Вы находитесь на странице: 1из 42

I.

Biographic Data
Name: Ms. NAST
Age: 18 Sex: Female
Date of Birth: September 13, 1989 Place of Birth: Ilagan, Isabela
Ethnic Group:
Primary Language Spoken: Filipino
Other Dialect Spoken: Ilocano, Ibanag
Civil Status: Single
Highest Educational Attainment:Second Year College, BS Nursing
Religion: Methodist
Health Care Financing and Usual Source:

II. Nursing History


A. Past Health History
According to the client, she had chicken pox and measles when she was 9 years old. She had no allergies occurred
yet. She has not met any accident. She had been hospitalized due to pneumonia when she was 8 years old for a
week. She has a complete set of immunization such as BCG, DPT, OPV, Hepatitis B vaccine, and AMV aside from
an ongoing adult immunization of Hepatitis B vaccine.

B. Present Health History


The client is taking ferrous sulfate 2 times a week but sometimes she told to us that she forget to take her vitamins.
She encountered pyrexia a high fever with 380 degree Celsius last semester and she takes biogesic every 4 hours.

C. Family Medical History

III.Patterns of Functioning

A. PSYCHOLOGICAL PATTERN
The major stressors in the client’s life right now are the school requirements that are needed to be
passed. The major stress that she had experience was when she had a problem regarding her relationships with
significant people in her life. Like when she had a fight with her best friend, Broke up with her boyfriend and when
her mother went to states to work. Her usual coping pattern with a serious problem or a high level of stress is
travelling to an unfamiliar place and she really enjoys it and she tends to forget her problems. She verbalized
appropriate emotions and even the non-verbal ones.
She is very optimistic person. She always looks at situations positively and maintains a positive outlook
in her life. Her most problematic mood is depression because she really feels down when she has problems. She gets
hurt when her ego is really harmed, But most of the time she tries to be patient with what’s going on in her life. Her
previous patterns of handling stress, she plays guitar and sings a song to relieve pain.

Analysis:
Individuals with positive concept are better to develop and maintain warm interpersonal relationship and
resist psychological and physical illness. Adaptive coping helps the person to deal effectively in stressful events and
minimize distress associate with them.
Fundamentals of Nursing 5th ed., Taylor, pg. 802,832

Interpretation:
The client has a positive outlook in life and maintains a constant communication with the significant
person in her life.

B. SOCIOCULTURAL PATTERN

The client’s support system are her family, friends and bible study group mates in times of stress his
father has diabetes and now her father’s kidneys are not as healthy as before it really affects her because her father is
important in her life & she feels sad whenever they talk about it.
She believes that health is very important to human so she takes good care of her health. Her highest
level of education is second Year College & she hasn’t experienced any difficulty in learning. She doesn’t have any
physical disability so she can work efficiently. She goes to school everyday and considers it as her activities of her
daily living. Her neighborhood & community services are available to meet her needs.

Analysis:
Family has functions that are important in how individual members meet their needs and maintain their
health. The family provides an individual with the necessary environment for discomfort and social interactions.
Fundamentals of Nursing, 5th edition, Taylor, pg.29

Interpretation:
The client has a good relationship with her family, friends and society where she belongs.
C. SPIRITUAL PATTERN

With regards to the spiritual pattern of the client, she has a good relation with god. She has a bible and
she enjoys reading it. She goes to the university chapel before meals and at other times of her life. She goes to the
university chapel before she attends the class everyday. She belongs to the Christian family. Her parents raised her
as a God fearing person and to be active in church services.
She views life as a sacred blessing from God. Life really means a lot to her & she lives it wisely &
fruitfully. For her, she must make the most out of her life, and live a life with deep meaning. She fears death because
she’s still young and she plans to do more in her life. She still needs to improve herself for her parents & society
around her. She believes that God is the Supreme Being and she strongly believes that every person needs his
guidance.

Analysis:
Spiritual and religious beliefs are important in many people’s lives. They can influence lifestyle, attitudes
and feelings about illness. Religions have central beliefs, rituals and practices usually related to death, marriage and
salvation. Many people satisfy their spiritual needs through a specific or religious framework.
Fundamentals of Nursing, 5th ed., Taylor, 311-322

Interpretation:
The client is a Methodist who has a personal relationship with God. She attend Bible study every week
and follows her religion faithfully.

D. ACTIVITY OF DAILY LIVING

Health Perception and Management


According to the client, health is a complete well being, can functions property everyday and does not
suffer from any illness or a disease that alters her daily routine. She describes herself as healthy and she function
well and she does not feel anything wrong with herself. She maintains her health by making sure that she eats three
times a day. She does not smoke and take drugs but she drink’s alcohol beverages occasionally. She also eats fruits
and considers herself not a soda drinker. According to her, current medications she takes ferrous sulfate for her
anemia and if she has menstrual period she takes mefenamic acid to ease or relieve the pain she feels because of
dysmenorrhea. She has no allergies. Before and after menstrual period, she does self-breast examination to check if
there’s any tenderness in her breast. Her father has diabetes and undergone operation for his gal stones and kidney
stones. She is aware that they have history of hypertension. As she describes her environment at home, she
verbalized “malinis naman kung saan ako nakatira. I live with my cousin, the house caretaker and her son. Apat
kami sa bahay, komportable naman kung saan kami nakatira at sinisiguro naming na malinis ang bahay. Araw-araw
kami nagwawalis at hindi kami nagtatambak ng hugasing plato”. According to the client, she takes a bathe three
times a day, brushes her teeth two times a day. “After my breakfast and before ako matulog ako nagto-toohtbrush.
Nagsusuot ako ng slippers, I also use hygienic products like shampoo, soap and other kikay condiments.”

Analysis:
Health is defined as state of complete physical, mental, emotional, and social well-being, and not merely
the absence of disease. (WHO, 1948)
Health is defined as in terms of role and performance “health is the ability to maintain normal roles,”
according to Talcott Parson. (1951)
Fundamentals of Nursing, Kozier, pg. 171

Interpretation:
Based on the client’s statements, the client fully understands the meaning of health. The client also
knows the proper ways on how to keep herself healthy and clean. She also knows what type of medications she
would take for her illness. The client also has a tendency of acquiring hypertension because they have a history of
hypertension in their family. The client also has knowledge on self-breast examination. Overall, the client is aware
about her health.

E. Nutrition and Metabolic Pattern


When asked regarding the nutrition and metabolic pattern, the client verbalized, “I usually eat thrice a
day, as in umagahan, tanghalian and hapunan. Starting ngayong summer class (2008) namin sa FEU (Far Eastern
University -- Manila), nadedelay na ako sa time ng pagkain dahil sa hectic class schedule ko pero I still make it to a
point na thrice a day pa din ako kung kumain. Two meals lang ako kung kumain ng rice, usually breakfast and lunch
tapos hindi ako nagra-rice kapag dinner kasi more on coffee lang ako. Feeling ko din super unhealthy nung mga
kinakain ko kasi usually mga galing sa fastfood chains (Mc Donalds), except sa dinner ko kasi nagluluto naman tita
ko sa bahay. Laging burgers saka pasta yung ino-order ko dun. Kapag nasa apartment naman ako, I usually eat fruits
and veggies, siguro mga 5 meals a week. Sa fluid intake naman, hindi ko namomonitor, eh kasi I drink when
everytime I feel thirsty saka every after meals. I am a coffee lover, nakaka two to three cups ako sa isang araw.” She
also verbalized “Gusto kong baguhin yung eating patterns at saka yung quality ng food na kinakaen ko. Mas
maganda sana kung healthy yung kinakaen ko araw-araw para ma-improve yung health ko.” The client also said
that she has no eating disorder because she can eat properly. and she is also taking Ferrous Sulfate as her food
supplement. Nutrition, according to her, is simply eating healthy foods. She also verbalized “I like to eat foods na
hindi masabaw kasi nakakatamad kainin, e. I don’t like to eat oily foods naman lalo na yung mga taba ng kahit
anong karne. Kahit madalas karne yung kinakain ko saka mga burger. Hindi ako kumakain ng ampalaya, labanos
saka talong. Tapos yung mga iba nang mga gulay, yun na yung mga kinakain ko.” According to her, she is not the
one who prepares her food. It is her auntie who cooks her meals when she eats at home. She usually eats with her
auntie and their housekeeper. When she is at school, she eats in fastfood chains with her friends. Her typical food
intakes are fried foods. “I gained weight, 2 lbs. to be exact, hindi ako nawawalan ng gana kumain. There’s no
problem with my skin and I don’t have skin allergy due to foods,” she added. She wears dental braces that she
started wearing when she was in her third year high school, which is three years ago from now. According to her,
she does not feel any eating discomforts.

