Finallllll H.A

St.
Paul University Philippines

Tuguegarao City, Cagayan 3500
SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES
COLLEGE OF NURSING
1ST SEMESTER, AY 2019-2020
BACHELOR OF SCIENCE IN NURSING – LEVEL II
HEALTH ASSESSMENT
Part 1. Health History

A. Biographic Data
Client C.L, is a male client who is currently residing at Liguitan Street, Zone 4,
Tagga together with his wife and 2 children. He was born December 5,1957. He is
now 62 years old and a college graduate. He speaks both Ybanag and Filipino. He is
a househusband, and at the same time, a hog raiser and spends some of his time
gardening. His religion is Roman Catholic.
B. Reason for seeking care/present health concern

According to Client C.L. his major concern is his hypertension that was diagnosed 2 days
ago prior to the interview. The client verbalized, “Nagsimulang sumakit yung batok ko
pagkatapos ng New Year. Natakot ako kasi akala ko may tumor na ako kaya ako
nagpacheck up”. He added that he sought healthcare because he cannot anymore tolerate
the pain. He only visits hospital or clinic when needed and with regards to seeking
healthcare he said, “Nagkapeace of mind ako nung nalaman ko yung sakit ko. Mas
nakakatakot kasi kapag tumor.” After his consultation, the client underwent maintenance.
Moreover, Client C.L verbalized that he was willing to undergo health education
regarding hypertension.
C. History of present health concern
Before the client was diagnosed with hypertension, he already felt a pain at his nape,
and verbalized, “Nakaramdam ako ng pagsakit sa batok ko pero kinakaya ko naman.
Tuwing sumasakit, nagpapahinga lang ako para mawala.” After which, he went for a
medical consultation because the pain is already 3 days long. He has mentioned,
“Nagtagal yung sakit ng tatlong araw. Nung una, nakakaya ko pa yung sakit. Pero nung
pangatlong araw na, iba na yung sakit niya kaya nagpatingin na ako.”
Client C.L was diagnosed to have hypertension, and when asked if how did he
handle the situation, he said that, “Dati rati, malakas akong kumain ng kanin at saka sa
mga mamantika tapos mahilig rin ako magkape. Pero nung nalaman ko na may highblood
ako, binawasan ko na yung kanin at medyo iniiwasan ko na rin ang mga mamantika.
Bukod dun, hindi naman niya naapektuhan ang mga pang-araw-araw ko na gawain.”
Moreover, in reducing the pain, he verbalized, “Kapag sumasakit yung batok ko,
umiinom lang ako ng gamut tapos nagpapahinga tapos mawawala na siya.”
D. Personal Health History

St. Paul University Philippines
COLLEGE OF NURSING
Client C.L said that he had chickenpox, measles and mumps when he was
young. He was vaccinated before but was not able to recall the vaccine/s
administered to him. During his childhood, he used to take Tikitiki for proper
nutrition. He had never undergone any surgery and never experienced any accidents
before. The client also said that he does not have any allergies and does not visit the
hospital for his monthly check- up. Moreover, the client denies previous
hospitalization due to any health condition.
Client C.L mentioned that 5 years ago, he had experience cramps due to heavy
work and exhaustion. When asked about his ways in relieving the pain, the client
verbalized, “Pinapahinga ko lang tapos minamasahe ko. Pinapahiran ko rin ng pain
relieve rub”. He had also mentioned that he experiences having boils on his right
lower foot 2 years ago and after 2 months the boils reoccurred again on his left upper
leg and on his armpit. Because of this, he decided to visit a doctor to ask for medical
advice. Client C.L said that his doctor gave him a cream for his boils but was not
able to recall the prescribed cream.
Last November 2019, he sought for a medical advice with regards to weight
gain. His physician prescribed Estamin to him. Client C.L said that he had consumed
40 tablets of Estamin 250 mg. Estamin is a multivitamin and mineral used for
therapeutic & nutritional supplementation in both normal & physiological stressful
conditions. Client said he had observed that his appetite had increased while taking
the vitamin. However, he said that he had not gain weight. As of now, the client’s
BMI is still 18.8. He said that he continued to take the vitamin but decided to stop
when he observed that his urine became yellowish. He decided to try another
Vitamin which is Revicon Forte for 2 weeks but he stopped taking it when he started
to experience pain on his buttocks. As of the moment, Client C.L is taking 500 mg of
Xanthone Plus Herbal capsule which he heard from the radio. Xanthones Plus Herbal
Capsule are known to possess a wide spectrum of pharmacologic properties,
including anti-oxidant, anti-tumor, anti-allergic, anti-inflammatory, anti-bacterial,
anti-fungal, and anti-viral activities. In addition, he said that he received vaccines last
December 2019 which are the pneumococcal vaccine and the anti- flu vaccine. He
received his vaccines at the barangay health center administered by their Barangay
Midwife.
E. Family Health History

COLLEGE OF NURSING
Grandfather Grandmother Grandfather Grandmother
Father Mother
Eldest Sister Elder Sister Client R.B. Wife
LEGEND:
- Hypertension
- Diabetes
- Cancer
F. Review of Systems
COLLEGE OF NURSING
Skin, Hair and Nails: Reports hair thinning; Denies problems with skin and
nails.
Head and Neck: Denies headaches, swelling, stiffness of neck; denies difficulty
in swallowing, sore throat, enlarged lymph nodes.
Eyes: Wears glasses for reading; Denies any eye infections, redness, excessive
tearing, eye pain.
Ears: Denies loss of hearing, ringing and buzzing, earache, drainage from ears,
dizziness and exposure of loud noises.
Mouth, throat, nose and sinuses: Denies bleeding of gums or other dental
problems; Denies sore throats and hoarseness; Denies nasal obstruction, frequent
colds, sneezing; Denies nose bleeds.
Thorax and lungs: Denies difficulty in breathing, pain, shortness of breath

during routine activity.
Breast and regional lymphatics: Denies lumps or discharge from nipples;

