ncp (nicole tandayu)

8/14/2019 NCP (Nicole Tandayu)

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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 clients 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.


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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 whats 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 clients support system are her family, friends and bible study group mates in times of stress his

father has diabetes and now her fathers 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 hasnt experienced any difficulty in learning. She doesnt 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.


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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

shes 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 peoples lives. They can influence lifestyle, attitudesand 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 drinks 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

theres 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


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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 clients 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 shewould 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 dont 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


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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. Theres no

problem with my skin and I dont 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

300 ml of coffee

2 packs of Pancit

CantonChilimansi

300 ml of coffee

1 cup rice

1 fried egg1 burger patty

100 ml of coffee

LUNCH 1 cup rice

1 piece fried

chicken leg

250 ml iced tea

1 serving of

spaghetti

250 ml iced tea

1 chicken burger

250 ml iced tea

1 regular sized

French fries

DINNER 1 cup rice

4 matchbox cut

pork adobo

1000 ml of water

300 ml of ice cold

coffee

1 cup rice

1 serving of

chopsuey

1000 ml of water

200 ml of ice cold

coffee

1 cup rice

1 serving of Pork

Sinigang

750 ml of water

100 ml of ice cold

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.


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


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patterns, she also verbalized, Hindi naman ako nakakarmdam ng discomfort when Im 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 clients statement, her elimination pattern is normal because she defecates four times aweek 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

6:00-6:30

Do morningexercise

Do morningexercise

Do morningexercise

Do morningexercise

Do morningexercise

Sleep Sleep

6:30-

7:30

Watch

television

Watch

television

Watch

television

Watch

television

Watch

television

7:30-

8:00

Eat breakfast Eat breakfast Eat breakfast Eat breakfast Eat breakfast Eat

breakfast

Eat

breakfast

8:00-

8:30

Read notes Read notes Read notes Read notes Read notes Take a

bath

Take a

bath

8:30- Take a bath Take a bath Take a bath Take a bath Take a bath Prepare Prepare for


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9:00 for school school

9:00-

9:30

Prepare for

school

Prepare for

school

Prepare for

school

Prepare for

school

Prepare for

school

Attend

Bible

study

Attend

Bible study

9:30-10:00

Travel toschool

Travel toschool

Travel toschool

Travel toschool

Travel toschool

10:00-1:00 AttendMicrobiology

&

Parasitology

class

AttendMicrobiology

&

Parasitology

class

AttendMicrobiology

&

Parasitology

class

AttendMicrobiology

&

Parasitology

class

AttendMicrobiology

&

Parasitology

class

Watchtelevision

and

browse

the

internet

Watchtelevision

and browse

the internet

1:00-

1:30

Eat lunch Eat lunch Eat lunch Eat lunch Eat lunch Eat lunch Eat lunch

1:30-

3:20

Attend PSTL

class

Attend PSTL

class

Attend PSTL

class

Attend PSTL

class

Attend PSTL

class

Watch

DVD/TV

Watch

DVD/TV

3:20-

4:00

Read notes Read notes Read notes Read notes Read notes

4:00-

7:00

Attend NCM

101 class

Attend NCM

101 class

Attend NCM

101 class

Attend NCM

101 class

Attend NCM

101 class

Go to the

mall7:00-8:00

Travel home Travel home Travel home Travel home Travel home Rest

8:00-8:30

Rest Rest Rest Rest Rest Eat dinner

8:30-

9:00

Eat dinner Eat dinner Eat dinner Eat dinner Eat dinner Eat

dinner

Read

notes/Do

homework9:00-

12:00

Read

notes/Do

homeworks

Read

notes/Do

homeworks

Read

notes/Do

homeworks

Read

notes/Do

homeworks

Read

notes/Do

homeworks

Play

guitar

12:00-

6:00

Sleep Sleep Sleep Sleep Sleep Sleep

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 clients 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 clients 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


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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.


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 persons 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 dont really have any idea kung


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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.


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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.


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 doesnt

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.


Interpretation:

Based on the clients 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 thats 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 shell 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


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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 ones 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 theres 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 doesnt take any medication for emotional

distress. She doesnt 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 persons physical, emotional, and social well-being. Stress and adaption are major

components in health and illness.


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


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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.

. 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 normalrange.

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 pressuredoes 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,

height & weight inrelation to the clients

age, lifestyle and health.

Proportionate weight to

height. BMI is 21.

Proportionate weight to

height.(Fundamentals of

Nursing: The Art of

Nursing Care by Taylor

et. al. P. 571)

normal Her BMI is in normal

range which is from 18-24.5.

Describe the client'sposture, gait, standing,

sitting & walking.

Relax and erect postureCoordinated movements

Relax and erect posturewith Coordinated

movements.

(Fundamentals of

Nursing: The Art of


et. al. P. 571)

normal The client stands inerect posture, she sits

relax and walks

coordinately.

Describe the client over

all hygiene andgrooming.

Clean and neat Clean and neat

(Fundamentals ofNursing by Kozier p.

normal The client doesnt have

stain or any kind of dirtin her dress.


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531)

Describe body and

breath odor

No body odor and

breath odor

No body odor and

breath odor

(Fundamentals of

Nursing: The Art of


et. al. P. 571)

normal The clients breath

doesnt smell like

acetone.

Identify signs of

distress, in posture of

facial expression

No distress noted No signs of distress.

(Fundamentals of

Nursing by Kozier p.

