NCP Group 1

Far Eastern University – Manila
Nicanor Reyes Street,

Sampaloc, Manila
.
INDIVIDUAL/ GROUP NURSING PROCESS FORMAT
A Case of:
Ineffective airway clearance related to bronchospasm and excessive mucus production secondary to
asthma as evidenced by a respiratory rate of 30 cpm, wheezing, use of accessory muscles, and
verbalized chest tightness
Presented by:
Abranted, Nobelyn
Almeron, Regene
Alonzo, Niesha
Aquinos, Achilles
Asis, Esmeralda
Barnedo, Klyde
Barrozo, John Kyle
Beltran, Katherine Rose
Billones, Jayvee
Calim, Stephanie
Presented to:
Mark Catalo, RN, MAN
Submitted on:
November 26, 2022
II. DEMOGRAPHIC PROFILE
Demographic Data
Name: JAB
Address: San Isidro, Bongabong, Oriental Mindoro
Age: 19 Birth Date: 01-26-2003 Birth Place: Calapan City, Oriental Mindoro
Gender: Male
Religion: Roman Catholic Race/Ethnic Origin: Filipino
Occupation: Student Educational Attainment: College
Undergraduate
Marital Status: Single Name of Spouse: N/A
Number of Children: N/A
Chief Complaints: The patient verbalized that “nahihirapan po ako huminga”
Date of Admission: November 26, 2022
Room & Bed Number: 509 A
Attending / Admitting Physician: Dr. Norma E. De-yera
Admitting/Final Diagnosis: Ineffective airway clearance related to bronchospasm and
excessive mucus production secondary to asthma as evidenced by a respiratory rate of
30 cpm, wheezing, use of accessory muscles, and verbalized chest tightness
Medical Insurance: None
III. NURSING HEALTH HISTORY

A. History of Present Illness
Last September 15, 2022, the client had an asthma attack after cleaning his new
dormitory. He said that “Pagkatapos ko maglinis ng dorm biglang naninikip dibdib ko tapos
ang hirap huminga parang pinipilit ko pa ayun naisip ko inaatake ako asthma”, as verbalized
by the client. The client perceived that the dust and tiredness was the root cause because the
attack occurred after cleaning his dormitory. He stated that he experienced shortness of breath,
chest tightness, and used accessory muscles when he breathed. In addition, the client performs
traditional interventions whenever he is experiencing an asthma attack. He verbalized that
“Kapag inaatake ako ng Asthma pinipilit ko buksan mga bintana para may hangin na pumasok
tapos umuupo ako saka humihinga ng malalim.” He only experiences relief when he opens all
the windows, sits down, and performs deep breathing. He also added that “Yun lang mga
ginagawa ako hindi ako gumagamit inhaler tapos nung bata lang ako nag nebulizer, ngayon
hindi na”, as verbalized by the client. However, he stated that these interventions were only
temporary since he does not feel that it is totally helping him to treat his asthma.
B. Past Health History
The client declared himself fully immunized. His childhood ailments included
chickenpox. When asked about his childhood diseases, including chicken pox, he recalled that
"una nagkaroon yung younger brother ko then yung pinsan ko at finally nagkaroon din ako."
He suffered from dengue when he was in grade 6, and he claimed, "I guess nakuha ko siya dun
sa stagnant water sa may school namin because mahilig ako maglaro." He also claimed that the
symptoms he experienced included a 2-day fever. Since his platelet count has decreased,
"Dinala na ako sa hospital for urine and fecalysis with cbc." And he was admitted for a week.
C. Obstetric History (For OB Patients ONLY)

D. Pediatric History (For PEDIA Patients ONLY)
E. Occupational History (For ADULT patients ONLY)
F. Family History (Include genogram with legend)
IV. GORDON’S HEALTH ASSESSMENT
A. HEALTH PERCEPTION AND HEALTH MANAGEMENT

The client said that he is having trouble breathing, stating “nahihirapan ako huminga sa
tuwing nagpapagod ako.” He indicated that his most recent asthma attack occurred in
September. Additionally, he has trouble cleaning the house and is sensitive to dust due to
allergic rhinitis. He could not sleep well due to his swollen gums. The client does smoking,
vape, and drinks alcohol but only
occasionally. "minsan lang ako manigarilyo at uminom ng alak kapag may ganap", he
said. The client has only been hospitalized once in his entire life due to dengue. He confessed
that he gained weight during the pandemic, from 55 kg to 75 kg. Despite being prone to illness,
he also wants to fix his condition by being healthy. He takes ascorbic acid for his daily vitamin
supplements. He is also involved in physical activities such as jogging around UST, WRP, and
walking. Lastly, his mental health deteriorates when he does too much at school.
Interpretation: Deviation from Normal
Analysis: The WHO (n.d), defined health as a state of complete physical, mental and social
well-being and not merely the absence of disease or infirmity. The client is struggling with his
health due to breathing issues, swollen gums, allergic rhinitis, being overweight, and issues
with his mental state. In order to improve health, the patient's eating habits should also be
changed in addition to incorporating a sport into their daily routine (Jessy, 2021). KVC (2020)
indicated that academic stress results in poorer well-being and increases the risk of getting
anxiety or depression, thus the client should learn how to manage time as he has troubles with
his mental state as a result of a lot of activity at school.
References:
Jessy, S. (2021). Nutrition and Diet Therapy.
https://www.pulsus.com/scholarly-articles/nutrition-and-dietary-therapy.pdf
KVC. (2020, November 10). How Does Academic Stress Affect Mental Health in the Age of
Digital Learning.
https://kansas.kvc.org/2020/11/10/how-does-academic-stress-affect-mental-health-in-th
e-age-of-digital-learning/
WHO. (n.d). Health and Well-Being.
https://www.who.int/data/gho/data/major-themes/health-and-well-being
B. NUTRITION AND METABOLIC PATTERN

The client stated that he eats three to four times a day with snacks in between. He
usually eats fast food and processed food. His usual drink other than water is soda and coffee.
The client also mentioned that he has no known allergies. The client drinks Five to eight glasses
of water each day. The client stated that he finds no difficulty in eating and swallowing.
Food Recall:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Breakfast Pandesal Coffee. Corned N/A Instant Instant N/A

with beef with noodle mac and
coffee. rice and s and cheese
coffee. coffee. and
coffee.
Lunch Spaghetti Pork Lumpiang Bicol Fried Fried 2 slices

with sisig with shanghai Express chicke siomai of pizza.
fried rice. with rice. with rice. n with with rice.
chicken. rice.
Dinner Canned Burger Instant Bacon Shawa Giniling Chinese

tuna with and fries noodles. and egg rma with rice. fried rice
rice. with with rice. wrap. with
soda. siomai.
Analysis: According to the World Health Organization, to prevent unnecessary forms of
malnutrition and noncommunicable diseases such as diabetes, heart disease, stroke, and cancer,
a healthy diet should be practiced by an individual. Dietary inconsistencies pose the greatest
threat to health worldwide.
References:
Healthy Diet (April 2020) https://www.who.int/news-room/fact-sheets/detail/healthy-diet
C. ELIMINATION PATTERN
The client stated that the frequency of his bowel movements in a week is determined by
his food consumption. He also mentioned that he has no problems with excretion and pooped
before going to bed. He further mentioned that his urine is yellow and clear with no strong odor
or foul smell and he pees three times a day. The client also said that when he urinates or
excretes, he feels no pain or discomfort.
Interpretation: Normal
Analysis: The healthy body balances the amount of fluid ingested with the amount of fluid
excreted during urine elimination. The production increases as the amount of fluid consumed
increases. In terms of fecal elimination, normal fecal matter is created, which is soft,
cylindrical, and brown in color and weighs 100-400 g every day. During fecal expulsion, there
should be no pain.
Reference: Fundamentals of Nursing by Kozier and Erb, page 2018
D. SLEEP-REST PATTERN
The client stated that he is not getting adequate sleep and is feeling tired as a result of his
academic responsibilities. “Medyo pagod yung feeling at inaantok ako tuwing gumigising”, as
verbalized by the client. He also stated that he consumes the majority of his time doing academic
responsibilities, which has affected his sleep schedule.
Monday Tuesday Wednesd Thursday Friday Saturday Sunday

ay
Time 12:00 AM 12:00 AM 12:00 AM 12:00 AM 12:00 AM 12:00 AM 12:00 AM

went to
bed
Approx. 12:30 AM 12:30 AM 12:30 AM 12:30 AM 12:30 AM 12:30 AM 12:30 AM

Time Fell
Asleep
Wake up 6:00 AM 6:00 AM 6:00 AM 10:00 AM 6:30 AM 6:00 AM 10:00 AM

period
Feeling Sleepy, Sleepy, Sleepy, Sleepy, Sleepy, Sleepy, Sleepy,

after Tired Tired Tired Tired Tired Tired Tired
waking
up
Naps 10:00 AM 11:00 AM 10:00 AM 2:00 PM - No nap No nap No nap

(time - 1:00 PM - 1:00 PM - 12:00 6:00 PM time time time
slept & PM
woke up;
duration)
Activities Studying, Studying, Studying, Studying, Studying Studying, Studying,

done Watching Watching Watching Watching Watching Watching
before on the on the on the on the on the on the
bedtime phone phone phone phone phone phone
Analysis: According to The American Academy of Sleep Medicine and Sleep Research
Society, the recommended hours sleep for a day of adults ages 18-10 years old is 7 or more
hours. This is to promote optimal health and well-being. Not getting enough sleep is affiliated
with an increased risk of developing health problems (CDC, n.d.).
Reference:
CDC, (n.d.). How much sleep do i need?
https://www.cdc.gov/sleep/about_sleep/how_much_sleep.html
E. COGNITIVE PERCEPTION
The client stated that his attention span depends on how interesting the topic is for him.
A factor that affects his attention span is noise. According to the patient, one way for him to
remain his focus is to cancel out the noise around his surroundings. Patient JAB said that he
still has normal eyesight with 20/20 vision. In order to observe his awareness, the patient was
asked to say the date that day, he answered November 11 instead of November 23 which is the
wrong date.
Analysis: According to Adam H. (2021), in the year 2000 the average attention span of a
human is 15 seconds, but 15 years later it drastically shrunk to 8.25 seconds which is way
below the attention span of a goldfish with 9 seconds.
References:
The human attention span. (n.d.). Wyzowl. https://www.wyzowl.com/human-attention-span/
F. SELF-PERCEPTION AND SELF MANAGEMENT
The client verbalized that lately he feels stressed; however, in order for him to not feel
stressed, he drinks a super cold coke. There are times when he has no one to talk to when he's
stressed. He tends to shout and be ill-tempered; he can either be quiet or his voice gets louder
as he speaks when he's stressed. He added that he doesn't feel any stress when he does his
hobbies. Moreover, the client also mentioned that he never overthinks his stress. His stress
management strategy is to first consider whether he can solve the problem; if not, he will
simply ignore the problem and not think about it at all.
Analysis: Self-management is the ability to control behaviors, thoughts, and feelings in a

deliberate and productive manner (Munro, 2021). For people who are unable or unwilling to get
formal treatment, self-management may be an acceptable substitute (Shepardson, Tapio, et al.,
2017). A person with great self-management skills knows how to react and what to do in
various situations, such as learning how to control their anger and how to manage their stress
(Munro, 2021).
References:
Munro, I. (2021 February 15). Why self-management is key to success and how to improve
yours. Better Up. Retrieved from
https://www.betterup.com/blog/what-is-self-management-and-how-can-you-improve-it
Robyn L. Shepardson, PhD, Jennie Tapio, MA, Jennifer S. Funderburk, PhD, Self-Management
Strategies for Stress and Anxiety Used by Nontreatment Seeking Veteran Primary Care
Patients, Military Medicine, Volume 182, Issue 7, July-August 2017, Pages
e1747–e1754, https://doi.org/10.7205/MILMED-D-16-00378
G. ACTIVITY LEVEL AND EXERCISE PATTERN
The client typically performs his daily routine before the asthma attack. He wakes up
early in the morning and prepares for school. He is usually in school from Monday to
Wednesday and then from Friday to Saturday. Whenever he had a vacant time, it became his
habit to go home since his dormitory was only a few blocks from his school. When he arrives
home, he usually takes a nap, and then when the client wakes up, he is either going back to
school or studying for his upcoming exams. In addition, the client stated that he is a busy
nursing student and he only performs physical activity when he goes to school. He said that
“Wala kasi akong time mag workout kasi ang daming kailangan tapusin sa school kaya ang
exercise ko lang is mag-lakad papunta at pauwi ng school”, as verbalized by the client. The
client spends most of his time studying, eating, and studying and has limited time for physical
activity since he is busy most of the time.
3-DAY ACTIVITY RECALL:
BEFORE ASTHMA ATTACK
Wednesday
06:00 A.M. Wakes up in the morning

