NCM 101 & 103 Rle Work Sheet Final

Cotabato Medical Foundation College, Inc
Quezon Ave. Poblacion 8, Midsayap, Cotabato

Tel: 064-229-8207
COMPREHENSIVE HEALTH ASSESSMENT
General Appearance:
Apparent age: The appearance is younger than her age
• General appearance: Looks well, No signs of distress, appears comfortable
• Grooming: Well groomed /wearing clean clothes/neat
• Hygiene: My Patient is clean and has good hygiene
• Odors: My Patient has No bad odors
• Nutritional status: Overweight but manifest weight loss
• Level of consciousness: Conscious
• Speech: Normal speech/Normal Volume
• Affect: Normal
• Gait: Normal Gait
• Posture: Regular/Posture erect/Normal spinal curve
• Movements: Can flex, can move, can extend, Can Walk
• Gross deformities: No deformities
• Signs of distress: Appears Comfortable
Integumentary:
1. Inspect color and lesions throughout examination
My Patient’s skin color is fair, No lesions and No edema, My Patient has scar at
her left leg, and her skin is oily and no excessive dryness.
2. Palpate temperature, turgor, and texture throughout examination

My Patient’s skin is warm which mean in normal range, The turgor skin springs
back to previous state is elastic.
HEENT:
Head:
1. Inspect size, shape, symmetry, position, hair distribution, and lesions
The head of my Patient is rounded shape, symmetric nasolabial, the position is
center at her body and No lesions or scar.
2. Palpate scalp mobility, tenderness, and hair texture

My Patient’s hair texture is smooth and oily, evenly distributed and has no
tenderness.
Face:
1. Inspect symmetry of nasolabial folds and palpebral fissures
The face of My Patient is symmetrically aligned and symmetric nasolabial folds.
2. Palpate temporal arteries and TMJ

My Patient’s temporal arteries can be felt, smooth symmetrical motion with no
pain.
3. Test ROM
My Patient’s facial movement are symmetrical, and there is no dropping of
eyelids or mouth, No involuntary movements of my patient’s face.
4. Test facial sensation (CN V), facial expression, and ability to smile and frown (CN
VII)
.
Tel: 064-229-8207
My Patient’s Facial sensation and Facial expression is Normal and appropriate in

situations, also ability to smile and frown.
Eyes:
1. Test visual acuity near/far with Snellen chart (CN II)
My Patient’s both eye visual have myopia or nearsightedness
2. Color vision
The color vision of My Patient is appropriate to the situation.
3. Peripheral vision by confrontation

When looking straight ahead, My Patient can see the object in the periphery.
4. EOM in 6 cardinal fields (CN III, IV, VI)

My Patient can able to see EOM in 6 Cardinal directions of gage of the object.
5. Corneal light reflex

The eye pupils of My Patient constrict when looking at the near object or when
using a pen light.
6. Cover/uncover test
My Patient can see the object clearly when she cover/uncover her one eye with
her arms when its near or far.
7. Corneal reflex/blink reflex

My Patient can blink normally or bilateral blinking both eyes coordinated and
can move with parallel alignment.
8. Inspect external structures of the eye

The eyebrows of My Patient is evenly distributed, the skin quality and movement
is symmetrically aligned the Eyelashes is equally distributed and the eyelids is
intact, no lesions, no discharges and no discoloration.
9. Test pupillary reaction

My Patient pupils constricted when looking at the near object and dilated when
looking at far object.
10. Palpate lacrimal glands and ducts

There has no swelling and no tenderness.
11. Perform fundoscopic examination
Ears:
1. Inspect/palpate external ear
My Patient’s external ear is distal contains hair follies and glands.
2. Check angle of attachment

My Patient’s ear angle attachment is symmetrically aligned.
3. Perform Weber, Rinne, and whisper tests (CN VIII)

My Patient can response normal voice tones audible, and able to repeat the
phrases correctly in both ears, And the sound is heard in both ears.
.
Tel: 064-229-8207
4. Perform orthoscopic exam

The ear canal of my patient is clear and has no tenderness or swelling, The
hearing is intact.
Nose and Sinuses:

1. Palpate sinuses and nasal patency
My patient nasal has no tenderness or no masses, and the air moves freely as the
client breathes.
2. Test sense of smell (CN I)

My Patient’s sense of smell is normal she can smell scents or odors.
3. Inspect nasal mucosa, septum, and turbinate’s

My Patient nasal mucosa is pink and has no tenderness the
nasal septum is intact.
Mouth:
1. Inspect/palpate lips, oral mucosa, teeth and gingiva, tongue
My Patient lips is smooth and no excessively dryness her teeth is 32 and the
tongue of My patient is no discoloration
2. Test sense of taste on anterior/posterior tongue (CN VII, IX)

My Patient sense of taste on anterior and posterior tongue is Normal.
3. Test mobility of tongue (CN XII)

The tongue of My patient can move freely in lateral and inferior movement.
4. Test gag reflex (CN IX, X)

My patient gag reflex is normal or regular.
5. Palpate parotids and submandibular gland

My patient’s parotids and submandibular gland has no signs of enlargement and
has no tenderness, and its normal.
Neck:
1. Inspect, palpate, and auscultate thyroid
My patient has not visible on glands ascends during swallowing.
2. Palpate and auscultate carotids and jugulars

My patient carotid is elastic arterial wall and no sound heard in auscultation.
3. Measure JVP
The JVP measures 6cm which is in normal range
4. Palpate lymph nodes

My Patient’s Lymph nodes has not palpable, No enlargement and no tenderness.
5. Palpate tracheal position

My Patient tracheal position is at the central placement in midline of neck.
.
Tel: 064-229-8207
6. Note ROM of neck

My Patient head flexes 45° with no painful movement when the chin move to the
chest, when head turns to the left and right the lateral rotates 70°.
7. Test neck muscle strength (CN XI)

There is no pain when the head turn to one side against the resistance of my
hand. And the strength is equal.
Posterior Thorax/Lungs:
1. Palpate excursion and fremitus
My Patient has full and symmetric thorax expansion and bilateral symmetry of
vocal fremitus, The fremitus is heard most clearly at the apex of the lungs.
2. Percuss lungs and diaphragmatic excursion

Upon percussion of the lungs and diaphragmatic excursion, percussion notes
resonate except over scapula. The lowest point of resonance is at the diaphragm.
3. Auscultate lungs
The lungs of my patient has vesicular and Broncho vesicular breath sounds.
There is no absence of breath sound noted.
Posterior Thorax/Spine:
1. Inspect normal spinal curves
The Spine is vertically aligned and the cervical is convex, the thorax is concave,
there is no exaggerated spinal curvature that can determine as scoliosis etc.
2. Test for scoliosis, kyphosis, and lordosis

The spinal column of my patient is straight the right and left shoulders and hips
are the same height, there has no exaggerated spinal curvature that can
determine as scoliosis, kyphosis, and lordosis.
3. Check ROM of spine

My patient can reach its toes while doing lumbar flexion, my patient can do
lumbar extension, lateral flexion and there is no presence of injury.
4. Palpate paravertebral muscles for tenderness

The paravertebral muscles of my patient is normal and there has no tenderness,
masses and movable structures.
5. Fist/blunt percuss stroke Tenderness

My Patient first blunt stroke is resonant sound and there has no presence of
asymmetry in position notes.
Anterior Thorax/Breast:
1. Inspect and palpate breast and lymph nodes with patient in various positions
The breast of My patient is even with the chest wall, the skin is uniform in color,
smooth and intact, No discoloration and hyper Pigmentation, No edema and
masses.
Anterior Thorax/Lungs:
1. Inspect AP: lateral ratio
My Patient has normal ches5 ratio which is 1:2
.
Tel: 064-229-8207
2. Palpate excursion and fremitus

The Respiratory excursion is fully symmetry, thumbs separated in 3 to 5 cm, the
fremitus decreased over heart and breast, has a bilateral symmetry of vocal
fremitus.
3. Percuss chest
The percussion notes resonate down to the sixty rib at the level of the
diaphragm, flat over areas of heavy muscles and bone heard, No dullness and
areas over lungs.
4. Auscultate breath sounds