Three Day Diet Recall


MONDAY TUESDAY WEDNESDAY
BREAKFAST 4 slices bread 2 packs of Pancit 1 cup rice
300 ml of coffee Canton 1 fried egg
Chilimansi 1 burger patty
300 ml of coffee 100 ml of coffee
LUNCH 1 cup rice 1 serving of 1 chicken burger
1 piece fried spaghetti 250 ml iced tea
chicken leg 250 ml iced tea 1 regular sized
250 ml iced tea French fries
DINNER 1 cup rice 1 cup rice 1 cup rice
4 matchbox cut 1 serving of 1 serving of Pork
pork adobo chopsuey Sinigang
1000 ml of water 1000 ml of water 750 ml of water
300 ml of ice cold 200 ml of ice cold 100 ml of ice cold
coffee coffee coffee

Analysis:
Certain lifestyles are linked to food-related behaviors. People who are always in a hurry probably buy
convenience grocery items or eat restaurant meals. People who spend many hours at home may take time to prepare
more meals “from scratch.”
Fundamentals of Nursing, Kozier, pg. 1176

Interpretation:
The client has an imbalanced nutrition due to her busy school activities. She is spending most of her
time in school than staying at home. Her main sources of food are fastfood chains whenever she has classes. She is
always eating burger and pasta. When she is at home, the housekeeper is the one preparing her meals.

F. Elimination Pattern
When the client asked regarding the frequency of her elimination, she verbalized, “I defecate, siguro
mga 4 times a week. Tapos in a day, hindi ko matandaan kung ilang beses ako kung umihi, pero sa tancha ko mga 5
times a day, basta pagkagising saka bago ako matulog talagang naihi ako”. She characterized her stool as soft,
purigent and color brown while her urine as amber, transparent and aromatic. With regards to her elimination
patterns, she also verbalized, “Hindi naman ako nakakarmdam ng discomfort when I’m doing these activities”.
During the interview, the client is not sweating.

Analysis:
The act of defecation is usually painless. If the bowels move at regular intervals and the stools are
formed and soft, functional problems involving frequency of elimination seldom occur. Many people become
concerned if they do not have a daily bowel movement, but there is no “normal” frequency of bowel movements.
Although many adults pass one stool each day, other healthy people have more frequent or less frequent bowel
movements. Some people have a bowel movement two or three times a week; others, two or three times a day.
Fundamentals of Nursing, Taylor, pg. 1340

Interpretation:
Based on the client’s statement, her elimination pattern is normal because she defecates four times a
week and urinates five times a day. In addition to this, she describes her feces as soft that is why she does not feel
any discomfort during elimination.

G. Activity – Exercise Pattern


The client describes her weekly pattern of activities and leisure, exercise and recreation as satisfying in
the sense that she feels good about her weekly accomplishments. She verbalized, “lagi akong pagod dahil sa school
activities ko, lakad ng lakad, walang time magpahinga”. According to her, she has no disease that affects her cardio-
respiratory system or her musculo-skeletal system. She allots 30 minutes of her time every morning to stretch out or
have some exercise which makes her really feel good and refreshed. When asked if she has sufficient energy for
completing desired or required activity, she verbalized, “hindi masyado, lagi kasing puyat at sobrang stressed out
ako”. She plays computer games and guitar with spare time.

Activity Plan
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
6:00- Do morning Do morning Do morning Do morning Do morning Sleep Sleep
6:30 exercise exercise exercise exercise exercise
6:30- Watch Watch Watch Watch Watch
7:30 television television television television television
7:30- Eat breakfast Eat breakfast Eat breakfast Eat breakfast Eat breakfast Eat Eat
8:00 breakfast breakfast
8:00- Read notes Read notes Read notes Read notes Read notes Take a Take a
8:30 bath bath
8:30- Take a bath Take a bath Take a bath Take a bath Take a bath Prepare Prepare for
9:00 for school school
9:00- Prepare for Prepare for Prepare for Prepare for Prepare for Attend Attend
9:30 school school school school school Bible Bible study
study
9:30- Travel to Travel to Travel to Travel to Travel to
10:00 school school school school school
10:00- Attend Attend Attend Attend Attend Watch Watch
1:00 Microbiology Microbiology Microbiology Microbiology Microbiology television television
& & & & & and and browse
Parasitology Parasitology Parasitology Parasitology Parasitology browse the internet
class class class class class the
internet
1:00- Eat lunch Eat lunch Eat lunch Eat lunch Eat lunch Eat lunch Eat lunch
1:30
1:30- Attend PSTL Attend PSTL Attend PSTL Attend PSTL Attend PSTL Watch Watch
3:20 class class class class class DVD/TV DVD/TV
3:20- Read notes Read notes Read notes Read notes Read notes
4:00
4:00- Attend NCM Attend NCM Attend NCM Attend NCM Attend NCM Go to the
7:00 101 class 101 class 101 class 101 class 101 class mall
7:00- Travel home Travel home Travel home Travel home Travel home Rest
8:00
8:00- Rest Rest Rest Rest Rest Eat dinner
8:30
8:30- Eat dinner Eat dinner Eat dinner Eat dinner Eat dinner Eat Read
9:00 dinner notes/Do
9:00- Read Read Read Read Read Play homework
12:00 notes/Do notes/Do notes/Do notes/Do notes/Do guitar
homeworks homeworks homeworks homeworks homeworks
12:00- Sleep Sleep Sleep Sleep Sleep Sleep
6:00

Analysis:
Exercise is a physical activity for the purpose of body conditioning, improving health and maintaining
fitness or it may be used as a therapeutic measure.
Fundamentals of Nursing 5th edition, Potter & Perry, pg. 941

Interpretation:
The client is satisfied with her everyday activities because she has many accomplishments that make her
feel good inspite of her busy schedule. The reason why she does not have any respiratory or circulatory diseases is
because she exercises daily. Based on the client’s statement, because there is time allotted to exercise everyday and
there are no cardio-respiratory and musculo-skeletal diseases

H. Cognitive Pattern
When asked regarding to the client’s learning abilities, she verbalized, “I easily learn naman. Wala
naman akong problems with my mental function pero sa sight, meron. I have an astigmatism kaya nga I wear
eyeglass to correct this deficit.” According to her, she had her last eye check-up last 2 months ago. Her easiest way
of learning things is through reading and understanding what she is reading. “So far hindi pa naman ako nahihirapan
matuto,” she added.

Analysis:
Cognitive awareness is the ability to perceive environmental stimuli and body reactions and to respond
appropriately through thought and action.
Fundamentals of Nursing, Kozier, pg. 671

Interpretation:
The client wears eyeglasses because she has a problem in her sight. She has astigmatism that is why she
has to wear eyeglasses to correct that deficit. She does not have any learning difficulty because she can acquire
things easily. Reading helps her in learning things because she can gather much information from it.

I. Self Perception/ Self Concept


The client describes herself as a simple individual who always feels good about herself. She said that
she is very much comfortable and contented with the way she looks. She is always happy and feels great all the time
despite of having busy schedule. She is quiet most of the time and gets tactless whenever she is angry. She gets
angry when she is pressured and tired. Her goals for the next 5 years are to finish her college, then pass the nursing
board and hopefully get a job so she can help her family. She would always want to be with her family and she also
wants to be with someone who could get along with her easily. She expresses herself when her mood changes by
being quiet and not talking at all.

Interpretation:
The client has a good perception and positive concept about herself despite of having a hectic schedule.
She has a great self- esteem and self- confidence.