06:20 A.M. Shower and getting ready
06:30 A.M. Eats breakfast
07:00 A.M. Leaves the house and goes to school
07:30 A.M. Class
09:00 A.M. Goes home
09:10 A.M. Sleeps
12:00 P.M.Wakes up from nap
12:10 P.M. East Lunch
12:30 P.M. Leaves the house and goes to school
13:30 P.M. Class
19:30 P.M. Goes home
19:40 P.M. Takes a nap
20:10 P.M. Eats dinner
20:20 P.M. Advance studying
22:00 P.M. Watch random videos
00:00 A.M. Sleeps
Thursday

10:30 A.M. Eats brunch
11:00 A.M. Watch a movie
15:00 P.M. Takes a nap
18:00 P.M. Wakes up from nap
18:10 P.M. Studying for quizzes
20:00 P.M. Eats dinner
20:30 P.M. Studying for quizzes
00:00 A.M. Sleep
Friday

06:40 A.M. Shower and getting ready
07:00 A.M. Leaves the house and goes to school
07:30 A.M. Class
11:30 A.M Eats lunch
13:30 P.M. Class
16:30 P.M. Study
18:00 P.M. Goes home
18:20 P.M. Shower
19:00 P.M. Study
20:30 P.M. Eats Dinner
00:00 A.M. Sleeps

Analysis: According to Bengs, B., an Orthopedic Surgeon at Saint John’s Health Center in
Santa Monica, California, walking can provide several health benefits, such as stress relief,
stronger bones, and improved metabolism (Hui, 2022). Walking exercises has no difference
with other forms of physical activity because regular movement can prevent chronic illness like
cardiovascular disease and diabetes. However, younger people requires a physical activity that
is moderate to vigorous in order to maintain adequate quality of life and health. Young adults
should perform a 60 minutes physical activity on most days and it must include exercises, such
as muscle-strengthening, aerobic, and bone strengthening (University of Rochester Medical
Center, n.d.).
References:
Exercise and teenagers - Health encyclopedia - University of Rochester Medical Center. (n.d.).
Welcome to URMC - Rochester, NY - University of Rochester Medical Center.
https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=90&Conte
ntID=P01602
Hui, A. (2022, July 22). If walking is the only exercise you do, is that enough to stay healthy?
Verywell Health.
https://www.verywellhealth.com/is-walking-enough-to-keep-you-healthy-5704137
H. VALUES AND BELIEFS PATTERN

The client stated that the most important things in his life are his two siblings and his
mother. And in terms of practicing his religion, he said that he only goes to church every
christmas. They stated that he values his religion and that it relies on God.
Analysis: Life will always have its obstacles, but a family may offer a feeling of security and
connection that can help you get through them (BetterHelp, 2022). Holy days are solemn
religious celebrations and feast days that occur every year. The client may be accustomed to
celebrating holidays and attending religious services such as Christmas with family
References:
BetterHelp Editorial Team. (2022, November 23). What Is The Importance Of Family In
Modern Society? | BetterHelp.
https://www.betterhelp.com/advice/family/what-is-the-importance-of-family-in-modern
-society/ Kozier & Erb’s Fundamentals of Nursing, Vol. 2, P. 1058
I. SEXUALITY AND REPRODUCTIVE
The client stated that he is sexually active in the past. He verbalizes “As of now, walang
akong ka-relasyon pero nakaranas na ako makipagtalik”. He said that he only had a
relationship with a female. Since the client stated that he already experienced having sex with
someone, the has knowledge about what contraceptives are as he verbalized “Oo, may
kaalaman naman ako tungkol sa mga contraceptives. Nalaman ko ang tungkol dito dahil sa
pagturo nito sa school, sa aming barangay, at sa ospital”.
Analysis: It is stated on the article of World Health Organization (2019), the usage of
contraceptives reduces the rate of unsafe abortion and helps for the prevention of HIV
transmissions. In relation to the client, it is good enough that the client has a knowledge to what
contraceptives are because it will help him to build limitations between him and his partner.
Reference:
Contraception. (2019, December 10). World Health Organization (WHO).
https://www.who.int/health-topics/contraception#tab=tab_1
J. ROLES AND RELATIONSHIP PATTERN
For the client’s relationship pattern, the client has two younger siblings and a lot of
friends that she often communicates with. He mentioned that his family is currently living in
Oriental Mindoro. The client currently lives with his friend in Sampaloc Manila. He gets along
with her family and neighbors without any arguments and maintains a good bond with them.
Her family and friends are her main sources of support
Analysis: According to Health Hub (n.d.) having a supportive network composed of friends
and families who are there for you in different stages of your life is the next most important
thing after physiological and safety needs. The client has a good relationship with her family
and friends that he can rely on mental support.
Reference:
Building a Supportive Network of Family and Friends. (n.d.).
https://www.healthhub.sg/live-healthy/448/buildingasupportivenetwork
K. COPING-STRESS TOLERANCE PATTERN
The client communicates with his friends whenever he is experiencing stress, in that
way, he is able to feel relief. The client also said that “Kapag nakakaramdam ako ng stress
kinausap ko lang mga kaibigan ko tapos minsan nag s’stress eating”, as verbalized by the
client. The client also perceived that the main stressors are his academic and organization
responsibilities. Another coping that the client performs is doing his hobbies such as watching
videos on youtube and playing games. These activities serve as his stress relievers; however it
is not enough to make him feel better regarding the responsibilities he is handling.
Analysis: As stated by Nurse Key (2016), methods of handling stressful life situations are
insufficient
which causes overthinking, procrastination, difficulty in decision-making, stress eating, and
mood swings.
Reference:
Coping-stress-tolerance pattern. Nurse Key. Retrieved November 24, 2022, from
https://l.messenger.com/l.php?u=https%3A%2F%2Fnursekey.com%2Fcoping-stress-tol
erance-p&h=AT3eJsc197Ak_WmC8iS-lhz9s8joDgFlAjbYPIZB7GH0vTJTuAjrRoeBh
55e9BQ8SjU1fb_HLXeCCPnr8rrPW2lf3djaJGDzPiU3lb_VHaiLCIPgVyJyFF0yqUMb
5yiEvW-DbQ
V. Physical Assessment
a. General Survey
GENERAL APPEARANCE & MENTAL STATE
Assessment Body Part Norms Actual Findings Analysis &

Method Used (Cephalo-caudal) Interpretation (with
reference)
Observe signs General appearance The Client maintains a Interpretation: No
of distress in & mental state. patient relatively relaxed deviation from normal.
posture or must posture with
facial show no minimal position
expression. visible changing. He has a
signs or pleasant and alert
symptom facial expression,
s of pain, with no unnecessary
difficulty facial expressions
in that could imply
breathing, distress. The patient
anxiety, shows no signs of
or distress.
distress in
his/her
posture or
facial
expressio
ns.
Observe body General appearance The Age: 20 years old Interpretation:

build, height, & mental state. patient’s Height: 170.18 cm Deviation from normal
and weight in height Weight: 79 kg Analysis: Body mass
relation to the and BMI: 27.3 index is a standard
client’s age, weight Body built: calculation of body fat
lifestyle, and should be Endomorph based on a person’s
health. proportio Based on the height and weight. The
nate to measured findings, formula is
his/her the body mass
body index of the patient
build; it is indicative of
may vary being overweight. where kg represents a
from the person’s weight in
patient’s kilograms and
age, represents their height
lifestyle in meters squared.
and According to the
health. Centers for Disease
Control and Prevention
(2022), the BMI of 18.5
to 24.9 falls within the
normal or Healthy
Weight range. However,
if the BMI is 25.0 to
29.9, it falls within the
overweight range. In
applying the mentioned
formula and levels of
BMI, the patient’s BMI
resulted in 27. 3, which
falls under the category
of overweight.
Observe General appearance The The client's posture Interpretation: No
client’s posture & mental state. patient’s is erect and deviation from normal.
and gait, posture in comfortable for his
standing, gait, age. He presents
sitting, and standing, himself in a proper
walking. and manner and with a
sitting comfortable stance
should be in sitting, standing,
relaxed and walking. The
and erect. gait is rhythmic and
His/her synchronized.
movemen
ts must
also be
coordinat
ed.
Observe General appearance The The client appears Interpretation: No

client’s overall & mental state. patient’s to be clean and deviation from normal.
hygiene and hygiene well-groomed, as he
grooming. must presents a neat and
coincide tidy overall
with the appearance.
level of
cleanlines
s in the
areas of
their skin,
hair,
nails,
together
with their
overall
grooming
appearanc
e.
Note body and General appearance The There were no Interpretation: No

breath odor. & mental state. patient’s unusual odors on deviation from normal.
body and the body or in the
breath breath.
odor
should be
pleasant
and
appropria
te based
on his/her
activity
level,
hygiene,
or health
state.
Note obvious General appearance The My client appears Interpretation: No
signs of health & mental state. patient to be in good deviation from normal.
or illness. must health, with no
appear to visible signs of
be illness.
healthy-lo
oking.
Assess the General appearance The Throughout the Interpretation: No

client’s & mental state. patient session, the client is deviation from normal.
attitude. must be cooperative and
cooperati focused in his
ve prior interactions.
to the
assessme
nt.
Note the General appearance The At the time of the Interpretation: No

client’s & mental state. patient’s assessment, the deviation from normal.
affect/mood; mood and client is alert and
assess the emotional aware of what is
appropriateness state going on. Client
of the client’s should be responds to
responses. seen questions and
appropria communicates in a
te based timely and
on his/her appropriate manner.
reactions The mood is
and appropriate for the
responses client's situation.
.
Listen for General appearance The The client's speech Interpretation: No

quantity, & mental state. patient’s is good in terms of deviation from normal.
quality, and quantity quantity, quality,
organization of and and organization: it
speech. quality of is clear, moderately
speech paced, and
must be culturally
normal, appropriate.
organized
and
properly
thought
out.
Assess the General appearance The The client's Interpretation: No

relevance and & mental state. patient’s thoughts were deviation from normal.
organization of organizati well-organized and
thoughts. on of coordinated with his
thoughts actions.
should
have an
order of
sequence
and has a
sense of
reality.
b. Measurements (Height, Weight, BMI, Vital signs)

