VISION MISSION

Republic of the Philippines Cavite State University shall provide

A premier university in historic
Cavite recognized for
excellence in the development
of morally upright and globally
competitive individuals.
CAVITE STATE UNIVERSITY
Don Severino Delas Alas Campus
Indang, Cavite
excellent, equitable and relevant
educational opportunities in the arts,
science and technology through
quality instruction and relevant
research and development activities.
It shall produce professional, skilled
and morally upright individuals for

College of Nursing global competitiveness.

GERIATRIC ASSESSMENT

Presented by:

YEAR LEVEL / SECTION / GROUP #:

Members

Presented to:

Prof. _________________ , RN, MAN

Prof. _________________ , RN, MAN
Prof. _________________ , RN, MAN
Prof. _________________ , RN, MAN
Clinical Instructors, Level IV

Date:

Month xx, year

In Partial Fulfillment of the Requirement in NURS 15 for the Degree Bachelor of Science in Nursing
 TABLE OF CONTENTS

I. Demographic Data………………………………………………………………………………….1

II. Reason for Seeking Health Care…………………………………………………………………1

III. History of Present Illness…………………………………………………………………………..1

IV. Past Medical

History………………………………………………………………………………...1

V. OB-Gynecological History………………………………………………………………………….1

VI. Heredo-familial History…………………………………………………………………………...1-2

VII. Developmental History……………………………………………………………………………...2

VIII.Gordon’s Functional Health Patterns…………………………………………………………..2-5

IX. Physical Examination…………………………………………………………………………….5-12

X. Diagnostic Test…………………………………………………………………………………..12-13

XI. Review of System……………………………………………………………………………………13

XII. Concept Maps………………………………………………………………………………………..13

XIII.Case Management…………………………………………………………………………………..14

A. Medical……………………………………………………………………………………………14

B. Surgical……………………………………………………………………………………………14

C. Nursing…………………………………………………………………………………………15-16

XIV. Ongoing Appraisal………………………………………………………………………………….16

I. DEMOGRAPHIC DATA
A. Initials of Clients’ Name Date of Admission:
B. Address Time of Admission:
C. Age
D. Birth Date Date of Interview:
E. Birth Place Primary Informant:
F. Sex Secondary Informant:
G. Civil Status Other Data Sources:
H. Religion
I. Highest Educational Attainment
J. Occupation
K. Monthly Income / Budget
II. REASON FOR SEEKING HEALTH CARE

III. HISTORY OF PRESENT ILLNESS

(Critical characteristics: setting, timing, location, quality, quantity, associated factors: aggravating /
alleviating; client’s perception)
IV. PAST MEDICAL HISTORY
A. Childhood / Adult Diseases
B. Injuries / Accidents
C. Hospitalization
D. Operation
E. Allergies
F. Medication
G. Immunization (to be tabulated for Pedia clients to keep track of time interval and dose, but for
Adult clients state if they have been fully immunized or not)
H. Last Examination
V. OBSTETRIC-GYNECOLOGICAL HISTORY (if applicable)
A. Menarche
B. Menstruation
- LMP
- Usual amount
- Usual Duration
- Cycle
- Associated discomforts and relief measures
C. EDC, AOG, GP-TPALM
VI. HEREDO-FAMILIAL HISTORY
A. Genogram
Paternal Side Maternal Side
CT DU DM MR

64 y/o 65 y/o 59 y/o 55 y/o

A&W CVA CA A&W

JT DM LB
unknown LEGENDS: will depend on what is used.
25 y/o 26 y/o 36 y/o
A&W PIH COPD

NDT ET GB

5 y/o 3 y/o 8 y/o

 A&W A&W A&W

VII. DEVELOPMENTAL HISTORY (Determine the exact stage based on client’s age and his
milestone and provide some justifications that would be most applicable to the specified
developmental stage)
A. J. Piaget’s Cognitive Development
Stage Specific Task(s) Evidences of Milestone Achievement