Denies swollen or tender lymph nodes in axilla.
Heart and neck vessels: Reports last blood pressure of 140/80mmHg; Denies
chest pain or pressure, palpitations and edema.
Peripheral Vascular: Reports leg cramping; Denies swelling or edema of legs

and feet; Denies sores on legs, changes of color or texture changes on the legs or
feet.
Abdomen: Denies loss of appetite and abdominal fullness; Denies pain and
tenderness.
Male genitalia: Denies sexual problems; STIs; Circumcised at age 12; Denies
difficulty in urinating and voiding problems.
Anus, rectum and prostate: Reports daily bowel movement of well-formed

brown stool; Denies pain with defection, hemorrhoids, blood in stool, constipation
and diarrhea.
Musculoskeletal: Denies swelling, redness, pain and stiffness of joints; Reports

ability to perform ADLs without difficulty.
COLLEGE OF NURSING
Neurologic: Denies depression, anger and suicidal thoughts; Denies headaches,

loss of strength or sensation, lack of coordination; Denies difficulty speaking,
memory problems, strange thoughts and actions, and difficulty in learning.
G. Lifestyle and Health Practices

The client does not smoke. He drinks liquors like Emperador and red wine for
relaxation, which started when he was around 18 years old. He says that a 500mL
bottle of red wine is good for 2 to 3 weeks. He also used to drink 3 to 4 cups of
coffee measuring 350 mL per cup in a day, but he had to cut it off to only 1 cup
every after breakfast when he found out about his condition.
Gordon’s Typology Of 11 Functional Health Pattern
1. Health Perception – Health Management

Client C.L said that although he was diagnosed with hypertension, he still
feels healthy and continues to do what he does like nothing happened. He also
mentioned that managing his health is his top priority at this moment. When asked if
what made him say so, he mentioned that his kids are still young, and he still wants
to see them grow. “Kahit maabutan ko lang hanggang mga 25 na sila, pwede na”,
Client C.L added. In connection to this, when ask about how he manages his health,
he said that he tries to lessens the amount of alcohol and coffee that he drinks as well
as the salty, fatty and oily foods that he usually eats, and makes sure that he eats a
balanced diet.
2. Nutritional – Metabolic
Although he eats vegetables, Client C.L admitted that his diet before consisted
mostly of fatty and oily foods, which he thinks caused his condition. He drinks 236
mL of water 8 times a day while consuming his meals 3 times a day with occasional
afternoon snacks like biscuits. His menu usually comprises of rice, adobo, fried
chicken, inabraw, coffee, and karahay. When asked for a 24-hour recall of his meal,
he said that he ate ampalaya with egg, rice, and coffee for breakfast, kalabasa with
petchay and rice for lunch and adobong pato with rice for dinner. He also added that
part of his diet plan is lessening the amount of rice he eats — from the usual 3 or
more cups, he now only consumes 1-1/2 cups per meal.
3. Elimination
Client C. L urinates 7- 8 times a day which measures up to 900 mL whose usual
color is light yellow. The client stated that 2 years ago, he used to drink Revicon
Forte that only lasted for 2 weeks when he noticed that his urine color became
brown. Out of fear, he stopped taking the said food supplement. After sometime, the
COLLEGE OF NURSING
client realized that it was just a side effect of the food supplement. He defecates 2
times a day in the morning and evening respectively, and describes his stool as
brown in color and well-formed in consistency. He added that he does not feel any
discomfort while urinating nor defecating.
4. Activity - Exercise
In a typical day, client C.L does some stretching and household errands like
feeding pigs, which he considers as a form of exercise, mostly every morning since
he does not have the time and much strength to do vigorous exercises because of his
age. When he does not have anything to do, he just spends his time sitting or
watching television with his family.
5. Cognitive - Perceptual
The client said that he uses reading glasses but stated that he does not have
difficulty seeing things. Client C.L also said that he has pain at the back of his ears
which started last December. He nonetheless said that he can still hear and
understand things clearly without any ringing or buzzing sounds. In addition, he does
not have any trouble processing any words or information, does not have strange or
unusual thoughts, can still think rationally, and does not have any short-term memory
loss.
6. Sleep - Rest
Client C.L sleeps at 9PM and wakes up at 4AM. He has a habit of waking up in
the middle of his sleep for 2-3 times just to urinate. However, the client said that he
feels rested when he wakes up. Although he has no difficulty in falling asleep after
10 minutes of lying down in bed, he tends to wake up very early and is not able to
return to his sleep even if he tries to. Despite his situation, he still does not feel any
discomfort or headache when he wakes up.
7. Self-perception and self-concept

The client stated that he is satisfied with his current status in life and what he has
achieved for himself and his family. Also, he does not experience depression and he
never once thought of hurting himself. In addition, the client said that he is satisfied
with who he is and what he has in life now.
8. Role-relationship
The client said that he does not have any problem with his family and he enjoys
and maintains his close relationship with his wife and his 2 children. He also stated
that his disease did not affect his everyday routine but since he was diagnosed, his
family became more considerate.
9. Sexuality- reproductive
COLLEGE OF NURSING
The client stated that he can still fulfill the sexual needs of his wife and vice
versa. The client and his wife are in good state in terms of their sexual- reproductive
aspect as evidenced by their 2 offspring. He answered none when asked if he has a
sexual problem or dysfunction in his reproductive system. The client was
circumcised at the age of 12.
10. Coping stress and coping tolerance

According to the client, one factor that makes him stressed is his children’s
overuse of cellphone especially at night. Another factor was the anxiety he felt
before consulting a healthcare professional. When he is stressed, he simply drinks
water and rest. He does not drink alcohol, use medication or take recreational drugs
to relieve stress.
11. Value-belief
The client believes that “health is wealth”. He stated that health is their top
priority as a family. Moreover, he believes that herbal medicine is effective because
his child uses oregano once to cure his cough. But the client himself does not
practice it since he only does water therapy. He also does not believe in any
superstitious beliefs.
•Developmental level
There are changes that occur to the client physically. He said that his skin
became less elastic and his hair became thin and turned gray as melanin decreases.
Part 2. Physical Assessment

