Assessment Database

FAR EASTERN UNIVERSITY - MANILA
Institute of Nursing
Assessment Database
Submitted by:
Paguirigan, Jhoana Nicole P.
Pataueg, Victoria Joy D.
Rafael, Christian Emmanuel N.
Roque, Ma. Nnyca Paula B.
Saludsong, Rasheed G.
Submitted to:
Mrs. Jennifer Padual
Clinical Instructor
NCM 104 - Community Health Nursing 1: Individual & Family As Clients
December 14, 2021
1
I. Family Structure, Characteristics, and Dynamic
Name of the head of the Family: _____ Length of Residency_____
Total Number of Family Members:__ Purok No:_____ Brgy No: Tandang Sora Zone No:_____ District No: 2
Block No.: __________ Lot No.: #2
Type of family: ____N____ Data on Family: No. of Children ____1____ Living ____1____ Dead ____0____ Abortion ____0_____
Name of Relation to Date of Birth Age Sex Civil Status Nationality Religion Highest Occupation Employment Place of
Family the head of Education Status Work
Member the family al
(indicate
ordinal
position in
the family)
R. A. S. Father 1971 50 M M F I CG E: General R Dr. Jose
Surgeon N.
Rodriguez
Memorial
2
Hospital
R. G. S. Mother March 52 F M F I CG E: R Dept. of
1969 Government Agrarian
Employee Reform
R. S. Son June 28, 21 Non- S F I C - 2nd Student N/A FEU
2000 binary year
Family members or living elsewhere (N/A if none) N/A
Member who tends to make decisions in matters of healthcare Mother
Conflicts between members of the family? N/A Communication patterns among members?___
LEGEND Type of Family O - Others
N - Nuclear Civil Status
E - Extended Gender S - Single
B - Blended F - Female M - Married
D - Dyad M - Male SE - Separated
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W - Widowed Religion
LI - Live In RC - Roman Catholic Higher Educational Attainment
C - Christian K - Kinder
Occupation (15-65 years old) INC - Iglesia Ni Cristo E - Elementary Level (specific)
E - Employed (Specify) I- Islam EG - Elementary Graduate
U - Unemployed Others, specify: ___________ H - High School Level (specific)
SE - Self-employed (Specify) HG - High School Graduate
P - Retired with Pension Employment Status C - College Level (specific)
R - Retired without Pension R - Regular CG - College Graduate
T - Temporary NFE - No Formal Education
Nationality V - Vocational
F - Filipino Place of Work
Retired without Pension I - Inside the community
O - Outside the community
4
Mr. R.A.S., a 50-year-old man, is married to Mrs. R.G.S., a 52-year-old
woman, for 29 years with one son. The son is named R.S., a 21-year-old non-binary
individual, who was born on June 28, 2000 via normal spontaneous delivery.
The family (all 3 members) are currently living in their house at Tandang Sora,
Quezon City. The family is a nuclear type of family structure where it consists of a
two married couple and a child who are living together in the same house but apart
from both sets of parents and other relatives. Furthermore, when it comes to
deciding, it has been identified during the assessment that their family is considered
to be matriarchal, where Mrs. R.G.S. (mother) usually decides for the family. This
also describes that Mrs. R.G.S. is the head of the family. In addition, when it comes
to the healthcare of the family, the mother is also in charge of making decisions.
In the interview, Mrs. R.G.S. said that the relationship among the family is
okay, and when there are times that one member of the family is having a hard time
Mrs. R.G.S. said that they provide each other with support. With regards to this,
when there are actions that affect the relationship of the family, they try to talk about
it. During the interview, Mrs. R.G.S verbalized that “We are okay naman as family,
we always make sure that everyone is okay and if something happens sa isang
member ng family namin, we always try to talk about it.” When it comes to the
healthcare of the family, they always make sure that they are all healthy. Since Mr.
R.A.S is a surgeon, he also makes sure that everyone in the family is healthy even
5
though Mrs. R.G.S. makes the decisions for the healthcare of the family. Mrs. R.G.S.
stated during the interview, “Since the pandemic started, nag-doble ingat talaga
kami. Since I am a government employee and Mr. R.A.S. (husband) is a doctor, we
always make sure talaga na we are healthy para na rin sa kaligtasan ni R.S (son)”.
In line with this, the family has a good relationship with each other because Mrs.
R.G.S. mentioned during the interview that they always make time for each other
and talk about the things that they want especially when it comes to how their day
went.
Analysis:
The family of Mr. R.A.S. is under a nuclear family structure. According to
Blessing (2021), the nuclear family is a typical family consisting of two parents and
children. In addition, their family is matriarchal, where the mother has authority over
a man and children and has the power to make decisions for the family. In the 10th
century BC, women were submissive to their husbands, but in the 1950s, the rise of
working mothers and wives began (McCarthy, 2020) as some families started
practicing the structure of matriarchal. Moreover, even though the father still has
authority over the family, it is commonly assumed and considered that the mother’s
choice will be the final decision regarding healthcare matters. According to Galal et
al. (n.d.), women have unique roles within the family that promote overall family
health.
References:
6
Blessing, M. (2021). Types of family structures. LoveToKnow. Retrieved December
2, 2021, from https://family.lovetoknow.com/about-family-values/types-family-
structures.
McCarthy, H. (2020, May 5). The rise of the working wife. History Today. Retrieved
December 2, 2021, from https://www.historytoday.com/history-matters/rise-
working-wife.
Galal , O. Y., Garrett, D. A., & Goodwin, P. (n.d.). Women and Family Health: The
Role of Mothers in Promoting Family and Child Health. Journals at UNI
ScholarWorks. Retrieved December 2, 2021, from
https://scholarworks.uni.edu/cgi/viewcontent.cgi?
referer=&httpsredir=1&article=1023&context=ijghhd.
Family Genogram: Paternal Side
7
The client's family - paternal side in the genogram has a history of hypertension. One
of the siblings of the client also has hypertension. Thus, the client’s mother, his other
two siblings and their children are A/W. Additionally, the client’s wife has color
blindness.
8
Family Genogram: Maternal Side
The client's family - maternal side in the genogram has a history of stroke and color
blindness. The mother of Mr. R.A.S. died at the age of 84 due to a stroke.
Consequently, his father died of natural death and had color blindness. Both her
siblings are A/W, as well as their children. However, the second child of her sister
also has color blindness.
9
II. Socio-economic and Cultural Characteristics
According to the Saludsong Family, the wife or Mrs. R.G.S. is the decision-
maker for the whole family when it comes to budgeting and spending. She stated
that she manages her own income from her employment and outside income from
her several businesses, as well as the salary of her husband for her to be able to
control the in and out flow of money. Mrs. R.G.S. works as a government employee
in the Department of Agrarian Reform (DAR) for a span of 29 years and until now as
a senior agrarian reform program officer (SARPO). Before working in the
government, Mrs. R.G.S. worked at AnaCars Corp as a cashier register. She also
highlighted that, along the way she managed to build her own business such as buy-
and-sell, sari-sari store, and an apartment where the money was used for paying
their child's tuition fee. Mrs. R.G.S. stated that her gross monthly salary from
employment is 53, 700 php along with her monthly income from business which is
120, 000 php. On the other hand, Mr. R.A.S. stated that for the past 13 years, he has
worked as a general surgeon at Dr. Jose N. Rodriguez Memorial Hospital. Prior to
that, he worked as a DOH Margus as a medical expert at Tubig Regional Hospitals
for two years. Currently Mr. R.A.S. has a gross monthly salary of 88, 600 php.
Furthermore, their only son , R.S. is still a student and does not have a monthly
income yet. Mrs. R.G.S. is a FEU-Manila BS Commerce Major in Accounting
graduate, while Mr. R.A.S. is a Manila Central University Optometry Collage
(PreMed), Medicine graduate (Post-Grad). Finally, their son R.S. is still a second-
year nursing student at FEU-Manila.
10
The Saludsong family’s combined monthly income is above Php. 20,000,00.
Therefore, they stated that it is adequate for meeting their basic needs such as food,
clothing and shelter. Mrs. R.G.S. expresses that she can meet his son's needs
because he eats 5 times a day, which is why he is overweight. In addition, she can
purchase his son the clothes he likes, some of which are even from the United
States, and they have their own house and other properties, so his son can no
longer complain. Mr. R.A.S., on the other hand, indicated that he provides his child
with too many necessities and even luxury. Mr. R.G.S. believes she should take note
of and document the family's monthly spending, which include essential
requirements, bills such as water, electricity, WiFi, and so on, as well as luxury
wishes such as travel expenses, affording premium brands, equipment updates, and
so on. Mr. R.A.S feels at ease with his wife managing the family's income and costs
since she prioritizes and manages expenditures well by fulfilling physiological
necessities first, conserving extra amounts, and gratifying luxury demands last when
feasible. The Saludsong family has a nuclear family in which the mother was born in
Asingan, Pangasinan and moved to Manila in 1984 to pursue a BS Commerce Major
in Accounting at FEU-Manila. The father, on the other hand, was born in Pagadian,
Labangan City and moved to Manila in 1984 to study at Manila Central University
Optometry Collage (PreMed), Medicine (Post-Grad). Therefore, the Saludsong family
was from the province and migrated here in Manila to both pursue studies and
career.
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The Saludsong family has a solid bond, and they both fulfill their obligations to
each other and to the family. The mother makes all family decisions, including
healthcare, health practices, expenditures, family decisions, and so on. The mother
has taken on the family's strict and disciplinarian role, but she has also created a
protective and caring reciprocal bond. Mr. R.A.S. is the household earner and
advises the mother on major decisions. According to the father, the child has been
distant from him since he was a child. According to R.S., he is far more attached to
his mother than to his father. According to the child, the mother has no trouble
executing family/significant other caretaker tasks. The father is highly conservative,
restricting, and prone to interruption of the parent-child connection. In comparison to
the father, the mother is more receptive to the kid's ideas and feelings, exhibits
caring and protective actions toward the child, and is the primary carer.
Since the family is a member of a community, cultivating strong relationships
with others is essential. Since the mother's side of the family came from the
province to the city, the family has developed positive ties with other neighbors and
the community; as a result, the kid likewise cultivates healthy relationships with other
neighbors and the community. The mother stated that it is critical for the family to
develop positive relationships with other neighbors since when she and her siblings
were younger, they were the ones who looked after them while their parents traveled
to the province for work. According to the father, the community holds events and
12
activities for the entire community, in which the entire family would actively engage.
Because the father is a doctor and the mother works in government, the father and
mother would be called to appear on several programs, especially when the themes
are related to health, wellness, business, and community management.
Analysis
It is said that education is vital for a highly skilled and productive labor force.
According to the International Labour Organization research, tertiary education in
developing countries increases the likelihood of finding a permanent job and earning
more money (QS, 2019). Economists have proved for over 60 years that it leads to
considerable economic returns in terms of salary and GDP. It shows that the greater
one's education, the higher one's income. (The Learning Agency Lab, 2020).
Following this, it is highly likely that the family can sustain their financial status. The
capacity to satisfy their most basic requirements is a crucial indicator of their
economic stability and well-being. However, despite having financial stability, it is
also vital to make a budget. Budgeting with your family allows you to grasp your
finances better. It also includes a baseline of your savings, debts, and spending,
allowing you to see how those figures change over time. Along with understanding
where your money is going, you also need to know how much money is coming in.
There is a thing called 50/30/20, which divides your money into three parts. 50%
goes into necessities like food, housing, essential utilities, transportation, insurance,
13
child care, and minimum loan payments; 30% goes toward luxuries like vacation,
presents, and dinners out; and 20% goes toward emergency or retirement savings
and debt payback (McCullen, 2021).
Mothers are essential family members, but they are also vital decision-
makers. When it comes to budgeting and spending, they strongly influence their
family's expenditures as they study items, go shopping, and make innumerable
judgments (McClellan, 2017). Further, it is critical to have a parent-child relationship
in the family's case. It promotes the physical, emotional, and social development of
the kid. It's a particular link that every child and parent may cherish. The child's
personality, life choices, and general conduct are all shaped by this bond. It may also
impact their social, physical, mental, and emotional well-being (Parenting NI, 2018).
Family and community are two of the most significant social structures in an
individual's growth and everyday life. They form who we are, implant values in us,
define what we think to be expected and aberrant, and educate us about what is and
is not possible. Our inner maps, which we use to orient ourselves to the world, are
printed by our families and communities. Although family and community are often
studied separately, they are intricately and reciprocally linked. The family's survival
as a social institution has always depended on community support, and active and
involved families characterize strong communities. Families develop and thrive in
their communities, or they flounder and fail—better knowledge of the complex,
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dynamic family and community benefits practitioners, policymakers, and scholars
(Miller, 2001). Children may grow up in a safe environment if their families cultivate
long-term community bonds. Being accessible and available for activities of interest
to the community members is an excellent way to start creating a trust (Mobley,
2017).
References
McClellan, S. (2017, May 11). Moms Relinquish Role As Family Decision Maker.
https://www.nerdwallet.com/article/finance/how-to-create-a-family-budget
McCullen, Laura. (2021, May 19). How to Create a Family Budget.
https://www.nerdwallet.com/article/finance/how-to-create-a-family-budget
Miller, Joshua. (2001, December 04). Family and Community Integrity.
https://scholarworks.wmich.edu/cgi/viewcontent.cgi?
article=2764&context=jssw
Mobley, K. (2019, October 28). The Impact of Building Community Relationships On
Family Engagement.
https://www.gpb.org/blogs/education-matters/2019/10/29/the-impact-of-
building-community-relationships-on-family
Parenting NI. (2018, October 25). Parent-Child Relationship - Why it’s Important.
https://www.parentingni.org/blog/parent-child-relationship-why-its-important/
15
QS. (2019, June 29). What Effect Does Education Level Have on Wealth.
https://www.the-learning-agency.com/insights/education-and-income-how-
learning-leads-to-better-salaries/
The Learning Agency Lab. (2020, August 04). Education and Income: How Learning
Leads to Better Salaries.
https://www.the-learning-agency.com/insights/education-and-income-how-
learning-leads-to-better-salaries
16
III. Home and Environment
Blueprint
The family lived in a remote village in Tandang Sora, Quezon City, specifically
the Philvirra Homes Village. During the interview, the family mentioned that their
village has wide streets and is not considered a congested village. Their barangay
health centers are in a fair condition where employed nurses and voluntary doctors
are present to give guidance and provide medical needs of the community. Although
their location is accessible to public transportations, they still owned two private
vehicles which were usually used by Mr. R.A.S. and Mrs. R.G.S.
The S. family lives in a 350 square meter house which is adequate for the
family since the house has four bedrooms and three bathrooms. Upon assessing the
home and environment of the family, it analyzed that their floor space criterions are
all adequate for the family. Namely, a Master’s bedroom of 36 square meters in
17
where Mr. R.A.S and Mrs. R.G.S. sleep. R.S. their son owns a bedroom for himself
of 30 square meters and a study room of 35 square meters. Another room is an
isolation room with a measure of 27 square meters that was used when her mother
had a covid before. Finally, they have a living room/ family room of 72 square meters
where the family spends some quality time together, and is adequate for the three of
them.
One bedroom is occupied by Mr. R.A.S. and Mrs. R.G.S. with a queen-sized
bed. The other room is used by R.S, which also has a queen-size bed. There are
three bathrooms in the house where it is located near the house's bedrooms. The
toilet of the bathroom is clean and has a flush. The water supply in the bathroom is in
pipes, where the family mentioned that it is cleaned twice a week.
Cleanliness and sanitation are valued inside the Saludsong’s residence. They
explained that they ensure a general cleaning every twice a week. They also adhere
to the community policies about waste management, separating the biodegradable
from non-biodegradable. The garbage was collected every Monday and Friday, and
the garbage containers that have been used are also sanitarily cleaned twice a week
after their garbage was collected. When it comes to the sanitation in the kitchen
area, Mrs. R.G.S also mentioned that they use a gas stove in cooking and use
refrigerator, pantry, food containers and food storage cabinets in storing their foods.
They have divided the pantry into dry and wet goods. The dry and canned goods are
18
stored in a cabinet located in their kitchen, while wet goods like meat are stored
inside their refrigerator.
Moreover, during the interview Mrs. R.G.S. mentioned that they owned an
internet which is helpful for her son’s online class. However, the son does not unplug
the appliances and electronic devices after using it. When it comes to the house's
water supply, Maynilad was the family's water provider. The family also has a pozo
negro located in the house's side yard, and Mrs. R.G.S stated their pozo negro was
cleaned every 2-3 in a year. The family's home has a side yard with stagnant water
due to the laundry machines and water tanks, which makes it a risk for resting sites
of mosquito vectors.
Analysis:
The barangay where Saldusong’s family resides made sure to provide proper
medical and guidance needed by the community. According to Sun Star Pampanga
(2016), barangay health centers offer basic health education and primary health care
services. In addition, the household size, 350 square meters, is appropriate for the
family size. According to Financial Samurai (2021), the ideal house size is 167
square meters to 195 square meters for a family of three.
According to the Healthy Homes Coalition of West Michigan (n.d.), a healthy
home is: (a.) dry, (b.) clean, (c.) pest-free, (d.) safe, (e.) contaminate free, and (f.)
ventilated. The family emphasizes that cleanliness and proper sanitation were well
19
maintained in the home through having a general cleaning twice a week, proper
waste management, and separating the dry and wet goods in the kitchen. However,
despite the efforts to keep the home clean, the family is still at risk of acquiring
diseases from the mosquito vectors due to the stagnant water of the laundry
machines and water tanks. According to Delhi (2020), mosquito vectors prefer
stagnant water as a nesting ground through laying the eggs to reproduce. Mosquito
larvae live in stagnant water, and they only need a small amount of water to survive.
Also, mosquito vectors can even be found in a puddle of water on a discarded plastic
bag.
Moreover, Mrs. R.G.S. also mentioned that the son does not unplug the
appliances and electronic devices. According to Brindley (2016), leaving a plugged
device could risk a fire. The family also mentioned cleaning the pozo negro every 2
to 3 years, which is significant because a cleaned pozo negro is as essential as
taking the garbage out.
References:
Financial Samurai. (2021, December 2). The Ideal House Size And Layout To Raise
A Family. Financial Samurai. Retrieved December 5, 2021, from
https://www.financialsamurai.com/the-ideal-house-size-and-layout-to-raise-a-
family/.
20
Healthy Homes Coalition of West Michigan. (n.d.). What is a Healthy Home? Healthy
Homes Coalition of West Michigan . Retrieved December 5, 2021, from
http://www.healthyhomescoalition.org/what-is-a-healthy-home.
Sun Star Pampanga. (2016, May 30). BHW's, important component of the Barangay.
PressReader.com - Digital Newspaper & Magazine subscriptions. Retrieved
December 5, 2021, from https://www.pressreader.com/philippines/sunstar-
pampanga/20160530/281612419650426.
Delhi, N. (2020, August 30). How to prevent mosquito breeding in stagnant water.
India Today Web Desk. Retrieved December 5, 2021, from
https://www.indiatoday.in/information/story/how-to-prevent-mosquito-breeding-
in-stagnant-water-1716758-2020-08-30.
Brindley, R. (2016, November 3). Why you shouldn't leave Electricals Plugged
in. Fire Protection Online. Retrieved December 5, 2021, from
https://www.fireprotectiononline.co.uk/info/why-shouldn-t-leave-electrical-
plugged-
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IV. Health Status of each Family Member
Mr. R.A.S., the father, indicated that he has had no illness or recurring
morbidity in the last year. But, as a result of the pandemic, he gained some weight
because of having a sedentary lifestyle, but currently he is now more conscious and
strict of maintaining an exercise program. He also stated that he is careful of his diet
and avoids consuming fatty meals and prefers high protein foods instead. He
underwent a head surgery back in 2015 as a result of a vehicle accident, but the
procedure has had no negative consequences on his health now. In 2019, he also
had his wisdom teeth removed, and all of the treatments and procedures also went
smoothly. Mr. R.A.S. denies any COVID infection or symptoms, however his wife
contracted the virus and experienced mild symptoms. With this the whole family
follows sanitary measures such as sanitising the home and putting her wife into
isolation. The only drug that Mr. R.A.S. is taking his Multivitamins specifically
Conzace. Since the family is a member of a community, cultivating strong
relationships with others is essential. Since the mother's side of the family came
from the province to the city, the family has developed positive ties with other
neighbours and the community; as a result, the kid likewise cultivates healthy
relationships with other neighbours and the community. The mother stated that it is
critical for the family to develop positive relationships with other neighbours since
when she and her siblings were younger, they were the ones who looked after them
while their parents travelled to the province for work. According to the father, the
community holds events and activities for the entire community, in which the entire
22
family would actively engage. Because the father is a doctor and the mother works in
government, the father and mother would be called to appear on several programs,
especially when the themes are related to health, wellness, business, and
community management.He also claimed that he doesn't want to eat fatty foods.
Instead he prefers to eat foods that are rich in protein, minimise his rice intake and
drink plenty of water since he is overweight. In terms of developmental assessment,
he is presently in adulthood at the age of 50. Because he is a doctor, he describes
himself as nice and personable. He is also a caring individual, particularly toward his
patients and family. In terms of relationships, he gets along well with his wife and
son. Above everything, he prioritises his family. In terms of his lifestyle practises, Mr.
R.A.S. stated that he does not have any vices such as alcoholic addiction or smoking
habits. He also rarely drinks soda and coffee and makes sure to drink plenty of water
everyday. Since the pandemic happened Mr. R.A.S. admitted that he got into a
sedentary lifestyle. Moreover, based on Mr. R.A.S. BMI he is overweight. However,
Mr. R.S.A. is also conscious of his body so he is now slowly building his exercise
routine like jogging in the neighbourhood and doing other cardio exercises, while
making sure to eat a healthy balanced diet. When Mr. R.A.S. was assessed, it was
determined that he has an endomorph body type and has a BMI of 29.3 which was
considered overweight that is due to his sedentary lifestyle for the past months.
Notably, it is also observed Mr. R.A.S. has a sign of distress since he has a laboured
breathing and is bending over. Moreover, it is also observed the use of accessory
muscles to assist in breathing and arms are seen in his lap. However, even when
23
Mr. R.A.S. has seen to have a slight breathing trouble, he can still speak clearly.
Along the arms of Mr. R.A.S. are several normothropic scars, this scars was formed
due to a vehicular accident that he experienced back in 2015. Furthermore, due to
his age Mr. R.A.S. has a presbyopia or the progressive deterioration of your eyes'
capacity to focus on adjacent objects. This condition is considered normal with age
and can be corrected by prescription glasses.
Analysis
The modern era was created to make living simpler. As a consequence,
individuals tend to move less and spend more time sitting than they did before.
Sitting and other sedentary practices may be harmful to one's health (Leech, 2019).
Weight gain and chronic disorders are often caused by inactivity. According to a
study of 464 obese and overweight persons, their average daily sitting duration was
6.2 hours on workdays and 6 hours on non-workdays. The most significant
contribution was work-related chores, followed by watching television (Kubala,
2019). Nonetheless, Mr. R.A.S started making a few simple lifestyle changes, such
as exercising and having a strict diet, making a big difference. Aside from that, the
client has also undergone surgeries that are likely to be successful. Mr. R.A.S's
family was also exposed to the COVID-19 virus as his wife suffered from one. Their
whole family followed safety protocols and sanitary procedures to make themselves
safer. Taking these steps isn't always easy. But they couldn't be more critical. They
24
aid in preventing the virus from infecting you, your family, friends, and neighbors
(Monarch Healthcare, 2019).
Mr. R.A.S. stated that their family has a positive relationship within the
community. He emphasized that they have helped, especially when he and his wife
are not around. According to the Management Study Guide (n.d.), the essential
aspect of a successful relationship is that it contributes to mental tranquility and a
great communal atmosphere. Unnecessary disputes and misunderstandings cause
stress. When stressed, they will never provide their best effort. Building community
ties has many advantages: your organization or school gains name recognition and a
favorable reputation, you are kept informed about local events and community
resources, and your organization's credibility is improved. Mutual respect and
admiration for providing the most pleasing experiences and resources for children is
the key to developing reciprocal connections. Families and early childhood groups
may talk freely and work together to meet each other's needs if they keep this shared
aim in mind (Battista, 2018).
Mr. R.A.S is a sedentary individual. It implies he'll probably fall short of the
national physical activity standards. Adults should receive at least 150 minutes of
moderate-intensity physical exercise each week, according to the government's 2008
Physical Activity Guidelines for Americans Trusted Source (Kandola, 2018). He
began to exercise regularly and adhere to a rigorous diet, though. It could also help
decrease his weight as it affects his health status. Healthy living should be a part of
25
your daily routine. Chronic diseases and long-term illnesses may be avoided by
leading a healthy lifestyle. It is critical for your self-esteem and self-image to feel
good about yourself and take care of your health. Maintain a healthy lifestyle by
following your body's instructions (Foundation for PN, 2021).
Mrs. R.G.S., the mother, tested positive to Covid-19 last August 2020 due to
exposure to an infected colleague in the Department of Agrarian Reform. After
contracting the disease, Mrs. R.G.S. always makes sure that she is fully sanitized
before interacting with her family. She also became critical to her health when she
took the prescribed vitamins and multivitamins, the B complex, Berocca daily, and
Conzace. Also, she became more conscious of what she ate and started avoiding
fatty and high cholesterol foods. The mother makes sure that she exercises at least
once a day in terms of physical activities. Moreover, she was not diagnosed with any
chronic or acute illness/es for the past twelve months. Mrs. R.G.S. weighs 121
pounds and has a height of 152.4 centimeters with a body mass index of 23.7.
According to her diet recall that has been recorded, she eats fried egg, smoked
salmon, broccoli, turkey bacon for her breakfast (3-day-diet recall) and makes sure
to drink at least 3 glasses of water during her breakfast. During her lunch (3-day-diet
recall), Mrs. R.G.S. eats grilled chicken, black beans, grilled salmon, roasted brussel
sprouts and grilled tuna. She mentioned that during her lunch break, she drinks 1
cup of coffee to wake her up. In addition, Mrs. R.G.S always has a snack and eats 1
slice of caramel cake. However, when it comes to her dinner (3-day-diet recall), she
26
eats grilled steak, sauteed chopped carrots with corn, sauteed shrimp, steamed
okra, chicken wings and a bowl of cream of mushroom. Generally, Mrs. R.G.S.
stated that she avoids eating fatty and high cholesterol foods. On a daily basis,
Mrs. R.G.S makes sures that she consumes at least 8 glasses of water every day
and takes her vitamins every morning. In terms of developmental assessment, at the
age of 52, she is currently in the stage of adulthood. Mrs. R.G.S. consider herself as
a strict but not authoritative and when it comes to her parenting style she describes it
as a reasonable parenting and disciplinarian. Since they are having a good
relationship with the people in her community, she offers her help to her
neighbourhood. Even Mrs. R.G.S has a busy schedule because of her work in the
government, she always makes time to bond with her family. Considering that she is
the one who makes decisions for the family, she makes sure that she decides what
is best not only for her but also to her husband and her son. Subsequently, in the
assessment of her lifestyle, she drinks one cup of coffee a day, and eats junk food
occasionally. Moreover, she exercises for 1 hour everyday before going home. In the
physical assessment, the matriarch has presbyopia, wherein her eye grade is within
+125, and compromised it with corrective lenses. Also, her lips were chapped and
dry. Lastly, the client could not hyperextend her finger in the muscle strength of
upper extremities assessment.
Analysis:
27
Mrs. R.G.S is a government employee and she acquired and tested positive
for COVID-19 and has experienced mild symptoms last August 2020 in her work.
Since Mrs. R.G.S works at a government office, she is careful and follows all the
safety protocols that the government is implementing to minimize the risk of getting
infected with COVID-19 virus. According to the Department of Health (2021), people
should still wear face masks, face shields, proper hand washing, physical distancing
and follow the 30% capacity of people in a workplace to minimize the risk of
transmitting and acquiring COVID-19. Therefore, Mrs. R.G.S follows all the safety
protocols to make sure that she will not acquire COVID-19 again to protect her family
also from acquiring and transmitting COVID-19.
Mrs. R.G.S. weighs 121 pounds and 152.4 centimeters in height with a body
mass index of 23.7. According to Dresden (2020), 18.5 to 24.9 BMI is considered
healthy for doctors. Based on the 3-day-diet recall of the client, the client never skips
breakfast, lunch, and dinner. According to the Medical Center (2021), it is healthier to
eat three square meals a day as it gives your body enough time to digest the
consumed food and prevents an individual from overeating. The client has a 3 to 4
hours interval before the next meal, which is good as it prevents bloating and
indigestion (Center for Health Eating and Activity Research, 2020). Moreover, the
client seldomly eats junk food and drinks at least 8 glasses of water a day. According
to the study of Lombard General Insurance Company (2015), not eating junk foods
regularly could lead to weight loss, a healthy heart, stronger bones, sharper memory,
28
and better digestion. Drinking at least 8 glasses a day helps an individual to hydrate
themselves and prevent drying of skin and wrinkles (Mayo Clinic, 2020).
In addition, Mrs. R.G.S is already on the 7th stage (Generativity and
Stagnation) of Erik Erikson;s Psychosocial Development in which people at this age
should have a caring virtue and engagement with the social community. During the
interview, Mrs. R.G.S. mentioned that she has a good relationship with her neighbors
and in fact she allows and offers help to her community. Mrs. R.G.S also mentioned
that she has a good relationship with her family and always makes time for each
other where they watch movies together, travel together, and family cook offs as
their way of showing love and bonding to each other. With all the data that have
been gathered through interview and assessment, Mrs. R.G.S lifestyle approach is
appropriate to her stage of development.
Lastly, Mrs. R.G.S. admitted that she has presbyopia with a grade of +125,
and compromised it with corrective lenses. According to Mayo Clinic (2021),
presbyopia is the gradual loss of the ability of the eyes to focus on surroundings, and
it's a common side effect of ageing. Also, the nurse noted in the physical
examination that the lips of the client were chapped and dry. According to Vann
(2019), exposure to sun could damage the lips which could result in dryness and
peeling of lips.
Mr. R. G. S. 1 is diagnosed with obesity generally caused by poor, excessive
eating habits and physical inactivity. To cope with the inadequate intake of nutrition
29
he religiously takes multivitamins (Conzace) and Berocca daily since he is not critical
of his daily intake. He usually eats friend food, meat & poultry, a big amount of rice,
and oftenly eats vegetables. Moreover, on November 27, 2021 he was diagnosed
with an allergy cough of unknown causes, other than that he was not able to be
infected with COVID-19 and no illness. Upon teleonsulation, the physician prescribed
levocetirizine 5 mg tablet once a day; fluimucil 600mg effervescent tablet once a day.
Also, the patient leads a sedentary lifestyle in which he consumes excessive
amounts of fats and sugar diet but little to no physical activity or exercise. This is
because of his busy schedule, academic priorities, and academic demands. R. G. S.
1 weights 130 kilograms with a height of 5 feet and 7 inches, arm circumference
measured 16 inches, and upon assessing his body mass index (BMI) it resulted with
44.9, indicating his weight is in the Obese category for adults of his height. Also, his
waist and hip circumference is measured and respectively resulting in 139.7 cm and
125.73 cm, as well as his waist–hip ratio (WHR) resulting in 1.11 which translates to
the presence of central obesity. R. G. S. 1 does not follow any dietary restrictions or
is critical of his nutrition and daily intake. According to his diet recall that has been
recorded, he constantly consumes excessively rice, protein, and fatty foods during
breakfast, lunch, and dinner. Meanwhile, in between he constantly consumes
unhealthy food that is high in calories from fat and sugar, with little nutritional value.
However, he consumes 8 glasses of water to stay constantly hydrated with 2
caffeinated beverages everyday and he patient claimed to avoid sugary beverages.
Moreover, Mr. R. G. S. 1 admitted that he has an unhealthy lifestyle wherein he
30
would excessively eat without any physical activity being done. Also, he claims to
have no other healthy lifestyle practices other than religiously consuming
multivitamin supplements. According to him and his parents he had received the
following vaccines: BCG vaccine, Hepatitis B, HB1, HB2, HB3, OPV1, OPV2, OPV3,
DPT1, DPT2, DPT3, AMV, and the COVID-19 vaccine. Furthermore, he only takes 3
to 5 hours of sleep which is insufficient, according to him, and rarely takes rests or
reduces sitting and screen time but when he does it usually takes 30 minutes during
the afternoon since it is the only vacant time he has. This is because he has a busy
schedule with his academics, prioritises his studying time more, and has academic
demands. Moreover, when he has time, he practices relaxation and other stress
management activities such as practicing deep breathing, aroma therapy, reading,
binge watching whenever there is a vacant time. Mr. R. G. S. 1 is keen on using
protective measures, especially when going out because of the COVID-19, he uses
adequate footwear and protective clothing, adequate PPEs face mask, and face
shield, while at home, his house is equipped with screen windows in mosquito-
infested areas, the house is cleaned and disinfected to reduce the presence of
pathogenic microorganism, closed and sealed garbage containers to prevent the
transmission of microorganisms, use of male plug covers to prevent accidents such
as electrocution, and the use of the extra bedroom as an isolation room for illnesses.
Since his parents are active participants in the community, especially when events or
programs are inclined with their profession and career paths, he too is very
participative in community activities along with his childhood friends. He is most
31
especially close with his neighboring childhood friends which is around his age since
they grew up together, play often together when they are kids, and hold a special
bond with. The family is active in participating and organizing health teaching
services, especially with regards to nutrition and diet. Moreover, the family uses
immunization services via the Tandang Sora Barangay Health Center. Also, the
barangay health center is equipped with ambulance service for COVID-19 patients to
be transferred and referred to the nearest accommodating hospital near the are in
which the family used to transfer the mother to a nearby hospital when she was
diagnosed with COVID-19. Since his father is a doctor, he is also keen to follow
through health consultations and instructions given to him, as well as, lifestyle check-
ups such as vices, diet, dental, and medical.
Analysis:
Upon assessing Mr. R. G. S. 1’s BMI, his BMI is 44.9, indicating his weight is
in the obese category for adults of his height since BMI resulting in 30 and above
indicates in the obese category which is a deviation from normal. According to the
CDC (n.d.), for his height, a healthy weight range would be from 118 to 159 pounds.
Obesity is a condition in which the patient accumulates abnormal or excessive fat for
his/her age and gender that exceeds overweight (Doenges et al., 2016). People who
are obese, such as Mr. R. G. S. 1, are at higher risk for chronic conditions such as
high blood pressure, diabetes, and high cholesterol (CDC, n.d.).
32
Weight Height Arm BMI Waist Hip WHR