531)

normal The patient is not

bending and no labored

breating.

Identify obvious signs

of heath or illness

Healthy appearance; no

signs of illness.

Healthy appearance

(Fundamentals of


531)

normal The clients color is not

pallor. She looks alive

during the assessment.

Describe the client's

attitude

cooperative Cooperative

Healthy appearance

(Fundamentals of

Nursing by Kozier p.531)

normal The client is cooperative

during the activity/

assessment.

Describe the client'saffect/mood; assess the

appropriateness of the

client's response

Responses appropriately Appropriate response tothe situation

Healthy appearance

(Fundamentals of


531)

normal The client responsesappropriately to the

questions asked to her.

Describe the quantity

and quality of speech

voice is clear and

understandable;

moderate pace

Understandable,

moderate pace; exhibits

thought association

Healthy appearance

(Fundamentals of


531)

normal The clients voice is in

moderate pace. She

speaks clearly and

understandable.

Listen for relevance and

organization of thoughts

The response has sense

and relevant to thequestion.

Logical sequence;

makes sense and hassense of realty

Healthy appearance

(Fundamentals of


531)

normal The clients responses

have sense and there isno confusion.

Integumentary

SKIN

Inspect for color;uniformity of color.

Fair skin complexion,uniform. Skins that are

normally expose is a

little darker.

Ranging from pinkishwhite to various shades

of brown. Skin color

relatively constant

except skin ares that are

normally exposed.

(Fundamentals of

Nursing: The Art of


et. al. P. 572)

normal The clients skin color islight brown and she

doesnt have

discolorization.

Inspect for presence of

edema.

No edema No edema

(Fundamentals of


a presence of edema.


14/42


538)

There is no are that

appears swollen, shiny

and taut.

Inspect for lesions

according to location,

color, size and shape

No lesions, has birth

mark on left shin.

Freckles, some birth

marks, some flat and

raised nevi; no

abrasions or otherlesions.

(Fundamentals of


538)


an alteration in her

normal skin appearance.

Palpate skin moisture No excessive moisture

and no excessivedryness.

Moisture in skin folds

and the axillae.(Fundamentals of


539)


excessive moisture inher ski folds or

excessive dryness.

Palpate skin temperature Warm and uniform Uniform temperature

within normal range.

(Fundamentals of


539)

normal The temperature of her

skin is warm and

uniform.

Palpate skin turgor When pinched skin

springs back on its

original state

When pinched skin

springs back to previous

state.

(Fundamentals of


539)

normal The clients skin springs

back immediately when

pinched.

Nails

Inspect fingernails plate

shape to determine its

curvature and angle

Convex curvature; angle

of nail plate is about

160 degrees

Convex and should

follow the natural curve

of the finger. Angle

between the nail and

base of the finger shouldbe about 160 degrees.

(Fundamentals of

Nursing: The Art of


et. al. P. 574)

normal The clients fingernail

shows a convex shape

and the nail plate angle

is about 160 degrees.

Inspect fingernails and

toenail bed color

Pink in color and highly

vascular

Highly vascular and

pink in light skinned

people; dark skinned

people may have brownor black pigmentation.


543)

normal The clients fingernails

and toenail bed is pink

in color highly vascular.

Palpate fingernail and

toenail texture

Smooth and firm Smooth firm and

nontender.

(Fundamentals of

Nursing: The Art of


et. al. P. 574)

normal Her fingernails and

toenails texture is

smooth and firm

because


15/42


16/42

Inspect the facial

feature, symmetry of

facial movements

Symmetrical feature and

movement; moles are

present. Uniform in on

color

Symmetrical' even

distribution of facial

hair and uniform in

color.

(Fundamentals of

Nursing: The Art of

Nursing Care by Tayloret. al. P. 576)

normal The clients facial

feature and facial

movements is

symmetrical. There is a

presence of moles. She

has uniform facial color.

Eyes

Eyebrows

Inspect of hair

distribution, alignment,

skin and quality and

movement

Symmetrical, evenly

distributed, black in

color, equal movement

Equal distribution;

parallel alignment.

(Fundamentals of

Nursing: The Art of


normal The hair in clients

eyebrows is evenly

distributed, black in

color and equal in

movement.

Eyelashes

Inspect for hair

distribution and

direction of curl

Evenly distributed,

curled outward

Equal distribution,

curled outward.

(Fundamentals ofNursing: The Art ofNursing Care by Taylor

et. al. P. 577)

normal The clients eyelashes is

evenly distributed and

curled outward.

Eyelids

Inspect for the surface

characteristics, position,

in relation to the cornea,ability to blink and

frequency of blinking

Skin intact, no

discharges and

discoloration,symmetrically 15-20

blinks per minute. Close

symmetrically

Skin intact, no

discharges and

discoloration,symmetrically 15-20

blinks;lids close

symmetrically; upper

and lower boundaries of

cornea are slightly

covered.

(Fundamentals of


normal Her eyelids skin is

intact, no discharge and

discolorization. It issymmetrically blinks

15-20 times per minute.

It is close

symmetrically.

Conjunctiva

Inspect the bulbar

conjunctiva for color,

texture, and presence of

lesions

Transparent with minute

capillaries, no presence

of lesions

Transparent; capillaries

sometimes evident.

(Fundamentals of


normal The clients bulbar

conjunctiva is

transparent in color with

minute capillaries, andthere is no presence of

lesions.

Inspect the palpebral

conjunctiva for color,

texture, and presence of

lesions

Pink in color, no lesions

and shiny.