Height 170.18 cm
Weight 79 kg
BMI 27.3
Body Temperature 36.5 °C
Pulse Rate 72 bpm
Respiration Rate 16 bpm
Blood Pressure 130/90 mmHg
c. Cephalocaudal
Assessment Body Part Norms Actual Analysis &
Method Used (Cephalo-caudal) Findings Interpretation (with
reference)
INTEGUMENTARY ASSESSMENT
Inspect skin Skin. The patient’s skin The Interpretation: No

color. color must vary complexion of deviation from
from light to deep the client normal.
brown; or from varies from
ruddy pink to light brown to
light pink. dark brown.
There were no
signs of
abnormalities.
Inspect Skin. The patient’s skin My client's Interpretation: No

uniformity of should be uniform skin tone is deviation from
skin color. in color; except equal and normal.
from areas distributed
exposed to uniformly and
sunlight or areas evenly. On the
of lighter parts of his
pigmentation in body that are
dark-skinned. exposed to the
sun, he has a
tanned
complexion.
Inspect, palpate, Skin. The skin of the There are no Interpretation: No
and describe patient must look visible lesions deviation from
skin lesions. intact and normal. on the skin. normal.
Presence of skin
lesions such as
abnormalities,
discolorations, or
breakdowns that
may result in
serious
complications
should be noted.
Observe and Skin. The patient’s skin The skin of the Interpretation: No
palpate skin should be moist, client is deviation from
moisture. especially in the slightly damp, normal.
skinfolds and the particularly in
axillae. his body folds.
The skin of the
patient is
smooth and
non-scaly.
Palpate skin Skin. The patient’s skin The client's Interpretation: No

temperature. temperature skin deviation from
should be in temperature is normal.
normal range. normal; there
are no
indicators of
infection or
fever.
Palpate to assess Skin. The patient’s skin On the client's Interpretation: No

for presence of must be lower deviation from
edema. rebounded easily extremities, normal.
and not remain there is no
indented after the evidence of
pressure is edema.
released.
Palpate to assess Skin. The skin turgor of When pinched, Interpretation: No

for skin turgor. the patient should after 1 second, deviation from
immediately coil the client's skin normal.
back to normal coils back to
after being normal. As a
pinched. result, there is
no turgor in the
skin.
Inspect the Hair. The patient’s hair The patient's Interpretation: No

evenness of growth must be hair growth is deviation from
growth over the evenly distributed evenly normal.
scalp. all over his/her distributed
scalp. across his
scalp.
Inspect hair Hair. The patient’s The client's Interpretation: No
thickness or thinness or hair has a thick deviation from
thinness. thickness of hair strand. normal.
should vary
among his/her
genetic traits,
practices, and
lifestyle.
Inspect hair Hair. The patient’s The client's Interpretation: No

texture and texture and hair has a deviation from
oiliness. coarseness of hair smooth texture. normal.
should vary
among his/her
genetic traits,
practices, and
lifestyle.
Note presence of Hair. Presence of In the patient's Interpretation: No

infections or lesions, hair, there are deviation from
infestations. infections, and no indications normal.
infestations must of infection or
not be observed infestation.
on the patient’s
hair and scalp.
Inspect amount Hair. The patient’s The client's Interpretation: No

of body hair. body must whole body has deviation from
possess a normal a normal normal.
amount of amount of hair.
androgenic hair
and terminal hair
among the parts
of his/her body.
Inspect Nail. A normal nail The shape of Interpretation: No

fingernail plate should be in the patient's deviation from
shape. convex shape; an fingernails is normal.
angle of 160° convex. The
between the nail angle of the
and nail bed must patient's nail
be observed. plates is all
around 160
degrees.
Inspect Nail. The patient’s The pinkish Interpretation: No

fingernail and fingernail and tone is equally deviation from
toenail bed toenail bed color distributed normal.
color. must be highly across the
vascular and pink patient's
for light-skinned; fingernail and
or brown or black toenail bed.
for dark-skinned.
Inspect tissues Nail. Presence of The patient's Interpretation: No
surrounding lesions, tissues that deviation from
nails. infections, or surrounds the normal.
other nails appeared
abnormalities to be in good
must not be condition, with
observed among no indications
the patient’s of
fingernails and abnormalities.
toenails.
Palpate Nail. The texture of the The patient's Interpretation: No

fingernail and patient’s fingernails and deviation from
toenail texture. fingernail and toenails were normal.
toenail must have found to be
a normal and normal and
smooth texture. smooth.
Perform blanch Nail. The blanch test The client's Interpretation: No

test of capillary for the patient’s capillary refill deviation from
refill. capillary refill was observed normal.
must have a to be normal
prompt return to after
its normal state. performing the
blanch test on
his fingernails
and toenails, as
it immediately
recovered to its
pinkish state
for about 3
seconds.
HEAD TO NECK ASSESSMENT
Inspect and Head The patient’s head The client's Interpretation: No

palpate the head size and shape head is erect, deviation from
should vary in still, round, normal.
accordance to his normocephalic,
body. The and centered in
patient’s head the midline.
should be There were no
hard and smooth. observable
Lesions of any lesions.
variations should
not be observed.
Inspect and Head The patient’s face The client’s Interpretation: No

palpate the face should be in a face is deviation from
symmetrical form symmetric and normal.
with a round, round. There
oval, square, or were no signs
elongated of drooping or
appearance. abnormal
Abnormal movements.
movements
should not be
noted.
Palpate the Head The temporal The temporal Interpretation: No
temporal artery artery which is artery is elastic deviation from
located between and there was normal.
the top of the no tenderness
ear and the eye of to be found.
the patient should
be elastic and not
tender
Palpate the Head The patient There was no Interpretation: No

temporomandib should not feel swelling, deviation from
ular any tenderness tenderness, nor normal.
joint (TMJ) and crepitation crepitation
when evident. The
he open and lower jaw
closes her mouth moves
upon palpation. laterally.
Inspect the neck Neck The patient’s neck The client’s Interpretation: No
should be neck is deviation from
symmetric and symmetric with normal.
head-centered. head centered.
No swelling, There was no
enlarged masses, swelling,
or nodules should lumps,nor
be observed. bulging masses
Inspect Neck The thyroid After Interpretation: No

movement of the cartilage and swallowing, deviation from
neck cricoid cartilage the client’s normal.
structures should be thyroid
observed to cartilage and
move cricoid
symmetrically. cartilage moves
The patient must upward
not feel any pain symmetrically.
when
swallowing
Inspect the Neck C7 vertebrae C7 is visible Interpretation: No

cervical prominens should and palpable deviation from
vertebrae be visible and normal.
palpable.
Inspect range of Neck The patient’s neck The client’s Interpretation: No

motion range of motion neck deviation from
should be in a movements are normal.
smooth and smooth and
controlled manner controlled.
There were no
spasms or
stiffness to be
noted of.
Palpate the Neck The trachea The client’s Interpretation: No

trachea should be on its Trachea is deviation from
midline position. located in normal.
midline.
Palpate the Neck The patient’s The key Interpretation: No
thyroid gland. thyroid gland landmarks are deviation from
landmarks are not obscured normal.
positioned and are
midline. positioned in
midline. The
thyroid gland is
not
enlarged.
Therefore,
there is no need
to perform
auscultation.
Palpate the Neck There should be The client’s Interpretation: No

lymph nodes no swelling, lymph nodes deviation from
enlargement, or were not normal.
tenderness on the swollen,
patient’s neck enlarged, nor
lymph nodes tender.
Test distant Eyes The patient’s During the Interpretation:

visual acuity normal distant procedure, the Deviation from
visual acuity patient has normal.
should be 20/20 reported that Analysis: Astigmatism
with or without the letters are is a condition where
any corrective moving and the lens inside the eye
lenses. The blurry. The has conflicting curves.
patient should patient also This condition causes
have stated that he blurred vision at all
the ability to has distances (Mayo
distinguish what a astigmatism. Clinic, 2019).
a person with a
normal vision can
distinguish from
20 feet away.
Test near visual Eyes The patient’s The client has Interpretation: No
acuity normal near normal near deviation from normal
visual acuity visual acuity of
should be 14/14 14/14. The
with or without patient can
corrective lenses. read what a
The patient normal eye can
should have the read 14 inches
ability to read away.
what a normal
person with a
normal vision
could read 14
inches away.
Test visual fields Eyes The patient The client has Interpretation: No
for gross should see the normal visual deviation from
peripheral vision examiner’s finger field for gross normal.
at the same time peripheral
the examiner sees vision because
it with a they can see
the pen at the
normal peripheral same time the
vision. examiner sees
it.
Perform Corneal Eyes The reflection of The light is Interpretation: No

Light reflex test light on the reflected on the deviation from
corneas should be exact same normal.
in the exact same spot of
spot on each eye both eyes
when the corneal which indicates
light reflex is parallel
performed. alignment.
Perform cover Eyes When performing During the Interpretation:

test the cover test, the cover test, the Deviation from
uncovered eye client’s eyes normal.
should remain were observed Analysis: Nystagmus
fixed straight to be not in is a common eye
ahead; the sync with each condition where there
covered other. One eye is an evident
eye should remain is left behind involuntary movement
fixed straight and moves observed from one eye
ahead after being slower or both (American
uncovered compared to Optometric
the other. Association, n.d.).
Perform Eyes The patient’s eye The client’s Interpretation: No