Circumf Circumf circu
erence erence mfere
nce
Father 90 kg 5’9 ft 13.4 in 29.3 113 cm 99 cm 1.14

(Mr. RA.S.) OW
Mother 55 kg 5’0 ft 11.3 in 23.7 74.2 cm 88.9 0.84

(Mrs. R.G.S.) NRML cm
Son 130 kg 5’7 ft 16 in 44.09 139.7 125.73 1.11

(R.G.S. 1) OB cm cm
VI. Gordon’s 11 A. Health Perception-Health Management
Functional Mr. R.A.S. regards his general health as improving since he is
Health Patterns following strict weight-loss strategies such as proper diet and
regular exercise. He considers health to be an essential aspect of
living a happy life because he is a doctor. However, because of
the pandemic, he has gained weight in recent months. He has
been immunised against the seven target diseases, including the
COVID vaccination. His most recent immunization was a COVID
vaccine booster in November 2021. He is not allergic to anything.
He had surgery in 2015 for a brain injury sustained in a vehicle
accident, and his most recent surgery is a wisdom teeth extraction
in 2019. Both of these procedures are completely cured and pose
no additional complications. The most recent physical examination
33
he has is a head-to-toe physical assessment completed by our
group. He only takes a multivitamin and does not use any
maintenance medication. Furthermore, he is knowledgeable of the
uses of the medicine he is taking. On the other hand, Mrs. R.G.S
rates her general and overall health as 8/10. She did not
experience colds for the past month. She stated that when it
comes to her health, she always makes sure that she is in a
healthy condition since she needs it for work and also for the
pandemic to keep her immune system strong. During the
interview, she mentioned that she was diagnosed with COVID-19
last August 2020. In line with this, she was already vaccinated
against the COVID-19. Even though Mrs. R.G.S. is already
vaccinated, she stated that she still follows safety protocols to
avoid getting infected again. In this case, Mrs. R.G.S. take
necessary actions such as eating healthy foods (vegetables and
fruits) since she is conscious of what she eats. Mrs. R.G.S. also
mentioned that she avoids fatty, high cholesterol food and
exercises thrice a day or when available with intake of plenty of
fluid preferably water and lessens coffee intake from 3 cups a day
to 1 cup only to keep her health in a good condition to effectively
manage her health. In addition, Mrs. R.G.S. is very critical when it
comes to her health and health practices where she takes
34
multivitamins (Conzace), B Complex, and Berocca daily. When it
comes to the exercise of Mrs. R.G.S., she mentioned that as much
as possible she exercised by jogging around their village or she
went to the gym which is located in their workplace. She also
avoids vices such as alcohol and smoking to make her body stay
healthy. While, the patient R. G. S. 1 describes his general and
overall health status as in poor condition regarding the physical
health and needing to be taken care of as the patient’s diagnosis
obesity which is a health risk. The patient did not have any colds
or flu within the last 6 months, but he had an allergic cough on
November 27. The doctor prescribed levocetirizine 5 mg tablet
once a day and fluimucil 600mg effervescent tablet once a day.
The patient takes multivitamin supplements (Conzace) and
multivitamin effervescent tablets (Berocca) twice a day to keep
healthy and prevent vitamin deficiency due to poor diet. He claims
that it is important for him to follow through with this since it makes
a difference with his health and it keeps him in good health.
According to the patient, he does not have vices wherein he does
not smoke, drink alcohol, or take any gateway or illegal
substances. The patient said that he did not have any accidents in
the past 12 months since he only stays at home and sits everyday.
The patient claimed that following through the health regimen,
35
instructions, and suggestions made by any healthcare professional
is important and easy for him to follow and take action. When
asked about his obesity condition, his response was “I lead a poor,
unhealthy lifestyle kgaya lamang ng poor eating habits ko, physical
inactivity which led me to a sedentary lifestyle while having
academic demands and busy schedule also contributed to my
obesity rin.”
Analysis: Normal
B. Cognitive-Perceptual
Mr. R.A.S. must wear prescription glasses due to his age, and his
doctor has advised him to do so. His glasses were replaced in
2019 and are still fitted to his vision needs. Sometimes he has
some hearing difficulties due to his age, especially when the voice
is very distant from him, but he does not use a hearing aid. He has
a great memory and usually never forgets anything. When Mr.
R.A.S. makes critical judgments He's not having a hard time
because he's a highly deliberate man who always plans things out.
He can create sentences and does not have any trouble creating
sentences. He learns best via hands-on teaching or
36
demonstration. Furthermore, he is not currently experiencing any
discomfort or pain in his body. On the other hand, Mrs. R.G.S. has
presbyopia therefore she wears eyeglasses with a grade of +125.
There are no signs of difficulty in hearing as well as loss of taste
experienced. Moreover, when it comes to visual or audio aid, Mrs.
R.G.S. does not have specific preferences. Mrs. R.G.S. also
stated that she feels well and healthy and does not feel any
discomfort or pain as of the moment. In addition, decision making
was not difficult because she always made sure that whenever he
decides for the family she considers all factors that are good for all
the family since she was the one who decides for the family. She
can openly express herself clearly and Mrs. R.G.S. understands
questions easily and the client answers in a well-organized and
well-constructed response. While, the patient R. G. S. 1 claimed
he did not have any hearing disability or problems in the past. He
also claimed that he did not have any visual problems such as
blurred vision, but he said that he was near-sighted and hadn't
gone to an Ophthalmologist to get his eyes checked. According to
the patient, he does not have any problems recalling memory, both
long-term and short-term, or changes in memory lately. The
patient said that he does not have any difficulty making important
decisions, instead it is mildly easy for him to make considering his
37
rational thinking. The patient claimed that he easily learns through
visual learning and through related learning experiences.
However, he has a hard time through auditory learning and online
learning. According to the patient, he had discomfort in the throat
last week due to allergies, diagnosed through teleconsultation. The
physician prescribed levocetirizine 5 mg tablet once a day and
fluimucil 600mg effervescent tablet once a day and he felt better.
Conclusively, all his sensories are functional and aware of his
environment.
Analysis: Deviation from normal
Interpretation:
Noise, age, sickness, and inheritance are all factors that contribute
to hearing problems. As a person grows older, they acquire
presbycusis or age-related hearing loss. It seems to run in families
and is thought to be caused by abnormalities in the inner ear and
auditory nerve. Presbycusis may make it challenging to endure
loud noises and understand what others say, especially when afar
(NIH, 2021).
Presbyopia is the inability of the eye to focus on objects
(Cleveland Clinic, n.d). The part of the eye specifically the lens is
38
not able to focus light on the retina due to aging. Having a
presbyopia is considered to be normal as the person gets older.
(National Eye Institute, n.d). Presbyopia requires eyeglasses or
corrective lenses to aid vision problems Cleveland Clinic, n.d).
Reference:
NIH. (2021, December 03). Hearing Loss: A Common
Problem for Older Adults.
https://www.nia.nih.gov/health/hearing-loss-common-
problem-older-adults
Cleveland Clinic. (n.d.). Eyeglasses: Types of vision
problems, types of
lenses.https://my.clevelandclinic.org/health/articles/8593-
eyeglasses
U.S. Department of Health and Human Services. (n.d.).
Presbyopia. National Eye Institute. Retrieved December 6,
2021, from
https://www.nei.nih.gov/learn-about-eye-health/eye-
conditions-and-diseases/presbyopia.
39
C. Self-Perception-Self-Concept
Mr. R.A.S. considers himself to be warm, serious, and kind. He
also feels good most of the time. He is pleased with his body since
he knows he is getting fitter as a result of his rigorous diet and
exercise regimen. He also enjoys grooming because he is a doctor
who sees a variety of patients on a daily basis. His child breaking
his rule, which is usual for parents, makes him upset, and he also
feels nervous whenever his son arrives home late. He is likewise
afraid of his parents and feels terror anytime his family is under
danger. According to him, he never lost hope since, as a God-
centered person, he always felt that there would be a solution to
every problem. On the other hand, Mrs. R.G.S. describes herself
as a hardworking mother, after having COVID-19 last August
2020, she feels extra careful in going outside to protect herself
from acquiring COVID-19 again. Mrs. R.G.S. also stated that she
noticed that there are no changes happening in her body because
as much as possible she makes sure that her body is in a good
condition. In line with this, Mrs. R.G.S. views her life as well
balanced and stable. While, the patient R. G. S. 1 describes
himself as a focused, ambition-driven person, but also a friendly
and humorous person. Most of the time he feels good about
himself, despite his current health condition. He is comfortable with
40
his body change but it would be better if he would lose some
weight and as often as possible, do some exercises. The patient
claimed to feel angry when tasks are not done with the designated
deadline and disorganization. The patient felt fearful and anxious
with regards to his academic demands since he claimed to be
conscious of his grades and class standing. Most often he does
not feel hopeless since he is said to be a very positive and
optimistic person. However, when he feels hopeless, mostly due to
academic problems, he can easily manage and cope with the
stressful problems.
Analysis: Normal
D. Role Relationship Pattern
Mr. R.A.S. is married and the father of a child. He is the head of
the family; he is also the breadwinner. They are a nuclear family
who lives in one house, and he said that he still has time for them
despite his work in the hospital. He says that his wife fulfills his
responsibilities whenever he is not around. He stated that his wife
usually makes all the decisions in line with this. Moreover, he also
gets along with his child well. He stated that they do not have any
problems in their relationship as all of them are cooperative
41
regarding their roles in the family. Thus, he does not have any
difficulty communicating with other people. On the other hand,
Mrs. R.G.S. was the mother of the nuclear family that is being
assessed. According to her, she was the one who decides for the
family especially when it comes to making decisions and for their
health care. In making the decision, Mrs. R.G.S. considered
herself as strict but not authoritative and described it as a
reasonable parenting and disciplinarian. Mrs. R.G.S. mentioned
that she has a good relationship with Mr. R.A.S (husband) and R.S
(son). When Mrs. R.G.S went home from work, she always made
sure that she was able to talk with R.S (son). Mrs. R.G.S. alo
mentioned that she has a good relationship with her colleagues
where she works. Also, her relationship with the people in their
community (village) is good as she feels belonged. While, the
patient R. G. S. 1 is said to be living with his family and classified
as a nuclear family. Currently, the family does not have family
problems or issues and the family feels more harmonious than
ever brought by the pandemic, according to the patient. However,
when they do have problems they often consult with other relatives
such as grandparents, but they couldn’t manage it. The family
feels restless and anxious when a member is ill and hospitalized,
most especially in severe cases such as the COVID-19 of his
42
mother last August 2020. The patient claimed to have a trusted
circle of friends inside and outside the university in which also his
support group when having problems. He claimed that his is most
often feels supported and wanted by his friends, especially since
the pandemic even though he frequently talks to them since the
start of November. Generally, the patient’s academic performance
goes well even though the demand for academic achievement is
high. The patient claims that his parents have sufficient income to
provide his basic needs and even luxury wants. The patient claims
to be actively participate with the community and is still sociable
with his neighbors even during the pandemic
Analysis: Normal
E. Sexuality-Reproductive
Mr. R.A.S. was not diagnosed with any reproductive issues or
sexual dysfunction. He added that he and his wife continue to
enjoy a very nice sexual life and have no issues during
intercourse. They solely use condoms as a form of contraception,
and he has not had any permanent surgical contraceptive
methods. On the other hand, Mrs. R.G.S. mentioned that she does
43
not experience and there are no signs of problems when it comes
to her reproductive and sexual concerns. Mrs. R.G.S. stated also
that she is sexually active. While, The patient R. G. S. 1 claimed
that he dos not have sexual relationships, changes, or problems
since he is solely focused academically. However, he is sexually
attracted to the same sex, but he is comfortable with his sexuality
and open. The patient said to be not sexually active even before
the pandemic, however, if he would be active he would opt to use
condoms to prevent STDs and HIV infection since he is aware of
the risk of unprotected sexual intercourse.
Analysis: Normal
F. Coping-Stress Tolerance
Mr. R.A.S. admitted that there had been some stressors in his
working environment. He said that he usually does some deep
breathing to relax whenever this happens. He also ensures to
have his leisure time for himself. Aside from that, praying and
communicating with his friends has also become one of his ways
to relieve his stress. According to him, it is also okay to cry to vent
out your emotions and feelings. He emphasized that toxic
44
masculinity should be less of your worry regarding coping
mechanisms. He also said that he handled situations calmly. On
the other hand, Mrs. R.G.S. stated that she has not experienced
any big changes or crises in the past year or two. When Mrs.
R.G.S experienced some challenges, she always talked to her
family to make her feel better because she believed that talking to
them would relax her and be able to focus. Mrs. R.G.S. also
mentioned that she bonds with her family where they watch
movies, family cookouts, and traveling and use it as her coping
mechanism whenever she feels stress about her work. Mrs. R.G.S
is calm most of the time and does not feel any tension. However,
when problems occur, Mrs. R.G.S. handles it well by evaluating
the problem and thinking it carefully, especially when it comes to
her work. When she is stressed about her work, she takes
adequate rest to relax and cope with stress and be able to think
carefully afterwards. Mrs. R.G.S. also practices breathing
techniques and use of aromatherapy to keep her mind free from
stress. In line with this, Mrs. R.G.S. does not take any
medications, drugs, or alcohol to relieve her stress. While, the
patient R. G. S. 1 latest encounter with big changes is when the
pandemic happened and his education is through online learning
which is hard for him. He vented out his problems with his peers,
45
parents, and the guidance counseling of the FEU which was
openly available for me and my time of need. Most of the time the
patient is relaxed on an average day as long as his schedule is
followed in which is most likely will, however, when he is tensed he
practices deep breathing, aromatherapy, and taking his leisure
time to do the thing he wants such as binge watching or reading
which helps him relax, according to the patient. He claimed to
have no vices such as smoking, drinking alcohol, or intake of
illegal medication and substances. The patient said that if he
encounters any big problems in his life he acknowledges it,
realizes that change is good, as much as possible adapt on his
regular schedule, but if he cannot he has his strong support group
to seek advice. Most of the time, when the terms are favorable, he
succeeds and achieves good things, most especially in his
academic demands when he plans it well, according to the patient.
Analysis: Normal
G. Value Belief Pattern
Mr. R.A.S. has several principles in his life; he believes that
while profession and achievement are vital, putting his family first
46
is the most important thing. He also prefers to grind and work hard
the most of the time, with a distinct period for relaxation. He is also
a devout follower of God. According to him, he typically gets what
he wants in life, and he is not overly upset or unhappy when he
does not achieve what he wants. He also has significant future
plans, such as relocating to the United States, planning for
retirement, and taking vacations in Western nations. He's religion
is Islam and prays five times a day. On the other hand, Mrs.
R.G.S. stated that she got the things she has now because she
worked hard for it. If things did not go on what she predicted, she
will just think that maybe it is not yet the right time. The client
shared that she and her family planned on migrating to the United
States and then just enjoy the elderly life through travelling abroad.
Moreover, the client is Islam and she mentioned that religion is
important as it builds her values like love, empathy, and respect.
While, the patient R. G. S. 1 claimed he has everything he wants
and is content but he does sometimes get the things he wants in
life when committed, ambition-driven, getting rid of stagnating
thoughts and distractions, and generally having fun in the process.
However, when he doesn’t he is fine with it since he is content with
what he has now and feels grateful for it. According to the patient,
religion is not that important to him, he believes there is an
47
existence of a prime mover but is not compounded in one religion
or religious interpretation and at times his belief helps when
difficulties arise. According to the patient, receiving medical
attention and treatment does not interfere with his belief system.
Analysis: Normal
H. Nutritional-Metabolic Pattern
Mr. R.A.S. eats three meals per day and eats snacks in the
afternoon. He stated that he usually eats meat and poultry, fish,
and vegetables on his meals. He also said that he always eats
rice. He prefers to eat food that is high in proteins. He does not
experience swallowing difficulties or discomfort. Thus, the patient
has diet restrictions. He avoids eating fatty, high in cholesterol,
and oily foods. He also does not eat pork due to religious beliefs.
He is also not fond of eating sweets. He always drinks water for
about eight to eleven glasses daily. He also said that she drinks a
cup of coffee every lunchtime. The patient said that he had gained
weight for the past months. There are no issues regarding the
condition of his skin, teeth, hair, and nails. Allergies are not also
48
prevalent.
3 Day Diet Recall
Wednesday Thursday Friday
Breakfast 2 fried egg 1 egg omelette; 3 pcs of turkey
whites; 1 cup 1 cup of rice; bacon; 1 cup of
rice; 1 piece of sauteed rice; 2 hard
25g smoked broccoli; 3 boiled eggs; 3
salmon; glasses of glasses of
asparagus; 3 water water
glasses of
water 7:30 am-8:00 7:30 am-8:00

am am
7:30 am-8:00
am
Snacks None None None
Lunch 2 pcs grilled 1 piece of 25g 1 pc 30g grilled
chicken breast; grilled salmon; tuna; 1 cup of
1 cup rice; roasted brussel rice; 3 glasses
black beans; 3 sprouts; 1 cup of water; 1 cup
glasses of of rice; 3 coffee
water and 1 cup glasses of milk;
49
of coffee 1 cup of coffee 12:00 pm-12:30
pm
12:00 pm-12:30 12:00 pm-

pm 12:30 pm
Snacks 30 g roasted 30 g roasted 30 g roasted

peanuts peanuts peanuts
Dinner 1 pc grilled Sauteed 2 pcs of roasted
steak; 1 cup of shrimp; 1 cup chicken breast;
rice; sauteed of rice; 1 cup of rice; 1
chopped steamed okra; bowl of cream
carrots with 3 glasses of of mushroom
corn; 4 glasses water soup; 4 glasses
of water of water
7:00 pm-7:30
pm
7:00 pm-7:30 7:00 pm-7:30
pm pm
Analysis: Normal
Mrs. R.G.S. mentioned that she never skips the three important
meals: breakfast, lunch, and dinner. She also stated that she is
taking supplements and vitamins consulted by a doctor, namely
multivitamins (Conzace), B complex, and Berocca daily. The client
50
admitted that she started taking those prescribed supplements and
vitamins after contracting a covid last 2020. Moreover, she does
not have a food restriction, but she avoids fatty and high
cholesterol food as much as possible. In terms of her water intake,
she usually drinks eight to ten times a day together with one cup of
coffee in the afternoon.
Breakfast 7:30 am to 7:30 am to 7:30 am to
8:00 am: 8:00 am: 8:00 am:
1 fried egg; 1 1 egg 3 pcs of turkey
cup rice; 1 omelette; 1 bacon; 1 cup
piece of 25g cup of rice; of rice; 2 hard
smoked sauteed boiled eggs; 3
salmon; broccoli; 3 glasses of
asparagus; 3 glasses of water
glasses of water
water
Snacks None None None
51
Lunch 12:00 pm to 12:00 pm to 12:00 pm to
12:30 pm: 12:30 pm: 12:30 pm:
2 pcs grilled 1 piece of 25g 1 pc 30g
chicken grilled salmon; grilled tuna; 1
breast; 1 cup roasted cup of rice; 3
rice; black brussel glasses of
beans; 3 sprouts; 1 cup water; 1 cup
glasses of of rice; 3 coffee
water and 1 glasses of
cup of coffee water; 1 cup of
coffee
Snacks 3:00 pm to 3:00 pm to 3:00 pm to
4:30 pm: 4:30 pm: 4:30 pm:
1 slice of 1 slice of 1 slice of
caramel cake caramel cake caramel cake
Dinner 7:00 pm to 7:00 pm to 7:00 pm to
7:30 pm: 7:30 pm: 7:30 pm:
52
1 pc grilled Sauteed 2 pcs of
steak; 1 cup of shrimp; 1 cup roasted
rice; sauteed of rice; chicken wings;
chopped steamed okra; 1 cup of rice; 1
carrots with 3 glasses of bowl of cream
corn; 4 water of mushroom
glasses of soup; 4
water glasses of
water
Snacks None 11:00 pm to None
11:30 pm:
Burger and
fries
Analysis: Normal
The patient R. G. S. 1 recalled his typical daily food intake wherein

he consumes high amounts of food which are usually high in
calories, sugar and fat, and oily food such as fried food. He takes
multivitamins (Conzace) and multivitamin effervescent tablets on a
daily basis to cope with the inadequate nutrient intake. He claimed
that he consumes water primarily and lessens his intake of sugary
53
beverages. In the past year he gained weight about 30 kg wherein

his last recall of his weight was last December 2020 measuring
100 kg while this December 2021 it measured 130 kg. Meanwhile,
he did not gain nor lose height, he sustained his 5 feet and 7
inches height, according to the patient. The patient claimed to
have a big appetite since he had excessive hunger from time to
time. He does not have any food discomfort when chewing or
swallowing or even dietary restrictions. He claimed that his
wounds heal well. He does not have any skin problems, any
lesions, or dryness. The last dental problem he had was when his
wisdom teeth emerged last 2019 but he underwent wisdom teeth
extraction in the same year.
Breakfast 2 fried egg; 3 1 egg 3 pcs of

cup rice; 3 pcs omelette; 1 turkey bacon;
of fried cup of rice; 1 cup of rice;
hotdogs; sauteed 2 hard boiled
asparagus; 3 broccoli; 3 eggs; 3
glasses of glasses of glasses of
water; 1 cup of water; 1 cup of water; 1 cup
coffee coffee of coffee
9:00 am-9:30 9:00 am-9:30 9:00 am-9:30

am am am
Snacks 1 bag of fried 1 slice of 1 BLT

potato chips; 1 caramel cake; sandwich; 1
54
cup of coffee 1 cup of coffee cup of coffee
Lunch 3 pcs grilled 2 piece of 25g 2 pc 30g

chicken breast; grilled salmon; grilled tuna; 3
2 cup rice; 3 roasted cup of rice; 3
glasses of brussel glasses of
water and 1 sprouts; 3 cup water; 1 cup
cup of coffee of rice; 3 coffee
glasses of
1:30 pm-2:00 milk; 1 cup of 1:30 pm-2:00
pm coffee pm
1:30 pm-2:00
pm
Snacks 1 slice of 1 1 bag of fried

caramel cake; potato chips;
1 cup of coffee 1 cup of
coffee
Dinner 2 pc grilled Sauteed 2 pcs of

steak; 3 cup of shrimp; 2 cup roasted
rice; sauteed of rice; chicken leg &
chopped steamed okra; thigh; 3 cup
carrots with 3 glasses of of rice; 2
corn; 4 glasses water bowl of
of water cream of
7:00 pm-7:30 mushroom
7:00 pm-7:30 pm soup; 4
55
pm glasses of
water
7:00 pm-7:30
pm
Snacks 10 pc fried Burger and 5 pcs of

chicken fries grilled hotdog
nuggets
11:00 pm 11:30 pm
12:00 am
Analysis: Deviation from Normal
Interpretation:
According to Manoogian et al., (2019), the quantity and quality of
the food that we eat is vital for the aspect of healthy eating habits.
Also, optimizing meal time offers considerable health advantages
and has tremendous potential for future lifestyle treatments.
References:
Manoogian, E. N. C., Chaix, A., & Panda, S. (2019). When to Eat:
The Importance of Eating Patterns in Health and Disease. Journal
of Biological Rhythms, 34(6), 579–581.
https://doi.org/10.1177/0748730419892105
56
I. Elimination Pattern
Mr. R.A.S. urinates at least three to five times in total. Every day,
roughly 2000mL of urine is excreted. He has no experience of any
urination discomfort, an unusual odor in his urine, or any blood.
Moreover , he defecates at least twice each day. He also does
not feel any discomfort when defecating. He is not using any
laxative. On the other hand, Mrs. R.G.S. stated that she defecates
once or twice a day, depending on the amount of food she took
that day. She also mentioned that the color of her eliminated bowel
is usually brown, shaped like a sausage, and added with an
unpleasant smell. In addition, she stated that she does not have
any problem controlling her bowel elimination or experiencing
discomfort while eliminating. In terms of her urine elimination, Mrs.
R.G.S. mentioned that she urinates around eight times a day,
depending on her water intake. She indicated that the usual color
of her urine is white with no odor, no problem in control, and no
discomfort. Moreover, Mrs. R.G.S. stated that she only sweats
excessively whenever she performs strenuous exercises. While,
the patient R. G. S. 1 recalled his bowel elimination pattern
wherein he defecates twice a day, eliminating semi-solid and
brown in color feces, but he does not have any problems
defecating such as feel of pain or discomfort, also he does noy
have any problems controlling his bowel elimination. Meanwhile, in
urination, he often urinates six times in a day, does not feel pain or
discomfort while urinating, and has control over his bladder and
urination. According to the patient, he often prespirate excessively
but does not have odor problems since he takes a shower as often
as possible and wears deodorant.
57
Analysis: Normal
J. Activity-Exercise Pattern
Mr. R.A.S. spends most of his time in the hospital. He does rounds
and does surgeries according to his schedule. He said that his
duty starts at 8 am and ends at 5 pm. After that, he spends his
time with his family. He said that he also has a strict exercise
schedule during the weekdays. He uses the weekends as his
leisure time. Moreover, his activities are appropriate for his age.
6:00 am Wake up , Get Wake up , Get Wake up , Get

ready for work ready for work ready for work
7:00 am Eat breakfast, Eat breakfast, Eat breakfast,

