundamentals of Nursing, Kozier pp 481-490) When looking straight ahead, client can see object in the periphery. (Fundamentals of Nursing, Kozier pp 481-490) Color same as facial skin; symmetrical; auricle aligned with outer canthus of eyes. (Fundamentals of Nursing, Kozier pp 492-495) Mobile, firm, and no tenderness; pinna recoils after it is folded. (Fundamentals of Nursing, Kozier pp 492-495) Dry cerumen, grayish tan color; or sticky, wet cerumen in various shades of brown. (Fundamentals of Nursing, Kozier pp 492-495) Normal voice tones audible.

adjusts the print closer to him. Test using Snellens chart was not performed. No notable enlargement or edema in the lacrimal apparatus. Lacrimal glands were nontender. Normal

Eyes move in cardinal gazes with unison.

Normal

Client can see objects in the periphery.

Normal

Test peripheral Fields

EARS Inspect the auricle for color, symmetry, and position Palpate for texture, elasticity, and areas for tenderness Inspect ear canal for cerumen, skin lesions, pus and blood Test hearing acuity. Assess

The clients ear color was the same as skin color, although slightly lighter. Auricles aligned with each other and are somewhat aligned with the outer canthus of the eyes. The clients ears were firm and nontender. Pinna recoils after it was folded.

Normal

Normal

The clients ear canal was clear. Cerumen was moist and light brown in color. No notable lesions, pus or blood in the canal.

Normal

The clients audition to normal voice tones were

Normal

normal voice tones

(Fundamentals of Nursing, Kozier pp 492-495) Able to hear ticking in both ears. (Fundamentals of Nursing, Kozier pp 492-495) Sound is heard in both ears; localized at the center of the head (Weber negative). (Fundamentals of Nursing, Kozier pp 492-495) Air-conducted (AC) hearing is greater than bone-conducted (BC) hearing. (Fundamentals of Nursing, Kozier pp 492-495) Symmetric and straight; No discharge, or flaring; uniform color. (Fundamentals of Nursing, Kozier pp 497-498) Mucosa pink; clear, watery discharge; no lesions. (Fundamentals of Nursing, Kozier pp 497-498)

normal, client can respond to commands with a normal voice tone. The client was able to hear ticking in both ears. n/a

Perform watch tick test

Webers test was not performed.

n/a

Perform Webers test

Rinnes test was not performed.

n/a

Perform Rinnes test

NOSE Inspect any deviations shape, size, or color and flaring or discharge Inspect nasal cavities for the presence of redness, swelling, growth, and discharge Inspect nasal septum between nasal chambers Test patency of both nasal

Symmetric and straight; No discharge, or flaring; uniform color.

Normal

The clients nares were pink and moist. No watery discharges or lesions noted.

Normal

Nasal septum intact and in midline Air moves freely, as the client breathes

The clients nasal septum was in midline and was intact. Air moves freely, as the client breathes through the

Normal

Normal

cavities

through the nares. (Fundamentals of Nursing, Kozier pp 497-498) No tenderness; no lesions, masses. (Fundamentals of Nursing, Kozier pp 492-495)

nares.

Palpate any tenderness, masses, displacement of bone and cartilage SINUSES Palpate the sinuses for tenderness

No lesions and masses noted on the left nose. Palpation in areas of NGT was not performed to avoid manipulation and deviation of NGT. No tenderness noted on the sinuses.

Normal

Normal

No tenderness. (Fundamentals of Nursing, Kozier pp 497-498) Uniform pink color; soft, moist, smooth texture; symmetry of contour; ability to purse mouth. (Fundamentals of Nursing, Kozier pp 499-502) Uniform pink color; soft, moist, smooth texture; symmetry of contour; ability to purse mouth.

Normal

MOUTH Inspect lips for symmetry, color, and texture

Inspect buccal mucosa for color, moisture, texture, and presence of lesions

Uniform pink color (freckled brown pigmentation in dark- skinned client). (Fundamentals of Nursing, Kozier pp 499-502) 32 adult teeth; smooth, white, shiny tooth enamel. (Fundamentals of Nursing, Kozier pp 499-502) Pink gums; moist, firm texture to gums; no restriction of gums. (Fundamentals of Nursing, Kozier pp 499-502)

Buccal mucosa was moist and pink in color.

Normal

Inspect teeth for color number and conditions

24 Yellowish teeth with dental carries

Not Normal

Inspect gums for color and conditions

Gums were pink, moist and firm.