COLLEGE OF NURSING
A. Vital Sign
Date: January 10, 2020
Time: 10:30 AM
Interviewers:
Jeremiah Allam Melizzae Mateo
Therese Battung Christian Matias
Krista Jinky Bravo Precious Pearl Meñano
Angelika Estabaya Sherwin Pazzibugan
Hanah Galupo Leah Purugganan
Jeremiah Lagrio Pauline Joy Sangdaan
Miguel Ligas Maxielle Suguitan
Noreen Navarro Marlalaine Verdadero
BLOOD PRESSURE: 140/ 80 mmHg

TEMPERATURE: 36.5 °C
PULSE RATE: 75 bpm (beats per minute)
RESPIRATORY RATE: 16 bpm (breaths per minute)
MEASUREMENTS:
HEIGHT 5’4 ft
WEIGHT 50 kgs
BMI 18.8 (normal weight)
B. General Survey
The client happily welcomed the interviewers in his home. The client stands
comfortably and his body is well coordinated. He is dressed appropriately in accordance
to the weather. The client is well-groomed. However, white hairs were observed during
the student-client interaction. During the interview, the client maintains eye contact, was
comfortable and very interactive. His voice is clear and the student-nurses did not
encounter any difficulty communicating with him. He distances himself from the existing
COLLEGE OF NURSING
and impending problems that may affect him. The client was cooperative and listened
attentively to the student nurses while assessing him. The client has a good memory for
he remembers the things that happened to him last week and years ago. He clarifies his
answers for the student nurses to understand what he is trying to tell. The client was able
to distinguish the medicines that he had taken and is presently taking at the moment. At
the end of the visit, the client accompanied the student nurses as they went out of the
house.
B. Head-to-toe Physical Assessment
Integumentary
AREA ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL FINDING INTERPRETATION
Hair Color Inspection Natural hair color, as He has a normal hair Normal
opposed to chemically color that is black, and
colored hair, varies some are white
among clients from pale
blond to black grey or
white
Scalp Cleanliness, Inspection Scalp is clean and dry, No sign of infection in Normal
Dryness, Sparse dandruff may be his hair follicle, lesions,
Parasites, visible; Hair is smooth and parasites; His hair
Lesions and firm, somewhat is not dry and has a
elastic good hygiene
Nails Grooming & Inspection Nails are clean He has a good hygiene Normal
cleanliness with a clean and
unbroken nail
Color & Inspection Pink tones should be The nails are not pale Normal
Marking seen and pink tones are seen;
No beau lines present
Shape Inspection There is normally a 160- No sign of early Normal

degree angle between clubbing; also, spoon
the nail base and the nails (concave) are not
skin. present.
Texture & Palpation Nails are smooth and Nail plate are attached Normal
consistency firm; nail plate should firmly to the nail bed;
be firmly attached to Nails are smooth and no
nail bed sign of inflammation
Capillary Refill Palpation Pink tone returns Capillary nail bed refills Normal
immediately to blanched immediately
nail beds when pressure
is released
Eyes Eyeballs Inspection Eyeballs are aligned in The eyeball is in normal Normal
sockets with no position and there is no
protrusion or sunken; bulging or protrusion;
Lacrimal Sac Inspection/Palpation No edema or increase There is no edema Normal

and Gland tearing between lower lid and in
nose; there is no
evidence of increase
tearing
Pupil Inspection Pupils appear round, The pupils are Normal

regular and both equal constricted whenever
in size the light is present and
dilating with the
absence of light; The
pupils are reactive to
accommodation
Peripheral Inspection Able to see the pen when Able to indicate location Normal
Visual Field moved into the client’s of the pen with gaze
field of vision when moved into her
field of vision
Skin Skin surface Inspection/palpation Evenly colored skin tone The client does not feel Normal
without unusual any itchiness or any
discoloration seen; irritation to the body,
Smooth with no upon inspection, the
presence of lesion, the client has an even skin
skin is warm, and it tone and has good skin
immediately recoil turgor
Head and Neck
Head Involuntary Inspection Head should be held still There are no sign of Normal
movement and upright horizontal jerking
movement and
involuntary nodding;
Head is not tilted and is
held upright
Consistency Palpation Head is normally hard There are no lumps or Normal

and smooth without lesions
lesions
Symmetry, Inspection The face is symmetric Face is not drooping & Normal
movement, with round, oval, no abnormal movement
expression elongated, or square in the face are seen
appearance; No
abnormal movements
noted
Temporomandi Palpation Normally there is no Range of motion are not Normal

bular joint swelling, tenderness, or limited; there are no
crepitation with swelling, tenderness, or
movement; Mouth crepitation
opens and closes fully;
Lower jaw moves
laterally 1-2cm in each
direction
Neck Neck muscle Inspection There is no abnormal ROM is performed well Normal
swelling or masses able to change direction
found of head slowly, with no
any tenderness felt
during the procedure
Lymph nodes Palpation There is no enlargement The lymph nodes are Normal
of lymph nodes; There not visible, and client
are no visible sign of did not feel any
swelling tenderness
Trachea Palpation There is no any It is located midline, and Normal

deviation there is no lateral
deviation see
Thyroid Gland Palpation There is no enlargement It is located in midline Normal

and located in midline with no enlargement
noted
Carotid Artery Palpation Smooth and equal Symmetrically Normal

bilaterally bilaterally, full and
strong
Ears and Mouth
AREA ASSEESED TECHNIQUE NORMAL FINDING ACTUAL FINDING INTERPRETATION
Ears Size Inspection Ears are equal in size Ears are equal in size Normal
bilaterally 4-10cm
Position Inspection The auricle aligns with The auricle is the same Normal
the corner of each eye alignment
and within a 10-degree
angle of the vertical
position
Tenderness Palpation The auricle, tragus, and Have no tenderness Normal

