Nursing Process Documentation

Far Eastern University
Institute of Nursing
Nicanor Reyes Street
Sampaloc, Manila
CASE PRESENTATION:
ACTIVITY INTOLERANCE
In partial fulfillment to the requirements in:

NUR1204: Fundamentals of Nursing Practice
Submitted to:
Ms. Anabella Garcia Javier
Ms. Stephanie Ornum
Submitted by:
Agor, Kevin Christian C.
Agulto, Fatima V.
Agustin, Alexander Allan D.M. IV
Alcantara, Kathreen Claire, DV.
Amihan, Ashley Mae A.
Arguelles, Jan Jericho T.
Bacorro, Sofia Isabelle G.
Basuel, Donovan E.
Belza, Sherine Nicole T.
Bolintiam, Ma. Franchesca M.
July 19, 2021

I. Demographic Profile
Name: Ma. Franchesca M. Bolintiam
Address: Albacura St., Brgy. Wawa, Nasugbu,

Batangas
Age: 19 years old
Birthdate: November 28, 2001
Birthplace: Nasugbu, Batangas
Gender: Female
Religion: Roman Catholic
Race: Asian/Filipino
Marital Status: Single
Educational Attainment: College Undergraduate
Chief Complaint: Dizziness, Weakness, Headache (prolonged

duration)
Admitting Diagnosis: Activity Intolerance
Attending/Admitting Physician: Dr. Kathreen Alcantara
II. Nursing Health History
a. History of Present Illness
In 2014, the patient started to feel symptoms such as dizziness, fatigue, weakness,
shortness of breath, and pallor. According to her, she self-diagnosed her condition, which she
thought to be from over fatigue and sleep deprivation caused by her online classes. During that
same year, the patient was diagnosed with anemia. Since then, the patient has been taking
medication for her condition, which is Ferrous Fumarate-Folic Acid. This medication keeps her
blood pressure normal. However, she still feels fatigue and dizziness often when given heavier
tasks such as cardio exercises, lifting, running, etc.
b. Past health History
According to the patient, she has no allergies, has not had any problems or complications
since birth, and that she is completely immunized up until now. However, she stated that she
was hospitalized before because of a gunshot wound at her foot during her middle school term,
being a grade 4 student because of an accident while she’s at a computer shop inside her
neighborhood.
c. Family History (Include Genogram with legend)
As stated by the patient, her paternal side is healthy but his father is currently hepatic. Whilst her
maternal side has more genetic diseases, having lung cancer from her grandfather while diabetes
and heart disease from her grandmother. The heart disease was inherited by the patient’s uncle
through his grandfather while her mother didn’t inherit anything, but is anemic. The reason she
also perceived that it’s the reason for her being diagnosed with anemia as well.
Diagram 1: Patient Franchesca’s Genogram
III. Gordon’s Patterns of Functioning
a. Health Perception-Health Management
Before hospitalization, the client stated that she was generally healthy in regards to her
lifestyle and food intake but she has been experiencing frequent headaches, dizziness and fatigue
due to hot temperature, the humidity of her environment and excessive exposure to electronic
gadgets. The client views her illness at a pain scale of 5/10 and alleviates her pain by taking
medications such as Advil or ibuprofen and perceives that her pain scale decreases to 2/10. In
spite of her headaches, she verbalized that she is an occasional drinker but does not have any
other vices.She maintained her healthy lifestyle by eating foods that are rich in protein such as
meat, eggs and chicken. As to her skin condition, it appears that she has a pale appearance upon
presenting to the interview stating that she is anemic and tries to get as much adequate sleep in
her free time.
Interpretation: Deviation from Normal

Analysis: The health perception and management describe how the client responds to her
health, well-being and lifestyle and how she manages it on a regular basis. Lifestyle choices may
have positive and negative effects on health. In addition to the client’s health perception and
management, she is anemic and that triggers negative factors such as headaches and sudden
fatigue. The client appears pale or pallor due to the deficiency in oxygen-rich hemoglobin near
the skin’s surface and protein.
b. Nutritional-Metabolic Pattern
Diet Recall
Date and Time Food and Beverage Amount/Measure Energy (Kcal)*
Intake
07/09/21 Breakfast - 9 am
● Coffee 1 cup/ 8 oz
● Pandesal 3 pcs/ 3 oz 80 Kcal
Lunch - 11:30 am
● White rice/ 4.7 oz/12 oz 867 Kcal
Adobo
Dinner - 7 pm
Adobo
Water intake a day
● 5 glasses of 25 oz
water
Lunch - 11:30 am
Tinola
Dinner - 7 pm
Tinola
Water intake a day
water
Lunch - 11:30 am
Sinigang
Dinner - 7 pm
Sinigang
Water intake a day
water
Lunch - 11:30 am
Pinakbet
Dinner - 7 pm
Pinakbet
Water intake a day
water
Lunch - 11:30 am
Sisig
Dinner - 7 pm
Sisig
Water intake a day
water
Lunch - 11:30 am
Bulalo
Dinner - 7 pm
Bulalo
Water intake a day
water
Lunch - 11:30 am
Kare-kare
Dinner - 7 pm
Kare-kare
Water intake a day
water
Analysis: The client does not take any supplements. She consumes 5 glasses of water a day,
which is not adequate enough and may lead to risks of fluid volume deficit. Patient’s weight is
constant and does not fluctuate. The patient’s food intake involves a balance between
carbohydrates, iron-rich food, and fruits and vegetables. Every day, she has breakfast, lunch, and
dinner. The patient eats the most during lunch and least during dinner. The client does not
experience any difficulties when eating.
c. Elimination Pattern
The client claims that she has no discomfort while urinating and that her urine is light yellow
in color. In addition, the client stated that she defecates twice a day (morning and evening) and
does not use laxatives. She doesn't have any problems releasing stool. Finally, she consumes five
glasses of water per day.
Interpretation: Normal
Analysis: Assisting the elimination pattern of the client is a crucial and essential process that has
important medical significance as well as psychosocial effects on the client's quality of life.
Assistance for healthy elimination patterns is needed to ensure patients are having regular soft
bowel movements and adequate urination and to identify abnormal patterns such as flatulence,
constipation, diarrhea, incontinence, fecal impaction, hemorrhoids as well as polyuria, anuria,
and other abnormalities which can be signs of underlying medical conditions. (Sharma & Bhutta,
2021)
d. Activity-Exercise Pattern
According to the client, she claims that she is living a sedentary lifestyle due to online classes
and not having the chance to go out of her house because of Covid-19. But she considers
household chores as one of her main exercises during the pandemic. The client stated that she is
tasked to wash the dishes every day. When she wakes up, she goes to her laptop or cell phone to
check if there are any activities that she needs to do during the day and right after checking, she
cooks breakfast for her family. After they eat their dinner, she is tasked to sweep and mop the
floor. She also stated that she gives her dogs a bath twice a week. Before sleeping, her routine is
to wash her face and do her skin care.
ACTIVITY DIARY/RECALL
Date Time of the Day Activity Estimated time of

Activity/Exercise
9:30 am -10:00 am Checking for activities 30 minutes
10:20 am - 10:50 am Cooking of Breakfast 30 minutes
07/08/2021 11:00 am - 2:00 pm Completing of requirements 3 hours

for the day
2:00 pm - 3:00 pm Taking the dogs for a bath 1 hour
4:00 pm - 7:00 pm Reading lectures 3 hours
9:00 pm - 10:00 pm Sweeping and mopping of the 1 hour

floor
2:00 am - 3:00 am Night routine 50 minutes
11:00 am - 2:00 pm Completing of requirements 3 hours

