UNIVERSITY OF

PERPETUAL
SYSTEM DALTA
HELP
COLLEGE OF NURSING

INTERVIEW AND ASSESSMENT TOOL

(Growth and Development)

Name: MANALILI, MA. NAOMIE D. BSN: 2A Date: December 1, 2022

NURSING HISTORY:
General Information
Client’s Initials: Ma. Franchesca Felix
Age: 8 yrs. old
Sex: Female
Civil Status: Single
Nationality: Filipino
Religion: Catholic
Educational Attainment: Grade 3
Occupation: None
Chief Complaints (If any): None

Vital Signs
T: 35.0 °C P: 105 Beats/min R: 12 Breaths/min
BP: N/A Mm/Hg Weight: 26.2 Kg Height: 129 cm
BMI Computation and Interpretation: 15.7 – Underweight
____________________________________________________________________________

Formula: Weight (kg) / (Height (m)) ^2

<18.5 – Underweight
18.5-24.9 – Normal (Healthy BMI Range)
25-29.9 – Overweight
30-39.9 – Obese

Alabang-Zapote Road, Pamplona 3, Las Piñas City, 1740 Philippines • Tel. No.: (632) 8871-0639
www.perpetualdalta.edu.ph
Las Piñas Campus
 UNIVERSITY OF
PERPETUAL
SYSTEM DALTA
HELP
COLLEGE OF NURSING

Nursing History (Based on the Functional Health Pattern by Gordon: MODIFIED)

HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN
Client’s description of his/her health:
According to the client, whenever she feels sick, she always goes to her doctor, and she
avoids salt in her diet because that's what her mother told her. Also, she loves to dance.

Health Management:
Self
According to the client, she feels good about herself, and she always follows her hygiene
practices, like taking a shower every day and brushing her teeth twice a day.

Family
The client claims that her mother had previously complained of abdominal pain, but she
has no idea what her mother's illness was. Her father, on the other hand, has previously
experienced diarrhea. Her grandfather tested positive for COVID-19 as well.

Past Illnesses:
According to the client, she swallowed her toy when she was young.

History of Hospitalization, if applicable (When, Where, Why)

Why: Aspiration due to swallowing a toy
When: Her mother told her that when she was young, she swallowed a toy
Where: UPHMC
 
History of Illnesses in the Family:

According to the client, she has no idea about that.

Alabang-Zapote Road, Pamplona 3, Las Piñas City, 1740 Philippines • Tel. No.: (632) 8871-0639
www.perpetualdalta.edu.ph
Las Piñas Campus
 UNIVERSITY OF
PERPETUAL
SYSTEM DALTA
HELP
COLLEGE OF NURSING
NUTRITION AND METABOLIC PATTERN
Usual Food Intake:
Cereal and bread, chicken nuggets at Mc Donald`s without sauce, and tilapia

Usual Fluid Intake (Type, Amounts):

Water (4-6 Glasses a day)

Any Fluid/Food Restrictions:

Squids and salty foods

Any problems with ability to eat:

According to the client, she experiences choking sometimes.

Any supplements (Vitamins, Feedings)

According to the client, she has her vitamins like Celine and Cherifer.

ELIMINATION PATTERN
Bladder:
According to the client, she has no pain or difficulty in any part of her abdomen.

Complaints of the usual pattern of urination:

None, because according to the client, she urinates well with no pain or difficulties.

Bowel:
She voids 1-2 times a day with brown and formed stools.

Complaints of the usual pattern of bowel movement:

None, she usually moves her bowel every morning.

Alabang-Zapote Road, Pamplona 3, Las Piñas City, 1740 Philippines • Tel. No.: (632) 8871-0639
www.perpetualdalta.edu.ph
Las Piñas Campus
 UNIVERSITY OF
PERPETUAL
SYSTEM DALTA
HELP
COLLEGE OF NURSING
ACTIVITY-EXERCISE PATTERN
Any limitations of physical ability:
None, she loves dancing, she`s able to bathe herself and she`s an active child.

SLEEP-REST PATTERN
Any problems regarding sleep
None, she goes to bed at 10 p.m. and wakes up at 6 a.m. (8 hours), and she falls asleep
easily.

ROLE-RELATIONSHIP PATTERN
Significant person the client:
According to the client, she`s closest to her father.

Complaints regarding family

She has none, because according to the client, she is loved and supported by her family,
with whom she has a close relationship.

COPING-STRESS MANAGEMENT PATTERN

Any significant stress in the past year and decision-making ability
There have been no traumatic events in the past, and the client claims that whenever she
makes a mistake, she always learns a lesson from it.

VALUE BELIEF SYSTEM

Source of strength or meaning:
According to the client, her inspiration was the famous K-pop group named BTS.

Importance of God to client

According to the client, she always prays to God, goes to church every Sunday with her
family, and does the rosary.

Alabang-Zapote Road, Pamplona 3, Las Piñas City, 1740 Philippines • Tel. No.: (632) 8871-0639
www.perpetualdalta.edu.ph
Las Piñas Campus
 UNIVERSITY OF
PERPETUAL
SYSTEM DALTA
HELP
COLLEGE OF NURSING
DEVELOPMENTAL TASKS
(Assess for the achievement of developmental tasks significant to patient’s age)
 Sigmund Freud

 Latency stage

 Client has a good relationship with her friends, enjoys exploring new hobbies, and
loves dancing.

 Erik Ericson

 Industry vs. Inferiority (Competency)

 She`s proud to herself when she finishes her assignments.

 Jean Piaget

 Concrete-operational stage

 The child can understand principles of cause and effect, size, and distance.