B. E. Erikson’s Psychosocial Development

Stage Specific Task(s) Evidences of Milestone Achievement

C. S. Freud’s Psychosexual Development

Stage Specific Task(s) Evidences of Milestone Achievement

D. J. Fowler’s Spiritual Development

Stage Specific Task(s) Evidences of Milestone Achievement

E. L. Kholberg’s Moral Development

Stage Specific Task(s) Evidences of Milestone Achievement

F. R. Havighurst’s Developmental Task

Stage Specific Task(s) Evidences of Milestone Achievement

VIII. GORDON’S 11 FUNCTIONAL HEALTH PATTERNS

A. Health Perception – Health Management
 Interaction
 Observation
 Measurement
B. Nutritional – Metabolic
 Interaction
 Observation
 Measurement
*3-day Diet Recall
MEALS Date & Day Date & Day Date & Day
Breakfast (time) - amount per serving - amount per serving - amount per serving
Snacks (if any) - amount per serving - amount per serving - amount per serving
Lunch (time) - amount per serving - amount per serving - amount per serving
 Snacks (if any) - amount per serving - amount per serving - amount per serving
Dinner (time) - amount per serving - amount per serving - amount per serving
Snacks (if any) - amount per serving - amount per serving - amount per serving
Total Fluid Intake ___mL ___mL ___mL

NUTRITION

Nutrition Checklist for Older Adults

"DETERMINE" Mnemonic
Name: _____________________ Today's Date: _________
Score for "Yes"
Possible Problem Question to Answer Answer
(Circle if "yes")

Do you have an illness or condition that makes you change the

Disease 2
kind and/or amount of food you eat?

Eating Poorly Do you eat fewer than 2 meals per day? 3

Do you eat few fruits, vegetables or milk products? 2

Do you have 3 or more drinks of beer, liquor or wine almost every

2
day?

Do you have tooth or mouth problems that make it hard for you to
Tooth Loss/Mouth Pain 2
eat?

Economic Hardship Do you sometimes have trouble affording the food you need? 4

Reduced Social
Do you eat alone most of the time? 1
Contact

Do you take 3 or more prescribed or over-the-counter drugs a

Multiple Medications 1
day?

Involuntary Weight Have you lost or gained 10 pounds in the last 6 months without
2
Loss/Gain trying?

Needs Assistance In Are you sometimes physically not able to shop, cook or feed
1
Self Care yourself?

Elder Years > Age 80 Are you over 80 years old? 1

TOTAL ________

 0-2--Good!
Recheck your nutritional score in 6 months.
  3-5--You are at moderate nutritional risk.
See what can be done to improve your eating habits and lifestyle. Your office on aging, senior nutrition
program (eg, Meals On Wheels), senior center or health department can help. Recheck your nutritional
score in 3 months.

 6 or more--You are at high nutritional risk.

C. Elimination
 Interaction
 Observation
 Measurement

URINARY CONTINENCE

Patient Assessment Tool--Urinary Function Assessment

Over the past month or so, how often have you...
Less than Less than About More than
Not at Almost
Symptom 1 time in half the half the half the
all always
5 time time time

1. ...had a sensation of not

emptying your bladder completely 0 1 2 3 4 5
after you finished urination?

2. ...had to urinate again less than

two hours after you finished 0 1 2 3 4 5
urinating?

3. ...found you stopped and started

again several times when you 0 1 2 3 4 5
urinated?

4. ...found it difficult to postpone

0 1 2 3 4 5
urination?

5. ...had a weak urinary stream? 0 1 2 3 4 5

6. ...had to push or strain to begin

0 1 2 3 4 5
urination?