07/09/2021 for the day

floor


floor


floor


floor

for the day
07/13/2021 4:00 pm - 7:00 pm Reading lectures 3 hours

floor

for the day
07/14/2021 2:00 pm - 3:00 pm Taking the dogs for a bath 1 hour

floor
Analysis: The patient reported decreased energy compared to usual. She has no regular exercise
but is physically active due to her daily household chores. She does not engage in any leisure or
child-play activities. The patient is usually able to do activities normally and without struggle but
for the past week, she reports a difficulty in achieving her usual tasks. Moreover, she also
observes proper posture and has no problem with Range of Motion (ROM) joints. Respiration
rate is 15 breaths per minute. Blood pressure is 90/60. A bit pale in appearance (pallor).
e. Cognitive-Perceptual Pattern
The client claims that he or she does not have any hearing or visual impairments. Furthermore,
the client said that she had 20/20 vision and that she had an eye exam around August of 2019. The
client claims there is no loss of taste or difficulty with scent. She is acutely aware of her
surroundings and has a complete grasp on the concept of time. She also claims that she has no
trouble following orders, recalling tasks, or making decisions.
Analysis: Environmental perception is usually characterized as being aware of or thinking about

the environment, as well as the process of apprehending the environment through the senses (Zube,
2021). And, as the client mentioned, she has no issues with her five senses. Furthermore, cognitive
functioning encompasses a wide range of cognitive domains, including memory, language,
vasoconstriction, perception, attention, and executive processes (Lezak et al., 2004). The client
expresses that she has no trouble following directions, remembering responsibilities, or making
decisions.
f. Sleep-Rest Pattern
M T W Th F Sat Sun
Time went to 3:30 AM 3:30 AM 3:30 AM 3:30 AM 3:30 AM 4:00 AM 4:00 AM

bed
Approximate 6 HOURS 6 6 6 6 6 6
time asleep HOURS HOURS HOURS HOURS HOURS, HOURS,
30 MINS 30 MINS
Wake up NONE NONE NONE NONE NONE NONE NONE

period/ sleep
interruptions
(how long)
Time woke- 9:30AM 9:30 AM 9:30 AM 9:30 AM 9:30 9:30 9:30

up the next AM AM AM
morning
Feeling after NORMAL. NORMAL. NORMAL. NORMAL NORMAL NORMAL. NORMAL

waking up . . .
Naps (time NONE NONE NONE NONE NONE 3:00 PM 3:00 PM

slept & woke - 5:00 - 5:00
up; duration) PM PM
Activities School School School School School Scrolling Scrolling

done before works, works, works, works, works, through through
bedtime modules, modules, modules, modules, modules, social social
and and and and and media media
studying studying studying studying studying
Bedtime Skin care, Skin Skin care, Skin Skin Skin Skin
rituals oral and care, oral oral and care, oral care, oral care, oral care, oral
body and body body and body and body and body and body
hygiene hygiene hygiene hygiene hygiene hygiene hygiene
before before before before before before before
bed. bed. bed. bed. bed. bed. bed.
Analysis: The patient feels generally well-rested and ready for activity after sleeping. Reports no
problems with falling asleep or taking short naps. However, the patient still does not get a
sufficient amount of sleeping time (6-7 hours every night). The patient goes to sleep at usually
3:30AM and wakes up at 9:30 AM. On a normal day, the patient rests during breaks after online
classes to eat lunch but is not able to take naps when she has classes. Patient has dark circles
around the eyes and eye bags.
g. Self-Perception - Self-Concept Pattern

The client describes herself as an optimistic, kind individual. She states that she is constantly
in a good mood and feels good about herself. She affirms that she is free of insecurities. What
causes her worry and anxiety are the pressures of academics and approaching deadlines.
Additionally, she stated that she is not distressed by her current condition. The client maintains
eye contact, speaks with a normal tone and pace, has proper body posture, and is assertive with
her thoughts.
Analysis: An individuals' body image views are determined by their subjective impressions, not
an objective vantage point. Self-perceptions of one’s physical appearance entail mental images of
how one looks. These perceptions are by no means accurate representations. As the client stated,
she has no insecurities and feels good about herself. Within Maslow's hierarchy of motives and
theory of personality development, self-esteem needs relate to individuals' wants to have a stable
and realistically positive perception of themselves (Maslow 1943). I believe our client embodied
this notion when she stated that she feels good about herself and is not self-conscious about her
body or facial characteristics.
h. Role-Relationship Pattern
The client lives with her family. Her parents and brother make up her family. The client
claims that her family lives together, but her relatives occasionally stay at their home. The client
often performs household chores and organizes their groceries. She manages her responsibilities
effectively, yet it may be stressful at times. The client claims to have social groups from several
schools. She has close friends, some of them are classmates. The client claims that she seldom
feels lonely, but that she is able to get over it quickly. She also mentioned that she does well in
school and does not feel isolated in her neighbourhood.
Analysis: As the client stated, she has strong bonds with her nuclear and extended family.
According to the Cultural Atlas (2021), for the majority of Filipinos, family is the foundation of
social life. Although the nuclear family is the primary family unit, connections between extended
family members are usually strong. People may be encouraged to establish relationships with
their aunts and uncles that are as strong as their relationships with their parents. The client also
stated that she has various social groups and close friends. Adolescents may identify with social
groups to build a social identity and a positive self-concept, as well as an improved level of self-
autonomy from parents (Brown and Lohr, 1987).
i. Sexuality - Reproductive Pattern
The client claims that she does not have an active sexual lifestyle. The client only has one
sexual partner. The client does not have any sexually transmitted disease/s. The client also stated
she does not experience any difficulties or problems during her period. She also stated that
before her period, she experiences Premenstrual Syndrome also known as PMS wherein she
experiences mood swings, headache, and menstrual cramps.
Analysis: The client stated that she had PMS before her menstruation started. Premenstrual
syndrome affects 95% of reproductive-age women. PMS psychological symptoms include
irritability, sadness, crying, and anxiety. Physical symptoms of PMS include stomach bloating,
breast soreness, and headaches (Kwan & Onwude, 2015). In addition, the client said that she
engages in sexual activity once every two weeks. Sexual health was a highly significant element
of quality of life for many participants, even those in poor health, in this major research of US
adults' evaluations of the significance of sexual health and satisfaction with sex life (Flynn et al.,
2016).
j. Coping-Stress Tolerance Pattern
The client claims that she learned to love herself more and realized her self-worth after her
breakup with her partner because of their toxic relationship. She finds it comfortable talking about
her problems with her best friends because she doesn’t feel judged when opening up to them and
doesn’t also make her feel like a burden when they try to comfort her and give her helpful advice.
She feels the most stress during her weekdays wherein it is also her school days because of the
online class that usually starts in the morning and ends at 7pm in the evening. She tried to consume
alcoholic beverages for her to be able to cope up with the stress that she is experiencing.
Analysis: According to (Stoll, 2020), there are 10 ways to cope up with stress and one of which is
connecting with supportive people wherein when you talk face to face with another person, it
releases hormones that reduce stress so you should lean on those good listeners in our life. Relating
it with the client, she claims to have her best friends to be with her in her toughest times and she
finds it comfortable being with them wherein she doesn’t feel judged. Having this kind of people
with her can let her cope with the stress that she is having as she has people to talk with her
problems and at the same time, have someone who always gets her back especially in situations
that she needs them the most. It is always hard to have people who are always there to help you,
guide you, and motivate you but in the client’s case, she has a strong support system that helps her
reduce her stress and have good listeners when talking about her problems. Bonding with best
friends are always good stress relievers especially in the pandemic wherein we stay at home and
not go outside of our houses. Her best friends also gave her advice which made her realize her self-
worth and also learned to love herself even more.
k. Value-Belief Pattern
The client claims to live on her own and become more independent for her future after the
pandemic to have a sense of responsibility and be self-sufficient as possible. She also said that she
can achieve this plan by means of managing her time wisely and practicing independence at an
early age so that when the time comes and she needs to live on her own, she would then know
what to do and not depend on anyone anymore. She also mentioned about her inspirations which
are her family and her loved ones wherein she becomes stronger and better because of them. She
usually gets the things that she wants because she worked hard and prayed for them to be a reality
and earn it in the best possible way she can. Coming from a family of religious members, she too
is religious and believes in God’s plans. She has faith and prays to God more often whenever she
experiences problems and difficulties in her daily living.
Analysis: According to (Hammond, 2013), there are 11 reasons why you need to be more
independent and one of which is boosting one’s own self-confidence and self-esteem. Having self-
confidence and self-esteem means that you trust yourself to be competent in the situations you
confront and also gives a positive outlook on yourself. Relating it with the client, she claims to
become more independent and also live on her own after the pandemic for her future and learning
to become independent instills confidence in herself more because she believes in the knowledge
and capacities that she possesses to deal with any challenge that will come along her way. She also
is religious so she has faith in God that He will guide her to the right path when she is already on
her own and trusts that one day, she will become successful and after it, she will give back to her
family and friends. It’s never bad for her to rely on others for help but being a strong independent
woman helps her to trust in her own capabilities and to God not being afraid of the problems that
she will be facing ahead and also knows how to handle and control things on her own.
References
Drzezo, N. (2016, June 12). Risk-prone Health Behavior. Nurse Key. https://nursekey.com/health-
perception-health-management-pattern/
Eustice, C. (2021, May 8). Overview of Advil (Ibuprofen). Verywellhealth.

