Fundamentals of Nursing

Name: Kristine Mae M. Merhan Score: ________ _

Course/section: BSN-1B Date: May 19, 2022 _

Assessment Practice Output

Subjective Cues:
 Pain Scale 5 out of 10
 “Ang sakit ng tiyan at ulo ko at medyo nahihilo mula
kaninang tanghali hanggang ngayong hapon”
– as verbalized by the patient

 States that he has been stressed lately because of school

works, thus resulting in lack of sleep and skipping of
meals often
Objective Cues: (Observation from head to toe)
 Conscious and coherent
 Facial grimace
 Profuse sweating
 Skin moisture
 Dry lips
 Appears irritable and sleepy
 Vital Signs: BP: 110/80 mmhg
RR: 16
PR: 96
Temp: 36.5 °C
 Breath sounds Loud, high-pitched bronchial breath
sounds over the trachea, inspiration and
expiration are equal and there is a pause
between inspiration and expiration.
 Abdominal sounds Hyperactive bowel sounds