 VISION Republic of the Philippines MISSION

A premier university in historic Cavite State University shall provide

Cavite recognized for CAVITE STATE UNIVERSITY excellent, equitable and relevant
excellence in the development Don Severino Delas Alas Campus educational opportunities in the arts,
of morally upright and globally science and technology through
competitive individuals. Indang, Cavite quality instruction and relevant
research and development activities.
It shall produce professional, skilled
and morally upright individuals for
global competitiveness.
College of Nursing

ASSESSMENT FOR SCHOOL AGE

Presented by:

LEVEL II/ BSN II-I / GROUP 4:

Members:
Beso, Janelle
Bringas, Erika
Conde, Mikaella
Deanching, Fiona
Empalmado, Jenny
Hernandez, Gerald
Mendoza, Krizia
Pescador, Rose
Rebillar, Jean
Sarmiento, Gia

Presented to:

Prof. Leticia del Rosairo, RN, MAN

Clinical Instructors, Level II

Date:
November 22, 2019

In Partial Fulfillment of the Requirement in NURS 05 for the Degree Bachelor of Science
in Nursing
 TABLE OF CONTENTS

I. Demographic Data……………………………………………………………….

II. Reason for Seeking Health Care………………………………

III. History of Present Illness………………………………………………..

IV. Past Medical History………………………………………………………...

V. Heredo-familial History…………………………………………...

VI. Gordon’s Functional Health Patterns…………………………..

VII. Physical Examination……………………………………………….

VIII.Diagnostic Test……………………………………………………..

IX. Review of System………………………………………………

X. Concept Maps……………………………………………………..

XI. Case Management……………………………………………………..

A. Medical…………………………………………………………………………………

…………

B. Nursing…………………………………………………………………………………

………
I. DEMOGRAPHIC DATA
A. Initials of Clients’ Name: A.D Date of Admission: October 24, 2019
B. Address: Bicol Region, Indang, Cavite Time of Admission: 13:00-13:30
C. Age: 10 y/o
D. Birth Date: April, 14, 2009 Date of Interview: October 24 and November 7,
2019
E. Birth Place: ? Primary Informant: client A.D
F. Gender: Female Secondary Informant: client’s mother (MJD)
G. Civil Status: Single Other Data Sources: none
H. Religion: Catholic
I. Highest Educational Attainment: Grade 4
J. Occupation: none
K. Monthly Income / Budget : ₱ 8, 000 00

II. REASON FOR HOME VISITING: To be able to conduct interview and determine
health problem

III. HISTORY OF PRESENT ILLNESS

Client AD is currently experiencing pain while urinating, and she void at least
8-10 times per day which is very unusual for her, she can sense that she have UTI
but they aren’t still sure about it because they’re not able to consult it to the doctor
due to lack of resources. The client also have lice which causes small wound in her
head. There’s also presence of small bites of mosquito in her arms. Other than that,
the client doesn’t feel any pain or unusual situation regarding her health as of now.

IV. PAST MEDICAL HISTORY

A. Childhood / Adult Diseases
B. Injuries / Accidents
C. Hospitalization
D. Operation
E. Allergies
F. Medication
G. Immunization (to be tabulated for Pedia clients to keep track of time interval and
dose, but for Adult clients state if they have been fully immunized or not)
H. Last Examination

Client AD experienced urinating with a blood when she’s 7 weeks old.

According to her mother, (paki-include na lang kung bakit). When she’s 3 y/o,
she’s diagnosed with Acute UTI at Batangas, Hospital. She was born premature
at (ilang weeks). Her fingers are still (dikit-dikit) when she’s born. (Paki-include
yung ginawa nung premature pa siya chaka kung bakit dikitdikit at ano ginawa
para maayos?). When she’s at the age of 1 to 3 y/o, she experienced
convulsions which is hard to control. According to her x-ray result when she’s 3
y/o, there’s also a hole in her lungs. (paki-include na lang din ano ginawa
 sakanya after). She doesn’t experience operation, or had any injuries, and
accidents. The client is allergic to eggs. She also experienced taking antibiotics
for 7 days when she’s 3 y/o. The client’s mother said that client AD is fully
immunized though they weren’t able to present an immunization card because
they lost it few years ago. The client’s last examination was September 26, 2019
due to her small wounds and lice.

