FAR EASTERN UNIVERSITY

Institute of Nursing

A case of:

Presented by:
Saguiguit, Francis Kate
Salinas, Jan Terrence
Solleza, Erick Lance B.
Sindayen, Zeyad
Tan, Geraldine
Tawasil, Esam
Vacante, Precious Chriza L.
Vajio, Mary Ann
Vasquez, Gabrielle P.
Zacarias, Ma. Antoinette

BSN Section 208

Presented to:
Mrs. Jennifer Padual
Submitted on:
October 18, 2019
 DEMOGRAPHIC PROFILE
Name: Butial, Shane Allen Ambrocio
Age: 11 years old Birth Date: January 9, 2008 Birth Place: Tarlac City
Gender: Female
Address: 2379 Sitio Matarik, Camarin, Caloocan City
Religion: Roman Catholic Nationality: Filipino
Occupation: Student
Marital Status: Child Number of Children: N/A
Name of Spouse: N/A Educational Attatinment: Currently a
6th grade student
Date of Admission: October 9, 2019
Chief complaint: Abdominal Pain
Admitting/Final Diagnosis: Dengue Fever Syndrome(DFS)
Room & Bed Number: 503 F
Attending/Admitting Physician: Dr. Chua
Medical Insurance: N/A

A. HISTORY OF PRESENT ILLNESS

Upon thorough interview and assessment, the client does not have any other
present illnesses besides having low blood count and abdominal pain.

B. PAST HEALTH HISTORY

The client has completed all of her immunization according to her aunt. This is
her first time hospitalization, and she has a history of UTI and was found out on her
laboratory last wednesday (Oct 9, 2019). She also has a fever last tuesday (indicate nyo
ung temp). The reason of her hospitalization was because she has a high grade fever and
low rbc count. Her first menstrual period was last may this year and the first day of her
last menstrual period was last october 10, 2019. She has allergies with "malalansang
foods."
 FAMILY GENOGRAM

MOTHER SIDE FATHER SIDE

GRANDFATHER GRANDMOTHER

EDUARDO
AGE: 40 plus

JOSEPH CLIENT’S
AGE: 40 plus FAMILY IS
DISCLOSED

EMELINDA TRINIDAD
AMBROSIO
 AGE: 41

CORAZON
AGE: 33

SHARMAINE
Female AMBROSIO AGE: 11

Male

Deceased Female

Deceased Male

Divorced

Married

Patient
GORDON’S 11 FUNCTIONAL HEALTH PATTERNS
1. HEALTH PERCEPTION / HEALTH MANAGEMENT
Before admission:
As verbalized by the patient, being healthy for her means having a lot of energy.
She also mentioned that she maintains her health by eating healthy foods like vegetables
and taking her vitamins.

Present:
As verbalized by the patient, being healthy for her still means having a lot of
energy. She also mentioned that she maintains her health by eating healthy foods like
vegetables. But since she was admitted she has stopped taking her vitamins.

Analysis: Health has different meanings for each patient, the clinical settings, and
the healthcare professions. It is a state of being that people define in relation to their
own values, personality, and lifestyle (Potter and Perry, 2018).

Interpretation: Normal

2. NUTRITIONAL AND METABOLIC PATTERN

Before hospitalization client said that she has no food allergies and she is not
picky when it comes to food. She eats 1 cup of rice per meal with a viand of either pork
or chicken but most often vegetables. When it comes to beverages, the client said that
water is the only beverage she drinks, her usual consumption of water is about 5-7 glasses
(8oz) of water per day and a glass(8oz) of milk (bearbrand) every morning. She did not
take any vitamins or food supplements.

During hospitalization, client said that the only meal she eats was the provided
food by the hospital. The food has a cup of rice, meat and vegetables. She consumes 2-3
bottles of water (12oz) per day.

Analysis: Having a complete set of nutrition and the recommended water consumption
daily is vital for every person. Because it helps the person to perform daily task with ease.
Nutrition helps the body, especially the mind and the muscle to function properly.
Moreover, water helps clean the body from toxins (Potter and Perry, 2018).

Interpretation: Normal

3. ELIMINATION PATTERN
Before admission: The client verbalized before that she was admitted to the hospital that
she eliminates once per day and doesn't have any problems on defecating. She stated as
 well that she urinates 5 to 6 times in a day and doesn't feel any pain when she urinates.
Also, she states that she doesn't perspire that much and perspires only when the weather
is hot.

Present: The client stated during that she is admitted to the hospital that she did not yet
eliminated and that she urinates ranging to 10 times in a day and doesn't feel any pain.
She perspires just a little due to the cold environment she's at.

Analysis: Normal body functioning requires waste elimination, and any deviation from
this practice is a sign of gastrointestinal problems (Potter & Perry, 2018).

Interpretation: Normal

4. ACTIVITY AND EXERCISE PATTERN

Before admission: Client verbalized that she is not active in engaging into sports. But
during her leisure time, she said that she spends it by playing with her friends. She
mentioned that she only exercise during their PE subjects at school.

Present: Client verbalized that she is not active in engaging into sports. But
unfortunately, since she said that she’s admitted to the hospital, she can’t spend her free
time playing with friends. She mentioned that she only exercise during their PE subjects
at school.

Analysis: Exercise and activity refers to a physical activity that maintains the fitness of a
person, but it is limited due to a certain any health related physical limitations. (Potter &
Perry, 2018)
Interpretation: Normal

5. COGNITION AND PERCEPTION

The client was able to read and write. She is not using any glasses, can read and
see far and near objects. The client is also not using or wearing any hearing aid. She said
that she is average--not so good but not so bad--in understanding things especially the
difficult ones.
Analysis: 20/20 is the normal distant visual acuity with or without corrective lenses. The
client can distinguish what the normal person with normal vision can distinguish 20 feet
away (Weber & Kelley, 2018).
Interpretation: Normal

6. SLEEP AND REST PATTERN

 Before admission: The client says that before admission she sleeps 9 hours every night.
And doesn't have any difficulties of sleeping. She says also that she sometimes sleeps
during the day when she's tired. The client's routine for her to be sleepy, by watching
TV's until she gets to sleep. There is no disturbance as well during the span of the client’s
rest.

Present: The clients tell that during admission and present she sleeps 10 to 11 hours on,
doesn't have any difficulties of sleeping, sleeps during the day due to sickness and
condition. She says also that she's tired during the day and doesn't feel well sometimes.

Analysis: Proper rest and sleep are as important to health as good nutrition and adequate
exercise. Individuals need different amount of sleep and rest. Without proper amounts,
the ability to concentrate, make judgements, and participate in daily activities decreases;
and irritability increases. Sleep provides healing and restoration. Achieving the best
possible sleep quality is important for the promotion of good health and recovery from
illness.

Interpretation: Normal

7. SELF-PERCEPTION AND SELF-CONCEPT PATTERN

Before and during hospitalization, client’s perception and concept pattern did not
changed. She is satisfied with her body image and didn’t feel any insecurities towards
others. She verbalizes that she loved her eyes the most. She is positive towards achieving
her goals and to become rich someday. She also loves singing and wanted to develop her
calligraphy skills.

Analysis: A positive self-concept gives a sense of meaningfulness and consistency to a

person. A healthy self-concept has a high-degree of stability, which generates positive
feelings towards self. Good self-esteem should be in be any health school-aged child.
School-aged children want to master whatever they do, and they get more competitive
(Potter and Perry 9th edition, p.703).

Interpretation: Normal

8. SEXUAL AND REPRODUCTIVE PATTERN

Before and during hospitalization, as verbalized by the client, she has a normal
menstrual cycle and her first menstruation was last May 2019. She also said that she’s
experiencing minimal pain and discomfort every time she has her period. She changes her
napkin for at least 4x a day and she has a regular menstrual flow. The first day of her last
menstrual cycle was on October 10, 2019. The client doesn’t have any reproductive
dysfunction.

Analysis: Sexual health is a state of physical, mental and social well-being in relation to
sexuality. It requires a positive and respectful approach to sexuality and sexual
relationships, as well as the possibility of having pleasurable and safe sexual experiences,
free of coercion, discrimination and violence. (WHO, 2019)
 Interpretation: Normal

9. COPING AND STRESS TOLERANCE PATTERN

Before admission: As verbalized by the client, she controls herself in stressful events by
trying to calm herself and stay silent for a while. She also said that she control’s her
temper by not minding the situation. She maintains a peaceful mind by not stressing
herself too much on the problems she’s facing

Present: Client verbalized that even though she’s admitted at hospital, she still controls
herself in stressful events by trying to calm herself and stay silent for a while. She also
said that she control’s her temper by not minding the situation. She maintains a peaceful
mind by not stressing herself too much on the problems she’s facing.
Analysis: 20/20 is the normal distant visual acuity with or without corrective lenses. The
client can distinguish what the normal person with normal vision can distinguish 20 feet
away (Weber & Kelley, 2018).