Travel to work Travel to work Travel to work
8:00 am - Work Work Work

12:00 pm
12:00 pm - Lunch Lunch Lunch

1:00 pm
1:00 pm- 5:00 Work Work Work

pm
5:00 - 6:00 pm Go home from Go home from Go home from

work, work, work,
6:00 pm - 7:00 Exercise Exercise Exercise

pm
7:00 pm Dinner Dinner Dinner
9:00 pm Sleep Sleep Sleep
58
Analysis: Normal
On the other hand, Mrs. R.G.S. works as a government employee
in the Department of Agrarian Reform. The client worked from 8 in
the morning to 5 in the afternoon every Monday to Friday. Despite
her busy schedule from work, she never misses exercising. She
mentioned that she usually exercises around 5 pm to 6 pm before
going home. On weekends, Saturdays and Sundays, she
exercises thrice a day. Moreover, she added that she exercises at
the gym or inside the home’s village.
6:00 am Woke up and Woke up and Woke up and
gets ready for gets ready for gets ready for
work work work
7:00 am Ate breakfast Ate breakfast Ate breakfast
8:00 am Start of work Start of work Start of work
12:00 pm Ate lunch Ate lunch Ate lunch
3:00 pm Ate snacks Ate snacks Ate snacks
5:00 pm End of work, End of work, End of work,
start start start
59
exercising exercising exercising
6:00 pm Went home Went home Went home
7:00 pm Ate dinner Ate dinner Ate dinner
10:00 pm Sleep Sleep
11:00 pm Ate snack
12:00 pm Sleep
Analysis: Normal
While, The patient R. G. S. 1 claimed that he had the energy and

motivation to do all his activities, both desired and required. Also,
due to his busy schedule and academic demands he is unable to
exercise and lead a sedentary lifestyle. During his spare time, he
spends the time sleeping or resting, binge watching, and reading
because most of the time he doesn’t fully sleep or rest and has a
small amount of time for leisure activities. According to the patient,
he is fully capable and independent of full self-care activities such
as feeding, bathing, toiliting, dressing, grooming, general mobility,
cooking, shopping, bed mobility, and home maintenance.
9:00 am Wake up Wake up Wake up
60
9:30 am Breakfast Breakfast Breakfast
10:00 am - Attend to Attend to Attend to

12:00 am school; Eat school; Eat school; Eat
Snacks Snacks Snacks
12:30 pm Lunch Lunch Lunch
1:00 pm - 5:00 Attend to Attend to Attend to

pm school; Eat school; Eat school; Eat
Snacks Snacks Snacks
5:00 pm - 7:00 Self-study Self-study Self-study

pm
7:00 pm Dinner Dinner Dinner
8:00 pm - Self-study Self-study Self-study

12:00 am
12:00 am Midnight Midnight Midnight

snacks snacks snacks
1:00-4:00 am Self-study Self-study Self-study
4:00 am Sleep Sleep Sleep
Interpretation:
According to Park et al., (2020), Sedentary behaviors have a wide
range of negative effects on the human body, including increased
all-cause mortality, cardiovascular disease mortality, cancer risk,
and risks of metabolic disorders such as diabetes mellitus,
hypertension, and dyslipidemia; musculoskeletal disorders such as
arthralgia and osteoporosis; and musculoskeletal disorders such
as arthralgia and osteoporosis.
61
References:
Park, J. H., Moon, J. H., Kim, H. J., Kong, M. H., & Oh, Y.
H. (2020). Sedentary Lifestyle: Overview of Updated
Evidence of Potential Health Risks. Korean journal of family
medicine, 41(6), 365–373.
https://doi.org/10.4082/kjfm.20.0165
K. Sleep-Rest Pattern
Mr. R. A. S. He gets roughly 8-9 hours of sleep every day,
especially on weekdays when he needs to work in the hospital. He
normally goes to bed around 9 p.m. and gets up around 5-6 a.m.
He sleeps without interruptions and ensures that his room is dark
and cool enough for him to get a decent night's sleep. He hasn't
used any sleeping drugs since and sleeps naturally whenever he
wants. He frequently takes naps in the afternoons when he gets a
break from work, and he normally feels refreshed when he wakes
up after a nap. On weekdays, he works out three hours before
bedtime. Mrs. R.G.S. stated that she often completed an eight-
hour sleep. She always slept around 10 pm and woke up around 6
am to work. She added that she did not have sleeping difficulties
since she was tired once she reached the bed. Also, the client did
not have insomnia, did not take medicines or remedies to sleep,
and did not have any sleeping interruptions. The client admitted
that she had happy dreams about her family and friends for the
past few days. Lastly, the client stated that she felt refreshed and
energized after waking up.
Analysis: Normal
62
While the patient R. G. S. 1 claimed that he does not get enough

sleep even since he only sleeps for 3 to 5 hours and feels tired
and restless after sleeping and not ready for his daily activities.
Though he doesn’t have any sleep onset problems or early
awakening, to help him sleep faster he needs a humidifier, aroma
diffuser, and little to no lit light. He rarely has nightmares and his
dreams are generally positive. During weekdays he rarely has
rest-relaxation periods because of academic demands and busy
schedules while on weekends he slightly has rest-relaxation
periods but prioritizes his academic demands.
Interpretation: According to Medic et al., (2017) Circadian rhythm

disruption and sleep deprivation have been proven to promote
tumor formation12 and may raise cancer risk. 12,92 Exposure to
light at night reduces melatonin synthesis, which may result in
increased production of reproductive hormones.
References: Medic, G., Wille, M., & Hemels, M. E. (2017). Short-

and long-term health consequences of sleep disruption. Nature
and science of sleep, 9, 151–161.
https://doi.org/10.2147/NSS.S134864
63
V. Values, Habits, Practices on Health Promotion, Maintenance and
Disease Prevention.
The family members had already completed their immunizations, namely BCG
vaccine, Hepatitis B, HB1, HB2, HB3, OPV1, OPV2, OPV3, DPT1, DPT2, DPT3,
AMV, and the COVID-19 vaccine. Regarding COVID-19 vaccinations, the family
stated that they do not have any beliefs that could make them hesitant against the
COVID-19 vaccines. Also, the family does not have any healthcare culture, customs,
or beliefs. As a result, they go to the hospital and seek medical advice from doctors
whenever they suffer from any symptoms or illnesses.
When it comes to the family’s rest and sleep pattern, the father and mother
sleep around 9 to 10 pm and wake up at 5 to 6 am. Thus, they usually complete an
8-hour sleep. However, their son, Mr. R.G.S. 1, sleeps at 4 am because of school
work, wherein he finishes it around that time and wakes up at 9 am to attend the
class.
While sleeping, all family members are comfortable and relaxed, with
adequate ventilation to get them through the night. Moreover, the family does not
forget to have enough rest every weekend, especially Sunday, and sometimes
spend it individually or with the family as a reward for getting through the week. Their
usual bonding is watching movies or browsing using their phones and other devices
64
as a family. Whenever they are free individually, especially the mother and the
father, they exercise while the child, Mr. R.G.S. 1, sleeps.
On a daily basis, the father and mother work as doctors and government
employees while the child attends online classes and does schoolwork. When asked
what makes them happy as a family, they replied that watching a movie together is
their type of family bonding, making them happy and content. While as an individual,
getting an adequate rest makes them relaxed.
Even though the house is neatly swept and mopped, the family members still
wear slippers inside the house to protect their feet from unexpected glass breakage
or any infectious foot diseases. The mother and the father take multivitamin
supplements such as Conzace, B Complex, and Berocca daily when it comes to
medication. While Mr. R.G.S. 1, the son, takes Conzace and Berocca daily to cope
with the inadequate nutrition intake since he is not critical of his daily intake. They
take paracetamol for fever, levocetirizine for allergies, fluimucil for dry cough, and
seek consultation for other illnesses whenever they are sick. The family does not use
herbal plants; instead, they opt for over-the-counter pharmaceuticals prescribed by
the doctor. Moreover, the family does not have maintenance medication.
Analysis:
A normal sleep hour of a person should be at least seven (7) or more hours of
sleep every night (Centers for Disease Control and Prevention). Most people sleep
65
less than 7 hours because of jobs, school work and other factors. Some people are
productive at night which allows them to stay up all night and it might end in not
getting enough sleep or being sleep deprived. Sleep deprived means not acquiring
enough sleep (Cedars Sinai, n.d.). When it comes to Mr. R.G.S (father) and Mrs.
R.A.S (mother) sleeping pattern, they stated that they usually sleep around 9:00 to
10:00 pm every night and they usually wake up around 5:00 to 6:00 am to prepare
for work. According on what Mr. R.G.S and Mrs. R.A.S have stated they are getting
enough sleep,having 8 hours of sleep every night which is considered to be a normal
hours of sleep for adults. On the other hand, Mr. R.G.S 1 (son) mentioned that he
only sleeps 4:00 in the morning and wakes up around 9:00 in the morning to attend
his class. Generally, Mr. R.G.S 1 only sleeps 5 hours a day, which is considered to
be a deviation from normal. The amount of sleep that Mr. R.G.S 1 is getting is not
enough for him to function well in everyday activities. Sleep deprivation can affect
various aspects of health such as the person’s immune system, where it is
responsible for protecting people from getting diseases and illness (Davis, 2020).
Having a weak immune system can cause a person to be more prone and
susceptible for diseases such as diabetes. In addition, sleep deprived people also
are prone to weight gain which may result to being obese and overweight that can
cause also cardiovascular diseases (Pullen and Davidson, 2021).
When it comes to the rest pattern of the family, Mr. R.G.S and Mrs. R.A.S
stated that they have an adequate rest because they need it for their work especially
66
Mr. R.G.S who is a Doctor. On the other hand, Mr. R.G.S 1 mentioned that he does
not have time to rest because of his school work. Having no rest can cause stress
and it will build up, and too much stress can cause anxiety (Sinrich, 2019).
The Saludsong family has a great relationship with each other wherein they
provide enough quality time for each other especially on weekends. Even though the
family’s house is always cleaned and mopped, they still wear slippers inside their
house just to give an added protection to their feet.
In terms of how the family maintains their health, all of the family members
drink their multivitamins such as Conzace, Berocca and B Complex. Drinking
multivitamins can help boost your immune system in order for your body to fight and
protect from disease and illnesses, in addition it also improves mood and provides
enough energy for daily activities (Unilab, n.d.). In addition, the family does not use
medicinal plants instead they always go to the hospital if they experience signs and
symptoms of the disease. Moreover, the family does not have maintenance
medication.
References:
Davis, K. (2020, July 23). Sleep deprivation: Causes, symptoms, and treatment.
Medical and health information.
https://www.medicalnewstoday.com/articles/307334
67
Pullen, C., & Davidson, K. (2021, November 9). 6 ways sleep may help you lose
weight. Healthline. Retrieved December 9, 2021, from
https://www.healthline.com/nutrition/sleep-and-weight-loss.
Sinrich, J. (2019, July 16). 5 rest day mistakes to avoid on your next day off from the
gym. Aaptiv. Retrieved December 9, 2021, from
https://aaptiv.com/magazine/rest-day-mistakes.
Unilab.com.ph. (n.d.). Retrieved December 9, 2021, from
https://www.unilab.com.ph/articles/5-benefits-of-taking-multivitamins-daily.
68
VI. PHYSICAL ASSESSMENT
A. PATRIARCH (MR. R.G.S)
GENERAL SURVEY
AREA TO BE NORMAL ACTUAL FINDINGS INTERPRETATION

ASSESSED FINDINGS
Observe for No distress The client is bending over The findings are
signs of noted. because of labored DEVIATION FROM
distress in breathing. NORMAL since the
posture or client is unable to breathe
facial appropriately. Breathing
expression pattern disruption is
further exacerbated by
poor posture. The rib
cage's capacity to extend
is limited, causing
individuals to breathe
more quickly and
shallowly (Marcin,
2020).
Observe body Proportionate, Using a height chart and a The findings are
build, varies with weighing scale, the actual DEVIATION FROM
height, and lifestyle findings are: Height: 175 NORMAL since the
weight in cm Weight: 90 kg client's BMI is 29.3
relation to the Active Age: 52 years old which indicates
client’s Health: overweight overweight. Being
age, lifestyle, (Endomorph) overweight is a precursor
and health to obesity (Tolliver
2019).
Observe client’s Relaxed, erect The client has poor posture, The findings are
posture and gait, posture, but his walk is well- DEVIATION FROM
standing, sitting, coordinated balanced. Gait is also NORMAL even if the
and walking. movement rhythmic and coordinated. client moves normally
and is relaxed since he
has a bad posture.
(Kozier et. al, 2004, pg.
532)
Observe client’s Clean, neat. The client is clean and neat. The findings are
overall hygiene He is well-dressed and NORMAL which means
69
and grooming well-groomed as well. that the client is not dirty

Moreover, his clothing is or unkempt to look at.
appropriate for the Also, he does not dress
situation. inappropriately (Kozier
et. al, 2004, pg. 532).
Note body and No body/ The client has no foul body The findings are
breath odor. breath odor or or breath odor. NORMAL which means
minor body that the client shows no
odor relative signs of foul body odor,
to work or ammonia odor, acetone
exercise. breath odor, or foul
breath (Kozier et. al,
2004, pg. 532)
Note obvious Healthy The client has labored The findings are
signs of health appearance. breathing and has trouble DEVIATION FROM
or illness. with his airway. But he can NORMAL since the client
speak clearly. shows signs of weakness,
or obvious illness. (Kozier
et. al, 2004, pg. 532)
Assess the Cooperative. The client responds to all of The findings are
client’s attitude. the things the examiner NORMAL which means
says and asks him. He has that the client shows no
been comfortable and signs of being hostile,
cooperative, and thus, has negative,or withdrawn
been awake and alert within the situation
during the assessment. (Kozier et. al, 2004, pg.
532).
Note the Appropriate to The client has been The findings are
client’s the situation. responding appropriately to NORMAL which means
affect/mood; the situation and question . that There is no
assess the Hence, his mood is pleasant inappropriateness to the
appropriateness and calm. client’s mood/behavior,
of the client’s and thus, his
responses mood/behavior is age
appropriate (Kozier et. al,
2004, pg. 532).
Listen for Understandable The client is well-spoken. The findings are

quantity, moderate pace, Hence, he has an organized NORMAL which means
quality, and exhibits thought and logical pattern of the client neither shows
organization of association. thoughts. Also, he talks rapid or slow pace, overly
70
speech clearly and at a moderate loud or soft voice, nor

pace. lacks association (Kozier
et. al, 2004, pg. 532)
Inspect skin Varies from The client has a deep The findings are
color light to deep brown or rich skin color NORMAL which means
brown, from with no unusual or that the client does not
ruddy pink to prominent discolorations. show Pallor, Cyanosis,
light pink. Jaundice nor Erythema
538).
Inspect Generally The client has a uniformed The findings are

uniformity of uniform deep brown skin color NORMAL which means
skin color. except in areas except in areas exposed to that the client does not
exposed to sun. have any areas of
sun; areas of hyperpigmentation or
lighter hypopigmentation
pigmentation (Kozier et. al, 2004, pg.
in dark 538).
skinned
Inspect, palpate, Freckles, some The client has visible The findings are
and describe birthmarks, normotrophic scars present DEVIATION FROM
skin lesions. some flat and in both of his upper arm NORMAL which means
raised nevi, no due. that There are visible
abrasion or normotrophic scars from
other lesion. the injury of the patient
in the past 6 years.
According to Safonov, l.
(2012) most of the
normotrophic scars result
from the reaction of the
human body to past
injury.
Observe and Moisture in The client’s skin is smooth The findings are
palpate skin skin folds and and even. His skin is dry but NORMAL which means
moisture. the axillae, well moisturized on the that the client shows no
affected by upper and lower extremities signs of excessive
different moisture or dryness on
factors. his skin (Kozier et. al,
2004, pg. 539).
Palpate skin Uniform; The client’s skin The findings are
71
temperature. within normal temperature on his upper NORMAL which means

range. and lower extremities are that the client shows no
slightly warm but it is still signs of generalized or
within the normal range. localized hypothermia or
hyperthermia (Kozier et.
al, 2004, pg. 539).
Palpate to No edema. The client has no present The findings are

assess for edema on his upper and NORMAL which means
presence of lower extremities. that the client shows no
edema. signs of indentation when
his extremities are
pressed (Kozier et. al,
2004, pg. 538).
Palpate to When pinched, The client’s skin springs The findings are
assess for skin skin springs back immediately to its NORMAL which means
turgor. back to previous state when it is that the client shows no
previous state pinched and lifted. sign of skin tenting.
Hence, his skin is well-
hydrated and mobile with
elasticity (Kozier et. al,
2004, pg. 539).
Inspect the Evenly The client’s hair is The findings are

evenness of distributed symmetrical which means NORMAL which means
growth over the hair it is evenly distributed over that the client has no
scalp. the scalp. excessive hair thinning,
meaning There were no
patches seen (Kozier et.
al,2004, pg. 541).
Inspect hair Thick hair. The client’s hair is thick. The findings are
thickness or NORMAL which means
thinness. that the client has no
excessive hair thinning
541).
Inspect hair Silky, resilient The client's hair is still The findings are
texture and hair silky and resilient. NORMAL which means
oiliness that the client has neither
excessively oily or dry
hair (Kozier et. al, 2004,
pg. 541)
72
Note presence No infection or There were no infections or The findings are

of infections or infestation. infestations seen on the NORMAL which means
infestations. scalp of the client, along his that the client shows no
hairline at the neck, and signs of flaking, sores,
behind his ears. Also, his lice, nits, and ringworms
scalp is clean and dry. (Berman et. al, 2016).
Inspect amount Variable. The client has visible body The findings are
of body hair. hair on both of his upper NORMAL which means
and lower extremities. that the client has no
excessive body hair,
meaning There is just a
variable amount of body
hair (Kozier et. al, 2004,
pg. 541).
Inspect Convex The fingernails and toenails The findings are

fingernail plate curvature; of the client are clean and NORMAL which means
shape. angle between well groomed. Both of his that the client has no
nail and nail fingernails and toenails are spoon-shaped or
bed usually round and have a convex clubbing nails (Kozier et.
160 degrees. curvature. Hence, There is al, 2004, pg. 543)
a 160 degree angle between
its nail base and the skin.
Inspect Highly Both fingernails and The findings are

fingernail and vascular and toenails of the client have NORMAL which means
toenail bed pink in light pink tones bed color since the client has no bluish
color skinned; dark his overall skin color is purplish, or pale nail
skinned may light color (Kozier et. al, 2004,
be brown or pg. 543).
black.
Inspect tissues Intact There were no visible The findings are

surrounding epidermis. hangnails on the proximal NORMAL which means
nails and lateral nail folds. the client has no
hangnails, paronychia, or
koilonychias (Kozier et.
al, 2004, pg. 543)
Palpate Smooth The nails of the client are The findings are
fingernail and texture. smooth and firm. His nail NORMAL which means
toenail texture. plates are firmly attached to the client has no
the nail beds. excessively thickness or
thinness of the nails nor
73
presence of grooves or
furrows; Beau’s line
543)
Perform blanch Prompt return There was a prompt return The findings are
test of capillary or pink or of the pink tone to the nail NORMAL which means
refill. usual color, bed when the nails of the that the client’s capillary
less than two client were pressed for a refill has no delayed
seconds. test of capillary refill. return of pinkish or
natural color (Kozier et.
al, 2004, pg. 543).
B. Measurements (Height, Weight, BMI, Vital signs)

MEASUREMENT OF THE BODY
ASSESSMENT MEASUREMENT
Height 5’2” (158 cm)
Weight 63.6 kgs (139.92 lbs)
BMI 25.5
Vital Signs BP: 110/70 mmHg

RR: 20 breaths/min
PR: 72 bpm
Temperature: 36.7
C. Head - Toe Assessment (Cephalo-caudal)
HEAD TO NECK
HEAD
74
INSPECTION Inspect the

Head size The head of the The findings are
head. and shape client is round, NORMAL which means
vary, erect, and midline. that the client is
especially in His head is normocephalic and has a
accord with appropriate in symmetrically round head
ethnicity. relation to his body with frontal, parietal, and
Usually the size. Also, There occipital prominences.
head is are no involuntary Thus, the client’s head is
symmetric, movements, and still and upright (Kozier
round, erect, thus, no lesions are et. al, 2004, pg. 544)
and in visible as well.
midline and
appropriately
related to
body size
(normocepha
lic). No
lesions are
visible.
INSPECTION Inspect the face The face is The client’s face is The findings are
symmetric round. There are NORMAL which means
with a round, also no abnormal that the client has a
oval, movements seen on symmetrically round face
elongated, or his face. Moreover, with symmetric facial
square his skin condition movements (Kozier et. al,
appearance. shows no signs of 2004,pg. 545).
No abnormal lesions or
movements abnormalities.
noted.
PALPATION Palpate the The head is The client’s head is The findings are
head normally hard and smooth. NORMAL which
hard and Thus, There are no means that the client’s
smooth, lumps, bumps, or head is smooth and
without protrusions. uniformly consistent.
lesions. There is an absence of
nodules or masses. Hence,
There are no sebaceous
cysts or local deformities
from trauma (Kozier et.
al, 2004, pg. 544)
PALPATION Palpate the The temporal The client reports The findings are
temporal artery artery is no pain on his NORMAL which means
elastic and temporal artery. that the client has an
75
not tender. elastic and non-tender

temporal artery upon
palpation (Weber et. al,
2018, pg. 291)
PALPATION Palpate the Normally The client can The findings are
temporomandib There is no open and close NORMAL.
ular joint swelling, his mouth without The client can move
(TMJ). tenderness, any problem. He his
or crepitation can also move his mouth open and close
with lower jaw without
movement. smoothly and any problem. No
Mouth opens controlled. indication of
and closes swelling,
fully (3 to 6 tenderness,,
cm between crepitation that may
upper and indicate
lower teeth). TMJ syndrome (Weber
Lower jaw et. al,
moves 2018, pg. 291)
laterally 1 to
2 cm in each
direction.
NECK
INSPECTION Inspect the Neck is The neck of the The findings are
neck. symmetric, client is symmetric NORMAL which means
with the head with head centered. that the client’s neck is
centered and Also, There are no symmetric with head
without bulging masses centered and with no
bulging seen. bulging masses (Weber et.
masses. al, 2018, pg. 291).
INSPECTION Inspect The thyroid As the client The findings are

movement of cartilage, swallows, his NORMAL which means
the neck cricoid thyroid and cricoid that the neck structures of
structures. cartilage cartilage move the client move upward
moves upward smoothly and
upward symmetrically. symmetrically (Weber et.
symmetricall al, 2018, pg. 292).
y as the client
swallows.
76
INSPECTION Inspect the C7 (vertebrae The C7 of the The findings are

cervical prominence) client is visible and NORMAL which means
vertebrae. is usually palpable. that the C7 of the client is
visible and free of prominence or
palpable. swellings (Weber et. al,
2018, pg. 292).
INSPECTION Inspect range Normally The neck The findings are

of motion. neck movement of the NORMAL which means
movement client is smooth that the client has
should be and controlled with coordinated, smooth
smooth and 45 degree flexion, movements with no
controlled 55 degree discomfort. His head
with 45- extension, 40 flexes 45 degrees, it
degree degree lateral hyperextends 60 degrees,
flexion, 55- abduction, and 70 it laterally flexes 40
degree degree rotation. degrees, and it rotates 70
extension, degrees (Kozier et. al,
40-degree 2004, pg. 568)
lateral
abduction,
and 70-
degree
rotation
PALPATION Palpate the Trachea is The trachea of the The findings are
trachea midline. client is midline NORMAL which means
that the client’s trachea
has a central placement in
the midline of the neck
and the spaces are equal
on both sides (Kozier et.
al, 2004, pg. 569).
PALPATION Palpate the Landmarks The landmarks of The findings are

thyroid gland. are the thyroid gland NORMAL which means
positioned are positioned that the gland of the client
midline. midline. Also, his ascends during
Glandular lobes are smooth swallowing and the lobes
thyroid tissue and free of are smooth, centrally
may be felt nodules. located, painless, and rise
rising freely with swallowing
underneath (Kozier et. al, 2004, pgs.
your fingers. 569-570).
77
Lobes should
feel smooth,
rubbery, and
free of
nodules.
PALPATION Palpate the There is no There is no The findings are
lymph nodes swelling or swelling or NORMAL which means
enlargement enlargement and no that the client has no
and no pain felt on the swelling or enlargement
tenderness. lymph nodes of the and no tenderness on his
client. lymph nodes (Weber et.
al, 2018, pg. 295).
EYES
DISTANT Test distant Normal The client’s distant The findings are
VISUAL visual acuity distant visual visual acuity are as NORMAL which means
ACUITY acuity is follows: OD (right that the client can
TEST 20/20 with or eye) – 20/45 OS distinguish what the
without (left eye) – 20/45 person with normal vision
corrective OU (both eyes) – can distinguish from 20
lenses. This 20/20 Note: with feet away unless he is not
means that corrective lenses wearing his corrective
the client can lenses (Weber et. al,
distinguish 2018, pg. 317).
what the
person with
normal vision
can
distinguish
from 20 feet
away
NEAR Test near visual Normal near The client was able The findings are
VISUAL acuity visual acuity to read the NORMAL which means
ACUITY is 14/14 following on the that the client has no
TEST (with or Jaeger’s chart: OD difficulty reading the
without (right eye) – J1 OS Jaeger’s chart unless he is
corrective (left eye) – J1 OU not wearing his corrective
lenses). This (both eyes) – J1 lenses (Kozier et. al,
means that Note: with 2004, pg. 552).
the client can corrective lenses
read what the **J stands for the
normal eye Jaeger system chart
can read that the client read
78
from a
distance of
14 inches
VISUAL Test visual With normal The client saw the The findings are
FIELDS FOR fields for gross peripheral examiner’s finger NORMAL which means
GROSS peripheral vision, the at the same time that the client can see
PERIPHERAL vision client should the examiner saw objects in his periphery
VISION TEST see the it. when looking straight
examiner’s ahead (Kozier et. al, 2004,
finger at the pg. 551) His visual field
same time degrees are approximately
the examiner as follows: • Inferior: 70
sees it. degrees • Superior: 50
Normal degrees • Temporal: 90
visual field degrees • Nasal: 60
degrees are degrees (Weber et. al,
approximatel 2018, pg. 318).
y as follows:
•Inferior: 70
degrees
•Superior: 50
degrees
Temporal: 90
degrees
•Nasal: 60
degrees
Perform The The reflection of The findings are
corneal light reflection of the light on the NORMAL which means
reflex light on the corneas of the that the reflection of light
corneas client is in the on the corneas are in the
should be in exact same spot exact same spot on each
the exact eye, indicating a parallel
same spot on alignment (Weber et. al,
each eye, 2018, pg. 319).
which
indicates
parallel
alignment.
Perform cover The The uncovered eye The findings are
test. uncovered of the client NORMAL which means
eye should remained fixed that the client’s uncovered
remain fixed straight ahead, eye did not move to
straight while the covered establish focus as well as
ahead. The eye remained fixed his covered eye after
79
covered eye straight ahead as being uncovered (Weber

should well after being et. al, 2018, pg. 319).
remain fixed uncovered
straight
ahead after
being
uncovered.
Perform the Eye The eye movement The findings are
positions test. movement of the client is NORMAL which means
should be smooth and that the client’s both eyes
smooth and symmetric are coordinated and they
symmetric throughout all six move in unison with
throughout direction parallel alignment (Kozier
all six et. al, 2004, pg. 552)
directions
INSPECTION Inspect the The upper lid The upper lid The findings are
eyelids and margin margin of the client NORMAL which means
eyelashes should be is between his that when the eyelids are
between the upper margin of the open, There is no visible
upper margin iris and upper white sclera above
of the iris and margin of the corneas, and thus, the
the upper pupil, while his upper and lower borders
margin of the lower margin rests of cornea are slightly
pupil. The on the lower border covered. The skin of his
lower lid of his iris. Also, eyelids are also intact
margin rests There is no white without any discharge or
on the lower sclera seen above discoloration. On the
border of the or below the iris. In other hand, the eyelashes
iris. No white addition, his of the client are equally
sclera is seen palpebral fissures distributed and they are
above or are horizontal. curled slightly outward
below the Lastly, his (Kozier et. al, 2004, pg.
iris. eyelashes are 548)
Palpebral evenly distributed
fissures may and both curve
be horizontal. outward along the
lid margins.

