BIOGRAPHIC DATA

Address: Cabatangan,
Zamboanga City
Educational Attainment:
kindergarten
Age: 12 y/o                                        
      Gender:  Female
Ordinal Position: 3rd                      
        Religious Affiliation: Islam
Dialect: Sama                                  
       Civil Status: Single
Nationality: Filipino                          
     Ethnicity: Sinama
Occupation: None
Chief Compliant:
“Mmbah ako katuli pahap bang
sangom,  katol toongan neyh ku.
Ati piddi iya bang ni katol sab
toongan.”
(Translated to English: “I canʼt
sleep very well at night, my foot is
very itchy. And it is painful when I
scratch it so hard.”)
I. NURSING HISTORY
A. History of Past Illness
1. Childhood illness: No illness
2. Immunization: Complete
immunization
3. Allergies: No known allergies
4. Accidents: No accidents
5. Hospitalization: n/a
6. Medication used/ currently
taking: no medications used/
currently taking
 
B. History of Present Illness
Client is a 12 y/o girl who
experiences severe itchiness on
her right and left foot, which is
associated with pain on the scale
of 4/10.
 
 
C. Family History
The client is living together with
her father, who has asthma.
Family has no history of Diabetes,
heart problem and hypertension.

II. GORDONʼS 11 FUNCTIONAL

PATTERN
 
1. Pattern of Health Perception
and Health Management
The patient verbalized that she is
restless at night due to the severe
itchiness on right and left foot,
which is associated with pain on
the scale of 4/10. Patient does not
use any specific medication to
alleviate the symptoms, and have
not consulted to a doctor/
physician due to financial status.
 
2. Nutritional-Metabolic Pattern
The patient eats meals 3x a day
with snack in between, and
usually drinks up to 4-8 glasses
of water a day. Clientʼs weight is
91.5 lb and height is 4 ft. 5 in.,
with a Body Mass Index (BMI) of
22.9.
 
3. Pattern of Elimination
The patient said that she usually
moves her bowel every morning,
with brown and formed stool.
Additionally, she urinates for at
least 2-3 times a day.
 
4. Pattern of Activity and Exercise
Patient helps her mother with the
daily house chores and baby sits
her 1 y/o sister. In the afternoon,
the client sells kakanin, which is
prepared by the patientʼs mother.
Additionally, the patient
complains about the severe
itchiness on both of her foot,
which is associated with pain, this
affects the clientʼs ADLʼs.
 
5. Cognitive-Perceptual Pattern
No sensory deficits, but functions
are affected due to current health
problem. Patient is oriented to
people, time, and place. Patient
responds to stimuli physically and
verbally. The patient verbalized
that she is experiencing severe
itchiness on her right and left
foot, which is usually associated
with pain. She rated pain as 4,
from the scale of 1-10. Also,
patient claimed symptom is
intermittent.
 
6. Pattern of Sleep and Rest
The patient gets 4-5 hours of
sleep a day. Patient is restless at
night due to severe itchiness on
right and left foot, which is
usually associated with pain on
the scale of 4/10.
 
7. Pattern of Self-perception/
Self-concept
Patient manages to practice
healthy lifestyle so as not to seek
medical assistance. Though
affected by the current health
problem, patient still manages to
perform her ADLʼs and IADLʼs.
 
 
 
8. Role-Relationship Pattern
The patient receives strong
support from her family, with
close relationship with her
mother. Patient is helping her
mother with the daily chores and
sells kakanin, which is prepared
by her mother.
 
9. Sexuality Reproductive Pattern
The client is a 12 y/o female who
recently had her menarche on 5th
of February, 2019. Client is 3rd in
the sibling ordinal position
 
10. Coping-Stress Tolerance
Pattern
The patient seems to be stoic
when it comes to her coping
mechanism towards the
symptoms. As the patient
claimed, that she have not used
any medications to alleviate the
symptoms.
 
11. Values-Beliefs Pattern
The patient is a Muslim who has a
strong faith in Allah s.w.t/ God.
The client added that she goes to
the mosque with her
grandmother to pray every Friday.

III. PHYSICAL EXAMINATION

 
A. Head
1. Skull
- The head is symmetrical and
normal cephalic. Size varies with
age and body stature.
- No tenderness are noted upon
palpation.
- No nodules, masses and
depressions upon palpation.
- Face is oval, smooth, and
symmetrical.
2. Scalp
- The scalp is free of swelling,
lesions, nodules, masses.
- Lighter in color than the
complexion.
- Positive to head lice, nits, and
little dandruff.
3. Hair
- The hair is in normal texture.
- Evenly distributed covers the
whole scalp.
• Hair is black
- No evidence of Alopecia.
- It is thick and smooth.
- Neither brittle nor dry.
B. Face
- Face is oval, smooth, and
symmetrical.
- No involuntary muscle
movements.
- Can move facial muscles at will.
- Intact cranial nerve V and VII.
 