mastoid process are not
tender
Mouth Color Inspection Pink lips are normal in Lips are pink Normal
light-skinned clients
Moisture Inspection Lips are smooth and The lips of the client are Normal
moist without lesions or smooth without swelling
swelling
Texture Inspection/Palpation Tongue should be pink, The tongue is pink and Normal
and moist moist
Nodules Palpation No lesions, or nodules No lesions and nodules Normal

are apparent
Nose Shape Inspection Smooth and symmetric Smooth and symmetric Normal
Color Inspection Color is the same as the Color of the nose is Normal
rest of the face same as the rest of the
face
Tenderness Palpation No tenderness No tenderness felt Normal
Patency of air Inspection Client is able to sniff The client was able to Normal
through each nostril breathe normally
while other is occluded
Internal nose Inspection The nasal mucosa is No sign of swelling and Normal
dark pink, moist, and free of ulcers, the
mucosa is dark pink and
free of exudate; The
moist
nasal septum is intact
and free of ulcers or
perforations
Sinuses Tenderness Palpation and Percussion No tenderness No tenderness Normal
Crepitus Palpation No crepitus No crepitus palpated Normal

Thorax and Lungs
Posterior
Thorax
Shoulder and Symmetry Inspection Scapulae are Scapulae are Normal

Scapulae symmetric; Shoulder symmetric, shoulder
and scapulae are at and scapulae are at
equal horizontal equal horizontal
positions position
Use of accessory Inspection The client does not use The client does not use Normal
muscles accessory muscle to accessory muscle to
assist breathing assist breathing
Posture and ability Inspection Client should sit up The patient is sitting Normal
to support weight and relaxed, breathing up and relaxed,
easily with arms on breathing easily with
sides arms on sides
Tenderness and Palpation No tenderness, pain or Client reports no Normal

sensation unusual sensation tenderness, pain or
unusual sensation
Crepitus Palpation No palpable crepitus No palpable crepitus Normal
Surface Palpation Skin and subcutaneous Skin and subcutaneous Normal

Characteristics tissue are free of tissue are free of
lesions and masses lesions and masses
Fremitus Palpation Fremitus is symmetric Fremitus is symmetric Normal

and easily identified in and easily identified in
the upper regions of the upper regions of
the lungs the lungs
Chest Expansion Palpation Client s takes a deep The client’s takes a Normal
breath. The examiners deep breath. The
thumbs should move 5- examiners thumbs
10cm apart move 7 cm apart
symmetrically symmetrically
Tone Percussion Resonance is the The tone elicited is Normal

percussion tone elicited resonance which is
over normal lung tissue normal over lung tissue
Diaphragmatic Percussion Excursion is should be Excursion is equal Normal

excursion equal bilaterally and bilaterally and
measure 3-5cm measure 3 cm
Breath sounds Auscultation Normal sounds are During the assessment Normal
Bronchial, Broncho the 3 types of normal
vesicular and vesicular breath sound were
heard
Adventitious Auscultation No adventitious sound No adventitious sound Normal

Sounds such as crackle or such as crackles and
wheezes are wheezes has been
auscultated auscultated
Voice Sounds Auscultation Voice transmission is Voice transmission is Normal

soft, muffled and soft muffled and
 Bronchopho indistinct; Voice may indistinct; The voice
ny be heard but the actual heard but the actual
phrase cannot be phrase cannot be
distinguishable distinguished
 Egophony
Voice transmission will Voice transmission is
be is soft and muffled soft and muffled and
but the letter ‘E’ the letter ‘E’ is
should be distinguished
distinguishable
 Whispered
Pectoriloquy
Transmission of sound The sound is a very

is a very faint and faint and muffled and
muffled; It may be inaudible
inaudible
Anterior Thorax Shape and Inspection The anteroposterior During assessing the Normal
Configuration diameter is less than client anterior thorax,
the transverse the student nurses; The
diameter; The ratio of ratio of the
anteroposterior anteroposterior
diameter to the diameter to the
transverse diameter is transverse diameter is
1:2 1:2
Position of the Inspection Sternum is positioned The student nurses Normal

sternum at midline and straight observed that the
positioned of the
sternum is at the
midline and straight
Quality and pattern Inspection Respirations are Respirations are Normal

relaxed, effortless, and relaxed, effortless, and
quiet; They are of a quiet. They are of a
regular rhythm and regular rhythm and
normal depth at a rate normal depth at a rate
of 10-20 per minute in of 12 per minute
adults; Tachypnea and
bradypnea may be
normal in some clients
Intercostal spaces Inspection No retraction or No retraction of Normal

bulging of intercostal bulging of intercostal
spaces are noted spaces are found
Use of accessory Inspection Use of accessory The use of accessory Normal

muscles (stern mastoid muscles is not seen
and rectus abdominis) during the assessment
is not seen with normal
respiratory effort;
after strenuous
exercise or activity,
clients with normal
respiratory status may
use neck muscles for a
short time to enhance
breathing
Tenderness, Palpation No tenderness or pain No tenderness or pain Normal

sensation and is palpated over the is palpated over the
surface masses lung area with lung area with
respirations respiratory
Tenderness at Palpation Palpation does not The client has not

costo-chondral elicit tenderness reported any Normal
junction of ribs tenderness during
palpation
Crepitus Palpation No crepitus is palpated No crepitus is palpated Normal
Surfaces masses Palpation No unusual surface No unusual surface Normal

and lesion. masses or lesions masses or lesions
palpated palpated
Fremitus Palpation Fremitus is symmetric Fremitus is symmetric Normal

and easily identified in and easily identified in
the upper regions of the upper regions of
the lungs; a decrease the regions of the lungs
intensity of fremitus is
expected toward the
base of the lungs
however, fremitus
should be symmetric
bilaterally
Anterior chest Palpation Thumbs move outward The client thumbs Normal
expansion in a symmetric fashion move outward in a
from the midline symmetric fashion
from the midline
Tone Percussion Percussion elicit Percussion elicit Normal