Normal

TONGUE/FLOOR OF THE MOUTH Inspect for color and texture of the mouth floor and frenulum Palpate for any nodules, lumps or excoriated areas PALATES AND UVULA Inspect and palpate for color, shape, texture, and the presence of bony prominences Inspect for position of the uvula and mobility while examining the palates OROPHARYNX AND TONSILS Inspect and palpate for color, and texture Inspect tonsils for size, color, and discharge

Central position; pink color moist; slightly rough; thin whitish coating color); smooth lateral margin; no lesions. (Fundamentals of Nursing, Kozier pp 499-502) Smooth with no palpable nodules. (Fundamentals of Nursing, Kozier pp 499-502) Light pink, smooth, soft palate Lighter pink hard palate, more irregular texture. (Fundamentals of Nursing, Kozier pp 499-502) Positioned in midline of soft palate. (Fundamentals of Nursing, Kozier pp 499-502) Pink and smooth posterior wall. (Fundamentals of Nursing, Kozier pp 499-502)

Tongue was in center, was pink in color, visible lateral margin. No lesions noted.

Normal

Tongue was smooth and has no palpable nodules. Client reported no tenderness.

Normal

Soft and hard palates were pink in color. Both palates are moist. No tenderness noted.

Normal

Uvula was in midline

Normal

Oropharynx was pink and smooth. No lesions or discharges noted.

Normal

Pink and smooth No discharge. (Fundamentals of Nursing, Kozier pp 499-502)

Tonsils were pink and smooth. No lesions or discharges noted. No enlargement noted

Normal

NECK AND LYMPH NODES Locate /palpate/identify lymph nodes and note for tenderness Not palpable; no tenderness. (Fundamentals of Nursing, Kozier pp 505)

The clients neck was not palpated for lymph node assessment to avoid manipulation and trauma of the organs in the respiratory tract.

n/a

TRACHEA Inspect and palpate for placement

Central placement in midline of neck; spaces are equal on both sides. (Fundamentals of Nursing, Kozier pp 506)

Visible stoma present in the midline of the tracheal area in the neck, with black scablike formation on the periphery. Stoma is pink and moist, bloody mucus discharge noted occasionally especially when coughing. Trachea was not palpated for tracheal node assessment to avoid manipulation and trauma of the stoma in the respiratory tract. Symmetry of the thyroid was not observable due to the emphasis and obscuration of the stoma. Thyroid gland was not palpated for thyroid assessment to avoid manipulation and trauma of the stoma and the organs in the respiratory tract.

Not normal

Not visible on inspection THYROID GLAND Inspect symmetry and visible masses Gland ascends during swallowing but not visible. (Fundamentals of Nursing, Kozier pp 506-507)

n/a

Lobe may not be palpable Palpate for smoothness and areas of enlargement, masses or nodules If palpated, lobe are small centrally located, painless, and rise freely with swallowing. (Fundamentals of Nursing, Kozier pp 506-507

The clients neck was not palpated for thyroid assessment to avoid manipulation and trauma of the stoma and organs in the respiratory tract.

n/a

POSTERIOR THORAX Inspect the size, shape, symmetry and compare the diameter of anteroposterior thorax to transverse diameter Inspect the spinal alignment Anteroposterior to transverse diameter in ration of 1: 2; chest symmetry

The clients thorax is cylindrical and symmetrical. Anteroposterior to transverse diameter was not performed as to avoid manipulation of the lesion inferior to the nipple, but AP diameter is approximately twice larger than of transverse diameter.

Normal

Spine vertically aligned; spinal column is straight, right and left shoulders and hips are at the same length Uniform temperature, no tenderness and masses

Spine vertically aligned. Shoulders and hips are on the Normal same length. Spinal column is straight.

Palpate for temperature tenderness and masses Assess respiratory excursion

The clients skin temperature in the thorax was slightly warmer than of the extremities. Further palpation was not performed. Symmetric chest expansion was noted.

Normal

Full and symmetric chest expansion Bilateral symmetry of vocal fremitus. It is heard most clearly at the apex of the lungs; low pitched voices of males are more readily palpable than higher pitched voices of females

Normal

Palpate vocal fremitus

Bilateral symmetry of vocal fremitus. It is heard most clearly at the apex of the lungs; low pitched voices of males are more readily palpable than higher pitched voices of females

Normal

Percuss the posterior thorax Auscultate the posterior thorax

Percussion notes resonate; except over Percussion elicited resonance on lung fields. scapula; lower pt. of resonance is at the diaphragm Vesicular and bronchovesicular sounds Upon auscultation, there were noted vesicular and bronchovesicular sounds. Clear breath sounds. No

Normal

Normal

adventitious sounds noted. ANTERIOR THORAX Inspect breathing patterns Palpate for temperature, tenderness, and masses Assess respiratory excursion Palpate vocal fremitus Quiet, rhythmic and effortless respirations Skin intact, uniform temp chest-wall intact; no tenderness / masses Full symmetric excursion; thumb normally separates 3 to 5 cm Percussion notes resonate down to the 6th rib at the level of the diaphragm but are flat over areas of heavy muscle and bone, dull Bronchial and lobular breath sounds Bronchovesicular and vesicular breath sounds The clients manner of breathing was quiet, rhythmic and effortless The clients skin temperature in the thorax was slightly warmer than of the extremities. No tenderness was noted on areas in the chest. The chest elicited full symmetric excursion. Separation of 3 cm was noted. Percussion notes resonate down to the 6th rib at the level of the diaphragm but are flat over areas of heavy muscle and bone, dull Normal

Normal

Normal

Normal

Auscultate the trachea Auscultate the anterior thorax HEART

Bronchial sounds noted on auscultated area. Upon auscultation, there were noted vesicular and bronchovesicular sounds. No adventitious sounds noted. No pulsations, lifts or heaves noted.