 James Fowler

 Stage 2 (Mythic-Literal faith)

 Client demonstrates her devotion to her religion by attending church every Sunday
and praying the rosary with her family.

 She also loves Japanese anime, which is why she focuses more on non-fictional
characters.

 Lawrence Kohlberg

 Level 2 - Conventional morality

 The client knows that she did something wrong or bad, and according to her, she
learned a lesson from it, which is why she knows the difference between right and
wrong.

Alabang-Zapote Road, Pamplona 3, Las Piñas City, 1740 Philippines • Tel. No.: (632) 8871-0639
www.perpetualdalta.edu.ph
Las Piñas Campus
 UNIVERSITY OF
PERPETUAL
SYSTEM DALTA
HELP
COLLEGE OF NURSING
PHYSICAL ASSESSMENT:
HEAD-TO-TOE EXAMINATION
General Survey:
The client`s vital signs are all normal, except for her BMI. Because her BMI is not in the
normal range and its interpretation is underweight. Also, she communicates well, responding to
questions attentively, making eye contact during the interview, and listening carefully and asking
for clarification when something isn’t clear to her. In terms of her basic nutritional and fluid
status, she drinks 4-6 glasses of water a day, which is good; she gets 8 hours of sleep, she eats
vegetables and avoids salty foods.
Head and Face:
 Hair: Evenly distributed with long, black and shiny hair, No evidence of Alopecia.

 Head: The head of the client is rounded; normocephalic and symmetrical.

 Skull: There are no nodules or masses and depressions when palpated.

 Face: The face of the client appeared smooth and has uniform consistency and with no
presence of nodules or masses.

EYES AND VISION

External Eye Structure:
 Symmetrical, no glasses, Eyelashes appeared to be equally distributed and curled slightly
outward, the Bulbar conjunctiva appeared transparent with few capillaries evident, sclera
appeared white, palpebral conjunctiva appeared shiny, smooth and pink, there is no
edema or tearing of the lacrimal gland and the cornea is transparent, smooth and shiny
and the details of the iris are visible.

Visual Acuity:
 Right Eye: Snellen Chart No. 4 – Perfect 20/50

 Left Eye: Snellen Chart No. 5 – Perfect 20/40

 Both Eye: Snellen Chart No. 6 – Perfect 20/30

Extraocular Muscle Function (Cranial Nerve III, IV, & VI)

Eye movements are smooth and without jerking.

Alabang-Zapote Road, Pamplona 3, Las Piñas City, 1740 Philippines • Tel. No.: (632) 8871-0639
www.perpetualdalta.edu.ph
Las Piñas Campus
 UNIVERSITY OF
PERPETUAL
SYSTEM DALTA
HELP
COLLEGE OF NURSING
EARS AND HEARING
External Ear:
The Auricles are symmetrical and has the same color with her facial skin. The auricles
are aligned with the outer canthus of eye. When palpating for the texture, the auricles are
mobile, firm and not tender. The pinna recoils when folded.

Hearing:
Voice sound audible in both ears

NECK
Lymph Nodes:
Non-palpable, non-tender
Thyroid Glands:
Not visible on inspection, glands ascend but not visible in the client because she`s a female

BACK
Musculoskeletal Structure
No abnormal curvature of spine, full range of motion, no muscle spasm or tenderness
and the right and left shoulders and hips are of the same height.
Posterior Thorax (Auscultation)
Air entry is normally clear with no abnormal sounds, Bronchovesicular breath sounds are
moderate in loudness; inspiration is equal to the expiration phase, and heard on the upper
thorax close to the vertebrae and near the bronchi.
ABDOMEN
The abdomen of the client has an unblemished skin and is uniform in color. The abdomen
has a symmetric contour. There were symmetric movements caused associated with client’s
respiration.
UPPER EXTREMITIES
Musculoskeletal Structures (Skin and Nails)
The extremities are symmetrical in size and length, no presence of bone deformities,
tenderness and swelling, no edema, color is even, temperature is warm and even.

Alabang-Zapote Road, Pamplona 3, Las Piñas City, 1740 Philippines • Tel. No.: (632) 8871-0639
www.perpetualdalta.edu.ph
Las Piñas Campus
 UNIVERSITY OF
PERPETUAL
SYSTEM DALTA
HELP
COLLEGE OF NURSING
Musculoskeletal Functions
No involuntary movements, can perform complete range of motion, have the same
contour with prominences of joints, t here were no swelling, tenderness and joints move
smoothly, the muscles are not palpable with the absence of tremors, they are normally firm and
showed smooth, coordinated movements.
Brachial and Radial Arteries
Both pulses are symmetrical, regular and between 70 and 120 bpm.
Deep Tendon Reflexes
2+ = a brisk response; normal

LOWER EXTREMITIES
Musculoskeletal Structures (Skin and Toe Nails)
The extremities are symmetrical in size and length, no presence of bone deformities,
tenderness and swelling, no edema, color is even, temperature is warm and even.
Musculoskeletal Function (Muscle Strength, Tone, and Range of Motion)
No involuntary movements, can perform complete range of motion, have the same
contour with prominences of joints, t here were no swelling, tenderness and joints move
smoothly, the muscles are not palpable with the absence of tremors, they are normally firm and
showed smooth, coordinated movements.

SUMMARY OF ABNORMAL FINDINGS:

The client is underweight. Her BMI is 15.7, which is lower than the normal range, and its
interpretation is underweight.

Alabang-Zapote Road, Pamplona 3, Las Piñas City, 1740 Philippines • Tel. No.: (632) 8871-0639
www.perpetualdalta.edu.ph
Las Piñas Campus