Shiny, smooth, pink or

red.

(Fundamentals of


548)

normal Her palpebral

conjunctiva is color

pink, smooth and shiny.

There is no presence of

lesions.

Sclera

Inspect the color and

clarity

White in color, clear White in color, clear.

(Fundamentals of


550)

normal The clients sclera is

white in color and clear.

Cornea

Inspect for clarity and Transparent, smooth and Transparent, smooth and normal The clients cornea is


17/42

texture shiny clear, no

irregularities

shiny, details of the iris

are visible.

(Fundamentals of


550)

transparent, smooth,

shiny and clear. There

are no irregularities.

Iris

Inspect for color andshape Brown in color, roundand flat. Flat and round(Fundamentals of


550)

normal The clients iris is brownin color, round and flat.

Pupils

Inspect for color, shape

and symmetry of size

Black in color; they are

equal in size

Black in color; equal in

size

(Fundamentals of


550)

normal The clients pupils are

black in color and they

are equal in size.

Visual Acuity

Test near vision Able to read newsprint. Able to read newsprint.

(Fundamentals of


normal The client was able to

read newsprints.

Test distant vision 20/20 vision without

glasses

20/20 vision

(Fundamentals of


552)

normal The clients vision is

20/20 without glasses.

Pupils

Test each pupil for light

reaction and

accommodation

Illuminated constrict;

non illuminated dilate;

viewing nearer object

constrict; viewing

farther object dilate

Pupil Equal Round and

reactaed to Light and

Accommodation

(Fundamentals of


550)

normal The clients pupils

constrict when

illuminated and dilate

when non-illuminated.

Lacrimal Gland,Lacrimal sac,

Lacrimal duct

Inspect and palpate the

lacrimal gland

No excessive tearing

and no edema

no edema or tearing.


550)

normal The client has no

excessive tearing and noedema.

Extraocular Muscle

Test for each eye for

alignment and

coordination

Coordinated movements

of the eye.

Both eyes coordinated,

move in unison,with

parallel alignment.(Fundamentals of


552)

normal The clients both eye is

coordinated, move in

unison and with parallelalignment.

Visual Field

Test for peripheral fields When looking straight

ahead, the client can seethe object in periphery

When looking straight

ahead, the client can seethe object in periphery

(Fundamentals of


551)

normal When looking straight

ahead, the client can seeobjects in periphery.

Ears

Auricles


18/42

Inspect for color

symmetry and position

Color same as the facial

color, symmetrically

aligned the with outer

canthus of eye.

Color same as the facial

color, symmetrical

auricle aligned with

outer canthus of eye,

about to form vertical.

(Fundamentals of


normal The clients auricle is

with same color to her

face, symmetrically

aligned to the outer

canthus of her eyes.

Palpate for texture,

elasticity and areas of

tenderness

Mobile, firm and tender,

pinna recoils when it is

folded

Mobile, firm and tender,

pinna recoils when it is

folded(Fundamentals of


556)

normal Her auricles are mobile,

firm and tender. Her

pinna recoils when it isfolded.

External ear canal

Inspect ear canal for

cerumen, skin lesions,

pus and blood

Ear canal is pink and

shiny. has dry cerumen,

no skin lesions pus and

blood deposits, contains

hair follicles

Ear canal should be

smooth and pinkish.

Tympanic membrane

intact, translucent, shiny

and gray. No redness or

discharge.

(Fundamentals of

Nursing: The Art of


et. al. P. 580)

normal The ear canal is pink

and shiny. It has a dry

cerumen, no skin

lesions, pus and blood

deposits. It contains hair

follicles.

Hearing Acuity test

Assess client's response

to normal voice tones

Voice is heard in both

ears.

Normal voice tones

audible.


558)

normal The client can hear

normal voice tones.

Perform watch tick test Able to hear ticking in

both ears.

Able to hear ticking in

both ears.(Fundamentals of


558)

normal The client able to hear

ticking in both ears.

Perform Weber's test Sound is heard on both

sides of the ears.

Sound is heard in both

ears or is localized at

the center of the head.

(Fundamentals of

Nursing: The Art of


et. al. P. 582)

normal The client can hear the

sound from the tuning

fork that was localized

at the center of the head.

Perform Rinne's test Rinne Positive Air conduction is

greater to bone

conduction or Rinne

positive.(Fundamentals of

Nursing: The Art of


et. al. P. 582)

normal The clients air-

conducting hearing is

greater than her bone-

conducting hearing.

Nose

Inspect for anydeviations in shape, size

and color and flaring or

In the midline of theface,symmetric and

straight no discharge

Symmetric and straightno discharge uniform in

color.

normal The clients nose is inthe midline of her face,

symmetric, straight, no


19/42

discharge from nares uniform in color. (Fundamentals of


560)

discharge and its color is

uniform to the color of

her face.

Inspect the nasal

cavities for the presence

of redness, swelling,

growths and discharge,using penlight

Reddish mucosa; watery

discharge and no

lesions.

Pink mucosa; watery

discharge, no lesions.

(Fundamentals of


Deviated from normal The clients nasal

cavities have a reddish

mucosa, watery

discharge but there is nolesion.

Inspect the nasal septum

between the nasal

chambers

Intact and in midline Intact and in midline

(Fundamentals of


561)

normal The clients nasal

septum is intact and

placed in the midline.