Normal Normal

Normal

No pulsations Aortic and pulmonic area Tricuspid area Apical area No pulsations; no lifts or heaves With pulsations and very visible in thin persons. No pulsations, lifts or heaves noted. No observable pulsations as for the gauze on the apical area, lifts noted. Normal Normal

Auscultate the aortic, pulmonic, tricuspid and apical valves

Pulsations visible in 50% of adults and palpable in most PMI in 5th LICS at or medial to MCI; diameter of 1-2cm; no lift or heave

Auscultation of the chest was not performed as the area is the site of lesion C.

n/a

CAROTID ARTERIES

Symmetric pulse volumes; full pulsations; thrusting quality; quality Palpate carotid artery with remains same when client breathes, extreme caution turns head; and charges from sitting to supine pos.; elastic arterial wall Auscultate the carotid arteries JUGULAR VEINS Inspect jugular veins BREAST AND AXILLAE Inspect breast for size, symmetry, contour, or shape while the client is in sitting position Inspect the skin of the breast for localized discoloration or hyper pigmentation, retraction, dimpling, localized

Carotid arteries were not palpated to prevent manipulation and trauma to the stoma and organs of the neck.

n/a

No sound heard on auscultation

Carotid arteries were not auscultated to prevent manipulation and trauma to the stoma and organs of the neck. The clients jugular veins were not visible.

n/a

Veins not visible indicating right of head is functioning normally Females; rounded shape; slightly unequal in size; generally symmetric. Males; breast even w/ the chest wall; of obese, may be similar in shape to female breast

Normal

The clients breasts are even with the chest wall.

Normal

Skin uniform in color; smooth and intact; diffuse Skin uniform in color; smooth and symmetric horizontal or vertical vascular pattern in intact; diffuse symmetric horizontal or vertical vascular pattern in light skinned light skinned people; striae, moles and nevi people; striae, moles and nevi

Normal

hypervascular areas, swelling or edema Inspect the areola for size, shape, symmetry, color surface characteristics and any mass or lesions Inspect the nipples for size, shape, position, color, discharge and lesions Palpate the axillary, subclavicular and supraclavicular lymph nodes Palpate for breast for masses, tenderness Palpate nipples for tenderness and discharges The clients areola is round. Color is dark brown and was the same color on the other areola. Some raised sebaceous glands were present in the periphery of the areola. The clients nipples were round, everted. The size was the same for the other nipple. Normal

Round or oval and bilaterally the same; light pink to dark brown in color; Irregular placement of sebaceous gland Round, everted, and equal in size

Normal

No tenderness, masses or nodules

No tenderness, masses or nodules noted on the said areas.

Normal

No tenderness, masses, nodules or nipple discharge No tenderness, masses, nodules or nipple discharge

Left breast was partially palpated. No tenderness and masses noted on the right and left breasts. No tenderness, masses, nodes or discharges noted in both nipples.

Normal

Normal

ABDOMEN Inspect the abdomen for skin integrity Unblemished skin , uniform color; silver white stria or surgical scars

The clients abdominal skin was dry, is dark brown but had a lighter tone than of the exposed areas. Skin was wrinkled on prominent skin folds.

Normal

Inspect the abdominal contour while standing at the clients side while the client is in dorsal recumbent position Inspect for an enlarged liver or spleen Assess the symmetry of contour while standing at the foot of the bed Inspect the abdominal movements associated w/ respirations, peristalsis, or aortic pulsations Observe vascular patterns Auscultate the abdomen for bowel sounds, vascular sounds, and peritoneal friction rubs

Flat rounded (convex) or scaphoid (concave)

Contour was flat-round

Normal

No evidence of enlargement of liver or spleen Symmetric contour

No notable evidence of liver or spleen enlargement.

Normal

Skin fold contour was symmetric.

Normal

Symmetric movements caused by respiration; visible peristalsis in very lean people; Aortic pulsation in thin persons at epigastic area No visible vascular pattern

Symmetric movement of the abdomen and chest upon respirations. Peristalsis was not visible. Aortic pulsations were not seen.