Interpretation: Normal

10. ROLES AND RELATIONSHIPS PATTERN

Before admission:
Client verbalized that she’s is in a good relationship with her family. Being with
her friends, she mentioned that she is the silent one in their group, she is also that silent
one in their room.
Present:
Client verbalized that she’s is in a good relationship with her family especially
now because her mom is taking care of her at the hospital. Being with her friends, she
mentioned that she is the silent one in their group, she is also that silent one in their room.
Analysis:
According to Kozier (2015), school age children are starting to make friends from
school, and more people that are out of the family circle. But the family home will be a
safe place where they can always come.

Interpretation: Normal

11. VALUES AND BELIEFS PATTERN

Before admission: The client said that her religion is Catholic. She says that her dream is
to become a teacher someday and become a flight attendant. She also says that she gets
her strength from her mother and God. She says that when she sick’s her way of getting
strength is to pray to God to help her when she feels weak.
 Present: The clients verbalized during her stay is still to become a teacher and a flight
attendant someday. Gets her strength from her mother and god and prays to god every
time she feels weak.

Analysis: Spirituality provides individuals the capacity to find a dynamic and creative
sense of inner strength to be used when deciding on difficult decisions resulting to people
to stay open to change and challenges in life. (Potter , Perry, Stockert, & Hall, 2017)

Interpretation: Normal

PHYSICAL ASSESMENT
VITAL SIGNS
Height: 154 cm
Weight: 64.5 kg
Body mass index (BMI): 27.20 kg/m2
Respiratory rate: 26 cycles per minute
Pulse rate: 64 bpm
Temperature: 35.2°C
Blood pressure: 130/90 mmHg
Pain numeric rating scale: 6/10

GENERAL SURVEY 

  NORMAL ACTUAL FINDINGS  INTERPRETATION

FINDINGS  AND ANALYSIS 
1. Observe for signs of No distress noted  No distress is noted while Normal 
distress in posture or observing the patient's
facial expression  posture and facial
expression. 
2. Observe body build, Mesomorph,  Body build is Height is 154 cm 
height, and weight in endomorph and
relation to the client’s Proportionate, varies proportionate to her Weight is 64.5 kg 
age, lifestyle, and with lifestyle  lifestyle.   BMI is 27.20 kg/m2 
health.  O2 Sat. is 97% 

Her BMI for her age

level is considered. 
 3. Observe body build, Relaxed, Erect Relaxed, erect posture Normal 
height, and weight in Posture, coordinated and coordinated
relation to the client’s movement  movement while
age, lifestyle, and standing, sitting and
health.  walking 
4. Observe the client’s Clean & Neat  Client is generally clean Fingernails should be
overall hygiene and and neat except for kept short, and the
grooming. Relate these dirty fingernails.   undersides should be
to the person’s  cleaned frequently
with soap and water.
Activities prior to the Because of their
assessment.  length, longer
fingernails can harbor
more dirt and bacteria
than short nails, thus
potentially
contributing to the
spread of infection.
(CDC, 2016) 
5. Note body and No body/ breathe No foul odor/ breath odor Normal 
breathe odor in relation odor or minor body noted with client.  
to activity level.  odor relative to work
or exercise 
6. Listen for quantity, Understandable, The patient’s speech is Normal 
quality, and moderate pace, understandable, and
organization of speech.  exhibits thought moderate pace. 
association 
7. Listen for relevance Logical sequence, The organization of Normal 
and organization of makes sense, has thoughts is of logical
thoughts  sense of reality  sequence, makes sense,
with a sense of reality. 
8. Note obvious signs of Healthy Appearance  Client appears healthy.   Normal 
health or illness. 
9. Assess the client’s Cooperative  The patient’s attitude is Normal 
attitude.  cooperative to the
situation. 
10. Note the client’s Appropriate to The patient’s affect/mood Normal 
affect/mood; assess the situation  is appropriate to the
appropriateness of the situation. 
client’s responses 

ASSESSING THE SKIN 

   NORMAL ACTUAL INTERPRETATION
FINDINGS  FINIDNGS  AND ANALYSIS 
1. Inspect skin color  Varies from light to Client has a light Normal 
deep brown, from ruddy brown skin color. 
pink to light pink 
2. Inspect uniformity Generally uniform Skin color is uniform Normal 
of skin color  except in areas exposed in all areas.  
to sun; areas of lighter
pigmentation in dark
skinned 
3. Assess edema, if No edema  No presence of edema  Normal 
present  is noted.  
4. Inspect, palpate, Freckles, some birth No freckles, Normal 
and describe skin marks, some flat and birthmarks, abrasions,
lesions. Apply gloves raised nevi, no abrasion and lesions noted. 
if lesions are open or or other lesion. 
draining. •describe
lesions according to
location, distribution,
color, configuration,
size, shape, type, or
structure. 
5. Observe and Moisture in skin folds Moisture is present in Normal 
palpate skin and the axillae, affected skin folds and axillae. 
moisture  by different factors 
6. Palpate skin Uniform; within normal Upper and lower Normal 
temperature.  range  extremities are
relatively warm to
•compare the two feet touch. 
and the two hands,
using the backs of
your fingers. 
7. Note skin turgor by When pinched, skin Skin springs back Normal 
lifting and pinching springs back to instantly after
the skin on an previous state  pinching. 
extremity. 

ASSESSING THE HAIR 

       
1. Inspect the evenness Evenly distributed hair  Evenly distributed hair  Normal 
of growth over the
scalp. 
2. Inspect hair Thick hair  Client’s hair is thick.   Normal 
thickness or thinness. 
3. Inspect hair texture Silky, resilient hair  Hair is resilient and Normal 
and oiliness.  silky to touch. 
4. Note presence of No infection or There is no presence of Normal 
infections or infestation  infection or infestation
infestations.  in her hair. 
5. Inspect amount of Variable  Amount of body hair is Normal 
body hair  variable in different
areas of the body.  

ASSESSING THE NAILS 

       
1. Inspect fingernail Convex curvature; Nails are of convex Normal 
plate shape to angle between nail and curvature, with angle of
determine its nail bed usually 160°  160°  
curvature and angle 
2. Inspect fingernail Highly vascular and Uniformly pinkish bed Normal 
and toenail bed color.  pink in light skinned; color in both her
dark skinned may be fingernails and
brown or black  toenails. 
3. Palpate fingernail Smooth texture  Fingernails and toenails Normal 
and toe nail texture  are smooth to touch. 
4. Inspect tissues Intact epidermis  No hang nails Normal 
surrounding nails  observed.  
5. Perform blanch test Prompt return or pink Capillary refill is Normal 
of capillary refill  or usual color, less than normal, and color
four seconds  returned in less than
•press two or more four seconds.  
nails between your
thumb and index
finger; look for
blanching and return
of pink color to nail
bed 

ASSESSING HEAD TO NECK 

ASSESSING THE NORMAL ACTUAL INTERPRETATION &

HEAD AND FACE  FINDINGS  FINDINGS  ANALYSIS 
Inspect the head.  Head size and shape The head is Normal 
vary, especially in normocephalic,
Inspect for size, shape accord with ethnicity. symmetric, round,
and configuration.  Usually the head is erect, and in midline.
symmetric, round, No lesions are
erect, and in midline visible.  
and appropriately
related to body size
(normocephalic). No
lesions are visible. 
Inspect for Head should be held The patient is able to Normal 
involuntary still and upright.  hold her head still and
movement.  upright. 
 

 
Palpate the head.  The head is normally The patient’s head is Normal 
hard and smooth, normally hard and
Note consistency  without lesions.  smooth without
lesions. 
 
Inspect the face, The face is symmetric The patient’s face is Normal 
inspect the with a round, oval, symmetrically round
symmetry, features, elongated, or square with no abnormal
movement, appearance. No movements noted.  
expression, and skin abnormal movements
condition  noted. 

 
Palpate the temporal The temporal artery is The patient’s temporal Normal 
artery.  elastic and not tender.  artery is elastic and
nontender.  
Which is located
between the top of the
ear and eye. 
Palpate for the Normally there is no No swelling and Normal 
temporal mandibular swelling, tenderness, or crepitation palpated in
joint (TMJ).  crepitation with the TMJ. 
movement. Mouth
To assess the TMJ, opens and closes fully  
place your index (3 to 6 cm between
finger over the front upper and lower teeth).  
of each ear as you ask Lower jaw moves
the client to open the laterally 1 to 2 cm in
mouth.  each direction. 