7. ...had to usually get up to

5
urinate from the time you went to 0 1 2 3 4
(5 times
bed until you got up in the (none) (once) (twice) (3 times) (4 times)
or more)
morning?
 Score=sum of answers to questions 1 through 7: ______

>=8 Moderate symptoms

>=20 Severe symptoms

D. Activity – Exercise
 Interaction
 Observation
 Measurement
*7-Day Activity Table
Time Days of the Week & Date
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
1 am
2 am
3 am
4 am
5 am
6 am
7 am
8 am
9 am
10 am
11 am
12 nn
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
11 pm
12 mn

*Katz Index of Independence in Activities of Daily Living

Activities Independence = 1 point Dependence = 0 point
Points (1 or 0) No supervision, direction or personal With supervision, direction or
assistance needed personal assistance or total care
Bathing
Dressing
Toileting
Transferring
Continence
Feeding
TOTAL POINTS:
Bristol Activities of Daily living Scale
This questionnaire is designed to reveal the everyday ability of people who have memory difficulties of one
form or another.
 For each activity (No. 1 - 20), statements a - e refer to a different level of ability.

Thinking of the last 2 weeks, tick the box that represents your relative’s/friend’s AVERAGE ability. (If in doubt
about which box to tick, choose the level of ability which represents their average performance over the last 2
Weeks. Tick ‘Not applicable’ if your relative never did that activity when they were well).

1. PREPARING a) Selects and prepares food as required

FOOD b) Able to prepare food if ingredients set out
c) Can prepare food if prompted step by step
d) Unable to prepare food even with prompting and
supervision
e) Not applicable

2. EATING a) Eats appropriately using correct cutlery

a) Eats appropriately if food made manageable and/or
uses spoon
b) Uses fingers to eat food
c) Needs to be fed
d) Not applicable

3. PREPARING a) Selects and prepares drinks as required

DRINK a) Can prepare drinks if ingredients left available
b) Can prepare drinks if prompted step by step
c) Unable to make a drink even with prompting and
supervision
d) Not applicable

4. DRINKING a) Drinks appropriately

a) Drinks appropriately with aids, beaker/straw etc.
b) Does not drink appropriately even with aids but
attempts to
c) Has to have drinks administered (fed)
d) Not applicable

5. DRESSING a) Selects appropriate clothing and dresses self

a) Puts clothes on in wrong order and/or back to front
and/or dirty clothing
 b) Unable to dress self but moves limbs to assist
c) Unable to assist and requires total dressing
d) Not applicable

6. HYGIENE a) Washes regularly and independently

a) Can wash self if given soap, flannel, towel, etc
b) Can wash self if prompted and supervised
c) Unable to wash self and needs full assistance
d) Not applicable

7. TEETH a) Cleans own teeth/dentures regularly and

independently
a) Cleans teeth/dentures if given appropriate items
b) Requires some assistance, toothpaste on brush,
brush to mouth etc
c) Full assistance given
d) Not applicable

8. BATH/SHOWER a) Bathes regularly and independently

a) Needs bath to be drawn/shower turned on but
washes independently
b) Needs supervision and prompting to wash
c) Totally dependent, needs full assistance
d) Not applicable

9. a) Uses toilet appropriately when required

TOILET/COMMODE a) Needs to be taken to the toilet and given assistance
b) Incontinent of urine or faeces
c) Incontinent of urine and faeces
d) Not applicable

10. TRANSFERS a) Can get in/out of chair unaided

 a) Can get into a chair but needs help to get out
b) Needs help getting in and out of a chair
c) Totally dependent on being put into and lifted from
chair
d) Not applicable

11. MOBILITY a) Walks independently

a) Walks with assistance ie furniture, arm for support
b) Uses aids to mobilise ie frame, sticks etc
c) Unable to walk
d) Not applicable

12. a) Fully orientated to time/day/date etc

ORIENTATION a) Unaware of time/day etc but seems unconcerned
– TIME
b) Repeatedly asks the time/day/date
c) Mixes up night and day
d) Not applicable

13. a) Fully orientated to surroundings

ORIENTATION a) Orientated to familiar surroundings only
– SPACE b) Gets lost in home, needs reminding where bathroom
is, etc
c) Does not recognise home as own and attempts to
leave
d) Not applicable

14. a) Able to hold appropriate conversation

COMMUNICATION a) Shows understanding and attempts to respond
verbally with gestures
b) Can make self understood but difficulty
understanding others
c) Does not respond to, or communicate with others
d) Not applicable