Positions Test movement should eye deviation from
be smooth and movement is normal.
symmetric smooth and
throughout the symmetric
pen directions while
following the
pen in all six
directions.
Inspect the Eyes The patient's The client’s Interpretation: No

eyelids and eyelash color of upper eyelid deviation from
eyelashes eyelashes should rests between normal.
vary depending the upper
on his race. It margin of the
should also be iris and the
evenly distributed upper margin
and turned of the pupil.
outward. On the The patient’s
other hand, the lower eyelid is
patient’s upper lid located on the
margin should be lower border of
between the iris.
the upper margin
of the iris and the
upper margin of
the pupil.
The lower lid
margin should
also rest on the
lower border of
the
iris. No white
sclera should be
seen above or
below the iris,
and
his palpebral
fissures should be
aligned
horizontally.
Assess the Eyes The patient’s Both of the Interpretation: No

ability of eyelids upper lids and client’s eyelids deviation from
to lower lids should close easily normal.
close close easily and and shuts
meet completely completely
when closed.
Note the Eyes The patient’s There was no Interpretation: No

position of the lower eyelid inward nor deviation from
eyelids should be in an outward normal.
in comparison upright position turning on the
with the with no eyelids.
eyeballs. inward or
outward turning.
Observe eyelids Eyes No redness, There was no Interpretation: No

for redness, swelling or any redness, deviation from
swelling, variations of swelling, normal.
discharge or lesions should be discharge, nor
lesions. observed on the lesions present
patient’s skin on on the client’s
both of his eyelids.
eyelids.
Observe eyelids Eyes The patient’s There was no Interpretation: No

for the position eyeballs are protruding or deviation from
and alignment of symmetrically sinking evident normal.
the eyeball in aligned in the eye on the eyeballs.
the eye socket sockets without They are also
protruding or symmetrically
sinking. aligned in eye
sockets.
Inspect the Eyes The patient’s The client’s Interpretation: No

bulbar bulbar bulbar deviation from
conjunctiva conjunctiva conjunctive is normal.
and sclera. should be clear, clear, moist,
moist, and and smooth.
smooth; the The sclera is
underlying also white.
structures should
also be clearly
visible. The
patient’s sclera
should also be
white in color.
palpebral lower and upper lower and deviation from
conjunctiva. palpebral upper palpebral normal.
conjunctivae conjunctiva are
should be clear and there
clear and free of were no
any signs of swelling
abnormalities. nor lesions
found.
Evert the upper Eyes The patient’s The upper Interpretation: No

eyelid. palpebral eyelid is free of deviation from
conjunctiva swelling, normal.
should be free foreign
from swelling, materials, and
foreign bodies, there was no
and trauma. sign of trauma
Inspect and Eyes There should be There was no Interpretation: No

palpate the no swelling or swelling not deviation from
lacrimal redness observed redness normal.
apparatus. on the evident. The
patient’s lacrimal puncta is also
glands. The visible and
puncta should turned to the
also be visible; eye
slightly turned
towards the eye.

cornea and lens. cornea and lens cornea is deviation from
should be smooth, moist, normal.
transparent and transparent,
free and has no
of opacities. The opacities. Their
lens should show lens is also
a smooth and completely
moist on the opaque
overall surface
from the oblique
view.
Inspect the iris Eyes The patient’s iris The iris is in Interpretation: No
and pupil should be round, dark brown deviation from
flat, and evenly color and a normal.
colored. round flat
The pupil should shape. It is
be centered in the centered with
patient’s iris; the pupil with
should be equal in the size of
size with a regular 4mm.
border.
Test pupillary Eyes The patient’s The client’s Interpretation: No

reaction to light pupil should pupils have deviation from
(Pupillary Light constrict as a constricted normal.
Reflex). response to after being
pupillary light directed to
reflex test light.
Assess Eyes The normal The client’s Interpretation: No
Consensual consensual pupils have deviation from
Response pupillary constricted normal.
response of the after being
patient should be shined to light.
constriction.
Test Eyes The patient’s The client’s Interpretation: No

accommodation pupils should pupils have deviation from
of pupils. constrict and his constricted normal.
eyes should after following
accommodate and the pen move
converge when towards them.
focusing on a near Eyes have
object. also converged
when doing the
test
Inspect the Ears The patient’s ears The client’s Interpretation: No

auricle, tragus, should be equal in auricle is equal deviation from
and size bilaterally. in size normal.
lobule. The patient’s bilaterally and
earlobe they are
should also be aligned on the
free, attached, or corner of each
soldered; tightly eye.
attached to The patient’s
adjacent skin with ear lobes are
no apparent lobe. free and
attached to the
ear.
Inspect the Ears The size, shape, The client’s Interpretation: No

external auditory and color of the external deviation from
canal external auditory auditory canal normal.
canal vary from is smooth,
person to person. the color is
The eardrum is consistent,
either light gray and there were
or pearly white in no lesions or
appearance discharges to
and light should be
reflect off the alarmed about.
surface of the
eardrum.
Palpate the Ears The patient There were no Interpretation: No

auricle and should not feel tenderness deviation from
mastoid any tenderness or found on both normal.
process pain on his auricle and
auricle, tragus, mastoid
and mastoid process.
process.
Perform whisper Ears The patient The client has Interpretation: No

test should be able to repeated deviation from
repeat the word correctly the normal.
sequence two-syllable
whispered to pass words that are
the test. whispered 2
feet away from
them.
Perform Ears The patient Vibrations are Interpretation: No

Weber’s Test should hear the heard equally deviation from
vibrations equally in both ears. normal.
on both of There was no
his ears. No lateralization of
lateralization of sound to either
sound should be ear.
heard on either of
his ears
Perform the Ears The patient The client has Interpretation: No

Rinne’s Test should hear the heard air deviation from
air conduction conduction normal.
sound longer than sound longer
the bone than the bone
conduction sound. conduction
sound.
Perform the Ears The patient The client’s Interpretation: No

Romberg Test should maintain a equilibrium is deviation from
balanced position in normal state normal.
for 20 seconds as to why the
without swaying patient is not
swaying while
performing the
test.
Inspect and Nose The color of the The client’s Interpretation: No

palpate the patient’s external nose is smooth deviation from
external nose should be as in a normal normal.
nose same size and shape,
as the rest of his and consistent
face. The nasal with the skin
structure should color. There
also be smooth was no
and symmetric. tenderness to
be found.
Check patency Nose The patient The client can Interpretation: No

of airflow should have the inhale air deviation from
through the ability to sniff properly while normal.
nostrils through each one of their
nostril when the nostrils is
other is occluded.
occluded.
Inspect the Nose The patient’s The client’s Interpretation: No
internal nose nasal mucosa and nasal mucosa is deviation from
turbinates should in dark, pinkish normal.
be in a normal shade, moist,
coloration. It and free of
should also be exudate. On the
moist and free of other hand, the
any exudates or patient’s nasal
lesions. The nasal septum is intact
septum should be and free of
intact and free of ulcers or
ulcers or perforations.
perforations.
Palpate and Nose The patient’s There was no Interpretation: No

percuss the frontal and tenderness deviation from
sinuses maxillary sinuses when palpating normal.
should not be the
tender upon frontal and
palpation. There maxillary
should also be no sinuses.
crepitus evident Crepitus was
in the sinus area. also
not evident
Inspect the lips Mouth The patient’s lips The client’s Interpretation: No
should be smooth lips are deviation from
and moist, smooth and normal.
without swelling moist. There
or any lesions. were no lesions
nor swelling to
be noted.
Inspect the teeth Mouth The patient The client has Interpretation: No
and gums should have a complete deviation from
complete set of thirty-two normal.
whitish teeth with pearly teeth
smooth surfaces (including the
and edges. The four
patient’s teeth wisdom teeth).
should not have The patient’s
any decayed gums are in
areas. His gums perfectly good
should be pink, condition with
moist, and firm moist, firm,
with tight margins and
to the tooth. pinkish color.
Inspect the Mouth The tissue The patient’s Interpretation: No

buccal mucosa pigmentation of buccal mucosa deviation from
the is in pinkish normal.
patient’s buccal color,and it is
mucosa should consistent with
vary among his the rest of their
skin mouth.
correlation.
Inspect and Mouth The patient’s The tongue Interpretation: No
palpate the tongue should be should be pink, deviation from
tongue pink and moist. It moist, and in normal.
should also be moderate size.
in a moderate size There were no
with little lesions visible.
protuberances
present.
Assess the Mouth The patient’s The client’s Interpretation: No

ventral surface ventral surface ventral surface deviation from
of the should be smooth, of tongue is normal.
tongue shiny, pink or smooth, shiny,
slightly pale in and in pinkish
color with veins color that is
being visible. consistent with
the rest of the
tongue. The
veins are also
visible with no
lesions.
Inspect for Mouth The patient’s The frenulum Interpretation: No

Wharton’s ducts frenulum should is in deviation from
be in a midline midline. The normal.
position and her Wharton’s
Wharton’s ducts ducts are
should also be evident and
visible with moist. There is
salivary flow or no
moistness in the swelling,
area. Swelling or redness, nor
unusual redness discomfort in
should not be the client
observed.
Observe the Mouth The patient The sides of Interpretation: No

sides of the should not have the tongue deviation from
tongue any apparent appear to not normal.
lesions, ulcers, or have any
nodules on the lesions, ulcers,
sides of his nor
tongue. nodules.
Check the Mouth The patient’s The client’s Interpretation: No

strength of the tongue should tongue has a deviation from
tongue. offer strong strong normal.
resistance when resistance
the when
examiner’s pressing
fingers are placed against the
on the sides of his cheek.
cheeks.
Inspect the hard Mouth The patient’s hard The hard palate Interpretation: No
(anterior) and palate should be is pale and has deviation from
soft (posterior) pale or whitish in a firm texture normal.
palates and color with a firm while the soft
uvula. and transverse palate is in
wrinkle-like pinkish color
folds. His/her with spongy
palatine tissues and smooth
should be intact texture
and the soft palate
should be pinkish,
movable, spongy,
and smooth.
Note odor while Mouth There should be There were no Interpretation: No

the mouth is no unusual or foul signs of deviation from
wide open odor noted on the unusual or bad normal.
inspection of the odor coming
mouth and throat. from the
mouth.
Assess the uvula Mouth The patient’s The client does Interpretation: No
uvula is fleshy not have a bifid deviation from
and has a solid uvula. Their normal.
structure that uvula also does
hangs not have any
freely in the redness,
midline; midline swelling, nor
elevation of uvula exudate from
and symmetric their uvula or
elevation of the soft palate. It is
soft palate. There positioned in
should be no midline and
redness or symmetric with
exudate from the the soft palate.
uvula or soft
palate
Inspect the Mouth The patient’s The client’s Interpretation: No

tonsils tonsils may be tonsils are deviation from
present or absent. present and in normal.
If present, the pinkish color.
tonsils should be There was no
symmetric and exudate,
pink in color. edema, nor
There should be lesions to be
no exudates, noted of.
swelling, or
lesions present on
the area.
Inspect the Mouth The patient’s The client’s Interpretation: No

posterior throat should be posterior deviation from
pharyngeal in a normal pink pharyngeal normal.
wall color, without any wall is pink
forms of exudates and free of
or lesions. lesions and
exudate.
CHEST TO ABDOMEN ASSESSMENT
Inspect Posterior thorax/ Scapulae are An Interpretation: No