The breath sound of My patient are vesicular and broncho vesicular, and there is
no presence of crackles.
Anterior Thorax/Heart:
Inspect and palpate precordium for pulsations
The precordium of My Patient has no pulsations and no irregularities.
2. Note PMI
Noted PMI is the 4th or 5th intercostal space.
3. Auscultate heart sounds

The result is 85Bpm which is in normal, nor abnormalities and the pulsation is
normal and has no turbulent blood flow or murmur sound.
Upper Extremities:
Palpate brachial, radial, and ulnar pulses
MY Patient has normal brachial, radial, ulnar pulses are easily palpated and
equal in strength.
2. Perform Allen test

My Patient Allen test shows that the color of her palm return immediately to its
pinkish color after blacking the radial within 2 seconds.
3. Perform Tinel and Phalen tests for carpal tunnel

My Patient cannot feel any tingling sensation upon doing the tinel and phalen
test.
4. Check color, temperature, capillary refill, deformities, clubbing
My Patient has pinkish skin color and the temperature is warm and the capillary
refill immediately return to its color and has no deformities.
5. Inspect joints for deformities

My Patient has no presence of any joints deformities.
6. Test hand grip

The Patient has normal hand grip in both hands.
7. Check ROM and strength

My patient has symmetrical movement and have a 100% strength without any
presence of deformities.
8. Measure arm lengths and circumferences

My Patient costal angle is less than 90° and the ribs insert into the spine approx.
.
Tel: 064-229-8207
9. Test pronator drift

My Patient both arms and legs motion are normal she can flex, bend, and extend
properly.
10. Test coordination with RAM and finger-thumb opposition

The finger and thumb of my patient can rapidly touch each finger to thumb with
each hand.
11. Test accuracy of movements with point-to-point localization

My Patient point to point localization can perform with accuracy and rapidly.
12. Test superficial and deep sensations

My Patient superficial and deep sensation can rapidly determine the position of
fingers and toes.
13. Test DTRs of upper Extremities

The DTRs of upper extremities of My patient shows normal with no presence of
abnormalities.
Abdomen:
Inspect size, shape, symmetry, and movements (respirations, pulsations, peristalsis)
My Patient has rounded abdomen and symmetrical movement caused by
respiration and not visible aortic pulsations.
2. Test for hernias

My Patient has no signs of hernias.
3. Auscultate bowel sounds and vascular sounds

My Patient has audible bowel sounds and has absence of arterial bruits.
4. Percuss abdomen and organs

My Patient has tympani over the stomach and gas filled bowel in the epigastric
region.
If ascites is present, test for shifting dullness or fluid wave

No ascites present in the patient abdomen.
5. Palpate abdominal organs (liver, spleen, kidneys), aorta, inguinal nodes, and femoral
Arteries
My Patient has no presence of tenderness, relaxed abdomen with smooth
consistent tension.
Extremities:
Inspect color, hair distribution, varicose veins
My Patient skin integrity is uniform in color the hair is evenly distributed and
has no varicose veins.
2. Perform Trendelenburg test or manual compression test to check venous circulation,

if indicated
There is no veins present in My patient lower extremities.
3. Palpate popliteal and pedal pulses, and temperature
.
Tel: 064-229-8207
The temperature of my patient is warm which is in normal range.
4. Inspect condition of feet and toenails, note lesions and deformities

The feet of My patient and toenails is in good condition No lesions and no
deformities.
Test ROM of lower extremities

My Patient can demonstrate bilateral equal condition and can move smoothly
with coordination.
6. Measure leg lengths and circumferences

The leg lengths of My Patient are equal in size on both side of the body.
7. Perform straight leg test if indicated

My Patient can perform straight leg.
8. Perform patellar tap or bulge sign if fluid is suspected

My Patient has no signs of any fluid suspected
9. Perform Apley’s and McMurray’s tests if indicated

My Patient can flex and extend lower extremities, no clicks sound heard and no
inflammation or swelling.
10. Perform Lachman test if indicated