Analysis:
A positive self- concept is essential to a person’s physical and psychologic well- being. When
individuals are able to conceptualize the self, they begin a life long process of deciding whether and to what extent
they are valuable and worthy.
Fundamentals of Nursing, Barbara Kozier, pg. 970

J. Rest and Sleep Patterns


According to client, she usually spends 4-6 hours in sleeping. She verbalized, “depende kasi, kung
matulog kasi ako, either 12 or 2 in the morning tapos kung magising naman mga 6 in the morning. I am well aware
that I have a sleeping disorder kasi nga I find it difficult to fall asleep. Kaya lang, I don’t really have any idea kung
anong specific sleeping disorder ang mayroon ako.” According to her, her usual bed routines are playing guitar and
reading science fictional books which helps her sleep. Her sleep is not interrupted at night but still does not feel
satisfied with the amount of sleep she gets and does not also feel refreshed and nice when waking up. When asked
regarding her naps, the client verbalized, “wala no, di uso yun… walang time umidlip saka kapag umidlip man ako,
hirap na ko makatulog sa gabi...” Her sleeping environment is well-ventilated and has an adequate space as
observed. When asked regarding her sleeping environment, the she verbalized, “double deck yung bed ko pero sa
babang deck ako natutulog. Foam yung hinihigaan ko with six pillows at isang blanket. Although very comfortable
it may seem, hindi pa din ako ganun kabilis makatulog”.

Analysis:
8 hours of sleep a night has been the accepted standards for adults. It is important, however, that each
person follow a pattern of rest that maintains well-being.
Adults average sleep is 7 to 9 hours. Those who are able to relax and rest easily, even while awake,
often find that less sleep is needed, whereas others may find that more sleep is required to overcome fatigue.
Sleep patterns of older adults vary. However, older people often need more time to fall asleep, wake
earlier, and more frequently during the night, and are less able to cope with changes in their usual sleep patterns than
younger people are.
Fundamentals of Nursing, Taylor, pgs. 1172-1173

Interpretation:
The client sleeps only for 4-6 hours only because she finds it hard to sleep at night due to excessive
amount of coffee intake and also because of too much school requirements. When she wakes up in the morning, she
does not feel refreshed because she did not get enough sleep which makes her feel sleepy during daytime.

K. Role-Relationship Pattern
The client belongs to nuclear family. It is composed of 5 family members. She is the eldest child and
has two younger siblings, a boy and a girl. She lives in Manila with her auntie, and the housekeeper. Her and her
family lives in the province of Isabela. The client verbalized, “First time ko lang malayo with my family at yun ay
simula nung nag-college ako.” The significant persons in her life are her family and friends. She has a good
relationship with her family because they are close to each other and talk about all matters. She plays the role of
being a good daughter to her parents and a good sister to her siblings. She actually fulfills her role by
communicating with them even though they are living apart. They have some family problems with regards to their
finances. There were times that their resources are insufficient because of high cost of tuition fee. Whenever they
have problems they talk about it and discuss it with the whole family so that they can solve it easily. Her relationship
with her family and friends are the most significant and important relationships in her life. Their usual activities are
going to church, eating together and having recreational activities. The client belongs to a bible study group that
serves as her support system.
Analysis:
Families that communicate effectively transmit messages clearly. Members are free to express their
feelings without fear of jeopardizing their standing in the family. Family members support one another and have the
ability to listen, emphatize, and reach out to one another in times of crisis.
Fundamentals of Nursing, Kozier, pg. 193

Interpretation:
Based on the relationship pattern of the client, she has a good relationship and open communication
with all her family members. One of the problems they encounter is about financial problem due to some payment in
her school like the tuition fee. When it comes to family problem, they discuss it with all of the members of the
family to be able for them to solve it.

L. Role Sexuality-Reproductive Pattern


The client expresses herself as a woman by just being simple with her acts and gestures. She doesn’t
have any difficulty/ problems in expressing her sexuality because she is satisfied and contented of what she is. She
shows affection to other by showing them that they are loved and cared and by being with them all the time. With
regards to her reproductive system, she menstruates regularly and usually around 7 days but she experiences
dysmenorrhea every month. “Pag meron ako, super sakit talaga ng puson ko, tapos nahihilo ako, pinagpapawisan ng
malamig, masakit ang ulo ko. Suffering talaga pag meron ako”.

Analysis:
At day 28, menses, or the menstrual flow, begins as a result of the uterus, shedding the useless portion
of its endometrium. Menses lasts for 3 to 7 days, the average length of flow being 5 days.
Fundamentals of Nursing, Taylor, pg. 933

Interpretation:
Based on the client’s statement, she menstruates regularly which is usually for about 7 days but she
experiences dysmenorrheal every month which is not normal among women.

M. Values And Belief


She was raised by her parents to become God-fearing person that’s why she grow up to be a religious
person. She is a very religious person, she makes sure that she maintains a strong relationship with God and she
believes that by this practice she’ll have a great flow of life. According to her, she practiced to be always prepared in
everything that she might encounter, this is very important for her before, now and in the future. She joins a bible
study every Thursday and she considers it as her support system. She sees herself as a good citizen in the society.
She makes sure that she follows the rules properly.

Analysis:
Spirituality shapes the self-becoming and is reflected in one’s being, knowing and doing. Spirituality
permeates life, providing purpose, strength and guidance and shaping the journey. Cultivate wisdom and helps us
find meaning in life, be in relationship with others, be true to ourselves, live in uncertainty and mystery, deal with
suffering, sickness, and honor life transitions. Cultivate awareness of the sacred dimension of life through practices
such as worship prayer, meditation and singing. Help us be generous in service to others. Respect our
connectedness as fellow human being.

Interpretation:
The client has her own values and beliefs in accordance on how she deals with her life.

N. Coping Stress
According to the client, her most stressful event is when there’s too many school works and
requirements. She copes with her problem by playing the guitar, singing and travelling to different places where she
has never been before. These activities really help her a lot and she doesn’t take any medication for emotional
distress. She doesn’t feel any tension at all. Her best friend is the one who helps her in taking things over. According
to the client, she and her best friend are only one call away from each other. The big change she considers in her life
tooks place last year during her first year in college, it was her first time to live in Manila. It was very hard for her to
adjust which took her 1 year and another big change was when her mother decided to wok in United States of
America.

Analysis:
Stress is a part of life: everyone feels stress at one time or another. Feeling “stressed out” is common,
and taking “stress breaks” to do physical exercise is recommended in many work settings. The experience of stress
and the ways have responds to it are unique to each individual. The process of responding to stress is constant and
dynamic and is essential to the person’s physical, emotional, and social well-being. Stress and adaption are major
components in health and illness.
Fundamentals of Nursing, Taylor, pg. 849

Interpretation:
The client is not that much stressed because the one that she is experiencing is common among students.
A major factor causing her stress was the change in environment. She was used in living at the province of Isabela
and had to move in Manila because of her studies. Basically, a student in distress needs to unwind in order to be
refreshed. On the case of the client, her ways of freeing herself of hassle and bustle were to play the guitar, to sing
and to go to places she has never been before. She is the kind of person, who would stick to her peers, specifically
her bestfriend unlike other students who would undergo medications just to cope up with stress.

II. PHYSICAL ASSESMENT


Client: Nicolle Ann S. Tandayu
Vital signs:
Behavior Actual Findings Normal Findings Analysis Interpretation
Temperature 36.90 C 36.50 – 37.50 C normal Her temperature is
within the normal
range.
Pulse Rate 75 beats per minute 60 – 100 bpm normal Her pulse rate is
within the normal
range.
Respiratory Rate 19 breaths per minute
Blood Pressure 110/80 mmHg 120/80mmHg abnormal Her blood pressure
does not meet the
normal findings. She
has a low blood
pressure.

Temperature: 36.90 C
Pulse Rate:
Respiratory Rate: Blood Pressure: 110/80 mmHg
Behavior Actual Findings Normal Findings Analysis Interpretation
Height 168.92 cm. BMI : 21
Weight 59 kg.