ASSESSING THE NORMAL ACTUAL INTERPRETATION

EYES FINDINGS FINDINGS AND ANALYSIS

1. Test distant visual Normal distant visual The patient’s visual Normal 
acuity.  acuity is 20/20 with or acuity in both eyes is
without corrective 20/20. Thus, she can
Position the client 20 lenses. This means read and see things
feet from that the client can from 20 feet away.  
the Snellen or e chart distinguish what the
and ask her to read person with normal  
each line until she vision can distinguish
cannot decipher the from 20 feet away.   
letters or their
direction. Document
the results. 
2. Test near visual Normal near visual The patient is able Normal 
acuity.  acuity is 14/14 (with to read from a distance
or without corrective of 14 inches. 
Use this test for lenses). This means
 that the client can read
middle-aged clients what the normal eye  
and other who can read from a
complain of difficulty distance of 14 inches.   
reading. 
 
Give the client a hand-
held vision chart (e.g.  
Jaeger reading
card, snellen card, or
comparable chart) to
hold 14 inches from
the eyes. Have the
client cover one eye
with an opaque card
before reading from
top (largest print) to
the bottom (smallest
print). Repeat test for
the other eye. 

  NORMAL ACTUAL INTERPRETATION

FINDINGS  FINDINGS  AND ANALYSIS 
3. Test visual fields With normal The patient can able to Normal 
for gross peripheral peripheral vision, the see the pen, same as
vision.  client should see the the examiner sees it  
examiner’s finger at approximately as
To perform the the same time the follows:   
confrontation test, examiner sees it.
position yourself Normal visual field • Inferior: 70 degrees   
approximately 2 feet degrees are 
away from the client • Superior: 50 degrees   
at eye level. Have the approximately as
client cover the left follows:  • Temporal: 90  
eye while you cover degrees 
your right eye. Look • Inferior: 70 degrees   
directly at each other • Nasal: 60 degrees 
with your uncovered • Superior: 50 degrees   
eyes. Next, fully  
extend  • Temporal: 90  
degrees   
Your left arm at
midline and slowly • Nasal: 60 degrees     
move one finger (or a
pencil) upward from      
below until the client
sees your finger (or      
pencil). Test the
remaining three      
visual fields of the
client’s right eye (i.e.,      
superior, temporal,
and nasal). Repeat      
the test for the
opposite eye.       

       

       

         

4.perform corneal The reflection of light The patient’s eye is in Normal 

light reflex test.  on the corneas should parallel alignment and
be in the exact same the reflection of light
This test assesses spot on each eye, on corneas are at the
parallel alignment of which indicates exact same spot on
the eyes. Hold a parallel alignment.  each eye. 
penlight
approximately 12
inches from the
client’s face. Shine
the light toward the
bridge of the nose
while the client stares
straight ahead. Note
the light reflected on
the corneas. 

 
 

  NORMAL ACTUAL INTERPRETATION

FINDINGS  FINDINGS  AND ANALYSIS 
5. Perform cover test.  The uncovered eye The eyes of the patient Normal 
should remain fixed remains fixed even
The cover test detects straight ahead. The after one eye is  
deviation in alignment covered eye should uncovered. 
or strength and slight remain fixed straight  
deviations in eye ahead after being  
movement by uncovered.   
interrupting the fusion  
reflex that normally    
keeps the eyes parallel.  
Ask the client to stare    
straight ahead and  
focus on a distant    
object. Cover one of  
the client’s eyes with    
an opaque card. As  
you cover the eye,    
observe the uncovered  
eye for movement.    
Now remove the  
opaque card and    
observe the previously  
covered eye for any    
movement. Repeat test  
on the opposite eye.     
 
     
 
6.perform the    
positions test, which  
assesses eye muscle    
strength and cranial  
nerve function.    
Instruct the client to
focus on an object you      
are holding
(approximately 12      
inches from the
client’s face). Move the      
object through the six
cardinal positions of       

Gaze in a      
clockwise direction,
and observe the Eye movement    
client’s eye should be smooth and
movements.  symmetric   Normal 
throughout all six
  directions.  The patient’s eye
movement are in
  conjugate manner,
smooth and symmetric
throughout all six
directions.  

ASSESSING THE
NORMAL ACTUAL INTERPRETATION &
EXTERNAL EYE
FINDINGS  FINDINGS  ANALYSIS 
STRUCTURE 
Inspect the eyelids The upper lid margin The patient’s upper lid Normal 
and eyelashes.  should be between the margin is within
upper margin of the iris between the upper
Note width and and the upper margin margin of the iris and
position of palpebral of the pupil. The lower lower lid margin rests
fissures.  lid margin rests on the on the lower border of
lower border of the iris. the iris. 
No white sclera is seen
above or below the iris.
Palpebral fissures may
be 

Horizontal. 
Assess ability of The upper and lower The client was able to Normal 
eyelids to close.  lids close easily and close her eyes easily
meet completely when and completely.  
closed. 
Note the position of The lower eyelid is The lower eyelid is Normal 
the eyelids in  upright with no inward upright with no inward
or outward turning. or outward turning.
Comparison with the Eyelashes are evenly Eyelashes are evenly
eyeballs.  distributed and curve distributed and curve
outward along the lid outward along the lid
Also note any margins.  margins. 
unusual 

• turnings 

• color 

• swelling 

• lesions 

• discharge 
Observe for redness, Skin on both eyelids is No signs of redness, Normal 
swelling, discharge, without redness, swelling or lesions
or lesions.  swelling, or lesions.  noted.  
Observe the position Eyeballs are No protrusion or Normal 
and alignment of the symmetrically aligned sinking of eyeballs
eyeball in the eye in sockets without observed. Both
socket.  protruding or sinking.  eyeballs are
symmetrically
aligned.  
Inspect the bulbar Bulbar conjunctiva is Bulbar conjunctiva is Normal 
conjunctiva and clear, moist, and clear, moist, and
sclera.  smooth. Underlying smooth. Underlying
structures are clearly structures are clearly
Have the client keep visible. Sclera is visible. Sclera is
the head straight white.  white. 
while looking from
side to side then up
toward the ceiling.
Observe clarity, color,
and texture. 
Inspect the palpebral The lower and upper The lower and upper Normal 
conjunctiva.  palpebral conjunctivae palpebral conjunctivae
are clear and free of are clear and free of
swelling or lesions.  swelling or lesions. 
Inspect the lacrimal No swelling or redness There is no redness Normal 
apparatus.  should appear over and swelling observed
areas of the lacrimal over areas of the
Assess the areas over gland. The lacrimal gland and
 puncta is visible puncta. 
the lacrimal glands  without swelling or
redness and is turned  
(lateral aspect of slightly toward the
upper eyelid) and the eye. 
puncta (medial aspect
of lower eyelid). 
Palpate the lacrimal No drainage should be No drainage observed Normal 
apparatus.  noted from the puncta upon palpation. 
when palpating the
Put on disposable nasolacrimal duct. 
gloves to palpate the
nasolacrimal duct to
assess for blockage. 

Use one finger and

palpate just inside 

The lower orbital rim. 

Inspect the cornea The cornea is Cornea and lens is Normal 
and lens.  transparent, with no transparent, moist, and
opacities. The oblique free of  opacities.  
Shine a light from the view shows a smooth
side of the eye for an and overall moist
oblique view. Look surface; the lens is free
through the pupil to of opacities. 
inspect the lens. 
Inspect the iris and The iris is typically The iris is round, flat, Normal 
pupil.  round, flat, and evenly and evenly colored
colored. The pupil, with a regular border.
Inspect shape and round with a regular Pupils are equally
color of iris and size border, is centered in 3mm in size.  
and shape of pupil. the iris. Pupils are
Measure pupils normally equal in size
against a gauge if (3 to 5 mm). An
they appear larger or inequality in pupil size
smaller than normal of less than 0.5 mm
or if they appear to be occurs in 20% of
two different sizes.  clients. This condition,
called anisocoria, is
  normal. 

 
 

Test pupillary The normal direct The patient’s eyes Normal 

reaction to light.  pupillary response is respond with constriction
constriction.  upon application of  
Test for direct light.  
response by darkening    
the room and asking  
the client to focus on a    
distant object. To test  
direct pupil reaction,    
shine a light obliquely  
into one eye and    
observe the pupillary  
reaction. Shining the    
light obliquely into the  
pupil and asking the    
client to focus on an  
object in the distance    
ensures that pupillary  
constriction is a    
reaction to light and  
not a near reaction.     
 
     
 
     
 
Assess consensual    
response at the same  
time as direct    
response by shining a  
light obliquely into    
one eye and observing  
the     
 
Pupillary reaction in    
the opposite eye.   
   
   
   
   
       

Test accommodation      
of pupils. 
     