Normal

No visible vascular patterns noted on the clients abdominal area. Auscultation of abdomen for NGT placement was elicited. NGT was in the gastric area. Acquisition of other sounds for auscultation like bowel sounds, arterial bruits, and friction rub was not performed. Percussion of the abdomen elicited tympany on the stomach and some areas in the large bowel. Dullness in liver and spleen was noted. Clients abdomen is was relaxed. No tenderness noted upon light palpation. Deep palpation was not

Normal

Normal

Audible bowel sounds; absence of arterial bruits; absence of friction rub

Tympany over the stomach and gasPercuss several areas in filled bowels; dullness specially over each of the four quadrants the liver and spleen; or a full bladder Perform light palpation followed by deep No tenderness, relaxed abdomen with

Normal

Normal

palpation of all four quadrants SKELETAL MUSCLES Inspect the muscles for size. Compare the muscles on one side of the body ( arm, thigh, calf ) to the same muscle on the other side Inspect the muscle and tendons for contractures (shortening ) Inspect the muscles for fasciculation and tremors. Inspect any tremors of the hands and arms out in front of the body Palpate muscle tonicity Test for strength (neck) Test for strength (upper extremities) Test for strength (lower

smooth, consistent tension

performed.

The clients muscles in the extremities (arm, forearm, thigh, calf) were of equal size on both sides. Equal size on both sides of the body

Normal

No contractures

No contractures noted on the muscles of the trunk and appendages.

Normal

No muscular fasciculation or tremors noted. No fasciculation or tremors

Normal

Normally firm Equal strength

Muscle tone was firm on movable muscle groups. Neck muscle strength was symmetrical. Strength was not tested. Upper limb muscle strength was symmetrical on both sides with fairly strong strength. Lower limb muscle strength was symmetrical on both

Normal Normal

Equal strength on each body side Equal strength on each body side

Normal

Normal

extremities) BONES Inspect the skeleton for normal structures and deformities Palpate the bone to locate any areas of edema or tenderness JOINTS Inspect the joint for swelling Palpate each joint for tenderness, smoothness of movement, swelling, crepitation and presence of nodule RANGE OF MOTION Upper extremities (shoulder and scapula) Upper extremities (elbows) Upper extremities (hands) No limitation of motion No swelling No deformities

sides with fairly strong strength. No gross deformities on the prominent bones noted. Normal

No tenderness or swelling

No tenderness was noted on palpation. No gross deformities or edema noted on the palpated areas.

Normal

No visible joint swelling or enlargement on the upper and lower limbs noted.

Normal

No tenderness, swelling, crepitation or nodules

The clients joints elicited no tenderness upon palpation, along with no nodules noted. No swelling, redness, enlargement or edema seen. No crepitation or rubbing sounds heard upon movement.

Normal

No reports of limitation of motion noted on moving and rotating the arm.

Normal

No limitation of motion No limitation of motion

No reports of limitation of motion noted on moving and rotating the forearm. No reports of limitation of motion noted on moving

Normal

Normal

the wrist and hands. Lower extremities (accetabulum /inguinal area) Lower extremities (popliteal) Lower extremities (ankles ) No reports of limitation of motion noted on moving the thigh. Normal

No limitation of motion

No limitation of motion

No reports of limitation of motion noted on moving the legs. No reports of limitation of motion noted on moving the feet.

Normal

No limitation of motion

Normal

Marlon Caylaluad AREA/BODY PART ASSESSES GENERAL SURVEY Describe the clients body built, height and weight in relation to clients age, lifestyle and behavior Observe clients posture, gait, standing, sitting and walking Describe the clients overall hygiene and grooming Note body odor in relation to activity level Proportionate, varies with lifestyle (and Erbs Fundamentals of Nursing 8th Edition, Kozier pp.572) Relaxed, erect posture; coordinated movement Clean, neat The clients body built is proportionate Normal NORMAL FINDINGS ACTUAL FINDINGS REMARKS

Observe signs of distress in posture or facial expression Note obvious signs of health or illness Assess the clients attitude

No body odor or minor odor relative r work or exercise; no breath odor No distress noted

The client is relaxed, ahs Normal an erect posture; and coordinated movement The client is clean and Normal neat in appearance and is groomed appropriately The client has no body Not normal odor and no breath odor

Healthy appearance Cooperative, able to follow instructions

Note the clients Appropriate to affect/mood; assess the situation appropriateness of the clients response

The client has no obseravable signs of distress in posture or facial expression The client has healthy appearance The client cooperates and able to follow instructions The client appropriate to situation

Normal

Normal Normal

Normal

Listen for quantity of speech Quantity of speech (amount and pace); quality (loudness, clarity, inflection) and organization (coherence of thought, over generalization, vagueness) Relevance and organization of thoughts Integumentary Inspect the skin color.

Understandable, Clients speech is understandable

Normal Normal

Understandable, moderate pace, exhibits thought association (Fundamentals of Nursing, Kozier pp 473)

Logical sequence, make sense, has sense of reality. (Fundamentals of Nursing, Kozier pp 473) Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive. Generally inform except in areas exposed to sun; areas of lighter pigmentation (palms lips, nail beds) in dark-skinned people. No edema

The clients written output has a logical sequence and apt relevance according to the questions asked; has sense of reality. The patients skin is brown

Normal

Normal Normal

Inspect the uniformity of skin color.