General Survey
Describe the body built, Proportionate weight to Proportionate weight to normal Her BMI is in normal
height & weight in height. BMI is 21. height. range which is from 18-
relation to the client’s (Fundamentals of 24.5.
age, lifestyle and health. Nursing: The Art of
Nursing Care by Taylor
et. al. P. 571)

Describe the client's Relax and erect posture Relax and erect posture normal The client stands in
posture, gait, standing, Coordinated movements with Coordinated erect posture, she sits
sitting & walking. movements. relax and walks
(Fundamentals of coordinately.
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 571)
Describe the client over Clean and neat Clean and neat normal The client doesn’t have
all hygiene and (Fundamentals of stain or any kind of dirt
grooming. Nursing by Kozier p. in her dress.
531)
Describe body and No body odor and No body odor and normal The client’s breath
breath odor breath odor breath odor doesn’t smell like
(Fundamentals of acetone.
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 571)
Identify signs of No distress noted No signs of distress. normal The patient is not
distress, in posture of (Fundamentals of bending and no labored
facial expression Nursing by Kozier p. breating.
531)
Identify obvious signs Healthy appearance; no Healthy appearance normal The client’s color is not
of heath or illness signs of illness. (Fundamentals of pallor. She looks alive
Nursing by Kozier p. during the assessment.
531)
Describe the client's cooperative Cooperative normal The client is cooperative
attitude Healthy appearance during the activity/
(Fundamentals of assessment.
Nursing by Kozier p.
531)
Describe the client's Responses appropriately Appropriate response to normal The client responses
affect/mood; assess the the situation appropriately to the
appropriateness of the Healthy appearance questions asked to her.
client's response (Fundamentals of
Nursing by Kozier p.
531)
Describe the quantity voice is clear and Understandable, normal The client’s voice is in
and quality of speech understandable; moderate pace; exhibits moderate pace. She
moderate pace thought association speaks clearly and
Healthy appearance understandable.
(Fundamentals of
Nursing by Kozier p.
531)
Listen for relevance and The response has sense Logical sequence; normal The client’s responses
organization of thoughts and relevant to the makes sense and has have sense and there is
question. sense of realty no confusion.
Healthy appearance
(Fundamentals of
Nursing by Kozier p.
531)
Integumentary
SKIN
Inspect for color; Fair skin complexion, Ranging from pinkish normal The client’s skin color is
uniformity of color. uniform. Skins that are white to various shades light brown and she
normally expose is a of brown. Skin color doesn’t have
little darker. relatively constant discolorization.
except skin ares that are
normally exposed.
(Fundamentals of
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 572)

Inspect for presence of No edema No edema normal The client doesn’t have
edema. (Fundamentals of a presence of edema.
Nursing by Kozier p. There is no are that
538) appears swollen, shiny
and taut.
Inspect for lesions No lesions, has birth Freckles, some birth normal The client doesn’t have
according to location, mark on left shin. marks, some flat and an alteration in her
color, size and shape raised nevi; no normal skin appearance.
abrasions or other
lesions.
(Fundamentals of
Nursing by Kozier p.
538)
Palpate skin moisture No excessive moisture Moisture in skin folds normal The client doesn’t have
and no excessive and the axillae. excessive moisture in
dryness. (Fundamentals of her ski folds or
Nursing by Kozier p. excessive dryness.
539)
Palpate skin temperature Warm and uniform Uniform temperature normal The temperature of her
within normal range. skin is warm and
(Fundamentals of uniform.
Nursing by Kozier p.
539)
Palpate skin turgor When pinched skin When pinched skin normal The client’s skin springs
springs back on its springs back to previous back immediately when
original state state. pinched.
(Fundamentals of
Nursing by Kozier p.
539)
Nails
Inspect fingernails plate Convex curvature; angle Convex and should normal The client’s fingernail
shape to determine its of nail plate is about follow the natural curve shows a convex shape
curvature and angle 160 degrees of the finger. Angle and the nail plate angle
between the nail and is about 160 degrees.
base of the finger should
be about 160 degrees.
(Fundamentals of
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 574)

Inspect fingernails and Pink in color and highly Highly vascular and normal The client’s fingernails
toenail bed color vascular pink in light skinned and toenail bed is pink
people; dark skinned in color highly vascular.
people may have brown
or black pigmentation.
(Fundamentals of
Nursing by Kozier p.
543)

Palpate fingernail and Smooth and firm Smooth firm and normal Her fingernails and
toenail texture nontender. toenails texture is
(Fundamentals of smooth and firm
Nursing: The Art of because
Nursing Care by Taylor
et. al. P. 574)
Inspect tissue Intact epidermis Intact epidermis normal The tissue surrounding
surrounding nails (Fundamentals of her fingernails and
Nursing by Kozier p. toenails is intact because
543) there is no
inflammation.
Perform blanch test of Prompt return on usual Prompt return of pink normal Her nail bed capillaries
capillary refill color color blanch when pressed but
(Fundamentals of quickly turn pink when
Nursing by Kozier p. pressure I released.
543)
Head
Skull
Inspect the skull for Rounded, smooth skull Symmetrical. Gently normal The client’s skull is
size, shape, or contour curved with rounded and has a
symmetry prominences at frontal smooth contour.
and parietal bones.
(Fundamentals of
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 574)

