1

Far Eastern University

Institute of Nursing

A Case Of:

THE WEIGHT OF AN ONLINE LEARNING SET UP TO A NURSING

STUDENT

In Partial Fulfillment of Requirements for

Related Learning Experience on Fundamentals of Nursing

Presented by:

Sandoval, Louise Bianca N.

Seña, Ronald Allen S.
Sison, Yasmina Red J.
Sugioka, Reina M.
Tugade, Patricia Nicole O.
Ulit, Ann Nicole Y.
Valderama, Ma. Kristine Joy P.
Veleña, Marjorie G.
Villasor, Viktoria Jenilee G.
Visperas, Trixie V.

Presented to/Submitted to:

Prof. Mary Ann Bayani
Clinical Instructor

Submitted on:
July 19, 2021
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I. Demographic Profile
Demographic Data

Name: Patient X
Address: Sapangan San Juan, Batangas
Age: 20 years old
Birth Date: July 18, 2001
Birthplace: San Juan, Batangas
Gender: Female
Religion: Roman Catholic
Race/Ethnic Origin: Filipino
Occupation: N/A
Educational Attainment: Senior Highschool Graduate
Marital Status: Single

II. Nursing Health History

A. History of Present Illness
Patient X, a 20-year-old female who presents who visits for an annual check-up and
claimed that she has no present chronic illness and any chief complain. She exhibits a normal
temperature in her axilla of 35.6 C, produced 98% oxygen saturation, normal blood pressure of
110/70 mmHg, with normal respiration rate of 17cpm, and pulse rate of 89 bpm.
B. Past Health History
According to the patient, his mother had no problems when she was born, and she was
deemed to be healthy at the time. The client also reported that she had no issues and that she was
making good progress as she grew into maturity. The client also stated that her immunizations
were up to date, but that there was no anti-dengue active immunization, hence she acquired dengue
fever. Dengue fever affected the client when she was seven years old. She was confined for one
month at FEU Fairview Hospital, and her life became 50/50 or critical at that time, therefore she
stayed in the hospital for one month. In 2008, the client was diagnosed with severe dengue fever,
was transfused with seven blood bags, and was confined for one month. She was in severe
condition at the time, however, after contracting dengue fever, she was given prescribed drugs and
was able to recover. The client had never had surgery or been in an accident and she does not suffer
from any allergies.

C. Family History
 3

The client’s grandparents on her father side are both deceased due to hypertension and old
age. While on her mother side, her grandmother died because of high level of cholesterol. The
client’s nuclear family are all alive and well with no chronic diseases and complications. Overall,
the client has a healthy and well family.
III. Gordon’s Pattern of Functioning
• Health Perception – Health Management
The patient mentioned that she gives importance on her health since she cannot
function properly if she is not well. She usually consults a doctor twice a year to have a
general checkup, she undergoes blood test and ultrasound in the abdomen every after 2
months to monitor the health state. She has no allergies when it comes to food and
medication. She includes exercise and activities, eating meal thrice a day, less hours of
sleep. In addition, she takes vitamin C and E daily, and perform self-examination through
checking her temperature, and breast examination.
Interpretation: NORMAL
 4

Analysis: Since the patient focuses more on achieving a healthy lifestyle, it does shows
positivity. Thus, good self-impression of a wellbeing might be gainful in light of the fact
that idealistic sentiments in themselves are protective (Mossey and Shapiro, 1982).

• Cognitive – Perceptual
Due to her regular activities and efforts to enhance her sense of coordination, the
patient has a high comprehension to understand instruction. The five senses improve
through everyday activities, but because of the routines to improve her senses through
daily exercise, not to mention the fact that she is still a student working on her academics,
which can be beneficial on enhancing her senses.
Interpretation: NORMAL
Analysis: The five senses — sight, taste, touch, hearing, and smell – collect information
about our surroundings that the brain perceives. We make sense of this information based
on prior experience (and subsequent learning) as well as the combination of information
from each sense. Most sensory input elicits a near-automatic response from us. Such a
reaction is necessary for survival in our environment. (VSG, 2018)
• Self – Perception – Self – Concept
The patient was vocal about experiencing regular anxiety about self – value conflict
and unmet needs and support from family members. She was also able to verbalize her self
– evaluation about the development of being short temperedness due to this. Also, she says
even though lately she experiences stress due to heavy schoolwork loads, she still feels
motivated in school.
Interpretation: DEVIATION FROM NORMAL
Analysis: Anxiety is normal for so many situations, but it can be abnormal if it obstructs
with a person’s daily living. Anxiety comes with feeling of palpitation, nausea, panic,
hyperventilation and sweating. Short temperedness and stress can be a factor of anxiety by
the presence of confusion. (Willacy, 2020).
• Roles and Relationship
The patient is single and lives with her family in the same house. Aside from
attending online classes, she’s also helping with the household chores, and she often cooks
for herself. Although she’s living with her family, she often resolves her problems on her
own due to their lack of support and interest. Since the pandemic, she became distant with
her friends due to being busy with the new set up of online classes depriving her from
sleeping which caused her to experience anxiety.
Interpretation: DEVIATION FROM NORMAL
 5

Analysis: Sleep greatly affects a person’s mental health including their psychological state.
Continuous experience of sleep deprivation could lead to more risks of contributing to
developing some psychiatric disorders and even worsen anxiety. (Harvard Medical School,
2019).
• Sexuality – Reproductive
The patient had her menarche when she was 13 years old. According to her, she
didn’t encounter any problems in regards with her menstrual pattern but she seldom
experiences cramping and discomfort which is for her is tolerable and can be aided by over-
the-counter drugs. The patient is not using any contraceptive method.
Interpretation: NORMAL
Analysis: According to Medline Plus (n.d.), Menstruation, or period, is normal vaginal
bleeding that happens as part of a woman’s monthly cycle. Many women have painful
periods, most often menstrual cramps which are throbbing, cramping pain in your lower
abdomen. Taking over-the-counter pain relievers such as non-steroidal anti-inflammatory
drugs (NSAID) reduce the amount of prostaglandins that your uterus makes and lessen
their effects eventually relieving pain.

• Coping – Stress Tolerance

The patient's life has changed significantly since the pandemic due to social
isolation and a new normal set-up. She's exhausted with her load of school works. As a
result, she suffers from sleep deprivation. She also regularly experiences anxiety attacks
whenever she feels pressured with her academics; thus, the client is not able to handle
well her stress coping mechanism.
Interpretation: DEVIATION FROM NORMAL
Analysis: Sleep issues are common in the general population, and medical students are one
group that is particularly susceptible to them. Medical students who reported more sleep
deprivation had higher odds of exhibiting anxiety and depression symptoms, as well as
lower odds of having a good quality of life or a positive opinion of their learning setting.
There is evidence that getting adequate healthy sleep is beneficial to long-term learning,
neurocognitive and psychomotor function, as well as physical and mental health.
Furthermore, sleep loss can make medical students more susceptible to depression and
anxiety problems. (Perotta et al., 2021)
• Values and Belief System
According to the patient, she believes that living the moment rather than focusing
on might what happen is the most significant thing in her life. But she all had it rough this
year. She witnessed different colors of herself throughout the year as she faced different
struggles, but she knows that she is greater than her struggles. She also believes that
having a religious bonding and having relationship with God is valuable.
 6

Interpretation: NORMAL
Analysis: Whether you’re struggling with the fear and isolation of the novel coronavirus
(COVID-19) pandemic or you’re just having one of those weeks where nothing seems to
go right, relying on faith can help carry you through. (Sister M. Mikela Meidl,
F.S.G.M.,2020)
• Nutritional – Metabolic Patterns
Diet Recall:
Date and Time Food and Beverage Measurements Energy (Kcal)*
intake
July 14, 2021

8:30 AM Egg with rice 1 egg 484 Kcal

2 cups of rice
12:00 PM Adobo and rice 1 serving of adobo and 512 Kcal
cups of rice
8:00 PM Rice, sinaing na 1 cup of rice, 1/2 324 Kcal
tulingan and boiled serving of sinaing na
eggplant tulingan, and 2 pieces
of eggplant
July 15, 2021

8:00 AM Rice and fish fillet 1 cup of rice, 2 pieces 597 Kcal
of fish fillet
12:00 PM Rice and pork 2 cups of rice and 1 696 Kcal
sinigang serving of pork sinigang
4:00 PM Soda and bread 1 can of soda and 2 298 Kcal
slices of bread
8:00 PM Rice and barbecue 1 cup of rice and 1 314 Kcal
piece of barbecue
July 16, 2021

8:00 AM Egg with rice 1 cup of rice and 1 281 Kcal

piece egg
2:00 AM Rice and adobo 2 cups of rice and 1 715 Kcal
serving of adobo
8:00 PM Rice and chicken 2 cups of rice and 1 622 Kcal
chicken breast
 7

The client weighs 50 kilograms, has a height of 157 centimeters, and has a BMI of
20.3 which is considered normal. The client usually eats three times a day and has a good
appetite. In addition to the nutrition, the client takes vitamin C regularly to strengthen her
immune system. According to the client, her diet is balanced on a daily basis, not more
than 2000 calories is her daily intake and occasionally drinks soda and alcohol. The client
eats in a restaurant but not that often and is sometimes stress eating. When the client was
asked about any eating disorder, as well as having discomfort or pain when swallowing,
the client stated that she doesn’t have any of these.

