TAGUM DOCTOR’S COLLEGE, INC.

Mahogany St. Rabe Subdivision, Tagum City

Bachelor of Science in Nursing

In Partial Fulfillment of the Requirements in

RLE 121: Intensive Nursing Practicum

Submitted to:

Heidi C. Cabanatan, RN

Submitted by:

Rachelle R. Donasco BSN 4

March 23, 2022

Name of client: Patient D Vital Signs:
Age: 27yo Temperature: 37.5 C
sex: Male Pulse: 110b/minute
Respiration: 20 breaths /minute
Blood Pressure: 140/90 mmHg

SYSTEM/ METHODS NORMAL FINDINGS ACTUAL FINDINGS

OF ASSESSMENT
- Oriented to time, people, and - LOC- Confused.
Sensory and Neurological Unable to think clearly
place.
and rapidly. Has
System
- Enable to demonstrate impaired judgment and
(Interview and decision making.
emotion appropriate to the
observation) - Anxious
scenario.
- Enable to comprehend and
speak fluently.

Integumentary System
- The skin is uniform in color. - Has visible bite mark at
Skin Soft, smooth skin over the the skin of the right leg.
(Inspection and palpation) entire body.
-Skin temperature is within
normal limits.

- Head is normocephalic, with - The client’s skull is

Head/Hair prominences in the frontal and
(Inspection and palpation) occipital area.
- No tenderness noted upon
palpation. -Symmetrical, no
lesions, nodules or masses.
- Free from lice, nits and
dandruff.
- May be thin or thick hair.
proportionate to the
body size.
- no tenderness in the
scalp.
- no presence of nodules,
and infestation.
- Hair is evenly
distributed, and the
 Neither brittle nor dry. strands are thin and
brittle.
- Symmetrical, no lesions,
Face - The shape of the face is
nodules or masses.
round and symmetrical.
(inspection) - (Pain scale: 0-no pain, 2- - facial grimace 9/10 due to
discomforting, 4-moderate pain on the bite site.
pain, 6-painful, 8-very intense,
10- unbearable pain.) No facial
grimace.

- No visible mass or - Neck has no

Neck involuntary
lumps.
movements.
(Inspection, palpation) - No jugular venous - No visible mass or
lumps.
distention.
- No jugular venous
- No involuntary distention.
movements.

- The Auricles are symmetrical

Ears - Ears are symmetrical.
and have the same color with
(inspection) his facial skin. - The alignment of the

-The auricles are mobile, firm pinna is symmetrical.

and not tender. The pinna - Both ear pinna is

recoils when folded. elastic and recoil when

- (Watch tick test) Client folded.

should be able to hear ticking - The mastoid process is

in both ears. tender.

- The auditory canal
contains some
cerumen, the color is
brown and there is an
absence of discharges.
 - Nails color is pinkish or - Nails are smooth but light
Nails white in color. pink in color (pale).
- Nails are smooth and is intact - Capillary refill in the nails is
(inspection) within 2seconds.
with the epidermis.
-When nails pressed between
the fingers (Blanch Test), the
nails return to usual color in
less than 3 seconds.
Visual System

- Light shines directly in the - No abnormalities on patient’s

Eyes eyes eyes.
(inspection) - Light seen symmetrically on
each cornea.
- Hair is evenly distributed.
The client’s eyebrows are
symmetrically aligned and
showed equal movement when
asked to raise and lower
eyebrows.
- There was no presence of
discharges, no discoloration
and lids close symmetrically
with involuntary blinks
approximately 15-20 times per
minute.
Extremities
Upper extremities - No skin lesions - No abnormalities seen
(Inspection) - Fingers, hands, arms on patient’s upper
and shoulder can be extremities.
moved easily.
- No swelling,
tenderness, joint
movement restriction
 Lower extremities - No skin lesions and - Pain in the right leg
(Inspection) - Bite mark about
masses.
2inches in the right leg.
- Legs and feet can be
moved easily
- No swelling,
tenderness, joint
movement restriction
Gastrointestinal System
- The lips are normally - The lips are symmetrical,
Mouth pink, smooth, and moist.
symmetrical, pink, smooth,
(inspection) and moist. - Teeth is clean with shiny
enamel and has decay,
- Teeth is clean with shiny
yellowish shiny enamel and
enamel and no decay, white smooth surfaces and edges.
with shiny enamel and smooth
- Oral mucosa appears moist,
surfaces and edges. smooth, shiny, and pink.
- Oral mucosa should appear
- dorsal tongue is symmetrical,
moist, smooth, shiny, and pink. pink and moist and slightly
rough from papillae.
- A healthy dorsal tongue is
symmetrical, pink and moist
and slightly rough from
papillae.

Abdomen - No evidence of enlargement - abdomen is normal.

of liver and spleen.
(Auscultation, inspection,
- Audible bowel sounds.
palpation)
Cardiovascular System
- No pulsation upon palpating - Tachycardia. HR-120bpm
Heart - BP: 140/90mmHg
the aortic and pulmonic areas.
- O2 sat- 89
(auscultation) - Heart rate ranges from 60-
100bpm
- Systolic BP ranges from 120-
129 and diastolic BP ranges
from 80-89
 Respiratory System
- Chest wall intact - Respiratory rate is 20bpm.
Lung - No tenderness and masses. Normal.
(auscultation) - Full and symmetric chest
expansion.
- Respiratory rate is 20-30
bpm, when resting.
- No crackles, no wheezing.
- No difficulty in breathing.
Genito-Urinary System
Bladder function - No pain or discomfort - No abnormalities.
in urinating (Dysuria).
(Interview)
- Urinate at least 4-
7times per day.
- urine color ranges from
pale yellow to deep
amber.