V. HEREDO-FAMILIAL HISTORY
A. Genogram

Maternal side Paternal side

VI. GORDON’S 11 FUNCTIONAL HEALTH PATTERNS

A. Health Perception – Health Management
 Interaction
 Observation
 Measurement
The client’s perception about health is fair. As she grow older, she’s also
learning how to manage her health by her own. She doesn’t have major illness
or disease. She is also fully immunized including vaccine for cervical cancer.
She has allergies in eggs but she can manage. Client AD’s home is safe to live
but there are presence of breeding sites.

B. Nutritional – Metabolic
 Interaction
  Observation
 Measurement
The client’s weight is 27. 13kg and her height is 125 cm. (BMI result) Client AD is
in regular diet and her appetite is normal. She can feed herself and her mouth’s
condition is normal.

*3-day Diet Recall

MEALS October 22, October 23, 2019 October 24, 2019
2019 Wednesday Thursday
Tuesday

Breakfast 6:00 6:00 6:00

(time) 1 cup rice Bread Bread
1 fried fish 1 cup Milo 1 cup coffee
1 glass of water

Snacks (if any) 10:00 none none

Bread
1 cup coffee
Lunch (time) 12nn 12nn 12nn
Bread 1 cup of rice 1 cup of rice
1 glasses of 1 pc. fried chicken 1 serving of Adobo
water 2 glasses of water 2 glasses of water

Snacks (if any) none none none

Dinner (time) 18:00 18:00 18:00
1 cup of rice 1 cup rice 1 cup rice
1 serving of 1 scrambled egg 1 barbeque
tortang balaksila 1 glass of water 1 glass of water
1 glass of water
Snacks (if any) none none none
Total Fluid 1000ml 1000ml 1000ml
Intake

Interpretation: The table above shows the 3-day diet of client AD. Based on the table,
the client can still have a good meal. It shows that they can still get a nutritious meal
and that they don’t have a problem regarding their food consumption.

C. Elimination
 Interaction
 Observation
 Measurement

Client AD voids at least 8-10 times per day and it is yellowish to reddish. The
client verbalized that there’s pain while urinating. Pain scale is 6/10 and she is
suspected for UTI but it’s still not sure. Client AD defecates 3 times a day, it is brown
and solid and there’s no presence of any problems.

D. Activity – Exercise
 Interaction
 Observation
 Measurement

The client is active when it comes into physical activities because she participates
in their school when there’s exercises and games. The client’s normal sleeping time is
9:00 pm and she rises at 5:00 am.
*7-Day Activity Table

Time Days of the Week & Date

Oct.18’ Oct.19’19 Oct.20’ Oct.21’ Oct.22 Oct.23‘19 Oct. 24’19
19 Saturday 19 19 ’19 Wednesday Thursday
Friday Sunday Monday Tuesday
1 am
sleepin
2 am sleeping
g
3 am sleeping
4 am
5 am Wake
Wake up
up
6 am breakfa
Wake up breakfast
st
7 am breakfast
8 am
9 am
at play at school
10
school
am
11 rest
am
12 nn lunch
1 pm watch tv
2 pm at take nap
at school
3 pm school
4 pm
watch tv
5 pm rest rest
6 pm dinner
7 pm do
8 pm school Watch tv do school works
works
9 pm sleeping
10
pm
 11
pm
12
mn

Interpretation: The client’s 7 day activity shows that she’s doing what other kids at her
age do normally. There’s no encountered problem within her activity.

*Katz Index of Independence in Activities of Daily Living

Activities Independence = 1 point Dependence = 0 point
Points (1 or 0) No supervision, direction or With supervision, direction
personal assistance needed or personal assistance or
total care
Bathing 1
Dressing 1
Toileting 1
Transferring 1
Continence 1
Feeding 1
TOTAL 6
POINTS:

Interpretation: The client scored 6/6 and she’s fully independent.