Interpretation: NORMAL
Analysis: Good eating habits like eating nutritious foods along with exercise are likely to
bring many benefits to the well-being of an individual. Nutritional habits are important,
with high intake of processed, energy-dense foods, high BMI which during this phase as
adolescents are already transitioning that persist into adult life. According to Sawyer, 2,000
calories per day are considered standard for most adults. This is needed in order for them
to have enough nutrients to suffice their activities for the whole day (Lassi, 2017).
• Elimination Pattern
The patient has a hectic schedule since she is a student and has a lot of school
activities to do, yet she manages to have a good elimination pattern. She mentioned that it
is her routine to eliminate after waking up daily, after eating, and before going to bed.
There are also instances that when she eats a lot at the afternoon she eliminates as well.
The client stated that “usually, po okay naman yung tae ko pero kapag di ako masyado
umiinom ng tubig matigas po yun at brown yung kulay at doon na sumasakit sa pwet pag
lumabas”. The charactersitics of the stool is usually brown but there are instances that it is
yellow or green, it is lumpy, and it is like a sausage or snake. When it comes to urination
the patient normally urinates upon waking up, before going to bed and in-between the day.
She typically urinates for 5-8 times a day, there is no pain felt when urinating. The usual
color of her urine is light yellow with no unpleasant odor.
Interpretation: NORMAL
Analysis: There is no such thing as a "normal" amount of bowel motions. Healthy bowel
movement frequency might range from three times a day to three times a week, according
to many healthcare providers (Cleveland Clinic, 2018). Brown is the most common stool
color. The presence of bile in the stool causes this. The color of a normal stool can range
from light yellow to brown to nearly black. This could indicate an issue if the stool is
crimson, maroon, black, clay-colored, light, yellow, or green (Cuncha, 2020). When it
comes to urination the average person urinates six to eight times per day. However, if you
drink a lot, it's not uncommon to go up to 10 times every day. If you're on some
medications, such as diuretics for high blood pressure, you may pee more frequently. The
color of normal urine varies from pale yellow to deep amber, depending on the amount of
 8

urochrome present and how diluted or concentrated the urine is. Urine that is abnormally
colored can be hazy, dark, or blood hued. (Whitworth, 2019).
• Activity – Exercise Pattern
The client has a light physical activity level which means she manages to do her
regular activities as part of her daily life. She usually takes her dog for a 30 minutes' walk
during her break time and as the client verbalized “Yung paglakad ko po sa aso ko, yun na
po nagsisilbing exercise ko.” The client does not experience any shortness of breath,
weakness, and muscle pain. She also can manage to do her daily activities such as bathing,
dressing, feeding, cooking, and cleaning without the assistance of other people.
Date: Activities:
July 14, 2021 (Wednesday) a. The client woke up 6:00 am in the morning.
b. The client started her day by bathing, dressing,
doing household chores and cooking breakfast.
I. She attended her online classes starting from the
8:00 am until 5:00 pm in the afternoon.
II. After classes, she walked her dog in the garden.
III. As she went home and usually cooks for their
dinner.
IV. After eating and cooking, she continuously finishes
her pile of school works and quizzes.
V. The client finished her school works 1:00 am.
July 15, 2021 (Thursday) c. The client woke up 6:00 am in the morning.
d. The client started her day by bathing, dressing,
doing household chores and cooking breakfast.
VI. She attended her online classes starting from the
8:00 am until 5:00 pm in the afternoon.
VII. After classes, she walked her dog in the garden.
VIII. As she went home and usually cooks for
their dinner.
IX. After eating and cooking, she continuously finishes
her pile of school works and quizzes.
X. The client finished her schoolworks 1:00 am.
July 16, 2021 (Friday) e. The client woke up 6:00 am in the morning.
f. The client started her day by bathing, dressing,
doing household chores and cooking breakfast.
XI. She attended her online classes starting from the
8:00 am until 5:00 pm in the afternoon.
XII. After classes, she walked her dog in the garden.
XIII. As she went home and usually cooks for
their dinner.
XIV. After eating and cooking, she continuously
finishes her pile of schoolworks and quizzes.
XV. The client finished her schoolworks 1:00 am.
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The client has a same routine every day since she has fixed and busy schedule
complying her assigned tasks and doing advance reading for her classes on the next day.
Interpretation: NORMAL
Analysis: A minimum of 2-1/2 hours of moderate-intensity aerobic activity per week is
recommended for healthy adults. Any sort of cardiovascular conditioning is classified as
aerobic exercise. Brisk walking, swimming, running, and cycling are examples of activities
that are considered aerobic. A brisk walk might be slow for some and relatively fast for
others, depending on fitness levels (Chan, 2013).
• Sleep – Rest Pattern
Due to client’s amount of workload as a nursing student in a virtual set-up, her sleep
and rest is being compromised. The client is not acquiring the minimum amount of sleep
which is 7-8 hours recommended to her age, instead, the client said that she is only getting
4-5 hours per day. The client does not have regular bedtime and wake up schedule because
it depends on the amount of stuffs, she needs to accomplish during the day which is
attending to class and house responsibilities and at night doing requirements and backlogs.
She also mentions the alteration on her sleeping pattern ever since summer term started,
before she would usually sleep before 12 AM and now, even though she sleeps late, it
became a routine for her to wake up at 6 AM.
Mon Tues Wed Thurs Fri Sat Sun
Time 1:30 AM 2:00 AM 2:00 AM 1:55 AM 2: 15 AM 2:35 AM 1:40 AM
went to
bed
Approxi 2:00 AM 2:20 AM 2:30 AM 2:15 AM 2:30 AM 2:50 AM 2:00 AM
mate
time fell
asleep
Wake up The The The The The The The
period/ client is client is client is client is client is client is client is
sleep not not not not not not not
interrupt having having having having having having having
ions (how sleep sleep sleep sleep sleep sleep sleep
long) interrupti interrupti interrupti interrupti interrupti interrupti interrupti
ons. ons. ons. ons. ons. ons. ons.
Time 6:00 AM 6:00 AM 6:00 AM 6:00 AM 6:00 AM 6:00 AM 6:00 AM
woke up
the next
morning
Feeling Client is Client is Client Client is Client is Client is Client is
after sleepy irritated feels sleepy sleepy irritated sleepy
waking restless
up
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Naps The The The The The The The

(time client client client client client client client
slept and does not does not does not does not does not does not does not
woke up; take naps take naps take naps take naps take naps take naps take naps
duration)
Activities The The The The The The The
done client is client is client is client is client is client is client is
before doing reading organizin doing reviewin doing doing
bedtime school modules. g notes. school g school school
works. works. modules works. works.
Bedtime The The The The The The The
rituals client client client client client client client
does her does her does her does her does her does her does her
skin care skin care skin care skin care skin care skin care skin care
routine. routine. routine. routine. routine. routine. routine.