15. TELEPHONE a) Uses telephone appropriately, including obtaining

 correct number
a) Uses telephone if number given verbally/visually or
predialled
b) Answers telephone but does not make calls
c) Unable/unwilling to use telephone at all
d) Not applicable
16. a) Able to do housework/gardening to previous
HOUSEWORK/ standard
GARDNEING a) Able to do housework/gardening but not to previous
standard
b) Limited participation with a lot of supervision
c) Unwilling/unable to participate in previous activities
d) Not applicable

17. SHOPPING a) Shops to previous standard

a) Only able to shop for 1 or 2 items with or without
a list
b) Unable to shop alone, but participates when
accompanied
c) Unable to participate in shopping even when
accompanied
d) Not applicable

18. FINANCES a) Responsible for own finances at previous level

a) Unable to write cheque. Can sign name &
recognises money values
b) Can sign name but unable to recognise money
values
c) Unable to sign name or recognise money values
d) Not applicable

19. GAMES/HOBBIES a) Participates in pastimes/activities to previous

standard
a) Participates but needs instruction/supervision
b) Reluctant to join in, very slow needs coaxing
c) No longer able or willing to join in
d) Not applicable

20. TRANSPORT a) Able to drive, cycle or use public transport

independently
a) Unable to drive but uses public transport or bike etc
 b) Unable to use public transport alone
c) Unable/unwilling to use transport even when
accompanied
d) Not applicable

E. Sleep – Rest
 Interaction
 Observation
 Measurement
*7-Day Sleep Diary
Constructs Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Hours of Sleep
Sleeping Time
Waking Time
Bedtime Rituals
Feeling upon
waking up
Problem
Encountered

F. Cognitive – Perceptual
 Interaction
 Observation
 Measurement

Abnormal Involuntary Movement Scale (AIMS)

The original reference for the AIMS seems to be Guy W. ECDEU Assessment Manual for
Psychopharmacology, revised ed. Washington, DC, US Department of Health, Education, and Welfare,
1976. A nice practical discussion can be found in Munetz MR, Benjamin S. How to examine patients using the
Abnormal Involuntary Movement Scale. Hospital and Community Psychiatry Nov 1988, 39 (11):1172-1177.

Most of the below was kindly submitted by Whit Garberson <jwgg@world.std.com>, Albert Maramis
<almarams@server.indo.net.id>, and Matthew J. Merkley <merkley@databank.com>. Mr Garberson also
notes:

Federal regs here require this test be administered every 6 mos. for nursing home patients currently on
antipsychotic meds. I'm not sure if there are similar regs for other populations/settings.

Instructions
There are two parallel procedures, the examination procedure, which tells the patient what to do, and
the scoring procedure, which tells the clinician how to rate what he or she observes.

Examination Procedure
Either before or after completing the examination procedure, observe the patient unobtrusively at rest (e.g., in
the waiting room).
 The chair to be used in this examination should be a hard, firm one without arms.

1. Ask the patient whether there is anything in his or her mouth (such as gum or candy) and, if so, to
remove it.
2. Ask about the *current* condition of the patient's teeth. Ask if he or she wears dentures. Ask whether
teeth or dentures bother the patient *now*.

3. Ask whether the patient notices any movements in his or her mouth, face, hands, or feet. If yes, ask the
patient to describe them and to indicate to what extent they *currently* bother the patient or interfere
with activities.

4. Have the patient sit in chair with hands on knees, legs slightly apart, and feet flat on floor. (Look at the
entire body for movements while the patient is in this position.)

5. Ask the patient to sit with hands hanging unsupported -- if male, between his legs, if female and
wearing a dress, hanging over her knees. (Observe hands and other body areas).