Uniform in color; areas that are not exposed in sunlight are lighter.

Normal

Assess the edema, If present (I,e. location, color, temperature, shape, and the degree to which the skin

No edema

Normal

remains indented or pitted when pressed by finger Inspect, palpate, and describe skin lesions according to location, distribution, color, configuration, size, shape, type or structure Observe and palpate skin Palpate skin temp. Compare the feet and two hands, using the back of your hands Note skin turgor (fullness or elasticity) by lifting and pinching the skin on an extremity Nails Inspect fingernail plate shape to determine its curvature and angle Inspect fingernail and toenail texture Inspect fingernail and toenail bed color

Freckles, some birthmarks, some flat and raised nevi; no abrasions or other lesions.

The patient has vesicles on different areas on his body because he has chicken pox

Not normal

Moisture skin folds Uniform; within normal range

Has moist skin folds Temperature within normal range

Normal Normal

When pinched, skin springs back to previous state; may be slower in elders

Skin bsprings back to previous state

Normal

Convex, curvature, angle of nail plate is about 160 Smooth texture

Has convex curvature

Normal Normal

Inspect tissues

Even surfaces and nor irregularities Highly vascular and The client has light pink in light-skinned brown toned fingernails clients; dark-skinned and toenails. Both clients may have brown fingernails and toenails or black pigmentation were dirty. or longitudinal streaks Intact epidermis Has intact epidermis

Normal Deviated from Normal

Normal

surrounding nails Perform blanch test capillary refill

Prompt return of pink or usual color (generally less than 4 seconds)

Return of usual color in 3 seconds

Normal

HEAD TO TOE ASSESSMENT SKULL Inspect the skull for size, shape and symmetry

Normal Normal Normal Normal

Palpate for presence of mass/nodules, depressions and tenderness HAIR AND SCALP Inspect the color of the scalp, presence of dandruff infection, odor and lesions.

Rounded (normocephalix), and symmetric with the frontal, parietal and occipital prominences Smooth, uniform consistency; absence of nodules or masses

The clients head shape is symmetric and normocephalic

Normal

No presence of dandruff infection, odor and lesions

Inspect for the color of the hair, strength , distribution, thinness, text ture, cleanliness, presence of lice, nits and spilt ends FACE Inspect for color of skin, symmetry,

Evenly distributed hair, thick, silky and resilient, no infection or infestation

The clients scalp color was light brown and was lighter than skin color. No notable tenderness noted upon palpation. Clients hair is black and evenly distributed

Normal Normal

Normal

Symmetric or slightly asymmetric facial

Symmetic facial features

Normal Normal

texture, shape/contour and facial movements EYES Eyelashes Inspect the eyelashes for distribution and direction of curl. Eyelids Inspect the eyelids for surface characteristics, position in relation to corner, ability to blink and frequency and lower lids when eyes closed. Conjuctiva Inspect the bulbar conjunctiva for color, texture, lesions and foreign nodies.

features with symmetrical facial movements Normal Normal Normal

Equally distributed slightly curled outward

Equally distributed and slightly curled outward

Skin intact; no discharge; no discoloration; lids close symmetrically; bilateral blinking with approx. 15-20 blinks/min

Skin intact; no discharge; no discoloration; lids close symmetrically; bilateral blinking with approx. 15blinks/min

Normal Normal

Transparent; capillaries sometimes evident; sclera appears white

Inspect the palpebral conjuctiva

Shiny, smooth, and pink or red

The patients bulbar conjunctiva is clear, moist and smooth; underlying structures are clearly visible and the sclera appears white The lower and upperpalpebral conjunctiva of the patient are clear and free of swelling and lesions The cornea of the patient is transparent with no opacities and shows smooth and

Normal Normal

Normal

Cornea Inspect the cornea for clarity, texture, transparency amd depth

Transparent, shiny, and smooth; details of the iris are visible; has a depth of about 3mm

Normal Normal

overall moist surface with details of iris visible Lacrimal gland, sac and nasolacrimal duct Palpate the , lacrimal sac and naslacrimal duct for edema and evidence of tearing Pupils Inspect the pupils for color, shape, symmetry of size. Normal Normal

Test each pupil for direct and nonsensual reaction to light (PERRLA)

Black in color, equal in size, normally 3- 7 mm in diameter, round, smooth border, iris flat and around Illuminated pupil constricts (direct response); non illuminated pupil constricts (consensual response When Looking straight ahead, client can see objects in the periphery

Black in color, equal in size, 3 mm in diameter, round, smooth border, iris flat and around, no presence of cloudiness Direct reaction to light is present