Also, the client said that there are times wherein she refuses to just even take a nap
even when she feels very sleepy during the day. The client is not using any medication to
promote sleep.
Interpretation: DEVIATION FROM NORMAL
Analysis: The optimal amount of sleep for each person may vary, but generally research
suggests 7-9 hours per night for college-aged populations. Lack of sleep can lead to a
number of consequences affecting behavior, memory, emotions, and learning. These
consequences include inattention, irritability, hyperactivity, poor impulse control, and
difficulty multitasking. (Chervin, R. and Hershner, S. (2014) )
IV. Physical Assessment
A. General Survey
General Survey
Area to be Assessed Normal Findings Actual Findings Interpretation
GENERAL APPEARANCE & MENTAL STATUS
Observe for signs of No distress noted. The patient appears DEVIATION FROM
distress in posture or to have signs of NORMAL
facial expression. distress such as
getting easily Analysis
irritated. Sleep and mood are
closely connected;
poor or inadequate
sleep can cause
irritability and stress.
Studies have shown
that even partial sleep
 11

deprivation has a
significant effect on
mood. University of
Pennsylvania
researchers found that
subjects who were
limited to only 4.5
hours of sleep a night
for one week reported
feeling more stressed,
angry, sad, and
mentally exhausted
(Dinges, D. et.al.,
2018)
Observe body build, Proportionate, varies The patient body NORMAL
height, and weight in with lifestyle build appears to be
relation to the client’s proportionate and
age, lifestyle, and varies with her
health. lifestyle.
Height: 157 cm
Weight: 50 kg
BMI: 20.3
Observe client’s Relaxed, erect The patient appears NORMAL
posture and gait, posture, coordinated to be relaxed, erect
standing, sitting, and movement posture, and
walking. coordinated
movement

Observe client’s Clean, neat The patient appears NORMAL

overall hygiene and to be clean and neat
grooming.
Note body and breath No body/breath odor There are no data THERE ARE NO
odor. or minor body odor recorded. DATA RECORDED
relative work or
exercise.
Note obvious signs of Healthy appearance The patient has NORMAL
health or illness. healthy appearance
Assess the client’s Cooperative The patient is NORMAL
attitude. cooperative
Note the client’s Appropriate to The patient is in an NORMAL
affect/mood; assess situation appropriate situation.
the appropriateness of
the client’s responses
 12

Listen for quantity, Logical sequence, The patient has a NORMAL

quality, and makes sense, has logical sequence and
organization of sense of reality has a sense of reality.
speech

B. Measurement (Height, Weight, BMI, Vital Signs)

Vital Signs
Area to be Assessed Normal Findings Actual Findings Interpretation
Temperature 35.8 °C to 37°C 35. 6 °C NORMAL
Pulse Rate 60 to 100 beats/min 89 bpm NORMAL
Respiratory Rate 12-20 breaths/min 17 cpm NORMAL
Blood Pressure Systolic BP between Systolic BP: 110 NORMAL
85 to 120 mmHg; mmHg
Diastolic BP between Diastolic BP: 70
60-80 mmHg mmHg
Oxygen 95 to 100% 98% NORMAL
Concentration
(O2 sat.)

C. Physical Assessment (Cephalo – Caudal)

*Note: Some data in the assessment are not provided due to online set up.
 Head to Toe Assessment (Cephalo – Caudal)
Area to be Assessed Normal Findings Actual Findings Interpretation
SKIN 13
Inspect skin color Varies from light to deep Based on my NORMAL
brown, from ruddy pink to inspection the patient
light pink has a warm medium
brown skin color.
Inspect uniformity of Generally uniform except in Based on my NORMAL
skin color areas exposed to sun, areas inspection, the patient
of lighter pigmentation in has a uniform skin
dark skinned color except in areas
exposed to sunlight.
Inspect, palpate, and Freckles, some birth marks, Based on my NORMAL
describe skin lesions some flat and raised nevi, no inspection and
abrasion or other lesion palpation, the patient
has no freckles and
birthmarks found.
There is also no
presence of abrasions
and skin lesions
Observe and palpate skin Moisture in skin folds and Based on my NORMAL
moisture the axillae, affected by observation and
different factors. palpation, the patient
appears to have
moisture in skin folds
and the axillae
Palpate skin temperature Uniform; within normal There are no data THERE ARE NO DATA
range recorded. RECORDED

Palpate to assess for No edema There are no data THERE ARE NO DATA
presence of edema recorded. RECORDED

Palpate to assess for skin When pinched, skin springs Based on my NORMAL
turgor back to previous state observation and
palpation, the patient’s
skin springs back to
its previous state when
pinched. The client is
hydrated.
HAIR
Inspect the evenness of Evenly distributed hair Based on my NORMAL
growth over the scalp inspection, the
patient’s hair is evenly
distributed on her
scalp.
Inspect hair texture and Silky, resilient hair Based on my DEVIATION FROM
oiliness inspection, the patient NORMAL
has massive hair loss
and dry hair. Analysis
There is a relationship
between stress and hair
 14

loss. There are three types

of hair loss linked to
high-stress levels: One is
telogen effluvium, which
is a condition in which a
person's hair starts to fall
out. Significant stress
causes telogen effluvium,
which causes a large
number of hair follicles to
fall (MayoClinic, 2019)
Note presence of No infection or infestation There are no data THERE ARE NO DATA
infections or infestations recorded. RECORDED.

Inspect amount of body Variable Based on my NORMAL

hair inspection, the amount
of the body hair of the
client is minimal.
NAILS
Fingernail Plate Shape Convex curvature; the angle There are no data THERE ARE NO DATA
between nail and nail bed recorded RECORDED
usually 160 degrees
Tissues Surrounding Smooth Texture and Strong There are no data THERE ARE NO DATA
Nails recorded RECORDED

Fingernail and Toenail Intact Epidermis Epidermis is intact in NORMAL

Texture fingernail and toenail
Fingernail and Toenail Highly vascular pink in light- The bed color of the NORMAL
Bed Color skinned; dark-skinned may patient’s fingernails
be brown or black. and toenails is
pinkish.
Capillary Refill Prompt return or pink or The patient’s skin NORMAL
usual color, less than four color recoils after 3
seconds. seconds.
HEAD & FACE
Inspect the head. Head size and shape vary, The head shape and NORMAL
especially in accord with size are proportion al
ethnicity. The head is to the client’s body
symmetric, round, erect, and size. The client’s head
in the midline and is erect and in the
appropriately related to body midline. No lesions
size (normocephalic). No were found.
lesions are visible
Inspect the face. The face is symmetric with a The patient’s face is NORMAL
round, oval, elongated, or oval. The facial
square appearance. No features are
 15

abnormal movements were symmetrical. No

noted.
Palpate the head. The head is normally
smooth, hard, without
lesions.
Palpate the temporal The temporal artery is elastic
artery. and not tender.
lesions. There are no
abnormal movements.
There are no data THERE ARE NO DATA
recorded. RECORDED
There are no data THERE ARE NO DATA
recorded. RECORDED

Palpate the Normally there is no There are no data THERE ARE NO DATA
temporomandibular joint swelling, tenderness, or recorded. RECORDED
(TMJ). crepitation with movement.
The mouth opens and closes
fully (3 to 6 cm between
upper and lower teeth). The
lower jaw moves laterally 1
to 2 cm in each direction.
NECK
Inspect the neck. Neck is symmetric, with The patient’s neck is NORMAL
head centered and without symmetric, with head
bulging masses. centered and no
bulging masses.
Inspect movement of the The thyroid cartilage, cricoid As the patient NORMAL
neck structures. cartilage moves upward swallows, the thyroid
symmetrically as the client cartilage and the
swallows. cricoid cartilage
moves upward
symmetrically.
Inspect the cervical C7 (vertebrae prominens) is The C7 vertebrae of NORMAL
vertebrae. usually visible and palpable. the patient is visible
and palpable.
Inspect range of motion. Normally neck movement There are no data THERE ARE NO DATA
should be smooth and recorded. RECORDED
controlled with 45-degree
flexion, 55-degree extension,
40-degree lateral abduction,
and 70- degree rotation.
Palpate the trachea. Trachea is midline. There are no data THERE ARE NO DATA
recorded. RECORDED

Palpate the thyroid gland. Landmarks are positioned There are no data THERE ARE NO DATA
midline. recorded. RECORDED