Accommodation
occurs when the client The normal consensual One eye constricts while  
moves his or her focus pupillary response is light is applied on the
of vision from a constriction.  other. Same response Normal 
distant point to a near was obtained from both
object, causing the   eyes.    
pupils to constrict.
Hold your finger or a      
pencil about 12 to 15
inches from the client.      
Ask the client to focus
on your finger or      
pencil and to remain
focused on it as you      
move it closer in
toward the eyes.       

       

     

The normal pupillary The  

response is constriction patient’s eyes constrict
of the pupils and and converge when  
convergence of the moving pen towards it. 
eyes when focusing on  
a near object
(accommodation and  
convergence). 
 

Normal 

ASSESSING THE
NORMAL ACTUAL INTERPRETATION &
INTERNAL EAR
FINDINGS  FINDINGS  ANALYSIS 
STRUCTURES 
Inspect the external A small amount of A small amount of Earwax is most often
auditory canal.  moist, yellow, amber orange to light
 odorless cerumen  odorless cerumen brown, wet, and sticky.
Use the otoscope.  found in both ears.   For some people, it is
(earwax) is the only drier and lighter in color,
Note any discharge discharge normally closer to off white or
along with the color present. Cerumen yellow. Some people
and  color may be yellow,  produce more wax than
is common, or the ears
Consistency of orange, red, brown, may produce more wax
cerumen (earwax).  gray, or black. when a person is very
Consistency may be stressed. When this
soft, moist, dry, flaky, happens, the ears may
or even hard.  not be able to get rid of
the wax fast enough, and
blockages can occur. 

Blockages in the ear can

change the color and
texture of the wax. If the
person cannot remove
the wax, the ear canal
may become fully
blocked, which could
impair hearing and
increase the risk of
infection. (Johnson,
2019) 

 
Observe the color and The canal walls The patient’s canal Normal 
consistency of the ear should be pink and walls are pink, smooth
canal walls and spect smooth, without and without lesions. 
the character of any nodules. 
nodules. 

ASSESSING THE
NORMAL ACTUAL INTERPRETATION &
HEARING AND
FINDINGS  FINDINGS  ANALYSIS 
EQUILIBRIUM 
Perform the whisper Able to correctly The patient is able to Normal 
test.  repeat the two- correctly repeat the
syllable word as whispered two-syllable
With your head 2 feet whispered.  word. 
behind the client (so
that the client cannot
see your lips move),
whisper a two-syllable
word such as
“popcorn” or
“football.” Ask the
client to repeat it back
to you. If the response
is incorrect the first
time, whisper the
word one more time.
Identifying three out
of six whispered
words is considered
passing the test. 
Perform weber’s Vibrations are heard The patient was able to Normal 
test if the client equally well in both feel the vibration in
reports diminished or ears. No lateralization both ear which
lost hearing in one of sound to either ear.  indicates a Weber’s
ear  negative. 
Perform Air conduction sound Air conduction sound Normal 
the rinne’s test.  is normally heard is normally heard
longer than bone longer than bone
Strike a tuning fork conduction sound  conduction sound. 
and place the base of
the fork on the client’s (AC > BC).   
mastoid process. Ask
the client to tell you
when the sound is no
longer heard. Move
the prongs of the
tuning fork to the
front of the external
auditory canal. Ask
the client to tell you if
the sound is audible
after the fork is
moved. 
Perform Client maintains The patient was able to Normal 
the Romberg test.  position for 20 maintain her balance in
seconds without 20 seconds with
This tests the client’s swaying or with minimal swaying.  
equilibrium. Ask the  minimal swaying. 

Client to stand with

feet together, arms at
sides, and eyes open,
 then with the eyes
closed. 

ASSESSING THE NORMAL ACTUAL INTERPRETATION &

NOSE  FINDINGS  FINDINGS  ANALYSIS 
Inspect and palpate Color is the same as The patient’s nose is Normal 
the external nose.  the rest of the face; the similar in color with
nasal structure is the rest of face,
Note nasal color, smooth and symmetrical and
shape, consistency, symmetric; the client smooth in stucture. No
and tenderness.  reports no tenderness.  signs of tenderness
was reported.  
Check patency of air Client is able to sniff Client’s nostrils are Normal 
flow through the  through each nostril congested.  
while other is
Nostrils  occluded. 

By occluding one
nostril at a time and
asking client to sniff. 
Inspect the internal The nasal mucosa is The nasal mucosa is  
nose.  dark pink, moist, and dark pink and moist.
free of exudate. The Nasal septum is intact
To inspect the nasal septum is intact and free of
internal nose, use an and free of ulcers or ulcers/perforations.  
otoscope  perforations. 

With a short wide-tip Turbinates are dark

attachment or you pink (redder than oral
can  mucosa), moist, and
free of lesions. 
Also use a nasal
speculum and
penlight 
 

 ASSESSING THE  ACTUAL INTERPRETATION

 NORMAL FINDINGS 
MOUTH  FINDINGS  & ANALYSIS 
Inspect the lips.  Lips are smooth and The lips are Normal 
moist without lesions or smooth, pink and
Observe lip consistency swelling.  moist with no
and color.  sign of lesions or
swelling. 
Inspect the teeth and Twenty-Eight pearly The patient has Acidic foods and
gums.  whitish teeth with smooth whitish teeth beverages can promote
surfaces and edges. Upper with smooth staining by eroding
Ask the client to open molars should rest surfaces and tooth enamel and
the mouth. Note the directly on the lower edges, presence making it easier for
number of teeth, color, molars and the front of slight yellow pigments to latch onto
and condition. Note any upper incisors should discoloration is the teeth 
repairs such as crowns slightly override the observed with
and any cosmetics such lower incisors.  dental caries.  
as veneers. Ask the client
to bite down as though
chewing on something
and note the alignment
of the lower and upper
jaws. 
Put on gloves and  No decayed areas; no There are 2 There must be no
missing teeth.  tooth cavities on decayed areas or
Retract the client’s  lower molar and missing teeth in the
Client may have 3 tooth cavities client’s mouth.
Lips and cheeks to  appliances on the teeth  on upper molar.  Presence of tooth decay
or if there’s a missing
Check gums for  (e.g., braces). Client may tooth might indicate
have evidence of repair poor oral hygiene. 
Color and  work done on teeth (e.g.,
fillings, crowns, or
Consistency.  cosmetics such as
veneers). Gums are pink,
moist, and firm with tight
margins to the tooth. No
lesions or masses. 
Inspect the buccal The buccal mucosa The buccal Normal 
mucosa.  should appear pink in mucosa appeared
light-skinned clients; pink and moist. 
Use a penlight and tissue pigmentation
tongue depressor to  typically increases in dark
skinned clients. 
Retract the lips and
cheeks to check color
and consistency. 
Inspect and palpate the Tongue should be pink, The tongue is Normal 
tongue.  moist, a moderate size pink and moist
with papillae (little with moderately
Ask client to stick out protuberances) present. A sized papillae. 
the tongue. Inspect for common variation is a
color, moisture, size, and fissured, topographic
texture. Observe for map– 
fasciculations (fine
tremors), and check for like tongue, which is not
midline protrusion. unusual in older clients.
Palpate any lesions No lesions are present. 
present for induration
(hardness). 
Assess the ventral The tongue’s ventral The tongue’s   Normal 
surface of the tongue.  surface is smooth, shiny, ventral surface is
pink, or slightly pale, with smooth, pink, and
Ask the client to touch visible veins and no moist with visible
the tongue to the roof of lesions.  veins. No lesions
mouth, and use a noted.  
penlight to inspect the 

Ventral surface of the

tongue, frenulum, 

And area under the

tongue 
Palpate the area if you The older client may have No lesions and  
see lesions, if the client is varicose veins on the induration
over age 50, or if the ventral surface of the palpated.  
client uses tobacco or tongue 
alcohol. Note any
induration. 

Check also for a

short frenulumthat limits
tongue motion (the
origin of “tonguetied”). 
Inspect The frenulum is midline; There is no Normal 
for wharton’s ducts—  Wharton’s ducts are swelling, redness,
visible, with salivary flow or pain. The
Openings from the or moistness in the area. frenulum is in
submandibular  The client has no midline along the
swelling, redness, or Wharton’s ducts
 pain.  that are moist
Salivary glands— with salivary
located on either side of flow. 
the frenulum on the
floor of the mouth. 
Observe the sides of the No lesions, ulcers, or Sides of tongue Normal 
tongue.  nodules are apparent.  has no lesions,
ulcers or nodules. 
Use a square gauze pad
to hold the client’s
tongue to each side.
Palpate any lesions,
ulcers, or nodules for
induration. 
Check the strength of The tongue offers strong Tongue offers Normal 
the tongue.  resistance  strong resistance,
resisting the force
Place your fingers on the when applied on
external surface of the both cheeks. 
client’s cheek. Ask the
client to press the 

Tongue’s tip against the

inside of the cheek to 

Resist pressure from

your fingers. Repeat on
the opposite cheek. 
       