https://www.verywellhealth.com/what-is-advil-2552182
Kohli, P. (2019, June 26). What to know about skin paleness.

https://www.medicalnewstoday.com/articles/325562
Hammond, D. (2013, November 26). 11 reasons why you need to be more independent. Lifehack.
https://www.lifehack.org/articles/productivity/11-reasons-why-you-need-more-
independent.html
Stoll, M. (2020, April 14). 10 simple ways to cope with stress. Sutter Health | Doctors and
Hospitals | Northern California. https://www.sutterhealth.org/health/mind-body/10-
simple-ways-to-cope-with-stress
Piyush Sharma, & Bhutta, B. S. (2020, June 16). Assisting Patients With Elimination. Nih.gov;
StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK559258/#:~:text=Nurses%20need%20to%20as
sist%20with
Flynn, K. E., Lin, L., Bruner, D. W., Cyranowski, J. M., Hahn, E. A., Jeffery, D. D., Reese, J. B.,
Reeve, B. B., Shelby, R. A., & Weinfurt, K. P. (2016). Sexual Satisfaction and the
Importance of Sexual Health to Quality of Life Throughout the Life Course of U.S.
Adults. The Journal of Sexual Medicine, 13(11), 1642–1650.
https://doi.org/10.1016/j.jsxm.2016.08.011
Kwan, I., & Onwude, J. L. (2015). Premenstrual syndrome. BMJ Clinical Evidence, 2015, 0806.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4548199/
IV. Physical Assessment
A. General Survey
ASSESSMENT NORMAL ACTUAL INTERPRETATIO
FINDINGS FINDINGS N AND ANALYSIS
Signs of Distress in No apparent distress There is a presence DEVIATION FROM
posture and facial noted with good of distress from the NORMAL
expression posture and normal client's facial
facial expression. expression due to her Analysis:
headache. She Studies often mention
verbalized her pain that headaches such as
on a scale of 5/10. migraine and tension
headaches are caused by
lack of sleep and sleep
deprivation. Upon the
age of the client she is
needed to have 7-9
hours of sleep in order
to prevent having
frequent headaches.
Cirino, E. (2018,
November 27). Sleep-
Headache link. Healthline.
https://www.he
althline.com/health/lack-
of-sleep-headache#sleep-
and-headaches
Body Build, Height Proportionate and The client is at a NORMAL

and Weight suited to the client's normal BMI range
age and lifestyle.
Height: 5 ft. 3 inches
Weight: 110 lbs
BMI: 19.5
(Normal range of
BMI for women is at
18.4-24.9 )
Client’s Posture Relaxed, erect posture The client is relaxed NORMAL

(Sitting, Standing and with coordinated during the
Walking) movements assessment as well
as her movements
are coordinated.
Hygiene and Clean and neat The client presented NORMAL

Grooming appearance with a clean and neat
appearance.
Body and Breath No body/breath odor or No foul odors from NORMAL

Odor minor body odor in her body and breath
relation to work and upon observation.
exercise.
Signs of Health and Healthy appearance The client showed a DEVIATION FROM
illness restless appearance NORMAL
due to her busy
schedule and Analysis:
verbalized that her Heat-induced headaches
headaches were can cause dehydration
caused by humidity especially when
and hot temperature. exposed to high
Eyebags and dark temperature because the
spots under the body system needs more
client’s eyes are also water to make up for the
visible. body sweats that have
been produced.
Dehydration is said to
trigger migraines and
headaches. Humidity or
weather conditions can
also produce changes in
serotonin levels and
hormonal changes. In
regards to the eye bags
and dark circles of the
client, it may be a cause
of dehydration and sleep
deprivation due to
oversleeping or lack of
sleeping hours. Lack of
sleeping hours causes
fluid to build up
underneath the eyes that
causes it to be swollen.
Anthony, K. (2019). Dark

circles under your eyes:
treatments and causes.
https://www.healthline.co
m/health/dark-circle-
under-eyes.
Watson, K. (2019. January

15). Heat-Induced
Headaches and Migraines.
Healthline.https://www.he
althline.com/health/heat-
headache
Client’s Attitude Cooperative Cooperative NORMAL

throughout the whole
assessment.
Client’s Responses are The affect and mood NORMAL

appropriateness of appropriate to the of the client is
response situation and appropriate to the
collaborative. said situation.
Quantity, quality and Understandable, The client’s thoughts NORMAL

organization of speech is at a moderate were clear and
speech pace and exhibits concise upon
thought association. observation.
Skin Color Varies from light to Upon observation, DEVIATION FROM

deep brown, from The client has a pale- NORMAL
ruddy pink to light like appearance
pink. Analysis:
Paleness or pallor is the
unusual lightness of skin
color from the client’s
normal skin complexion
that is caused by either
the reduction of blood
flow and oxygen or
decreased number of
blood cells. Factors that
cause pallor are illness,
emotional shock, stress
and anemia.
Biggers, A. (2019,
September 18) Paleness:
Causes, Symptoms,
Diseases and Treatments.
Healthline.
https://www.healthline.co
m/health/paleness
Uniformity of Skin Generally uniform The client has a NORMAL

Color except in areas to sun; uniformed skin
areas of lighter color.
pigmentation and dark
skinned
Presence of edema or No edema or any skin The client has no NORMAL

skin lesions lesions/abrasion found. signs of any
inflammation,
edema, skin lesions
and abrasions found
on lower and higher
extremities.
Hair Evenly distributed, The client’s hair is NORMAL

thick, silky, resilient evenly distributed,
hair. No presence of thick, silky and
any infections or resilient. There is
infestations. also no presence of
infections and
infestations upon
observation.
Nails Convex curvature; the The client’s nails are DEVIATION FROM
angle between the nail round with a NORMAL
and nail bed at 160° characteristic of
convex curvature Analysis:
Highly vascular and and 160° nail bed. Paleness of nails or
pink in light-skinned brittle nails are common
while brown or black Her fingernails signs of anemia and
for dark-skinned appear in pale or pallor where the body
white color than the lacks hemoglobin and a
Blanch test: Prompt normal color of the protein that has the
return of pink or the nail bed which is purpose to carry oxygen
usual color in less than pink. starting from the lungs
four seconds to the rest of the body.
The client’s nail
color has returned to Penn Medicine (2019,
its normal state/color January 7). Nail Health
in less than two Can Tell You: Don’t
seconds. Ignore These 5 Signs.
https://www.pennmedicine.
org/updates/blogs/health-
and-
wellness/2019/january/nail
-health
B. Measurement (Height, Weight, BMI and Vital Signs)
HEIGHT, WEIGHT & BMI
NORMAL ACTUAL FINDINGS INTERPRETATION

FINDINGS AND ANALYSIS
Height Proportionate to 5 ft. 3 inches NORMAL

Weight
Weight Proportionate to 110 pounds (49.89 kg)

Height
Body Mass Index Body Mass Index

(BMI) 19.5 kg/m2
Underweight: less
than 18.5
Normal Weight:
18.5 to 24.9
Overweight: 25 to
29.9
Obese: 30 and
above
VITAL SIGNS
MEASUREMENTS NORMAL ACTUAL FINDINGS INTERPRETATION