E. Sleep – Rest
 Interaction
 Observation
 Measurement

Client AD goes to bed at 9:00 pm every day and she wakes up at 5:00 am every
school days and 6 at weekends. She usually watch tv before sleeping. She doesn’t use
any assistive device to sleep and she can sleep soundly and easily every night.

*7-Day Sleep Diary

Constructs Oct.18’ Oct.19’ Oct.20’ Oct.21’ Oct.22’ Oct.23’ Oct.24’
19 19 19 19 19 19 19
Friday Saturda Sunday Monday Tuesda Wedne Thursd
y y sday ay
Hours of Sleep 8-9 hrs.
Sleeping Time 9:00 pm
Waking Time 5:00-6:00 am
Bedtime Rituals watch tv
Feeling upon happy and excited
waking up
Problem none
 Encountered

Interpretation: The client’s sleeping diary is normal for her age. She doesn’t encounter
any problems while sleeping and she feels fine, happy, and excited upon waking up.
F. Cognitive – Perceptual
 Interaction
 Observation
 Measurement
The client is alert, she can answer questions easily though it’s seen that she’s shy
at first. She is also calm. Her reflexes are normal and her right hand is stronger than her
left. Her visuals are still 20/20, she can hear perfectly, touch and smell without any
problems. She can also read and speak clearly.
G. Self-Perception – Self-Concept
 Interaction
 Observation
 Measurement
Client AD is anxious at first due to her shyness but as time goes by she became calm
and comfortable. She wears appropriate dress and she’s a good hygiene. She only do
eye contact occasionally but she can answer questions readily.
H. Role-Relationship
 Interaction
 Observation
 Measurement

The client lives together with her family, and she’s very close with them. She’s has 2
other siblings and she’s the middle child. They are close so they don’t encounter any
problems regarding their relationship.

*Ecomap

I. Sexuality – Reproductive
  Interaction
 Observation
 Measurement
Client AD doesn’t have her menarche yet. She’s still not yet fully informed
regarding sexual talks but she’s willing to learn all the appropriate things that any
individual should know properly.
J. Coping-Stress
 Interaction
 Observation
 Measurement
The client doesn’t seem to be stressed that much. She verbalized that she can also
handle her mood properly, but if there are times that she really loose her mood, she’ll
just listen to music, eat, or sleep. If there’re problem, she wants to talk about it easily
and fix it.

K. Value-Belief
 Interaction
 Observation
 Measurement
The client is Roman Catholic and she goes to church occasionally. She always
pray at night and she’s a firm believer that there’s God. Her family knows a lot of belief
and it’s their tradition to follow it so they still practice their values and beliefs.

VII. COMPREHENSIVE PHYSICAL EXAMINATION

A. Vital Signs Date / Time of Exam: October 24, 2019/1:00-1:30 pm
T = 36.0OC
PR = 87 bpm
RR = 20 cpm
BP = __/__ mmHg
Pain
Provoking factor – pain while urinating
Quality – burning sensation
Region/radiation – pain in the bladder
Severity (using pain or face pain scale) – 6/10
Time – everytime she urinates
B. Anthropometric Data (only those applicable)
Height = __ cm (for both adult & pedia) BMI = __ (for adult)
Weight = __ Kg (for both adult & pedia) IBW = __ (for adult & pedia)
Head Circumference = __ cm (for pedia)
Chest Circumference = __ cm (for pedia)
Abdominal Circumference = __ cm (for pedia0
C. General Appearance
1. Body build and height-weight proportionality
2. Posture and Gait
 3. Over-all hygiene and grooming
4. Body and breath odor
5. Obvious signs of distress / illness
6. Mental status
7. Attitude
8. Affect/mood; appropriateness of responses
9. Quantity and quality of speech
10. Relevance and organization of thoughts
Client AD’s _____. Her posture is normal as well as her gait. She also looks
clean, and there’s no problem regarding her hygiene. She doesn’t have any body and
breath odor as she always take a bath and brush her teeth. As of now, she doesn’t look
like stress, she’s looks happy, and contented. Her mental status is also healthy, she’s
surrounded by her close friends and family. She has also a great attitude towards other
people, she may be shy but she’s still respectful. Client AD is also calm and her
responses are all appropriate. She knows how to answer correctly and properly, and her
thoughts are all organized and well.