Test patency of both

nasal cavities

Air freely flows through

nares

Air flows freely as the

client breathes through

the nares.(Fundamentals of


560)

normal The air freely flows

through the nares of the

clients nose.

Palpate for anytenderness, masses

displacements of bone

and cartilage

No tenderness nolesions, no

displacements of bones

and cartilage

No tenderness nolesions, no lesions.

(Fundamentals of


560)

normal The clients nose has notenderness, no lesion, no

displacement of bones

and cartilage.

Sinuses

Locate/ palpate/ identifythe sinuses and note for

any tenderness

Non-tender Not painful whenpalpated.

(Fundamentals of

Nursing: The Art of


et. al. P. 583)

normal The clients sinuses isnot painful when

palpated.

Mouth

Lips

Inspect for symmetry ofcontour, color and

texture

Pink in color, smooth,symmetrically aligned

and in movement

Symmetrical, pinkmoist, smooth and free

of swelling or lesions.

(Fundamentals of

Nursing: The Art of


et. al. P. 583)

normal The lips of the client iscolor pink, it is smooth,

free of swelling or

lesion.

Buccal Mucosa

Inspect for color,

moisture, texture and

presence of lesions

Pink in color, moist, no

lesions,

Pink, moist, free of

swelling or lesions.

(Fundamentals of

Nursing: The Art of


et. al. P. 583)

normal The buccal mucosa of

the client is pink in

color, moist and has no

lesion.

Teeth

Inspect for color,

number and condition,

and presence of

dentures

28 numbers of teeth,

enamel in color, shiny

and smooth.

32 numbers of adult

teeth; shiny, smooth and

white.


564)

normal The client has 28 teeths.

It is enamel in color,

shiny and smooth.

Gums

Inspect for the color and Pink in color, no Pink in color, moist normal The clients gums is


20/42

condition bleeding, moist firm, no

retraction

firm.

(Fundamentals of


564)

pink in color, no

bleeding, it is moist, and

has no retraction.

Tongue/Floor of

Mouth

Inspect for color andtexture of the mouth

floor and frenelum

Pink in color, moist. Pink in color, moist,slightly rough, frenulum

is at the center

(Fundamentals of


564)

normal The tongue and floor of the mouth is color pink

and moist.

Inspect and palpate the

position, color and

texture, movement andbase of the tongue

Pink in color, slightly

rough, thin whitish

coated, no lesions

Moves freely no

tenderness


564)

normal The base of her tongue

is pink in color, slightly

rough, has a tin whitishcoated and has no

lesion.

Palpate for any nodules,

lumps or excoriatedareas

smooth, no lumps No palpable nodules


564)

normal There are no nodules,

lumps or any excoriatedareas.

Palates and Uvula

Inspect and palpate forcolor, shape, texture and

the presence of presenceof bony prominences

Light pink, smooth, softpalate, hard palate, more

irregular texture

Light pink, smooth, softpalate, hard palate, more

irregular texture(Fundamentals of


565)

normal The soft and hard palateof the client is color

light pink and moreirregular in texture.

Inspect for position of

the uvula and mobility

while examining the

palates

At the center and freely

movable.

Is normally centered

and freely movable.

(Fundamentals of

Nursing: the Art of


et. al. p. 583)

normal The uvula of the client is

placed at the center and

freely movable.

Oropharynx and

tonsils

Inspect and palpate for

color and texture

Pink, smooth, posterior

wall

Pink, smooth, posterior

wall.

(Fundamentals of


565)

normal The color of the clients

oropharynx is pink, and

it has a smooth posterior

wall.

Inspect the size of the

tonsils, color anddischarge

Pink and smooth, with

no discharge.

Pink, smooth, no

discharges of normalsize.

(Fundamentals of

Nursing: the Art of


et. al. p. 584)

Inflamed The color of the clients

tonsils is pink, it issmooth and with no

discharge.

Neck and Lymph

Nodes

Lymph nodes

Locate/palpate/identify

lymph nodes and note

for tenderness

Not palpable, no

tenderness

Normally not palpable;

if palpable it should be

small mobile, smooth

and nontender.

normal The lymph nodes of the

client is not palpable

and has no tenderness


21/42

(Fundamentals of

Nursing: the Art of


et. al. p. 584)

Trachea

Inspect and palpate for

placements

Midline of neck; spaces

are equal on both sides

Midline of neck at the

supresternal notch;spaces are equal on both

sides

(Fundamentals of

Nursing: the Art of


et. al. p. 584)

normal The trachea of the client

is placed in the midlineof her neck and it has

equal spaces on both

sides.

Thyroid gland

Inspect symmetry and

visible masses

Not visible, glands

ascends during

swallowing

Not visible, glands

ascends during

swallowing

(Fundamentals of

Nursing ny Kozier p.569)

normal The thyroid gland of the

client is not visible and

its gland ascends during

swallowing.

Palpate for smoothnessand areas of

enlargement, masses

and nodules

Not palpable, centrallylocated, no tenderness

Normally not palpable;if palpable it should feel

soft bur elastic, non

tender and should have

no enlargements, masses

or nodules.

(Fundamentals of

Nursing: The Art of


normal Her thyroid gland is notpalpable, centrally

located and has no

tenderness.

Thorax Normal Findings Actual Findings Analysis Interpretation

Posterior Thorax

a. size, shape,

symmetry, diameter of

anteroposterior thoraxand transverse

diameter.