       
Note odor.   No unusual or foul odor Uvula hangs Normal 
noted.   freely at midline
with no redness or
exudate.  
       
       
Assess the uvula.  The uvula is a fleshy, The uvula hangs Normal 
solid structure that hangs freely at midline
freely in the midline. No with no signs of
redness of or exudate redness or
from uvula or soft palate. exudate. 
Midline elevation of
uvula and symmetric
elevation of the soft
palate.  
Inspect the tonsils.  Tonsils may be present. Tonsils are  
They are normally pink present but
and symmetric and may enlarged to 2+.  
be enlarged to 1+ in
healthy clients. No
exudate, swelling, or
lesions should be present. 
Inspect the posterior Throat is normally pink, Throat is Normal 
pharyngeal wall.  without exudate or normally pink
lesions.  without exudate
or lesions. 

ASSESSING THE NORMAL ACTUAL

INTERPRETATIONS 
SINUSES  FINDINGS  FINDINGS 
Palpate the sinuses.  Frontal and maxillary No tenderness and Normal 
sinuses are non-tender crepitus evident upon
When an infection is to palpation, and no palpation. 
suspected, the nurse  crepitus is evident. 

can examine the

sinuses through
palpation, percussion,
and transillumination.
Palpate the frontal
sinuses by using your
thumbs to press up on
the brow on each side
of nose. 
Percuss the sinuses.  The sinuses are not No tenderness upon Normal 
tender on percussion  percussion. 
Lightly tap (percuss)
over the frontal
sinuses 

And over the

maxillary sinuses for
tenderness. 

ASSESSING THORAX-HEART-BREAST 

AREA TO BE NORMAL ACTUAL FINDINGS  INTERPRETATION

 ASSESSED/ BODY
FINDINGS  AND ANALYSIS 
PART 
Inspect configuration.  Scapulae are Upon inspecting, the  
symmetric and non- patient’s
protruding. scapulae is symmetric Normal 
Shoulders and and nonprotruding.
scapulae are at equal Shoulders and scapulae
horizontal positions. are at equal horizontal
The ratio positions. The ratio of
of anteroposterior anteroposterior to
to transverse transverse diameter is 1:2.
diameter is 1:2. The spinous processes
Spinous processes appear straight, and
appear straight, and thorax appears
thorax appears symmetric, with ribs
symmetric, with ribs sloping downward. 
sloping downward
at approximately a
45-degreeangle in
relation to the
spine. 
Observe use of The client does not Upon observing, the  
accessory muscles. use accessory patient does not use
Watch as the client (trapezius/ shoulder) accessory muscles to Normal 
breathes and note use muscles to assist assist her breathing. 
of muscles.  breathing. The
diaphragm is the
major muscle at
work. This is
evidenced by
expansion of the
lower chest during
inspiration. 
Inspect the client’s Client should be The patient is relaxed  
positioning.  sitting up and while sitting up with her
relaxed, breathing arms on her lap. He is Normal 
easily with arms at also breathing easily. 
sides or in lap 
Palpate for tenderness Client reports no While doing palpation,  
and sensation.  tenderness, pain, or the patient reports that he
unusual sensations. doesn’t feel any Normal 
Temperature should tenderness or any unusual
be equal bilaterally.  sensations. The
temperature is equal
bilaterally. 
Palpate for crepitus.  The examiner finds There is no crepitus  
no palpable palpable. 
crepitus.  Normal 
Palpate surface Skin and The skin and  
characteristics.  subcutaneous tissue subcutaneous tissue are
are free of lesions free of lesions and Normal 
and masses.  masses. 
Palpate for fremitus.  Fremitus is Fremitus is symmetric  
symmetric and and easily identified in
easily identified in the upper lung regions.   Normal 
the upper regions of
the lungs. If
fremitus is not
palpable on either
side, the client may
need to speak
louder. A decrease
in the intensity of
fremitus is normal
as the examiner
moves toward the
base of the lungs.
However, fremitus
should remain
symmetric for
bilateral positions. 
Assess chest When the client As client takes a deep  
expansion.  takes a deep breath, breath, thumbs
the examiner’s symmetrically move 5cm Normal 
thumbs should move apart. 
5 to 10 cm apart
symmetrically. 
Percuss for tone  Resonance is the Tone is resonant over  
percussion tone normal lung tissue while
elicited over normal flat over bones and Normal 
lung tissue. scapula.  
Percussion elicits
flat tones over the
scapula. 
Percuss for Excursion should be The diaphragmatic  
diaphragmatic equal bilaterally and excursion of the patient is
excursion.  measure 3–5 cm in equal bilaterally and has a Normal 
adults. The level of measure of 5 cm on both
the diaphragm may sides. 
be higher on the
 right because of the
position of the liver.
In well-conditioned
clients, excursion
can measure up to 7
or 8 cm. 
Auscultate for breath Three types of Upon auscultating, the  
sounds.  normal breath bronchial sounds are
sounds may be elicited from trachea,  Normal 
auscultated— bronchovesicular between
bronchial, scapula, and vesicular
bronchovesicular, breath sounds over lungs. 
and vesicular 
Auscultate for No adventitious There is no adventitious  
adventitious sounds.  sounds, such sounds, such as crackles
as crackles(discrete or wheezes are Normal 
and discontinuous auscultated. 
sounds) or wheezes
(musical and
continuous), are
auscultated. 
Auscultate voice Voice transmission The voice transmission is  
sounds. Bronchophony: is soft, muffled, and soft, muffled, and
ask the client to repeat indistinct. The indistinct.  Normal 
the phrase “ninety- sound of the voice
nine” while you may be heard but
auscultate the chest the actual phrase
wall.  cannot be
distinguished. 
Egophony: ask the Voice transmission The voice transmission is  
client to repeat will be soft and soft, muffled and the
the letter“e” while you muffled but the letter “E” is Normal 
listen over the chest letter “E” should be distinguishable 
wall.  distinguishable 
Whispered Transmission of Upon doing the test, the  
pectoriloquy: ask the sound is very faint transmission of sound
client to whisper the and muffled. It may is inaudible.  Normal 
phrase “one–two– be inaudible. 
three” while you
auscultate the chest
wall. 

 
 

ANTERIOR THORAX 

AREA TO BE
NORMAL INTERPRETATION
ASSESSED/ BODY ACTUAL FINIDNGS 
FINDINGS  AND ANALYSIS 
PART 
Inspect for shape and The anteroposterior The anteroposterior  
configuration.  diameter is less than diameter measures with
the transverse a ratio of 1:2.  Normal 
diameter. The ratio of
anteroposterior
diameter to the
transverse diameter is
1:2. 
Inspect position of Sternum is positioned The sternum is  
the sternum.  at midline and positioned straight at
straight.  midline.  Normal 
Watch for sternal Retractions not No retractions noted.    
retractions.  observed. 
Normal 
Inspect slope of the Ribs slope downward Ribs slope of the  
ribs.  with symmetric patient is downward
intercostal spaces. with symmetric Normal 
Costal angle is within intercostal spaces. The
90 degrees.  costal angle is within
90 degrees. 
Observe quality and Respirations are Client offers relaxed,  
pattern of relaxed, effortless, and effortless, and quiet
respiration.  quiet. They are of a respirations of regular Normal 
regular rhythm and rhythm and normal
normal depth at a rate depth at a rate of 26
of 10–20 per minute in cycles per minute.  
adults. Tachypnea and
bradypnea may be
normal in some
clients 
Inspect intercostal No retractions or Upon inspecting, there  
spaces.  bulging of intercostal is no retractions or
spaces are noted.  bulging of intercostal Normal 
spaces that are
observed. 
Observe for use of Use of accessory Client does not require  
accessory muscles.  muscles the use of accessory
(sternomastoid and muscles for breathing.  Normal 
 rectus abdominis) is
not seen with normal
respiratory effort.
After strenuous
exercise or activity,
clients with normal
respiratory status may
use neck muscles for a
short time to enhance
breathing. 
Palpate for No tenderness or pain Upon palpation, there is  
tenderness, is palpated over the no tenderness or pain
sensation, and lung area with reported over the lung Normal 
surface masses.  respirations.  area with respirations. 
Palpate for Palpation does not Palpation does not  
tenderness at elicit tenderness.  elicit tenderness. 
costochondral Normal 
junctions of ribs. 
Palpate for crepitus  No crepitus is There is no crepitus  
palpated  palpated. 
Normal 
Palpate for any No unusual surface There are no lesions or  
surface masses or masses or lesions are masses palpated. 
lesions.  palpated.  Normal 
Palpate for fremitus.  Fremitus is symmetric The fremitus is  
and easily identified in symmetric bilaterally
the upper regions of and it is easily Normal 
the lungs. A decreased identified in the upper
intensity of fremitus is regions of the lungs. 
expected toward the
base of the lungs.
However, fremitus
should be symmetric
bilaterally. 
Palpate anterior Thumbs move outward Thumbs move outward  
chest expansion.  in a symmetric fashion for at least 5cm in a
from the midline.  symmetric fashion from Normal 
the midline. 
Percuss for tone.  Resonance is the Resonance is elicited  
percussion tone over normal lung
elicited over normal tissue.  Normal 
lung tissue. Percussion
elicits dullness over Dullness is present over
breast tissue, the heart, breast tissue, heart, and
and the liver. liver. Tympanic sounds
 Tympany is detected
over the stomach, and are heard over stomach.
flatness is detected Flat sounds auscultated
over the muscles and over muscles and
bones.  bones.  
Auscultate for Refer to text in the Upon auscultating,  
anterior breath posterior thorax there are three normal
sounds, adventitious section for normal breath sounds heard Normal 
sounds, and voice voice sounds.  such as bronchial,
sounds.  bronchovesicular, and
vesicular breath
sounds. There is no
adventitious sounds
noted and normal voice
sounds are heard. 