Palpate for nodule, No nodules, masses or Smooth, uniform normal The skull of the client
masses and depressions depressions consistency; absence of has no nodules, masses
nodules or masses. or depressions.
(Fundamentals of
Nursing by Kozier p.
544)
Scalp
Inspect for color and Lighter than the color of Lighter on the usual normal Her scalp color is lighter
appearance the face color of the skin. than the color of her
(Fundamentals of face
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 574)
Palpate for areas of No tenderness No tenderness normal Her scalp has no
tenderness (Fundamentals of tenderness.
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 574)
Hair
Inspect for evenness Evenly distributed, thick Resilient, evenly normal The client’s hair is
growth, thickness or black hair. distributed, neither dry evenly distributed and
thinness nor oily. thick.
(Fundamentals of
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 574)
Palpate for texture and Smooth, straight and Resilient, evenly normal The texture of her scalp
oiliness over the scalp neither dry nor oily. distributed, neither dry is smooth. Her hair is
nor oily. straight and neither dry
(Fundamentals of nor oily.
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 574)
Face
Inspect the facial Symmetrical feature and Symmetrical' even normal The client’s facial
feature, symmetry of movement; moles are distribution of facial feature and facial
facial movements present. Uniform in on hair and uniform in movements is
color color. symmetrical. There is a
(Fundamentals of presence of moles. She
Nursing: The Art of has uniform facial color.
Nursing Care by Taylor
et. al. P. 576)
Eyes
Eyebrows
Inspect of hair Symmetrical, evenly Equal distribution; normal The hair in client’s
distribution, alignment, distributed, black in parallel alignment. eyebrows is evenly
skin and quality and color, equal movement (Fundamentals of distributed, black in
movement Nursing: The Art of color and equal in
Nursing Care by Taylor movement.
et. al. P. 577)
Eyelashes
Inspect for hair Evenly distributed, Equal distribution, normal The client’s eyelashes is
distribution and curled outward curled outward. evenly distributed and
direction of curl (Fundamentals of curled outward.
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 577)
Eyelids
Inspect for the surface Skin intact, no Skin intact, no normal Her eyelids’ skin is
characteristics, position, discharges and discharges and intact, no discharge and
in relation to the cornea, discoloration, discoloration, discolorization. It is
ability to blink and symmetrically 15-20 symmetrically 15-20 symmetrically blinks
frequency of blinking blinks per minute. Close blinks;lids close 15-20 times per minute.
symmetrically symmetrically; upper It is close
and lower boundaries of symmetrically.
cornea are slightly
covered.
(Fundamentals of
Nursing by Kozier p.
548)
Conjunctiva
Inspect the bulbar Transparent with minute Transparent; capillaries normal The client’s bulbar
conjunctiva for color, capillaries, no presence sometimes evident. conjunctiva is
texture, and presence of of lesions (Fundamentals of transparent in color with
lesions Nursing by Kozier p. minute capillaries, and
548) there is no presence of
lesions.
Inspect the palpebral Pink in color, no lesions Shiny, smooth, pink or normal Her palpebral
conjunctiva for color, and shiny. red. conjunctiva is color
texture, and presence of (Fundamentals of pink, smooth and shiny.
lesions Nursing by Kozier p. There is no presence of
548) lesions.
Sclera
Inspect the color and White in color, clear White in color, clear. normal The client’s sclera is
clarity (Fundamentals of white in color and clear.
Nursing by Kozier p.
550)
Cornea
Inspect for clarity and Transparent, smooth andTransparent, smooth and normal The client’s cornea is
texture shiny clear, no shiny, details of the iris transparent, smooth,
irregularities are visible. shiny and clear. There
(Fundamentals of are no irregularities.
Nursing by Kozier p.
550)
Iris
Inspect for color and Brown in color, round Flat and round normal The client’s iris is brown
shape and flat. (Fundamentals of in color, round and flat.
Nursing by Kozier p.
550)
Pupils
Inspect for color, shape Black in color; they are Black in color; equal in normal The client’s pupils are
and symmetry of size equal in size size black in color and they
(Fundamentals of are equal in size.
Nursing by Kozier p.
550)
Visual Acuity
Test near vision Able to read newsprint. Able to read newsprint. normal The client was able to
(Fundamentals of read newsprints.
Nursing by Kozier p.
552)
Test distant vision 20/20 vision without 20/20 vision normal The client’s vision is
glasses (Fundamentals of 20/20 without glasses.
Nursing by Kozier p.
552)
Pupils
Test each pupil for light Illuminated constrict; Pupil Equal Round and normal The client’s pupils
reaction and non illuminated dilate; reactaed to Light and constrict when
accommodation viewing nearer object Accommodation illuminated and dilate
constrict; viewing (Fundamentals of when non-illuminated.
farther object dilate Nursing by Kozier p.
550)
Lacrimal Gland,
Lacrimal sac,
Lacrimal duct
Inspect and palpate the No excessive tearing no edema or tearing. normal The client has no
lacrimal gland and no edema (Fundamentals of excessive tearing and no
Nursing by Kozier p. edema.
550)
Extraocular Muscle
Test for each eye for Coordinated movements Both eyes coordinated, normal The client’s both eye is
alignment and of the eye. move in unison,with coordinated, move in
coordination parallel alignment. unison and with parallel
(Fundamentals of alignment.
Nursing by Kozier p.
552)
Visual Field
Test for peripheral fields When looking straight When looking straight normal When looking straight
ahead, the client can see ahead, the client can see ahead, the client can see
the object in periphery the object in periphery objects in periphery.
(Fundamentals of
Nursing by Kozier p.
551)
Ears
Auricles
Inspect for color Color same as the facial Color same as the facial normal The client’s auricle is
symmetry and position color, symmetrically color, symmetrical with same color to her
aligned the with outer auricle aligned with face, symmetrically
canthus of eye. outer canthus of eye, aligned to the outer
about to form vertical. canthus of her eyes.
(Fundamentals of
Nursing by Kozier p.
556)
Palpate for texture, Mobile, firm and tender, Mobile, firm and tender, normal Her auricles are mobile,
elasticity and areas of pinna recoils when it is pinna recoils when it is firm and tender. Her
tenderness folded folded pinna recoils when it is
(Fundamentals of folded.
Nursing by Kozier p.
556)
External ear canal
Inspect ear canal for Ear canal is pink and Ear canal should be normal The ear canal is pink
cerumen, skin lesions, shiny. has dry cerumen, smooth and pinkish. and shiny. It has a dry
pus and blood no skin lesions pus and Tympanic membrane cerumen, no skin
blood deposits, contains intact, translucent, shiny lesions, pus and blood
hair follicles and gray. No redness or deposits. It contains hair
discharge. follicles.
(Fundamentals of
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 580)
Hearing Acuity test
Assess client's response Voice is heard in both Normal voice tones normal The client can hear
to normal voice tones ears. audible. normal voice tones.
(Fundamentals of
Nursing by Kozier p.
558)
Perform watch tick test Able to hear ticking in Able to hear ticking in normal The client able to hear
both ears. both ears. ticking in both ears.
(Fundamentals of
Nursing by Kozier p.
558)
Perform Weber's test Sound is heard on both Sound is heard in both normal The client can hear the
sides of the ears. ears or is localized at sound from the tuning
the center of the head. fork that was localized
(Fundamentals of at the center of the head.
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 582)
Perform Rinne's test Rinne Positive Air conduction is normal The client’s air-
greater to bone conducting hearing is
conduction or Rinne greater than her bone-
positive. conducting hearing.
(Fundamentals of
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 582)
Nose
Inspect for any In the midline of the Symmetric and straight normal The client’s nose is in
deviations in shape, size face,symmetric and no discharge uniform in the midline of her face,
and color and flaring or straight no discharge color. symmetric, straight, no
discharge from nares uniform in color. (Fundamentals of discharge and its color is
Nursing by Kozier p. uniform to the color of
560) her face.
Inspect the nasal Reddish mucosa; watery Pink mucosa; watery Deviated from normal The client’s nasal
cavities for the presence discharge and no discharge, no lesions. cavities have a reddish
of redness, swelling, lesions. (Fundamentals of mucosa, watery
growths and discharge, Nursing by Kozier p. discharge but there is no
using penlight 561) lesion.
Inspect the nasal septum Intact and in midline Intact and in midline normal The client’s nasal
between the nasal (Fundamentals of septum is intact and
chambers Nursing by Kozier p. placed in the midline.
561)
Test patency of both Air freely flows through Air flows freely as the normal The air freely flows
nasal cavities nares client breathes through through the nares of the
the nares. client’s nose.
(Fundamentals of
Nursing by Kozier p.
560)
Palpate for any No tenderness no No tenderness no normal The client’s nose has no
tenderness, masses lesions, no lesions, no lesions. tenderness, no lesion, no
displacements of bone displacements of bones (Fundamentals of displacement of bones
and cartilage and cartilage Nursing by Kozier p. and cartilage.
560)
Sinuses
Locate/ palpate/ identify Non-tender Not painful when normal The client’s sinuses is
the sinuses and note for palpated. not painful when
any tenderness (Fundamentals of palpated.
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 583)
Mouth
Lips
Inspect for symmetry of Pink in color, smooth, Symmetrical, pink normal The lips of the client is
contour, color and symmetrically aligned moist, smooth and free color pink, it is smooth,
texture and in movement of swelling or lesions. free of swelling or
(Fundamentals of lesion.
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 583)
Buccal Mucosa
Inspect for color, Pink in color, moist, no Pink, moist, free of normal The buccal mucosa of
moisture, texture and lesions, swelling or lesions. the client is pink in
presence of lesions (Fundamentals of color, moist and has no
Nursing: The Art of lesion.
Nursing Care by Taylor
et. al. P. 583)
Teeth
Inspect for color, 28 numbers of teeth, 32 numbers of adult normal The client has 28 teeths.
number and condition, enamel in color, shiny teeth; shiny, smooth and It is enamel in color,
and presence of and smooth. white. shiny and smooth.
dentures (Fundamentals of
Nursing by Kozier p.
564)
Gums
Inspect for the color and Pink in color, no Pink in color, moist normal The client’s gums is
condition bleeding, moist firm, no firm. pink in color, no
retraction (Fundamentals of bleeding, it is moist, and
Nursing by Kozier p. has no retraction.
564)
Tongue/Floor of
Mouth
Inspect for color and Pink in color, moist. Pink in color, moist, normal The tongue and floor of
texture of the mouth slightly rough, frenulum the mouth is color pink
floor and frenelum is at the center and moist.
(Fundamentals of
Nursing by Kozier p.
564)
Inspect and palpate the Pink in color, slightly Moves freely no normal The base of her tongue
position, color and rough, thin whitish tenderness is pink in color, slightly
texture, movement and coated, no lesions (Fundamentals of rough, has a tin whitish
base of the tongue Nursing by Kozier p. coated and has no
564) lesion.
Palpate for any nodules, smooth, no lumps No palpable nodules normal There are no nodules,
lumps or excoriated (Fundamentals of lumps or any excoriated
areas Nursing by Kozier p. areas.
564)
Palates and Uvula
Inspect and palpate for Light pink, smooth, soft Light pink, smooth, soft normal The soft and hard palate
color, shape, texture and palate, hard palate, more palate, hard palate, more of the client is color
the presence of presence irregular texture irregular texture light pink and more
of bony prominences (Fundamentals of irregular in texture.
Nursing by Kozier p.
565)
Inspect for position of At the center and freely Is normally centered normal The uvula of the client is
the uvula and mobility movable. and freely movable. placed at the center and
while examining the (Fundamentals of freely movable.
palates Nursing: the Art of
Nursing Care by Taylor
et. al. p. 583)
Oropharynx and
tonsils
Inspect and palpate for Pink, smooth, posterior Pink, smooth, posterior normal The color of the client’s
color and texture wall wall. oropharynx is pink, and
(Fundamentals of it has a smooth posterior
Nursing by Kozier p. wall.
565)
Inspect the size of the Pink and smooth, with Pink, smooth, no Inflamed The color of the client’s
tonsils, color and no discharge. discharges of normal tonsils is pink, it is
discharge size. smooth and with no
(Fundamentals of discharge.
Nursing: the Art of
Nursing Care by Taylor
et. al. p. 584)
Neck and Lymph
Nodes
Lymph nodes
Locate/palpate/identify Not palpable, no Normally not palpable; normal The lymph nodes of the
lymph nodes and note tenderness if palpable it should be client is not palpable
for tenderness small mobile, smooth and has no tenderness
and nontender.
(Fundamentals of
Nursing: the Art of
Nursing Care by Taylor
et. al. p. 584)
Trachea
Inspect and palpate for Midline of neck; spaces Midline of neck at the normal The trachea of the client
placements are equal on both sides supresternal notch; is placed in the midline
spaces are equal on both of her neck and it has
sides equal spaces on both
(Fundamentals of sides.
Nursing: the Art of
Nursing Care by Taylor
et. al. p. 584)
Thyroid gland
Inspect symmetry and Not visible, glands Not visible, glands normal The thyroid gland of the
visible masses ascends during ascends during client is not visible and
swallowing swallowing its gland ascends during
(Fundamentals of swallowing.
Nursing ny Kozier p.
569)
Palpate for smoothness Not palpable, centrally Normally not palpable; normal Her thyroid gland is not
and areas of located, no tenderness if palpable it should feel palpable, centrally
enlargement, masses soft bur elastic, non located and has no
and nodules tender and should have tenderness.
no enlargements, masses
or nodules.
(Fundamentals of
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 572)