dullness over breast dullness over breast
tissue, the heart and tissue, the heart and
the liver; tympany is the liver; tympany was
detected over the detected over the
stomach, and flatness is stomach, and flatness is
detected over the detected over the
muscles and bones muscles and bones
Breast and Lymphatic System
Breast and Size Inspection Breast can be a variety The sizes are the same Normal
Lymphatic of sizes in the other
System
Color Inspection Color varies depend on The same on the skin Normal
the client’s skin tone tone of the client
Texture Palpation Texture is smooth, with No edema Normal
no edema
Tenderness Inspection/ Palpation No tenderness No tenderness Normal
Masses Palpation No masses should be No masses Normal

palpated
Lymph Palpation No nodules and lumps No nodules Normal

nodes
Heart and Neck Vessel
Heart Irregular Palpation and The radial and apical The radial and apical Normal
rhythm and auscultation pulse rates should be pulse rate are identical
pulse rate identical
RADIAL PULSE: 75
deficit
bpm (beats per minute)
APICAL PULSE: 75
bpm (beats per minute)
Neck vessels Jugular venous Inspection The jugular venous The venous pulse was Normal
pulse. pulse is not normally not visible during the
visible with the client assessment due to the
sitting upright positioned of the client
Jugular venous Inspection The jugular vein The jugular vein has Normal
pressure should not be no distention, bulging
distended, bulging, or or protruding
protruding at 45
degrees or greater
Carotid artery Auscultate No blowing, swishing No blowing, swishing Normal

or other sounds are or other sounds are
heard heard
Carotid arteries Palpation Pulse are equally The pulse of the client Normal
strong and normal is normal and equally
strong
Pulsation on Inspection The apical pulse may The apical pulse of the Normal
anterior chest or may not be visible client was not visible
over heart
Apical impulse Palpation The apical impulse is The apical impulse was Normal
palpated at mitral area palpated at mitral area
HR and rhythm Auscultate Rate should be 60-100 Rate was 72 beats per Normal
beats per min with min with regular
regular rhythm rhythm
Abdomen
Abdomen Coloration of the Inspection Abdominal skin may The client’s Normal
skin be paler than the abdominal skin is
general skin tone paler that the
because this skin is so general skin tone
seldom exposed to the
natural elements
Vascularity of the Inspection Scattered fine veins The veins of the Normal
abdominal skin may be visible, Blood client’s abdomen
in the veins located were visible
above the umbilicus
flows toward the
head; blood in the
veins located below
the umbilicus flows
toward the lower body
Striae Inspection New striae are pink or There is no presence Normal
bluish in color; old of striae in client’s
striae are silvery, abdomen
white, linear
Scars Inspection Pale, smooth, There is no presence Normal

minimally raised old of scars in client’s
scars may be seen abdomen
Lesions and rashes Inspection Abdomen is free of Abdomen is free of Normal

lesions or rashes, Flat lesions or rashes
or raised brown
moles, however, are
normal and may be
apparent
Umbilicus Inspection Umbilical skin tones Umbilical skin tones Normal

are similar to are similar to
surrounding surrounding
abdominal skin tones abdominal skin
or even pinkish tones or even
pinkish
Umbilical location Inspection Umbilicus is midline Umbilicus is midline Normal

at lateral line at lateral line
Abdominal contour Inspection Abdomen is flat, Abdomen is evenly Normal
rounded, or scaphoid rounded
Symmetry Inspection Abdomen is Abdomen is Normal

symmetric symmetric
Abdominal Inspection Abdominal Abdominal Normal

movement respiratory movement respiratory
may be seen movement has been
seen
Peristaltic waves Inspection Normally, peristaltic Peristaltic waves are Normal

waves are not seen, not seen
although they may be
visible in very thin
people as slight ripples
on the abdominal wall
Bowel sounds Auscultation A series of A series Normal

intermittent, soft intermittent, soft
clicks and gurgles are clicks and gurgles
heard at a rate of 5–30 are heard at a rate
per minute, of 11 per minute
Hyperactive bowel
sounds referred to as
"borborygmus" may
also be heard; These
are the loud,
prolonged gurgles
characteristic of one's
"stomach growling"
Vascular sounds Auscultation Bruits are not Bruits are not heard Normal
normally heard over over abdominal
abdominal aorta or aorta or renal, iliac,
renal, iliac, or femoral or femoral arteries
arteries; However,
bruits confined to
systole may be normal
in some clients
depending on other
differentiating factors
Friction rub over Auscultation No friction rub over No friction rub over Normal
the liver and spleen liver or spleen is liver or spleen is
present present
Tone Percussion Generalized tympany Dullness is heard Normal

predominates over the over the liver and
abdomen because of spleen
air in the stomach and
intestines. Dullness is
heard over the liver
and spleen; Dullness
may be elicited over a
non-evacuated
descending colon
Span and height of Percussion The lower border of The lower border of Normal
the liver liver dullness is liver dullness is
located at the costal located at the costal
margin to 1-2 cm margin to 2 cm
below; The upper below
border of liver
dullness is located
between the left fifth
and seventh
intercostal spaces
Spleen Percussion The spleen is an oval The spleen is an Normal

area of dullness oval area of dullness
approximately 7 cm
wide near the left
tenth rib and slightly
posterior to the MAL
Liver and kidney Blunt percussion Normally, no No tenderness is Normal

tenderness is elicited elicited
Abdomen Light palpation Abdomen is non- Abdomen is non- Normal

tender and soft, there tender and soft,
is no guarding there is no guarding
All quadrants Deep palpation Normal (mild) There was no Normal

tenderness is possible presence of
over the xiphoid, tenderness during
aorta, cecum, sigmoid the procedure,
colon, and ovaries
with deep palpation
Masses Palpation No palpable masses No palpable masses Normal

are present are present
Umbilicus and Palpation Umbilicus and Umbilicus and Normal

surrounding areas surrounding area are surrounding area
free of swelling, are free of swelling,
bulges, or masses bulges, or masses
Liver Palpation The liver is usually The liver is not Normal

not palpable, although palpable
it may be felt in some
thin
clients. If the lower
edge is felt, it should
be firm, smooth, and
even; Mild tenderness
may be normal
Spleen Palpation The spleen is seldom The spleen is not Normal