6. Ask the patient to open his or her mouth. (Observe the tongue at rest within the mouth.) Do this twice.

7. Ask the patient to protrude his or her tongue. (Observe abnormalities of tongue movement.) Do this
twice.

8. Ask the patient to tap his or her thumb with each finger as rapidly as possible for 10 to 15 seconds, first
with right hand, then with left hand. (Observe facial and leg movements.) [±activated]

9. Flex and extend the patient's left and right arms, one at a time.

10. Ask the patient to stand up. (Observe the patient in profile. Observe all body areas again, hips
included.)

11. Ask the patient to extend both arms out in front, palms down. (Observe trunk, legs, and mouth.)
[activated]

12. Have the patient walk a few paces, turn, and walk back to the chair. (Observe hands and gait.) Do this
twice. [activated]

Scoring Procedure
Complete the examination procedure before making ratings.

For the movement ratings (the first three categories below), rate the highest severity observed. 0 = none, 1 =
minimal (may be extreme normal), 2 = mild, 3 = moderate, and 4 = severe. According to the original AIMS
instructions, one point is subtracted if movements are seen only on activation, but not all investigators follow
that convention.

Facial and Oral Movements

1. Muscles of facial expression,
e.g., movements of forehead, eyebrows, periorbital area, cheeks. Include frowning, blinking, grimacing
of upper face. 0 1 2 3 4
2. Lips and perioral area,
e.g., puckering, pouting, smacking. 0 1 2 3 4

3. Jaw,
e.g., biting, clenching, chewing, mouth opening, lateral movement. 0 1 2 3 4

4. Tongue.
Rate only increase in movement both in and out of mouth, not inability to sustain movement.0 1 2 3 4
 Extremity Movements
5. Upper (arms, wrists, hands, fingers).
Include movements that are choreic (rapid, objectively purposeless, irregular, spontaneous) or athetoid
(slow, irregular, complex, serpentine). Do not include tremor (repetitive, regular, rhythmic movements).
01234
6. Lower (legs, knees, ankles, toes),
e.g., lateral knee movement, foot tapping, heel dropping, foot squirming, inversion and eversion of foot.
01234

Trunk Movements
7. Neck, shoulders, hips,
e.g., rocking, twisting, squirming, pelvic gyrations. Include diaphragmatic movements. 01234

Global Judgments
8. Severity of abnormal movements. 0 1 2 3 4
based on the highest single score on the above items.
9. Incapacitation due to abnormal movements.

0 = none, normal
1 = minimal
2 = mild
3 = moderate
4 = severe

10. Patient's awareness of abnormal movements.

0 = no awareness
1 = aware, no distress
2 = aware, mild distress
3 = aware, moderate distress
4 = aware, severe distress

Dental Status
11. Current problems with teeth and/or dentures.

0 = no
1 = yes

12. Does patient usually wear dentures?

0 = no
1 = yes
 CLINICAL DEMENTIA RATING (CDR)

CLINICAL
DEMENTIA
RATING 0 0.5 1 2 3
(CDR):

Impairment

None Questionable Mild Moderate Severe

1 2 3
0 0.5

No memory Consistent Moderate memory loss; Severe memory loss; Severe memory loss;
loss or slight slight more marked for recent only highly learned only fragments remain
inconsistent forgetfulness; events; defect interferes material retained; new
forgetfulness partial with everyday activities material rapidly lost
Memory
recollection of
events;
"benign"
forgetfulness

Fully oriented Fully oriented Moderate difficulty with Severe difficulty with Oriented to person only
except for slight time relationships; time relationships;
difficulty with oriented for place at usually disoriented to
Orientation time examination; may have time, often to place
relationships geographic
disorientation
elsewhere

Solves Slight Moderate difficulty in Severely impaired in Unable to make

everyday impairment in handling problems, handling problems, judgments or solve
problems & solving similarities, and similarities, and problems
handles problems, differences; social differences; social
Judgment &
business & similarities, and judgment usually judgment usually
Problem
financial affairs differences maintained impaired
Solving
well; judgment
good in relation
to past
performance

Independent Slight Unable to function No pretense of Appears too ill to be

function at impairment in independently at these independent function taken to functions
Community usual level in these activities activities although may outside home outside a family home
Affairs job, shopping, still be engaged in
Appears well enough to
volunteer and some; appears normal
be taken to functions
social groups to casual inspection
outside a family home