Configuration Scapula Shoulder symmetric and examination deviation from
non-protruding. reveals no normal.
Shoulders and protrusion or
scapula are at dislocation of
equal horizontal the scapula,
positions. The which are
ratio of found to be in
anteroposterior to an equal
transverse horizontal
diameter is 1:2. position. The
Spinous processes anterior
appear straight, posterior
and thorax to-anterior
appears transverse
symmetric, with diameter ratio
ribs sloping is 1:2. While
downward at inspecting, the
approximately a spine appears
45-degree angle straight and the
in relation to the posterior
spine. thorax appears
symmetrical,
with the ribs
dipping
downward at a
45-degree
angle.
Observe use of Posterior Thorax/ The client does There were no Interpretation: No
accessory chest & not use accessory accessory deviation from
muscles diaphragm muscles to assist muscles, such normal.
breathing. The as trapezius,
diaphragm is the being used by
major muscle at the client
work. This is during the
evidenced by inspection.
expansion of the Since the lower
lower chest chest expands
during as a result of
inspiration. inspiration, it's
obvious that
the diaphragm
is the primary
muscle at
work.
Inspect the Posterior thorax Client should be The client, Interpretation: No

client’s sitting up and during deviation from
positioning relaxed, breathing assessment, is normal.
easily with arms sitting upright
at sides or in lap. and relaxed; he
is breathing
easily while
arms at his lap.
No distress
found.
Palpate for posterior thorax Client reports no The patients Interpretation: No

tenderness, tenderness, pain, report no deviation from
sensation and or unusual tenderness, normal.
crepitus sensations. pain, or other
Temperature unusual
should be equal sensations
bilaterally. The during the
examiner finds no palpation
palpable crepitus. procedure.
Bilaterally, the
client's
temperature is
the same as the
rest of his
body. In
addition, there
is no
discernible
crepitus.
Palpate surface posterior thorax/ Skin and The patients Interpretation: No

characteristics skin subcutaneous report no deviation from
tissue are free of tenderness, normal.
lesions and pain, or other
masses. unusual
sensations
during the
palpation
procedure.
Bilaterally, the
client's
temperature is
the same as the
rest of his
body. In
addition, there
is no
discernible
crepitus.
Palpate for posterior thorax/ Fremitus is The client used Interpretation: No
fremitus fremitus symmetric and the word deviation from
easily identified "ninety-nine" normal.
in the upper during the
regions of the evaluation of
lungs. A decrease fremitus.
in the intensity of Within the
fremitus is normal upper lobes of
as the examiner the lungs, the
moves toward the fremitus shows
base of the lungs. evidence of
symmetry. In
addition, it is
clear that the
intensity of the
assessment
decreases as it
moves toward
the base of the
lungs. No
abnormalities
have been
found in the
fremitus, which
is symmetrical
on both sides.
Assess chest posterior thorax When the client The nurse's Interpretation: No
expansion takes a deep thumb moves 6 deviation from
breath, the cm apart in a normal.
examiner’s symmetrical
thumbs should manner as the
move 5 to 10 cm patient's chest
apart expands during
symmetrically. inhalation. The
base of the
chest does not
show any signs
of decreasing
organs that
breathe: the
lungs.
Percuss the tone posterior thorax Resonance is the During Interpretation: No

percussion tone percussion, the deviation from
elicited over scapula elicits normal.
normal lung flat tones while
tissue. Percussion the percussion
elicits flat tones over the lungs
over the scapula. elicits
resonance
tones which
indicates
normal lung
tissue. There
are no sounds
of
hyperresonance
present during
percussion.
Percuss for posterior The excursion It is clear that Interpretation: No

diaphragmatic thorax/diaphragm should be equal both sides of deviation from
excursion bilaterally and the lower normal.
measure 3–5 cm scapular line
in adults. The show equal
level of the diaphragmatic
diaphragm may excursion with
be higher on the a 4 cm size
right because of when
the position of the percussion is
liver. started from
the T7 of the
spine
downwards,
from resonance
to dullness.
During
percussion,
there are no
signs of fluid
or solid tissue.
Auscultate for posterior thorax Three types of The Broncho Interpretation: No

breath sounds normal breath vesicular deviation from
sounds may be sounds and the normal.
auscultated— vesicular
bronchial, sounds are two
Broncho distinct types
vesicular, and of breath
vesicular. sounds that can
be heard during
auscultation,
which is the
process of
listening to the
lungs.
Auscultate for posterior thorax The voice The sound Interpretation: No

voice sounds transmission is transmission is deviation from
soft, muffled, and weak, normal.
indistinct. The muddled, and
sound of the voice difficult to
may be heard, but make out.
the actual phrase Although the
cannot be voice can be
distinguished. heard and felt
vibrating, it is
difficult to
make out the
individual
words or
phrases that are
being said.
Inspect for Anterior thorax The The transverse Interpretation: No
shape and anteroposterior diameter is deviation from
configuration diameter is less greater than the normal.
than the anteroposterior
transverse diameter, with
diameter. The a ratio of 1:2.
ratio of the No signs of a
anteroposterior barrel chest or
diameter to the hyperinflation
transverse of the lungs.
diameter is 1:2.
Inspect position Anterior Sternum is The sternum of Interpretation: No

of the sternum thorax/sternum positioned at the client can deviation from
midline and be seen at the normal.
straight. midpoint of the
body, where it
is parallel to
the ribs.
Watch for Anterior Retractions not During the Interpretation: No

sternal thorax/sternum observed evaluation, no deviation from
retractions retractions normal.
have been
found to have
taken place.
There was no
associated
breathing that
was extremely
difficult.
Inspect slope of Anterior Ribs slope Intercostal Interpretation: No

the ribs thorax/ribs downward with spaces are deviation from
symmetric symmetric in normal.
intercostal spaces. the ribs of the
The costal angle client. Within a
is within 90 90-degree
degrees. angle, the
costal angle is
correct. Neither
a barrel-chest
nor any other
abnormalities
were found.
Observe quality Anterior thorax Respirations are Their breathing Interpretation: No

and pattern of relaxed, and deviation from
respirations effortless, and respirations are normal.
quiet. They have effortless,
a regular rhythm quiet, and at
and normal depth rest. They
at a rate of 10– 20 occur at a rate
per minute in of 15 per
adults. Tachypnea minute and
and bradypnea have a regular
may be normal in rhythm and
some clients. depth. In terms
of breathing,
there are no
abnormalities.
Inspect Anterior No retractions or In the course of Interpretation: No

intercostal thorax/intercostal bulging of an deviation from
spaces spaces intercostal spaces examination, normal.
are noted. the client's
intercostal
spaces are not
retracted or
bulging.
Indicators of a
blocked
respiratory
tract or trapped
air have been
eliminated.
Observe for use Anterior thorax Use of accessory During Interpretation: No

of accessory muscles is not inspection, the deviation from
muscles seen with normal client did not normal.
respiratory effort. use any
After strenuous accessory
exercise or muscles, such
activity, clients as
with normal sternomastoid
respiratory status and rectus
may use neck abdominis, to
muscles for a assist him with
short time to his breathing. It
enhance is evident that
breathing. the major
muscle at work
is the
diaphragm due
to the
expansion of
the lower chest
during
inspiration.
Palpate for Anterior thorax No tenderness or There is no Interpretation: No

tenderness, pain is palpated tenderness, deviation from
sensation and over the lung area pain, or normal.
surface masses with respirations. unusual
sensation over
the lung area
with respiration
during
palpation for
the patient to
report.
Palpate for Anterior Palpation does There is no Interpretation: No
tenderness at thorax/costochon not elicit tenderness in deviation from
costochondral dral junctions of tenderness. the palpation. normal.
junctions of ribs ribs There were no
signs of
discomfort at
the rib's
costochondral
junction
Palpate for Anterior thorax No crepitus is There are no Interpretation: No

crepitus palpated palpable deviation from
crepitus. No normal.
signs of
congestion or
consolidation
Palpate for Anterior thorax No unusual During Interpretation: No

tenderness, surface masses or palpation, there deviation from
sensation and lesions are are no unusual normal.
surface masses palpated. surface masses
or lesions that
are palpated.
Palpate for Anterior Fremitus is The client used Interpretation: No

fremitus thorax/fremitus symmetric and the word deviation from
easily identified "ninety-nine" normal.
in the upper during the
regions of the evaluation of
lungs. A fremitus.
decreased Within the
intensity of upper lobes of
fremitus is the lungs, the
expected toward fremitus shows
the base of the evidence of
lungs. However, symmetry. In
fremitus should addition, it is
be symmetric clear that the
bilaterally. intensity of the
assessment
decreases as it
moves toward
the base of the
lungs. No
abnormalities
have been
found in the
fremitus, which
is symmetrical
on both sides.
Anterior thorax The thumbs move During Interpretation: No
outward in a inhalation, the deviation from
symmetric thumbs move normal.
fashion from the outward in a
midline. symmetrical
fashion from
the midline.
There were no
signs of
decreased chest
excursion or
any
abnormalities
that may be
associated with
unequal chest
expansion.
Percuss the tone Anterior thorax Resonance is the When Interpretation: No

percussion tone percussion is deviation from
elicited over applied to the normal.
normal lung breast, heart,
tissue. Percussion and liver,
elicits dullness dullness tones
over breast tissue, are heard,
the heart, and the whereas
liver. Tympany is resonance
detected over the tones are heard
stomach, and over the lungs,
flatness is indicating
detected over the healthy lung
muscles and tissue.
bones. Tympany tones
are also heard
over the
stomach; and
flat tones are
generated by
muscle
contractions as
well as by bone
movement. In
percussion,
there are no
hyperresonant
sounds.
Auscultate for Anterior Refer to text in In terms of Interpretation: No
breath sounds thorax/Anterior the posterior breath sounds, deviation from
Breath Sounds, thorax section for there are three normal.
Adventitious normal voice distinct types
Sounds, and sounds. to be heard.
Voice Sounds. The tracheal
bronchial
sounds, the
broncho
vesicular
sounds, and the
vesicular
sounds within
the lung areas
are all
examples of
pulmonary
sounds. During
auscultation,
there are no
extraneous
sounds; no
murmurs or
other noises.
The voice
transmission of
sounds is soft,
muddled, and
indistinct for
the voice
sounds.
Although the
voice can be
heard and felt
vibrating, it is
difficult to
make out the
individual
words or
phrases that are
being said.
Inspect the areolas Areolas vary from As a result of Interpretation: No

areolas. dark pink to dark the client's skin deviation from
brown, depending tone, her normal.
on the client’s areolas appear
skin tones. They to be a darker
are round and shade of
may vary in size. brown. It has a
Small round shape
Montgomery and is slightly
tubercles are larger than the
present. nipples in
diameter.
Inspect the nipples Nipples are nearly The client's Interpretation: No
nipples. equal bilaterally nipples are deviation from
in size and are in nearly identical normal.
the same location in size and
on each breast. placement on
Nipples are each breast.
usually everted, Nipples that
but they may be are everted are
inverted or flat. considered
Supernumerary normal in this
nipples may case. During
appear along the the inspection,
embryonic “milk there were no
line.” No signs of
discharge should discharge.
be present.
Inspect and Axillae No rash or During the Interpretation: No

palpate the infection noted. palpation of the deviation from
axillae. axillae and the normal.
lymph nodes
present within
the thorax, it
shows no rash
or infection
present. There
are no palpable
nodes and it is
discrete and
non-tender.
Observe the Heart & neck The jugular The artery is Interpretation: No
jugular venous vessels / Jugular venous pulse is not dilated, and deviation from
pulse. Venous not normally the patient is in normal.
visible with the a supine
client sitting position with
upright. This no visible
position fully pulse.
distends the vein, Additionally,
and pulsations there is no
may or may not visible jugular
be discernible. venous pulse,
which is
considered to
be normal.
Inspection
revealed no
signs of
elevated
venous
pressure or
other
abnormalities.
Evaluate jugular Heart & neck The jugular vein The jugular Interpretation: No
venous pressure. vessels / Jugular should not be venous deviation from
Venous distended, pressure of the normal.
bulging, or patient is
protruding at 45 normal, and the
degrees or greater. vein does not
bulge or
protrude at an
angle of 45
degrees or
more. There
are no
abnormalities
in the venous
pressure or any
other signs of
elevated
pressure.
Auscultate the Heart & neck / No blowing or During Interpretation: No