palpable at the left palpable
costal margin; Rarely,
the tip is palpable in
the presence of a low,
flat diaphragm (e.g.,
chronic obstructive
lung disease) or with
deep diaphragmatic
descent on
inspiration; If the
edge of the spleen can
be palpated, it should
be soft and non-tender
Kidney Palpation The kidneys are The client kidney is Normal

usually not palpable, not palpable
Sometimes the lower
pole of the right
kidney may be
palpable by the
capture method
because of its lower
position; If palpated,
it should feel firm,
smooth, and rounded,
the kidney may or
may not be slightly
tender
Urinary bladder Palpation An empty bladder is The client’s empty Normal

neither palpable nor bladder is not
tender palpable
Abdomen Fluid wave test No fluid is transmitted No fluid is Normal

transmitted
Rebound tenderness No rebound No rebound Normal
tenderness is present tenderness is
present
Psoas sign No abdominal pain is No abdominal pain Normal

present is present
Obturator No abdominal pain is No abdominal pain Normal

present is present
MUSCULOSKELETAL SYSTEM
Posture is erect with the

Posture is erect and
Posture Standing Inspection head, trunk, and pelvis
comfortable for age
aligned to each other Normal
Client’s back rests on

Posture is erect and the back of the chair
Standing Inspection Normal
comfortable for age with feet slightly far
from each other
Gait -Base of support Inspection Evenly distributed Weight is evenly Normal

weight. Client able to distributed, Client was
-Weight-bearing
stability stand on heels and toes,
Toes point straight
-Foot position able to stand and walk
ahead, Equal on both
straight with
-Stride and length sides, Posture erect,
appropriate stride
and cadence of movements coordinated
length and arm swing,
stride and rhythmic, arms
Toes do not point in or
swing in opposition,
-Arm swing out
stride length
-Posture appropriate
Risk of falling Client does not fall Client did not fall
Inspection Normal
backward backward backward
Temporoma Snapping and clicking

Inspection and No swelling, tenderness,
ndibular Muscle strength may be felt and heard in Normal
Palpation or crepitus felt and seen
joint the normal client
Mouth opens 1-2 inches

(distance between upper
and lower teeth), The Mouth opens at an
client’s mouth opens appropriate distance,
Range and closes smoothly, Mouth opens and closes
Palpation Jaw moves laterally 1-2 smoothly, and jaw Normal
of Motion cm, Jaw protrudes and protrudes and retracts
retracts easily, no pain easily, no pain or
or spasms felt when spasms reported
moved against
resistance
Cervical, Curvature Inspection Cervical and lumbar Cervical and lumbar Normal (Thoracic spine
thoracic, spines are concave; spine are in appropriate that is slightly curved
curvature while
and lumbar thoracic spine is slightly
thoracic spine is convex. than normal is a
curves from more curved than
Spine is straight (when consideration for older
the side and normal. The spine is
observed from behind) clients)
behind straight when viewed
from behind
Client was able to flex

Flexion of the cervical
and extend his neck
Range of spine is 45 degrees,
within appropriate
Motion of Flexion and Inspection and Extension of the
length without any Normal
Cervical extension palpation cervical spine is 45
report of pain even
Spine degrees, no pain when
when applied with
applied with resistance
resistance
Client was able to bend

The client can bend 40 his neck sideways
degrees to the left side within appropriate
Inspection and
Lateral bending and 40 degrees to the length without any Normal
palpation
right side, no pain when report of pain even
applied with resistance when applied with
resistance
Inspection and About 70 degrees of Client was able to rotate

Rotation Normal
palpation rotation his head
Range of Flexion Inspection Flexion of 75–90 Client has slight Normal (Older clients
motion of degrees, smooth difficulty bending tend to experience
lumbar and movement, lumbar forward and was not difficulty bending
thoracic concavity flattens out, able to touch his toes, forward and reaching
spine and the spinal processes Lumbar concavity
are in alignment, flattens out and spinal
processes are in toes)
alignment
Shoulders are
symmetrically round; Both shoulders are
no redness, swelling, or symmetrically round at
Clavicle,
deformity or heat, the same height; no
acromioclavicular
Shoulders Inspection and Muscles are fully redness, swelling, or
joint, subacromial Normal
and arms palpation developed, Clavicles heat, Clavicles and
area, and the
and scapulae are even scapulae are even and
biceps.
and symmetric, the symmetric and client
client reports no reports no tenderness
tenderness
Range of motion Inspection -Extent of forward -The client was able to Normal
flexion should be 180 flex, extend, and rotate
degrees; both arms to
hyperextension, 50 appropriate range
degrees; adduction, 50
-The client was able to
degrees; and abduction
do the mentioned
180 degrees
motions against
- Extent of external and resistance without any
internal rotation should reports of pain
be about 90 degrees,
respectively
-The client can flex,
extend, adduct, abduct,
rotate, and shrug
shoulders against
resistance
Elbows are symmetric, Both elbows are of the

Elbow Inspection without deformities, same size, no lesions, Normal
redness, or swelling redness, and swelling
Olecranon process Nontender; without

Palpation No nodules palpated Normal
and epicondyles. nodules
Normal ranges of
motion are 160 degrees
of flexion, 180 degrees Client was able to
of extension, 90 degrees perform the following
Range of motion Inspection of pronation, and 90 movements smoothly Normal
degrees of supination, even when resistance is
some clients may lack applied
5–10 degrees or have
hyperextension
Client’s wrists are of

Size, shape, Wrists are symmetric,
the same shape, same
Wrists symmetry, color, Inspection without redness, or Normal
color with the skin and
and swelling swelling
no deformities
Client does not report

Tenderness and Inspection and Wrists are nontender
of any tenderness and Normal
nodules Palpation and free of nodules
no nodule is palpated
Anatomic snuffbox Palpation No tenderness palpated Client does not report Normal
in anatomic snuffbox of any tenderness or
pain in his anatomic
snuffbox
The client smoothly