Auscultate the thyroid
only if you find an
enlarged thyroid gland.
Palpate the lymph nodes.
Test distant visual acuity.
Test near visual acuity.
Test visual fields for
gross peripheral vision.
Perform corneal light
reflex test.
Perform cover test.
16
No bruits are auscultated. There are no data THERE ARE NO DATA
recorded. RECORDED
There is no swelling or There are no data THERE ARE NO DATA
enlargement and no recorded. RECORDED
tenderness.
EYES
Normal distant visual acuity There are no data THERE ARE NO DATA
is 20/20 with or without recorded. RECORDED
corrective lenses. This means
that the client can distinguish
what the person with normal
vision can distinguish from
20 feet away.
Normal near visual acuity is There are no data THERE ARE NO DATA
14/14 (with or without recorded. RECORDED
corrective lenses). This
means that the client can
read what the normal eye can
read from a distance of 14
inches.
With normal peripheral There are no data THERE ARE NO DATA
vision, the client should see recorded. RECORDED
the examiner’s finger at the
same time the examiner sees
it. Normal visual field
degrees are approximately as
follows:
• Inferior: 70 degrees
• Superior: 50 degrees
• Temporal: 90 degrees
• Nasal: 60 degrees
The reflection of light on the There are no data THERE ARE NO DATA
corneas should be in the recorded. RECORDED
exact same spot on each eye,
which indicates parallel
alignment.
The uncovered eye should There are no data THERE ARE NO DATA
remain fixed straight ahead. recorded. RECORDED
The covered eye should

remain fixed straight ahead
after being uncovered.
Perform the positions test. Eye movement should be
smooth and symmetric
throughout all six directions.
Inspect the eyelids and The upper lid margin should
eyelashes. be between the upper margin
of the iris and the upper
margin of the pupil. The
lower lid margin rests on the
lower border of the iris. No
white sclera is seen above or
below the iris. Palpebral
fissures may be horizontal.
Assess ability of eyelids The upper and lower lids
to close. close easily and meet
completely when closed.
Note the position of the The lower eyelid is upright
eyelids in comparison with no inward or outward
with the eyeballs. turning. Eyelashes are evenly
distributed and curve
outward along the lid
margins.
Observe for redness, Skin on both eyelids is
swelling, discharge, or without redness, swelling, or
lesions. lesions.
Observe the position and Eyeballs are symmetrically
alignment of the eyeball aligned in sockets without
in the eye socket protruding or sinking.
Inspect the bulbar Bulbar conjunctiva is clear,
conjunctiva and sclera. moist, and smooth.
Underlying structures are
clearly visible. Sclera is
white.
17
There are no data THERE ARE NO DATA
recorded. RECORDED
The upper lid margin NORMAL
of the patient is
between the upper
margin of the iris and
the upper margin of
the pupil. The lower
lid margin rests on the
lower border of the
iris. No white sclera is
seen above or below
the iris.
The upper and lower NORMAL
lids of the patient
close easily and meet
completely when
closed.
The lower eyelid of NORMAL
the patient is upright
with no inward or
outward turning. The
patient’s eyelashes are
evenly distributed and
curve outward along
the lid margins.
Skin on both eyelids NORMAL
of the patient has no
redness, swelling, and
free from lesions.
Patient’s eyeballs are NORMAL
symmetrically aligned
in sockets without
protruding or sinking.
As I observe, the DEVIATION FROM
patient’s bulbar NORMAL
conjunctiva has
redness and dry. Analysis
Underlying structures In response to stress, the
are somehow not body produces
clearly visible, and the adrenaline, which can
sclera has redness. cause tension and dry

Inspect the palpebral
conjunctiva.
Evert the upper eyelid.
Inspect the lacrimal
apparatus.
Palpate the lacrimal
apparatus.
Inspect the cornea and
lens.
Inspect the iris and pupil.
The lower and upper
palpebral conjunctivae are
clear and free of swelling or
lesions.
Palpebral conjunctiva is free
of swelling, foreign bodies,
or trauma.
No swelling or redness
should appear over areas of
the lacrimal gland. The
puncta are visible without
swelling or redness and is
turned slightly toward the
eye.
No drainage should be noted
from the puncta when
palpating the nasolacrimal
duct.
The cornea is transparent,
with no opacities. The
oblique view shows a smooth
and overall moist surface; the
lens is free of opacities.
The iris is typically round,
flat, and evenly colored. The
pupil, round with a regular
border, is centered in the iris.
Pupils are normally equal in
size (3 to 5 mm). An
18
eyes. As discussed, both
tension and dry eyes can
contribute to your red
eyes. Lack of sleep
decreases oxygen that is
available for the eyes; this
causes blood vessels to
dilate and give the
appearance of being red
or bloodshot.
(FloridaEye, 2020).
The lower and upper NORMAL
palpebral conjunctivae
of the patient are clear
and free of swelling or
lesions.
The patient’s NORMAL
palpebral conjunctiva
is free from swelling,
foreign bodies, or
trauma.
There are no swelling NORMAL
or redness appear over
areas of the patient’s
lacrimal gland.
There are no data THERE ARE NO DATA
recorded. RECORDED
The cornea of the NORMAL
patient is transparent,
with no opacities.
The iris of the patient NORMAL
is round, flat, and
evenly colored. The
pupil is round with a
regular border and
centered in the iris.
 19

inequality in pupil size of The patient’s pupils

less than 0.5 mm occurs in are normally equal in
20% of clients. This size.
condition, called anisocoria,
is normal.
Test pupillary reaction to The normal direct pupillary There are no data THERE ARE NO DATA
light. response is constriction. recorded. RECORDED

Assess consensual The normal consensual There are no data THERE ARE NO DATA
response pupillary response is recorded. RECORDED
constriction.
Test accommodation of The normal pupillary There are no data THERE ARE NO DATA
pupils. response is constriction of recorded. RECORDED
the pupils and convergence
of the eyes when focusing on
a near object
(accommodation and
convergence).
EARS
Inspect the auricle, Ears are equal in size There are no data THERE ARE NO DATA
tragus, and lobule. Note bilaterally (normally 4-10 recorded. RECORDED
size, shape, and position cm).
The auricle aligns with the
corner of each eye and within
a 10-degree angle of the
vertical position.
Earlobes may be free,
attached, or soldered (tightly
attached to adjacent skin with
no apparent lobe).

Continue inspecting the The skin is smooth, with no
auricle, tragus, and lesions, lumps, or nodules.
lobule. Observe for Color is consistent with facial
lesions, discolorations, color.
and discharge. Darwin’s tubercle, which is a
clinically insignificant
projection, may be seen on
the auricle.
No discharge should be
present.
Palpate the auricle and Normally the auricle, tragus,
mastoid process. and mastoid process are not
tender.
On the client's skin, THERE ARE NO DATA
there are no infections, RECORDED
lumps, or nodules.
There is no discharge,
and the hue is
consistent with the
facial color.
There are no data THERE ARE NO DATA
recorded. RECORDED
 20

Inspect the external A small amount of odorless There are no data THERE ARE NO DATA
auditory canal. cerumen (earwax) is the only recorded. RECORDED
Use the otoscope. Note discharge normally present.
any discharge along with Cerumen color may be
the color and consistency yellow, orange, red, brown,
of cerumen (earwax). gray, or black. Consistency
may be soft, moist, dry, flaky,
or even hard.
Observe the color and The canal walls should be There are no data THERE ARE NO DATA
consistency of the ear pink and smooth, without recorded. RECORDED
canal walls and inspect nodules.
the character of any
nodules.
Inspect the tympanic The tympanic membrane There are no data THERE ARE NO DATA
membrane (eardrum). should be pearly, gray, shiny, recorded. RECORDED
Note color, shape, and translucent, with no
consistency, and bulging or retract ion. It is
landmarks. slightly concave, smooth, and
intact. A cone-shaped
reflection of the otoscope
light is normally seen at 5
o’clock in the right ear and 7
o’clock in the left ear. The
short process and handle of
the malleus and the umbo are
clearly visible.
Perform the whisper test Able to correctly repeat the There are no data THERE ARE NO DATA
With your hand 2 feet two-syllable word as recorded. RECORDED
behind the client (so that whispered.
the client cannot see your
lips move), whisper a two-
syllable word such as
“popcorn” or “football”.
Ask the client to repeat it
back to you. If the
response is in correct the
first time, whisper the
word one more time.
Identifying three out of six
whispered words is
considered passing the
test.
Perform Weber’s test if Vibrations are heard equally There are no data THERE ARE NO DATA
the client reports well in both ears. No recorded. RECORDED
diminished or lost hearing lateralization of sound to
in one ear. either ear.
 21