Thorax Normal Findings Actual Findings Analysis Interpretation

Posterior Thorax

a. size, shape, Anteroposterior to Anteroposterior Within normal range.


symmetry, diameter of transverse diameter diameter to the
anteroposterior thorax diameter in ratio of 1:2 transverse diameter by
and transverse a ratio of 2:1 (17:34)
diameter. Chest symmetric
Chest symmetric
(Fundamentals of
Nursing by Kozier p.
576)
b. spinal alignment Spine Vertically aligned Spine is vertically Within normal range. The spinal column of
aligned
(Fundamentals of the client is vertically
Nursing by Kozier p.
576) aligned.

c. temperature, Uniform temperature Uniform temperature Within normal range. The posterior thorax of
tenderness and masses
No tenderness No tenderness the client has a uniform

temperature, has no
No masses No masses
tenderness and no
(Fundamentals of
Nursing by Kozier p. masses
576)

d. respiratory excursion Full symmetric chest Has full and Within normal range. During the deep
expansion during deep symmetrical chest
inspiration expansion inspiration of the client,

(Fundamentals of her chest has a full


Nursing by Kozier p.
576) symmetric expansion.

e. vocal fremitus Bilateral symmetry of Bilateral symmetry of Within normal range. The vocal fremitus of
vocal fremitus vocal fremitus
the client has a bilateral
Fremitus is heard most The vibrations diminish
clearly at the apex of from superior to symmetry, and its
the lungs inferior thorax.
(Fundamentals of fremitus is heard most
Nursing by Kozier p.
577) clearly at the apex of

her lungs.
f.percuss posterior Percussion notes There is a resonant Within normal range. On the posterior thorax
thorax resonate, except over sound over lung field
scapula and dullness over the of the client, the
ares of the liver and
(Fundamentals of spleen percussion notes
Nursing by Kozier p.
577) resonate, except over

scapula.

g. auscultate posterior Vesicular and Has bronchovesicular Within normal range. In the auscultation of
thorax bronchovesicular breath breath sound in the
sounds apex of lungs and the posterior thorax of
vesicular breath sound
(Fundamentals of base of the lungs. the client, it notes
Nursing by Kozier p.
577) vesicular and

bronchovesicular breath

sounds

Anterior Thorax

a. breathing patterns Quiet, rhythmic, and Has quiet, rhythmic and Within normal range. The breathing pattern
effortless respirations effortless respirations
or has eupnic of the client is quiet,
(Fundamentals of respiration.
Nursing by Kozier p. rhythmic and has a
578)
eupnic respiration.

b. temperature, Uniform temperature Uniform temperature Within normal range. On the anterior thorax
tenderness and masses
No tenderness No tenderness of the client, it has a

uniform temperature,
No masses No masses
no tenderness, and no
(Fundamentals of
Nursing by Kozier p. masses
578)
c. respiratory excursion Full and symmetric Full and symmetric Within normal range. During the deep
chest expansion during chest expansion
deep inspiration inspiration of the client,

(Fundamentals of her chest has a full


Nursing by Kozier p.
578) symmetric expansion.

d. vocal fremitus Bilateral symmetry of Bilateral symmetry of Within normal range. On the anterior thorax
vocal fremitus vocal fremitus.
(Fundamentals of Diminishing vibrations of the client, it has a
Nursing by Kozier p. from superior to
579) inferior thorax. bilateral symmetry of

vocal fremitus

e. percuss anterior Percussion notes Has resonated sound. Within normal range. On the client’s anterior
thorax resonate down to the thorax, percussion
sixth rib at the level of notes resonate down to
diaphragm but flat over the sixth rib at the level
areas of heavy muscles of the diaphragm, but
and bone, dull over flat over areas of heavy
areas over the heart and muscles and bone, dull
the liver, tympanic over over areas over the
the underlying stomach. heart and the liver,
tympanic over the
(Fundamentals of underlying stomach.
Nursing by Kozier p.
579)

f. auscultate trachea Bronchial and breath Has bronchial breath Within normal range. The client’s trachea has
sounds sounds
bronchial breath
(Fundamentals of
Nursing by Kozier p. sounds.
579)
g. auscultate anterior Bronchovesicular and Has bronchovesicular Within normal range. In the auscultation of
thorax vesicular breath sounds breath sound in the
apex of lungs and the client’s anterior
(Fundamentals of vesicular breath sound
Nursing by Kozier p. base of the lungs. thorax, it notes
579)
bronchovesicular breath

sounds.

Cardiovascular

a. Inspect and Palpate


at the same time

aortic and No Pulsations No pulsations felt Within normal range. There are no pulsations
pulmonic areas
(Fundamentals of on the client’s aortic
Nursing by Kozier p.
583) and pulmonic areas.

Tricuspid areas No Pulsations Light pulsations are felt Within normal range. There are light

(Fundamentals of pulsations on the


Nursing by Kozier p.
583) client’s aortic and

tricuspid areas.

Apical area Pulsations visible in the Pulsations are felt Within normal range. There are pulsations
5th LICS at medial to specifically in the fifth felt specifically in the
MCL intercostal space fifth intercostal space
of the client’s apical
area.
(Fundamentals of
Nursing by Kozier p.
583)

b. Auscultation
aortic S1: usually heard at all S2 heart sounds is Within normal range. In the aortic of the
sites heard.
client, heart sounds is
S2: usually heard at all
sites heard

(Fundamentals of
Nursing by Kozier p.
583)

pulmonic S1: usually heard at all S2 heart sounds is Within normal range. In the pulmonic of the
sites heard
client, heart sound is
S2: usually heard at all
site. heard.

(Fundamentals of
Nursing by Kozier p.
583)

tricuspid S1: usually heard at all S1 Heart sounds is Within normal range. In the tricuspid of the
sites heard
client, heart sound is
S2: usually heard at all
sites heard.

(Fundamentals of
Nursing by Kozier p.
583)
apical valves S1: usually heard at all S1 heart sounds is Within normal range. In the apical valves of
sites heard.
the client, heart sounds
S2: usually heard at all
sites is heard.