carotid arteries Carotid Arteries swishing or other auscultation, deviation from
sounds are heard. there normal.
Pulses are equally are no blowing
strong; a 2+ or or swishing
normal with no or bruit sounds
variation in that are
strength from beat heard. The
to beat. Contour pulse are
is normally equally
smooth and rapid strong with a
on the upstroke 2+ or normal
and slower and with no
less abrupt on the variation in
down stroke. strength
Arteries are from beat to
elastic and no beat. The
thrills are noted. contour is
smooth and
rapid on the
upstroke and
slower and less
abrupt on the
down stroke.
Arteries also
show elasticity
and no thrills
are noted.
There are no
indications of
reduced
cerebral blood
flow or any
abnormalities
that may result
in
atherosclerosis
and narrowing
of the artery.
. Inspect Heart & neck The apical The apical Interpretation: No
pulsations. vessels impulse may or pulse is not deviation from
may not be visible during normal.
visible. The apical an examination
impulse is a result because of the
of the left client's body
ventricle moving proportion.
outward during There are no
systole. abnormal
pulsations or
signs of an
apical impulse.
Palpate the Heart & neck The apical When Interpretation: No

apical impulse. vessels / apical impulse is palpating the deviation from
impulse palpated in the mitral area of normal.
mitral area and the heart, 2
may be the size of cm-wide apical
a nickel (1-2 cm). impulses can
be felt. For
only the first
two-thirds of
the heart's
cycle, the
amplitude is a
slight tap, and
the duration is
brief.
Auscultate heart Heart & neck Rate should be Client's heart Interpretation: No
rate and rhythm. vessels 60-100 bpm with rate is 72 bpm deviation from
a regular rhythm. with a steady normal.
rhythm
following
auscultation. It
appears that the
patient's heart
rate and
cardiac output
have not
changed at all.
Auscultate to Heart & neck S1 corresponds S1 and S2 have Interpretation: No

identify S 1 and vessels with each carotid both distinct deviation from
S 2. pulsation and is sounds with no normal.
loudest at the An S sound
apex of the heart. that is
S2 immediately accentuated or
follows after S1 split into two
and is loudest at distinct S
the base of the sounds. The S1
heart. is clearly heard
most clearly at
the top of the
heart, while the
S2 is heard
most clearly at
the bottom.
Auscultate for Heart & neck Normally no There are no Interpretation: No
extra heart vessels sounds are heard extra heart deviation from
sounds. sounds that are normal.
heard. No
evidence of S3
and S4 during
auscultation.
Auscultate for Heart & neck Normally no There are no Interpretation: No

murmurs. vessels murmurs are murmurs or deviation from
heard any normal.
adventitious
sounds during
auscultation.
. Observe the Abdomen/skin Abdominal skin Inspection Interpretation: No

coloration of the may be paler than reveals that the deviation from
skin. the general skin client's normal.
tone because this abdominal skin
skin is so seldom has a paler tone
exposed to the than the rest of
natural elements. their body,
likely as a
result of their
infrequent
exposure to the
elements. The
abdomen of the
client was clear
of any
discoloration or
inflammation.
Note the Abdomen Scattered fine In light of the Interpretation: No

vascularity of veins may be client's skin deviation from
the abdominal visible. Blood in tone, scattered normal.
skin. the veins located fine veins
above the ambient aren't as
light of the visible.
client's skin Dilation or
tone, scattered insufficient
fine veins blood flow to
aren't as visible. lower
Dilation or extremities
insufficient blood have not been
flow to observed.
lower extremities
have not
been
observed.licus
flows toward the
head; blood in the
veins located
below the
umbilicus flows
toward the lower
body
Inspect for scars Abdomen New striae are No evidence of Interpretation: No
pink or bluish in striae or any deviation from
color; old striae abnormalities normal.
are silvery, white, related to
linear, and uneven stretch marks
stretch marks that might be a
from past deviation from
pregnancies or normal.
weight gain.
Assess for Abdomen Pale, smooth, During Interpretation: No

lesions and minimally raised inspection, deviation from
rashes. old scars may be there are no normal.
seen. scars that are
present, even
the old ones.
No signs of
non-healing
wounds,
redness, or
inflammation.
Inspect the Abdomen Abdomen is free No lesions, Interpretation: No

umbilicus. of lesions or rashes, or deviation from
rashes. Flat or infections have normal.
raised brown been found on
moles, however, the client's
are normal and abdomen at
may be apparent. this time. Flat
nevi are still
considered
normal, despite
the fact that
there are only a
few of them.
There are no
abnormalities
or changes in
the nevi's
physical
characteristics.
Abdomen/ Umbilical skin The client's Interpretation: No

umbilicus tones are similar umbilical skin deviation from
to surrounding tone is normal.
abdominal skin indistinguishab
tones or even le from the
pinkish. surrounding
abdominal skin
tone. The
umbilicus is
located at the
lateral line of
the midline.
The umbilicus
was not
deviated or
discolored in
any way that
could indicate
abdominal
disease.
Inspect Abdomen It is recessed The umbilicus Interpretation: No

abdominal (inverted) or of the client deviation from
contour and protruding no measures 0.4 normal.
symmetry more than 0.5 cm, cm in length
and is round or and is rounded
conical. in shape. There
were no signs
of an umbilical
hernia, such as
eversion or an
enlarged
umbilicus.
Inspect Abdomen Abdomen is flat, The client's Interpretation: No

abdominal rounded, or torso is evenly deviation from
movement when scaphoid; shaped. There normal.
the client Abdomen should are no signs of
breathes be evenly distention or
rounded. generalized
protuberance.
. Inspect Abdomen Abdomen is The abdomen Interpretation: No

abdominal symmetric. of the client deviation from
contour and shows normal.
symmetry symmetry.
. Inspect Abdomen Abdominal It is evident Interpretation: No

abdominal respiratory that there is an deviation from
movement when movement may abdominal normal.
the client be seen, respiratory
breathes especially in male movement seen
clients. from the
patient.
Observe aortic Abdomen/aorta A slight pulsation Due to the Interpretation: No

pulsations. of the abdominal client’s body deviation from
aorta, which is ratio, the aortic normal.
visible in the pulsation is not
epigastrium, that visible.
extends full However, if we
length in thin focus on the
people. epigastrium, it
shows a slight
pulsation in the
abdominal
aorta. No signs
of exaggeration
or any
abnormalities.
Observe Abdomen Normally, Peristaltic Interpretation: No
peristaltic peristaltic waves waves are not deviation from
waves. are not seen, visible to the normal.
although they naked eye
may be visible in because of the
very thin people client's body
as slight ripples proportions.
on the abdominal There are no
wall. signs of a rise
in intensity or
a bulge in the
abdomen.
Auscultate for Abdomen A series of It is normal to Interpretation: No

bowel sounds. intermittent, soft audibly detect deviation from
clicks and gurgles three soft normal.
are heard at a rate clicks and
of 5–30 per gurgles in the
minute. left lower
quadrant over
the course of
30 seconds.
There are no
signs of
abnormally
active or
inactive bowel
movements.
Auscultate for Abdomen Bruits are not It is normal to Interpretation: No

vascular sounds. normally heard audibly detect deviation from
over abdominal three soft normal.
aorta or renal, clicks and
iliac, or femoral gurgles in the
arteries. left lower
quadrant over
the course of
30 seconds.
There are no
signs of
abnormally
active or
inactive bowel
movements.
Percuss for tone. Abdomen Venous hum is In the Interpretation: No

not normally epigastric and deviation from
heard over the umbilical normal.
epigastric and regions, there
umbilical areas. is evidence of
venous hum or
any other
accentuation of
these areas
during
auscultation.
Auscultate for a Abdomen No friction rub To assess Interpretation: No
friction rub over over the liver or friction rub, deviation from
the liver and spleen is present. there aren't any normal.
spleen. friction rubs
over the liver
and spleen
positions at all.
Inflammation,
infection, or
tumor in the
spleen are all
absent.
Perform blunt Abdomen Generalized During Interpretation: No

percussion on tympany percussion, deviation from
the liver and the predominates tympany is the normal.
kidneys. over the abdomen generalized
because of air in tone that
the stomach and predominates
intestines. over the
Dullness is heard abdomen due
over the liver and to the presence
spleen. of air in the
stomach and
intestines.
However, the
liver and
spleen elicit
dull tones. No
signs of
accentuated
tympany or
hyperresonance
.
Abdomen / liver The lower border After taking a Interpretation: No

of liver dullness deep breath, deviation from
may descend the dullness normal.
from 1 to 4 cm tones that
below the costal descend over
margin. The the lower
normal liver span border of the
at the MSL is 4 – liver measure 4
8 cm. cm below the
costal margin.
There are 9 cm
in the right
midclavicular
line of the
liver's right
lobe and 5 cm
in the
midsternal line
of its left lobe.
There are no
signs of a
swollen liver or
loud noises
coming from
the liver's
outline.
Abdomen / spleen The spleen is an There is an Interpretation: No

oval area of oval area with deviation from
dullness approximately normal.
approximately 7 7 cm of
cm wide near the diameter near
left tenth rib and the left 10th rib
slightly posterior and slightly
to the MAL. posterior to
Normally, midaxillary
tympany is heard live that is dull
at the last left when spleen is
interspace. played upon.
The tympany
tones of the
final left
interspace are
elicited.
Palpate the liver. Abdomen / liver Normally, no A dull thud is Interpretation: No

& kidney tenderness is all that can be deviation from
elicited. heard when normal.
blunt
percussion is
applied,
according to
the client.
Abdomen Abdomen is The abdomen Interpretation: No

non-tender and of the clients deviation from
soft. There is no shows no normal.
guarding. tenderness and
have a smooth
surface. There
are also no
evidences of
guarding.
Abdomen Normal (mild) Normal Interpretation: No

tenderness is tenderness is deviation from
possible over the palpated during normal.
xiphoid, aorta, deep palpation
cecum, sigmoid of the xiphoid
colon, and ovaries (aorta, aorta,
with deep cecum,
palpation. sigmoid, and
ovaries), and
this tenderness
is considered
normal. During
palpation, the
client reports
no discomfort
or pain of any
kind.
Deeply palpate Abdomen No palpable There are no Interpretation: No
all quadrants to masses are palpable deviation from
delineate present. masses present normal.
abdominal within all the
organs and quadrants of
detect subtle the abdomen.
masses.
Deeply palpate Abdomen / The umbilicus The umbilicus Interpretation: No

all quadrants to umbilicus and surrounding and deviation from
delineate area are free of surrounding normal.
abdominal swellings, bulges, area of the
organs and or masses. client are free
detect subtle of any
masses. swellings,
bulges, or
masses.. A
nodule or soft
center is not
visible.
Perform light Abdomen / aorta The aorta is The aorta is 2.5 Interpretation: No
palpation. approximately to 3.0 cm wide deviation from
2.5–3.0 cm wide and has a normal.
with a moderately moderately
strong and regular strong and
pulse. Possibly regular pulse
mild tenderness when palpated
may be elicited. with the thumb
and index
finger in the
epigastrium.
Palpation
elicits mild
tenderness, as
well.
Abdominal
aortic
aneurysm may
cause a
pulsating,
pulsating pulse,
but there was
no evidence of
this.
Palpate the liver. Abdomen / liver The liver is The liver Interpretation: No
usually not cannot be felt deviation from
palpable, when normal.
although it may performing a
be felt in some bimanual
thin clients. If the palpation. Even
lower edge is felt, though a slight
it should be firm, amount of
smooth, and even. tenderness can
Mild tenderness be felt, this is
may be normal. still considered
normal. There
are no signs of
liver nodules or
enlargement.
Abdomen / An empty bladder During Interpretation: No