FINDINGS AND ANALYSIS
Temperature 36.5°C - 37.5°C 37.2°C NORMAL
Pulse Rate 60-100 bpm 89 bpm NORMAL
Respiratory Rate 12-20 cpm 15 cpm NORMAL
Blood Pressure Less than 120 90 / 60 mmHg DEVIATION FROM

systolic and less NORMAL
than 80 diastolic
Analysis:
Hypotension is where the
arterial blood pressure is
abnormally low. This
commonly happens when
the nervous system is
deprived of an adequate
blood supply that leads to
dizziness and
lightheadedness. If a blood
pressure drops too low it
means that the body system
does not get enough
oxygen and nutrients that
can cause heart
palpitations, blurry vision,
muscle pain, nausea and
shock.
Beckerman, J. MD. (2021,

June 14). Understanding Low
Blood Pressure -- The Basics.
WebMD.
https://www.webmd.com/heart
/understanding-low-blood-
pressure-basics
NHLBI (2021, April 29). Low

Blood Pressure: Also known
as Hypotension.
https://www.nhlbi.nih.gov/hea
lth-topics/low-blood-pressure
Oxygen Saturation 95% - 100% 98% NORMAL
C. Head to Toe Assessment (Cephalo-caudal)
Head to Neck Assessment

BODY PART/ AREA NORMAL ACTUAL INTERPRETATION
TO BE ASSESSED FINDINGS FINDINGS AND ANALYSIS
Head and Face
Head Head size and shape The head is symmetric, NORMAL

vary. Head is round, erect and in
symmetric, round, midline and
erect and in midline appropriately related to
and appropriate to body size
body size (normocephalic). No
presence of lesions and
Must be hard and lumps noted upon
smooth and free from inspection.
lesions upon palpating
Face The face is The face is NORMAL

symmetrically round, symmetrically rounded
oval, elongated or and there are no
square. No involuntary tremors and lesions
movements noted. found upon inspection.
Temporal Artery Elastic and not tender The temporal artery of NORMAL
the client is smooth
upon palpation and
there are no signs of
inflammation.
Temporal No swelling, The client’s TMJ is NORMAL

Mandibular Joint tenderness or within normal range
(TMJ) crepitation and no crepitation is
noted when jaws are in
Opens and closes to 3- motion as palpated.
6 cm between upper
and lower teeth
Neck
Inspect the neck Neck is symmetric and The client’s neck is NORMAL
in midline without any symmetrical and in
bulging masses. midline without any
bulging or tumors
upon inspecting.
Movement of Neck The thyroid and There are no NORMAL

structures cricoid cartilage moves abnormalities noted
upward and downward found from the
within the midline as cartilage and is within
the client swallows. normal range as
inspected.
Cervical Vertebrae Usually visible and The C7 of the client is NORMAL

(C7) palpable visible and palpable.
Range of Motion Neck should be Neck movement is NORMAL

smooth and controlled smooth and controlled.
within 45 degree
flexion, 55 degrees
extension and 40
degree lateral
abduction and 70
degree rotation.
Trachea Trachea is in midline Trachea is in midline NORMAL

position position.
Thyroid Gland Landmarks such as Upon palpation, The NORMAL

hyoid bone, Thyroid thyroid gland is in
cartilage and cricoid midline and there is no
cartilage are positioned presence of any
midline. enlarged thyroid gland.
Enlarged Thyroid Auscultation is needed Auscultation is not NORMAL

Gland if there is a presence of needed since there are
enlargement in the no signs of diffuse
thyroid glands. enlargement.
Lymph Nodes There must be no There is no swelling or NORMAL

swelling, tenderness enlargement of lymph
and enlargement nodes as well as no
present from the tenderness noted upon
lymph nodes. palpation.
Eyes
Test Visual Acuity Normal distant visual Upon examination, the NORMAL
acuity is 20/20 with or patient’s distant visual
without corrective acuity is 20/20 without
lenses and the client corrective lens and is
can distinguish a normal.
person or an object
from 20 feet away.
Test Near Visual Normal near visual The patient’s near NORMAL
Acuity acuity is 14/14 with or visual acuity is 14/14
without corrective without corrective lens
lenses. The client can and is normal as
read what the normal examined.
eye can read from a
distance of 14 inches.
Corneal light reflex Reflection on both Upon inspection by the NORMAL

test corneas should be in use of penlight, the
parallel alignment. cornea’s reflection in
the light is at an
appropriate spot.
Cover test Uncovered eye should The uncovered eye NORMAL

be in a fixed position remains fixed straight
straight ahead and the ahead while the
covered eye should covered eye also
also remain fixed remains fixed straight
when uncovered. ahead after being
uncovered.
Positions test Eye movement should Eye movement is NORMAL

be smooth and smooth and symmetric
controlled through all through all six cardinal
six cardinal positions positions without any
delayed perception.
Eyelids and eyelashes The upper lid margin The upper lid margin NORMAL
should be between the is between the upper
upper margins of the margin of the iris and
pupil. The lower lid of pupil. The lower lid
margin tests in the margin rests on the
lower border of the lower border of the
iris. No white sclera is iris. No white sclera is
seen above and below seen above and below
the iris. the iris. Lastly the
palpebral fissures are
Palpebral fissures may horizontal.
be horizontal.
Ability of eyelids to The upper and lower The client’s eyelids NORMAL
close lids close easily and open and close easily
meet completely when when asked.
closed.
Position of the eyelids The lower eyelid is Both eyeballs of the NORMAL
in comparison with upward with no inward client are aligned to
the eyeballs or outward turning. the eye socket without
any presence of
Eyelashes are evenly protruding or sinking.
distributed and curve
outward along the lid
margins.
Bulbar conjunctiva Bulbar conjunctiva is Bulbar conjunctiva is NORMAL

and sclera moist, underlying clear, moist and
structures are clearly smooth. Underlying
visible and the sclera is structures are clearly
white. visible and the sclera is
white.
Palpebral The lower and the The palpebral NORMAL

Conjunctiva upper conjunctivae are conjunctivae of the
clear and free of any client are free from
swelling or lesions. and clear of lesions
and swelling upon
inspection.
Upper eyelid The palpebral Upon palpation, the NORMAL
conjunctiva or the upper eyelids of the
upper eyelid is free client are free from
from any foreign swelling and there are
objects or trauma. no foreign objects
present.
Lacrimal Apparatus No swelling or redness The lacrimal duct of NORMAL

present over the areas the client shows no
of the lacrimal gland. signs of swelling and
redness upon palpation
and the nasolacrimal
duct of the client is
moist and free from
drainage.
Cornea and Lens The cornea and lens is The cornea of the NORMAL
transparent and moist client is transparent
with no opacities. while the lens is free
from any opacity upon
inspection.
Iris and Pupil The iris is typically Upon inspecting, the NORMAL
round, flat and evenly iris is normal and well-
colored. The pupils are rounded and the colors
equal in size within 3- of her iris are brown.
5 mm.
Both pupils in her eyes
are evenly identical
from its shape.
Pupillary light reflex The normal direct The client’s eyes upon NORMAL
pupillary response is inspecting are that
constriction both of her eyes
constrict when the
light is near.
Assess consensual The normal consensual The client’s eyes upon NORMAL
response pupillary response is inspecting for the
constriction consensual response is
also constricting.
Test Accommodation The normal pupillary There is constriction of NORMAL

of pupils response is the pupils and
constriction of the convergence of the
pupils and eyes upon focusing on
convergence of the a near object.
eyes when focusing on
a near object.
Ears
Auricle, Tragus and Ears are equal in size The client’s ears are NORMAL
Lobule (normally 4-10 cm) equal in size bilaterally
The auricle aligns (6 cm). The auricle
from the corner of aligns with the corner
each eye. of each eye and within
a 10-degree angle of
the vertical position
and earlobes are
attached tightly with
no apparent lobe.
External Auditory A small amount of Upon inspection, the NORMAL
Canal odorless cerumen or patient’s external
earwax is normally auditory canal is
discharged when normal with no
present. abnormalities.
Auricle and Mastoid The auricle and The patient’s auricle NORMAL
Process mastoid process must and mastoid process
not be tender. are not tender and are
normal.
Whisper’s test Able to correctly The patient was able to NORMAL