(Fundamentals of
Nursing by Kozier p.
583)

Carotid Arteries

a. palpation Symmetric pulse Pulsation is full and has Within normal range. In the carotid arteries of
volumes a symmetric pulse
volume the client, pulsation is
(Fundamentals of
Nursing by Kozier p. full and has a
584)
symmetric pulse

volume

b. Auscultation No sound heard on No sound heard. Within normal range. In the carotid arteries of
auscultation
the client, auscultation
(Fundamentals of
Nursing by Kozier p. is no sound heard
584)

Jugular Veins

a. inspect Veins not visible Veins not visible Within normal range. In the jugular veins of

(Fundamentals of the client, veins are not


Nursing by Kozier p.
584) visible.
Breast and Axillae

a. size, symmetry, Round in shape; Flat, rounded shape, Within normal range. The breast of the client
contour, shape slightly unequal in size; slightly unequal in size,
generally symmetric right breast is slightly is flat, rounded shape,
bigger than the left.
(Fundamentals of slightly unequal in size;
Nursing by Kozier p.
589) her right breast is

slightly bigger than the

left.

b. discoloration of the Skin uniform in color Skin uniform in color Within normal range. The skin of the client’s
skin,
hypopigmentation, Skin smooth and intact Skin smooth and intact. breast is uniform in
retraction,dimpling,
hypervascular areas, color, it is smooth and
(Fundamentals of Has no stretch marks
swelling or edema.
Nursing by Kozier p.
intact, and it has no
589)
stretch marks.

c. areola for size, shape, Round or oval and Round and bilaterally Within normal range. The size of the areola
symmetry, color, bilaterally the same. the same
surface characteristics of the client is round
and any mass or lesions Color varies widely, Brown in color
from light pink to dark and bilaterally the
brown.
same. It is brown in
Irregular placement of
color.
sebaceous glands on the
surface of the areola

(Fundamentals of
Nursing by Kozier p.
590)
d. nipples for size, Round, everted, and Everted nipple. Within normal range. The nipples of the
shape, position, color, equal in size; similar in
discgarge, and lesions color; both nipples Pointing at the same client is everted,
point in same direction. direction.
pointing at the same
No discharge No discharge
direction, and it has no
(Fundamentals of
discharge
Nursing by Kozier p.
590)

e. Palpation

axillary, No tenderness, masses, Lymph node Within normal range. In the axillary,
subclavicular or nodules. not palpable
and subclavicular ans
superclavicular (Fundamentals of
lymph nodes Nursing by Kozier p. superclavicular lymph
590)
nodes of the client are

not palpable

breast for No tenderness, masses, No tenderness, masses, Within normal range. The breast of the client
masses, nodules, or nipple nodules, or nipple
tenderness discharge. discharge has no tenderness,

(Fundamentals of masses, nodules, and it


Nursing by Kozier p.
590) doesn’t have nipple

discharge.
nipples No tenderness, masses, No tenderness, masses , Within normal range. The nipples of the
tenderness and nodules, or nipple nodules, or nipple
masses discharge. discharge client has no

(Fundamentals of tenderness, no nodules


Nursing by Kozier p.
590) and doesn’t have nipple

discharge

Abdomen

a. inspection abdomen Unblemished skin Unblemished skin, Within normal range. The abdomen of the
for skin uniform in color. No
(Fundamentals of stretch marks. client has unblemished
Nursing by Kozier p.
594) skin, it has uniform

color and doesn’t have

stretch marks.
b. inspection abdomen Flat, rounded (convex), Flat abdomen Within normal range. The abdomen of the
for contour and scaphoid (concave)
symmetry client is flat
(Fundamentals of
Nursing by Kozier p.
594)

c. inspection No evidence of No enlargement of Within normal range. The client has no


enlargement of enlargement of liver or spleen or liver
abdomen/spleen. spleen (Fundamentals enlargement of spleen
of Nursing by Kozier p.
594) or liver.
d. symmetry of contour Symmetric contour Symmetric contour Within normal range. The client has a
while standing at the
foot of the bed (Fundamentals of symmetric contour
Nursing by Kozier p.
594)

e. Abdominal Symmetric movements Symmetric movements. Within normal range. The abdominal
movement caused by respirations.
movements of the client
(Fundamentals of
Nursing by Kozier p. is symmetric
595)

f. vascular pattern No vascular pattern. No visible vascular Within normal range. The client has no
pattern
(Fundamentals of visible vascular pattern
Nursing by Kozier p.
595)

g. Auscultation Audible bowel sounds Audible bowel sounds Within normal range. The abdomen of the

Absence of arterial Absence of arterial client has an audible


bruits bruits
bowel sounds. There is
Absence of friction rub Absence of friction rub
no presence of arterial
(Fundamentals of bruits, and no presence
Nursing by Kozier p.
595) of friction rub
h. Percuss each of the 4 Tympany over the Tympanic sound heard Within normal range. In the percussion of the
quadrants stomach and gas-filled in the stomach and
bowels; dullness, dullness in liver and 4 quadrants of the
especially over the liver spleen.
and spleen, or full abdomen of the client,
bladder (Fundamentals
of Nursing by Kozier p. tympanic sound is
596)
heard in the stomach

and dullness in liver

and spleen
i. Palpation No tenderness; relaxed No tenderness; relaxed Within normal range. In the palpation of the
abdomen with smooth, abdomen with smooth,
consistent tension. consistent tension. abdomen of the client,

(Fundamentals of it has no tenderness, her


Nursing by Kozier p.
596) abdomen was relaxed

and with smooth, and

has a consistent tension

Musculoskeletal
System
a. Size Equal size on both sidesEqual size on both sidesWithin normal range. The musculoskeletal
of the body
system of the client is
(Fundamentals of
Nursing by Kozier p. equal in size on both
600)
sides

b. Tendons for No contractures No contractures Within normal range. The tendons of the
contractures
(Fundamentals of musculoskeletal system
Nursing by Kozier p.
600) of the client has no

contractures
c. Fasciculation and No fasciculation and No fasciculations and Within normal range. There are no
tremors tremors (Fundamentals tremors
of Nursing by Kozier p. fasciculations and
600)
tremors in the

musculoskeletal system
d. Palpate muscle Normally firm Tonicity is normally Within normal range. The muscle tonicity of
tonicity firm
(Fundamentals of the client is normally
Nursing by Kozier p.
600) firm

e. Test for muscle (Fundamentals of


strength Nursing by Kozier p.
600)

Neck Grade 5 Able to resist Within normal range. She can able to resist

Able to resist her neck in normal

range.

Upper Grade 5 Able to resist Within normal range. The upper extremities
extremities
able to resist of the client can able to

resist.

lower Grade 5 Able to resist Within normal range. The lower extremities
extremities
able to resist of the client can able to

resist and it is in normal

range.

Bones

a. Deformities and No deformities No deformities Within normal range. There’s no deformity


skeleton for normal
structures (Fundamentals of on the client’s bone
Nursing by Kozier p.
601) structure.
b. Palpation No tenderness or No tenderness or Within normal range. There’s no sign of
swelling swelling
tenderness and
(Fundamentals of
Nursing by Kozier p. swelling.
601)

Joints

a. Joint for swelling No swelling No swelling Within normal range. The joints of the client

(Fundamentals of has no swelling


Nursing by Kozier p.
601)

b. Palpation No tenderness, No tenderness, Within normal range. In the palpation of the


swelling, crepitation, or swelling, crepitation, or
nodules. nodules joints of the client,

(Fundamentals of there is no tenderness,


Nursing by Kozier p.
601) no swelling no

crepitation nor nodules


Upper Complete Complete Within normal range. Her upper extremities
Extremities
(shoulder and are complete.
scapula)

Elbows Complete complete Within normal range. The Elbows of the

client is complete.

Hands Complete complete Within normal range. The hand of the client

is complete and it is in

normal range without.


Lower Complete complete Within normal range. The Lower Extremities
Extremities
(acetabalum/in (acetabalum/inguinal
guinal area)
area) is complete.

Popliteal Complete complete Within normal range. The Popliteal of the

client is complete.

ankles complete complete Within normal range. Her ankle is complete

and in it is on the

normal range.