80
INSPECTION Assess the The upper The client was able The findings are
ability of and lower to close his upper NORMAL which means
eyelids to lids close and lower eyelids that the eyelids of the
close. easily and easily and they met client close symmetrically
meet completely when and completely, and thus,
completely closed. he did not have any
when closed difficulty with closing his
eyelids (Kozier et. al,
2004, pg. 548).
INSPECTION Note the The lower There is no inward The findings are
position of eyelid is or outward turning NORMAL which means
eyelids in upright with in the lower eyelid that the client’s lower
comparison no inward or of the client. eyelid is upright and
with the outward shows no signs of inward
eyeballs turning. or outward turning
(Weber et. al, 2018, pg.
320).
INSPECTION Observe Skin on both The client’s skin on The findings are
eyelids for eyelids is both eyelids is NORMAL which means
redness, without without redness, that the client’s skin on
swelling, redness, swelling, or both eyelids is without
discharge, or swelling, or lesions. redness, swelling, or
lesions. lesions. lesions (Weber et. al,
2018, pg. 320).
INSPECTION inspect the Bulbar The bulbar

NORMAL which means that
bulbar conjunctiva conjunctiva the ofclient’s
the bulbar conjunctiva is
conjunctiva and is clear, client istransparent.
clear, There are capillaries
sclera. moist, and moist, and evident,
smooth which is normal. Lastly, his
smooth. with few capillaries
sclera appear white (Kozier et. al,
Underlying evident. 2004, Also, pg.
the548)
structures are underlying
clearly structures are
visible. clearly visible and
Sclera is his sclera is white.
white.
INSPECTION Inspect the The lower The lower and The findings are
palpebral and upper upper palpebral NORMAL which means
conjunctiva. palpebral conjunctivae of the that the client’s palpebral
conjunctivae client are clear, and conjunctivae are shiny,
81
are clear and also, free of smooth, and pink with no

free of swelling or lesions. swelling or lesions
swelling or (Kozier et. al, 2004, pg.
lesions 548).
INSPECTION Evert the upper Palpebral TheThe palpebral conjunctivae of the client
eyelid. conjunctiva conjunctiva are offreethe
of swelling, foreign bodies,
is free of client areor free trauma.of
swelling, swelling, foreign
foreign bodies, or trauma.
bodies, or
trauma.
INSPECTION Inspect the No swelling There is no The findings are
lacrimal or redness swelling or redness NORMAL which means
apparatus should over the areas of that There is no edema or
appear over the lacrimal gland. tearing in the lacrimal sac
areas of the His puncta in both and nasolacrimal duct of
lacrimal eyes are visible and the client (Kozier et. al,
gland. The are turned slightly 2004, pg. 550)
puncta is toward the eye.
visible
without
swelling or
redness and
is turned
slightly
toward the
eye.
PALPATION Palpate the No drainage The The nasolacrimal
findings are NORMAL which
lacrimal should be duct of themeans client
that the corneas of the client
apparatus noted from shows noare signs
transparent,
of shiny, and smooth.
the puncta drainage Also,
from boththe of his lenses are free of
when puncta. opacities (Kozier et. al, 2004, pg.
palpating the
nasolacrimal
duct.
INSPECTION Inspect the Both
The cornea
corneasis of the client are The findings are
cornea and lens transparent,
transparent with no opacities. NORMAL which means
withThe oblique
no view shows a that the details of both of
opacities.
smooth and moist surface. the client’s iris are visible,
TheAlso,
oblique
his lenses are free of and thus, they are flat and
viewopacities
shows aas well. round. Also, his pupils are
smooth and 3mm in diameter,
overall moist meaning they are equal in
82
surface; the size, and so, have a

lens is free of smooth border and are
opacities round (Kozier et. al, 2004,
pg. 550).
INSPECTION Inspect the iris The iris is Both irises of the The findings are
and pupil. typically client are round, NORMAL which means
round, flat, flat, and evenly that the details of both of
and evenly colored. On the the client’s iris are visible,
colored. The other hand, his and thus, they are flat and
pupil, round pupils are also round. Also, his pupils are
with a round with regular 3mm in diameter,
regular borders and are meaning they are equal in
border, is centered in both of size, and so, have a
centered in his iris. Both of his smooth border and are
the iris. pupils are also round (Kozier et. al, 2004,
Pupils are 3mm. pg. 550).
normally
equal in size
(3 to 5 mm).
An inequality
in pupil size
of less than
0.5 mm
occurs in
20% of
clients. This
condition,
called
anisocoria, is
normal.
INSPECTION Test pupillary The normal The direct The findings are
reaction to light direct pupillary response NORMAL which means
(Pupillary pupillary of the client is that the illuminated pupil
Light Reflex) response is constriction. constricts (direct
constriction response) (Kozier et. al,
2004, pg. 550).
INSPECTION Assess The normal The consensual The findings are

consensual consensual pupillary response NORMAL which means
response. pupillary of the client is that the non-illuminated
response is constriction. pupil constricts
constriction. (consensual response)
550)
83
INSPECTION Test The normal The pupillary The findings are

accommodatio pupillary response of the NORMAL which means
n of pupils. response is client is that the client’s pupils
constriction constriction of the constrict when looking at
of the pupils pupils and a near object and his
and convergence of the pupils converge when the
convergence eyes when focusing near object is moved
of the eyes on a near object. toward the nose (Kozier
when et. al, 2004, pg. 550).
focusing on a
near object
(accommodat
ion and
convergence)
.
EARS
INSPECTION Inspect the Ears are The client’s ears The findings are
auricle, tragus, equal in size are 6 cm NORMAL which means
and lobule bilaterally bilaterally. his that the client’s ears are
(normally 4– auricle aligns with symmetrical. His auricle
10 cm). The each corner of his is aligned with the outer
auricle aligns eyes. Also, his canthus of his eyes, about
with the earlobes are free. 10 degrees from vertical.
corner of Furthermore, the Moreover, the color is the
each eye and skin of the ears of same as facial skin, and
within a 10- the client is smooth thus, There are no lesions,
degree angle with no lesions, lumps, or nodules seen
of the lumps, or nodules (Kozier et. al, 2004, pg.
vertical and the color is 556)
position. consistent with
Earlobes may facial color. Lastly,
be free, no discharge is
attached, or present.
soldered
(tightly
attached to
adjacent skin
with no
apparent
lobe).

The skin is
84
smooth, with
no lesions,
lumps, or
nodules.
Color is
consistent
with facial
color.

Darwin’s
tubercle,
which is a
clinically
insignificant
projection,
may be seen
on the
auricle. No
discharge
should be
present
INSPECTION Inspect the A small There is a visible The findings are
external amount of small amount of NORMAL which means
auditory canal. odorless dry, yellow, that the distal third
cerumen odorless cerumen contains hair follicles and
(earwax) is on the external glands, and thus, There is
the only auditory canal of no redness, scaling, or
discharge the client. His excessive cerumen
normally canal walls are obstructing the canal
present. pink and smooth, (Kozier et. al, 2004, pg.
Cerumen without nodules. 556)
color may be
yellow,
orange, red,
brown, gray,
or black.
Consistency
may be soft,
moist, dry,
flaky, or even
hard.
85
PALPATION Palpate the Normally the There is no pain The findings are
auricle and auricle, felt on the auricle, NORMAL which means
mastoid tragus, and tragus, and mastoid that the auricle, tragus,
process mastoid process of the and mastoid process of
process are client. the client are mobile,
not tender firm, and not tender. Also,
his pinna recoils after it is
folded (Kozier et. al,
2004, pg. 556)
Perform the Able to The client was able The findings are
whisper test. correctly to hear and NORMAL which means
repeat the correctly repeat all that normal voice tones
two syllable the two[1]syllable are audible for the client
words as words as whispered (Kozier et. al, 2004, pg.
whispered. 558)
Perform the Vibrations The client heard The findings are

Weber’s test. are heard the vibrations NORMAL which means
equally well equally well on that the sound is heard by
in both ears. both ears and There the client in both ears or is
No is no lateralization localized at the center of
lateralization of sound to either the head (Kozier et. al,
of sound to ear. 204, pg. 558) Perform the
either ear. Rinne’s test. Air
conduction sound is
normally heard longer
than bone conduction
sound (AC > BC). The
client heard the vibrations
longer when the tuning
fork was in front of his
external auditory canal
than in the mastoid
process. The findings are
NORMAL wh
Perform the Air The client heard means that the client’s
Rinne’s test. conduction the vibrations air[1]conducted (AC)
sound is longer when the hearing is greater than
86
normally tuning fork was in bone-conducted (BC)

heard longer front of his external hearing (Kozier et. al,
than bone auditory canal than 2004, pg. 558)
conduction in the mastoid
sound (AC > process.
BC).
Perform the Client The client was able The findings are
Romberg test. maintains to maintain his NORMAL which means
position for position for 20 that the client has a
20 seconds seconds without balanced equilibrium
without swaying. (Weber et. al, 2018, pg.
swaying or 351).
with minimal
swaying.
NOSE
INSPECTION inspect and Color is the the color of the The findings are
palpate the same as the nose of the client is NORMAL which means
external nose. rest of the the same as the rest that the client’s nose is
face; the of the face. His symmetric and straight
nasal nasal structure is with no discharge or
structure is smooth and flaring. Also, his nose has
smooth and symmetric, and a uniform color and There
symmetric; thus, the client are no tenderness or
the client reports no pain. lesions noted (Kozier et.
reports no al, 2004, pg. 560)
tenderness
INSPECTION Check patency Clients are The client is able to The findings are
of airflow able to sniff sniff through each NORMAL which means
through the through each nostril while the that the air moves freely
nostrils. nostril while other is occluded as the client breathes
the other is with no difficulty through the nares (Kozier
occluded. at all. et. al, 2004, pg. 560).
INSPECTION Inspect the The nasal The nasal mucosa The findings are
internal nose. mucosa is of the patent is NORMAL which means
dark pink, dark pink, moist, that the client’s nasal
moist, and and free of mucosa is dark pink and
free of exudate. His nasal moist with no lesions. His
exudate. The septum is intact nasal septum is intact and
nasal septum and free of ulcers in midline without ulcers
is intact and or perforations. or perforations. Lastly, his
87
free of ulcers Also, his turbinates turbinates are dark pink,

or are dark pink, moist, and free of lesions
perforations. moist, and free of as well (Kozier et. al,
Turbinates lesions. 2004, pg. 561).
are dark pink
(redder than
oral mucosa),
moist, and
free of
lesions.
PALPATI Palpate The findings are NORMAL which
ON theFrontal
sinuses. and The maxillary
frontal and meansmaxillary
that the sinuses of the client
sinuses are non-tender
sinuses are
to non-tender, and
are not tender (Kozier et. al, 2004,
palpation, thus,
and There
no is no crepitus
crepitus is evident.
PERCUSS Percuss The findings are NORMAL which

ION theThe sinuses Sinuses
sinuses. are notof the clientmeans
are not
that the sinuses of the client
tender on percussion
tender and no pain is felt.
are not tender (Kozier et. al, 2004,
MOUTH & THROAT

INSPECTION Inspect the lips. Lips are The lips of the The findings are
smooth and client are smooth NORMAL which means
moist without and moist with no that the client has a
lesions or lesions or swelling. uniform pink color of lips.
swelling They are soft, moist, and
have a smooth texture.
Lastly, There is also a
symmetry of contour
563).
INSPECTION Inspect the Thirty-two The client has The findings are
teeth and gums pearly thirty – NORMAL. The client
whitish teeth two yellowish drinks
with smooth teeth that caused his teeth to
surfaces and with smooth be
edges. Upper surfaces yellowish. other than that
molars and edges, the There
should rest upper are no decayed and
directly on molars rest missing
88
the lower directly on teeth

molars and the lower molars (Weber et. al, 2018, pg.
the front and 367)
upper the front upper
incisors incisors
should are slightly
slightly override in
override the the lower
lower incisors; the
incisors. client doesn’t
Some clients have
normally any decayed areas
have only 28 nor
teeth if the Missing teeth.
four wisdom The
teeth do not client
erupt. No undergoes
decayed teeth repair (
areas; no fillings)
missing on the other
teeth. Clients hand his
may have gums
appliances on are
the teeth pinkish,
(e.g., braces). moist and free
Clients may from
have lesions
evidence of
repair work
done on teeth
(e.g., fillings,
crowns, or
cosmetics
such as
veneers).
Gums are
pink, moist,
and firm with
tight margins
to the tooth.
No lesions or
masses.
89
INSPECTION Inspect the The buccal The buccal mucosa The findings are
buccal mucosa mucosa of the client is pink NORMAL which means
should since he is light- that the buccal mucosa of
appear pink skinned. the client is moist,
in light smooth, soft, glistening,
skinned and has an elastic texture.
clients; tissue There were no white
pigmentation patches (leukoplakia)
typically seen, no excessive
increases in dryness, and no mucosal
dark skinned cysts were present
clients (Kozier et. al, 2004, pg.
563).
INSPECTION Inspect and

Tongue The client’s tongue The findings are
palpate the
should be is pink, moist, a NORMAL which means
tongue pink, moist, a moderate size with that his tongue has no
moderate size papillae is present, iron, vitamin B12, or
with papillae and There are no vitamin B3 deficiency.
(little lesions present There are no nodes,
protuberance ulcerations,
s) present. A discolorations, or areas of
common tenderness (Kozier et. al,
variation is a 2004, pg. 564).
fissured,
topographic
map–like
tongue,
which is not
unusual in
older clients.
No lesions
are present
INSPECTION Assess the The tongue’s The client’s ventral The findings are
ventral surface ventral surface of the NORMAL which means
of the tongue. surface is tongue is smooth, that the client has a
smooth, shiny, and pink smooth tongue base with
shiny, pink, with visible veins prominent veins. There
or slightly and no lesions are are also no signs of
pale, with seen. swelling or ulceration
visible veins (Kozier et. al, 2004, pg.
and no 564).
lesions
INSPECTION Inspect for The frenulum The frenulum of The findings are
90
Wharton’s is midline; the client is NORMAL which means

ducts Wharton’s midline. His that There are no signs of
ducts are Wharton’s ducts swelling, redness, or pain
visible, with are visible, with on the frenulum and the
salivary flow salivary flow or Wharton’s ducts of the
or moistness moistness in the client are visible with
in the area. area. Also, the good salivary flow and
The client client has no moistness over the area
has no swelling, redness, (Weber et. al, 2018, pg.
swelling, or pain. 370)
redness, or
pain.
INSPECTION Observe the No lesions, There are no The findings are
sides of the ulcers, or lesions, ulcers, or NORMAL which means
tongue. nodules are nodules apparent that the sides of the
apparent on the sides of the tongue of the client are
tongue of the smooth with no palpable
client. nodules (Kozier et. al,
2004, pg. 564).

INSPECTION Check the The tongue The tongue of the The findings are
strength of the offers strong client offers strong NORMAL which means
tongue. resistance. resistance. that the tongue of the
client is strong (Weber et.
al, 2018, pg. 371)
91
INSPECTION Inspect the The hard The hard palate of The findings are
hard (anterior) palate is pale the client is pale NORMAL which means
and soft or whitish but with firm, that the hard palate of the
(posterior) with firm, transverse rugae. client is lighter pink and
palates and transverse Also, his palatine has a more irregular
uvula. rugae tissues are intact. shape. There are also no
(wrinkle-like On the other hand, bony growths growing
folds). his soft palate is from the hard palate. On
Palatine pinkish, movable, the other hand, his soft
tissues are spongy, and palate is light pink and
intact; the smooth smooth. There are no
soft palate discolorations and
should be irritations on both the
pinkish, palates (Kozier et. al,
movable, 2004, pg. 565)
spongy, and
smooth.
INSPECTION Note odor No unusual There is no unusual The findings are

or foul odor or foul odor noted NORMAL which means
is noted. from the client’s that the client has no foul
mouth or unusual breath odor
(Weber et. al, 2018, pg.
371)
INSPECTION Assess the The uvula is The uvula of the The findings are
uvula. a fleshy, client is in the NORMAL which means
solid midline. There is that the uvula of the client
structure that no redness of or is positioned in the
hangs freely exudate from uvula midline of soft palate
in the or soft palate. Also, without any tumor or
midline. No There is a midline trauma (Kozier et. al,
redness of or elevation of uvula 2004, pg. 565)
exudate from and symmetric
uvula or soft elevation of the
palate. soft palate.
Midline
elevation of
uvula and
symmetric
elevation of
92
the soft
palate.
INSPECTION Inspect the Tonsils may The tonsils of the The findings are
tonsils. be present or client are present NORMAL which means
absent. They and are enlarged to that the client has a pink
are normally 1+. There is no and smooth tonsils with
pink and exudate, swelling, no presence of discharge
symmetric or lesions present. or inflammation (Kozier
and may be et. al, 2004, pg. 565).
enlarged to Enlarged to 1+ tonsils are
1+ in healthy also normal for healthy
clients. No people (Weber et. al,
exudate, 2018, pg. 372)
swelling, or
lesions
should be
present.
INSPECTION inspect the Throat is The throat of the The findings are
posterior normally client is pink, NORMAL which means
pharyngeal pink, without without exudate or that the client has a pink
wall. exudate or lesions and smooth posterior
lesions. wall. There are no areas
that are reddened or
edematous. There is also
no presence of lesions,
plaques, or drainage
565)
CHEST TO ABDOMEN
POSTERIOR THORAX
INSPECTION Inspect the Scapulae are The scapula of
configuration. symmetric and the client is not The findings are
non-protruding. uneven and is NORMAL which
Shoulders and not bulging. means that the
93
scapula are at Also, the

equal horizontal scapulae are in client’s scapulae
positions. The equal position are symmetric and
ratio of with the non- protruding,
anteroposterior shoulders. When and thus, his
to transverse measured the shoulders and
diameter is 1:2. anteroposterior scapula are at
Spinous to Transverse equal horizontal
processes appear diameter has a positions (Weber
straight, and ratio of 1:2. By et. al, 2018, pg.
thorax appears observation the 393). he also has a
symmetric, with spinous process symmetric thorax
ribs sloping is vertical and and chest. His
downward at the thorax has a ratio of
approximately a uniform position anteroposterior to
45-degree angle with ribs sloping transverse
in relation to the downward at diameter is 1:2
spine. approximately a (Kozier et. al,
45-degree angle 2004, pg. 576).
in relation to the
spine.
INSPECTION Observe the use of The client does The client uses
accessory muscles not use his accessory The findings are
accessory muscles to assist DEVIATION
(trapezius/ his breathing. FROM
shoulder) NORMAL which
muscles to assist means that the
breathing. The client leaned
diaphragm is the forward and he
major muscle at did use his arms
work. This is to support weight
evidenced by and lift his chest
expansion of the as well to increase
lower chest breathing
during capacity. Hence,
inspiration. his lower chest
expanded during
inspiration.
Moreover, he did
use accessory
muscles
(trapezius/shoulde
r) to assist
breathing (Weber
94
et. al, 2018, pg.

394).
INSPECTION Inspect the client’s Clients should The client is not

positioning. be sitting up and sitting upright The findings are
relaxed, and. He is also DEVIATION
breathing easily breathing FROM
with arms at uncomfortably NORMAL which
sides or in lap. with his arms in means that the
lap. client reports no
tenderness or
painful areas over
the ribs and the
intercostal spaces.
However, the
client is not sitting
upright and he
breathes uneasily
with arms on his
lap (Weber et. al,
2018, pg. 394).
PALPATION Palpate for Client reports no There is no pain

tenderness, tenderness, pain, elicited or any The findings are
sensation, and or unusual unusual NORMAL which
crepitus sensations. responses. means that the
Temperature Crepitus is not client reports no
should be equal palpable. Also, muscle soreness
bilaterally. The both sides of the and increased
examiner finds posterior thorax warmth, and thus,
no palpable have an equal There are no
crepitus. temperature. tenderness, pain,
or unusual
sensations. In
addition, the
temperature is
uniform which
means it is equal
bilaterally (Weber
et. al, 2018, pg.
395).
PALPATION Palpate surface Skin and client’s skin and

characteristics subcutaneous subcutaneous the findings are
95
tissue are free of tissue does not

lesions and reveal any NORMAL which
masses. palpable lesions means that the
or masses rathis client’s chest wall
it is smooth. is intact with no
areas of
tenderness, no
lumps, no bulges,
no depressions,
and There are no
movable structures
as well (Kozier et.
al, 2004, pg. 576).
PALPATION Palpate for fremitus Fremitus is Fremitus is

symmetric and symmetric and The findings are
easily identified easily identified NORMAL which
in the upper in the upper means that the
regions of the regions of the client has a
lungs. If lungs. bilateral symmetry
fremitus is not of vocal fremitus.
palpable on Also, fremitus is
either side, the heard most clearly
client may need at the apex of his
to speak louder. lungs (Kozier et.
A decrease in al, 2004, pg. 577).
the intensity of
fremitus is
normal as the
examiner moves
toward the base
of the lungs.
INSPECTION Assess chest When the client As the client
expansion takes a deep takes deep The findings are
breath, the breath, the chest NORMAL which
examiner’s expansion is means that the
thumbs should equal and client has no
move 5 to 10 cm symmetrical as unequal chest
apart the examiner’s expansion and has
symmetrically. thumb moves 5 - no decreased chest
10 cm apart. excursion at the
base of his lungs
(Weber et. al,
2018, pg. 395).
96
PERCUSSION Resonance is the Resonance is the

Percuss for tone percussion tone percussion tone The findings are
elicited over elicited over NORMAL which
normal lung normal lung means that the
tissue. tissue of the percussion notes
Percussion client and elicits resonate, except
elicits flat tones flat tones over over scapula. The
over the scapula. the scapula. lowest point of
resonance is at his
diaphragm. Also,
There are no areas
of dullness or
flatness over lung
tissue and no
asymmetry in
percussion (Kozier
et. al, 2004, pg.
577).
PERCUSSION Excursion Excursion is

Percuss for should be equal equal bilaterally The findings are
diaphragmatic bilaterally and and it measures NORMAL which
excursion measure 3–5 cm about 8cm. means that the
in adults. The client’s diaphragm
level of the is slightly higher
diaphragm may on his right side.
be higher on the There is also no
right because of restricted
the position of excursion of the
the liver. In diaphragm (Kozier
well- et. al, 2004, pg.
conditioned 577).
clients,
excursion can
measure up to 7
or 8 cm.
AUSCULTATIO Auscultate for Three types of The client’s
N breath sounds normal breath breath sound is The findings are
sounds may be auscultated in NORMAL which
auscultated— the bronchial, means that the
bronchial, bronchovesicula client has no
bronchovesicula r, and vesicular diminished or
r, and vesicular area. There are absent breath
no absent or sounds. On the
97
diminished
breath sounds. other hand, he
does not have an
increased breath
sound (Weber et.
al, 2018, pg. 397).
AUSCULTATIO Auscultate voice Voice There equal

N sounds transmission is vocal fremitus, The findings are
soft, muffled, equal NORMAL which
and indistinct. bronchophony means that words
The sound of the (ninety-nine are not easily
voice may be sound), equal understood and
heard but the egophony (e not loud over
actual phrase sound), and areas of increased
cannot be equal whispered density on the
distinguished. pectoriloquy chest wall of the
(123 sound). client.
The transmission
of the voice is soft
and muffled but
the letter “E” is
distinguishable.
The transmission
of sound is very
faint and muffled
(Weber et. al,
2018, pg. 398).
ANTERIOR THORAX
INSPECTION Inspect forshape The The anterior
and configuration anteroposterior diameter is The findings are
diameter is less narrower than NORMAL which
than the the transverse means that the
transverse diameter and client does not
diameter. has a ratio of have a barrel or
1:2. funnel chest, and
thus, he does not
have a
hyperinflation of
the lungs (Weber
et. al, pg. 398).
INSPECTION Inspect position for Sternum is The client’s

the sternum positioned at sternum is The findings are
98
midline and positioned at

straight. midline and NORMAL which
vertical. means that the
client does not
have a sunken
sternum and
adjacent cartilages
(Weber et. al, pg.
398).
INSPECTION Watch for sternal Retractions not The sternum is

retractions observed. plain and The findings are
normal; There NORMAL which
are no means that the
retractions seen. client does not
have sternal
retractions.
Moreover, he also
does not have a
severely labored
breathing (Weber
et. al, pg. 398).
INSPECTION Inspect slope of the Ribs slope The client’s ribs

ribs downward with are slanting in a The findings are
symmetric NORMAL which
downward
intercostal means that the
position with
spaces. The uniform client has no more
Coastal angle is intercostal horizontal position
within 90 spaces. of the ribs and no
degrees. costal angle of
Moreover,
more than 90-
costal angle is degrees (Weber et.
within 90 al, pg. 398).
degrees.
INSPECTION Observe Quality Respirations are The client’s
and pattern of relaxed, respirations are The findings are
respiration effortless, and relaxed and NORMAL which
quiet. They are quiet. means that the
of a regular The client has a client has no
rhythm and regular rhythm labored and noisy
normal depth at and normal breathing (Weber
a rate of 10–20 depth at a rate of et. al, pg. 398).
per minute in 20 per minute.
adults. They are
99
of a regular
rhythm and
normal depth at
a rate of 10–20
per minute in
adults.
Tachypnea and
bradypnea may
be normal in
some clients.
INSPECTION Inspect Intercostal No retractions There are no
Spaces protuberance or The findings are
retractions of NORMAL which
the intercostal means that the
spaces. They are client has no
also aligned increased
properly. inspiratory effort.
Also, he doesn’t
have a trapped air
on his intercostal
spaces (Weber et.
al, pg. 399).
INSPECTION Observe use of Use of accessory The client does

accessory muscles muscles not use his The findings are
(sternomastoid accessory NORMAL which
and rectus muscles and is means that the
abdominis) is seen with client has no acute
not seen. After normal or chronic airway
strenuous respiratory obstruction
exercise or effort. (Weber et. al, pg.
activity, clients 399).
with normal
respiratory
status may use
neck muscles for
a short time to
enhance
breathing.
PALPATION Palpate for No tenderness The client does The findings are
tenderness, or pain is not report pain NORMAL which
sensation, palpated over over the lung means that the
andsurfacemasses. the lung area area with client has no
with respirations. tenderness over
100
respirations. his thoracic

muscles (Weber
et. al, pg. 399).
PALPATION Palpate for Palpation does The client’s
tenderness at not elicit costochondral The findings are
costochondral tenderness. junctions of ribs NORMAL which
junction of ribs. do not elicit any means that the
pain or unusual client has no
responses. tenderness or pain
felt at his
costochondral
junctions of ribs
(Weber et. al, pg.
399).
PALPATION Palpate for crepitus No crepitus There is no

palpated. crepitus The findings are
palpated in the NORMAL which
client. means that the
client has no
extreme
congestion or
consolidation
(Weber et. al, pg.
399).
PALPATION Palpate for fremitus Fremitus is The client’s

symmetric and fremitus is The findings are
easily identified symmetric NORMAL which
in the upper bilaterally and means that the
regions of the easily identified client has no
lungs. A in the upper diminished
decreased regions of the vibrations (Weber
intensity of lungs. et. al, pg. 400).
fremitus is
expected toward
the base of the
lungs. However,
fremitus should
be symmetric
bilaterally.
PALPATION Palpate Anterior Thumbs move The examiner’s
chest expansion outward in a thumbs move The findings are
symmetric outward in a NORMAL which
101
fashion from the similar fashion

midline. from the means that the
midline. client has no
unequal chest
expansion (Weber
et. al, pg. 400).
PERCUSSION Percuss for tone

Resonance is the Resonance is
percussion tone elicited over the The findings are
elicited over lung tissue, NORMAL which
normal lung dullness is heard means that the
tissue. over the breast client has no
Percussion tissue and the sounds of
elicits dullness liver, while hyperresonance on
over breast tympany is his anterior thorax
tissue, the heart, detected over (Weber et. al, pg.
and the liver. the client’s 400).
Tympany is stomach and
detected over lastly flat tones
the stomach, and is heard over the
flatness is muscles and the
detected over bones.
the muscles and
bones.
AUSCULTATIO Auscultate for Refer to text in The client’s The findings are
N anterior breath the posterior breath sound is NORMAL which
sounds, adventitious thorax section auscultated in means that the
sounds, and voice for normal voice the bronchial, client has no
sounds sounds. bronchovesicula diminished or
r, and vesicular absent breath
area. There are sounds. On the
no absent or other hand, he
diminished does not have an
breath sounds. increased breath
sound. In addition,
There were also
no adventitious
sounds heard
(Weber et. al,
2018, pg. 397).
Furthermore, for
bronchophony, the
words are not
easily understood
102
and not loud over

areas of increased
density on the
chest wall of the
client. While for
egophony, the
transmission of
the voice is soft
and muffled but
the letter “E” is
distinguishable.
Lastly, for
whispered
pectoriloquy, the
transmission of
sound is very faint
and muffled
(Weber et. al,
2018, pg. 398).
BREAST & LYMPHATIC SYSTEM
INSPECTION Inspect and palpate No swelling,
AND the breast, areolas, nodules, or When inspected The findings are
PALPATION nipples, and axillae. ulceration and palpated the NORMAL which
should be clients breast is means that the
detected. free of any client’s breast and
swelling, axillary skin has
nodules and no redness,
ulcerations. ulceration,
nodules and
inflammation.
There are also no
enlarged lymph
nodes upon
palpation (Weber
et. al, 2018, pg.
424).
HEART & NECK VESSELS

INSPECTION Observe the jugular The jugular When the client
venous pulse. venous pulse is is in supine The findings are
not normally position with the NORMAL which
visible with the head elevated to means that the
client sitting 30 degrees, it is client’s jugular
upright. This observed that venous pulse is
103
position fully the jugular

distends the venous pulse is not visible and not
vein, and distended, and distended (Kozier
pulsations may the pulsation is et. al, 2004, pg.
or may not be discernible. 584).
discernible.
INSPECTION Evaluate jugular The
jugular vein When observed
venous pressure. should not be at 45 degrees or The findings are
distended, greater the NORMAL which
bulging, or jugular vein is means that the
protruding at 45 not distended or client’s jugular
degrees or bulging. venous pulse is
greater not visible and not
distended (Kozier
et. al, 2004, pg.
584).
PALPATION Palpate the carotid Arteries are Pulses are

Arteries elastic and no equally strong; a The findings are
thrills are noted. 2+ or normal NORMAL which
with no means that the
variation in client has a
strength from symmetric pulse
beat to beat. volume. There are
Also, contour is also full pulsations
smooth and and thrusting
rapid on the quality. Moreover,
upstroke and the quality
slower and less remains the same
abrupt on the when he breathes,
downstroke. turns head, and
Moreover, changes from
arteries are sitting to supine
elastic, and no position. His
thrills are noted. arterial wall is also
elastic (Kozier et.
al, 2004, pg. 584).
AUSCULTATIO Auscultate the No blowing or There is an

N carotid arteries swishing or absence of The findings are
other sounds are blowing,swishin NORMAL which
heard. Pulses are g or other means that the
equally strong; a sounds. client exhibits no
2+ or normal bruits in one or
both arteries
104
with no
variation in (Kozier et. al,
strength from 2004, pg 584).
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.
INSPECTION Inspect pulsations The apical The apical
impulse may or impulse is not The findings are
may not be visible in the NORMAL which
visible. If mitral area. means that
apparent, it pulsations are
would be in the visible with a
mitral area. The diameter of 1 to 2
apical impulse is cm. Also, There is
a result of the no lift or heave
left ventricle noted (Kozier et.
moving outward al, 2004, pg. 583).
during systole.
INSPECTION Palpate the apical The apical The apical
impulse impulse is impulse is felt in The findings are
palpated in the the mitral area NORMAL which
mitral area and and in the size means that the
may be the size of 2 cm. client’s apical
of a nickel (1-2 Amplitude is impulse is
cm). Amplitude small, the palpable in the
is usually small duration is brief. mitral area
- like a gentle (Kozier et. al,
tap. The 2004, pg. 583).
duration is brief,
lasting through
the 1st 2/3 of
systole and
often less. In
105
obese clients or
clients with
large breasts, the
apical impulse
may not be
palpable.
PALPATION Palpate for No pulsations or No pulsations or
abnormal vibrations are vibration are felt The findings are
pulsations. palpated in the in the areas of NORMAL which
areas of the the apex, left means that the
apex, left sternal sternal border, client has no thrill
border, or base. or base. or pulsations in
the areas of the
apex, left sternal
border, or base
(Weber et. al,
2018, pg. 449).
AUSCULTATIO Auscultate heart Rate should be The rate of the

N rate and rhythm. 60-100 bpm client ranges The findings are
with a regular between 72-81 NORMAL which
rhythm. A bpm with a means that the
regularly regular rhythm. client has no
irregular decreased cardiac
rhythm, such as output. Also, he
sinus arrhythmia has an evenly
when the heart spaced beat
rate increases (Weber et. al,
with inspiration 2018, pg. 449).
and decreases
with expiration,
may be normal
in young adults.
AUSCULTATIO Auscultate to S1 corresponds S1 corresponds
N identify S1and S2. with each with each The findings are
carotid pulsation carotid pulsation NORMAL which
and is loudest at and is loudest at means that the
the apex of the the apex of the client has no
heart. S2 heart. S2 accentuated,
immediately immediately diminished,
follows after s1 follows after S1 varying, or split S
and is loudest at and is loudest at sounds (Weber et.
the base of the the base of the al, 2018, pg. 450).
heart. heart.
106
AUSCULTATIO Auscultate for extra Normally no There are no

N heart sounds. sounds are extra heart The findings are
heard. A sounds noted. NORMAL which
physiologic s3 means that the
heart sound is a client has no
benign finding ejection sounds or
commonly heard clicks. No friction
at the beginning rub heard during
of the diastolic the systolic
pause in pressure and no
children, pathologic S4 is
adolescents and also heard (Weber
young adults et. al, 2018, pg.
(rare after age 451).
40)
AUSCULTATIO Auscultate for Normally no There is an
N murmurs. murmurs are absence of The findings are
heard. murmur sounds. NORMAL which
means that the
client shows no
signs of
Pathologic mid-
systolic,
Pansystolic and
diastolic murmurs
(Weber et. al
2018, pg. 451).
ABDOMEN
INSPECTION Observe the Abdominal skin The client’s
coloration of the may be paler abdominal skin The findings are
skin than the general is paler than the NORMAL which
skin tone general skin means that the
because this skin tone since this client has no
is so seldom part is rarely unblemished
exposed to the exposed. abdominal skin
natural with no rash or
elements. other lesions.
There is also no
tense and
glistening skin
noted. Lastly,
There are no
visible purple
107
striae (Kozier et.

al, 2004, pg. 594).
INSPECTION Note the vascularity Scattered fine The client’s

of the abdominal veins may be veins are visible The findings are
skin. visible. Blood in as well as the NORMAL which
the veins located uneven and means that the
above the linear silvery client does not
umbilicus flows white stretch have dilated veins.
toward the head; marks of the There are also no
blood in the client due to dilated surface
veins located pregnancy. arterioles and
below the capillaries with a
umbilicus flows central star seen
toward the (Weber et. al,
lower body. 2018, pg. 504).
New striae are
pink or bluish in
color; old striae
are silvery,
white, linear,
and uneven
stretch marks
from past
pregnancies or
weight gain.