repeat two-syllable repeat the two-
words correctly. syllable words without
any problems in both
ears as examined.
Weber’s test Vibrations must be By the use of the NORMAL

heard from both ears tuning fork, the client
equally and no has stated that she
lateralization of sound heard and felt the
to either ear. vibration coming from
the tuning fork from
both of her ears. No
lateralizations of sound
are also noted to either
ear.
Rinne’s test Air conduction sound Air conduction is NORMAL

is normally hear longer heard longer than bone
than the bone conduction sound as
conduction (AC > BC) examined.
Romberg’s test Client maintains As for the position of DEVIATION FROM

position for 20 seconds the client through the NORMAL
without swaying. Romberg’s test. I have
observed that there is a Analysis:
minimal swaying on The client might have
her head. a balance disorder.
Dizziness upon
standing from her
current lying position
in a sudden amount of
time marks that the
client has a low blood
pressure or
hypotension.
Methesda, M (2018).
Balance disorders.
Retrieved from
https:///balance-disorders
Nose
External Nose The color is identical Upon palpating and NORMAL

to the skin tone and the inspecting the external
nasal structure must be nose of the client, it is
smooth and within normal range
symmetric. Must not and the color of the
show any presence of nose is also identical to
tenderness from the her skin tone which is
nose light brown.
Patency of airflow The client must be able The client was able to NORMAL
through nostrils to sniff through each sniff through each
nostril while the other nostril while the other
is covered or occluded. side was occluded.
Internal Nose The nasal mucosa Upon inspection, the NORMAL

must be pink, moist client’s internal nose
and free from exudate. was dark pink, moist,
The nasal septum must and free of exudate
also be intact and free
of ulcers.
Sinuses
Palpate Sinuses There are no signs of The client’s frontal NORMAL

tenderness and and maxillary sinuses
crepitation upon are nontender upon
palpating the frontal palpation.
and maxillary sinuses.
Percuss Sinuses The sinuses are not The sinuses are non- NORMAL
tender on percussion. tender upon
percussion.
Mouth
Lips Lips are smooth and The client’s lips are NORMAL
moist without any moist, without
lesions or swelling. swelling or lesions as
observed.
Teeth and Gums 32 pearly whitish teeth The client’s teeth and NORMAL
with smooth surfaces gums show normal
and edges. Upper signs. Complete 32
molars should rest and teeth intact and gums
the lower must have smooth surfaces.
override the lower and
upper incisors. No
decayed areas in the
teeth.
Buccal Mucosa The buccal mucosa Upon inspecting and NORMAL

must be pink or light- palpating the buccal
pink. mucosa of the client,
the color appears
pinkish.
Tongue Tongue should be pink Upon palpating the NORMAL

and moist, within a tongue of the client, it
moderate size with the is also pinkish in color
papillae. No lesions and there are no signs
must be present in the of any lesions or
tongue upon palpating. inflammation.
Ventral Surface of The tongue’s ventral The ventral surface NORMAL

the tongue surface must be tongue of the client is
smooth and shiny, pink moist, smooth and
or slightly pale and the pink while the vein or
veins are visible. slightly visible.
Inspect for The frenulum part is in As for the frenulum NORMAL

Wharton’s ducts midline position; part of the client, it is
Wharton’s ducts are within normal range
visible with the and the frenulum is in
salivary flow and midline while there is
moistness in the area no presence of any
and free from any swelling or redness
swelling, redness and from the Wharton’s
discomfort. duct.
Strength of the The tongue offers Upon palpation and NORMAL

tongue strong resistance. resisting the tongue of
the client on the outer
part of the cheeks, it
appeared that the client
had a strong tongue
resistance.
Sides of the tongue No lesions, ulcers or There are no lesions or NORMAL

nodules are apparent. ulcers present upon
palpation.
Hard and Soft The hard palate is pale The hard palate of the NORMAL
palates of the uvula or whitish with firm client upon palpating
transverse rugae while is whitish in color with
the soft palate is firm transverse rugae
pinkish, smooth, while the soft palate is
spongy and smooth. more pinkish in color
and smooth.
Mouth Odor No unusual poor foul Upon assessing and NORMAL

odor is noted. inspecting the
following assessments,
there are no foul odors
coming from the
mouth of the client.
Uvula The uvula must have a The uvula hangs freely NORMAL
fleshy and solid in the midline and no
structure and hangs redness or exudate
freely on the midline from the uvula and soft
of the mouth and no palate. Midline
redness must be elevation of uvula and
present from the uvula symmetric elevation of
or soft palate. the soft palate are
noted.
Tonsils Tonsils may be present The tonsils of the NORMAL

or absent and must be client are visible or
pink and symmetric. present and the tonsils
The grading scale must are also in the grading
not exceed within 1+. scale of 1+ which is
within normal range.
Posterior Pharyngeal Throat is normally The throat of the client NORMAL

Wall pink without exudate upon inspecting, it is
or lesions. pinkish in color and
there is no presence of
any lesions or exudate.
Chest to Abdomen Assessment
BODY PART/AREA NORMAL ACTUAL INTERPRETATION

Posterior Thorax
Configuration Scapulae are As inspected, scapulae NORMAL

symmetric and non- are visible and
protruding. symmetric and the ribs
Shoulders and scapula are sloping downward
are at equal horizontal in about 45-degree
positions angle and it is
symmetric.
Use of Accessory Client does not use Upon observation, the NORMAL
Muscles accessory muscles to patient does not have
assist breathing and any trouble breathing.
the diaphragm must be The patient also is not
the one at work. using any accessory
muscles in breathing.
Client’s Positioning Client should be sitting The client is seated NORMAL

up, relaxed and upright and breathing
breathing easily with normally as observed.
arms at the sides of the
lap.
Tenderness, sensation No tenderness, pain or Upon palpation, there NORMAL

and crepitus unusual sensations and is no tenderness and
the temperature is any unusual sensations
equal bilaterally. found and the
temperature is equal to
the whole-body
temperature. There is
no presence of crepitus
found.
Surface Skin and subcutaneous The skin and NORMAL

characteristics tissue is free from subcutaneous tissue of
lesions and masses. the client are free of
lesions and masses.
Fremitus Fremitus is easily Upon observation, the NORMAL

symmetric and patient’s fremitus was
identified in the upper palpable and normal.
regions of the lungs.
Chest Expansion The examiner’s thumb Upon observation, the NORMAL

must move 5-10 cm patient’s posterior
apart symmetrically as chest wall moved
the client breathes. around 5-10 cm apart
symmetrically.
Percuss for tone Resonance is the Upon percussion over NORMAL

percussion tone the lung tissues,
elicited over normal resonance is heard.
lung tissue and flat When percussing over
tones over the scapula. the scapula, flat tones
or dullness is heard.
Diaphragmatic Excursion should be The client’s excursion NORMAL

Excursion equally bilateral and is equal bilaterally and
measures from 3-5 cm measures about 4cm.
for adults and 7-8 for
well- conditioned
clients.
Breath Sounds Breath sounds may Normal breath sounds NORMAL

either be bronchial, are auscultated.
bronchovesicular and
vesicular.
Voice Sounds Voice transmission is Upon performing NORMAL

soft, muffled and Bronchophony, voice
indistinct and the transmission of the
phrase cannot be client is soft, muffled,
distinguished. and indistinct. The
client’s voice is
audible but the phrase
“ninety-nine” is
unclear.
In Egophony, the letter
“E” is distinguishable
but soft and muffled.
In Whispered
pectoriloquy, the
phrase is faint and
muffled.
Anterior Thorax
Shape and The anteroposterior Upon observation, NORMAL