Perform the Rinne’s test. Air condition sound is There are no data THERE ARE NO DATA
Strike a tuning fork and normally heard longer than recorded. RECORDED
place the base of the fork bone conduction sound
on the client’s mastoid (AC>BC).
process. Ask the client to
tell you when the sound is
no longer heard.
Move the prongs of the
tuning fork to the front of
the external auditory
canal. Ask the client to tell
you if the sound is audible
after the fork is moved.
Perform the Romberg test. Client maintains position for There are no data THERE ARE NO DATA
This tests the client’s 20 seconds without swaying recorded. RECORDED
equilibrium. Ask the client or with minimal swaying.
to stand with feet together,
arms at sides, and eyes
open, then with the eyes
closed.
NOSE
Inspect and palpate the Color is the same as the rest There are no data THERE ARE NO DATA
external nose. of the face; the nasal structure recorded. RECORDED
Note nasal color, shape, is smooth and symmetric; the
consistency, and client reports no tenderness.
tenderness.
Check patency of air flow Client is able to sniff through There are no data THERE ARE NO DATA
through the nostrils by each nostril while other is recorded. RECORDED
occluding one nostril at a occluded.
time and asking client to
sniff.
Inspect the internal nose. The nasal mucosa is dark There are no data THERE ARE NO DATA
To inspect the internal pink, moist, and free of recorded. RECORDED
nose, use an otoscope with exudates. The nasal septum is
a short wide-tipintact and free of ulcers or
attachment or you can perforations.
also use a nasal speculum Turbinates are dark pink
and penlight. (redder than oral mucosa),
moist, and free of lesions.
SINUS
Palpate the sinuses. When Frontal and maxillary sinuses There are no data THERE ARE NO DATA
an infection is suspected, are nontender to palpation, recorded. RECORDED
the nurse can examine the and no crepitus is evident.
sinuses through
palpation, percussion,
and transillumination.
 22

Palpate the frontal

sinuses by using your
thumbs to press up on the
brow on each side of nose.
Percuss the sinuses. The sinuses are not tender on There are no data THERE ARE NO DATA
Lightly tap (percuss) over percussion. recorded. RECORDED
the frontal sinuses and
over the maxillary sinuses
for tenderness.

MOUTH & THROAT

Inspect lips, and angle of The lips are normally Lips are pink, moist, NORMAL
mouth symmetrical, pink, smooth, has no cracking or any
and moist. lesions.
Inspect the posterior Normal mucosa is pink with No noted any tonsillar NORMAL
oropharynx by depressing a ridged hard palate. Torus enlargement, redness,
the tongue and asking the palatinus may be present and or discharge
patient to say "Ah." is a variation of normal.
Inspect buccal mucosa Normal tissues of the buccal Buccal mucosa NORMAL
mucosa appear moist and appears to be pink in
pink/dark pink. They are soft color, moist, no noted
and pliable on palpation with nodules or lesions.
no discernible indurations.

Inspect the teeth and Thirty-two pearly whitish The patient has 28 NORMAL
gums teeth with smooth
surfaces pearly white teeth. Her
and edges. Upper molars wisdom tooth hasn’t
should rest directly on the erupted yet. No decay
and missing teeth.
lower molars and the front
Her gums are light pink
upper incisors should slightly and moist. The margins
override the lower incisors. of the teeth are visible.
Some clients normally have No lesions, swelling and
only 28 teeth if the four masses.
wisdom teeth do not erupt.
No decayed areas; no
missing teeth. Gums are
pink, moist, and firm with
tight margins to the tooth. No
lesions or masses.
Inspect and palpate the Tongue should be pink, There are no data THERE ARE NO DATA
tongue. moist, a moderate
size with recorded. RECORDED
papillae (little protuberances)
present. A common variation
is a fissured, topographic-
map–like tongue, which is
 23

not unusual in older

clients.
No lesions are
present.
Assess the ventral surface The tongue’s ventral surface The ventral surface of NORMAL
of the tongue is smooth, shiny, 
pink, or the tongue is smooth,
slightly pale, with visible pinkish in color without
veins and no lesions. lesions. The veins are
visible as well.
Inspect for Wharton’s The frenulum is midline; The frenulum of the NORMAL
ducts Wharton’s ducts are
 client is attached in the
visible, with salivary flow or midline. The ducts are
moistness in the area. The visible and moist. There
is no redness, swelling
client has no swelling,
and lesions.
redness, or pain.
Observe the sides of the No lesions, ulcers, or nodules The side of the tongue is NORMAL
tongue. are apparent. free from nodules,
lesions, and ulcers.

Check the strength of the The tongue offers strong There are no data THERE ARE NO DATA
tongue. resistance recorded. RECORDED

Inspect the hard The hard palate is pale or
(anterior) and soft whitish with firm, transverse
(posterior) palates and rugae (wrinkle-like folds).
uvula. Palatine tissues are intact; the
soft palate should be pinkish,
movable, spongy, and
smooth
Note odor while the No unusual or foul odor is
mouth is wide open noted
The hard palate of the NORMAL
patient is light pink and
firm rugae. The soft
palate is pinkish,
smooth, and movable.
There are no data THERE ARE NO DATA
recorded. RECORDED

Assess the uvula The uvula is a fleshy, solid There are no data THERE ARE NO DATA
structure that hangs freely in recorded. RECORDED
the midline. No redness of or
exudate from uvula or soft
palate. Midline elevation of
uvula and symmetric
elevation of the soft palate.
A bifid uvula, common in
Native Americans, looks like
it is split in two or partially
severed
Inspect the tonsils Tonsils may be present or There are no data THERE ARE NO DATA
absent. They are normally recorded. RECORDED
pink and symmetric and may
be enlarged to 1+ in healthy
 24

clients. No exudate, swelling,

or lesions should be present.
Inspect the posterior Throat is normally pink, There are no data THERE ARE NO DATA
pharyngeal wall without exudate or lesions recorded. RECORDED

POSTERIOR THORAX
Inspect configuration Scapulae are symmetric and Shoulders and NORMAL
non-protruding. scapulae of the client
Shoulders and scapulae are at are symmetric. Spinal
equal horizontal positions. cord appears to be
The ratio of anteroposterior straight and centered.
to transverse diameter is 1:2.
Spinous processes appear
straight, and thorax appears
symmetric, with ribs sloping
downward at approximately
a 45-degree angle in relation
to the spine.

Observe use of accessory Client does not use accessory The breathing of the NORMAL
muscles muscles to assist breathing. clients is visible
The major muscles at work. through the expansion
This is evidenced by of the lower chest.
expansion of the lower chest
during inspiration.
Inspect the client’s Client should be sitting up The client’s posture is NORMAL
positioning and relaxed, breathing easily erected and relaxed.
with arms at side or in lap.
Palpate for tenderness Client reports no tenderness, There are no data THERE ARE NO DATA
and sensation pain, or unusual sensations. recorded. RECORDED
Temperature should be equal
bilaterally.
Palpate for crepitus The examiner finds no There are no data THERE ARE NO DATA
palpable crepitus. recorded. RECORDED
Palpate surface Skin and subcutaneous tissue There are no data THERE ARE NO DATA
characteristics are free of lesions and recorded. RECORDED
masses.
Palpate for fremitus Fremitus is symmetric and There are no data THERE ARE NO DATA
easily identified in the upper recorded. RECORDED
regions of the lungs. If
fremitus is not palpable on
either side, the client may
need to speak louder. A
decrease in the intensity of
fremitus is normal as the
examiner moves toward the
 25

base of the lungs. However,

fremitus should remain
symmetric for bilateral
positions.
Assess chest expansion Client takes a deep breath; There are no data THERE ARE NO DATA
the examiner’s thumbs recorded. RECORDED
should move 5 to 10 cm
apart symmetrically.
Percuss for tone Resonance is the percussion There are no data THERE ARE NO DATA
tone elicited over normal recorded. RECORDED
lung tissue. Percussion elicits
flat tones over the scapula.
Percuss for diaphragm Excursion should equal There are no data THERE ARE NO DATA
excursion bilaterally and measure 3-5 recorded. RECORDED
cm in adults. Level of the
diaphragm may be higher on
the right because of the
position of the liver. In well-
conditioned clients,
excursion can measure up to
7 to 8 cm.
Auscultate for breath Three types of normal breath There are no data THERE ARE NO DATA
sounds sounds may be auscultated- recorded. RECORDED
bronchial, bronchovesicular,
and vesicular.
Auscultate for No adventitious sounds such There are no data THERE ARE NO DATA
adventitious sounds as crackles or wheezes are recorded. RECORDED
auscultated.
Auscultate voice sounds Voice transmission is soft, There are no data THERE ARE NO DATA
muffled and indistinct. The recorded. RECORDED
sound of voice may be heard
but may be heard but the
actual phrase cannot be
distinguished.
Voice transmission will be
soft and muffled but the
letter “E” should be
distinguishable.
During whispered
pectoriloquy, transmission of
sound is faint and muffled. It
may be inaudible.
ANTERIOR THORAX
Inspect position of the Sternum is positioned at Sternum appears to be NORMAL
sternum midline and straight. straight and centered.
 26