INSPECTION Inspect for scars. Pale, smooth, The client has
minimally raised no visible scar. The findings are
old scars may be NORMAL which
seen. means that the
client has no non-
healing wounds,
redness or
inflammation.
There are also no
deep, irregular
scars (Weber et.
al, 2018, pg. 505).
INSPECTION Assess for lesions Abdomen

is free The client’s
and rashes. of lesions or abdomen is free The findings are
rashes. Flat or from any lesions NORMAL which
means that the
108
raised brown and rashes.

moles, however, client’s abdomen
are normal and is free of lesions
may be or rashes. There
apparent. are also no
changes in size,
color, and border
symmetry in his
moles, and thus,
no bleeding moles
or petechiae
(Weber et. al,
2018, pg. 505).
INSPECTION Inspect the Umbilical skin The client’s

umbilicus and tones are similar umbilicus is in The findings are
umbilical location. to surrounding midline. His NORMAL which
abdominal skin umbilical skin means that the
tones or even tone is similar to client has no
pinkish. the surrounding bluish or purple
Umbilicus is abdominal skin discoloration
midline at the tone and it is around the
lateral line. evenly circular. umbilicus. Hence,
It is recessed his umbilical skin
(inverted) or tones are similar
protruding no to surrounding
more than 0.5 abdominal skin
cm, and is round tones (Weber et.
or conical. al, 2018, pg. 505).
INSPECTION Inspect abdominal Abdomen is flat, The client’s

contour and rounded, or abdomen is The findings are
symmetry. scaphoid rounded and NORMAL which
(usually seen in symmetric. means that the
thin adults; client has a
abdomen should rounded abdomen
be evenly with no distension.
rounded. His abdomen has
Abdomen is also a symmetric
symmetric. contour which
means it is evenly
rounded (Kozier
et. al, 2004, pg.
594).
109
INSPECTION Inspect abdominal Abdominal The client’s

movement when the respiratory abdominal The findings are
client breathes movement may respiratory NORMAL which
(respiratory be seen, movement is means that the
movements) especially in visible. client has a
male clients. symmetric
movement caused
by respiration
(Kozier et. al,
2004, pg. 595).
INSPECTION Observe Aortic A slight A succession of

Pulsations. pulsation of the irregular, The findings are
abdominal aorta, restrained clicks NORMAL which
which is visible and gurgles are means that the
in the heard at a rate client has shown
epigastrium, 15 per minute. no vigorous, wide,
extends full Also, exaggerated
length in thin hyperactive pulsations (Weber
people. bowel sounds et. al, 2018, pg.
Normally, are heard. 506).
peristaltic waves
are not seen,
although they
may be visible
in very thin
people as slight
ripples on the
abdominal wall.
INSPECTION Observe Peristaltic Normally, There are
Waves. peristaltic waves absence of bruit The findings are
are not seen, sounds over NORMAL which
although they abdominal aorta means that the
may be visible or renal, iliac, or client has no
in very thin femoral arteries. increased and
people as slight progressed
ripples on the peristaltic waves,
abdominal wall. and thus, There is
no abdominal
distention (Weber
et. al, 2018, pg.
507).
AUSCULTATIO Auscultate for A series of An absence of

The findings are
110
N bowel sounds intermittent, soft venous hum is

clicks and heard over NORMAL which
gurgles are epigastric and means that the
heard at a rate of umbilical areas. client has no
5–30 per absent,
minute. hypoactive, or
Hyperactive hyperactive bowel
bowel sounds sounds. There is
referred to as also no loud bruit
“borborygmus” over the aortic
may also be area (Kozier et. al,
heard. 2004, pg. 595).
AUSCULTATIO Auscultate for Bruits are not Bruits are not

N vascular sounds. normally heard heard over the The findings are
over abdominal client’s NORMAL which
aorta or renal, abdominal aorta means that the
iliac, or femoral and renal, iliac, client has no bruit
arteries. and femoral over renal or iliac
However, bruits arteries. arteries (Kozier et.
confined to al, 2004, pg. 595).
systole may be
normal in some
clients
depending on
other
differentiating
factors.
AUSCULTATIO Auscultate For a No friction rub There is no
N friction rub over the over the liver or friction rub The findings
liver and spleen. spleen is present over the areNORMAL
present. liver and the which means that
spleen. the client has no
friction rubs over
his liver or spleen
(Weber et. al,
2018, pg. 508).
PERCUSSION Percuss for tone. Generalized The client’s

tympany abdomen The findings
predominates predominates areNORMAL
over the tympany over which means that
abdomen the 4 quadrants the client has no
because of air in because of the accentuated
tympany or
111
the stomach and air in his

intestines. stomach and hyperresonance
Dullness is intestines. over a gaseous
heard over the distended
liver and spleen. abdomen. There is
Dullness may also no enlarged
also be elicited area of dullness
over a non- heard in his liver
evacuated or spleen. Lastly,
descending There is no
colon. abnormal dullness
heard over his
bladder, largest
masses, or ascites
(Weber et. al,
2018, pg. 508).
PERCUSSION Percuss the span or The upper On the client’s

height of the liver border of liver deep inspiration, The findings
by determining its dullness is the lower border areNORMAL
lower and upper located between of the liver, which means that
borders. the left fifth and dullness the client has no
seventh descends from 1 enlarged size in
intercostal to 4 cm below his liver (Kozier
spaces. the costal et. al, 2004, pg.
margin while 596).
the upper border
of liver dullness
is located
between the left
fifth and seventh
intercostal
spaces.
PERCUSSION Blunt percussion on Normally, no No tenderness

the liver and the tenderness is or pain elicited. The findings
kidneys elicited. areNORMAL
Normally, no which means that
tenderness or the client has no
pain is elicited tenderness or
or reported by sharp pain over his
the client. The liver and kidneys,
examiner senses which means that
only a dull thud. There is no
inflammation or
112
infection present
(Weber et. al,
2018, pg. 512).
PALPATION Perform light Abdomen is No tenderness

palpation nontender and or pain is The findings are
soft. There is no elicited or NORMAL which
guarding. reported by the means that the
client and only a client has no
dull thud is tenderness and
sensed. hypersensitivity
on his abdomen.
There are also no
superficial masses
as well as no
localized areas of
increased tension
noted on his
abdomen (Kozier
et. al, 2004, pg.
597).
PALPATION Deeply palpate all Normal (mild) Mild tenderness

quadrants to tenderness is is elicited over The findings are
delineate abdominal possible over xiphoid, aorta, NORMAL which
organs and detect the xiphoid, cecum, sigmoid means that the
subtle masses. aorta, cecum, colon, and client has no
sigmoid colon, ovaries with generalized or
and ovaries with deep palpation. localized areas of
deep palpation. tenderness over all
four quadrants.
Hence, There are
no mobile or fixed
masses noted
(Kozier et. al,
2004, pg. 597).
PALPATION Palpate the liver. The liver is The liver is not

usually not felt. No The findings are
palpable, tenderness NORMAL which
although it may elicited. means that the
be felt in some client has no
thin clients. If enlarged liver. In
the lower edge addition, his liver
113
is felt, it should
be firm, smooth, is also smooth but
and even. Mild not tender. Hence,
tenderness may There it is neither
be normal. nodular nor hard
(Kozier et. al,
2004, pg. 598).
PALPATION Palpate the urinary An empty The client’s

bladder. bladder is urinary bladder The findings are
neither palpable does not show NORMAL which
nor tender. any tenderness means that the
nor is palpable. client has no
distended bladder
which means that
it is neither tender
nor palpable as
smooth, round,
and somewhat
tense mass
(Kozier et. al,
2004, pg. 598).
PALPATION Assess for rebound No rebound There is no

tenderness. tenderness is rebound The findings are
present. tenderness NORMAL which
present upon means that the
assessing the client has no
right lower rebound
quadrant. tenderness as the
examiner releases
pressure from his
abdomen (Weber
et. al, 2018,pg.
517).
MUSCLES, BONES, & JOINTS

MUSCLES
114
The muscles of the

client are equal in size
on his upper extremities
with a measurement of
11 inches on his arm
and 9 inches on his The findings are
forearm. On the other NORMAL
hand, his lower which means
Equal size on extremities are equal in that the client
Muscles both sides of size as well with a has no decrease
Inspection the body. measurement of 21 or increase in
inches on both of his muscle size
thighs and 13 inches on (Kozier et. al,
his legs. Hence, with 2004, pg. 600).
the equality of sizes, the
upper and lower
extremities of the client
are symmetrical on each
body side.
There are no The findings are
contractures noted on NORMAL
the upper and lower which means
extremities of the client that the client
No
Inspection Muscles and tendons that prevent the normal has no
contractures.
movement of a joint of malposition of
other body parts. Thus, body part
his muscles and tendons (Kozier et. al,
are not stiff. 2004, pg. 600).
The findings are
NORMAL
There are no which means
No fasciculation and that the client
Inspection Muscles fasciculation tremors noted on the has no presence
or tremors. upper and lower of fasciculation
extremities. or tremor
(Kozier et. al,
2004, pg. 600).
The findings are
The muscles of the
NORMAL
client on his upper and
Normally which means
Palpation Muscles lower extremities are
firm. that the client
firm with no lacking
has no lacking
tones.
tone, and thus,
115
has a firm
muscle tone
(Kozier et. al,
2004, pg. 600)
The findings are
NORMAL
The muscles of the
which means
client are firm when he
that the client
is both active and
has neither
Smooth passive. His muscles
weakness or
Palpation Muscles coordinated are smooth with
laxness nor
movements. coordinated
sudden
movements. Also,
involuntary
There was no flaccidity
muscle contracts
and spasticity noted.
(Kozier et. al,
2004, pg. 600).
The
sternocleidomastoid of
the client in each body
side has an equal The findings are
strength with a 100% of NORMAL
muscle strength, normal which means
full movement against that the client
gravity and against full has an equal
resistance. Thus, the muscle strength
client did not feel any on each body
pain and did not have side, and thus,
Muscles of the head Equal any difficulty with has no 25% or
Observatio and shoulders strength on resisting as well. less the normal
n (sternocleidomastoid each body strength in his
& trapezius) side. The trapezius of the head and
client in each body side shoulders.
has an equal strength Furthermore, he
with a 100% of muscle has a grade 5
strength, normal full muscle strength
movement against in his head and
gravity and against full shoulders
resistance. Thus, the (Kozier et. al,
client did not feel any 2004, pg. 600).
pain and did not have
any difficulty with
resisting as well.
116
Observatio Muscles of the upper Equal The deltoid of the client The findings are
n extremities ( deltoid, strength on in each body side has an NORMAL
biceps, triceps, wrist each body equal strength with a which means
and finger muscles) side. 100% of muscle that the client
strength, normal full has an equal
movement against muscle strength
gravity and against full on each body
resistance. Thus, the side, and thus,
client did not feel any has no 25% or
pain and did not have less the normal
any difficulty with strength in his
resisting as well. upper
extremities.
The biceps of the client Furthermore, he
in each body side has an has a grade 5
equal strength with a muscle strength
100% of muscle in his upper
strength, normal full extremities
movement against (Kozier et. al,
gravity and against full 2004, pg. 600).
resistance. Thus, the
client did not feel any
any difficulty with
resisting as well.
The triceps of the client

in each body side has an
equal strength with a
100% of muscle
strength, normal full
movement against
gravity and against full
any difficulty with
resisting as well.
The wrist and finger

muscles of the client in
each body side has an
equal strength with a
100% of muscle
117

movement against
any difficulty with
resisting as well.
The grip strength of the

client in each body side
has an equal strength
with a 100% of muscle
movement against
any difficulty with
resisting as well.
118
Observatio Muscles of the upper Equal The hip muscles of the The findings are
n extremities (hip strength on client in each body side NORMAL
muscles, hamstrings, each body has an equal strength which means
quadriceps, muscles side. with a 100% of muscle that the client
of the ankle and feet) strength, normal full has an equal
movement against muscle strength
gravity and against full on each body
resistance. Thus, the side, and thus,
client did not feel any has no 25% or
pain and did not have less the normal
any difficulty with strength in his
resisting as well. lower
extremities.
The hamstrings of the Furthermore, he
client in each body side has a grade 5
has an equal strength muscle strength
with a 100% of muscle in his lower
strength, normal full extremities
movement against (Kozier et. al,
gravity and against full 2004, pg. 600).
any difficulty with
resisting as well.
The quadriceps of the

movement against
any difficulty with
resisting as well.
The muscles of the

ankle and feet of the
119

movement against
any difficulty with
resisting as well.
The findings are
NORMAL
There were no which means
deformities of bones that the client
No
Inspection Bones noted in the upper and has no
deformities.
lower extremities of the misaligned
client. bones (Kozier
et. al, 2004, pg.
601).
The findings are
NORMAL
There was no which means
tenderness or swelling that the client
No tenderness
Palpation Bones in the client’s bones. has no presence
of swelling.
Hence, his bones were of tenderness or
firm and hard. swelling (Kozier
et. al, 2004, pg.
601).
The findings are
NORMAL
which means
that the client
has no one or
more swollen
There was neither
No swelling, joints.
swelling nor nodules
no tenderness, Moreover,
Inspection Joints found in the client’s
crepitation, or There is no
bones. Thus, his joints
nodules. presence of
move smoothly.
tenderness,
swelling,
crepitation, or
nodules (Kozier
et. al, 2004, pg.
601).
120
The flexion of the

client’s head is 45
The findings are
degrees. Extension is
NORMAL
upright. While
Varies to which means
hyperextension is 55
some degree that the client
degrees. Moreover, the
in accordance has no limited
client bent his head 40
with a range of motion
degrees to the left side
person's in one or more
and 40 degrees to the
Observatio genetic joints in his
Joints right side. Lastly, the
n makeup and head, and so, he
client turned 70 degrees
degree of was able to do it
of rotation to the left
physical easily without
side and 70 degrees as
activity. Full eliciting any
well on the right side.
range of difficulty or
With that being said,
motion. pain (Kozier et.
the client was able to
al, 2004, pg.
move his head in full
601).
range of motion without
any difficulty or pain.
While standing upright, The findings are
hip flexion of the client NORMAL
Varies to is 90 degrees and hip which means
some degree hyperextension is 30 that the client
in accordance degrees. Last of all, has no limited
with a lateral flexion is 35 range of motion
Joints of the body person's degrees on both right in one or more
Observatio trunk (Hip-Ball-and- genetic and left side while joints in his
n Socket Joint, Trunk- makeup and rotation of the trunk is body trunk, and
Gliding Joint) degree of 30 degrees on each side. so, he was able
physical With that being said, to do it easily
activity. Full the client was able to without eliciting
range of move his body trunk in any difficulty or
motion. full range of motion pain (Kozier et.
without any difficulty al, 2004, pg.
or pain. 601).
121
His extended flexion is

180 degrees,
hyperextension is 50
degrees, adduction is 50
degrees as well,
abduction is 180
degrees, and also,
circumduction is 360
degrees. Moreover, the
internal rotation of the
upper extremities is 90
The findings are
degrees as well as the
NORMAL
external rotation.
which means
Varies to Additionally, the
that the client
some degree flexion of the client’s
has no limited
Joints of the upper in accordance elbow is 160 degrees.
range of motion
extremities (Neck- with a Supination and
in one or more
Pivot Joint, Shoulder- person's pronation of the hand
joints in his
Observatio Ball-and-Socket Joint, genetic and forearm is 90
upper
n Elbow-Hinge Joint, makeup and degrees. Furthermore,
extremities, and
Wrist-Condyloid degree of flexion of both his
so, he was able
Joint, Thumb-Saddle physical wrists is 90 degrees,
to do it easily
Joint) activity. Full extension is in the same
without eliciting
range of plane as the arm, and
any difficulty or
motion. hypertension is 70
pain (Kozier et.
degrees. Additionally,
al, 2004, pg.
radial flexion is 20
601).
degrees and ulnar
flexion is 55 degrees.
Last of all, flexion of
fingers is 90 degrees
and hyperextension is
30 degrees. With that
being said, the client
was able to move his
upper extremities in full
122
The hip flexion of the

client in supine position
with the knee straight is
90 degrees and the hip The findings are
flexion with the knee NORMAL
bent while the other leg which means
Varies to
is remaining straight is that the client
some degree
120 degrees. Also, hip has no limited
in accordance
hyperextension is 15 range of motion
with a
Joints of the lower degrees. On the other in one or more
person's
extremities (Knee- hand, hip abduction of joints in his
Observatio genetic
Hinge Joint, Ankle- the client is 45 degrees, lower
n makeup and
Hinge Joint, Foot- hip adduction is 30 extremities, and
degree of
Gliding) degrees. In addition, so, he was able
physical
internal hip rotation is to do it easily
activity. Full
40 degrees while without eliciting
range of
external hip rotation is any difficulty or
motion.
45 degrees. With that pain (Kozier et.
being said, the client al, 2004, pg.
was able to move his 601).
lower extremities in full
123
B. MATRIARCH (MRS. R.A.S)
Body Part/Area Normal Findings Actual Findings Interpretation

to be Assessed and Analysis
General Appearance & Mental Status
Signs of distress No distress noted. There are no signs of NORMAL

in Posture or distress in the client’s
Facial posture or facial
Expression expression. The
client’s not bending
over nor wincing,
frowning, or having a
labored breathing.
Body build, Body build, height, The body build of the NORMAL
weight, and and weight should client is mesomorph.
height in relation be proportionate The height of the
to the age, which varies with client is 152.4cm,
lifestyle, and lifestyle. while the weight is
health 55kg.
Posture and gait, The posture and gait The posture of the NORMAL
standing, sitting, of an individual client in terms of
and walking should be relaxed, sitting and standing is
erected, and have a relaxed, erected and
coordinated straight. There are no
movement. visible signs of
tension. In terms of
the client’s gait, she
has a coordinated
movement. There are
no signs of bent
postures, and
tremors.
Overall hygiene The client should be The client is clean NORMAL

and clean and neat. and neat. There is no
Grooming visible part that is
unkempt and pleats
on her shirt. Her nails
are well trimmed and
clean. There are no
124
visible areas of her

face that are dirty.
Body breath and There should be The client has no NORMAL

body slight or no odor of body or breath odor.
Odor perspiration or She doesn’t smell
breath, depending acidic but fragrant
on activity. due to perfume.
Obvious signs of Healthy appearance. The client has no NORMAL

health or illness obvious signs of
illness and has a
healthy appearance.
Client’s attitude Cooperative. The client was NORMAL

cooperative when he
was asked to stand
up and responsive
when he was asked a
few questions.
Affect/mood and Appropriate to the The response of the NORMAL

appropriateness situation. client to questions
of the response asked were all
appropriate.
Quantity, quality, Understandable, The client has NORMAL

and organization moderate pace, understandable
of speech. exhibits thought speech, in moderate
association. pace, and associated
thoughts.
Skin
Skin Color Skin color should be Skin color is evenly NORMAL

evenly distributed distributed except for
without unusual or the body parts that
prominent are exposed to the
discolorations. sun such as the arms
and the legs. Those
parts are a little
darker than the part
that is not exposed to
the sun. But, the part
that is not exposed to
125
the sun is evenly

distributed. Moreover,
there are no unusual
or prominent
discolorations to the
client’s skin color.
Skin color Skin color variation The client has no NORMAL

variation should be no rash or rashes across the
a butterfly rash bridge of her nose
across the bridge of and cheeks. Her face
the nose and color is evenly
cheeks. distributed as well.
Skin integrity Skin integrity should The skin is complete NORMAL

be intact, and there and undamaged. It is
must be no intact and there are
reddened areas. no signs of reddened
areas that may
progress to serious
and painful pressure
ulcers.
Skin Skin should be The skin of the client NORMAL

smooth, there should is smooth and there
be no lesions. are no lesions. There
Stretch marks, are no visible stretch
healed scars, marks, healed scars,
freckles, moles, or birthmarks, except for
birthmarks are the freckles.
common findings. Moreover, there are
Freckles and moles visible scattered
may be scattered moles in the face,
over the skin in no neck, and arms of the
particular pattern. client.
Skin texture Skin texture should The skin is smooth NORMAL

be smooth and even. and even after
palpating it using my
three middle fingers.
There are no signs of
rough, flaky, dry skin.
Skin moisture Skin moisture varies After checking the NORMAL

from moist to dry skin folds of the
126
depending on the client, the skin

area assessed. moisture is dryer
Moreover, an older compared to a
client’s skin may feel younger patient as
dryer than a younger skin moisture can
client’s skin. change due to sebum
production decreases
with age.
Skin temperature Skin temperature is The skin temperature NORMAL

normally a warm of the client is warm
temperature. but not very warm.
Skin mobility Skin mobility, on how The skin of the client NORMAL
the skin is easily is mobile and it
pinched, and turgor, returns to its original
skin’s elasticity, is shape quickly after I
normally elastic and pinched the skin over
returns to its original the arm. Also, there is
shape quickly. Recoil no visible edema. The
is usually immediate. skin of the client is
very well hydrated.
Scalp
Scalp The scalp should be After palpating the NORMAL

clean and dry. scalp of the client
Sparse dandruff may through parting the
be visible but it is hair from the scalp,
normal. Hair should the client’s scalp is
be smooth and firm, clean and dry. There
and somewhat are no lesions and
elastic. But due to parasites. It appears
aging, hair feels to be thinner than the
coarse and drier. It is usual thickness of the
also expected to be hair compared to the
thinner. younger clients.
Hair distribution The hair distribution Although the client’s NORMAL

may vary on the hair is thinner than
amount of terminal usual, it is evenly
hair covered in the distributed.
scalp. Older women
127
may have a terminal

hair growth on the
chin owing to
hormonal changes.
Body Hair
Body Hair The hair distribution The hair distribution NORMAL

may vary on the of the client's visible
amount of terminal body parts which are
hair covered in the arms and legs are
body. Older women evenly distributed.
may have a terminal The hair is thin.
hair growth on the
chin owing to
hormonal changes
HEAD TO NECK ASSESSMENT

Body Part/Area Normal Actual Interpretation and Analysis
to be Assessed Findings Findings
Head
Head Head size The client’s NORMAL

and shape head is
vary, normocephalic;
especially symmetric,
in accord round, and
with erect. Also,
ethnicity. there are no
Usually the lesions visible.
head is
symmetric,
round,
erect, and
in midline
and
appropriatel
y related to
body size
normoceph
128
alic No
lesions are
visible.
Involuntary Head The client’s NORMAL

movement of the should be head was held
head held still still and upright.
and There are no
upright. signs of jerking
and involuntary
nodding
movements.
Face
Face The face is The face of the NORMAL

symmetric client is
with a symmetric with
round, oval, a round
elongated, appearance.
or square After instructing
appearance the client to
. No smile with and
abnormal without showing
movements her teeth,
noted. blasting her
cheeks, raising
an eyebrow,
and closing her
eyes really
tight, there are
no signs of
weakness and
asymmetric in
the facial
movements and
expressions of
the client.
Temporal artery The After palpating NORMAL

temporal the temporal
artery is artery of the
elastic and client, there is
not tender. no hardness,
thickness, nor
129
tenderness.
The temporal
artery of the
client is elastic
and definitely
not tender.
Temporomandib Normally After palpating NORMAL

ular Joint (TMJ) there is no the
swelling, temporomandib
tenderness ular joint of the
or client, there is
crepitation no sign of
with swelling,
movement. tenderness, nor
Mouth popping sound
opens and in the palpated
closes fully, area. The
3 to 6 cm mouth opens 5
between cm between the
upper and upper and
lower teeth. lower teeth, and
Lower jaw closes fully.
moves Also, the lower
laterally 1 to jaw moves
2 cm in laterally 2 cm in
each each direction.
direction.
Neck
Neck Neck is The neck of NORMAL

symmetric, the client is
with the symmetric,
head placed in the
centered center, and
and without there are no
bulging signs of
masses. swelling,
enlarged
masses, or any
nodules.
Movement of Normally After NORMAL

neck structure neck instructing the
130
movement client to turn the

should be head to the
smooth and right and to the
controlled left, which is
with 45- chin to
degree shoulder, touch
flexion, 55- each ear at the
degree shoulder, touch
extension, chin to chest,
40-degree and lift the chin
lateral to the ceiling,
abduction, the neck
and 70- movement of
degree the client is
rotation. smooth and
well-controlled.
Although the
client is older,
there is no
decrease in
flexion,
extension,
lateral bending,
and rotation of
the neck.
Moreover, there
are no signs of
stiffness,
rigidity, and
limited mobility
of the neck.
Cervical Cervical After NORMAL

vertebrae vertebrae instructing the
are usually client to flex her
visible and neck from chin
palpable. to chest, the C7
is visible. There
are prominence
or swellings
other than the
C7 vertebrae.
Trachea Trachea is The trachea of NORMAL
131
midline. the client is in

midline.
Thyroid gland The After NORMAL

landmarks positioning
of the myself behind
thyroid the client and
gland are instructing the
positioned client to raise
midline. her head and
slightly turn to
the right, I
palpate right
away the
thyroid
cartilage. The
landmarks are
positioned
midline and
there are no
signs of
abnormal
masses or
growth.
Lymph nodes There is no After palpating NORMAL.

swelling or the
enlargemen preauricular,
t and no postauricular,
tenderness and occipital
in the nodes, there is
preauricular no swelling or
, enlargement of
postauricula the nodes.
r, and Also, there is
occipital no tenderness
nodes. on the palpated
nodes.
Eyes
Distant visual Normal Without the NORMAL

acuity distant corrective
visual lenses, the
acuity is client is
132
20/20 with squinting her

or without eyes as she
corrective admitted that
lenses. This she cannot
means that read the letters.
the client However, with
can her corrective
distinguish lenses, the
what the client is not
person with unconsciously
normal tilting her head
vision can nor squinting
distinguish her eyes. She
from 20 feet can read the
away. snellen chart
fully.
Near visual Normal The client was NORMAL

acuity near visual able to read the
acuity is hand held
14/14 which Snellen chart
means that and the visual
the client acuity of the
can read client is 14/14.
what the
normal eye
can read
from a
distance of
14 inches.
Visual fields for With After NORMAL

gross peripheral normal performing the
vision peripheral confrontation
vision, the test, the client
client was able to see
should see the number of
the fingers I
examiner’s present the way
finger at the I see it at the
same time same time.
the There is no
examiner delayed or
sees it. absent
133
Normal perception the

visual field way the client
degrees are indicates the
approximat number of my
ely as finger.
follows: -
Inferior: 70
degrees -
Superior:
50 degrees
- Temporal:
90 degrees
- Nasal: 60
degrees
Corneal light The After NORMAL.