Normal

Normal

Peripheral Vision Assess the peripheral visual fields (ona at a time) Temporal Central Nasal Ears EARS Inspect the auricle for color, symmetry, and position

normal Normal

Color same as facial skin; symmetrical; auricle aligned with outer canthus of eyes. (Fundamentals of

The clients ear color was the same as skin color, although slightly lighter. Auricles aligned with each other and are

Normal Not normal

Nursing, Kozier pp 492495) Mobile, firm, and no tenderness; pinna recoils after it is folded. (Fundamentals of Nursing, Kozier pp 492495) Dry cerumen, grayish tan color; or sticky, wet cerumen in various shades of brown. (Fundamentals of Nursing, Kozier pp 492495) Normal voice tones audible. (Fundamentals of Nursing, Kozier pp 492-495) Able to hear ticking in both ears. (Fundamentals of Nursing, Kozier pp 492495) Sound is heard in both ears; localized at the center of the head (Weber negative). (Fundamentals of Nursing, Kozier pp 492495)

Palpate for texture, elasticity, and areas for tenderness

somewhat aligned with the outer canthus of the eyes. The clients ears were Normal firm and nontender. Pinna recoils after it was folded.

Inspect ear canal for cerumen, skin lesions, pus and blood

The clients ear canal was clear. Cerumen was moist and light brown in color. No notable lesions, pus or blood in the canal. The clients audition to normal voice tones were normal, client can respond to commands with a normal voice tone. The client was able to hear ticking in both ears.

Normal

Normal

Test hearing acuity. Assess normal voice tones

Normal

Perform watch tick test

Webers test was not performed.

Normal

Perform Webers test

Air-conducted (AC) hearing is greater than bone-conducted (BC) Perform Rinnes test hearing. (Fundamentals of Nursing, Kozier pp 492495) Symmetric and NOSE straight; No discharge, Inspect any deviations or flaring; uniform shape, size, or color and color. (Fundamentals of flaring or discharge Nursing, Kozier pp 497498) Mucosa pink; clear, Inspect nasal cavities watery discharge; no for the presence of lesions. (Fundamentals redness, swelling, of Nursing, Kozier pp growth, and discharge 497-498) Inspect nasal septum Nasal septum intact between nasal and in midline chambers Air moves freely, as the client breathes through Test patency of both the nares. nasal cavities (Fundamentals of Nursing, Kozier pp 497498) No tenderness; no Palpate any tenderness, lesions, masses. masses, displacement (Fundamentals of of bone and cartilage Nursing, Kozier pp 492495) SINUSES No tenderness. Palpate the sinuses for (Fundamentals of

Rinnes test was not performed.

Normal

The clients nose was symmetric and straight. Nasal flaring was not present. Nose had uniform color. The clients nares were pink and moist. No watery discharges or lesions noted. The clients nasal septum was in midline and was intact. Patency of both nasal cavities were not noted,.

Normal

Normal

Normal

n/a

No lesions and masses note.

Not normal

No tenderness noted on the sinuses.

n/a

tenderness

MOUTH Inspect lips for symmetry, color, and texture

Nursing, Kozier pp 497498) Uniform pink color; soft, moist, smooth texture; symmetry of contour; ability to purse mouth. (Fundamentals of Nursing, Kozier pp 499502) Uniform pink color (freckled brown pigmentation in darkskinned client). (Fundamentals of Nursing, Kozier pp 499502) 32 adult teeth; smooth, white, shiny tooth enamel. (Fundamentals of Nursing, Kozier pp 499-502) Pink gums; moist, firm texture to gums; no restriction of gums. (Fundamentals of Nursing, Kozier pp 499502) Central position; pink color moist; slightly rough; thin whitish coating color); smooth lateral margin; no

The clients visible lips were pink. Normal symmetry and contour was noted. Ability to purse mouth was observed.

n/a

Inspect buccal mucosa for color, moisture, texture, and presence of lesions

Buccal mucosa was moist and pink in color.

Normal

Inspect teeth for color number and conditions

Teeth were white and smooth.

Normal

Gums were pink, moist and firm.

Normal

Inspect gums for color and conditions

TONGUE/FLOOR OF THE MOUTH Inspect for color and texture of the mouth floor and frenulum

Tongue was in center, was pink in color, visible lateral margin. No lesions noted.

Normal

Palpate for any nodules, lumps or excoriated areas

PALATES AND UVULA Inspect and palpate for color, shape, texture, and the presence of bony prominences Inspect for position of the uvula and mobility while examining the palates OROPHARYNX AND TONSILS Inspect and palpate for color, and texture

Inspect tonsils for size, color, and discharge NECK AND LYMPH NODES Locate /palpate/identify lymph

lesions. (Fundamentals of Nursing, Kozier pp 499-502) Smooth with no palpable nodules. (Fundamentals of Nursing, Kozier pp 499502) Light pink, smooth, soft palate Lighter pink hard palate, more irregular texture. (Fundamentals of Nursing, Kozier pp 499-502) Positioned in midline of soft palate. (Fundamentals of Nursing, Kozier pp 499502) Pink and smooth posterior wall. (Fundamentals of Nursing, Kozier pp 499502) Pink and smooth No discharge. (Fundamentals of Nursing, Kozier pp 499502) Not palpable; no tenderness. (Fundamentals of Nursing, Kozier pp 505)

Tongue was smooth and has no palpable nodules. Client reported no tenderness. Soft and hard palates were pink in color. Both palates are moist. No tenderness noted.