urinary bladder is neither palpable palpation, it deviation from
nor tender. shows that the normal.
client has an
empty bladder
and is neither
palpable nor
tender. No
signs of firm
mass or any
distention.
Assess for Abdomen No rebound Client Interpretation: No

rebound tenderness is tenderness does deviation from
tenderness. present. not appear to normal.
rebound during
the assessment.
Examiner
releases
abdominal
pressure
without
detecting any
signs of sharp,
stabbing pain.
MUSCULOSKELETAL ASSESSMENT
Inspect the Muscles Equal size on An Interpretation: No

muscles for size. both sides of body examination of deviation from
Compare each the muscles normal.
muscle on one reveals that
side of the body they are
to the same symmetrical on
muscle on the both sides of
other side. the body.
Atrophy or
hypertrophy
have not been
observed.
Inspect the Muscles No contractures Tendons and Interpretation: No

muscles and muscles are deviation from
tendons for free of normal.
contractures. contractures.
Body parts
appear to be in
the correct
positions.
Inspect the Muscles No fasciculation During the Interpretation: No

muscles for or tremors inspection, deviation from
tremors. there are no normal.
signs of
fasciculation or
tremors in the
upper limbs.
Palpate muscles Muscles Normally firm Muscles have a Interpretation: No

at rest to firm feel to deviation from
determine them when normal.
muscle tonicity. they're being
felt.
Involuntary
muscle
contractions
have not been
detected.
Palpate muscles Muscles Smooth The muscles Interpretation: No

while the client coordinated move in a deviation from
is active and movements synchronized normal.
passive for fashion. During
flaccidity, palpation, there
spasticity, and were no signs
smoothness of of weakness or
movement. laxity, and no
sudden,
involuntary
muscle
contractions.
Test muscle Muscles Equal Strength on During the Interpretation: No

strength of the each body side. assessment for deviation from
head & We also use the muscle normal.
shoulders Grading Muscle strength, all
Strength for have equal
assessing the strength on
resistance of each side of the
pressure in every body. For the
muscle to be grading muscle
assessed. strength, the
client has grade
5
Test muscle Muscles Have 100 Interpretation: No
strength of G Description percent of deviation from
upper and lower R normal strength normal.
extremities. A
D
E
5 100% of normal
muscle strength
4 75% of normal
muscle strength
3 50%of normal
muscle strength
2 25% of normal
muscle strength
1 10% of normal
muscle strength
0 0% of normal
muscle strength
Inspect the Bones No deformities During Interpretation: No

skeleton for inspection, deviation from
normal structure there are no normal.
and deformities. signs of
deformities or
misaligned
bones.
Palpate the bones No tenderness or During Interpretation: No

bones to locate swelling palpation, there deviation from
any areas of are NORMAL normal.
edema or edema or
tenderness. tenderness no
signs of
tenderness,ede
ma, or swelling
within bony
prominence of
the upper and
lower
Palpate each bones No tenderness, During Interpretation: No

joint for swelling, inspection and deviation from
tenderness, crepitation, or palpation, there normal.
smoothness of nodules. Joint are no signs of
movement, moves smoothly. swelling,
swelling, tenderness,
crepitation, and
presence of
nodules.
Joints Full range of Each joint in Interpretation: No
motion varies to the client's deviation from
some degree in body normal.
accordance with a can move
person's genetic completely
makeup and freely.
degree of physical In general, it
activity. varies from
person to
person and
from
joint to joint
depending on
their level of
physical
activity. The
following is a
breakdown of
the range of
motion for
each joint
joints Flexion – 45 Flexion – 45 Interpretation: No

degrees from degrees from deviation from
midline Extension midline normal.
– 45 degrees from Extension – 45
midline degrees from
Hyperextension – midline
45 degrees from Hyperextensio
midline Lateral n – 45 degrees
Flexion – 40 from midline
degrees from Lateral Flexion
midline Rotation – 40 degrees
– 70 degrees from from midline
midline Rotation – 70
degrees from
midline

degrees from the degrees from deviation from
side Extension – the side normal.
180 degrees from Extension –
vertical position 180 degrees
beside the head from vertical
Hyperextension – position beside
50 degrees from the head
side position Hyperextensio
Abduction – 180 n – 50 degrees
degrees from side
Adduction – 50 position
degrees Abduction –
Circumduction – 180 degrees
360 degrees Adduction – 50
External Rotation degrees
– 90 degrees Circumduction
Internal Rotation – 360 degrees
– 90 degrees External
Rotation – 90
degrees
Internal
Rotation – 90
degrees

degrees Extension degrees deviation from
– 150 degrees Extension – normal.
Supination and 150 degrees
Pronation – 70 to Supination –
90 degrees 90 degrees
Pronation – 80
degrees
joints Flexion – 80 to 90 Flexion – 90 Interpretation: No

– 80 to 90 degrees Extension – 88 normal.
Hyperextension – degrees
70 to 90 degrees Hyperextensio
Radial flexion – 0 n – 80 degrees
to 20 degrees Radial flexion
Ulnar flexion – 30 – 15 degrees
to 50 degrees Ulnar flexion –
50 degrees

– 90 degrees Extension – 90 normal.
Hyperextension – degrees
30 degrees Hyperextensio
Abduction – 20 n – 30 degrees
degrees Abduction – 20
Adduction – 20 degrees
degrees Adduction – 20
degrees
joints lexion – 90 Flexion – 90 Interpretation: No

– 90 degrees Extension – 90 normal.
Abduction – 30 degrees
degrees Abduction – 30
Adduction – 30 degrees
degrees Adduction – 30
degrees
joints Flexion – knee Flexion – knee Interpretation: No
extended: 90 extended: 90 deviation from
degrees; knee degrees; knee normal.
flexed: 120 flexed: 120
degrees Extension degrees
– 90 to 120 Extension –
degrees 120 degrees
Hyperextension – Hyperextensio
30 to 50 degrees n – 45 degrees
Abduction – 45 to Abduction – 45
50 degrees degrees
Adduction – 20 to Adduction – 45
30 degrees degrees beyond
beyond other leg other leg
Circumduction – Circumduction
360 degrees – 360 degrees
Internal Rotation Internal
– 90 degrees Rotation – 90
External Rotation degrees
– 90 degrees External
Rotation – 90
degrees
joints Flexion – 120 to Flexion – 128 Interpretation: No

130 degrees degrees deviation from
Extension – 120 Extension – normal.
to 130 degrees 128 degrees
joints Plantar flexion – Plantar flexion Interpretation: No

45 to 50 degrees – 48 degrees deviation from
Dorsiflexion – 20 Dorsiflexion – normal.
degrees 20 degrees
joints Eversion – 5 Eversion – 5 Interpretation: No

degrees Inversion degrees deviation from
– 5 degrees Inversion – 5 normal.
degrees
joints Flexion – 35 to 60 Flexion – 35 to Interpretation: No

degrees Extension 60 degrees deviation from
– 35 to 60 degrees Extension – 35 normal.
to 60 degrees
joints Flexion – 70 to 90 Flexion – 70 to Interpretation: No

degrees 90 degrees deviation from
Hyperextension – Hyperextensio normal.
20 to 30 degrees n – 20 to 30
Lateral Flexion – degrees Lateral
35 degrees on Flexion – 35
each side degrees on
Rotation – 30 to each side
45 degrees Rotation – 30
to 45 degrees
VI. Problem Identification and Prioritization
Nursing Diagnosis Cues Rank Justification according to ABC

or Maslows
Ineffective airway clearance 1 It is classified as the first

related to bronchospasm and priority because ineffective
excessive mucus production airway clearance can be
secondary to asthma as life-threatening and according
evidenced by respiratory rate of to Maslow’s Hierarchy of needs
30 cpm, wheezing use of this is under physiological
accessory muscles and needs, hence immediate
verbalized chest tightness intervention is needed.
Subjective cues:
● Reports of chest
tightness and difficulty
of breathing
● “Naninikip ang dibdib
ko at kinakapos ako ng
hininga”
● “Madalas akong
inaatake kapag
napapagod ako at
nakakalanghap ng
alikabok”
● “May mga oras na
nagigising nalang ako
bigla tapos di ako
makahinga”
Objective cues:
● Respiratory rate of 30
cycles per minute
● Wheezing sounds
● Usage of accessory
muscles when breathing
Disturbed sleeping pattern 2 Sleep is ranked second on

related to insufficient privacy as Maslow's Hierarchy of Needs
evidenced by unintentional because it is a physiological
awakening need, which needs immediate
intervention.
Subjective cues:
● The client verbalized
“hindi ako makatulog ng
maayos dahil maingay
yung mga kasama ko sa
dorm.”
● The client expresses that
he is not satisfied with his
sleep because it is
incomplete.
objective cues:
● The client appears to be
worn out.
● Presence of a dark circle
underneath his eyes.
● Frequent yawning.
Overweight related to shorten 3 It is classified as the third
sleep time as evidenced by priority because being
increased body mass index overweight may increase the
risk of developing serious
Subjective cues: disease or health conditions. it
● The client stated that he is under
gained weight during
the pandemic, from 55
kg to 75 kg.
objective cues:
● The BMI of the client is
over 27
Impaired home maintenance 4 It is classified as the fourth

related to insufficient family priority due to the Maslow's
organization as evidenced by Hierarchy of Needs stating that
excessive family poor family organization might
responsibilities be linked to poor home
maintenance since it exhibits a
Subjective cues: glaring misalignment of the
objective cues: client's family obligations.
Stress overload related to 5 Stress overload can be linked to

feeling of pressure as evidenced emotional security, which is a
by increase in anger behavior component of safety needs,
hence it is ranked as being of
Subjective cues: the lowest priority.
● Negative impact from
stress and Excessive
stress.
● "Pag stress ako,
sumisigaw nalang ako
bigla”
objective cues:
● The client’s anger issues
worsened
VII. Nursing Care Plan
Cues Nursing Analysis Goal and Intervention Rationale Evaluation

Diagnosis Objectives
Subjective: Ineffective A. Scientific Goal: Independent Outcome