Watch for sternal Retractions not There are no data THERE ARE NO DATA
retractions observed. recorded. RECORDED

Inspect slope of the ribs Ribs slope downward with The slope of the ribs is NORMAL
symmetric intercostal spaces. symmetrical.
The Coastal angle is within
90 degrees.
Observe quality and Respirations are relaxed, Respiration is NORMAL
pattern of respiration effortless, and quiet. They effortless with a
are of a regular rhythm and regular rhythm.
normal depth at a rate of 10–
20 per minute in adults.
Tachypnea and bradypnea
may be normal in some
clients.
Inspect intercostal spaces No retractions or bulging of There are no bulging NORMAL
intercostal spaces are noted. or retractions present.
Observe for use of Use of accessory muscles is The use of accessory NORMAL
accessory muscles not seen with normal muscles is not that
respiratory effort. After visible.
strenuous exercise or
activity, clients with normal
respiratory status may use
neck muscles for a short time
to enhance breathing.
Palpate for tenderness, No tenderness or pain is There are no data THERE ARE NO DATA
sensation, and surface palpated over the lung area recorded. RECORDED
masses with respirations.
Palpate for tenderness at Palpation does not elicit There are no data THERE ARE NO DATA
costochondral junctions tenderness. recorded. RECORDED
of ribs
Palpate for crepitus No crepitus is palpated. There are no data THERE ARE NO DATA
recorded.. RECORDED
Palpate for any surface No unusual surface masses There are no data THERE ARE NO DATA
masses or lesions or lesions are palpated. recorded. RECORDED

Palpate for fremitus Fremitus is symmetric and There are no data THERE ARE NO DATA
easily identified in the upper recorded. RECORDED
regions of the lungs. A
decreased intensity of
fremitus is expected toward
the base of the lungs.
However, fremitus should be
symmetric bilaterally.
 27

Palpate anterior chest Thumbs move outward in a There are no data THERE ARE NO DATA
expansion symmetric fashion from the recorded. RECORDED
midline.
Percussion for tone Resonance is the percussion There are no data THERE ARE NO DATA
tone elicited over normal recorded. RECORDED
lung tissue. Percussion elicits
dullness over breast tissue,
the heart, and the liver.
Tympany is detected over the
stomach, and flatness is
detected over the muscles
and bones.
Auscultate for anterior Refer to text in the posterior There are no data THERE ARE NO DATA
breath sounds, thorax section for normal recorded. RECORDED
adventitious sounds, and voice sounds.
voice sounds
BREAST & LYMPHATIC SYSTEM
Inspect size and Breasts can be a variety of The right breast of the NORMAL
symmetry. sizes and are round and patient was observed
pendulous. One breast may larger in size
normally be larger than the compared to the other.
other. Both patient’s breasts
are round and
pendulous
Inspect color and texture. Color varies depending on The color of the breast NORMAL
the client’s skin tone. is medium like the
Texture is smooth, with no skin of the patient. It
edema. Linear stretch marks is smooth without the
may be seen during and after presence of edema.
pregnancy or with significant
weight gain or loss.
Inspect superficial venous Veins radiate either The veins on the NORMAL
pattern. horizontally and toward the breast of the patient
axilla (transverse) or are radiating
vertically with a lateral flare horizontally towards
(longitudinal). Veins are the axilla.
more prominent during
pregnancy.
Inspect the areolas. Areolas vary from dark pink The patient’s areola is NORMAL
to dark brown, depending on pinkish in color. It is
the client’s skin tones. They round in size, and
are round and may vary in Montgomery is
size. Small Montgomery present in the areolas.
tubercles are present
Inspect the nipples Nipples are nearly equal The patient’s nipples NORMAL
bilaterally in size and are in are equal in size

the same location on each
breast. Nipples are usually
everted, but they may be
inverted or flat.
Supernumerary nipples may
appear along the embryonic
“milk line.” No discharge
should be present.
Inspect for retraction and The client’s breasts should
dimpling rise symmetrically, with no
sign of dimpling or
retraction.
Palpate texture and Palpation reveals smooth,
elasticity firm, elastic tissue.
Palpate for tenderness A generalized increase in
and temperature. nodularity and tenderness
may be a normal finding
associated with the menstrual
cycle or hormonal
medications. Breasts should
be a normal body
temperature
Palpate for masses No masses should be
palpated. However, a firm
inframammary transverse
ridge may normally be
palpated at the lower base of
the breasts.
Palpate the nipples. The nipple may become
erect, and the areola may
pucker in response to
stimulation. A milky
discharge is usually normal
only during pregnancy and
lactation. However, some
women may normally have a
clear discharge.
Inspect and palpate the No rash or infection noted.
axillae.
Demonstrate how to Client may request
perform Breast Self- instructions on how to
Exam perform the exam or choose
not to learn how to perform
28
bilaterally to each
other. Both of them
are symmetric in
location. The nipples
of the patient appear
to be everted with no
presence of any
discharges.
The client’s breast NORMAL
rises symmetrically
without signs of
dimpling and
retraction.
There are no data THERE ARE NO DATA
recorded. RECORDED
There are no data THERE ARE NO DATA
recorded. RECORDED
There are no data THERE ARE NO DATA
recorded. RECORDED
There are no data THERE ARE NO DATA
recorded. RECORDED
There are no data THERE ARE NO DATA
recorded. RECORDED
The patient has NORMAL
performed and
demonstrated the
proper techniques for
 29

the exam. Either choice BSE and she has

needs to be accepted by the requested for more
examiner. instructions for BSE.
HEART & NECK VESSELS
Observe the jugular The jugular venous pulse is There were no NORMAL
venous pulse. not normally visible with the pulsations visible on
client sitting upright. This the jugular vein of the
position fully distends the patient during upright
vein, and pulsations may or sitting position.
may not be discernible.
Evaluate jugular venous The jugular vein should not There are no data THERE ARE NO DATA
pressure. be distended, bulging, or recorded. RECORDED
protruding at 45 degrees or
greater.
Auscultate the carotid No blowing or swishing or There are no data THERE ARE NO DATA
arteries other sounds are heard. recorded. RECORDED
Pulses are equally strong; a
2+ or normal with no
variation in strength from
beat to beat. Contour is
normally smooth and rapid
on the upstroke and slower
and less abrupt on the
downstroke. The strength of
the pulse is evaluated on a
scale from 0 to 4
Palpate the carotid Arteries are elastic and no There are no data THERE ARE NO DATA
arteries. thrills are noted. recorded. RECORDED

Inspect pulsations. The apical impulse The apical pulse is NORMAL

may or may not be visible. If found at the mitral
apparent, it would be in the area, and it is not
mitral area. The apical visible.
impulse is a result of the left
ventricle moving outward
during systole.
Palpate the apical impulse The apical impulse is There are no data THERE ARE NO DATA
palpated in the mitral area recorded. RECORDED
and may be the size of a
nickel (1-2 cm). Amplitude
is small - like a gentle tap.
The duration is brief, lasting
through the 1st 2/3 of systole
and often less. In obese
clients or clients with large
 30

breasts, the apical impulse

may not be palpable.
Palpate for abnormal No pulsations or vibrations There are no data THERE ARE NO DATA
pulsations are palpated in the areas of recorded. RECORDED
the apex, left sternal border,
or base.

Auscultate heart rate and Rate should be 60-100 bpm There are no data THERE ARE NO DATA
rhythm. with a regular rhythm. A recorded. RECORDED
regularly irregular rhythm,
such as sinus arrhythmia
when the heart rate increases
with inspiration and
decreases with expiration,
may be normal in young
adults.