Not normal

Normal

Uvula was in midline

Normal

Oropharynx was pink and smooth. No lesions or discharges noted.

Normal

Tonsils were pink and smooth. No lesions or discharges noted. No enlargement noted The clients neck was not palpated for lymph node assessment to avoid manipulation and

Normal

Normal

nodes and note for tenderness TRACHEA Inspect and palpate for placement

THYROID GLAND Inspect symmetry and visible masses

trauma of the organs in the respiratory tract. Central placement in Central placement in midline of neck; spaces midline of neck; spaces are equal on both sides. are equal on both sides (Fundamentals of Nursing, Kozier pp 506) Not visible on inspection Gland ascends during swallowing but not visible. (Fundamentals of Nursing, Kozier pp 506-507) Lobe may not be palpable If palpated, lobe are small centrally located, painless, and rise freely with swallowing. (Fundamentals of Nursing, Kozier pp 506507 The clients thorax is cylindrical and symmetrical. Anteroposterior to transverse diameter was not performed as to avoid manipulation of the lesion inferior to the nipple, but AP diameter is approximately twice

Not normal

Normal

Normal

Palpate for smoothness and areas of enlargement, masses or nodules

Normal

POSTERIOR THORAX Inspect the size, shape, symmetry and compare the diameter of anteroposterior thorax to transverse diameter

Anteroposterior to transverse diameter in ration of 1: 2; chest symmetry

Inspect the spinal alignment

Spine vertically aligned; spinal column is straight, right and left shoulders and hips are at the same length

Palpate for temperature tenderness and masses

Uniform temperature, no tenderness and masses

Assess respiratory excursion

Palpate vocal fremitus

Percuss the posterior thorax

Full and symmetric chest expansion Bilateral symmetry of vocal fremitus. It is heard most clearly at the apex of the lungs; low pitched voices of males are more readily palpable than higher pitched voices of females Percussion notes resonate; except over scapula; lower pt. of resonance is at the diaphragm Vesicular and bronchovesicular sounds

larger than of transverse diameter. Spine vertically aligned. Shoulders and hips are on the same length. Spinal column is straight. The clients skin temperature in the thorax was slightly warmer than of the extremities. Further palpation was not performed. Symmetric chest expansion was noted. Vocal fremitus was not noted, with client unable to produce vocal sounds.

Normal

Normal

n/a n/a

Percussion elicited resonance on lung fields.

Normal

Auscultate the posterior thorax

Upon auscultation, there were noted vesicular and bronchovesicular

Normal

ANTERIOR THORAX Inspect breathing patterns

Quiet, rhythmic and effortless respirations

Palpate for Skin intact, uniform temperature, temp chest-wall intact; tenderness, and masses no tenderness / masses Full symmetric excursion; thumb normally separates 3 to 5 cm Percussion notes resonate down to the 6th rib at the level of the diaphragm but are flat over areas of heavy muscle and bone, dull Bronchial and lobular breath sounds

Assess respiratory excursion

Palpate vocal fremitus

sounds. Clear breath sounds. No adventitious sounds noted. The clients manner of breathing was quiet, rhythmic and effortless The clients skin temperature is uniform. No tenderness was noted on areas in the chest. The chest elicited full symmetric excursion. Separation of 3 cm was noted. Palpation of vocal fremitus was not done, as client cannot produce vocal sounds.

Normal

Normal

Normal

Normal

Auscultate the trachea

Auscultate the anterior thorax

Bronchovesicular and vesicular breath sounds

HEART Aortic and pulmonic area Tricuspid area

No pulsations No pulsations; no lifts or heaves

Bronchial sounds noted on auscultated area. Upon auscultation, there were noted vesicular and bronchovesicular sounds. No adventitious sounds noted. No pulsations, lifts or heaves noted. No pulsations, lifts or heaves noted.

Normal Normal

Normal

Normal

Apical area

With pulsations and very visible in thin persons. Pulsations visible in 50% of adults and palpable in most PMI in 5th LICS at or medial to MCI; diameter of 12cm; no lift or heave Symmetric pulse volumes; full pulsations; thrusting quality; quality remains same when client breathes, turns head; and charges from sitting to supine pos.; elastic arterial wall No sound heard on auscultation Veins not visible indicating right of head is functioning normally Unblemished skin , uniform color; silver white stria or surgical scars Flat rounded (convex) or scaphoid (concave)

Auscultate the aortic, pulmonic, tricuspid and apical valves

No observable pulsations as for the gauze on the apical area, lifts noted. Auscultation of the chest was not performed as the area is the site of lesion C.