Home and Life at home, Life at home, Mild but definite Only simple chores No significant function in
Hobbies hobbies, and hobbies, and impairment of function preserved; very
intellectual intellectual at home; more difficult restricted interests, home
interests well interests chores abandoned; poorly maintained
maintained slightly more complicated
impaired hobbies and interests
 abandoned

Fully capable of self-care Needs prompting Requires assistance in Requires much help with
Personal dressing, hygiene, personal care; frequent
Care keeping of personal incontinence
effects

Score only as decline from previous usual level due to cognitive loss, not impairment due to
other factors.

G. Self-Perception – Self-Concept
 Interaction
 Observation
 Measurement
H. Role-Relationship
 Interaction
 Observation
 Measurement
 *Ecomap

I. Sexuality - Reproductive
 Interaction
 Observation
 Measurement
J. Coping-Stress
 Interaction
 Observation
 Measurement

K. Value-Belief
 Interaction
 Observation
 Measurement

IX. COMPREHENSIVE PHYSICAL EXAMINATION

A. Vital Signs Date / Time of Exam: ____________
T = __OC
PR = __ bpm
RR = __ cpm
BP = __/__ mmHg
Pain (if any…since this is the 5th vital sign, using the PQRST method)
Provoking factor
Quality
Region/radiation
Severity (using pain or face pain scale)
Time
B. Anthropometric Data (only those applicable)
Height = __ cm (for both adult & pedia) BMI = __ (for adult)
Weight = __ Kg (for both adult & pedia) IBW = __ (for adult & pedia)
Head Circumference = __ cm (for pedia)
Chest Circumference = __ cm (for pedia)
Abdominal Circumference = __ cm (for pedia0
C. General Appearance
1. Body build and height-weight proportionality
2. Posture and Gait
3. Over-all hygiene and grooming
4. Body and breath odor
5. Obvious signs of distress / illness
6. Mental status
7. Attitude
8. Affect/mood; appropriateness of responses
9. Quantity and quality of speech
10. Relevance and organization of thoughts

D. Focused Assessment
Body Part Examined Actual Finding Normal Finding Clinical Significance
INTEGUMENT
Skin
I: color, uniformity,
edema, lesions
P: moisture, temp.
turgor
Hair
I: evenness of growth
thickness, texture,
oiliness, infection
or infestation, body
hair
P: smoothness
Nail
I: plate shape, texture,
bed color,
surrounding tissues
P: Blanch test
HEAD
Skull and Face
I: size, shape ,
symmetry
: facial features
: eyes for edema
and hollowness
P: nodules, masses,
depressions
Eyes and Vision
I: eyebrows for
distribution &
alignment, quality &
movement
: eyelashes for
evenness of
distribution &
direction of curl
: eyelids for surface
 characteristics,
position in relation to
cornea, ability to
blink & frequency
: bulbar & palpebral
conjunctiva for
color, texture, and
lesion
I/P: lacrimal gland
sac, nasolacrimal
duct for edema,
tenderness / tearing
I: cornea for clarity,
texture & sensitivity
I: pupils for color,
shape, symmetry of
size, direct and
consensual reaction
to light, &
accommodation
* Visual Acuity (near
& far vision test)
* Visual Field Test
* EOM Test
Ears and Hearing
I: auricles for color,
symmetry and
position
: external canal for
cerumen, lesions,
pus or blood
P: auricles for texture,
elasticity and areas
of tenderness
* Gross Hearing Acuity
Tests: normal voice
tone and whispered
voice
* Watch Tick Test
* Tunning Fork Tests:
- Weber for bone
conduction
- Rinne’s to compare
air and bone
conductions
Nose and Sinuses
I: nose deviation in
shape size, color,
flaring, discharge;
: nasal mucosa for
redness, swelling,
growth or discharge
Pa: tenderness,
masses,
displacements;
: nasal patency
: maxillary and
frontal sinuses for
tenderness
Pe: the above sinuses
for tenderness
Transillumination Test
Mouth / Oropharynx
I: lips for symmetry of
contour, color,
texture, moisture,
lesion
: teeth for alignment,
loss, dental filings
and caries;
: gums for bleeding,
color, retraction,
lesions, swelling
: tongue for position,
color & texture;
movement, as well
as the base of the
tongue, mouth floor
and frenulum
: salivary gland
ducts for swelling,
redness
: palates for color,
shape, texture,
presence of bony
prominences
: uvula for position &
mobility
: oropharynx for color
& texture
: tonsils for color,
discharge, and size
Test for Gag Reflex
P: nodules, lump and
excoriated areas
NECK
Neck Muscles
I: abnormal swelling or
masses, head
movement, and
muscle strength
Lymph Nodes
P: enlargement
Trachea
P: lateral deviation
Thyroid Gland
I: symmetry and visible
masses, rise during
swallowing
P: smoothness
A: bruit
THORAX & LUNGS
Posterior Thorax
I: shape & symmetry
from posterior-lateral
views; spinal
alignment for
deformities
Pa: temperature,
bulges, tenderness,
abnormal
movements,
respiratory
excursion, vocal
fremitus
Pe: for symmetry of
resonance;
diaphragmatic
excursion
A: breath sounds