- Reports of airway Analysis intervention: evaluation:
chest tightness clearance Short-term
and difficulty of Ineffective Within 8 1. Reduce the 1. Indoor The client
related to
breathing airway hours of amount ofenvironmen reported difficulty
- “Naninikip ang bronchospasm clearance is nurse-patient pollutants, tal breathing to be
dibdib ko at and excessive the inability such as dust, exposures, relieved or
interaction
kinakapos ako ng mucus to clear smoke, and such as controlled and
hininga” production secretions or and feather allergens demonstrates a
- “Madalas secondary to obstructions intervention, pillows. and relaxed body
akong inaatake asthma as from the the patient pollutants, posture with no
kapag napapagod respiratory will maintain 2. Encourage contribute utilization of
evidenced by a
ako at tract. This clear open the client to to asthma accessory
nakakalanghap respiratory rate can be airways and increase the morbidity. muscles when
ng alikabok” of 30 cpm, harmful to without use fluid intake Environmen inhaling and
- “May mga oras wheezing, use breathing of accessory of up to 3000 tal control exhaling.
na nagigising of accessory and cause muscles when ml/day within practices
nalang ako bigla complication cardiac have shown Met __
muscles, and breathing as
tapos di ako s. (Wagner, tolerance. that Partially met __
makahinga” verbalized 2022) evidenced. Provide the reducing Unmet __
chest tightness client warm exposure to
In relation, versus cold these
Objective: ineffective liquids as factors has
- Respiratory rate airway Objectives: appropriate. been an
Process
of 30 cycles per clearance integral
1. The client evaluation:
minute leads to 3. Encourage component
- Wheezing asthma would be able deep of asthma
- The nursing
sounds where to verbalize 4 breathing managemen
interventions
- Usage of bronchospas out of 5 exercises. t
were appropriate
accessory m and therapeutic (Abramson
to the condition
muscles when excessive 4. Pace the et al.,
regimen. of the patient as
breathing mucus activities of 2016).
they were
production the client.
carefully assessed
occurs which 2.
2. The client and planned
are key 5. Encourage Hydration is
specifically for
abnormalitie would be able the client to beneficial in
the patient's care.
s of asthma. to effectively cough. Teach preventing
demonstrate effective the
Bronchospas the proper coughing accumulatio
m is defined techniques. n of viscous
deep -The nursing
as the secretions
breathing and interventions
tightening of Dependent and
coughing were effective
the muscles intervention: improving
because they
that line your exercises to secretion
were planned and
lungs' improve 6. Maintain clearance
administered to
airways airway oxygen as (Nurse’s
the patient and
(bronchi). prescribed. pocket
clearance showed favorable
Your airways guide, p.
results that was
narrow when 7. Administer 30). Also,
reflected in being
these medications drinking
3. The client able to attain the
muscles and IV fluids warm fluids
would be able goals ans
contract. as ordered. may
objectives of the
Airways that to foster decrease
care plan. In
are too effective bronchospas
addition, the
narrow do coping m compared
patient
not allow as strategies to to cold
manifested the
much air to (Martin,
alleviate parameters listed
enter or exit 2022).
difficulty of in the objectives
your lungs.
breathing. which led to
This reduces 3. Deep
achieving the
the amount breathing
goal of having a
of oxygen in exercises
clear and
your blood contribute
unobstructed
and the to effective
airway.
amount of clearance of
carbon mucus out
-The nursing
dioxide out of the lungs
interventions
of your and it helps
were also
blood. in loosening
efficient because
Asthmatics excess
it also included
and allergy secretions.
nonpharmacologi
sufferers are Also, it
frequently provides the c interventions
affected by client the for the betterment
bronchospas means to of the patient that
m. It control and would help the
aggravates cope patient achieve
asthma dyspnea, the goals and
symptoms and objectives that
such as alleviate air were set.
wheezing trapping Furthermore,
and shortness (Martin, these methods
of breath. 2022). would not use and
(Watson, need other
2018) 4. Limiting resources which
the is proven to be
Due to the activities efficient not only
effects of into smaller for the patient,
asthma to the parts and but also for the
airways, taking a nurse and the
excess short break whole healthcare
mucus in between team.
production is necessary
occurs or for the
chronic prevention/r
sputum eduction of
production. fatigue and
This can be increased
an effort in
uncomfortabl breathing
e and correctly. In
irritating addition,
symptom as there are no
it can cause specific
coughing , limitations
wheezing of activities
and other for patients
symptoms diagnosed
depending on with
the cause and asthma;
severity however,
(Leader, they should
2022). avoid
exposure to
One can agents that
experience may worsen
the two their
health condition
problems if (Morris &
they Mosefinar,
experience 2022).
asthma as
they cannot 5. There are
get enough two
air and classificatio
cannot ns of
eliminate asthma:
mucus due to productive
the and
constricted non-product
airway. Any ive. A
swelling or productive
irritation in cough has
the airways been
can lead to associated
bronchospas beneficial to
m and excess people with
mucus asthma
production. because it
pushes the
B. mucus away
Situational from the
Analysis lungs
(Coastal
Based on the Allergy &
patient’s Asthma,
assessment 2022).
and Coughing
interview, the techniques
immediate could also
cause of the help in
patient’s removing
ineffective the
airway secretions
clearance is from
due to the smaller to
constriction larger
of lungs airways
airways since the
which is the coughing is
bronchi performed
cause by more
bronchospas effectively.
m and excess
mucus 6. Oxygen
production therapy can
wherein he decrease the
was risk for
diagnosed hypoxia.
with asthma. Oxygen
As saturation
mentioned in should be
the scientific maintained
analysis at 90% or
above, higher
asthma (Bhagol et
causes al., 2022).
bronchospas
ms, which 7.
result in the Administeri
constriction ng
of the medications
bronchi and as
the prescribed
accumulation by the
of mucus in Physician
the airways could relax
leading to smooth
ineffective respiratory
airway musculature
clearance. , reduce
airway
Root cause edema, and
The root mobilize
cause of the secretions
problem is (Nurse’s
the inability pocket
to control the guide, p.
signs and 30). Also, in
symptoms severe
brought by exacerbatio
asthma. ns, IV
Moreover, access is
being needed for
exposed to the
triggers such administrati
as dust and on of IV
fatigue also corticosteroi
lead to the ds and for
onset of this emergency
condition. medication
Furthermore, administrati
it is evident on
that the (Alangari,
patient has 2014).
eczema
which
according to
Cherney
(2020),
increases the
risk of
developing
asthma.
Moreover,
the patient
did not
utilize
prevention
measures in
order to
avoid the
triggering
and
worsening of
the condition
such as
wearing
personal
protective
equipment
(PPE). With
Cues Nursing Analysis Goal and Intervention Rationale Evaluation
Diagnosis Objectives
objective Stress Scientific Goal: Independent The client

● The overload analysis: intervention: reported stress
client’s related to Within 8 overload to be
anger feeling The hours of 1. To controlled and
issues pressure as sensation of nurse-patient assist demonstrates
worsened evidenced being interaction the the breathing
by overburden and client to exercise as
subjective increased ed or short-term determi coping
● Negative anger unable to intervention, ne the management
impact behavior handle the patient causativ with no
from mental or will be able e of the intensification
stress and emotional to manage stress. of stress.
Excessiv strain is his anger 2. to assist
e stress referred to issues the
● The as stress. without a bad client to
client There may coping deal the Met __
verbalize be physical mechanism. current Partially met
d “naiinis and mental situatio __
ako repercussio n by
kapag ns (Link, doing
maingay 2021). the
ang aking Anger may coping
paligid” result from Objectives: mechan
stress, 1. The ism will
which client be
might result will utilize
in further be 3. to
stress. able promot
Although to e
neither demo wellnes
emotion is a nstrat s
good thing, e
we breath Dependent
shouldn't ing intervention:
strive to exerci
force them ses to 4. To
away mana demons
(Scott, ge trate
2020). anger how to
issues do
. breathin
Situational 2. The g
analysis: client exercise
will s to
According be manage
to the able anger
patient's to issues.
assessment under
and stand
interview, the
the cause of effect
his anger s of
issues was stress
stress from 3. The
his client
schoolwork. will
be
able
to
value
good
copin
g
mech
anism
to
mana
ge
stress

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Far Eastern University – Manila

Nicanor Reyes Street,

INDIVIDUAL/ GROUP NURSING PROCESS FORMAT

III. NURSING HEALTH HISTORY

B. Past Health History

C. Obstetric History (For OB Patients ONLY)

A. HEALTH PERCEPTION AND HEALTH MANAGEMENT

Interpretation: Deviation from Normal

his mental state as a result of a lot of activity at school.

B. NUTRITION AND METABOLIC PATTERN

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Breakfast Pandesal Coffee. Corned N/A Instant Instant N/A

Lunch Spaghetti Pork Lumpiang Bicol Fried Fried 2 slices

Dinner Canned Burger Instant Bacon Shawa Giniling Chinese

Interpretation: Deviation from Normal

Analysis: According to the World Health Organization, to prevent unnecessary forms of

threat to health worldwide.

Reference: Fundamentals of Nursing by Kozier and Erb, page 2018

Monday Tuesday Wednesd Thursday Friday Saturday Sunday

Time 12:00 AM 12:00 AM 12:00 AM 12:00 AM 12:00 AM 12:00 AM 12:00 AM

Approx. 12:30 AM 12:30 AM 12:30 AM 12:30 AM 12:30 AM 12:30 AM 12:30 AM

Wake up 6:00 AM 6:00 AM 6:00 AM 10:00 AM 6:30 AM 6:00 AM 10:00 AM

Feeling Sleepy, Sleepy, Sleepy, Sleepy, Sleepy, Sleepy, Sleepy,

Naps 10:00 AM 11:00 AM 10:00 AM 2:00 PM - No nap No nap No nap

Activities Studying, Studying, Studying, Studying, Studying Studying, Studying,

Interpretation: Deviation from Normal

Interpretation: Deviation from Normal

F. SELF-PERCEPTION AND SELF MANAGEMENT

Interpretation: Deviation from Normal

Analysis: Self-management is the ability to control behaviors, thoughts, and feelings in a

G. ACTIVITY LEVEL AND EXERCISE PATTERN

3-DAY ACTIVITY RECALL:

BEFORE ASTHMA ATTACK

06:00 A.M. Wakes up in the morning

10:00 A.M. Wakes up in the morning

06:30 A.M. Wakes up in the morning

Interpretation: Deviation from Normal

H. VALUES AND BELIEFS PATTERN

I. SEXUALITY AND REPRODUCTIVE

J. ROLES AND RELATIONSHIP PATTERN

K. COPING-STRESS TOLERANCE PATTERN

GENERAL APPEARANCE & MENTAL STATE

Assessment Body Part Norms Actual Findings Analysis &

Observe body General appearance The Age: 20 years old Interpretation:

Observe General appearance The The client appears Interpretation: No

Note body and General appearance The There were no Interpretation: No

Assess the General appearance The Throughout the Interpretation: No

Note the General appearance The At the time of the Interpretation: No

Listen for General appearance The The client's speech Interpretation: No

Assess the General appearance The The client's Interpretation: No

b. Measurements (Height, Weight, BMI, Vital signs)

Body Temperature 36.5 °C

Pulse Rate 72 bpm

Respiration Rate 16 bpm

Blood Pressure 130/90 mmHg

Inspect skin Skin. The patient’s skin The Interpretation: No

Inspect Skin. The patient’s skin My client's Interpretation: No

Palpate skin Skin. The patient’s skin The client's Interpretation: No

Palpate to assess Skin. The patient’s skin On the client's Interpretation: No

Palpate to assess Skin. The skin turgor of When pinched, Interpretation: No

Inspect the Hair. The patient’s hair The patient's Interpretation: No

Inspect hair Hair. The patient’s The client's Interpretation: No

Note presence of Hair. Presence of In the patient's Interpretation: No