Anteroposterior to

transverse diameter

diameter in ratio of 1:2

Chest symmetric


576)

Anteroposterior

diameter to the

transverse diameter bya ratio of 2:1 (17:34)

Chest symmetric

Within normal range.


22/42

b. spinal alignment Spine Vertically aligned

(Fundamentals of


576)

Spine is vertically

aligned

Within normal range. The spinal column of

the client is vertically

aligned.

c. temperature,tenderness and masses

Uniform temperature

No tenderness

No masses

(Fundamentals of


576)

Uniform temperature

No tenderness

No masses

Within normal range. The posterior thorax of

the client has a uniform

temperature, has no

tenderness and no

masses

d. respiratory excursion Full symmetric chest

expansion during deep

inspiration

(Fundamentals of


Has full and

symmetrical chest

expansion

Within normal range. During the deep

inspiration of the client,

her chest has a full

symmetric expansion.

e. vocal fremitus Bilateral symmetry ofvocal fremitus

Fremitus is heard most

clearly at the apex of

the lungs

(Fundamentals of


577)

Bilateral symmetry ofvocal fremitus

The vibrations diminish

from superior to

inferior thorax.

Within normal range. The vocal fremitus of

the client has a bilateral

symmetry, and its

fremitus is heard most

clearly at the apex of

her lungs.


23/42

f.percuss posterior

thorax

Percussion notes

resonate, except over

scapula

(Fundamentals of


577)

There is a resonant

sound over lung field

and dullness over the

ares of the liver and

spleen

Within normal range. On the posterior thorax

of the client, the

percussion notes

resonate, except over

scapula.

g. auscultate posterior

thorax

Vesicular and

bronchovesicular breath

sounds

(Fundamentals of


577)

Has bronchovesicular

breath sound in the

apex of lungs and

vesicular breath sound

base of the lungs.

Within normal range. In the auscultation of

the posterior thorax of

the client, it notes

vesicular and


sounds

Anterior Thorax

a. breathing patterns Quiet, rhythmic, and

effortless respirations

(Fundamentals of


578)

Has quiet, rhythmic and

effortless respirations

or has eupnic

respiration.

Within normal range. The breathing pattern

of the client is quiet,

rhythmic and has a

eupnic respiration.

b. temperature,

tenderness and masses

Uniform temperature

No tenderness

No masses

(Fundamentals of


578)

Uniform temperature

No tenderness

No masses

Within normal range. On the anterior thorax

of the client, it has a

uniform temperature,

no tenderness, and no

masses


24/42

c. respiratory excursion Full and symmetric

chest expansion during

deep inspiration

(Fundamentals of


578)

Full and symmetric

chest expansion

Within normal range. During the deep

inspiration of the client,

her chest has a full

symmetric expansion.

d. vocal fremitus Bilateral symmetry of

vocal fremitus

(Fundamentals of


579)

Bilateral symmetry of

vocal fremitus.

Diminishing vibrations

from superior to

inferior thorax.

Within normal range. On the anterior thorax

of the client, it has a

bilateral symmetry of

vocal fremitus

e. percuss anterior

thorax

Percussion notes

resonate down to thesixth rib at the level of

diaphragm but flat over

areas of heavy muscles

and bone, dull over

areas over the heart and

the liver, tympanic over

the underlying stomach.

(Fundamentals of


579)

Has resonated sound. Within normal range. On the clients anterior

thorax, percussionnotes resonate down to

the sixth rib at the level

of the diaphragm, but

flat over areas of heavy

muscles and bone, dull

over areas over the

heart and the liver,

tympanic over theunderlying stomach.

f. auscultate trachea Bronchial and breath

sounds

(Fundamentals of


579)

Has bronchial breath

sounds

Within normal range. The clients trachea has

bronchial breath

sounds.


25/42

g. auscultate anterior

thorax

Bronchovesicular and

vesicular breath sounds

(Fundamentals of


579)

Has bronchovesicular

breath sound in the

apex of lungs and

vesicular breath sound

base of the lungs.

Within normal range. In the auscultation of

the clients anterior

thorax, it notes


sounds.

Cardiovascular

a. Inspect and Palpate

at the same time

aortic and

pulmonic areas

No Pulsations


583)

No pulsations felt Within normal range. There are no pulsations

on the clients aortic

and pulmonic areas.

Tricuspid areas No Pulsations

(Fundamentals of


583)

Light pulsations are feltWithin normal range. There are light

pulsations on the

clients aortic and

tricuspid areas.

Apical area Pulsations visible in the

5th LICS at medial to

MCL

(Fundamentals of


583)

Pulsations are felt

specifically in the fifth

intercostal space

Within normal range. There are pulsations

felt specifically in the

fifth intercostal space

of the clients apical

area.

b. Auscultation


26/42

aortic S1: usually heard at all

sites

S2: usually heard at all

sites


583)

S2 heart sounds is

heard.

Within normal range. In the aortic of the

client, heart sounds is

heard

pulmonic S1: usually heard at all

sites

S2: usually heard at allsite.

(Fundamentals of


S2 heart sounds is

heard

Within normal range. In the pulmonic of the

client, heart sound is

heard.

tricuspid S1: usually heard at all

sites


sites

(Fundamentals of


583)

S1 Heart sounds is

heard

Within normal range. In the tricuspid of the

client, heart sound is

heard.


27/42

apical valves S1: usually heard at all

sites


sites


583)

S1 heart sounds is

heard.

Within normal range. In the apical valves of

the client, heart sounds

is heard.