Auscultate to identify S1 S1 corresponds with each There are no data THERE ARE NO DATA
and S2 carotid pulsation and is recorded. RECORDED
loudest at the apex of the
heart. S2 immediately
follows after S1 and is
loudest at the base of the
heart.
Auscultate for extra heart Normally no sounds are There are no data THERE ARE NO DATA
sounds. heard A physiologic S3 heart recorded. RECORDED
sound is a benign finding
commonly heard at the
beginning of the diastolic
pause in children,
adolescents, and young
adults (rare after age 40) A
physiologic S4 heart sound
may be heard near the end of
diastole in well- conditioned
athletes and adults older than
age 40 or 50 with no
evidence of heart disease

Auscultate for murmurs. Normally no murmurs are There are no data THERE ARE NO DATA
heard recorded. RECORDED

ABDOMEN
Observe the coloration of abdominal skin may be paler Abdominal skin is NORMAL
the skin. than the general skin tone paler than the general
because this skin is so

seldom exposed to the
natural elements.
Note the vascularity of Scattered fine veins may be
the abdominal skin. visible. Blood in the veins
located above the umbilicus
flows toward the head; blood
in the veins located below
the umbilicus flows toward
the lower body
Inspect for scars. Pale, smooth, minimally
raised old scars may be seen.
Assess for lesions and Abdomen is free of lesions
rashes. or rashes. Flat or raised
brown moles, however, are
normal and may be apparent.
Inspect the umbilicus. Umbilical skin tones are
similar to surrounding
abdominal skin tones or even
pinkish.
Inspect abdominal Abdomen is flat, rounded, or
contour and symmetry. scaphoid (usually seen in
thin adults; Abdomen should
be evenly rounded. Abdomen
is symmetric.
Inspect abdominal Abdominal respiratory
movement when the movement may be seen,
client breathes especially in male clients.
(respiratory movements).
Observe aortic pulsations. A slight pulsation of the
abdominal aorta, which is
visible in the epigastrium,
extends full length in thin
people.
Observe for peristaltic Normally, peristaltic waves
waves are not seen, although they
may be visible in very thin
people as slight ripples on
the abdominal wall.
Auscultate for bowel A series of intermittent, soft There are no data
sounds. clicks and gurgles are heard
at a rate of 5–30 per minute.
Hyperactive bowel sounds
referred to as “borborygmus”
31
skin tone. It is whiter
or paler.
The visible fine veins NORMAL
are minimal in the
abdominal skin. They
are located in the left
lower quadrant.
Majority of the scars NORMAL
are pale, there are no
raised old scars
inspected.
There are no lesions NORMAL
and rashes. There are
three red – brown
moles on the right
upper quadrant.
Umbilicus is clean, NORMAL
skin tone is similar
with abdominal skin
tone.
Abdomen is slight flat NORMAL
and is symmetric.
Abdominal movement NORMAL
is seen. There were no
abnormal movements
upon respiration.
There are no data THERE ARE NO DATA
recorded RECORDED
There are no data THERE ARE NO DATA
recorded RECORDED
THERE ARE NO DATA
recorded RECORDED
 32

may also be heard. These are

the loud, prolonged gurgles
characteristic of one’s
“stomach growling.
Auscultate for vascular Bruits are not normally heard There are no data THERE ARE NO DATA
sounds. over abdominal aorta or recorded RECORDED
renal, iliac, or femoral
arteries. However, bruits
confined to systole may be
normal in some clients
depending on other
differentiating factors
Auscultate for a friction No friction rub over liver or There are no data THERE ARE NO DATA
rub over the liver and spleen is present. recorded RECORDED
spleen.
Percuss for tone. Generalized tympany There are no data THERE ARE NO DATA
predominates over the recorded RECORDED
abdomen because of air in
the stomach and intestines.
Dullness is heard over the
liver and spleen. Dullness
may also be elicited over a
non-evacuated descending
colon.
Percuss the span or height On deep inspiration, the There are no data THERE ARE NO DATA
of the liver by lower border of liver dullness recorded RECORDED
determining its lower and may descend from 1 to 4 cm
upper borders. below the costal margin. The
upper border of liver dullness
is located between the left
fifth and seventh intercostal
spaces. The normal liver
span at the MSL is 4 – 8 cm.
Perform blunt percussion Normally, no tenderness is There are no data THERE ARE NO DATA
on the liver and the elicited. recorded RECORDED
kidneys.
Perform light palpation. Abdomen is nontender and There are no data THERE ARE NO DATA
soft. There is no guarding. recorded RECORDED

Deeply palpate all Normal (mild) tenderness is There are no data THERE ARE NO DATA
quadrants to delineate possible over the xiphoid, recorded RECORDED
abdominal organs and aorta, cecum, sigmoid colon,
detect subtle masses. and ovaries with deep
palpation.
 33

Palpate the liver. The liver is usually not There are no data THERE ARE NO DATA
palpable, although it may be recorded RECORDED
felt in some thin clients. If
the lower edge is felt, it
should be firm, smooth, and
even. Mild tenderness may
be normal.
Palpate the urinary An empty bladder is neither There are no data THERE ARE NO DATA
bladder. palpable nor tender. recorded RECORDED

Assess for rebound No rebound tenderness is There are no data THERE ARE NO DATA
tenderness. present. recorded RECORDED

UPPER and LOWER EXTREMITIES (Muscles, Bones, Joints)

Inspect the muscles for Equal size on both sides of There are no data THERE ARE NO DATA
size. Compare each body. recorded RECORDED
muscle on one side of the
body to the same muscle
on the other side.
Inspect the muscles and No contractures. Trapezius, Biceps, NORMAL
tendons for contractures. Triceps, Forearms,
Quadriceps, and
Hamstrings are
muscles that were
inspected. There are
no contractures
inspected on the
muscles.
Inspect the muscles for No fasciculation or tremors. Trapezius, Biceps, NORMAL
tremors. Triceps, Forearms,
Quadriceps, and
Hamstrings are
muscles that were
inspected. There are
no fasciculation or
tremors noted.
Palpate muscles at rest to Palpate muscles at rest to There are no data THERE ARE NO DATA
determine muscle determine muscle tonicity. recorded RECORDED
tonicity.
Palpate muscles while the Smooth coordinated There are no data THERE ARE NO DATA
client is active and movements. recorded RECORDED
passive for flaccidity,
spasticity, and
smoothness of movement.
 34

Test muscle strength of Equal strength on each body There are no data THERE ARE NO DATA
the head & shoulders side. Grade 3 to 5 of muscle recorded RECORDED
strength.
Test muscle strength of Grade 3 to 5 of muscle There are no data THERE ARE NO DATA
upper extremities. strength. recorded RECORDED

Assess joint range of Varies to some degree in There are no data THERE ARE NO DATA
motion of the head accordance with person’s recorded RECORDED
genetic makeup and degree
of physical activity. Full
range of motion.
Assess joint range of Varies to some degree in There are no data THERE ARE NO DATA
motion of body trunk accordance with person’s recorded RECORDED
genetic makeup and degree
of physical activity. Full
range of motion.
Assess joint range of Varies to some degree in There are no data THERE ARE NO DATA
motion of upper accordance with person’s recorded RECORDED
extremities genetic makeup and degree
of physical activity. Full
range of motion.
Test muscle strength of Hip Abduction: Client is There are no data THERE ARE NO DATA
lower extremities supine, both legs extended. recorded RECORDED
Nurse will place her hands
on the lateral surface of each
knee; client spreads the legs
apart against nurse’s
resistance.
Hip Adduction: Client brings
the legs together against
nurse’s resistance.
Hamstrings: Client resist
while the nurse attempts to
straighten the legs.
Quadriceps: Client resist
while the nurse attempt to
flex the knee.
Muscles of the ankle and
feet: Client resist as the nurse
attempts to dorsiflex the foot
and again resist as the nurse
attempt to flex the foot.

Inspect the joint for No swelling Patient does not show NORMAL
swelling presence of swelling.