Configuration diameter is less than there is no presence of
the transverse barrel chest from the
diameter. client and the ratio of
anteroposterior to
transverse diameter is
1:2.
Position of the Sternum is positioned The client’s sternum is NORMAL

sternum at midline and straight. in midline position and
straight and there is no
presence of a sunken
sternum.
Sternal Retractions Retractions not The client shows no NORMAL

observed. retractions.
Slope of the Ribs Ribs slope downward The ribs of the client NORMAL
with symmetric slope downward. The
intercostal spaces and intercostal spaces are
costal angle is symmetric and the
within 90 degrees. costal angle is within
90 degrees.
Quality and pattern Respirations are The client has no NORMAL

of the respirations relaxed, effortless and trouble breathing. Her
quiet. The regular respirations are
rhythm is within 10-20 relaxed, effortless, and
per minute for adults. quiet. Her respiratory
rate is 15 cpm.
Intercostal Spaces No retractions or There were no NORMAL

bulging of intercostal retractions or bulging
spaces are noted. of intercostal spaces
observed.
Use of Accessory Not seen with normal The client did not NORMAL
Muscles respiratory effort. engage in any physical
Clients who underwent activities before the
through an exercise assessment and it is
can use neck shown that there is no
muscles in a short time use of any accessory
to enhance breathing. muscles upon
breathing.
Tenderness, No tenderness or pain Upon palpation, there NORMAL

Sensation and surface is palpated over the is no pain expressed by
masses lung area with the client and the lung
respirations. area shows no
tenderness.
Tenderness at Palpation does not No tenderness upon NORMAL

costochondral elicit tenderness. palpation is shown
junction of ribs from the client.
Crepitus No crepitus is palpated No friction or crepitus NORMAL

is heard and felt while
the ribs are palpated.
Fremitus Must be symmetric The client’s fremitus is NORMAL

and easily identified symmetric and easy to
within the upper identify in the upper
regions of the lungs. regions of the lungs. It
is also symmetric
bilaterally upon
palpation.
Anterior chest Thumbs move outward Upon palpation, there NORMAL

expansion in a symmetric way are no signs of unequal
from the midline. chest expansion noted
and the thumbs move
symmetrically outward
from the midline.
Percuss for Tone Resonance is the No presence of hyper NORMAL

percussion tone resonance noted during
elicited over normal percussion.
lung tissue.
Breath Sounds Breath sounds may Upon auscultating, the NORMAL

either be bronchial, breath sound is the
bronchovesicular and same for the posterior
vesicular. thorax which is
bronchovesicular and
there are no signs of
adventitious breath
sounds.
Breasts and Lymphatic System
Size and symmetry One breast may The left breast of the NORMAL
normally be larger patient is slightly
than the other. bigger than her right
breast.
Color and Texture Color varies on the The breasts are equally NORMAL
client’s skin tone and identical to the overall
the texture must be skin color and there is
smooth. no presence of edema
found as inspected.
Superficial venous Veins radiate either The veins of the NORMAL

pattern horizontally and patient’s breasts
toward the axilla radiate horizontally
(transverse) or towards the axilla.
vertically.
Areolas Areolas vary from The client’s areolas are NORMAL

dark pink to dark light brown and very
brown depending on well-rounded on both
the client’s skin tone. breasts.
Nipples Nipples are equally Nipples are almost NORMAL

bilateral in size and are equal bilaterally in size
in the same location on and located the same
both sides. Nipples on each breast. Nipples
may be everted, are everted. No
inverted or flat. discharge is present
upon inspection.
Retraction and Breasts should rise As observed, there are NORMAL

Dimpling symmetrically with no no signs of dimpling or
signs of dimpling or retraction. In all the
retraction. positions, the breasts
were able to rise
symmetrically.
Texture and Upon palpation, both The breasts are both NORMAL
Elasticity breasts must be smooth and firm and
smooth, firm and there are no signs of
elastic tissues. any tumors as
palpated.
Tenderness and Breast should be at a Breasts are both within NORMAL

Temperature normal body normal body
temperature and non- temperature and it
tender. shows no tenderness
upon palpation.
Palpation for masses No masses should be No presence of masses NORMAL

palpated. or tumors present in
the client’s breasts
upon palpation.
Palpation of the The nipple may In response to NORMAL

nipples become erect and the palpation, the nipples
areola may pucker in of the client became
response to erect. No discharge
stimulation. was observed.
Axillae No rash or infection There are no rashes or NORMAL

present. infections detected.
Heart and Neck Vessels
Jugular venous pulse Not normally visible While the client sits NORMAL
when the client is upright, the jugular
sitting upright venous pressure is not
which distends the visible.
vein and pulsations.
Jugular venous The vein should not be The jugular vein of the NORMAL
pressure distended, bulging or client is not distended,
protruding and must be bulging, or protruding.
at 45 degrees or
greater.
Carotid Arteries No blowing or Upon auscultating NORMAL

swishing must be there are no bruits or
heard and the abnormal sounds heard
strength of the pulse is and the pulse
evaluated on a scale amplitude scale are
from 0 to 4 upon within 2+ or in normal
auscultation. range
Arteries must be Upon palpation, there

elastic and are no thrills noted and
no thrills are noted. the arteries are
normally elastic.
Pulsations Apical impulse may The apical impulse of NORMAL

not be visible. If the patient is visible in
apparent, it would the mitral area upon
be in the mitral area. inspection.
Apical Impulse The apical impulse is The apical impulse of NORMAL

palpated in the mitral the patient is palpable
area and has a size of a and is approximately
nickel which is 1-2 1-2 cm.
cm.
Abnormal Pulsations No abnormal There is no presence of NORMAL

pulsations or abnormal pulsations
vibrations must be upon palpation in the
palpated on the apex, apex, left sternal
left sternal border or border or base.
base.
Heart rate and Heart rate must be at As auscultated, The NORMAL

Rhythms 60-100 bpm with a client’s heart rate is at
regular rhythm. 89 beats per minute
and heart rhythm is
normal.
Identifying S1 and S2 S1 and S2 must Upon auscultation, it NORMAL

correspond on the apex appears that the s1 is
and base of the heart. heard the loudest on
the apex area while the
s2 is the loudest on the
base.
Extra Heart sounds Normally no sounds No extra heart sounds NORMAL

are heard. were heard upon
auscultation.
Murmurs Normally no murmurs No murmurs are heard. NORMAL

are heard.
Abdomen
Coloration of the skin Abdominal skin may As observed to the NORMAL

be paler than the client’s abdomen, it is
general skin tone. pale since it’s not
exposed to sunlight
most of the time.
Vascularity of the Scattered fine veins Scattered fine veins NORMAL
abdominal skin may be visible. are fairly visible.
Inspect for scars Pale, smooth, As inspected, there are NORMAL

minimally raised old no scars on the client’s
scars may be seen. abdomen.
Presence of lesions Abdomen is free from The abdomen of the NORMAL

and rashes lesions and rashes. Flat client is free from
or raised moles may be lesions and rashes.
present which is
normal.
Umbilicus Umbilical skin tones The umbilicus is NORMAL

are similar to within the midline of
surrounding abdominal the abdomen and it’s
skin tones or even equally toned to the
pinkish. abdominal skin stone.
Contour and It is recessed Upon inspection, it is NORMAL

symmetry of the (inverted) or recessed or inverted.
umbilicus protruding in no more
than 0.5 cm and is
round and conical.
Abdominal Abdominal respiratory Upon breathing, the NORMAL

movement when the movement may be client’s abdominal
client breathes seen especially on respiratory movement
male clients. is seen.
Aortic pulsations Might be slightly There is a slight NORMAL

visible on the pulsation of the
epigastrium. abdominal aorta in the
client’s abdomen.
Peristaltic waves Peristaltic waves are Peristaltic waves are NORMAL

not normally seen but not seen in the client.
it may be visible for
thin people.
Bowel Sounds A series of Upon auscultation, NORMAL