My Patient can move the joints side to side and up and down, There is no injury
noted.
11. Test muscle strength of lower extremities

My Patient has equal strength on each muscles area, 100% normal strength,
normal full movement against gravity.
12. Test superficial and deep sensations of lower extremities

My Patient has no superficial and able to discriminate “sharp” and “dull”
sensations can rapidly determine.
13. Inspect gait, toe and heel walking tandem walk, deep knee bend
My Patient has upright posture and strength gait with opposing arm swing,
maintaining balance.
14. Perform Romberg test

My Patient is Ability maintain balance within 5 seconds.
15. Have patient toe-tap and run heel down shin

My patient has coordination of motor strength. There is no abnormal loss of
strength.
Test Achilles, patellar, and plantar reflexes and DTRs

My Patient patellar responds percussion done in deep tenders, there is no injury
found.
.
Tel: 064-229-8207
Female Genitalia/Rectum:
Inspect/palpate external and internal genitalia
My Patient genitalia/rectum shows kinky or curly pubic hair and skin is intact
and no lesions
2. Obtain specimens as indicated
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
3. Inspect and palpate rectum for masses
My Patient rectum has no masses.
4. Test stool for occult blood

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Male Genitalia/Rectum:
1. Inspect and palpate male genitalia
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
2. Inspect and palpate rectum for masses, prostate
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
3. Test stool for occult blood
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
.
Tel: 064-229-8207
NURSING HEALTH HISTORY
Biographical Data (10 points):

Name (Optional): ELLA S. MATABALAO Address: Poblacion Datu Piang Maguindanao
Phone number (Optional: 09275400798 Contact: 09275400798
Age: 48 Birth date: August 8 Birthplace: COTABATO CITY
Gender: FEMALE Civil Status: Married. Ethnicity/Nationality: __Maguindanaon_____
Referral: ____________ Number of dependents _3_ Health Insurance: __Philhealth_______
Educational level: ____College Graduate____
Informant: ____________________________
Reason for Seeking Health Care (5 points):

Primary level: (Usual state of health, major health problems, usual patterns of health care, health
concerns)
___Frequent acid reflux__________________________________________________________
Secondary and tertiary levels: (Identify chief complaint and do symptom analysis)
Upper abdominal pain and sometimes a burning sensation in chest usually after eating which
becomes worst at night
Past Health History (20 points):

Childhood illnesses:
My patient had chickenpox when she was child and also had fever and cough.
2. Hospitalizations
My Patient said that she was hospitalized several times.
Surgeries
My Patient has no experience with surgeries.
4. Serious injuries
No Serious injuries
5. Chronic illnesses
No Chronic illnesses
6. Immunizations
My Patient said that she is already immunized, she has been vaccinated with covid vaccine last
month.
7. Allergies
My Patient has no allergies on skin or drugs.
8. Medications
She used to take medicine before but now she said that she already stop taking medicine because
she’s feeling well now.
9. Recent travel
No recent travel
.
Tel: 064-229-8207
10. Military service

No military service
Family Health History (10 points):

Patient
_____The sometimes complain of hyperacidity and upper abdominal pain
______________________________________________________________________________
_________________________________________________________________________
______________________________________________________________________________
2. Spouse
Her husband is high blood
3. Children Patient’s children are all well and so far no problem with their health __________
______________________________________________________________________________
4. Parents
____The patient’s parents are both hypertensive
5. Siblings
_____The patient has no siblings___________________________________________________
______________________________________________________________________________
6. Aunts/uncles
_____The patient’s aunts and uncles had high blood and some had diabetes_________________
7. Grandparents
_____One of the grandparents is hypertensive________________________________________
______________________________________________________________________________
Review of Systems (20 points):