Anterior Thorax
I: breathing pattern,
coastal and
costovertebral angle
Pa: respiratory
excursion, tactile
fremitus
Pe: symmetry of
resonance
A: breath sounds
Heart
I: precordium for
pulsations & lifts or
heaves
A: heart sounds (S1,
S2, etc.)
Central Vessels:
Carotid Arteries
P: volume, quality
A: bruit
Jugular Veins
I: distention
Peripheral Vessels
I: presence or
 appearance of
superficial veins,
signs of phlebitis
*Buerger’s Test
*Capillary Refill
Breast & Axillae
I: breast for size,
symmetry, contour or
shape, discoloration,
retraction,
hypervascularity,
swelling, edema
: areaola for size,
shape, symmetry,
color, surface
characteristics,
masses, lesions
: nipples for size,
shape, position,
color, discharge,
lesion
P: lymph nodes,
breast, areola &
nipples for
tenderness, masses,
nodules, discharge
ABDOMEN
I: skin integrity, contour
& symmetry, hernia,
distention (girth),
movements
associated w/
respiration,
peristalsis & aortic
pulsations
A: bowel, vascular, &
peritoneal friction rub
sounds
Pe: all quadrants /
regions for tympany
and deviations
Pa: light to deep
palpations ALL
quadrants from least
painful to most
painful for masses,
tenderness, muscle
guarding; liver
(bimanual) and
bladder palpation
* Leopold’s Maneuver
for OB clients for
 presentation, lie,
engagement,
attitude, position If necessary /
MUSCULOSKELETAL applicable / significant
Muscles
I: size, contractures,
fasciculations,
tremors
P: tonicity, flaccidity,
spasticity,
smoothness of
movement, strength
Bones
I: structure, deformity
P: edema, tenderness
Joints
I: swelling
P: tenderness,
smoothness of
movement, swelling,
crepitation, nodules
NEUROLOGIC
Mental Status
- Language
- Orientation
- Memory
- Attention Span /
Calculation
Consciousness Level
Glassgow Coma Scale
Cranial Nerves
- I to XII
Reflexes
- Deep, superficial & For Adult
pathologic
- Neonatal Reflexes For Pedia
Gross Motor/Balance
* Walking Gait
* Romberg
* Standing on 1 foot w/
eyes closed
* Heel-toe walking
Fine Motor
- Upper Extremities:
* Finger-Nose Test
* Alternate Supination
& Pronation of hands
on knees
* Finger to Nose & to
RN finger
* Fingers-to-fingers
* Fingers-to-thumb
- Lower Extremities:
* Heel down opposite
skin
* Toe / Ball of Foot to
RN’s finger
Sensory Function
* Light/Deep Touch
* Pain Sensation
* Temperature
* Position / Kinesthetic
* Tactile Discrimination If necessary /
GENITALS applicable / significant
*For males:
I: pubic hair for
distribution, amount,
characteristics
: penis shaft and
glans for lesions,
nodules, swelling,
inflammation
: urethral meatus for
swelling,
inflammation,
discharge
: inguinal areas for
bulges or swelling
P: penis for
tenderness,
thickening, nodules
: scrotum for
appearance, size and
symmetry, and
underlying testes,
epididymis and
spermatic cord
: inguinal areas for
palpable bulge If necessary /
* For females: applicable / significant
I: pubic hair
distribution, amount,
characteristics; its
areas for parasites,
inflammation,
swelling, lesions
: clitoris, urethral
and vaginal orifices
for inflammation or
discharge
P: bartholin’s glands,
lymph nodes for
enlargement,
tenderness, swelling
 * Internal Exam for OB
clients for cervical
dilation, effacement
and AP pelvic If necessary /
diameter applicable / significant
RECTUM & ANUS
I: anus and
surrounding tissue
for color, integrity,
lesions
P: anal spinchter
tonicity, nodules,
masses and
tenderness
: if male, prostate
gland for tenderness
: if female, cervix
through the anterior
rectal wall for
tenderness