intermittent, soft and bowel sounds are
gurgles are heard at a heard. These are a
rate of 5-3 minute. series of intermittent,
soft clicks, and
gurgles.
Vascular Sounds Bruits are not normally Bruits are not heard NORMAL
heard over abdominal upon auscultation over
aorta or renal, iliac, or abdominal aorta or the
femoral arteries. renal, iliac, or femoral
However, bruits arteries.
confined to systole
may be normal in
some clients
depending on other
differentiating factors.
Friction rub over the No friction rub over There is no present NORMAL
liver and spleen the liver or spleen is friction rub over the
present. liver or spleen of the
client upon
auscultation.
Percuss for tone Generalized tympany Upon auscultation, NORMAL
predominates over the tympany is heard over
abdomen because of the abdomen.
the air in the stomach However, over the
and intestines. liver and spleen, only
dullness is heard.
Span or height of the On a deep inspiration, The lower border liver NORMAL
liver by determining the lower border of of the client descends
its lower and upper liver dullness may from 3 cm below the
borders descend from 1-4 cm costal margin.
below the costal
margin.
The normal liver span The MSL of the client

at the midsternal line is upon percussion marks
at 4-8 cm. at 5 cm.
Blunt percussion on No tenderness must be Upon percussing the NORMAL

the liver and the elicited. posterior part of the
kidneys liver and kidneys, it
appears that no
tenderness is present.
Light Palpation Abdomen is nontender Upon palpating the NORMAL

and soft. There is no four quadrants, no
presence of guarding. tenderness is palpated
and the abdomen is
soft and free from any
guarding.
4 quadrants to Normal or slight No tenderness is NORMAL

delineate abdominal tenderness is possible shown upon deeply
organs and detect over the xiphoid, aorta, palpating the following
subtle masses cecum, sigmoid colon quadrants and no
and ovaries. enlarged organs are
present.
Liver The liver is usually not As palpated, the liver NORMAL

palpable except for is palpable on the
thin clients. Must be client and it is slightly
firm and smooth. tender.
Urinary Bladder An empty bladder is The urinary bladder of NORMAL

neither palpable nor the client is neither
tender. palpable nor tender.
Rebound Tenderness No rebound pain is No expression of pain NORMAL

elicited. is shown on the client
and she stated that she
feels more pressure
while the abdomen is
being pressed down
which is normal upon
palpation.
Musculoskeletal Assessment
BODY PART/ AREA NORMAL ACTUAL INTERPRETATION

Size of the muscles Equal sides on both Upon inspection by the NORMAL
sides of the body use of tape measure,
the muscle sizes of the
upper and lower
extremities of the
client are symmetrical.
Inspect muscles and No contractures There are no signs of NORMAL

tendons for any contractions in
contractures both muscles and
tendons upon
inspection.
Inspect muscles for No fasciculation or There are no NORMAL

tremors tremors. contractures on the
client’s muscles and
tendons as inspected.
Determining Muscle Normally firm. Upon palpation, it is NORMAL

tonicity not atonic and there
are also no signs of
inflammation on both
upper and lower
extremities.
Inspect the skeleton No deformities Upon inspecting the NORMAL

for normal structures skeleton of the patient,
and deformities the findings show that
there are no
deformities.
Muscle’s presence of Smooth coordinated There is no presence of NORMAL

flaccidity, spasticity movements flaccidity and
and smoothness of spasticity present on
movement. the client's muscles as
palpated.
Muscle strength of Equal strength on each Upon testing the NORMAL

head and shoulders body side strength of the
sternocleidomastoid
and trapezius, they are
equal on both sides.
Muscle strength of Equal strength on each As for the Deltoid, it is NORMAL

the upper extremities body side in 75% of the normal
strength meanwhile in
the biceps, triceps,
Finger muscle and grip
strength shows 100%
of muscle strength or
in full resistance on
both body sides
Muscle strength of Equal strength on each Muscles of the lower NORMAL

the lower extremities body side extremities are all
within normal strength
of 75% and against
minimal resistance on
both sides.
Skeleton No deformities The skeleton of the NORMAL

client is at a normal
structure and there are
no signs of any
misaligned bones
present upon
inspection.
Presence of edema or No tenderness or Upon palpation, there NORMAL

tenderness in the swelling is no presence of
bones swelling or edema
present.
Palpate each joint for No swelling, There is no swelling, NORMAL

tenderness, crepitation or nodules tenderness, crepitation
smoothness of are present. or nodules observed on
movement, swelling, the client.
crepitation and
presence of nodules
Assess joint range of Varies to some degree The range of motion of NORMAL
motion in accordance with a the client’s joints are
person’s genetic make- all able to meet full
up and degree of range of motion
physical activity. Full without any
range of motion from difficulties.
head to lower
extremities
V. Ecologic Model
1. Hypothesis
Activity intolerance which is the insufficient physiological or psychological energy to
endure or complete required or desired daily activities experienced by the client for the past
week prior to check-up is caused by her pre-existing condition which is iron deficiency anemia.
The condition of the client was triggered mainly by excessive fatigue, sleep deprivation, and lack
of fluid intake.
2. Predisposing Factors
Host Factors:
a. Age: The patient is 19 years old
b. Diet: The patient’s diet lacks fluid intake
c. Resistance: Lowered resistance due to the pre-existing condition of the patient.
(Iron deficiency anemia)
Agent:
a. Pre-existing condition which is iron deficiency anemia
b. Excessive fatigue, sleep deprivation, and lack of fluid intake
Environment:
a. Stress and pressure from online class
b. Excessive exposure to radiation via usage of electronic devices
c. Flickering lights due to constant blackouts
d. Change in the weather (temperature)
e. Nutritional Inadequacy
f. Sleep and rest deprivation
3. Model
4. Analysis of the Model and the Predisposing Factors
Based on a study by Murat (2015), iron deficiency anemia (IDA) affects sleep quality
together with its psychological symptoms such as depression and anxiety. The results of the
study also showed that subjective sleep quality was worse in patients with IDA in comparison to
normal respondents.
As the name implies, iron deficiency anemia is caused by insufficient iron in the body.
Without enough iron, your body can't produce enough of a substance in red blood cells that
enables them to carry oxygen (hemoglobin). As a result, iron deficiency anemia may leave you
tired and short of breath. Moreover, symptoms of IDA include extreme fatigue, weakness,
paleness, headache, and dizziness, all of which can be alleviated with ineffective health
maintenance and practices. Women are also more prone to this condition because women lose
blood during menstruation. (Mayo Clinic, 2019).
5. Conclusions and Recommendations
Finally, It may be concluded that the dizziness, prolonged headache, and weakness
symptoms that was experienced by the patient for 3 days was triggered mainly by excessive
fatigue, sleep deprivation, and lack of fluid intake. Confirmed by her activity intolerance having
an insufficient energy to endure or complete required or desired daily activities, which
overwhelmed the patient with specific physiological, biological and environmental circumstances
making the patient vulnerable to the symptoms.
The goal for the activity intolerance is to improve the patient's ability to perform daily tasks
without feeling weak. By that the patient should be fully hydrated having an efficient fluid intake,
physically fit having proper physical exercise, and lastly to have a good sleeping pattern to prevent
further implications in the future. This way the patient’s health can be maintained with a
satisfactory quality of life.
References
Semiz, M., Uslu, A., Korkmaz, S., Demir, S., Parlak, I., Sencan, M., Aydin, B., & Uncu, T. (2015).
Assessment of subjective sleep quality in iron deficiency anaemia. African Health
Sciences, 15(2), 621. https://doi.org/10.4314/ahs.v15i2.40
Mayo Clinic. (2019, October 18). Iron deficiency anemia - Symptoms and causes. Mayo Clinic;
https://www.mayoclinic.org/diseases-conditions/iron-deficiency-anemia/symptoms-
causes/syc-20355034
VI. Problem Identification and Prioritization
Problem Rank Justification
Activity intolerance 1 The ability to execute basic

High Priority activities throughout the day
is crucial for the wellbeing
of a patient. According to
North American Nursing
Diagnosis Association
(2012), activity intolerance
is a state in which a person
has insufficient
physiological or
psychological energy to
endure or complete
necessary or desired daily
activities.
Moreover, based on
Maslow’s Hierarchy of
Needs, meeting
physiological needs is the
most important. This makes
activity intolerance the
highest priority among the
given problems.
Risk for Fluid volume 2 Dehydration is when the

deficit Medium Priority body loses more fluid than
intake and when your body
does not have enough fluid
to be able to function
normally.
Fluid volume deficits usually

occur when the
gastrointestinal tract loses
fluid and causes risks such
as vomiting, diarrhea,
sweating, decreased intake,
and inability to intake fluid
normally. These problems
can add up to more severe
problems. (Wayne, 2019)
Additionally, in Maslow’s
Hierarchy of Needs,
physiological needs are
amongst the top priority.
Sleep deprivation 3 Sleep is a basic