reflex reflection of performing the
the light on light reflex test,
the corneas the reflection of
should be in light on the
the exact corneas is in
same sport the exact same
on each spot on each
eye, which eye. There is
indicates no sign of
parallel deviated
alignment. alignment of the
eyes.
Cover test The While NORMAL

uncovered performing the
eye should cover test, the
remain uncovered right
fixed eye remains
straight fixed straight
ahead. The ahead while the
covered covered left eye
eye should remains fixed
remain ahead after
straight being
ahead after uncovered.
being
uncovered.
134
Eyelids Skin in The skin in the NORMAL

both eyelids both eyelids of
is without the client has
redness, no signs of
swelling, or redness,
lesions. swelling, nor
lesions.
And vice versa.
Eyeballs Eyeballs The eyeballs of NORMAL

are the client are
symmetrical symmetrically
ly aligned in aligned in the
sockets sockets and
without there are no
protruding signs of
or sinking. protrusion of
the eyeballs or
sunken
appearance of
the eyes.
Bulbar Bulbar The bulbar NORMAL

conjunctiva and conjunctiva conjunctiva of
sclera is clear, the client is
moist, and clear, moist,
smooth. and smooth.
Underlying There are no
structures signs of
are clearly dryness in the
visible. bulbar
Sclera is conjunctiva of
white. the client. The
underlying
structures of
the client are
clearly visible.
The sclera of
the client is
white and there
are no signs of
yellowish color
in the sclera of
the client.
135
Palpebral Palpebral The palpebral NORMAL

conjunctiva conjunctiva conjunctiva of
is free of the client is free
swelling, from foreign
foreign bodies such as
bodies, or dust, sand, and
trauma. small insects.
Also, the area
is free from any
lesions
Lacrimal No swelling The areas of NORMAL

apparatus or redness the lacrimal
should apparatus of
appear over the client have
areas of the no sign of
lacrimal swelling or
gland. The redness. The
puncta is puncta is visible
visible and has no
without swelling or
swelling or redness in the
redness area. Moreover,
and is the puncta is
turned turned slightly
slightly toward the eye
toward the of the client.
eye.
Cornea and lens The cornea There are no NORMAL

is areas of
transparent, roughness or
with no dryness in the
opacities. cornea of the
The oblique client. It is
view shows transparent and
a smooth has no opacity.
and overall While the lens
moist is also free from
surface; the opacities.
lens is free
of opacities.
Iris and pupil The iris is The iris of the NORMAL
136
typically client is round,

round, flat, flat, and the
and evenly color of the iris
colored. of the client is
The pupil is dark brown
round with which is evenly
a regular distributed. The
border, and pupil of the
is centered client is round
in the iris. and located at
Pupils are the center of
normally the iris. The
equal in pupil size of the
size (3-5 client is 4 mm
mm). An and equal in
inequality in both eyes.
pupil size of
less than
0.5 mm is
normal.
Pupillary The normal After NORMAL

reaction to light direct performing the
pupillary pupillary test
response is reaction to light,
constriction both pupils of
the client
constrict.
Consensual The normal After shining a NORMAL

response consensual light to the
pupillary client’s one eye
response is and putting a
constriction. barrier between
both eyes, I
have observed
that the both
pupils constrict.
Ears
Auricle, tragus, Normally There are no NORMAL

and lobule the auricle, signs of
tragus, and tenderness in
mastoid the auricle,
137
process are tragus, and

not tender. mastoid
process of the
client.
External A small After NORMAL

auditory canal amount of inspecting the
odorless external
cerumen is auditory canal
the only of the client,
discharge there is a small
normally amount of
present. yellow and flaky
Cerumen cerumen. There
color may are no smells
be yellow, noted nor
orange, red, bloody and
brown, watery
gray, or discharge.
black.
Consistenc
y may be
soft, moist,
dry, flaky,
or even
hard.
Tympanic The The tympanic NORMAL

membrane tympanic membrane of
(eardrum) membrane the client is
should be pearly gray. It is
pearly gray, shiny,
shiny, and translucent, and
translucent, there is no
with no bulging nor
bulging or retraction. It is
retraction. It in a slightly
is slightly concave shape,
concave, and is smooth,
smooth, and intact. After
and intact. shining a
A cone- penlight on the
shaped right ear of the
reflection of client, the
138
the tympanic
otoscope membrane is
light is located at 5
normally o’clock while
seen at 5 the left ear is
o’clock in located at 7
the right ear o’clock. There
and 7 are no red,
o’clock in yellowish,
the left ear. bluish, white
The short spots, or any
process bulging
and handle eardrum noted
of the in the tympanic
malleus and membrane of
the umbo the client. The
are clearly short process
visible. and handle of
the malleus is
not noted as it
is not visible in
penlight.
Whisper test The client After NORMAL

should be performing the
able to whisper test,
correctly the client was
repeat the able to repeat 3
two-syllable out 3 words.
word as
whispered.
Weber’s test Vibrations The client was NORMAL

are heard able to hear the
equally well vibration
in both equally in both
ears. No ears.
lateralizatio
n of sound
to either
ear.
Rinne’s test Air The client was NORMAL

conduction able to hear the
139
sound is bone
normally conduction for 7
heard seconds in both
longer than ears while air
bone conduction was
conduction heard for 14
sound. seconds.
Romberg’s test Client The client was NORMAL

maintains able to stand
position for still with her
20 seconds eyes closed
without and open for
swaying or about 20
with seconds.
minimal
swaying.
Nose
External nose Color is the The color of NORMAL

same as the nose of the
the rest of client is the
the face; same as the
the nasal color of this
structure is face. The nasal
smooth and structure is
symmetric; smooth and
the client symmetric.
reports no After palpating
tenderness. the nose, the
client stated
that there is no
pain.
Patency of Clients are The client was NORMAL

airflow through able to sniff able to sniff
the nostrils through through both
each nostril nostrils without
while the any problem.
other is
occluded.
Internal nose The nasal The nasal NORMAL

mucosa is mucosa of the
140
dark pink, client is dark

moist, and pink, moist, and
free of free of lesions
exudate. and
The nasal inflammation.
septum is The nasal
intact and septum is intact
free of and free of
ulcers or ulcers.
perforations Meanwhile, the
. Turbinates inferior
are dark turbinate of the
pink, moist, client is dark
and free of pink, moist, and
lesions. free of lesions.
Sinuses Frontal and After palpating NORMAL

maxillary the frontal and
sinuses are maxillary
nontender sinuses of the
to client, she
palpation, reported that
and no there is no any
crepitus is pain in the
evident. palpated area.
Also, there are
no cracks or
crepitus noted.
Mouth
Lips Lips are Lips of the DEVIATION FROM NORMAL

smooth and client are
moist chapped and Interpretation:
without dry. Chapped and dry lips could be
lesions or caused by hot weather. It
swelling. could also indicate yeast
infection, allergic reaction, and
actinic cheilitis.
Reference:
American Academy of
Dermatology Association.
(n.d.). 7 dermatologists' tips
141
for healing dry, Chapped Lips.

American Academy of
Dermatology. Retrieved
December 6, 2021, from
https://www.aad.org/public/ev
eryday-care/skin-care-
basics/dry/heal-dry-chapped-
lips.
Teeth Thirty-two Despite the NORMAL

pearly age, the client
whitish still has 32
teeth with teeth with
smooth smooth
surfaces surfaces and
and edges. edges. In
Upper addition, the
molars jaws of the
should rest client are
directly on aligned with no
the lower deviation seen
molars and when biting
the front down.
upper
incisors
should
slightly
override the
lower
incisors.
Some
clients
normally
have only
28 teeth of
the four
wisdom
teeth that
do not
erupt.
Gum Gums are The gums of NORMAL

pink, moist, the client are
and firm pink, moist, and
142
with tight form with tight

margins to margins to the
the tooth. tooth. There are
No lesions no signs of
or masses. redness and
redness or
swelling in the
gums. Also,
there are no
lesions or
masses noted.
Buccal mucosa The buccal The buccal NORMAL

mucosa in mucosa of the
all clients is client is pink.
smooth and There are no
moist whitish spots in
without the buccal
lesions. mucosa of the
client. Also, it is
smooth and
moist. There
are no lesions
noted.
Tongue Tongue The tongue of NORMAL

should be the client is
pink, moist, pink, moist, and
a moderate in moderate
size with size. It is not
papillae too long nor too
present. short. The color
of the papillae
present in the
tongue of the
client is evenly
distributed.
Ventral surface The The ventral NORMAL

of tongue tongue’s surface of the
ventral client’s tongue
surface is is smooth. It is
smooth. shiny and pink.
Shiny, pink, There are
143
or slightly visible veins

pale, with noted and no
visible veins lesions
and no observed.
lesions.
Wharton’s ducts The The frenulum NORMAL

frenulum is of the client is
midline. in midline.
Wharton Wharton duct is
ducts are visible with
visible, with moistness in
salivary the area. It has
flow or no swelling, nor
moistness redness. When
in the area. the client was
The client asked if there
has no are any pain in
swelling, the area, she
redness, or stated that
pain. there are none.
Sides of the There are There are no NORMAL

tongue no lesions, lesions, ulcers,
ulcers, or or any nodules
nodules noted in the
apparent in side of the
the side of tongue of the
the tongue. client.
Strength of the The tongue After checking NORMAL

tongue offers the strength of
strong the tongue of
resistance. the client, the
tongue is strong
enough to resist
the pressure of
my fingers on
both cheeks.
Hard and soft The hard The hard NORMAL

palate palate is palate of the
pale or client is in pale
whitish with pink color with
firm, firm and wrinkle
144
transverse like folds. While

rugae the palatine
(wrinkle like tissue of the
folds). client is intact.
Palatine Also, the soft
tissues are palate of the
intact. The client is in
soft palate pinkish color. It
should be is movable,
pinkish, soft, and
movable, smooth.
spongy,
and
smooth.
Mouth odor No unusual There is no NORMAL

or foul odor fruity or foul
is noted. odor noted in
the breath of
the client.
There is no
odor in the
mouth of the
client.
Uvula The uvula The uvula of NORMAL

is a fleshy, the client is
solid fleshy and
structure solid. It hangs
that hangs freely in the
freely in the middle. There is
midline. No no redness,
redness of lesion, or any
or exudate swollen area in
from uvula the uvula and
or soft soft palate. Soft
palate. palate is
Midline elevated
elevation of symmetrically.
uvula and
symmetric
elevation of
the soft
palate.
145
Tonsils Tonsils The tonsils of NORMAL

may be the client are
present or pink. It is
absent. symmetric and
They are enlarged to 1+.
normally There are no
pink and exudates,
symmetric swelling, or
and may be lesions noted.
enlarged to
1+ in
healthy
clients. No
exudate,
swelling, or
lesions
should be
present.

CHEST TO ABDOMEN ASSESSMENT
to be and Analysis
Assessed
Posterior Thorax
Configuration Scapulae are The scapulae of the NORMAL

symmetric and non- client are symmetric
protruding. Shoulders and not protruding.
and scapula are at The scapulae and the
equal horizontal shoulders are at
positions. The ratio of equal horizontal
anteroposterior to positions. Also, the
transverse diameter is ratio of the
1:2. Spinous processes anteroposterior to
appear straight, and transverse diameter
thorax appears of the client is 1:2.
symmetric, with ribs Meanwhile, the
sloping downward at spinous process of
approximately a 45- the client is straight,
degree angle in relation and the thorax are
to the spine. symmetric. The ribs
of the client are
146
sloping downward in
a 45-degree angle.
Use of The client does not The client is using NORMAL

accessory use accessory muscles the diaphragm as the
muscles namely trapezius or lower chest of the
shoulder to assist client expands as she
breathing. The breathes. There are
diaphragm is the major no signs of using the
muscle at work. This is trapezius or shoulder
evidenced by to assist her
expansion of the lower breathing.
chest during inspiration.
Client’s Clients should be The client is sitting NORMAL

positioning sitting up and relaxed, relaxedly with arms at
breathing easily with sides. She is also
arms at sides or in lap. breathing easily with
no any problems.
Tenderness, Client reports no The client reports no NORMAL

Sensation, and tenderness, pain, or pain and unusual
crepitus unusual sensations. sensations in the
Temperature should be palpated area. The
equal bilaterally. temperature of the
area is equal
bilaterally.
Fremitus Fremitus is symmetric The fremitus of the NORMAL

and easily identified in client is symmetric in
the upper regions of the a bilateral position
lungs. If fremitus is not and easily identified.
palpable on either side Although the intensity
the client may need to of fremitus decreases
speak louder. A as I move towards
decrease in the the base of the lungs,
intensity of fremitus is it is normal as I still
normal as the examiner felt the fremitus of the
moves toward the base client.
of the lungs. However,
fremitus should remain
symmetric for bilateral
positions.
Chest When the client takes When the client NORMAL
147
expansion a deep breath, the takes a deep breath,

examiner’s thumbs my thumb moves
should move 5 to 10 symmetrically from 5
cm apart symmetrically. cm apart.
Tone Resonance is the As I percuss over the NORMAL

percussion tone elicited lung tissue of the
over normal lung client, the percussion
tissue. Percussion tone is resonance
elicits flat tones over while over the
the scapula. scapula of the client
elicits flat tone.
Diaphragmatic Excursion should be The excursion of the NORMAL

excursion equal bilaterally and client is bilaterally
measure 3-5 cm in equal, measuring 5
adults. The level of cm.
diaphragm may be
higher on the right
because of the position
of the liver. In well-
conditioned clients,
excursions can
measure up to 7-8 cm.
Breath sounds Three types of normal After auscultating the NORMAL

breath sounds may be breathing sound of
auscultated which are the client, it is clear
the bronchial, that the client has no
bronchovesicular, and absent breath sounds
vesicular. as there are
indications that the
air is moving in and
out of the lung area.
Voice sounds Voice transmission is The voice NORMAL

soft, muffled, and transmission of the
indistinct. The sound of client in the
the voice may be heard bronchophony is
but the actual phrase indistinct. While in the
cannot be egophony, the voice
distinguished. transmission is soft,
muffled, and the letter
E is distinguishable.
And last, the
148
transmission of
sound in the
whispered
pectoriloquy is very
faint and muffled. It is
inaudible.
Anterior Thorax
Shape and The anteroposterior The ratio of the NORMAL

configuration diameter is less than anteroposterior
the transverse diameter to the
diameter. The ratio of transverse diameter
anteroposterior of the client is 1:2.
diameter to the
transverse diameter is
1:2.
Watch for Sternum is positioned The sternum of the NORMAL

sternal at midline and straight. client is straight and
retractions Retractions not in midline. There are
observed in the no retractions
sternum. observed in the
sternum.
Slope of the Ribs slope downward The ribs of the client NORMAL
ribs with symmetric are sloping
intercostal spaces. The downward and
Coastal angle is within intercostal spaces
90 degrees. are symmetric. The
costal angle of the
client is 90 degrees.
Quality and Respirations are The respirations of NORMAL

pattern of relaxed, effortless, and the client are relaxed,
respirations quiet. They are of a effortless, and quiet.
regular rhythm and There are no signs of
normal depth at a rate labored nor noisy
of 10-20 per minute in breathing. The
adults. Tachypnea and respiration rate of the
bradypnea may be client is 15 per
normal in some clients. minute.
Intercostal No retractions or There are no NORMAL

spaces bulging of intercostal retractions nor bulged
149
spaces are noted. notes in the

intercostal spaces of
the client.
Use of Use of accessory The client is not NORMAL

accessory muscles (sternomastoid using any accessory
muscles and rectus abdominis) muscles to support
is not seen with normal her breathing.
respiratory effort. After
strenuous exercise or
activity, clients with
normal respiratory
status may use neck
muscles for a short
time to enhance
breathing.
Tenderness, No tenderness or pain There are no signs NORMAL

sensation and is palpated over the of tenderness or pain
surface lung area with in the palpated area.
masses respirations.
Tenderness at Palpation does not There are no signs NORMAL

costochondral elicit tenderness. of tenderness noted
junctions of in the costochondral
ribs junctions of the ribs.
Crepitus No crepitus is There are no NORMAL

palpated. crepitus noted in the
palpated area.
Surface No unusual surface There are no NORMAL.

masses or masses or lesions are unusual masses or
lesions palpated. lesions noted in the
palpated area.
Fremitus Fremitus is symmetric The fremitus of the NORMAL

and easily identified in client is symmetric
the upper regions of the bilaterally and easy to
lungs. A decreased identify. There is a
intensity of fremitus is decrease in the
expected toward the intensity of the
base of the lungs. fremitus of the client
However, fremitus but it is normal.
should be symmetric
150
bilaterally.
Anterior chest Thumbs move outward The thumbs move NORMAL

expansion in a symmetric fashion outward
from the midline. symmetrically from
the midline.
Tone Resonance is the Resonance is the NORMAL

percussion tone elicited tone elicited over the
over normal lung lung tissue of the
tissue. Percussion client while dullness
elicits dullness over is the percussion
breast tissue, the heart, tone elicited over the
and the liver, Tympany breast tissue, heart,
is detected over the and liver of the client.
stomach, and flatness Tympany is the tone
is detected over the elicited over the
muscles and bones. stomach of the client
and flatness is the
tone elicited over the
muscles and bones
of the client.
Breath sounds, Three types of normal After auscultating the NORMAL

adventitious breath sounds may be breathing sound of
sounds, voice auscultated which are the client, it is clear
sound the bronchial, that the client has no
bronchovesicular, and absent breath sounds
vesicular. No as there are
adventitious such as indications that the
crackles or wheezes air is moving in and
are auscultated. Voice out of the lung area.
transmission is soft, There are no crackles
muffled, and indistinct. or wheezes. The
The sound of the voice voice transmission of
151
may be heard but the the client in the

actual phrase cannot bronchophony is
be distinguished. indistinct. While in the
egophony, the voice
transmission is soft,
muffled, and the letter
E is distinguishable.
And last, the
transmission of
sound in the
whispered
pectoriloquy is very
faint and muffled. It is
inaudible.
FEMALE BREAST
Inspect size Breasts can be a Breasts of the client NORMAL

and variety of sizes and are are round and
symmetry. somewhat round and symmetric.
pendulous. One breast
may normally be larger
than the other.
Inspect color Color varies depending The client’s breasts NORMAL

and on the client’s skin color is brown,
texture. tone. Texture is symmetric to his body
smooth, with no skin tone. Also,
edema. Linear stretch breast is smooth.
marks may be seen There is no edema
during and after present.
pregnancy or with
significant weight gain
or loss.
Inspect Veins radiate either The client has no NORMAL

superficial horizontally and toward visible veins around
venous the axilla (transverse) the breast area
pattern. or vertically with a
lateral flare
(longitudinal). Veins are
more prominent during
pregnancy.
Inspect the Areolas vary from dark The client’s areola NORMAL
152
areolas. pink to dark brown, are dark brown and

depending on the round.
client’s skin tones.
They are round and
may vary in size. Small
Montgomery tubercles
are present.
Inspect the Nipples are nearly The client’s nipples NORMAL

nipples. equal bilaterally in size are bilaterally equal,
and are in the same same location on
location on each each breast, and
breast. everted.
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 The client’s breasts The client’s breasts NORMAL

retraction and should rise rose symmetrically
dimpling. symmetrically, with no with no sign of
sign of dimpling or dimpling nor
retraction. retraction.
Palpate for A generalized increase The client did not NORMAL

tenderness in nodularity and report any
and tenderness may be a tenderness upon
temperature. normal finding palpation of each
associated with the breast. Also, breasts
menstrual cycle or are in a normal body
hormonal medications. temperature.
Breasts should be a
normal body
temperature.
Palpate for No masses should be The client’s breasts NORMAL

masses. palpated. However, a have no masses or
153
firm inframammary nodules palpated.

transverse ridge may
normally be palpated at
the lower base of the
breasts.
Palpate for The nipple may The client’s nipples NORMAL

nipples. become erect and the have no discharge.
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 No rash or infection The client’s both NORMAL

palpate noted. No palpable axillae have no
the axillae. nodes or one to two redness, rash, or
small (less than 1 cm), infection. Also, both
discrete, nontender, axillae are discrete,
movable nodes in the nontender, and no
central area. palpable nodes.
Ask the client Client may request The client NORMAL

to instructions on how to cooperated and
demonstrate perform the exam or followed the
how choose not to learn examiner’s
she performs how to perform the demonstration of
BSE exam. Either choice breast self
needs to be accepted examination.
by the examiner.
HEART AND NECK VESSELS
Observe the The jugular venous The jugular venous NORMAL

jugular pulse is not normally pulse of the client is
venous pulse. visible with the client not visible.
sitting upright. This
position fully distends
the vein, and pulsations
may or may not be
discernible.
154
Evaluate The jugular vein The jugular vein NORMAL

jugular should not be should not be
venous distended, bulging, or distended, bulging, or
pressure. protruding at 45 protruding at 45
degrees or greater. degrees or greater.
Auscultate the No blowing or swishing There are no blowing NORMAL

carotid arteries or other sounds are or swishing sounds
heard. noted in the carotid
arteries of the client.
Palpate the Pulses are equally Both pulses of the NORMAL

carotid strong; a 2+ or normal carotid artery of the
arteries. with no variation in client are equally
strength from beat to strong at 2+ with no
beat. Contour is variation in the
normally smooth and strength from beat to
rapid on the upstroke beat. The contour of
and slower and less the carotid artery of
abrupt on the the client in the
downstroke. The upstroke is smooth
strength of the pulse is and rapid while on
elevated on a scale the down stroke, it is
from 0 to3. Arteries are slower and less
elastic and no thrills are abrupt. Also, the
noted. arteries of the client
are elastic and there
are no thrills noted.
HEART
Inspect The apical impulse The apical impulse NORMAL

pulsations. may or may not be of the client is not
visible, it would be in visible.
the mitral area. The
apical impulse is a
result of the left
ventricle moving
outward during systole.
Palpate the The apical impulse is The apical impulse is NORMAL

apical impulse. palpated in the mitral visible in the mitral
area and may be the area of the client.
size of a nickel (1-2 There are no any
cm). Amplitude is pulsations noted
155
usually small – like a aside from the apical

gentle tap. The duration pulsations. The apical
is brief, lasting through impulse is in the size
the first two-thirds of of 1 cm. The apical
systole and often less. impulse feels like a
In obese clients or gentle tap and is
clients with large small in amplitude
breasts, the apical and corresponds to
impulse may not be the first two thirds of
palpable. systole.
Palpate for No pulsations or There are no any NORMAL

abnormal vibrations are palpated pulsations or
pulsations. in the areas of the vibrations noted on
apex, left sternal the areas of the apex,
border, or base. left sternal border,
and base of the
client.
Auscultate Rate should be 60-100 The heart rate of the NORMAL

heart beats/min, with regular client beats 65 per
rate and rhythm. A regularly minute with regular
rhythm. irregular rhythm, such rhythm.
as sinus arrhythmia
when the HR increases
with inspiration and
decreases with
expiration, may be
normal in young adults.
Resting pulse rate
(RPR) varies by age,
gender, and
ethnic/racial factors.
Adult female RPRs are
a few beats faster than
male RPRs.
Auscultate to S1 corresponds with The S1 of the client NORMAL

identify S1 and each carotid pulsation is heard the loudest
S2 and is loudest at the at the apex of the
apex of the heart. S2 heart. The sound
immediately follows becomes softer with
after S1 and is loudest inspiration. While the
at the base of the heart. S2 is heard the
156
loudest at the base of

the heart of the client.
Auscultate for Normally no sounds After auscultating the NORMAL

extra are heard. A heart of the client,
heart sounds. physiologic S3 heart there are no extra
sound is a benign heart sounds heard
finding commonly like clicking or
heard at the beginning ejection sounds.
of the diastolic pause in
children, adolescents,
and young adults, It is
rare after age 40. A
physiologic S4 heart
sound may be heard
near the end of diastole
in well-conditioned
athletes and in adults
older than age 40 or 50
with no evidence of
heart disease,
especially after
exercise.
Auscultate for Normally no murmurs There are no NORMAL

murmurs. are heard. However, murmurs noted after
innocent and auscultating the heart
physiologic midsystolic of the client.
murmurs may be
present in a healthy
heart.
ABDOMEN
Observe the Abdominal skin may The abdominal skin NORMAL

coloration of be paler than the of the client is lighter
the general skin tone than the general skin
skin. because this skin is so tone. There are no
seldom exposed to the signs of purple and
natural elements. yellowish
discoloration. There
are also no signs of
redness and bruises
in the abdomen of the
client.
157
Note the Scattered fine veins The veins in the NORMAL

vascularity of may be visible. Blood in abdomen of the client
the abdominal the veins located above are not visible.
skin. the umbilicus flows However, it is still a
toward the head; blood normal finding as
in the veins located there are no dilated
below the umbilicus veins noted in the
flows toward the lower abdomen of the
body. client.
Note any striae New striae are pink or The client had NORMAL
bluish in color; Old stretch marks from
striae are silvery, white, the past pregnancy.
linear, and uneven
stretch marks from past
pregnancies or weight
gain.
Inspect for Pale, smooth, The client had an old NORMAL

scars. minimally raised old scar due to her past
scars may be seen. cesarean delivery.
Assess for Abdomen is free of The abdomen of the NORMAL

lesions and lesions or rashes. Flat client is free from
rashes. or raised brown moles, lesions and rashes.
however, are normal There are scattered
and may be apparent. flat moles noted.
Inspect the Umbilical skin tones The umbilical skin NORMAL

umbilicus. are similar to tone of the client is
surrounding abdominal similar to the
skin tones or even surrounding
pinkish. abdominal skin tones.
Observe Umbilicus is midline at The umbilicus is in NORMAL

umbilical the lateral line. the midline at the
location. lateral line.

Assess It is recessed or The shape of the NORMAL

contour of protruding no more umbilicus of the client
umbilicus. than 0.5 cm and is is round and it is
round or conical. inverted.
Inspect Abdomen is flat, The abdomen of the NORMAL
158
abdominal rounded, or scaphoid. client is evenly

Contour and Abdomen should be rounded.
symmetry evenly rounded.

Observe aortic A slight pulsation of In observing the NORMAL

pulsations. the abdominal aorta, aortic pulsations,
which is visible in the pulsations in the
epigastrium, extends abdomen are not
full length in thin visible.
people.
Observe for Normally, peristaltic Peristaltic waves are NORMAL

peristaltic waves are not seen, not seen in the client.
waves. although they may be
visible in very thin
people as slight ripples
on the abdominal wall.
Auscultate for A series of intermittent, There are soft clicks NORMAL

bowel soft clicks and gurgles and gurgles heard at
sounds. are heard at a rate of 5- a rate of 15 per
30 per minute. minute.
Hyperactive bowel
sounds referred to as
“borborygmus” may
also be heard. These
are the loud, prolonged
gurgles characteristic of
one’s “stomach
growling.”
Auscultate for Bruits are not normally There are no bruits NORMAL
vascular heard over abdominal sounds observed in
sounds. aorta or renal, iliac, or the abdominal aorta
femoral arteries. of the client.
However, bruits
confined to systole may
be normal in some
clients depending on
other differentiating
factors.
Listen for Venous hum is not There are no venous NORMAL

venous normally heard over the hum notes in the
159
hum. epigastric and umbilical epigastric and

areas. umbilical areas of the
client.
Auscultate for No friction rub over the There is no friction NORMAL

a liver or spleen is rub over the liver or
friction rub present. spleen.
over the
liver and
spleen.

Percuss for Generalized tympany The heard in the NORMAL

tone. predominates over the abdomen of the client
abdomen because of is tympany due to the
air in the stomach and air in the stomach
intestines. Dullness is and intestines while
heard over the liver and dullness is heard
spleen. over the liver and
spleen area.
Percuss the The lower border of The lower border of NORMAL

span or height the liver dullness is the liver dullness is
of the liver by located at the costal located at the costal
determining its margin to 1-2 cm margin to 2 cm
lower and below. On deep below. On deep
upper borders. inspiration, the lower inspiration, the lower
border of liver dullness border of liver
may descend from 1 to dullness descends
4 cm below the costal from 3 cm below the
margin. The upper costal margin. The
border of the liver upper border of the
dullness is located liver dullness is
between the left fifth located in the sixth
and seventh intercostal intercostal space.
spaces. The normal The liver span of the
liver span at the MCL is client at midclavicular
6-12 c. The normal liver line is 10 cm while in
span at the MSL is 4-8 the midsternal line is
cm. 6 cm.
Perform light Abdomen is nontender After performing the NORMAL

palpation. and soft. There is no light palpation, the
guarding client reports no
tenderness and the
160
abdomen is soft.
There is no guarding
noted.
Deeply palpate Normal tenderness is The client reports NORMAL

all possible over the mild tenderness over
quadrants to xiphoid, aorta, cecum, the xiphoid, aorta,
delineate sigmoid colon, and cecum, sigmoid
abdominal ovaries with deep colon, and ovaries
organs and palpation. after performing deep
detect palpation.
subtle masses.

Palpate for No palpable masses No palpable masses NORMAL

masses. are present. are present.
Palpate the Umbilicus and The umbilicus and NORMAL

umbilicus and surrounding area are surrounding area are
surrounding free of swelling, bulges, free of swelling,
area or masses. bulges, or masses.
for swellings,
bulges, or
masses.

Palpate the The aorta is The aorta has only a NORMAL

aorta. approximately 2.5-3.0 regular pulse. There
cm wide with a is mild tenderness
moderately strong and reported by the client.
regular pulse. Possibly
mild tenderness may
be elicited.
Palpate the The liver is usually not The liver of the client NORMAL
liver. palpable, although it is not palpable.
may be felt on some
thin clients. If the lower
edge is felt, it should be
firm, smooth, and even.
Mild tenderness may
be normal.
Palpate the An empty bladder is The client reports no NORMAL

urinary neither palpable nor tenderness in
161
bladder. tender. palpating the urinary

bladder. There are no
distended bladder
notes.
Assess for No rebound No rebound NORMAL

rebound tenderness is present. tenderness is
tenderness. present.