X. Diagnostic Test
A. Non-Invasive
Specific Test Actual Finding Normal Finding Clinical Significance
Sputum Microscopy
Urinalysis
Fecalysis
Radiology
Other: ECG, MRI, CT
B. Invasive
Specific Test Actual Finding Normal Finding Clinical Significance
Blood Chemistry
Hematology
Electrolytes
ABG
Visualization
procedures (surgical
approach)
Note: Please indicate ONLY those diagnostic tests that were actually performed to confirm the
identified pathology. For OB and Pedia clients, please utilize the appropriate tools for labor and
delivery as well as newborn assessment.
XI. Review of System (include only those that are significant to the case under study)
A. Neurologic
B. Pulmonary
C. Cardiovascular
D. Hematologic
E. Immunologic
F. Gastrointestinal
G. Renal
H. Musculoskeletal
 I. Reproductive
J. Integumentary
XIII. CASE MANAGEMENT

A. Medical (present only those that are applicable and w/c have been done for the patient)
1. Pharmacologic Intervention
Drug Features Therapeutic Effects Nursing
Responsibilities
- Brand / Generic Name Indication Contraindication Desire Untoward
- Classification d
- Prescribed Dosage
- Route
- Frequency
2. Dietary Prescription / Restriction

B. Nursing Management
1. List of Nursing Problems (minimum of 5 for 2nd year; minimum of 10 for 3rd year)
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.

2. Plans for Nursing Actions

a. Nursing Care Plan
Assessment Diagnosis Planning Implementation Evaluation
Subjective: Problem r/t At the end After 4 hours of
The client Etiology, w/ of 4 hours nursing care,
verbalized, Sign/symptom of rendering goal was met /
“_______” (defining nursing unmet /
characteristics) care, the partially met,
client will be as evidenced
Objective: *Choose the able to: by:
 PE applicable: 1.________ Independent Rationale & 1.
Findings 1. Actual Dependent Reference
 Lab 2. Probable Collaborative
Findings 3. Risk
4. Syndrome 2.________ Independent Rationale & 2.
5. Wellness Dx Dependent Reference
Collaborative

3.________ Independent Rationale & 3.

Dependent Reference
Collaborative
 b. Teaching Plan
Intended Outcomes Content Strategies Resources Evaluation
1. Cognitive Topic Teaching Learning * Materials Pen and paper
2. Affective Subtopic Activity Activity * Human test
3. Psychomotor - concept Resources
- concept * Time Recitation
Subtopic
- concept Return
- concept demonstration

Observation

Prepared by:

SUNNY ROSE FERRERA, RN, MAN

MARY ANTONIETTE D. VIRAY, RN, MAN
MARIBEL L. CHUA, RN, MAN

Approved by:

EVELYN M. DEL MUNDO, PhD

Dean