The client bends the
bends his wrists down
Inspection and wrist down and back
Range of Motion and back. He does not Normal
Palpation (flexion and extension)
report of any pain when
even with resistance
resistance is applied
The client was able to

No tingling, numbness, perform the test within
Phalen’s Test Inspection or pain result from the given time and Normal
Phalen’s test reports slight numbness
after 70 seconds
Hands and fingers are

symmetric, nontender,
and without nodules,
Fingers lie in straight Client’s fingers are
line, no swelling or long, symmetric, no
Size, shape,
Hands and Inspection and deformities, Rounded blisters, nodules,
symmetry, swelling, Normal
fingers Palpation protuberance noted calluses, or masses
and color.
next to the thumb over noticed, No swelling or
the thenar prominence; deformities
Smaller protuberance
seen adjacent to the
small finger
Range of motion Inspection Normal ranges are 20 The client can perform Normal
degrees of abduction, the different movements
full adduction of fingers within appropriate
(touching), 90 degrees range even with
of flexion, and 30
degrees of
hyperextension, the
thumb should easily
move away from other
resistance
fingers and 50 degrees
of thumb flexion is
normal, there is also no
report of pain when
resistance is applied
Knees symmetric, The client’s knees are

Size, shape, hollows present on both symmetric, hollows are
symmetry, swelling, sides of the patella, no present, no deformities
Knees Inspection Normal
deformities, and swelling or deformities, or swelling, Upper leg
alignment Lower leg in alignment is, and lower leg are
with the upper leg same in size
Ankles and Position, alignment, Inspection Toes usually point No deformities present Normal
foot shape, and skin. forward and lie flat, in both toes and ankles,
Toes and feet are in Toes are smooth and
alignment with the pointed forward, free of
lower leg, Smooth, calluses or corns
rounded medial
malleolar prominences
with prominent heels
and
metatarsophalangeal
joints, Skin is smooth
and free of corns and
calluses, Longitudinal
arch; most of the weight
bearing is on the foot
midline
Client reports no
Tenderness, heat, Inspection and No pain, heat, swelling, tenderness when
Normal
swelling, or nodules Palpation or nodules are noted. palpated, no swelling or
nodules palpated
Normal ranges:
• 20 degrees
dorsiflexion of ankle
and foot and 45 degrees
plantarflexion of ankle
and foot Client’s feet and ankle
performed the following
• 20 degrees of eversion movements within
and 30 degrees of appropriate range; He
Range of Motion Inspection inversion still has full ROM even Normal
• 10 degrees of when resistance is
abduction and 20 applied and does not
degrees of adduction report any pain or
tenderness
• 40 degrees of flexion
and 40 degrees of
extension
Client has full ROM
against resistance
Neurological System
The client responds The client responds to

Level of
Inspection immediately when being first call of the Normal
consciousness
called examiner
The client does not elicit

The client posture is
Posture and any tension,
Inspection normal and there is no Normal
body movement nervousness, restless
extra body movement
behavior
Grooming, The client wears The client wears t-shirt,

dress and Inspection appropriately and looks shorts and slippers that Normal
hygiene hygienic are comfortable to him
Facial The client maintains The client doesn’t have Normal

Inspection eyes contact and shows any involuntary
expression
appropriate facial movement in his face,
and he smile while
expression
responding
Tone, clarity The client spoke in a

The client speaks
Speech and pace of Inspection manner that everybody Normal
clearly and audibly
speech can understand
The client expresses

The client expresses the
Moods, Feelings sadness when he talks
Inspection appropriate emotion for Normal
and Expressions about his condition but
each situation
still thinks positively
The client expresses

The client understands
Thought, Clarity, clear understanding
that his health is Normal
Process and Content and Inspection with regards to his
important and treasures
Perception Perception health and doesn’t have
his life
any negative thoughts
The client is able to The client was able to

Recent Memory Inspection recall previous recall the last thing he Normal
memories ate
Remote The client is able to The client was able to

Inspection Normal
Memory recall past memories recall his birthdate
Abstract Inspection The client is able to The client was able to Normal
Reasoning compare two objects differentiate a square
and differentiate them from a rectangle
The client is able to explain what the
explain a proverb proverb “time is gold”
means to him

The client is able to
think of a solution when
Judgement Inspection express judgement in a Normal
problems arise in a
particular situation
given scenario
Condition and The client’s muscles is The Clients muscles are

Size and
Movement of Inspection equal in size and proportionate to his Normal
Symmetry
Muscles symmetry body
The client’s muscles is

The Client was able to
Strength Inspection strong and right for his Normal
lift chairs
age
The Client was able to

Tandem The client walks in a
Balance Inspection walk without tripping Normal
Walking heel to toe fashion
and assistance
The client stands erect The Client stands

Romberg
Inspection with arms and feet steadily without Normal
Test
together changing position
Finger to The client performs the The Client was able to

Coordination Inspection Normal
Nose Test test smoothly touch his nose while his
eyes are closed at a
certain speed

The client correctly
Sensitivity to tell the direction in
Inspection determines where his Normal
position which his finger is
finger is pointed
pointed

identifies the object
Stereognosis Inspection tell what object is on his Normal
being handed to him
hand
while his eyes are closed