 
 

BREASTS 

NORMAL ACTUAL INTERPRETATION

 
FINDINGS  FINIDNGS  AND ANALYSIS 
Inspect size and Breasts can be a variety Patient did not agree  
symmetry.  of sizes and are to the said
somewhat round and assessment.  Normal 
pendulous. One breast
may normally be larger
than the other. 
Inspect color and Color varies depending Patient did not agree  
texture.  on the client’s skin tone. to the said
Texture is smooth, with assessment.  Normal 
no edema. Linear
stretch marks may be
seen during and after
pregnancy or with
significant weight gain
or loss. 
Inspect superficial Veins radiate either Patient did not agree  
venous pattern.  horizontally and toward to the said
the axilla (transverse) or assessment.  Normal 
vertically with a lateral
flare (longitudinal).
Veins are more
prominent during
pregnancy. 
Inspect the areolas.  Areolas vary from dark Patient did not agree  
pink to dark brown, to the said
depending on the assessment.  Normal 
client’s skin tones. They
are round and may vary
in size. Small
Montgomery tubercles
are present. 
Inspect the nipples.  Nipples are nearly equal Patient did not agree  
bilaterally in size and to the said
are in the same location assessment.  Normal 
on each breast. Nipples
are usually everted, but
they may be inverted or
flat. Supernumerary
nipples may appear
 along the embryonic
“milk line.” No
discharge should be
present. 
Inspect for retraction The client’s breasts Patient did not agree  
and dimpling.  should rise to the said
symmetrically, with no assessment.  Normal 
sign of dimpling or
retraction. 
Ask the client to lean Breasts should hang Patient did not agree  
forward from the freely and to the said
waist.  symmetrically.  assessment.  Normal 
Palpate texture and Palpation reveals Patient did not agree  
elasticity  smooth, firm, elastic to the said
tissue.  assessment.  Normal 
Palpate for A generalized increase Patient did not agree  
tenderness and in nodularity and to the said
temperature.  tenderness may be a assessment.  Normal 
normal finding
associated with the
menstrual cycle or
hormonal medications.
Breasts should be a
normal body
temperature. 
Palpate for masses.  No masses should be Patient did not agree  
palpated. However, a to the said
  firm inframammary assessment.  Normal 
transverse ridge may
  normally be palpated at
the lower base of the
If you detect any breasts. 
lump, refer the client
for further Fibrocystic breast tissue
evaluation.  that feels ropy, lumpy,
or bumpy in texture is
referred to as “nodular”
or “glandular” breast
tissue. Benign breast
disease consists of
bilateral, multiple, firm,
regular, rubbery, mobile
nodules with well-
demarcated borders.
Pain and
 fullness occurs just
before menses. 
Palpate the nipples.  The nipple may become Patient did not agree  
erect and the areola may to the said
pucker in response to assessment.  Normal 
stimulation. A milky
discharge is usually
normal only during
pregnancy and lactation.
However, some women
may normally have a
clear discharge. 

THE AXILLAE 

  NORMAL ACTUAL INTERPRETATION

FINDINGS  FINDINGS  AND ANALYSIS 
Inspect and palpate No rash or infection Upon inspection and  
the axillae.  noted.  palpating the axillae
of the patient, there is Normal 
No palpable nodes or no rash or infection
one to two small (less noted and there is also
than 1 cm), discrete, no palpable nodes. 
nontender, movable
nodes in the central
area. 
Ask the client to Client may request The patient has the  
demonstrate how she instructions on how to knowledge on how to
performs BSE.  perform the exam or perform a proper Normal 
choose not to learn BSE. 
how to perform the
exam. Either choice
needs to be accepted
by the examiner. 

 
  

NECK VESSELS 

AREA TO BE
NORMAL ACTUAL INTERPRETATION
ASSESSED/BODY
FINDINGS  FINDINGS  AND ANALYSIS 
PART 
Observe the jugular The jugular venous The jugular venous Normal 
venous pulse.  pulse is not normally pulse is not normally
visible with the client visible with the client
sitting upright. This sitting upright. 
position fully distends
the vein, and
pulsations may or
may not be
discernible. 
Evaluate jugular The jugular vein By using tangential  
venous pressure.  should not be lighting, there is no
distended, bulging, or distention, protrusion, Normal 
protruding at 45 or bulging observed. 
degrees or greater. 
Auscultate the carotid No blowing or There is no blowing  
arteries if the client is swishing or other or swishing or other
middle- aged or older sounds are heard. sounds are heard. The Normal 
or if you suspect Pulses are equally pulses of the client
cardiovascular strong; a 2+ or normal have a grade of 2+
disease.  with no variation in and equally strong.
strength from beat to The contour is
beat. Contour is normally smooth and
normally smooth and rapid. 
rapid on the upstroke
and slower and less
abrupt on the down
stroke. The strength of
the pulse is evaluated
on a scale from 0 to 4 
Palpate the carotid Arteries are elastic Arteries are elastic  
arteries.  and no thrills are and no thrills are
noted.  noted.  Normal 

 
  

HEART (PRECORDIUM) 

AREA TO BE
NORMAL ACTUAL INTERPRETATION
ASSESSED/ BODY
FINDINGS  FINDINGS  AND ANALYSIS 
PART 
Inspect pulsations.  The apical impulse The apical impulse is  
may or may not be not visible upon
visible. If apparent, it inspection.  Normal 
would be in the mitral
area.  The apical
impulse is a result of
the left ventricle
moving outward during
systole. 
Palpate the apical The apical impulse is The apical impulse is  
impulse.  palpated in the mitral palpable in the mitral
area and may be the area and the size is in Normal 
size of a nickel (1-2 2 cm. 
cm). Amplitude is
usually small -like a
gentle tap. The
duration is brief,
lasting through the 1st
2/3 of systole and often
less. In obese clients or
clients with large
breasts, the apical
impulse may not be
palpable. 
Palpate for abnormal No pulsations or There is no abnormal  
pulsations.  vibrations are palpated pulsations or
in the areas of the apex,
vibrations palpated in Normal 
left sternal border, or
the areas of the apex,
base.  left sternal border, or
base. 
Auscultate heart rate Rate should be 60-100 Client has a heart rate  
and rhythm.  bpm with a regular of 64 beats per minute
rhythm. A regularly with regular depth and Normal 
irregular rhythm, such rhythm.  
as sinus arrhythmia
when the heart rate
increases with
 inspiration and
decreases with
expiration, may be
normal in young
adults. 
Auscultate to identify S1corresponds with S1 is loudest at the  
s1and s2.  each carotid pulsation apex of the heart while
and is loudest at the the S2 is loudest at the Normal 
apex of the heart. base of the heart. 
S2immediately follows
after S1and is loudest
at the base of the heart 
Listen to s1 use the A distinct sound is Distinct sound is heard  
diaphragm of the heard in each area but loudest at the apex.  
stethoscope to best loudest at the apex. Normal 
hear s1.  May become softer
with inspiration. A split
S1may be heard
normally in young
adults at the left lateral
sternal border. 
Listen to s2.  Distinct sound is heard Distinct sound is heard  
in each area but is loudest at the base.  
loudest at the base.  Normal 
Auscultate for extra Normally no sounds Upon auscultation,  
heart sounds.  are heard A there is no extra heart
physiologic S3 heart sound heard.  Normal 
sound is a benign
finding commonly
heard at the beginning
of the diastolic pause in
children, adolescents
and young adults (rare
after age 40) A
physiologic S4 heart
sound may be heard
near the end of diastole
in well- conditioned
athletes and adults
older than age 40 or 50
with no evidence of
heart disease 
Auscultate for Normally no murmurs There are no murmurs  
murmurs.  are heard  heard. 
Normal 
 