Musculoskeletal Assessment
Body Part/Area Normal findings Actual findings Interpretation and
to be Assessed analysis.
Muscles
Muscle size Muscle size The muscle size NORMAL

should be equal on both sides of
on both sides of the body of the
the body. client is symmetric
as there are no
signs of increased
or decreased
muscle size.
Muscles and The muscles and The muscles and NORMAL

tendons for tendons of the tendons of the
contractures client should have client have no
no contractures. signs of
contractures
Muscle for Muscles should There are no NORMAL

tremors have no fasciculations nor
fasciculation nor tremors noted in
tremors. the muscles of the
client.
Muscle tonicity The muscles at After palpating the

rest should be muscles of the
normally firm. client while it is at
rest, it is firm and
there are no signs
of lacking tone.
162
Flaccidity, The muscles The muscles of NORMAL

spasticity, and while the client is the client while it is
smoothness of active and passive active and passive
movement should be in is smooth and
smooth moves
coordinated coordinately.
movements. There are no signs
of flaccidity or
spasticity on the
muscles of the
client.
Muscle strength The The client was NORMAL

of the head & sternocleidomastoi able to turn her
shoulders d muscle of the head to both sides
(Sternocleidoma client should be against the
st oid) equally strong. resistance of my
hands. The
sternocleidomastoi
d muscle strength
of the client is at
100%.
Muscle strength The trapezius The client was

of the head & muscle of the able to shrug her
shoulders client should be shoulders against
(Trapezius) equally strong. the resistance of
my hands. The
trapezius muscle
strength of the
client is at 100%.
Muscle strength The deltoid While I was trying NORMAL

of the head & muscle of the to push down the
shoulders client should be arms of the client,
(Deltoid) equally strong. he was able to
hold both of her
arms up. The
deltoid muscle
strength of the
client is at 100%.
Muscle strength The biceps While I was trying NORMAL

of upper muscle of the to extend the arms
extremities client should be of the client, he
163
(Biceps) equally strong. was able to flex

both of her arms.
The biceps muscle
strength of the
client is at 100%.
Muscle strength The triceps While I was trying NORMAL

of muscle of the to flex the arms of
upper client should be the client, he was
extremities equally strong. able to extend
(Triceps) both of her arms.
The triceps muscle
strength of the
client is at 100%.
Muscle strength The wrist and The client was DEVIATION FROM
of upper finger muscles of able to spread her NORMAL
extremities the client should fingers and resist
(Wrist and be equally strong. my attempt to Interpretation:
fingers) push the fingers Common causes of
together except for the inability to bend
the pinky finger fingers are arthritis,
which the client injuries, locked
can’t trigger finger, etc.
hyperextend. As of the client, she
admitted that it is
from her past bone
fracture.
Reference:
Mahmood, Z. S.
(2020, September
2). Common causes
of finger stiffness.
The Orthopaedic
Institute. Retrieved
December 6, 2021,
from https://www.toi-
health.com/physicia
n-articles/common-
causes-finger-
stiffness/.
Muscle strength The grip muscle The grip muscle NORMAL
164
of upper strength of the strength of the

extremities (Grip client should be client on both
strength) equal. hands is equally
strong.
Muscle strength The hip muscles While testing the NORMAL

of lower of the client should strength of the hip
extremities (Hip be equally strong. muscles of the
muscles) client, he was able
to raise both one
leg at a time while
I was attempting to
hold it down. In
testing the hip
abduction of the
client, he was able
to resist my
attempt to close
her legs. While
testing the hip
adduction, the
client was able to
close her legs
together while I
was trying to bring
her legs apart. The
hip muscle
strength of the
client in terms of
abduction and
adduction is at
100%.
Muscle strength The hamstring The client was NORMAL

of lower muscle strength of able to resist my
extremities the client should attempt to
(Hamstrings) be equally strong. straighten her both
legs. Therefore,
the muscle
strength of the
client is 100%.
Muscle strength The quadriceps The client was NORMAL

of lower muscle strength of able to resist my
165
extremities the client should attempt to flex

(Quadriceps) be equal. both of her knees.
Therefore, the
muscle strength of
the client is 100%.
Muscle strength The ankle and The client was NORMAL

of lower feet muscle able to resist my
extremities strength of the attempt to
(Muscles of the client should be dorsiflex her foot,
Ankle and Feet) equal. as well as flexing
her foot.
Therefore, the
muscle strength of
the client is 100%.
Bones
Normal structure The skeleton of There are no NORMAL

and deformities the client should signs of
of the bone not have any deformities in the
deformities. skeleton of the
client.
Edema or The bones of the There are no NORMAL

tenderness of client should not signs of
the bones have any tenderness or
presence of swelling in the
tenderness or palpated bones of
swelling. the client.
Joint
Joint swelling, The joint should There is no NORMAL

tenderness, not have any tenderness,
smoothness of presence of swelling,
movement, swelling, crepitation, nor
crepitation, and tenderness, any nodules noted
presence of crepitation, and in the joint of the
nodules nodules. client.
Joint range of The range of The client was NORMAL

motion of the motion of the able to flex her
head (Neck-Pivot neck-pivot joint of neck-pivot joint at
166
joint) the client should 45 degrees while

be in full range of extending her
motion. neck at 55
degrees. In terms
of lateral flexion,
the client was able
to bend her neck
laterally at 40
degrees. And last,
the client was able
to rotate her head
at 70 degrees.

motion of body motion of the able to flex at 70
trunk (Trunk- trunk-gliding joint degrees and
gliding joints) of the client should extend her trunk-
be in full range of gliding joint
motion. without any limit
on her range of
motion. In terms of
hyperextension,
she was able to
perform it at 20
degrees. In terms
of lateral flexion,
he was able to
bend her left and
right trunk at 35
degrees and rotate
it at 30 degrees.
Joint range of The range of In terms of NORMAL

motion of upper motion of the assessing the
extremities shoulder-ball-and- range of motion of
(Shoulder-ball socket joint of the the shoulder-ball-
and-socket-joint) client should be in and-socket joint of
full range of the client, he was
motion. able to perform the
flexion at 180
degrees,
extension,
hyperextension at
50 degrees,
167
abduction at 180
degrees,
adduction at 50
degrees,
circumduction,
external rotation
and internal
rotation at 90
degrees without
any limit on her
range of motion.

motion of upper motion of the able to flex her
extremities wrist-condyloid wrist-condyloid
(wrist-condyloid joint of the client joint at 90 degrees
joints) should be in full while extending it
range of motion. at 70 degrees.
She was able to
perform
hyperextension at
30 degrees. In
terms of radial
flexion, the client
was able to bend
her wrist-condyloid
joint at 20 degrees
while ulnar flexion
is 55 degrees.

motion of upper motion of the able to perform the
extremities thumb-saddle joint flexion and
(Thumb-saddle of the client should extension at 90
joints) be in full range of degrees,
motion. abduction and
adduction at 30
degrees, and
opposition without
any limit on her
range of motion.
Joint range of The range of The hip-ball-and- NORMAL

motion of lower motion of the hip- socket joint of the
168
extremities (Hip- ball-and-socket client, in flexion,

ball-and-socket joint of the client was able to extend
joint) should be in full both of her knees
range of motion. at 90 degrees and
flexed it at 120
degrees. In
addition, she was
able to move each
leg at 90 degrees
and
hyperextended it
at 30 degrees. In
terms of abduction
and adduction,
she was able to
move each leg out
at 45 degrees and
move it back
beyond the other
leg at 20 degrees.
Also, the client
was able to
perform
circumduction at
360 degrees,
internal and
external rotation at
90 degrees
without any limit
on her range of
motion.

motion of lower motion of the able to flex and
extremities knee-hinge joint of extend both of her
(Knee-hinge the client should knee-hinge joints
joints) be in full range of at 120 degrees.
motion.

motion of lower motion of the able to flex his
extremities ankle-hinge joint of ankle-hinge joint at
(Ankle-hinge the client should 20 degrees and
joints) be in full range of extend it at 45
169
motion. degrees without

any limit on her
range of motion.

motion of lower motion of the foot- able to evert and
extremities gliding joint of the invert her foot at 5
(Foot-gliding client should be in degrees.
joints) full range of
motion.
C. SON (MR. R.G.S 1)
1.
Body Part/Area Normal Findings Actual Findings Interpretation and

to be Assessed Analysis
General Appearance & Mental Status
Signs of distress No distress The client is relaxed Normal

in Posture or noted and sitting upright.
Facial Respiratory Rate
Expression (RR): 16 breaths
per minute.
170

Body build, Proportionate, The client’s body Deviation

weight, and varies with build is Upon assessing Mr.
height in relation lifestyle endomoroph, R. G. S. 1’s BMI, his
to the age, measured 130 kg in BMI is 44.9,
lifestyle, and weight, and 5’7 in indicating his weight
health height. The client’s is in the obese
overall lifestyle is category for adults of
unhealthy at a his height since BMI
young age since his resulting in 30 and
nutrition and dietary above indicates in
is inadequate and the obese category
excessive amounts which is a deviation
of foods. from normal.
According to the
CDC (n.d.), for his
height, a healthy
weight range would
be from 118 to 159
pounds. Obesity is a
condition in which
the patient
accumulates
abnormal or
excessive fat for
his/her age and
gender that exceeds
overweight (Doenges
et al., 2016). People
who are obese, such
as Mr. R. G. S. 1, are
at higher risk for
chronic conditions
such as high blood
pressure, diabetes,
and high cholesterol
(CDC, n.d.). The
patient exhibits poor
eating habits of over
eating high in fat, salt
and/or sugar that
impair our daily
171

health and wellbeing

and reduce our
ability to lead an
enjoyable and active
life. He also displays
a sedentary lifestyle
wherein little to or no
physical activity and
exercise is done, as
opposed to an active
lifestyle that
increases all-cause
mortality and the
risks for
cardiovascular
diseases (Park et al.,
2020).
Posture and gait, Relaxed, erect The client is Normal

standing, sitting, posture, relaxed, has erect
and walking coordinated posture, and
movement coordinated
movement.
Overall hygiene Clean, neat The client has a Normal

and clean and neat
Grooming appearance.
Body breath and No body or The client has no Normal

body breath odor or body and breath
Odor minor body odor odor.
relative to work or
exercise.
Obvious signs of Healthy It is observable that Deviation

health or illness appearance the client has a
higher percentage Endomorph, a
of body fat with less human physical type
muscle mass. He is (somatotype) tending
rounder in shape toward roundness,
with smaller joints, a as determined by the
172

smaller body size, physique-

and a narrower classification system
frame. developed by
American
psychologist W.H.
Sheldon. The
extreme endomorph
has a body as nearly
globular as humanly
possible; he has a
round head, a large,
round abdomen,
large internal organs
relative to his size,
rather short arms
and legs with fat
upper arms and
thighs, but slender
wrists and ankles
(Britannica, 2019).
High body fat can
increase the risk of
conditions such as
diabetes and
cardiovascular
disease. Having too
little body fat can
also be harmful,
potentially affecting
fertility, immunity,
and heart health
(Villines, 2020_).
Client’s attitude Cooperative The client was Normal

cooperative when
he was asked to
stand up and
responsive when he
was asked a few
questions.
173

Affect/mood and Appropriate to The response of the Normal

appropriateness situation client to questions
of the response asked were all
appropriate.
Quantity, quality, Understandable, The client has Normal

and organization moderate pace, understandable
of speech. exhibits thought speech, in
association moderate pace, and
associated
thoughts.
HEAD TO NECK ASSESSMENT

Integumentary System Assessment: SKIN
Skin color Varies from light The client has a deep Normal
to deep brown, brown or rich skin color
from ruddy pink to
light pink.
Uniformity of Skin Generally uniform The client has a Normal

color in the areas except in areas uniformed deep brown
of the face, arms, exposed to sun; skin color except in
chest, abdomen, areas of lighter areas exposed to sun.
and legs pigmentation in
dark skinned.
Skin lesions on Freckles, some The patient has no skin Normal

the anterior and birthmarks, some lesions, raised nevi, or
posterior of the flat and raised abrasion on the arms,
upper body, arms, nevi, no abrasion anterior & posterior of
and legs or other lesion the upper body. There
are only observable
freckles on the posterior
174
of the upper body of the

patient.
Skin moisture on Moisture in skin The client has moisture Normal

the upper and folds and the in skin folds and the
lower extremities axillae, affected axillae; and hence, no
by different excessive skin moisture
factors or dryness.
Skin temperature Uniform, within The client has a uniform Normal

on the upper and normal range skin temperature in
lower extremities comparing his upper
and lower limbs. The
temperature in both
upper and lower limbs
are warm to touch and
within the normal range.
Presence of No edema There is no assessed Normal

edema. presence of edema in
the skin of the client.
Presence of turgor When pinched, The skin of the client Normal

on skin springs back returned to its normal or
the mid-clavicle to previous state previous state after
and palpation.
the posterior of
both
hands
Integumentary System Assessment: HAIR
Evenness of hair Evenly distributed The client has evenly Normal

scalp growth hair distributed
Thickness or Thick hair The client has thick Normal

thinness of the hair.
hair scalp
Texture and Silky, resilient The client has silky and Normal
oiliness of hair hair resilient hair.
scalp
175
Presence of No infection or There was no presence Normal

infections or infestation of infections and
infestations on the infestations.
hair, scalp, behind
the ears, and
between the
hairline and neck
Amount of body Variable The client has variable Normal

hair on the amount of body hair
axillary, arms, and
legs
Integumentary System Assessment: NAILS
Plate shape of Convex curvature; The fingernail plate, the

fingernails angle between client has a convex Normal
nail and nail bed curvature nail plate
usually 160̇⁰ shape.
Color of fingernail Highly vascular The fingernail plate, the Normal

and toenail bed and pink in light client has a convex
skinned; dark curvature nail plate
skinned may be shape.
brown or black
Tissues Intact epidermis The client has intact Normal

surrounding nails. epidermis.
Texture of Smooth texture The client has a smooth Normal

fingernail and texture in both fingernail
toenail and toenail.
Blanch test of Prompt return or The usual color of the Normal

capillary refill of pink or usual nail bed of the client
the nails color, less than returned after palpation
four seconds in less than four
seconds.

Body Part/Area to Normal Findings Actual Findings Interpretation
be Assessed and Analysis
Head Head size and shape The client’s head is Normal

vary, especially in normocephalic;
176
accord with ethnicity. symmetric, round,

Usually the head is and erect. Also,
symmetric, round, there are no lesions
erect, and in midline visible.
and appropriately
related to body size
normocephalic No
lesions are visible.
Involuntary Head should be held The head is held Normal

movement of the still and upright. upright with no
head signs of involuntary
movements.
Face The face is The client’s face is Normal

symmetric with a round in shape,
round, oval, symmetric, equal on
elongated, or square each side, and is
appearance. No positioned at the
abnormal midline. His facial
movements noted. skin is smooth and
free from skin
lesions or snake
diseases.
Temporal artery The temporal artery The patient’s Normal

is elastic and not temporal artery is
tender. palpable and elastic
with no tenderness.
Temporomandibular Normally there is no The patient’s TMJ is Normal

Joint (TMJ) swelling, tenderness, free from swelling,
or crepitation with tenderness, and
movement. Mouth crepitation. His
opens and closes mouth opens and
fully (3-6 cm between closes fully
the upper & lower measured 6 cm and
teeth). Lower jaw his lower jaw moves
moves laterally 1-2 laterally on each
cm in each direction. side measured by 2
cm.
Neck Neck is symmetric, Upon inspection, Normal

with the head the patient’s neck is
centered and without symmetric, with his
177
bulging masses. head positioned at

the center, with no
presence of bulging
masses.
Movement of neck The thyroid cartilage, When the patient is Normal

structure corticoid cartilage asked to sip small
move upward amounts of water to
symmetrically as the inspect the
client swallows. movement of his
neck structures,
they thyroid and
cricoid cartilage
moved upward
symmetrically as he
swallowed.
Cervical vertebrae C7 (vertebra The patient’s C7 Nomal

prominens) is usually vertebrae are not
visible and palpable. visible but palpable
due to fat
accumulated fat.
Range of motion Normally neck As inspected on the Normal

(Neck) movement should be neck’s range of
smooth and motion of the client,
controlled with 45 his neck movement
degree flexion, 55- is controlled and
degree extension, smooth with 45-
40-degree extension, degree flexion, 55-
40- degree extension,
degree lateral 40- degree lateral
abduction, and 70- abduction, and 70-
degree rotation degree rotation.
Trachea Trachea is midline Upon palpation, the Normal

patient’s trachea is
positioned midline.
Thyroid gland Landmarks are Upon palpation, the Normal

positioned midline. patient’s thyroid
Glandular thyroid gland is positioned
tissue may be felt midline with, lobes
rising underneath are smooth, rubbery
your fingers. Lobes and free from
178
should feel smooth, nodules. No bruits

rubbery, and free of were also
nodules. No bruits auscultated.
are auscultated.
Lymph nodes There is no swelling Upon palpation, the Normal

or enlargement and client’s lymph
no tenderness. nodes are not
present, inflamed,
enlarged, or
tender.
Distant visual acuity Normal distant visual As assessed by Normal

acuity is 20/20 with making the client
or without corrective read the Snellen
lenses. This means chart, the client's
that the client can distant acuity is
distinguish what the 20/20 for both right
person with normal and left eye. This
vision can distinguish means that the
from 20 feet away. client can
distinguish what the
person with normal
vision can
distinguish from 20
feet away.
Near visual acuity Normal near visual Upon assessing Normal

acuity is 14/14 (with near visual acuity,
or without corrective the client can read
lenses). This means the Snellen chart 14
that the client can inches from the
read what the normal eyes, which means
eye can read from a the client has a
distance of 14 inches normal near visual
acuity of 14/14.
Visual fields for With normal The client was able Normal
gross peripheral peripheral vision, the to see the
vision client should see the examiner’s finger at
examiner’s finger at the same time the
the same time the examiner sees it.
examiner sees it. With inferior visual
Normal visual field field measured 70
degrees are degrees, superior
179
approximately as measured 50
follows: degrees, temporal
• Inferior: 70 degrees measured 90
• Superior: 50 degrees, and nasal
degrees measured 60
• Temporal: 90 degrees.
degrees
• Nasal: 60 degrees
Corneal light reflex The reflection of light Upon assessment Normal

on the corneas for the corneal light
should be in the reflex of the client
exact same spot on using a penlight, the
each eye, which reflection of light in
indicates parallel his corneas are in
alignment. the exact same spot
on each eye.
Cover test The uncovered eye Upon doing a cover Normal

should remain fixed test on the client’s
straight ahead. The eye, the uncovered
covered eye should eye remained fixed
remain fixed straight straight ahead and
ahead after being his covered eye
uncovered. also remained fixed
after being
uncovered.
Position test Eye movement As performed the Normal

should be smooth position test on the
and symmetric client’s eye, his eye
throughout all six movement is
directions smooth and
symmetric
throughout all six
directions.
Position of eyelids The lower eyelid is Upon assessment Normal

upright with no of the client’s
inward or outward position of her
turning. Eyelashes eyelids, her lower
are evenly distributed eyelids are upright
and curve outward with no inward or
along the lid outward turning, her
margins. eyelashes are
180
evenly distributed
Skin on both eyelids and are curved
is without redness, outward, and her
swelling, or lesions skin on both eyelids
have no presence
of redness,
swelling, and
lesions.
Eyeballs Eyeballs are The client’s eyeball Normal

symmetrically aligned positioning, his
in sockets without eyeballs are
protruding or symmetrically
sinking. aligned in sockets
without protruding
or sinking.
Bulbar conjunctiva Bulbar conjunctiva is Upon assessing, Normal

and sclera clear, moist, and the client’s bulbar
smooth. Underlying conjunctiva is clear,
structures are clearly moist and smooth.
visible. Sclera is The underlying
white. structures were
clearly visible and
the client’s sclera is
white.
Palpebral The lower and upper The client’s Normal

conjunctiva palpebral palpebral
conjunctivae are conjunctiva is clear
clear and free of and is free from any
swelling or lesions. lesions, swelling,
Palpebral conjunctiva foreign bodies or
is free of swelling, trauma.
foreign bodies, or
trauma.
Lacrimal apparatus No swelling or Upon assessment, Normal

redness should there was no
appear over areas of swelling or redness
the lacrimal gland. in the areas of the
The puncta is visible lacrimal gland of the
without swelling or client as well as in
redness and is the area around the
turned slightly toward puncta, which
181
the eye. No drainage appears to be

should be noted from turned slightly
the puncta when toward the eye.
palpating the While upon
nasolacrimal duct palpation, the
nasolacrimal duct of
the client has no
drainage.
Cornea and lens The cornea is The client’s cornea Normal

transparent, with no is transparent and
opacities. The with no opacities.
oblique view shows a The oblique view of
smooth and overall the cornea showed
moist surface; the a smooth and
lens is free of overall moist
opacities. surface; The lens
has no opacities.
Iris and pupil The iris is typically Upon assessing, Normal

round, flat, and the client’s iris is
evenly colored. The round, flat and has
pupil, round with a evenly colored
regular border, is brown eyes. While
centered in the iris. her pupil was
Pupils are normally observed to be
equal in size (3 to 5 round with a regular
mm). An inequality in border and have
pupil size of less than irises on its center.
0.5 mm occurs in The client’s pupils
20% of clients. This are approximately 4
condition, called mm.
anisocoria, is
normal.
Pupillary reaction to The normal direct The client’s eyes Normal

light pupillary response is constricted when it
constriction. was tested for direct
pupillary response.
Consensual The normal Upon testing for the Normal

response consensual pupillary consensual
response is response,
constriction constriction was
observed in the
182
pupils of the client.
Accommodation test The normal pupillary The client’s pupils Normal

to pupil response is constrict as the
constriction of the examiner's penlight
pupils and moves near her
convergence of the nose. Convergence
eyes when focusing of the eyes was
on a near object also observed.
(accommodation and
convergence).
Auricle, tragus, and Ears are equal in Upon inspection, Normal

lobule size bilaterally the client’s ears are
(normally 4–10 cm). bilaterally equal in
The auricle aligns size and are
with the corner of approximately 6 cm,
each eye and within his auricle aligns
a 10- degree angle of the corner of each
the vertical position. eye and within a
Earlobes may be 10° angle of
free, attached, or position, her
soldered (tightly earlobes are freely
attached to adjacent attached, and the
skin with no apparent skin of her ears are
lobe). The skin is smooth with no
smooth, with no presence of lesions,
lesions, lumps, or lumps, and nodules.
nodules. Color is Color is also
consistent with facial consistent with
color. Darwin’s facial color. There is
tubercle, which is a no discharge
clinically insignificant present.
projection, may be
seen on the auricle.
No discharge should
be present
External auditory A small amount of The client has a Normal

canal odorless cerumen small amount of
(earwax) is the only yellow, moist and
discharge normally odorless cerumen.
present. Cerumen The client’s canal
color may be yellow, walls are pink and
183
orange, red, brown, smooth.

gray, or black.
Consistency may be
soft, moist, dry, flaky,
or even hard. The
canal walls should be
pink and smooth,
without nodules.
Auricle and mastoid Normally the auricle, The client’s auricle, Normal
process tragus, and mastoid tragus, and mastoid
process are not process are
tender nontender.
Tympanic The expected normal Upon assessing, Normal

membrane tympanic membrane the client’s eardrum
(eardrum) should be pearly, is pearly, gray,
gray, shiny, and shiny, slightly
translucent, with no concave, intact and
bulging or retraction. translucent. There
It should be slightly are no nodules or
concave and intact. bulging seen.
Whisper test Able to correctly The client was able Normal

repeat the two to repeat all of the
syllable words as two syllable word as
whispered. whispered.
Weber’s test Vibrations are heard The client was able Normal
equally well in both to equally hear the
ears. No vibrations on his
lateralization of both ears and there
sound to either ear. is no reported
lateralization to
either ear.
Rinne’s test Air conduction sound The client heard the Normal
is normally heard air conduction
longer than bone sound longer than
conduction sound the bone
(AC > BC) conduction sound.
Romberg’s test Client maintains The client was able Normal

position for 20 to stand straight for
seconds without 20 seconds with his
184
swaying or with eyes open, without

minimal swaying. swaying and was
also able to stand
straight for 20
seconds with his
eyes closed, with
minimal swaying.
External nose Color is the same as Upon assessment, Normal

the rest of the face; the client’s nose
the nasal structure is color is uniform with
smooth and his facial color while
symmetric; the client his nasal structure
reports no is smooth and
tenderness. symmetric and the
client does not
complain for any
tenderness.
Patency of airflow Client was able to Upon assessing for Normal

through the nostrils sniff through each patency of airflow,
nostril while the other the client was able
was occluded. to sniff through
each of her nostrils
even though the
other nostril was
being occluded.
Internal nose The nasal mucosa is The client was Normal

dark pink, moist, and observed to have
free of exudate. The an internal nose
nasal septum is which is dark, pink,
intact and free of moist, and free from
ulcers or exudate or any
perforations. fluids. The client’s
Turbinate is dark pink nasal septum is free
(redder than oral from lesions and
mucosa), moist, and ulcers while the
free of lesions. turbinate is dark
pink moist and free
from lesions.
Sinuses Frontal and maxillary As the sinuses Normal

sinuses are (temporal and
nontender to maxillary sinus) are
185
palpation, and no palpated, there is

crepitus is evident. no crepitation
The sinuses are not observed.
tender on Moreover, the
percussion. patient’s sinuses
are palpated, the
patient claimed
there is no
tenderness felt.
Lips Lips are smooth and Upon assessing the Normal

moist without lesions lips of the patient
or swelling. looks moist and
smooth.
Teeth Thirty-two pearly The patient has a Normal

whitish teeth with full set of white
smooth surfaces and teeth, with 16 lower
edges. Upper molars and 16 upper teeth.
should rest directly And there is no
on the lower molars such issue as tooth
and the front upper decay upon
incisors should inspection.
slightly override the Moreover, the
lower incisors. Some upper molars lie
clients normally have exactly on lower
only 28 teeth if the molars, and the
four wisdom teeth do front upper incisors
not erupt. No override the lower
decayed areas; no incisors. The patient
missing teeth. Client undergone wisdom
may have appliances tooth extraction to
on the teeth (e.g., remove the four
braces). Client may misaligned wisdom
have evidence of teeth.
repair work done on
teeth (e.g., fillings,
crowns, or cosmetics
such as veneers)
Gum Gums are pink, The client’s gums Normal

moist, and firm with are pink, moist and
tight margins to the firm. There are no
tooth. No lesions or lesions or building
186
masses masses found on

the area.
Buccal mucosa The buccal mucosa The client's buccal Normal

should appear pink in mucosa seems to
light-skinned clients; have a brighter pink
tissue pigmentation tone than his
typically increases in gums.
dark skinned clients.
Tongue Tongue should be Inspection reveals Normal

pink, moist, a that the client's
moderate size with tongue is pink in
papillae (little color, wet, and has
protuberances) papillae of modest
present. A common size on the surface
variation is a of the tongue.
fissured, topographic There is no
map–like tongue, variation on the
which is not unusual tongue, and there
in older clients. No are no lesions.
lesions are present.
Ventral surface of The tongue’s ventral Upon examination, Normal

tongue surface is smooth, the client's ventral
shiny, pink, or slightly surface of the
pale, with visible tongue is smooth,
veins and no lesions. glossy, and lighter
The older client may pink in color, with
have varicose veins some minor veins
on the ventral but no lesions.
surface of the
tongue
Wharton’s ducts The frenulum is the Wharton's duct Normal

midline; Wharton’s may be seen
ducts are visible, with beneath the client's
salivary flow or frenulum and
moistness in the positioned at the
area. The client has midline. Wharton's
no swelling, redness, ducts are visible,
or pain. moist, no signs of
swelling, redness
and pain.
187
Sides of the tongue No lesions, ulcers, or After examining the Normal

nodules are patient's side of the
apparent. tongue, it is
observable that
there are no
symptoms of
lesions, ulcers, or
nodules on either
side of the patient's
tongue.
Strength of the The tongue offers After testing the Normal

tongue strong resistance patient's tongue
strength, the tongue
throws out a lot of
resistance when the
operation is being
performed.
Hard and soft palate The hard palate is The hard and soft Normal
pale or whitish with palates, as well as
firm, transverse the uvula, of the
rugae (wrinkled like patient are white,
folds). Palatine firm, and the tissues
tissues are intact; the are intact. While the
soft palate should be soft palate is pink
pinkish, movable, and smooth in
spongy, and smooth. appearance.
Mouth odor No unusual or foul Upon assessment Normal

odor is noted of the client’s
mouth, it was noted
that the client has
no foul order or bad
breath.
Uvula The uvula is a fleshy, The client’s uvula Normal

solid structure that dangles freely in the
hangs freely in the middle of the back
midline. No redness of the mouth. It has
of or exudate from a firm structure with
uvula or soft palate. no redness.
Midline elevation of
uvula and symmetric
elevation of the soft
188
palate. A bifid uvula,

common in Native
Americans, looks like
it is split in two or
partially severed
Tonsils Tonsils may be Upon inspection, Normal

present or absent. the patient’s tonsils
They are normally are present but not
pink and symmetric swollen with a
and may be enlarged grade +1 scale. It
to 1+ in healthy appears to be
clients. No exudate, pinkish in color with
swelling, or lesions no presence of
should be present. exudate, swelling,
or lesions.
Posterior Throat is normally Upon inspection, Normal

pharyngeal wall pink, without exudate the patient’s
or lesions. posterior, the
pharyngeal wall is
pinkish in color, not
inflamed, swollen or
dry with no exudate
or lesions.