General health status
_____________________The patient’s general health status has no unusual problems, no
exercise intolerance and does not manifest easy fatigability _________________________
2. Integumentary
She had no problem with her skin, and no allergies
3. HEENT
My patient said that she doesn’t have pain in her nose, mouth and eyes
4. Respiratory
My Patient has normal breathing and no any abnormalities in her respiratory.
5. Cardiovascular
___the patient has no chest pain, palpitations, murmurs and no noted weakness, does not feel
dizziness and hands and feet do not feel cold numb and cold
______________________________________________________________________________
6. Breasts
_________No nodules and lumps were noted, no tenderness and the breasts are symmetrical in
size, no unusual redness _______________________________________________________
7. Gastrointestinal
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
8. Genitourinary
_____________The patient does not have painful urination, no backpain and urine is pale yellow
in color__________
.
Tel: 064-229-8207
8. Female/male reproductive
My Patient has normal and regular menstruation.
10. Musculoskeletal
Since I already assessed her musculoskeletal there has no abnormalities or deformities on her
bones or muscles and has no tenderness, swelling.
11. Neurological
My Patient seems oriented.
12. Lymphatic/hematological
___There is no visible lumps and nodes are accessible to palpitation but not large or firm enough
to be felt. No unusual bleeding and normal complete blood count_______________
Developmental (5 points):
Current developmental level
_____Current developmental level is normal and appropriate for her age, the patient is in the
middle adulthood stage _______________________________________________________
2. Past developmental problems
______The patient has no problem with her past developmental stage ___________________
Psychosocial (20 points):

Health practices and beliefs/self-care activities
___The patient is fond of skipping breakfast and her type of work is sedentary___________
Typical day
She said that she cleans the house every day and cooks for her family.
3. Nutritional pattern
___Usually skips breakfast and have her brunch at noontime and usually does not eat for dinner
4. Activity/exercise
The patient usually does household chores every morning which becomes her exercise everyday
5. Recreation, pets, hobbies

Her hobbies are cooking and eating, she also like cats
6. Sleep/rest patterns
Usually has sleep disturbance when her acid reflux attacks, but usually sleeps at 10PM and
wakes up at 4 to 5AM in normal situation
7. Personal habits (tobacco, alcohol, caffeine, and drugs)

No Personal habits
8. Occupational health patterns

___Usually goes to work at morning and goes home in the afternoon, annual medical check-up is
also required in their type of work
9. Socioeconomic status
_____The patient belongs to the average income group of economic status
.
Tel: 064-229-8207
10. Environmental health patterns

______The patient is very careful in using products that may cause danger to environment and
people’s health
11. Roles, relationships, self- concept

_____The patient is a family oriented person and has a good relationship with her family and
friends
12. Cultural/religious influences

My Patient said that she is Islam.
13. Family roles/relationships

Mother of 2 sons and 2 daughters
14. Sexuality patterns

The patient has moderately active sexual life with her husband
15. Social supports

___The patient is active in her advocacy towards social health especially precautionary measures
in preventing diseases
Stress/coping patterns
____The patient has a very positive outlook in life and handle problems and stresses smoothly,
she does not think or focus much on problems
.
Tel: 064-229-8207
Documentation (10 points)

Cluster the data and formulate at least 5 nursing diagnosis.
Cluster of Data Nursing Diagnosis

S: Hindi po ako masyado nakakatulog pag
umaatake ang sakit ko sa tiyan Sleep disturbance related to frequent
abdominal pain
O: Eyebags are visible in her eyes
S: masakit po masyado ang aking tiyan lalo

na sa bandang taas parang may pressure na Acute abdominal pain related to gastro
na nagpupush pataas esophageal reflux disease
O: Gimace on her face

S: Parang kumikirot po banda dito sa aking
dibdib mam Chest pain related to inflammation of
esophageal tissues caused by gastric
O: put hands on her chest with a grimace on reflux
her face
S: hindi na po ako masyadong kumakain
ngayon mam kasi pag nalalagyan ng pagkain Imbalanced Nutrition related to
ang tiyan ko ay sumaskit inability to intake food because of
epigastric pain after eating
O: Weight loss manifested by her weight
records from 83kls. Down to 73kls.
S: Nasusuka ako mam Nausea and vomiting related to gastric