ASSESSING ABDOMEN 

       
1. Inspect the Slighty pale, the  color is The abdomen is Normal 
coloration of the skin  symmetrical with symmetrical with
surrounding skin.  surrounding skin. 
2. Inspect the striae Stretch marks No stretch marks, Normal 
and lesions.  may occured and the lesions and scars over
normal color is pinkish abdomen. 
or bluish but it should not
be dark bluish. Scars may
be found but it should be
smooth. 
3. Inspect the Umbilical skin tones The umbilicus is in Normal 
umbilicus  are similar to surrounding midline, similar to
abdominal skin tones. surrounding abdominal
The umbilicus is in the skin tones, round and
midline and it is round not protruding.  
and protruding. 
4. Inspect the The abdominal contour Client has evenly Normal 
abdominal contour  must be evenly rounded rounded abdominal
flat, scaphoid and contour.  
symmetrical. 
5. Inspect for aortic Slight pulsation The aortic pulsation Normal 
pulsation  may seen if the patient is was not seen on the
thin.  patient’s abdomen. 
6. Inspect for the Normally peristaltic No peristaltic waves Normal 
peristaltic waves  may seen in the thin observed. 
patients. 
7. Auscultate for A series of gurgles and A series of growling, Normal 
bowel sounds  soft clicks is been heard sound is heard over the
at the rate of 5-30 per abdomen. 
minute. Absent bowel
sounds is signify
as a absence of bowel
motility. 
8. Auscultate for Bruits are not normally Bruits were not heard Normal 
vascular sounds  heard in the aorta, renal over the aorta, renal,
,iliac and femoral artery.  iliac and femoral area. 
9. Percuss the tone Tympany is heard over Tympany is heard over Normal 
over the abdominal the patient abdomen and the patient abdomen
area.  dullness is heard from the and dullness is heard
patient liver and spleen.  from the patient liver
 and spleen. 
10. Percuss the span The measurement Client has a liver span Normal 
and height of the of an liver span in MCL of 5cm. 
liver.  should be 6-12 cm 
11. Perform the blunt No tenderness must be No tenderness and pain Normal 
percussion.  observed.  observed. 
12. Perform the light The Abdomen should not Client reports  
palpation  elicit tenderness.  tenderness over the
epigastric region of
the abdomen on a
pain scale of 5. 
13. Palpate No masses should No bulges, masses and Normal 
for massess, lesions or be palpated and it should lesions and the aorta
bulges and the aorta.  be free from bulges, elicited. 
swellings and the aorta
may elicit mild
tenderness. 
14. Palpate the liver.  The liver is not palpable The liver is not Normal 
and if it is palpable in palpable, but elicits
thin patient it should be mild tenderness. 
smooth and elicit some
mild tenderness. 
15. Palpate the The spleen is palpable.  The spleen is palpable.  Normal 
spleen. 
16. Assess for the There should not be No tenderness Normal 
psoas sign  observed tenderness.  observed 

- in performing for
the psoas sigh the
patient must lie to the
left side and
hyperextend her right
leg. 

ASSESSING MUSCULOSKELETAL 

AREA TO BE NORMAL ACTUAL FINDINGS  DEVIATION FROM

ASSESSED/ BODY FINDINGS  NORMAL 
PART 
Inspect the muscles Equal size on both Patient’s muscles are of Normal 
for size. Compare sides of body  equal size on both sides
each muscle on one of the body. 
side of the body to the
same muscle on the
other side. 
Inspect the muscles No contractures  There are no contractures Normal 
and tendons for observed when client was
contractures.  asked to raise both
arms.  
Inspect the muscles No fasciculation or No fasciculation or Normal 
for tremors.  tremors  tremors noted. 
Palpate muscles at Normally firm  Muscles, when at rest, Normal 
rest to determine are normally firm. 
muscle tonicity. 
Palpate muscles while Smooth coordinated The muscles have Normal 
the client is active movements  a smooth, coordinated
and passive for movements. 
flaccidity, spasticity,
and smoothness of
movement. 
Test muscle strength Equal strength on each The muscle strength of Normal 
of the head and body side  the  head and shoulders
shoulders.  has an equal strength on
each body side. 
Test muscle strength   Upon performing the test, Normal 
of upper extremities.  the muscle strength of the
upper extremities has an
equal strength on each
body side 
Test muscle strength   Upon performing the test, Normal 
of lower extremities.  the muscle strength
of the  lower extremities
has an equal strength on
each body side 
Inspect the skeleton No deformities  No Deformities.  Normal 
for normal structure
and deformities. 
Palpate the bones to No tenderness of No tenderness or Normal 
locate any areas of swelling  swelling. 
edema or tenderness. 
Inspect the joint for No swelling. No There is no swelling, Normal 
swelling  tenderness, tenderness, crepitation, or
crepitation, or nodules observed. 
nodules 
Palpate each joint for No tenderness, There is no tenderness, Normal 
tenderness, swelling, crepitation, swelling, crepitation, or
smoothness of or presence of presence of nodules
movement, swelling, nodules.  noted. 
crepitation, and
presence of nodules. 
Assess joint range of Varies to some degree The patient was able to Normal 
motion. Ask the client in accordance with perform in full range of
to move selected body person’s genetic motion. 
parts. If available, makeup and degree of
use a goniometer to physical activity. Full
measure the angle of range of motion. 
the joint in degrees. 
Assess joint range of Full range of motion.  The patient was able to Normal 
motion of the head.  perform in full range of
motion. 
Assess joint range of Full range of motion.  The patient was able to Normal 
motion of the body perform in full range of
trunk.  motion. 
Assess joint range of Full range of motion.  The patient  was able to Normal 
motion of the upper perform in full range of
extremities.  motion. 
Assess joint range of Full range of motion.  The patient as able to Normal 
motion of the lower perform in full range of
extremities.  motion. 
 GORDON’S CUES INFERENCES NURSING
PATTERN DIAGNOSIS