Medium Priority physiological need,
according to Psychologist
Abraham Maslow who
categorised sleep in the first
set of needs, at the bottom of
the pyramid or hierarchy of
needs. Without sleep, it is
impossible to function
effectively every day.
For a few days, sleep

deprivation could go on, but
not after that. The body
needs sleep. The mind needs
rest. Sleep is required for
bodily nourishment,
rejuvenation and to keep the
metabolism functioning
well. Without adequate
sleep, the individual's
cognitive capacities diminish
and his/her emotional
intelligence gets reduced.
Excessive stress 3 According to the Cleveland

Low Priority Clinic (2021), stress is the
reaction of a person when
changes in his/her
environment, herself, or in
anything that involves the
person itself occurs. Stress
responses help the body
adjust to new situations but
stress becomes a problem
when stressors become too
much to the point that the
person is not having periods
of relaxation.
And because of the

Maslow’s Hierarchy of
Needs, Esteem Needs is one
of the lowest priorities on
the hierarchy of needs. This
makes excessive stress a low
priority among the rest of the
problems (RNspeak, 2021).
Ineffective health 5 Falling under the Safety &

maintenance Low Priority Security Needs of Maslow’s
Hierarchy, ineffective health
maintenance is less of a
priority compared to the
other identified problems
because Physiologic Needs
are more prioritized.
According to NANDA
(2012), ineffective health
maintenance refers to the
inability to follow measures
needed to help to maintain
health, which is one of the
problems encountered by the
client.
References:
5 Levels Of Maslow's Hierarchy Of Needs. RNspeak. (2021). https://rnspeak.com/maslows-

hierarchy-of-needs/.
Stress: Signs, Symptoms, Management & Prevention. Cleveland Clinic. (2021).

https://my.clevelandclinic.org/health/articles/11874-stress.
Wayne, G. B. (2020, September 6). Fluid Volume Deficit (Dehydration) Nursing Care Plan.
Nurseslabs. https://nurseslabs.com/deficient-fluid-
volume/#:%7E:text=Risk%20factors%20for%20FVD%20are,%2C%20ascites%2C%20a
nd%20liver%20dysfunction.
Mayo Clinic. (2019, October 18). Iron deficiency anemia - Symptoms and causes. Mayo Clinic;
https://www.mayoclinic.org/diseases-conditions/iron-deficiency-anemia/symptoms-
causes/syc-20355034
Cognitive Functioning - an overview | ScienceDirect Topics. (2014). Sciencedirect.com.

https://www.sciencedirect.com/topics/psychology/cognitive-functioning
Zube E.H. (1999) Environmental perception. In: Environmental Geology. Encyclopedia of Earth
Science. Springer, Dordrecht. https://doi.org/10.1007/1-4020-4494-1_120
Self-Perceptions - an overview | ScienceDirect Topics. (2012). Sciencedirect.com.

https://www.sciencedirect.com/topics/psychology/self-perceptions
Di Domenico S.I., Fournier M.A. (2017) Esteem Needs. In: Zeigler-Hill V., Shackelford T. (eds)
Encyclopedia of Personality and Individual Differences. Springer, Cham.
https://doi.org/10.1007/978-3-319-28099-8_1465-1
IES (2021). The Cultural Atlas. Retrieved from: https://culturalatlas.sbs.com.au.
Brown, B. B., & Lohr, M. J. (1987). Peer-group affiliation and adolescent self-esteem: an
integration of ego-identity and symbolic-interaction theories. Journal of personality and
social psychology, 52(1), 47–55. https://doi.org/10.1037//0022-3514.52.1.47
VII. Nursing Care Plan
References
Activity Intolerance. (2020). Simple Nursing. https://simplenursing.ph/nursing-intervention-for-
activity-intolerance/#:~:text=Activity%20intolerance%20is%20a%20common
Berman, A. T. (2020). Kozier & Erb’s Fundamentals of Nursing : concepts, process and
practice. Prentice Hall.
T Heather Herdman, Shigemi Kamitsuru, & North. (2014). NANDA International, Inc. Nursing
Diagnoses : Definitions & Classification 2015-2017. Wiley Blackwell.

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Far Eastern University

In partial fulfillment to the requirements in:

July 19, 2021

Name: Ma. Franchesca M. Bolintiam

Address: Albacura St., Brgy. Wawa, Nasugbu,

Age: 19 years old

Birthdate: November 28, 2001

Birthplace: Nasugbu, Batangas

Religion: Roman Catholic

Marital Status: Single

Educational Attainment: College Undergraduate

Chief Complaint: Dizziness, Weakness, Headache (prolonged

Admitting Diagnosis: Activity Intolerance

Attending/Admitting Physician: Dr. Kathreen Alcantara

II. Nursing Health History

a. History of Present Illness

b. Past health History

c. Family History (Include Genogram with legend)

Diagram 1: Patient Franchesca’s Genogram

III. Gordon’s Patterns of Functioning

a. Health Perception-Health Management

Interpretation: Deviation from Normal

Interpretation: Deviation from Normal

Date Time of the Day Activity Estimated time of

9:30 am -10:00 am Checking for activities 30 minutes

10:20 am - 10:50 am Cooking of Breakfast 30 minutes

07/08/2021 11:00 am - 2:00 pm Completing of requirements 3 hours

2:00 pm - 3:00 pm Taking the dogs for a bath 1 hour

4:00 pm - 7:00 pm Reading lectures 3 hours

9:00 pm - 10:00 pm Sweeping and mopping of the 1 hour

9:30 am -10:00 am Checking for activities 30 minutes

10:20 am - 10:50 am Cooking of Breakfast 30 minutes

11:00 am - 2:00 pm Completing of requirements 3 hours

4:00 pm - 7:00 pm Reading lectures 3 hours

9:00 pm - 10:00 pm Sweeping and mopping of the 1 hour

2:00 am - 3:00 am Night routine 50 minutes

9:30 am -10:00 am Checking for activities 30 minutes

10:20 am - 10:50 am Cooking of Breakfast 30 minutes

11:00 am - 2:00 pm Completing of requirements 3 hours

4:00 pm - 7:00 pm Reading lectures 3 hours

9:00 pm - 10:00 pm Sweeping and mopping of the 1 hour

2:00 am - 3:00 am Night routine 50 minutes

9:30 am -10:00 am Checking for activities 30 minutes

10:20 am - 10:50 am Cooking of Breakfast 30 minutes

11:00 am - 2:00 pm Completing of requirements 3 hours

4:00 pm - 7:00 pm Reading lectures 3 hours

9:00 pm - 10:00 pm Sweeping and mopping of the 1 hour

2:00 am - 3:00 am Night routine 50 minutes

9:30 am -10:00 am Checking for activities 30 minutes

10:20 am - 10:50 am Cooking of Breakfast 30 minutes

11:00 am - 2:00 pm Completing of requirements 3 hours

4:00 pm - 7:00 pm Reading lectures 3 hours

9:00 pm - 10:00 pm Sweeping and mopping of the 1 hour

2:00 am - 3:00 am Night routine 50 minutes

9:30 am -10:00 am Checking for activities 30 minutes

10:20 am - 10:50 am Cooking of Breakfast 30 minutes

07/13/2021 4:00 pm - 7:00 pm Reading lectures 3 hours

9:00 pm - 10:00 pm Sweeping and mopping of the 1 hour

2:00 am - 3:00 am Night routine 50 minutes

9:30 am -10:00 am Checking for activities 30 minutes

10:20 am - 10:50 am Cooking of Breakfast 30 minutes

11:00 am - 2:00 pm Completing of requirements 3 hours

4:00 pm - 7:00 pm Reading lectures 3 hours