Palpate each joint for No tenderness, crepitation, or
tenderness, smoothness of nodules.
movement, swelling,
crepitation, and presence
of nodules.
Assess joint range of Full range of motion
motion of lower
extremities
VII. Problem Identification and Prioritization
Nursing Diagnosis
Deprived sleep related to
heavy schoolwork loads as
evidenced by stress and short
temperedness.
Parasympathetic Anxiety
related to stress as evidenced
by alteration in sleeping
pattern.
35
There are no data THERE ARE NO DATA
recorded RECORDED
There are no data THERE ARE NO DATA
recorded RECORDED
Rank Justification
1 According to Psychologist
Abraham Maslow, sleep is a
basic physiological need that
belongs in the first set of
requirements, at the bottom of
the pyramid or hierarchy of
needs, where it must be
addressed. It is impossible to
function efficiently daily
without sleep (Science,
2018). Sleep deprivation can
have devastating
repercussions. High blood
pressure, diabetes, heart
attack, stroke, and mortality
are all risks associated with it
(health essentials, 2020).
2 Anxiety problems are
frequently connected with
challenges in starting and
keeping up with sleep
(American Psychiatric
Association [APA], 1994;
Benca, Obermeyer, Thisted
and Gillin, 1992;
Soldatos and Dikeos, 2003).
However, the more the
parasympathetic system
dominates during sleep, the
more the body is able to
recover and the more
resources for the following
days and tasks. Thus, a good
night's sleep contains plenty

Compromised Family Coping
related to insufficient
reciprocal support as
evidenced by verbalization of
feeling the lack of interest of
family members.
36
of parasympathetic
domination that balances
daily stress responses.
(Elbakyan, 2005)
3 Ineffective coping is the
inability to assess a stressful
situation or event
comprehensively and
therefore fail to make sound
decisions using inappropriate
resources or none at all (RN
lessons, 2021).
Compromised family coping
is termed as a situation in
which when usually a
supportive primary person
(family member or close
friend) is providing
insufficient, ineffective, or
compromised support,
comfort, assistance, or
encouragement that may be
needed by the client to
manage or master adaptive
tasks related to his/her health
challenge (Medical
Dictionary, nd).
 37

VIII. Nursing Care Plan

Nursing Care Plan
Name of Patient: X Age & Sex: 20 y/o - Female
Nursing Diagnosis: Deprived sleep related to heavy schoolwork loads Date: July 17, 2021
as evidenced by stress and short temperedness.
Prepared By: Group 2B CI/Supervisor: Ms. Mary Ann Bayani

Cues Nursing Analysis Goals and Implementation Rationale Evaluation

Diagno Objectives
sis

Subjective: Deprive Scientific Goal: Independent, Summative:

d sleep Analysis: Dependent,
The client verbalized: Short term After 1 hour
related Collaborative
goal of nursing
to Nursing
intervention,
heavy Sleep and mood Intervention
“Madami po talagang the client was
school are linked;
kailangang tapusin na After 1 hour able to
work insufficient or bad
mga schoolworks kaya of nursing verbalize and
loads as sleep can lead to
po late na ako interventions, identify
evidenc irritation and
nakakatulog.” the client will certain
ed by tension, whereas
verbalize and techniques
stress adequate sleep
identify that help
and can improve well-
“Madalas pong short
certain enhance
being. Inadequate
inaabot na ako ng techniques sleep.
tempere sleep can lead to
madaling araw para that help
dness. even more stress. Met: _/_
lang matapos mga enhance her
Consistent sleep
activities ko .”
deprivation or
 38

sleep of poor- sleeping Partially met:

quality causes pattern. __
“Kung maari, gusto
sleep deprivation.
ko po sana ng Unmet: __
(Johnson, 2018)
kompletong oras ng
tulog.”
Situational
Analysis: Formative:
Objective:
Effectivenes
s
Lack of sleep is
-Dark circles/ eyebags
caused by
-Distress in posture increased Independent
agitation and Objectives: Nursing
-Distress in facial
arousal which can Intervention: 1. The client
expression
cause sleep was guided
-Irritable deprivation due to 1. After 10 and assisted
client’s heavy minutes of about the
-Frequent yawning school workloads. client various
-Restless a. The nurse will
orientation, factors that
guide the patient
the client will lead to sleep
about proper food
be guided a. Having full meals deprivation.
and fluid intake
about the before bedtime causes
such as avoiding Met: _/_
Anthropometrics: factors that the production of
heavy meals,
lead to sleep gastrointestinal upset Partially met:
-Height: 157 cm alcohol, smoking,
deprivation. and hinders sleep __
caffeine before
-Weight: 50 kg (Cognitive) onset. Coffee, tea,
bedtime.
chocolate, and colas Unmet: __
-BMI: 20.3 contain caffeine
stimulate the nervous
system. This may
 39

interfere with the

patient’s ability to
relax and fall asleep.
Alcohol produces
drowsiness and may
facilitate the onset of
sleep but interferes
with rapid eye
movement sleep.
(Wayne, 2019)

b. Bananas are not

only high in
tryptophan but also in
b. Advise the potassium. This is a
client to consume vital component of
foods high in human health as well
potassium such as as a natural muscle
bananas, oranges, relaxant. According to
cantaloupe, one study, potassium
honeydew, levels play a role in
apricots, and sleep, with higher
grapefruit. As levels promoting better
well as the food sleep. Almonds may
rich in magnesium also aid in improving
such as nuts, sleep quality. This is
almonds and because almonds,
peanuts. along with a variety of
 40

other nuts, contain the

hormone melatonin.
Melatonin is a
hormone that controls
your internal clock and
tells your body when
it's time to sleep.
Magnesium's capacity
to alleviate
inflammation is
suggested to play a
role in encouraging
sleep. It may also help
lower the stress
hormone cortisol
levels, which has been
linked to sleep
disruption (Healthline,
2020).

a. Relaxation
strategies should be
 41

utilized in conjunction
with, not in absence of,
exposure and cognitive
skills. Relaxation
techniques might
sometimes make
anxiety worse in the
long run. Why?
Independent
Because relaxation
Nursing
techniques are
Intervention:
sometimes used to
a. The nurse will alleviate anxiety when
instruct and assist we are in distress;
the patient for 5 attempting to eliminate
minutes about something educates
relaxing activities our brains to perceive
such as arts and it as “bad.” So, we
teach the brain to set 2. The client
crafts and music
off the anxiety "alarm" acquired
2. After health therapy, which
much louder when the enough
teaching, the will allow anxious
anxiety appears. In the knowledge
client will be energy to be used
long run, this about the
able to gain in a constructive
exacerbates the different
knowledge of way and may
anxiety. In a summary, relaxing
relaxing reduce anxiety.
there are times and diversional
diversional
places for relaxing activities.
activities.
(Cognitive) approaches. (Goodwin Met: _/_
and Harris, 2018)
Partially met:
__
 42

Unmet: __

b. Stress makes it
difficult for a person
to relax, rest, and
sleep. Taking time to
relax and wind down
before bed is vital to
sleeping well and
reducing the stress of
the day. A period of
peaceful time before
bed allows you to
walk away from daily
anxieties and set them
aside before sleep
(SleepScore Labs,
2016).

b. The nurse will

allot 5 minutes to a. Undeniable level of
encourage the stress negatively
 43

patient to avoid affects the physical

stressful events and emotional
before going to wellness of medical
sleep to reduce students. (Behere SP,
anxiety and have a Yadav R, Behere PB,
good rest. 2011) Specifically,
high levels of stress
can influence
psychological
working, level of
fixation, and
scholastic execution.
(Dahlin M, Joneborg
N, Runeson B, 2005)
Medical students may
not consider rest as a
main concern with
regards to their
scholarly prerequisites
as they decrease their
Independent dozing time to have
Nursing additional hours for
Intervention: examining and
responsibility. Thus,
they foster helpless
a. The nurse will dozing propensities
give 10 minutes to particularly in the
explain and reflect weeks going before an
on the expected examination (Ahrberg
changes and be K, Dresler M,
able to know the
 44

relevance of Niedermaier S, Steiger

having adequate A, Genzel L, 2012).
sleep pattern.

3. The client
was able to
grasp
3. After one- information
on-one about the
discussion changes that
about time can be done
management, on how to
the client will deal with her
be able to stress due to
explain the school
expected works.
changes and
Met: _/_
their
relevance on Partially met:
having __
adequate sleep
Unmet: __
pattern.
 45

Efficiency:
The
strategies
were suitable
within the
 46

given time
frame.
Yes_/_ No__

Appropriate
ness: The
selected
strategies/
interventions
were
appropriate
to the client’s
needs.
Yes_/_
No__

Adequacy:
The specific
learning
objectives
and its
content were
enough to
meet the
client’s
needs.
 47

Yes_/_
No___

Acceptabilit
y: The
strategies/
interventions
were
acceptable to
the patient.
Yes_/_
No ___
 1 48

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dictionary.thefreedictionary.com/compromised+family+coping

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