EMILIO AGUINALDO COLLEGE

Dasmariñas, Cavite
COLLEGE OF NURSING & SCHOOL OF MIDWIFERY
NURSING PROCESS OF INDIVIDUAL CLIENT

A. Individual Profile
Client’s Name: N. P. DL. Sex: F
Age: 54 y.o Civil Status: MARRIED
Nationality: Religion: R. CATHOLIC
Occupation: EMPLOYEE Educational Attainment: COLLEGE
GRADUATE
Usual Source of Medical Health: MAXICARE

B. Assessment:
Areas Findings
1. Physical Normal Abnormal
1.1. Head -Generally round, with prominences in the
frontal and occipital area.
-No scars noted and free from lice, nits and
dandruff. (Scalp)

1.2. Eyes -eyebrows are symmetrical and in line with

each other.
-black in color and evenly distributed.
-eyes are evenly placed and inline with each
other.
-Non protruding.
1.3. Ears -The ear lobes are bean shaped, parallel, and
symmetrical.
 -Skin is same in color as in the complexion.
-No lesions noted on inspection.

1.4. Nose -Nose in the midline.

-No Discharges.
-No tenderness noted on palpation.
1.5. Mouth and throat -white teeth. -pale lips.
-moves freely.
-no tenderness
1.6. Neck -muscles equal size; head.
- ( - ) palpable lymph nodes
1.7. Breast and axillary - No lumps or masses are palpable.
- No tenderness upon palpation.
1.8. Chest
1.9. Abdomen -No tenderness noted.
-Skin color is uniform, no lesions.
1.10. Extremities (upper) - Both extremities are equal in size.
- Temperature is warm and even.
- Color is even.
1.11. Extremities (lower) - Both extremities are equal in size.
- Color is even.
- No involuntary movements.
1.12. Skin - no acne -dry
-pale in color
1.13. Hair -Black in color
-evenly distributed covers the whole scalp.
-has dry and thin strands
1.14. Nails
1.15. Respiratory - no retractions - ( + ) wheezing sounds
1.16. Cardiovascular - ( - ) murmur
1.17. Gastrointestinal
tract
1.18. Urinary
1.19. Musculoskeletal
1.20. Neurologic
1.21. Cranial Nerves
1.21.1. Olfactory
1.21.2. Optic
1.21.3. Occulomotor
1.21.4. Trigeminal
1.21.5. Trochlear
1.21.6. Abducens
1.21.7. Facial
1.21.8. Auditory
1.21.9.
Glossopharyngeal
1.21.10. Vagus
1.21.11. Accessory
1.21.12. Hypoglossal

2. Non Physical
2.1. Developmental
(Havighurst)
2.1.1. Achieving gender
specific social role;
independence; acquiring
a set of values and an
ethical system to guide
behavior.
2.2. Psychosocial
(Erikson)
2.2.1. Intimacy vs.
Isolation
2.3. Psychosocial
(Freud)
2.3.1. Genital Stage
2.4. Faith (Fowlers)
2.4.1. Selects principles
to follow; concern for
the rights and needs of
others.
2.5. Moral (Kohlberg)
2.5.1. Morality of
maintaining good
relations and approval
of other; aware of need
to respect authority.
 C. Planning (Short term / Long term)
1. health teaching
2.
3.

D. Implementation (Short term / Long term)

1.
2.
3.

Evaluation (Short term / Long term)

1.
2.
3.