CHEST TO ABDOMEN ASSESSMENT
Posterior Thorax
Configuration Scapulae are The client’s scapulae Normal

symmetric and non are symmetric and
protruding. Shoulders non protruding. The
and scapula are at ratio of his
equal horizontal anteroposterior to
positions. The ratio of transverse diameter
anteroposterior to is 1:2. Thus, his
transverse diameter is spinous processes
1:2. Spinous and thorax appear
processes appear straight and
straight, and thorax symmetric, with his
appears symmetric, ribs sloping
189
with ribs sloping downward at a 45

downward at degree angle in
approximately a 45- relation to the spine.
degree angle in
relation to the spine.
Use of The client does not As observed, the Normal

accessory use accessory client did not use any
muscles (trapezius/ shoulder) of her accessory
muscles to assist muscles to assist her
breathing. The breathing.
diaphragm is the major
muscle at work. This is
evidence by expansion
of the lower chest
during inspiration
Client’s Clients should be The client’s position Normal

positioning sitting up and relaxed, is sitting upright and
breathing easily with relaxed and breathing
arms at sides or in easily with arms on
lap. the side.
Tenderness, Client reports no Upon palpation, the Normal

Sensation, and tenderness, pain, or client did not report
crepitus unusual sensations. any tenderness, pain,
Temperature should or unusual
be equal bilaterally. sensations on her
The examiner finds no back. There were no
palpable crepitus. palpable crepitus
evident.
Surface Skin and As palpated, the Normal

characteristics subcutaneous tissue client is free from
Joint (TMJ) are free of lesions and lesions and masses.
masses.
Fremitus Fremitus is symmetric Upon asking the Normal

and easily identified in client to repeat the
the upper regions of word “99” while
the lungs. If fremitus is palpating his back
not palpable on either from one side to
side, the client may another for fremitus,
need to speak louder. fremitus was easily
A decrease in the identified in the upper
190
intensity of fremitus is regions of his lungs

normal as the and is symmetric.
examiner moves
toward the base of
lungs. However,
fremitus should remain
symmetric for bilateral
positions
Chest When the client takes Upon asking the Normal

expansion a deep breath, the client to take deep
examiner’s thumbs breaths, my thumbs
should move 5 to 10 moved around 6 cm
cm apart apart symmetrically.
symmetrically.
Tone Resonance is the As percussed the Normal

percussion tone client for tone,
elicited over normal resonance is the
lung tissue. percussion tone
Percussion elicits flat elicited over normal
tones over the lung tissue. Flat
scapulae. tones were elicited
over the scapulae.
Diaphragmatic Excursion should be As percussed the Normal

excursion equal bilaterally and client for
measure 3-5 cm in diaphragmatic
adults. The level of the excursion, excursion
diaphragm may be is bilaterally equal
higher on the right and measured in
because of the 4cm.
position of the liver. In
well-conditioned
clients, excursion can
measure to 7 or 8 cm.
Breath sounds Three types of normal As auscultated, Normal

breath sounds may be bronchovesicular
auscultated – breath sounds are
bronchial, detected on the
bronchovesicular, and anterior spine, medial
vesicular. to the left and right
scapula. Vesicular
noises are then
191
detected over the

regions of the
posterior thorax,
particularly the
client's intercostal
spaces.
Voice sounds Voice transmission is As I asked my client Normal

soft, muffled, and to repeat the word
indistinct. The sound “99” while
of the voice may be auscultating his
heard but the actual posterior chest wall,
phrase cannot be his voice
distinguished. transmission was
muffled, soft, and
Indistinct.
As I asked my client
to repeat the letter
“E” while I auscultate,
his voice
transmission was
muffled, soft, but the
letter E was still
distinguishable.
As I asked my client
to repeat the
numbers “1,2,3” while
I auscultate, his voice
transmission was
faint and muffled.
Anterior Thorax
Shape and The anteroposterior As inspected the Normal

configuration diameter is less than shape and
the transverse configuration of the
diameter. The ration of client’s anterior
anteroposterior thorax, the
diameter to the anteroposterior
transverse diameter is diameter is less than
1:2.. the transverse
diameter.
192
Watch for Retractions not Sternal reactions are Normal

sternal observed quite observed due to
retractions breathing fast.
Slope of the Ribs slope downward As assessed the Normal

ribs with symmetric client’s ribs from an
intercostal spaces. anterior and lateral
Costal angle is within viewpoint, his ribs
90 degrees slope downward with
symmetric intercostal
spaces. Costal angle
was measured within
90 degrees.
Quality and Respirations are As observed, the Normal

pattern of relaxed, effortless, and client’s quality and
respirations quiet. They are of a pattern of breathing is
regular rhythm and relaxed, effortless,
normal depth at a rate and quiet with a
of 10–20 per minute in regular rhythm and
adults. Tachypnea and normal depth at a
Bradypnea may be rate of 18
normal in some breaths/minute.
clients.
Intercostal No retractions or There is no bulging or Normal

spaces bulging of intercostal retractions in the
spaces are noted. patient's intercostal
gaps.
Use of Use of accessory Observation reveals Normal

accessory muscles that the client does
muscles (sternomastoid and not use any auxiliary
rectus abdominis) is muscles when at
not seen with normal rest.
respiratory effort. After
strenuous exercise or
activity, clients with
normal respiratory
status may use neck
muscles for a short
time to enhance
breathing
Tenderness, No tenderness or pain Upon palpation, no Normal
193
sensation and is palpated over the tenderness or pain is

surface lung area with palpated over his
masses respirations. lung area with
respirations.
Tenderness at Palpation does not As palpated the Normal

costochondral elicit tenderness. client’s costochondral
junctions of junctions of ribs,
ribs palpation does not
elicit tenderness.
Crepitus No crepitus is No crepitus is Normal

palpated palpated over the
client's anterior
thorax.
Surface No unusual surface As palpated, there Normal

masses or masses or lesions are are no unusual
lesions palpated. surface masses or
lesions evident and
palpable.
Fremitus Fremitus is symmetric As palpated the client Normal

and easily identified in for fremitus, fremitus
the upper regions of is bilaterally
the lungs. A symmetric and is
decreased intensity of easily identified in the
fremitus is expected upper regions of her
toward the base of the lungs.
lungs. However,
fremitus should be
symmetric bilaterally.
Anterior chest Thumbs move outward As asked my client to Normal

expansion in a symmetric fashion take deep breaths,
from the midline my thumbs moved
outward in a
symmetric fashion
from the midline.
Tone Resonance is the As percussed for Normal

percussion tone tone, resonance is
elicited over normal the percussion tone
lung tissue. elicited over normal
Percussion elicits lung tissue. Dullness
194
dullness over breast was elicited over

tissue, the heart, and breast tissue, heart,
the liver. Tympany is and liver. Dullness is
detected over the elicited over the
stomach, and flatness stomach, and
is detected over the flatness is elicited
muscles and bones. over the muscles and
bones.
Breath sounds, Three types of normal Bronchial breath Normal

adventitious breath sounds may be sounds were
sounds, voice auscultated – auscultated.
sound bronchial,
bronchovesicular, and No adventitious
vesicular. No sounds such as
adventitious sounds, crackles or wheezes
such as crackles auscultated.
(discrete and
discontinuous sounds) Voice transmission is
or wheezes (musical soft, muffled, and
or continuous), are indistinct.
auscultated. Voice
transmission is soft,
muffled, and indistinct.
The sound of the voice
may be heard but the
actual phrase cannot
be distinguished.
HEART AND NECK VESSELS
Observe the Note that the jugular As observed, the Normal

jugular venous pulse of the is neck of the patient,
venous pulse. not normally visible the jugular venous
with the client sitting in pulse can only be
upright position, it seen while the patient
could be somehow is in supine position.
seen and discernable
in supine position.
Evaluate Upon the evaluation of Upon evaluating the Normal

jugular the examiner, the patient, it is noted
venous jugular vein of the that the jugular vein
pressure. patient should not be of the patient is not
distended, bulging, protruding.
195
and protruding around

45 degrees or higher
to it.
Auscultate the Upon the auscultation Upon auscultating the Normal

carotid arteries of the examiner, there carotid arteries of the
should be no blowing patient, I was able to
or swishing or other hear a strong pulse,
sounds that can be with a scale of 2+.
heard. Note that More so, there are no
pulses must be equally swishing sounds that
strong —a scale 2+ or can be heard.
normal with no
variation in strength
coming from beat to
beat. As for the
contour it should be
normally smooth and
rapid on the upstroke
and slower and has
less abrupt on the
downstroke area. The
strength of the pulse is
evaluated on a scale
starting from 0 to 4.
Palpate the Upon the palpation of Upon palpation, the Normal

carotid the examiner, arteries carotid arteries of the
arteries. should be elastic and patient, it is noted
no thrills should be that it is elastic and
noted. has no trills.
HEART
Inspect Upon the inspection of Upon inspecting for Normal

pulsations. the examiner for the the apical impulse of
he apical impulse, it the patient, it is noted
could be apparent or that is only quite
not, If it is apparent, it visible since the
would be along the patient has a large
mitral area. Note that round breast.
this kind of impulse is
a result of the left
ventricle moving
outward during the
196
systole. Next to note

is, a patient who has a
large breast could
result in the apical
impulse not to be
seen.
Palpate the The palpable size of Upon palpating for Normal

apical impulse. apical impulse in mitral the apical impulse of
area is around 1-2 the patient, it is noted
cm). Note that that it is not quite
amplitude is typically visible since the
small – may be patient has uis obese
observed during a but it is palpable.
gentle tap, having a
brief duration that is
lasting through the 1st
2/3 of systole and
often less. More so,
patient who has large
breast or obese
patient could result for
the apical impulse not
to palpable.
Palpate for The examiner should As palpated, the apex Normal

abnormal not be able to palpate and base heart of the
pulsations. pulsations and patient, there is no
vibrations in the areas noted vibration or any
of the apex, left sternal pulsation on it.
border, or base.
Auscultate Rate should be 60- Heart rate exhibits 96 Normal

heart 100 bpm with a regular beats per minute with
rate and rhythm. Note the regular rhythm upon
rhythm. irregular rhythm could auscultation.
indicate sinus
arrhythmia Note that,
when the heart rate
increases with
inspiration and
decreases with
expiration, it occur
normally among young
197
adults.
Auscultate to S1 corresponds with The S1 is audible Normal

identify S1 and each carotid pulsation with each carotid
S2 and is loudest at the pulse, although it is
apex of the heart. A strongest near the
distinct sound could be apex of the heart. S2
heard in each area but appears after S1 and
the loudest sound is most audible near
could be heard at the the base of the heart.
apex. Note that it Each region has a
could become softer distinct sound, but
during inspiration. S1 the peak is the
could be heard loudest.
commonly in young
adults at the left lateral
sternal border. S2
immediately follows
after S1 and is loudest
at the base of the
heart. Distinct sound
could be heard in each
area but is loudest at
the base.
Auscultate for Normally no extra There are no Normal

extra sounds are heard. physiologic S3 and
heart sounds. Note that a physiologic S4 sounds detected
S3 heart sound is a on the client's heart
benign finding during an
commonly heard at the auscultation for
beginning of the additional heart
diastolic pause in sounds.
children, adolescents
and young adults (rare
after age 40). More so,
a physiologic S4 heart
sound ought to be
heard along the end of
diastole in well-
conditioned athletes
and adults older than
age 40 or 50 with no
evidence of
198
cardiovascular
disease.
Auscultate for The examiner should As auscultated, there Normal

murmurs. not hear any murmurs are no murmurs that
during auscultation. can be heard.
ABDOMEN
Observe the Abdominal skin may As observed, the skin Normal

coloration of be paler than the of the abdominal area
the general skin tone of the patient is
skin. because this skin is so lighter than the
seldom exposed to the general color of the
natural elements. body.
Note the The examiner must As observed, there Normal

vascularity of note that a visible are veins scattered
the abdominal scattered vein is around the abdominal
skin. typically fine, that is area of the patient
located above the but only minimal fine
umbilicus and toward veins.
the lower body.
Note any striae The examiner could As observed, there Deviation

note a new striae are are pinkish strie The finding of
pink or bluish in color present along the striae in an
and old striae that is, lower part of the obese patient
white, linear. As well abdomen area of the can most often
as uneven stretch patient. be
marks. All those are attributed to
normal, results from the mechanical
past pregnancies or changes
weight gain. associated with
weight gain;
however,
because striae
have other
etiologies this
cutaneous
lesion
can
occasionally
serve as the
first sign of a
199
more serious,
systemic
issue
(Waldman &
Kettler, 2010).
Inspect for The scar of a patient As observed, there is Normal

scars. could be pale, smooth, no presence of scar
and minimally seen if on the abdominal
it’s old. area of the patient.
Assess for The abdomen should As assessed, there Normal

lesions and be free from any are no lesions and
rashes. lesions or rashes. rashes can be noted
Note that flat or raised on the abdominal
brown moles that are area of the patient.
apparent are typically
normal.
Inspect the The umbilical skin tone As inspected, the Normal

umbilicus. of the patient should skin tone of the
be similar or umbilical of the
compliment the patient compliments
surrounding skin tone the skin tone of the
of the abdomen. abdominal area.
Observe Note that the umbilicus As observed, the Normal

umbilical should be midline at placement of the
location. the lateral line. umbilicus of the
patient is at the
midline laterally.
Assess It is recessed As assessed, the Normal

contour of (inverted) or protruding umbilicus of patient is
umbilicus. no more than 0.5 cm, conical and it only
and is round or protrudes for about
conical. 0.3cm
Inspect The patient abdomen As assessed, the Normal

abdominal could be flat, rounded, contour of the client’s
Contour and or scaphoid Note that abdomen is evenly
symmetry scaphoid could be rounded, symmetrical
seen among thin and the scaphoid is
adults. More so, the not visible.
abdomen could be
200
evenly rounded and

symmetric.
Observe aortic The examiner could As observed, there is Normal

pulsations. see a slight pulsation only a slight pulsation
of the abdominal on the abdominal
aorta. This is usually aorta of the client.
seen in the
epigastrium, extending
its full length in thin
people.
Observe for The examiner could As observed, there Normal

peristaltic normally see the are no peristaltic
waves. peristaltic waves but it waves evident.
is easily seen on very
thin people.
Auscultate for The examiner could Upon auscultation, a Normal

bowel hear a series of clicks series of clicks and
sounds. and gurgles at around gurgles at 6 per
5–30 per minute. Note minute could be
that hyperactive bowel heard.
sounds called
“borborygmus” can be
heard too. More so,
loud and long gurgling
sounds of the stomach
are known as
“stomach growling.”
Auscultate for Bruits are not normally Upon auscultation, Normal

vascular heard over abdominal bruits are not
sounds. aorta or renal, iliac, or normally heard over
femoral arteries. the abdominal aorta,
However, bruits renal, iliac, and
confined to systole femoral arteries.
may be normal in
some clients
depending on other
differentiating factors.
Listen for The examiner could As auscultated, along Normal

venous not hear a Venous the umbilical area of
hum. hum over the the patient, there is
201
epigastric and only minimal venous

umbilical areas, which hums that can be
is typically normal. heard,
Auscultate for There should be no As auscultated over Normal

a friction rub over liver or liver and spleen,
friction rub spleen is Present, there are no rubbing
over the during the auscultation sounds that can be
liver and of the examiner. heard.
spleen.

Percuss for During the percussion Upon percussing for Normal

tone. of the examiner: The tone, the abdomen
tympany tone should elicited a tympanic
be elicited over tone. Also, dullness is
abdomen due to air heard over the liver,
within the stomach spleen and in non
and intestines. Next, evacuated
dullness. should be descending colon.
heard over the liver, Moreover, there was
spleen and in non no tenderness
evacuated descending elicited.
colon.
Percuss the Examiner on Upon percussion for Normal

span or height percussing the height the height of the liver,
of the liver by of the liver and its the lower border of
determining its border are the the liver is dull and
lower and following criteria can descend around
upper borders. below: On deep 1 to 4 cm below the
inspiration, the lower costal margin. Upper
border of liver dullness border of liver
could descend around dullness is located
1 to 4 cm below the between the left fifth
costal margin. The and seventh
upper border of liver intercostal spaces.
dullness is located
between the left fifth
and seventh
intercostal spaces.
The normal liver span
at the MSL is around 4
– 8 cm.
202
Perform blunt Examiner on Upon performing the Normal

percussion on performing a blunt blunt percussion,
the percussion on the liver there was no elicited
liver and the and kidneys are the tenderness or pain.
kidneys. following criteria
below: 1)Normally, no
tenderness is elicited.
2) Normally, no
tenderness or pain is
elicited or reported by
the client. Note that,
examiner senses only
a dull thud
Perform light Examiner on Upon palpation on Normal

palpation. performing a light the client’s abdominal
palpation should note region, it is found that
the following criteria the clients has a
below: 1)The tender abdomen with
abdomen is Nontender guarding behavior.
and soft.
2)There is no
guarding.
Deeply palpate Normal (mild) Upon palpation on Normal

all tenderness is possible the four quadrants,
quadrants to over the xiphoid, aorta, there was little to no
delineate cecum, sigmoid colon, tenderness or pain
abdominal and ovaries with deep elicited.
organs and palpation
detect
subtle masses.

Palpate for There should be no Upon palpation there Normal

masses. palpable masses. are no masses
found.
Palpate the Upon the palpation the The umbilicus and Normal
umbilicus and Examiner will assess surrounding area are
surrounding the umbilicus and free of any swellings,
area surrounding area must bulges and masses.
for swellings, be free of any
bulges, or swellings, bulges and
masses. masses.
203
Palpate the The aorta is Aorta is less than 3.0 Normal

aorta. approximately 2.5– 3.0 wide and has a
cm wide with a moderately strong
moderately strong and and regular pulse.
regular pulse. Possibly
mild tenderness may
be elicited.
Palpate the The liver is typically Liver was palpated Normal

liver. not palpable, but it due to the client's thin
could be at some point body build. It is also
to those clients who smooth and even,
are relatively thin. mild tenderness is
Note that the lower present.
edge could be felt, it
must be firm, smooth,
and even more so,
mild tenderness may
be present.
Palpate the Examiner palpating an Upon palpating the Normal

urinary empty bladder is urinary bladder, it is
bladder. neither palpable nor not palpable and not
tender. tender since the
patient urinated
before the
examination.
Assess for There should be no Upon assessment, Normal

rebound rebound tenderness there is no rebound
tenderness. that is present. tenderness noted on
the client’s
abdomen.

Body Part/Area to be Normal Actual findings Interpretation
Assessed findings and analysis.
Musculoskeletal Assessment (Upper/Lower extremities)
Muscle size Equal size on Upon inspection, the Normal

both sides of muscle of the client is
body equal on both sides of
the body when being
compared.
204
Muscles and tendons No Upon further Normal

for contractures contractures inspection, there are
no malposition of the
body observed on the
client.
Muscle for tremors No Through inspection, Normal

fasciculation there are no observed
or tremors trembling, tremors, or
fasciculation on the
client’s muscles.
Muscle tonicity Normally firm Through palpation, the Normal

muscles of the client
are normally firm to
touch when muscles
are at rest.
Flaccidity, spasticity, Smooth Upon further palpation Normal

and smoothness of coordinated for finding flaccidity,
movement movements spasticity, and
smoothness of
movement, the client is
found with no sign of
weakness or laxness of
the muscles. There are
also no sudden
involuntary muscle
contractions elicited by
the client’s muscle.
The muscles elicit
smooth coordinated
movements when
active.
Muscle strength of the Equal Upon performing Normal

head & shoulders strength on proper procedures to
(Sternocleidomastoid) each body test the muscle
side strength of the client’s
head & shoulders, it is
found that it has equal
strength on each body
side. The test done to
the
Sternocleidomastoid of
205
the client elicits normal

full movement against
gravity and against
moderate resistance -
Grade 4.
Muscle strength of Equal Upon performing Normal

the head & shoulders strength on proper procedures to
(Trapezius) each body test the muscle
found that the muscles
of the client are equal
in strength. The test
done to the Trapezius
of the client elicits
normal full movement
against gravity and
against moderate
resistance - Grade 4
Muscle strength of the Equal Upon performing Normal

head & shoulders strength on proper procedures to
(Deltoid) each body test the muscle
done to the deltoid of
the client elicits normal
full movement against
gravity and against
Grade 4
Muscle strength of Equal Through performing Normal

upper extremities strength on proper procedures to
(Biceps) each body test the muscle
upper extremities, it is
206
for biceps shows that it

can move the joint it
crosses through a full
range of motions
against gravity with
Grade 4.

(Triceps) each body test the muscle
for triceps shows that it
range of motions
against gravity and
against moderate
resistance - Grade 4.

(Wrist and fingers) each body test the muscle
in strength. The test for
Wrist and fingers
shows that it can move
the joint it crosses
through a full range of
motions against gravity
and against moderate

(Grip strength) each body test the muscle
207
in strength. The test for
Grip strength shows
that it can move the
joint it crosses through
a full range of motions
against gravity and
against moderate
Muscle strength of Equal Upon further Normal

lower extremities (Hip strength on performing proper
muscles) each body procedures to test the
side muscle strength of the
client’s lower
extremities, it is found
that the muscles of the
client are equal in
strength. The test for
Hip muscle shows that
it can move the joint it
range of motions
against gravity and
against moderate

abduction) each body procedures to test the
client’s lower
client are equal in
Hip abduction shows
against gravity and
against moderate
208

adduction) each body procedures to test the
client’s lower
client are equal in
Hip adduction shows
against gravity and
against moderate

lower extremities strength on performing proper
(Hamstrings) each body procedures to test the
client’s lower
client are equal in
hamstrings show that it
range of motions
against gravity and
against moderate

(Quadriceps) each body procedures to test the
client’s lower
client are equal in
209

quadriceps can move
the joint it crosses
through a full range of
motions against gravity
and against moderate

(Muscles of the Ankle each body procedures to test the
and Feet) side muscle strength of the
client’s lower
client have equal
strength on each body
side. The test for
muscle of the ankle
and feet normally
elicits full movement
against gravity and
against moderate
resistance - Grade 4
Normal structure and No Upon inspecting the Normal

deformities of the deformities skeleton, it is found
bone that the client has no
visible bone
misalignment in all
areas of the body. The
bones are also equal
on each side.
Edema or tenderness No Through further Normal

of the bones tenderness of palpation of the bones,
swelling there are no located
areas of swelling or
tenderness found on
the client.
Joint swelling, No swelling, By inspection and Normal

tenderness, no palpation of the client’s
smoothness of tenderness, joint areas, the joints
movement, crepitation, or elicit smooth
210
crepitation, and nodules coordinated

presence of nodules movements. The client
does not report any
pain or tenderness
when asked. There are
also no observed
presence of nodules
and crepitation during
the assessment.
Joint range of motion Varies to Upon assessing the Normal

of the head (Neck- some degree joint range of motion of
Pivot joint) in accordance the head, the neck
with a pivot joint is found to
person's flex in about 45
genetic degrees, extend back,
makeup and and hyperextend to 50
degree of degrees. When asked
physical to do lateral flexion, the
activity. Full client can flex 50
range of degrees without
motion. experiencing any pain
the client can also
rotates 70 degrees left
and right
Joint range of motion Varies to Upon assessing the Normal

of body trunk (Trunk- some degree joint range of motion of
gliding joints) in accordance the body trunk of the
with a client, trunk gliding
person's joints can flex 90
genetic degrees, extend back,
makeup and and hyperextend 40
degree of degrees. The client
physical also can laterally flex at
activity. Full 35 degrees and rotate
range of 30 degrees, left and
motion. right, with no pain or
discomfort.
Joint range of motion Varies to Done through Normal

of upper extremities some degree performing proper
(Shoulder-ball and- in accordance procedures to assess
socket-joint) with a Shoulder-ball-and
211
person's socket joint, the client

genetic can do:
makeup and ● Flexion at 180
degree of degrees
physical ● Extend back
activity. Full ● Hyperextension at 50
range of degrees
motion. ● Abduction at 180
degrees
● Adduction at 50
degrees; and
● Circumference in full
range of motion
● External and internal
rotation at 90 degrees
● Elbow-hinge joints
Flexion at 160 degrees
and extend back
● Rotation for
supination and
pronation for 90
degrees.
Joint range of motion Varies to Further assessment for Normal

of upper extremities some degree wrist-condyloid joint:
(wrist-condyloid in accordance ● Flexion can do to 90
joints) with a degrees and extend
person's ● back Hyperextension
genetic at 80 degrees
makeup and ● Radial flexion
degree of (abduction) to 20
physical degrees
activity. Full ● Ulnar flexion
range of (adduction) up to 55
motion. degrees
● Finger flexion to 90
degrees and extend
straight
● Finger
hyperextension to 30
degrees
● Finger Abduction is
able to spread
● Finger adduction
212
able to close
Joint range of motion Varies to For the assessment of Normal

of upper extremities some degree Thumb-saddle joint,
(Thumb-saddle joints) in accordance the client is found able
with a to flex, extend back,
person's and hyperextend
genetic without any pain. The
makeup and client’s joints are also
degree of able to do abduction,
physical adduction, and
activity. Full opposition of the
range of fingers and thumb.
motion.
Joint range of motion Varies to Upon further Normal

of lower extremities some degree assessment on the
(Hip-ball-and-socket in accordance lower extremities of the
joint) with a client on Hip Ball-and
person's socket joint, the
genetic assessment showed:
makeup and ● Knee flexed to 150
degree of degrees flexion and
physical extend back
activity. Full ● Knee straight to 90
range of degrees flexion and
motion. extend back
Hyperextension to 30
degrees
● Abduction to 50
degrees
● Adduction to 30
degrees Circumduction
is able to be performed
at full range of motion
● Internal and external
rotation is able to
performed at full range
of motion
Joint range of motion Varies to The knee-hinge joint of Normal

of lower extremities some degree the client is able to
(Knee-hinge joints) in accordance perform flexion,
with a extension, and
213
person's hyperextension at full

genetic range of motion.
makeup and
degree of
physical
activity. Full
range of
motion.
Joint range of motion Varies to Ankle-hinge joints can Normal

of lower extremities some degree perform plantar flex,
(Ankle-hinge joints) in accordance and dorsiflex at full
with a range of motion.
person's
genetic
makeup and
degree of
physical
activity. Full
range of
motion.
Joint range of motion Varies to The client’s foot gliding Normal

of lower extremities some degree joints can perform
(Foot-gliding joints) in accordance eversion and inversion
with a at full range of motion
person's as well as the toes
genetic flexion and extension.
makeup and
degree of
physical
activity. Full
range of
motion.
214

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FAR EASTERN UNIVERSITY - MANILA

Paguirigan, Jhoana Nicole P.

Pataueg, Victoria Joy D.

Rafael, Christian Emmanuel N.

Roque, Ma. Nnyca Paula B.

Mrs. Jennifer Padual

NCM 104 - Community Health Nursing 1: Individual & Family As Clients

December 14, 2021

I. Family Structure, Characteristics, and Dynamic

Name of the head of the Family: _____ Length of Residency_____

Block No.: __________ Lot No.: #2

Family the head of Education Status Work

Member the family al

R. A. S. Father 1971 50 M M F I CG E: General R Dr. Jose

R. G. S. Mother March 52 F M F I CG E: R Dept. of

1969 Government Agrarian

R. S. Son June 28, 21 Non- S F I C - 2nd Student N/A FEU

2000 binary year

Family members or living elsewhere (N/A if none) N/A

Member who tends to make decisions in matters of healthcare Mother

LEGEND Type of Family O - Others

N - Nuclear Civil Status

E - Extended Gender S - Single

B - Blended F - Female M - Married

D - Dyad M - Male SE - Separated

LI - Live In RC - Roman Catholic Higher Educational Attainment

E - Employed (Specify) I- Islam EG - Elementary Graduate

U - Unemployed Others, specify: ___________ H - High School Level (specific)

SE - Self-employed (Specify) HG - High School Graduate

P - Retired with Pension Employment Status C - College Level (specific)

R - Retired without Pension R - Regular CG - College Graduate

T - Temporary NFE - No Formal Education

F - Filipino Place of Work

Retired without Pension I - Inside the community

O - Outside the community

Mr. R.A.S., a 50-year-old man, is married to Mrs. R.G.S., a 52-year-old

kami. Since I am a government employee and Mr. R.A.S. (husband) is a doctor, we

The family of Mr. R.A.S. is under a nuclear family structure. According to

Blessing, M. (2021). Types of family structures. LoveToKnow. Retrieved December

2, 2021, from https://family.lovetoknow.com/about-family-values/types-family-

December 2, 2021, from https://www.historytoday.com/history-matters/rise-

Role of Mothers in Promoting Family and Child Health. Journals at UNI

ScholarWorks. Retrieved December 2, 2021, from

Family Genogram: Paternal Side

Family Genogram: Maternal Side

also has color blindness.

II. Socio-economic and Cultural Characteristics

a senior agrarian reform program officer (SARPO). Before working in the

worked as a general surgeon at Dr. Jose N. Rodriguez Memorial Hospital. Prior to

that, he worked as a DOH Margus as a medical expert at Tubig Regional Hospitals

income yet. Mrs. R.G.S. is a FEU-Manila BS Commerce Major in Accounting

graduate, while Mr. R.A.S. is a Manila Central University Optometry Collage

year nursing student at FEU-Manila.

The Saludsong family’s combined monthly income is above Php. 20,000,00.

of and document the family's monthly spending, which include essential

since she prioritizes and manages expenditures well by fulfilling physiological

Asingan, Pangasinan and moved to Manila in 1984 to pursue a BS Commerce Major

Optometry Collage (PreMed), Medicine (Post-Grad). Therefore, the Saludsong family

executing family/significant other caretaker tasks. The father is highly conservative,

restricting, and prone to interruption of the parent-child connection. In comparison to

Since the family is a member of a community, cultivating strong relationships

are related to health, wellness, business, and community management.

According to the International Labour Organization research, tertiary education in

Name of the head of the Family: _ Length of Residency_