Carotid Arteries

a. palpation Symmetric pulse

volumes

(Fundamentals of


584)

Pulsation is full and has

a symmetric pulse

volume

Within normal range. In the carotid arteries of

the client, pulsation is

full and has a

symmetric pulse

volume

b. Auscultation No sound heard on

auscultation


584)

No sound heard. Within normal range. In the carotid arteries of

the client, auscultation

is no sound heard

Jugular Veins

a. inspect Veins not visible


584)

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

the client, veins are not

visible.


28/42

Breast and Axillae

a. size, symmetry,

contour, shape

Round in shape;

slightly unequal in size;

generally symmetric

(Fundamentals of


589)

Flat, rounded shape,

slightly unequal in size,

right breast is slightly

bigger than the left.

Within normal range. The breast of the client

is flat, rounded shape,

slightly unequal in size;

her right breast is

slightly bigger than the

left.

b. discoloration of the

skin,

hypopigmentation,retraction,dimpling,

hypervascular areas,swelling or edema.

Skin uniform in color

Skin smooth and intact

(Fundamentals of


589)

Skin uniform in color

Skin smooth and intact.

Has no stretch marks

Within normal range. The skin of the clients

breast is uniform in

color, it is smooth and

intact, and it has no

stretch marks.

c. areola for size, shape,

symmetry, color,

surface characteristics

and any mass or lesions

Round or oval and

bilaterally the same.

Color varies widely,

from light pink to dark

brown.

Irregular placement of

sebaceous glands on the

surface of the areola

(Fundamentals of


590)

Round and bilaterally

the same

Brown in color

Within normal range. The size of the areola

of the client is round

and bilaterally the

same. It is brown in

color.


29/42

d. nipples for size,

shape, position, color,

discgarge, and lesions

Round, everted, and

equal in size; similar in

color; both nipples

point in same direction.

No discharge

(Fundamentals of


590)

Everted nipple.

Pointing at the same

direction.

No discharge

Within normal range. The nipples of the

client is everted,

pointing at the same

direction, and it has no

discharge

e. Palpation

axillary,

subclavicular

and

superclavicular

lymph nodes

No tenderness, masses,

or nodules.


590)

Lymph node

not palpable

Within normal range. In the axillary,

subclavicular ans

superclavicular lymph

nodes of the client are

not palpable

breast formasses,

tenderness

No tenderness, masses,nodules, or nipple

discharge.

(Fundamentals of


590)

No tenderness, masses,nodules, or nipple

discharge

Within normal range. The breast of the client

has no tenderness,

masses, nodules, and it

doesnt have nipple

discharge.


30/42

nipples

tenderness and

masses

No tenderness, masses,

nodules, or nipple

discharge.

(Fundamentals of


590)

No tenderness, masses ,

nodules, or nipple

discharge

Within normal range. The nipples of the

client has no

tenderness, no nodules

and doesnt have nipple

discharge

Abdomen

a. inspection abdomenfor skin Unblemished skin

(Fundamentals of


594)

Unblemished skin,uniform in color. Nostretch marks.

Within normal range. The abdomen of the

client has unblemished

skin, it has uniform

color and doesnt have

stretch marks.

b. inspection abdomen

for contour and

symmetry

Flat, rounded (convex),

scaphoid (concave)

(Fundamentals of


Flat abdomen Within normal range. The abdomen of the

client is flat

c. inspection

enlargement of

abdomen/spleen.

No evidence of

enlargement of liver or

spleen (Fundamentals

of Nursing by Kozier p.

594)

No enlargement of

spleen or liver

Within normal range. The client has no

enlargement of spleen

or liver.


31/42

d. symmetry of contour

while standing at the

foot of the bed

Symmetric contour

(Fundamentals of


594)

Symmetric contour Within normal range. The client has a

symmetric contour

e. Abdominal

movement

Symmetric movements

caused by respirations.

(Fundamentals of


595)

Symmetric movements.Within normal range. The abdominal

movements of the client

is symmetric

f. vascular pattern No vascular pattern.

(Fundamentals of


595)

No visible vascularpattern

Within normal range. The client has no

visible vascular pattern

g. Auscultation Audible bowel sounds

Absence of arterialbruits

Absence of friction rub

(Fundamentals of


Audible bowel sounds

Absence of arterialbruits

Absence of friction rub

Within normal range. The abdomen of the

client has an audible

bowel sounds. There is

no presence of arterial

bruits, and no presence

of friction rub


32/42

h. Percuss each of the 4

quadrants

Tympany over the

stomach and gas-filled

bowels; dullness,

especially over the liver

and spleen, or full

bladder (Fundamentals

of Nursing by Kozier p.596)

Tympanic sound heard

in the stomach and

dullness in liver and

spleen.

Within normal range. In the percussion of the

4 quadrants of the

abdomen of the client,

tympanic sound is

heard in the stomach

and dullness in liver

and s leeni. Palpation No tenderness; relaxed

abdomen with smooth,

consistent tension.

(Fundamentals of


No tenderness; relaxed

abdomen with smooth,

consistent tension.

Within normal range. In the palpation of the

abdomen of the client,

it has no tenderness, her

abdomen was relaxed

and with smooth, and

has a consistent tension

Musculoskeletal

System

a. Size Equal size on both sides

of the body

(Fundamentals of


Equal size on both sidesWithin normal range. The musculoskeletal

system of the client is

equal in size on both

sides

b. Tendons for

contractures

No contractures

(Fundamentals of


No contractures Within normal range. The tendons of the

musculoskeletal system

of the client has no

contractures


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c. Fasciculation and

tremors

No fasciculation and

tremors (Fundamentals

of Nursing by Kozier p.