reflux
O: vomitous comes out of her mouth
.
Tel: 064-229-8207
Nursing
Objective of Nursing Actions
Date / Cues Needs Diagnosis w/ Evaluation
Care with Rationale
Rationale
Acute abdominal pain After 2 hours of Assess for heartburn.
June 5, 2021 related to gastro nursing  Rationale: Heartburn is the most common feature
esophageal reflux interventions,the of GERD. This becomes more severe with vigorous
S: verbalization of pain disease patient will exercise, bending, or lying down.
like “masakit po verbalize relief Carefully assess pain location and discern pain from GERD
masyado ang aking from pain and and angina pectoris.
rate it as 2/10
tiyan lalo na sa  Rationale: Pain of esophageal spasm resulting
from 7/10
bandang taas parang from reflux esophagitis tends to be chronic and
may pressure na na may mimic angina pectoris: radiating to the neck,
nagpupush pataas” jaws, and arms.
O:
 Restless
 Rapidbreathin
g
 Rated pain as
7/10 in a
painscale of 0-
10
.
Tel: 064-229-8207
Generic Dosage and Pharmacologic

Ordered Name Route of Effects / Indicatio Contraindicatio Side
Classification Nursing Responsibilities
Medicine (Brand Administratio Mechanism of n n Effects
Name) n Action
.
Tel: 064-229-8207
.
Tel: 064-229-8207
JOURNAL READINGS RELATED TO THE CASE
(Attach the photocopy of your journal reading)
Summary
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Reaction
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Bibliography
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____

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Cotabato Medical Foundation College, Inc

Quezon Ave. Poblacion 8, Midsayap, Cotabato

COMPREHENSIVE HEALTH ASSESSMENT

2. Palpate temperature, turgor, and texture throughout examination

2. Palpate scalp mobility, tenderness, and hair texture

2. Palpate temporal arteries and TMJ

My Patient’s Facial sensation and Facial expression is Normal and appropriate in

3. Peripheral vision by confrontation

4. EOM in 6 cardinal fields (CN III, IV, VI)

5. Corneal light reflex

7. Corneal reflex/blink reflex

8. Inspect external structures of the eye

9. Test pupillary reaction

10. Palpate lacrimal glands and ducts

11. Perform fundoscopic examination

2. Check angle of attachment

3. Perform Weber, Rinne, and whisper tests (CN VIII)

4. Perform orthoscopic exam

Nose and Sinuses:

2. Test sense of smell (CN I)

3. Inspect nasal mucosa, septum, and turbinate’s

2. Test sense of taste on anterior/posterior tongue (CN VII, IX)

3. Test mobility of tongue (CN XII)

4. Test gag reflex (CN IX, X)

5. Palpate parotids and submandibular gland

2. Palpate and auscultate carotids and jugulars

4. Palpate lymph nodes

5. Palpate tracheal position

6. Note ROM of neck

7. Test neck muscle strength (CN XI)

2. Percuss lungs and diaphragmatic excursion

2. Test for scoliosis, kyphosis, and lordosis

3. Check ROM of spine

4. Palpate paravertebral muscles for tenderness

5. Fist/blunt percuss stroke Tenderness

2. Palpate excursion and fremitus

4. Auscultate breath sounds

3. Auscultate heart sounds

2. Perform Allen test

3. Perform Tinel and Phalen tests for carpal tunnel

5. Inspect joints for deformities

6. Test hand grip

7. Check ROM and strength

8. Measure arm lengths and circumferences

9. Test pronator drift

10. Test coordination with RAM and finger-thumb opposition

11. Test accuracy of movements with point-to-point localization

12. Test superficial and deep sensations

13. Test DTRs of upper Extremities

2. Test for hernias

3. Auscultate bowel sounds and vascular sounds

4. Percuss abdomen and organs

If ascites is present, test for shifting dullness or fluid wave

2. Perform Trendelenburg test or manual compression test to check venous circulation,

3. Palpate popliteal and pedal pulses, and temperature

The temperature of my patient is warm which is in normal range.

4. Inspect condition of feet and toenails, note lesions and deformities

Test ROM of lower extremities

6. Measure leg lengths and circumferences

7. Perform straight leg test if indicated

8. Perform patellar tap or bulge sign if fluid is suspected

9. Perform Apley’s and McMurray’s tests if indicated

10. Perform Lachman test if indicated