identifies the number The client was able to Normal
Graphesthesia Inspection being drawn on his tell the number that was
palm while his eyes are drawn on his palm
closed
NURSING CARE PLAN
NURSING NURSING
ASSESSMENT GOAL OF CARE RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
Subjective: Readiness for enhanced Short Term Goal:  Ascertained client’s  Belief in ability to The goals were
health management beliefs about health accomplish desired met as evidenced
“Willing akong After three days of and his ability to action is predictive of by the client’s
makinig sa mga nursing intervention, maintain health. performance.
sasabihin niyo sa the client will: acceptance of
akin, lalo na kung responsibility for
 Accepted client’s  Promotes sense of
 Assume managing
tungkol sa evaluation of own self- esteem and
responsibility strengths/ limitations confidence to continue treatment regimen,
highblood.”, Client
for managing while working together efforts. and client
C.L verbalized.
treatment to improve abilities. remained free of
Objective: regimen.
 Provides positive preventable
 Acknowledged
 Blood Long Term Goal: reinforcement complications,
individual capabilities
pressure of encouraging continued progression of
After one week of to reinforce movement
140/80mmHg progress toward illness and
nursing intervention, toward attainment of
the client will: desired goals. sequelae.
 Lessens desired outcomes.
coffee intake  Remain free of
from 3-4 preventable
cups to 1 cup complications,
every progression of
breakfast. illness and
sequelae.
NURSING NURSING
ASSESSMENT GOAL OF CARE RATIONALE EVALUATION
Subjective: Deficient knowledge Short Term Goal:  Determine client’s  Identifies individual’s After three days of
related to unfamiliarity ability, readiness, and physical, emotional, or nursing
“Dati umiinom ako After three days of mental capability.
with information barriers to learning. intervention, the
ng Revicon Forte nursing intervention, the
resources client will: goal was met as
na sinabi sa akin  Provided positive  Encourages
ng kaibigan ko. reinforcement. continuation of efforts. evidenced by
 Participate in client’s
Pero 2 weeks lang learning process.  Makes the client feel participation in
tapos tinigil ko.  Discussed client’s
competent and learning process,
Ngayon Xanthone  Exhibit perception of need.
respected. and exhibition of
plus naman increased
increased interest
iniinom ko. interest and
assume and assumed
Narinig ko yun sa
responsibility for responsibility for
radio.”, Client C.L
own learning by own learning by
stated.
beginning to beginning to look
look for for information
information and and ask questions.
ask questions.
ASSESSMENT NURSING GOAL OF CARE NURSING RATIONALE EVALUATION

Subjective: Risk for imbalanced Short Term Goal:  Assessed the client’s  Provides positive After one week of
nutrition: more than readiness to change his reinforcement nursing
“Mahilig akong After three days of dietary behavior encouraging continued
body requirements intervention, the
kumain ng nursing intervention, the progress toward
matataba, lalo na client will: goal was met as
 Provided health desired goals.
kapag adobo yung evidenced by the
education about the
 Verbalize verbalization of the
ulam. Madami client’s condition  This would help in
understanding of client about his
akong nakakain. developing an
body and energy
Ganun rin sa kain. individualized teaching understanding of
needs  Provided appropriate
3-4 cups ng kanin plan based on patient’s body and energy
diet plan in accordance condition.
yung nakakain Long Term Goals: needs, and client’s
to his medical condition
ko.” as verbalized change in dietary
After one week of  This would lessen the
by the client. behavior like
nursing intervention, the risks he might get from
reduced amount of
client will: his condition.
rice to 1 ½ cups.
Objective:
 Demonstrate
Height: 5’4 ft behaviors,
lifestyle changes
Weight: 50 kgs to reduce risk
BMI: 18.8 factors like
limiting the
amount of rice
from 3-4 cups to
1 ½ cups of rice.

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St.

Paul University Philippines

SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES

1ST SEMESTER, AY 2019-2020

BACHELOR OF SCIENCE IN NURSING – LEVEL II

Part 1. Health History

B. Reason for seeking care/present health concern

D. Personal Health History

SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES

1ST SEMESTER, AY 2019-2020

BACHELOR OF SCIENCE IN NURSING – LEVEL II

E. Family Health History

SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES

1ST SEMESTER, AY 2019-2020

BACHELOR OF SCIENCE IN NURSING – LEVEL II

Grandfather Grandmother Grandfather Grandmother

Eldest Sister Elder Sister Client R.B. Wife

SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES

1ST SEMESTER, AY 2019-2020

BACHELOR OF SCIENCE IN NURSING – LEVEL II

Thorax and lungs: Denies difficulty in breathing, pain, shortness of breath

Breast and regional lymphatics: Denies lumps or discharge from nipples;

Peripheral Vascular: Reports leg cramping; Denies swelling or edema of legs

Anus, rectum and prostate: Reports daily bowel movement of well-formed

Musculoskeletal: Denies swelling, redness, pain and stiffness of joints; Reports

SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES

1ST SEMESTER, AY 2019-2020

BACHELOR OF SCIENCE IN NURSING – LEVEL II

Neurologic: Denies depression, anger and suicidal thoughts; Denies headaches,

G. Lifestyle and Health Practices

Gordon’s Typology Of 11 Functional Health Pattern

1. Health Perception – Health Management

SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES

1ST SEMESTER, AY 2019-2020

BACHELOR OF SCIENCE IN NURSING – LEVEL II

7. Self-perception and self-concept

SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES

1ST SEMESTER, AY 2019-2020

BACHELOR OF SCIENCE IN NURSING – LEVEL II

10. Coping stress and coping tolerance

Part 2. Physical Assessment

SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES

1ST SEMESTER, AY 2019-2020

BACHELOR OF SCIENCE IN NURSING – LEVEL II

BLOOD PRESSURE: 140/ 80 mmHg

SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES

1ST SEMESTER, AY 2019-2020

BACHELOR OF SCIENCE IN NURSING – LEVEL II

AREA ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL FINDING INTERPRETATION

Shape Inspection There is normally a 160- No sign of early Normal

Lacrimal Sac Inspection/Palpation No edema or increase There is no edema Normal

Pupil Inspection Pupils appear round, The pupils are Normal

Head and Neck

AREA ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL FINDING INTERPRETATION

Consistency Palpation Head is normally hard There are no lumps or Normal

Temporomandi Palpation Normally there is no Range of motion are not Normal

Trachea Palpation There is no any It is located midline, and Normal

Thyroid Gland Palpation There is no enlargement It is located in midline Normal

Carotid Artery Palpation Smooth and equal Symmetrically Normal

Ears and Mouth

AREA ASSEESED TECHNIQUE NORMAL FINDING ACTUAL FINDING INTERPRETATION

Tenderness Palpation The auricle, tragus, and Have no tenderness Normal

Nodules Palpation No lesions, or nodules No lesions and nodules Normal