600)

No fasciculations and

tremors

Within normal range. There are no

fasciculations and

tremors in the

d. Palpate muscletonicity

Normally firm

(Fundamentals of


600)

Tonicity is normallyfirm

Within normal range. The muscle tonicity of

the client is normally

firm

e. Test for musclestrength


600)

Neck Grade 5

Able to resist

Able to resist Within normal range. She can able to resist

her neck in normal

range.

Upper

extremities

Grade 5

able to resist

Able to resist Within normal range. The upper extremities

of the client can able to

resist.

lower

extremities

Grade 5

able to resist

Able to resist Within normal range. The lower extremities

of the client can able to

resist and it is in normal

range.

Bones

a. Deformities and

skeleton for normal

structures

No deformities


601)

No deformities Within normal range. Theres no deformity

on the clients bone

structure.


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b. Palpation No tenderness or

swelling

(Fundamentals of


601)

No tenderness or

swelling

Within normal range. Theres no sign of

tenderness and

swelling.

Joints

a. Joint for swelling No swelling


601)

No swelling Within normal range. The joints of the client

has no swelling

b. Palpation No tenderness,

swelling, crepitation, ornodules.

(Fundamentals of


601)

No tenderness,

swelling, crepitation, ornodules

Within normal range. In the palpation of the

joints of the client,

there is no tenderness,

no swelling no

crepitation nor nodules

Upper

Extremities

(shoulder and

scapula)

Complete Complete Within normal range. Her upper extremities

are complete.

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.


35/42

Lower

Extremities

(acetabalum/in

guinal area)

Complete complete Within normal range. The Lower Extremities

(acetabalum/inguinal

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.

II. LIST OF NURSING PROBLEMS

Nursing Diagnosis Cues Justification

Sleep Deprivation related to

sustained inadequate sleep hygiene.

I

-I find it difficult to fall asleep

- I am well aware that I have a

sleeping problem, hindi ko lang

alam kung ano problem ko, gusto ko

sana mamodify yun.

O

- Dark circles around her eyes

- looks sleepy and tired.

M

- yawned 8x during the interview.

-Sleep is a physiologic need

according to Maslows hierarchy of

needs.

- actual problem

- recognizes it as a problem

- has a desire to modify the problem,

- If left untreated, may arise to

potential problems.

- resources like time and personnel

are available


36/42

Nursing

Diagnos

is

Cues Justificat

ion

Ineffecti

ve

coping

related

to

gender

differen

ces in

coping

strategie

s

specific

ally no

vacation

and too

many

deadline

s.

I

-

Monday Tuesday Wednesd

ay

Thursday Friday Saturd

ay

Sunday

6:00

-

6:30

Do

morning

exercise

Do

morning

exercise

Do

morning

exercise

Do

morning

exercise

Do

morning

exercise

Sleep Sleep

6:30

-

7:30

Watch

television

Watch

television

Watch

television

Watch

television

Watch

television

7:30

-

8:00

Eat

breakfast

Eat

breakfast

Eat

breakfast

Eat

breakfast

Eat

breakfast

Eat

breakf

ast

Eat

breakfa

st

8:00

-8:30

Read

notes

Read

notes

Read

notes

Read

notes

Read

notes

Take a

bath

Take a

bath

8:30

-

9:00

Take a

bath

Take a

bath

Take a

bath

Take a

bath

Take a

bath

Prepar

e for

school

Prepare

for

school

9:00

-

9:30

Prepare

for school

Prepare

for school

Prepare

for school

Prepare

for school

Prepare

for school

Attend

Bible

study

Attend

Bible

study

9:30

-10:0

0

Travel to

school

Travel to

school

Travel to

school

Travel to

school

Travel to

school

10:0

0-1:00

Attend

Microbiology &

Parasitolo

gy class

Attend

Microbiology &

Parasitolo

gy class

Attend

Microbiology &

Parasitolo

gy class

Attend

Microbiology &

Parasitolo

gy class

Attend

Microbiology &

Parasitolo

gy class

Watch

television and

browse

the

interne

t

Watch

television and

browse

the

internet

1:00

-

1:30

Eat lunch Eat lunch Eat lunch Eat lunch Eat lunch Eat

lunch

Eat

lunch

1:30

-

3:20

Attend

PSTL

class

Attend

PSTL

class

Attend

PSTL

class

Attend

PSTL

class

Attend

PSTL

class

Watch

DVD/

TV

Watch

DVD/T

V

3:20

-

4:00

Read

notes

Read

notes

Read

notes

Read

notes

Read

notes

4:00

-

7:00

Attend

NCM 101

class

Attend

NCM 101

class

Attend

NCM 101

class

Attend

NCM 101

class

Attend

NCM 101

class

Go to

the

mall

7:00

-

8:00

Travel

home

Travel

home

Travel

home

Travel

home

Travel

home

Rest

8:00

-

Rest Rest Rest Rest Rest Eat

dinner

- love

and

belongin

g needs

accordin

g to

Maslow

s

- an

actual

problem

-my

arise to

potential

problems

-

resource

s like

time and

personnel are

available


37/42

8:30

8:30

-

9:00

Eat dinner Eat dinner Eat dinner Eat dinner Eat dinner Eat

dinner

Read

notes/D

o

homework

9:00

-

12:00

Read

notes/Do

homeworks

Read

notes/Do

homeworks

Read

notes/Do

homeworks

Read

notes/Do

homeworks

Read

notes/Do

homeworks

Play

guitar

12:00-

6:00

Sleep Sleep Sleep Sleep Sleep Sleep

O

-yawns during the inerview

Nursing Diagnosis Cues Justification

Readiness for enhanced Nutrition I

-Gusto ko baguhin yung eating

patterns at saka yung quality ng food

na kinakain ko.