Nasal congestion ACTUAL

Health perception & SUBJECTIVE Congestion is when your Acute pain related
management: nose becomes stuffed to self-report of
Before the “Nagbago yung and inflamed, it intensity using
hospitalization, the mga kinakain ko commonly occurs on standardized pain
client has, araw araw kasi minor illnesses such as scale as manifested
Healthy for her is to yung ospital, sila cold and flu, illness- by presence of
have lots of energy nagbibigay sa akin related congestion abdominal pain
When it comes to ng pagkain" usually improves within
health maintenance, a week. Symptoms of
eating healthy foods "Hindi ako nasal congestion Ineffective health
such as vegetable and nakadumi ngayong includes a stuffy nose, management
taking vitamins is her araw tapos kahit sinus pain, mucus related to poor
means of health na malamig sa buildup and swollen hygiene as
management pwesto ko nasal tissue (Chirico G, evidenced by dental
During the pinagpapawisan et al., 2014). caries and dirty
hospitalization, the ako ng onti lang" fingernails
client has, Inflamed tonsils
"Hindi ko gusto
The same health Tonsillitis is also known
sports"
perception which is as the inflammation of
being healthy means to "Natutulog pa rin one’s tonsils due to
have a lot of energy. ako kahit may infection caused by POTENTIAL
However, due to her araw kasi pagod foreign microorganisms, Potential for
condition, she stopped lagi pakiramdam it can occur at any age ineffective
taking her vitamins but ko” and is a common breathing pattern
still eat healthy foods childhood illness. related to
“Meron po akong Symptoms include a sore hyperventilation
Nutritional & nararamdamang throat, swollen tonsils, AEB 26 breathing
metabolic: and fever. Furthermore, cycles per minute
Before she was sakit sa tyan ko po this disease is contagious
hospitalized, the client bandang taas” and if not treated earyl, it
Potential for
said has no food may infect other person infection related to
allergies and she is not within the area.insufficient
picky when it comes to Tonsillitis is easy to knowledge to avoid
food. She eats 1 cup of diagnose and usually go exposure to
rice per meal and her away within 7-10 days pathogens AEB
usual viand is either Anderson J, et al. (2019). change in
pork or chicken, but it physiological
is most often than not Rashes parameter, tonsil
vegetables. A rash is a visible grade 2+
Furthermore, the client change in texture or
said that the only color of the skin, it may
beverage she drinks is become scaly, bumpy, RISK
water and her usual itchy, or otherwise Risk for infection
consumption is about 5- irritated one of the related to alteration
7 glasses of water per causes of rash may be in skin integrity
day. In addition, she drug allergy and is AEB rashes on
drinks a glass of milk considered a medical upper & lower
every morning. emergency and urgent extremities
Then when she got care may be required
hospitalized, the (Rashes: The itchy truth, Risk for infection
client;s usual eating 2014). related to
pattern pattern has insufficient
changed because food Overweight knowledge to avoid
is provided by the Complaints of abdominal exposure to
hospital. The hospital pain are more common pathogens AEB
food contains a cup of in children younger than nail biting
rice, meat and 11 years and are often
vegetables. When it caused by changes in Risk for overweight
comes to drinks, 2-3 eating and bowel habits. related to
bottles of water (12 oz) Most cases of abdominal BMI>25kg/m2
is her usual water pain are not serious, and AEB client’s BMI,
consumption per day. home treatment is often 27.20 kg/m2
all that is needed to help
relieve the discomfort.
Elimination: Girls who start having
When the patient was menstrual periods may
not hospitalized, her have abdominal pain
usual elimination is each month, and the pain
once per day and may be more severe in
further stated that there some months than
are no deviations from others.
defacating.
Furthermore, she also Generalized pain occurs
said that her urination is in half of the abdomen or
about 5 to 6 times in a more. Localized pain is
day and doesn’t feel located in one area of the
any pain when abdomen. Babies and
urinating. Perspiration toddlers often react
is not a problem for her differently to pain than
either because she only older children who can
perspire when the talk about their pain. A
weather is hot. baby may become fussy,
However when she was draw his or her legs up
hospitalized, the client toward the belly, or eat
said that she did not poorly. Older children
defacate during the day may be able to point to
she was interviewed the area of the pain and
and her urination describe how severe it is
ranges from 10 times a (Blahd, W. H., 2018).
day, even if her
urination has increased, Abdominal Pain
she did not feel any During puberty the body
pain when urinating. goes through some very
Her perspiration also important changes
changes because even increasing the need for a
when she was in a cold regular regime for
environment, she still maintaining personal
sweat a little. hygiene. Many teenagers
and indeed parents find
these changes
Activity & exercise: embarrassing to discuss
Before the patient was and many teenagers can
hospitalized, the client be left in the dark about
was, what they need to do and
Not active in sports, the products available to
however she is playing them (Johnson, J., 2017).
with her friends during
her leisure time Overweight
She only exercise The Center for Disease
during their PE subjects Control and Prevention
at school reports that a 12-year-old
During her girl’s weight is usually
hospitalization, the between 68 and 135
client was pounds, and the 50th
Still not active on percentile weight for
sports due to her girls is 92 pounds. f your
condition and since she child is in the 50th
was admitted to the percentile for weight, it
hospital, she cannot means that out of 100
spend time and play children their age, 50
with her friends may weigh more than
they do and the other 50
Cognition & may weigh less. If your
perception: child is in the 75th
Client is able to read percentile, it means that
and write. out of 100 kids their age,
Client does not need 25 may weigh more and
glasses in viewing and 75 may weigh less. As
reading near/distant kids approach puberty,
objects and texts. their weight can vary a
Client considers herself lot. According to Johns
"average" when it Hopkins Medicine, some
comes to understanding kids may begin puberty
things, especially the as early as age 8, while
difficult ones. others don’t see changes
until they are closer to 14
Sleep and rest: years old. During
Before hospitalization puberty, children grow
the client, taller — by as much as
Is able to sleep for 9 10 inches — before
hourse every night reaching their full adult
Does not have any height. They also gain
trouble with regards to muscle and develop new
sleepong fat deposits as their
After hospitalization bodies become more like
the client, those of adults. All this
Is able to sleep for 10- morphing may lead to
11 hrs significant changes in
Does not have any weight and feelings of
difficulties in sleeping self-consciousness
Also sleeps during the (Center for Disease
day due to her sickness, Control and Prevention,
furthermore, she feels 2019)
tired during the day and
does not feel way that
is why she chooses to
sleep during the day

Self-perception & self-

concept:
The client’s self
perception and concept
did not change at all
before and during her
hospitalization. She is
still satisfied and
confident with her own
body. Furthermore, the
client said that she
loves her eyes the most.
In addition the client
loves singing and
calligraphy and she has
a positive outlook on
life

Coping & stress

tolerance:
Before hospitalization,
the client was
Able to control herself
in stressful situations
by staying calm and
silent
Able to maintain a
peaceful mind by not
stressing herself too
much on the problem
she’s facing

During hospitalization,
the client was
Still able to control
herself in stressful
situations and also
maintains a peaceful
mind

Roles & relationships:

Before hospitalization,
the client was
In a good relationship
with her family.
When it comes to circle
of friends she is the
silent type among her
friend and also in the
classroom

During hospitalization,
the client still has the
same relationship
before hospitalization

Values & beliefs:

Before hospitalization
the client,
Said that her dream is
to become a teacher and
also a flight attendant
Said that she gets her
strength from her
mother and God
especially in her
situation today where
she is ill and weak
After hospitalization
the client,
Still has the same
dreams and source of
strength which is her
mother and God.

OBJECTIVE

Height: 154 cm

Weight: 64.5 kg

Body mass index

(BMI): 27.20
kg/m2

Respiratory rate:
26 cycles per
minute

Pain scale: 6/10,

pain on the
epigastric region

Congested nostrils
inflamed tonsils
 Rashes on upper &
lower extremities

Overweight

Abdominal pain

Dirty fingernails

Moist, yellow,
odorless cerumen

PROBLEM IDENTIFICATION AND PRIORITIZATION

NURSING DIAGNOSIS
RANK
CUES
Acute pain related to self-
report of intensity using
standardized pain scale as
manifested by presence of
abdominal pain
JUSTIFICATION ACCORDING TO
MASLOW’S HIERARCHY OF NEEDS
1 This is the 1st nursing diagnosis that needs to be
prioritized, because pain is number one priority
because it is affecting the whole system of the
client and it is her immediate concern. Since
different patients have different responses to pain,
it must be first treated.
If a person does not feel safe in an environment,
they will seek to find alleviation on the pain
before they attempt to meet any higher- level
needs
 Ineffective health
management related to poor
hygiene as evidenced by
dental caries and dirty
fingernails
Potential for ineffective
breathing pattern related to
fast breathing AEB 26
breathing cycles per minute
Risk for overweight related to
BMI>25kg/m2 AEB client’s
BMI, 27.20 kg/m2
Potential for infection related
to insufficient knowledge to
avoid exposure to pathogens
AEB change in physiological
parameter, tonsil grade 2+
Risk for infection related to
alteration in skin integrity
AEB rashes on upper & lower
extremities
Risk for infection related to
insufficient knowledge to
2 This is the 2nd nursing diagnosis that needs to be
prioritized, According to Maslow`s Hierarchy of
Needs, the safety needs is the second level of the
hierarchy of needs and is the second most
important levels of needs. Under this level are the
needs of personal security, employment,
resources, health, and property. In this matter, the
focus will be on the need of dental health safety.
According to Delmar’s Dental Assisting: A
Comprehensive Approach by Phinney and
Halstead (n.d) states that when the clients needs
are not met, they cannot go and feel safe and
cared for. Deficiency needs arise due to
deprivation and are said to motivate people when
they are unmet. Maslow (1943) stated that the
lower needs must be fully met first before
progressing to the secondary level of growth
needs.
Reference: Phinney and Halstead (n.d)
3 This is the 3rd nursing diagnosis, since according
to Maslow’s hierarchy of needs, breathing is one
of the foundational needs (physiological) that
must be fulfilled in order to give something for
the rest of the pyramid to be built upon and is
essential for survival.
4 This is the 4th prioritized nursing diagnosis,
because according to Maslow’s hierarchy of
needs, physiological needs which includes
nutrition is vital and one of the basic requirements
for survival.
5 This is the 5th nursing diagnosis, insufficient
knowledge to avoid exposure to pathogens is
under of safety and security of needs (Safety of
health). Then insufficient knowledge to avoid
pathogens may the client vulnerable in any
danger.
6 This is the 6th nursing diagnosis, client becomes
prone to infection because skin integrity has
already been altered/weakend by development of
rashes. Their presence on the upper and lower
extremities of the client may also affect the
client's self-esteem.
7 This is the 7th nursing diagnosis, Deficient
knowledge is part of safety and security needs.
avoid exposure to pathogens Addressing the deficiency of knowledge will
AEB nail biting prevent the client to become susceptible in any
danger, promote protection and continuity through
solid and evidenced-based knowledge and
practice.