Normal

Normal

CAROTID ARTERIES Palpate carotid artery with extreme caution

Symmetric pulse volumes; full pulsations; thrusting quality; quality remains same when client breathes, turns head; and charges from sitting to supine pos.; elastic arterial wall No sound heard on auscultation The clients jugular veins were not visible. The clients abdominal skin color was uniform, is dark brown but had a lighter tone than of the exposed areas. Contour was flat-round

Normal

Auscultate the carotid arteries JUGULAR VEINS Inspect jugular veins ABDOMEN Inspect the abdomen for skin integrity Inspect the abdominal contour while standing at the clients side while the client is in dorsal recumbent

Normal Normal

Normal

Normal

position Inspect for an enlarged liver or spleen Assess the symmetry of contour while standing at the foot of the bed Inspect the abdominal movements associated w/ respirations, peristalsis, or aortic pulsations Observe vascular patterns Auscultate the abdomen for bowel sounds, vascular sounds, and peritoneal friction rubs No evidence of enlargement of liver or spleen Symmetric contour Symmetric movements caused by respiration; visible peristalsis in very lean people; Aortic pulsation in thin persons at epigastic area No visible vascular pattern Audible bowel sounds; absence of arterial bruits; absence of friction rub Tympany over the stomach and gas-filled bowels; dullness specially over the liver and spleen; or a full bladder No tenderness, relaxed abdomen with smooth, consistent tension No notable evidence of liver or spleen enlargement. Skin fold contour was symmetric. Normal

Normal

Symmetric movement of Normal the abdomen and chest upon respirations. Peristalsis was not visible. Aortic pulsations were not seen. No visible vascular patterns noted on the clients abdominal area. Audible bowel sounds; Normal

Normal

Percuss several areas in each of the four quadrants

Perform light palpation followed by deep palpation of all four quadrants

Percussion of the abdomen elicited tympany on the stomach and some areas in the large bowel. Dullness in liver and spleen was noted. Clients abdomen is was relaxed. No tenderness noted upon light palpation. Deep palpation was not

Normal

Normal

SKELETAL MUSCLES Inspect the muscles for size. Compare the muscles on one side of the body ( arm, thigh, calf ) to the same muscle on the other side Inspect the muscle and tendons for contractures (shortening ) Inspect the muscles for fasciculation and tremors. Inspect any tremors of the hands and arms out in front of the body Palpate muscle tonicity Test for strength (neck)

Equal size on both sides of the body

performed. The clients muscles in the extremities (arm, forearm, thigh, calf) were of equal size on both sides.

Normal

No contractures

No contractures noted on the muscles of the trunk and appendages. No muscular fasciculation or tremors noted.

Normal

Normal

No fasciculation or tremors

Normally firm Equal strength

Test for strength (upper Equal strength on each extremities) body side

Test for strength (lower extremities)

Equal strength on each body side

Muscle tone was firm on movable muscle groups. Neck muscle strength was symmetrical. Strength was not tested. Upper limb muscle strength was symmetrical on both sides with fairly strong strength. Lower limb muscle strength was symmetrical on both sides with fairly strong strength.

Normal

Normal

Normal

BONES Inspect the skeleton for normal structures and deformities Palpate the bone to locate any areas of edema or tenderness JOINTS Inspect the joint for swelling

No deformities

No gross deformities on the prominent bones noted. No tenderness was noted on palpation. No gross deformities or edema noted on the palpated areas. No visible joint swelling or enlargement on the upper and lower limbs noted. The clients joints elicited no tenderness upon palpation, along with no nodules noted. No swelling, redness, enlargement or edema seen. No crepitation or rubbing sounds heard upon movement. No reports of limitation of motion noted on moving and rotating the arm. No reports of limitation of motion noted on moving and rotating the forearm. No reports of limitation of motion noted on moving the wrist and hands.

Normal

Normal

No tenderness or swelling

Normal

No swelling

Normal

Palpate each joint for tenderness, smoothness of movement, swelling, crepitation and presence of nodule

No tenderness, swelling, crepitation or nodules

RANGE OF MOTION Upper extremities (shoulder and scapula) Upper extremities (elbows)

Normal

No limitation of motion

Normal

No limitation of motion

Normal

Upper extremities (hands)

No limitation of motion

Lower extremities (accetabulum /inguinal area) Lower extremities (popliteal) Lower extremities (ankles )

No limitation of motion

No limitation of motion

No limitation of motion

No reports of limitation of motion noted on moving the thigh. No reports of limitation of motion noted on moving the legs. No reports of limitation of motion noted on moving the feet.

Normal

Normal

Normal