- mas maganda sana kapag healthy

yung kinakain ko araw-araw para

maimprove yung health ko.

- denotes no existing problem

- client has the desire for a

higher level of wellness

-resources like time and personnel

are available

Nursing Diagnosis Cues JustificationImbalanced Nutrition: less than body

requirements related to inability to

ingest food necessary for formation

of normal red blood cells. As

evidence by:

Istarting ngayong summer

class, nadedelay na yung time

ng pagkain dahil sa hectic

schedule ko.

feeling ko super unhealthy

nung mga kinakain ko kasi

usually mga galling sa fastfood

chains

I drink when I feel thirsty saka

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.

Nutrition is a physiologic need,

according to the Maslows Hierarchy

of Needs

- it is an actual problem

- if left untreated, may arise

to potential problems

- recognize it as a problem

- resources like time and

personnel are available


38/42

O

- pale

Nursing Diagnosis


39/42

VI- Nursing Care Plan

Nursing

Diagnosis

Analysis Outcomes Intervention Rationale Evaluation

Sleep

deprivation

related to

inadequate as

evidence by:

I

-I find it

difficult to fall

asleep

- I am well

aware that I

have a

sleeping

problem, hindi

ko lang alam

kung ano

problem ko,

gusto ko sanamamodify

yun.

O

- Dark circles

around her

eyes

- looks sleepy

and tired.

a. Situational

Analysis

The client is able

to achieve a longer

duration of sleep

because of the

elimination of thefactors such as

difficulty in falling

asleep, working

late etc.

b. Health

Implication

Sleep exerts

physiological

effects on both the

nervous system

and other body

structures. Sleep

on someway

restore normallevel of activity a

normal balance

among parts of the

nervous system.

Sleep also

necessary for

protein synthesis,

which allows

repair process to

occur.

Illness that causes

Goal:

After nursing

intervention,

the client will

be able to

achieve a

longer

duration ofsleep.

Objectives:

After the

nursing

intervention,

the client will

be able to:

1. Know the

importance of

eliminating

caffeine

intake before

sleep in 30

minutes of

discussion.

2. Choose an

alternative for

caffeine

intake in 20

minutes.

1. Discuss with the

client then

importance of

eliminating

caffeine intake

before sleep

2. Provide choices

of alternatives or

substitute for

caffeine.

1. Caffeine is a CNS stimulant.

For many people beverages

containing caffeine interfere of

the activity to fall asleep.

Example of beverage containing

caffeine, include coffee, tea and

most cola drinks(FON 5th edition

by Karol Taylor p. 1176)

2. Small protein containing snack

before bedtime used to be

recommended for patient with

insomnia. Protein may actually

increase alertness and

concentration whereas

carbohydrates appears to affect

brain serotonin level and promote

calmness and relaxation(FON 5th

edition by K. Taylor page 1175)

3. What they do to accomplish

Goal:

met

Partially met

not met

Objectives:

Effectiveness:

1. Was the client able to

decrease the amount of

caffeine intake before going

to sleep?

_yes

_No

Why? ___________

2. Was the client able to look

for substitute to coffee beforegoing to sleep?

_yes

_ no

Why?______

3. Was the client able to

manage her time properly?


40/42

M

- yawned 8x

during the

interview.

pain or physical

distress can result

on sleep problems.

People who are ill

require more sleep

than normal and

the normal rhythm

of sleep and

wakefulness is

often disturbed.

People deprived ofREM sleep

subsequently spend

more time than

normal in this

stage.

Kozier pp. 1115 to

1117

3. Manage her

time properliy

.

4. Engage in

relaxation

techniques,

such as

reading or

listening to

quiet music to

reduce

stimulation.

!

5. Gradually

increase theno. of hours

of sleep per

day.

3. Discuss with the

client proper time

arrangement:

3.1 provide a

sample activity

plan for a day

3.2 guide theclient in making

her own activity

plan.

4. Discuss

importance of

relaxation

techniques.

4.1 Provide list of

relaxation

techniques to

stimulate sleep.

5. Monitor the

sleep hours off the

client.

more at work and thereby reduce

stress.

4. Relaxation techniques are

useful in many situation such as

childbirth, pain, sleeplessness,

anxiety (FON 5th edition K.

Taylor page 864)

5. For no known reasons, 8 hours

of sleep a night has been the

accepted standards for adults,

despite obvious variations own in

the general population.

_yes

_no

why?___________

4. Was the client engageherself in relaxation

techniques?

_yes

_no

Why?____________

5. Was the client to prolong

the no. of hours of her sleep

per day?

_yes

_no

why?___________

Efficiency:

Were the time, materials and

human resources and used

economically?

__Ye

__No Why?

_______________

Appropriateness:

Were the intervention setting

and timetable realistic to


41/42

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?

_________________


42/42

VII. References

ncp (nicole tandayu)

Documents