• Eyebrows
- Symmetrical and in line with
each other.
- It is color black.
- Evenly distributed.
C. Eyes
- The sclera is white with no
lesions or redness.
- The conjunctiva is pink.
- The pupils are equally round
and reactive to light.
- Eyelids in normal position with
no abnormal widening or ptosis.
- Cornea is transparent, smooth,
and moist with no opacities, lens
is free of opacities.
- Irises are round, flat, and evenly
colored.
 
• Lacrimal Gland
- Lacrimal gland is non-palpable.
- No tenderness gland on
palpation.
- No regulation from the
nasolacrimal duct.
- 
D. Ears
- Ears are equal in size bilaterally.
- Auricles are aligned with the
corner of the each eye.
- The ears skin is smooth, no
lumps, lesions, nodules.
- No discharge.
- Non tender on palpation
- The auricles have firm cartilage
on palpation
- The pinna recoils when folded
- There is no pain or tenderness
on the palpation of the auricles
and mastoid process
- The ear canal has normally
some cerumen of inspection
- No discharges or lesions noted
at the ear canal
 
E. Mouth & Gums
- Lips pink, smooth, and moist
without lesions
- Buccal mucosa is pink, moist,
and without exudates
- 28 white to yellowish teeth
present
- Gums is pink without redness or
swelling
- Protrudes geographic tongue in
midline with no tremors
- Equal bilateral strength in
tongue
- Ventral surface of tongue is
smooth and shiny pink with small
visible veins present
- Frenulum in midline
- Soft palate smooth and pink
- Tonsil pillar pink and symmetric
F. Nose
- The shape of the external nose
can vary greatly among individual
- Normally, it is located
symmetrically on the midline of
the face that is without selling,
bleeding, lesions, or masses
- No discharge or flaring and
uniform color
- There is a sense of smell
- Bone nares are patent
- No bone and cartilage deviation
noted on palpation
- No tenderness noted on
palpation
- Nasal septum in the midline and
not perforated
- The nasal mucosa is pinkish
- No tenderness noted on
palpation of the paranasal
sinuses
G. Neck
- The muscles of the neck are
symmetrically with the head at a
central position
- The patient is able to move
head through a full range of
motion with no complaint of
discomfort or noticeable
limitation
- The patient may be breathing
through a stoma or tracheostomy
- Lymph nodes are not visible or
inflamed
- No visible mass or lumps
- No jugular venous distension
(suggestive of cardiac
congestion)
• Trachea
- The trachea is palpable
- It is positioned in the line and
straight
H. Breasts
The patient is exempted from
breast examination; since patient
is a 12 y/o female and verbalized
“Mmbah aku bilahi ni kamba
duruh ku.” (“I donʼt want you to
undergo breast exam.”).
I. Thorax, lungs, and Abdomen
- The chest wall is intact with no
tenderness and masses
- There is a full an symmetric
expansion and the thumbs
separate 2- cm during deep
inspiration when assessing for the
respiratory and excursion
- The client manifested quite,
rhythmic and effortless
respirations
- The spine is vertically aligned.
The right and left shoulders and
hips are of the same height
- There were no visible pulsations
on the aortic and pulmonic areas.
- The abdomen of the client has
an unblemished skin and is
uniform in alignment
- The abdomen has a symmetric
contour.
J. Nails
- Nail beds pink without clubbing
- Hands well-manicured with
clear enamel
- The client has a light brown
nails and has the shape of convex
curve. It is smooth and is intact
with the epidermis
- When are pressed between the
fingers (Blanch Test), the nails
return to usual color in less than 4
seconds.
K. Extremities
- The extremities are symmetrical
in size and length
- The muscles are not palpable
with the absence of tremors.
They are normally firm and
showed smooth, coordinated
movements
- There were no presence of bone
deformities, tenderness and
swelling
- There were no swelling,
tenderness and joints move
smoothly
• Have the same contour with
prominences of joints
• No involuntary movements
• No edema
• Color s even
• Temperature is warm and even
• Has equal contraction and even
• Can perform complete range of
motion
• No crepitus no crepitus noted
on joints
• Can counteract gravity and
resistance on ROM.
 
L. Skin
- Skin pink, warm, dry and elastic.
- There are no rashes
- There are 2 moles on her right
anterior arm
- Normal skin temperature. No
edema or superficial varicosities.
 
• The following are observed on
the foot of the patient
Right foot:
- Scaly red patch surrounding the
toes, ranging in size from 2-3 cm
- Scaling on the soled that
extends up to the side of the foot
- Cracked, blistered, or peeling
between the toes
- Raw skin from scratching
The same is observed on the left
foot.
 
IIII. NURSING DIAGNOSIS
Restlessness related to impaired
skin integrity, inflammatory
response to fungal infection.