III. LIST OF NURSING PROBLEMS

Nursing Diagnosis Cues Justification


Sleep Deprivation related to I -Sleep is a physiologic need
sustained inadequate sleep hygiene. -“I find it difficult to fall asleep” according to Maslow’s hierarchy of
- “ I am well aware that I have a needs.
sleeping problem, hindi ko lang - actual problem
alam kung ano problem ko, gusto ko - recognizes it as a problem
sana mamodify yun.” - has a desire to modify the problem,
O - If left untreated, may arise to
- Dark circles around her eyes potential problems.
- looks sleepy and tired. - resources like time and personnel
M are available
- yawned 8x during the interview.
Nursing Cues Justificat
Diagnos ion
is
Ineffecti I - love
ve - and
coping Monday Tuesday Wednesd Thursday Friday Saturd Sunday belongin
ay ay
related g needs
6:00 Do Do Do Do Do Sleep Sleep
to - morning morning morning morning morning accordin
gender 6:30 exercise exercise exercise exercise exercise g to
6:30 Watch Watch Watch Watch Watch
differen - television television television television television Maslow’
ces in 7:30 s
7:30 Eat Eat Eat Eat Eat Eat Eat
coping - breakfast breakfast breakfast breakfast breakfast breakf breakfa - an
strategie 8:00 ast st actual
8:00 Read Read Read Read Read Take a Take a
s - notes notes notes notes notes bath bath problem
specific 8:30 -my
8:30 Take a Take a Take a Take a Take a Prepar Prepare
ally no - bath bath bath bath bath e for for arise to
vacation 9:00 school school potential
9:00 Prepare Prepare Prepare Prepare Prepare Attend Attend
and too - for school for school for school for school for school Bible Bible problems
many 9:30 study study -
9:30 Travel to Travel to Travel to Travel to Travel to
deadline - school school school school school resource
s. 10:0 s like
0
10:0 Attend Attend Attend Attend Attend Watch Watch time and
0- Microbiol Microbiol Microbiol Microbiol Microbiol televisi televisi personne
1:00 ogy & ogy & ogy & ogy & ogy & on and on and
l are
Parasitolo Parasitolo Parasitolo Parasitolo Parasitolo browse browse
gy class gy class gy class gy class gy class the the available
interne internet
t
1:00 Eat lunch Eat lunch Eat lunch Eat lunch Eat lunch Eat Eat
- lunch lunch
1:30
1:30 Attend Attend Attend Attend Attend Watch Watch
- PSTL PSTL PSTL PSTL PSTL DVD/ DVD/T
3:20 class class class class class TV V
3:20 Read Read Read Read Read
- notes notes notes notes notes
4:00
4:00 Attend Attend Attend Attend Attend Go to
- NCM 101 NCM 101 NCM 101 NCM 101 NCM 101 the
7:00 class class class class class mall
7:00 Travel Travel Travel Travel Travel Rest
- home home home home home
8:00
8:00 Rest Rest Rest Rest Rest Eat
- dinner
8:30
8:30 Eat dinner Eat dinner Eat dinner Eat dinner Eat dinner Eat Read
- dinner notes/D
9:00 o
9:00 Read Read Read Read Read Play homew
- notes/Do notes/Do notes/Do notes/Do notes/Do guitar ork
12:0 homewor homewor homewor homewor homewor
0 ks ks ks ks ks
12:0 Sleep Sleep Sleep Sleep Sleep Sleep
0-
6:00

O
-yawns during the inerview

Nursing Diagnosis Cues Justification


Readiness for enhanced Nutrition I - denotes no existing problem

-“Gusto ko baguhin yung eating - client has the desire for a

patterns at saka yung quality ng food higher level of wellness

na kinakain ko. -resources like time and personnel

- “mas maganda sana kapag healthy are available

yung kinakain ko araw-araw para

maimprove yung health ko.”

Nursing Diagnosis Cues Justification


Imbalanced Nutrition: less than body I“starting ngayong summer Nutrition is a physiologic need,
requirements related to inability to class, nadedelay na yung time according to the Maslow’s Hierarchy
ingest food necessary for formation ng pagkain dahil sa hectic of Needs
of normal red blood cells. As schedule ko”. - it is an actual problem
evidence by: “ feeling ko super unhealthy - if left untreated, may arise
nung mga kinakain ko kasi to potential problems
usually mga galling sa fastfood - recognize it as a problem
chains” - resources like time and
“I drink when I feel thirsty saka personnel are available
every after meals.”
“According to her, she takes
ferrous sulfate for her anemia.”
“Gusto ko baguhin yung eating
patterns at saka yung quality ng
food na kinakain ko.”
O
- pale

Nursing Diagnosis
VI- Nursing Care Plan
Nursing Analysis Outcomes Intervention Rationale Evaluation
Diagnosis
Sleep a. Situational Goal: Goal:
deprivation Analysis After nursing met
related to intervention, Partially met
inadequate as The client is able the client will not met
evidence by: to achieve a longer be able to
duration of sleep achieve a
I because of the longer
elimination of the duration of
-“I find it
factors such as sleep.
difficult to fall difficulty in falling
asleep, working Objectives: Objectives:
asleep”
late etc. After the Effectiveness:
- “ I am well nursing 1. Was the client able to
intervention, decrease the amount of
aware that I
b. Health the client will caffeine intake before going
have a Implication be able to: to sleep?
1. Caffeine is a CNS stimulant.
sleeping
Sleep exerts 1. Know the 1. Discuss with the For many people beverages _yes
problem, hindi physiological importance of client then containing caffeine interfere of _No
effects on both the eliminating importance of the activity to fall asleep. Why? ___________
ko lang alam
nervous system caffeine eliminating Example of beverage containing
kung ano and other body intake before caffeine intake caffeine, include coffee, tea and
structures. Sleep sleep in 30 before sleep most cola drinks(FON 5th edition
problem ko,
on someway minutes of by Karol Taylor p. 1176) 2. Was the client able to look
gusto ko sana restore normal discussion. for substitute to coffee before
level of activity a 2. Small protein containing snack going to sleep?
mamodify
normal balance before bedtime used to be
yun.” among parts of the recommended for patient with _yes
nervous system. insomnia. Protein may actually _ no
O
Sleep also 2. Choose an 2. Provide choices increase alertness and Why?______
- Dark circles necessary for alternative for of alternatives or concentration whereas
protein synthesis, caffeine substitute for carbohydrates appears to affect
around her
which allows intake in 20 caffeine. brain serotonin level and promote
eyes repair process to minutes. calmness and relaxation(FON 5th
occur. edition by K. Taylor page 1175)
- looks sleepy
3. Was the client able to
and tired. Illness that causes 3. What they do to accomplish manage her time properly?
M pain or physical more at work and thereby reduce
distress can result stress. _yes
- yawned 8x
on sleep problems. _no
during the
People who are ill why?___________
interview.
require more sleep 3. Manage her 3. Discuss with the
than normal and time properliy client proper time
the normal rhythm . arrangement:
of sleep and 3.1 provide a
wakefulness is sample activity
often disturbed. plan for a day
People deprived of 3.2 guide the 4. Was the client engage
REM sleep client in making 4. Relaxation techniques are herself in relaxation
subsequently spend her own activity useful in many situation such as techniques?
more time than plan. childbirth, pain, sleeplessness, _yes
normal in this anxiety (FON 5th edition K. _no
stage. 4. Discuss Taylor page 864) Why?____________
4. Engage in importance of
Kozier pp. 1115 to relaxation relaxation
1117 techniques, techniques.
such as 4.1 Provide list of 5. Was the client to prolong
reading or relaxation 5. For no known reasons, 8 hours the no. of hours of her sleep
listening to techniques to of sleep a night has been the per day?
quiet music to stimulate sleep. accepted standards for adults,
reduce despite obvious variations own in _yes
stimulation. the general population. _no
! 5. Monitor the why?___________
5. Gradually sleep hours off the
increase the client.
no. of hours Efficiency:
of sleep per Were the time, materials and
day. human resources and used
economically?

__Ye
__No Why?
_______________

Appropriateness:
Were the intervention setting
and timetable realistic to
client situation?

Yes___
No___
Why?________

Acceptability:
Were the interventions
suitable to the clients’
situation?
Yes_____
No___
Why?___________

Adequacy:
Were the number of
intervention sufficient?

Yes____
No____ why?
_________________
VII. References

Вам также может понравиться