LINTEGUMENT
Skin
I: color, uniformity,
edema, lesions
P: moisture, temp.
turgor
Hair
I: evenness of growth
thickness, texture,
oiliness, infection
or infestation, body
hair
P: smoothness
Nail
I: plate shape, texture,
bed color,
surrounding tissues
P: Blanch test
HEAD
Skull and Face
I: size, shape ,
symmetry
: facial features
: eyes for edema
and hollowness
P: nodules, masses,
depressions
Eyes and Vision
I: eyebrows for
 distribution &
alignment, quality &
movement
: eyelashes for
evenness of
distribution &
direction of curl
: eyelids for surface
characteristics,
position in relation to
cornea, ability to
blink & frequency
: bulbar & palpebral
conjunctiva for
color, texture, and
lesion
I/P: lacrimal gland
sac, nasolacrimal
duct for edema,
tenderness / tearing
I: cornea for clarity,
texture & sensitivity
I: pupils for color,
shape, symmetry of
size, direct and
consensual reaction
to light, &
accommodation
* Visual Acuity (near
& far vision test)
* Visual Field Test
* EOM Test
Ears and Hearing
I: auricles for color,
symmetry and
position
: external canal for
cerumen, lesions,
pus or blood
P: auricles for texture,
elasticity and areas
of tenderness
* Gross Hearing Acuity
Tests: normal voice
tone and whispered
voice
* Watch Tick Test
* Tunning Fork Tests:
- Weber for bone
conduction
- Rinne’s to compare
air and bone
conductions
Nose and Sinuses
I: nose deviation in
shape size, color,
flaring, discharge;
: nasal mucosa for
redness, swelling,
growth or discharge
Pa: tenderness,
masses,
displacements;
: nasal patency
: maxillary and
frontal sinuses for
tenderness
Pe: the above sinuses
for tenderness
Transillumination Test
Mouth / Oropharynx
I: lips for symmetry of
contour, color,
texture, moisture,
lesion
: teeth for alignment,
loss, dental filings
and caries;
: gums for bleeding,
color, retraction,
lesions, swelling
: tongue for position,
color & texture;
movement, as well
as the base of the
tongue, mouth floor
and frenulum
: salivary gland
ducts for swelling,
redness
: palates for color,
shape, texture,
 presence of bony
prominences
: uvula for position &
mobility
: oropharynx for color
& texture
: tonsils for color,
discharge, and size
Test for Gag Reflex
P: nodules, lump and
excoriated areas
NECK
Neck Muscles
I: abnormal swelling or
masses, head
movement, and
muscle strength
Lymph Nodes
P: enlargement
Trachea
P: lateral deviation
Thyroid Gland
I: symmetry and visible
masses, rise during
swallowing
P: smoothness
A: bruit
THORAX & LUNGS
Posterior Thorax
I: shape & symmetry
from posterior-lateral
views; spinal
alignment for
deformities
Pa: temperature,
bulges, tenderness,
abnormal
movements,
respiratory
excursion, vocal
fremitus
Pe: for symmetry of
resonance;
diaphragmatic
excursion
A: breath sounds
Anterior Thorax
I: breathing pattern,
coastal and
costovertebral angle
Pa: respiratory
excursion, tactile
fremitus
Pe: symmetry of
resonance
A: breath sounds
Heart
I: precordium for
pulsations & lifts or
heaves
A: heart sounds (S1,
S2, etc.)
Central Vessels:
Carotid Arteries
P: volume, quality
A: bruit
Jugular Veins
I: distention
Peripheral Vessels
I: presence or
appearance of
superficial veins,
signs of phlebitis
*Buerger’s Test
*Capillary Refill
Breast & Axillae
I: breast for size,
symmetry, contour or
shape, discoloration,
retraction,
hypervascularity,
swelling, edema
: areaola for size,
shape, symmetry,
color, surface
characteristics,
masses, lesions
: nipples for size,
shape, position,
color, discharge,
 lesion
P: lymph nodes,
breast, areola &
nipples for
tenderness, masses,
nodules, discharge
ABDOMEN
I: skin integrity, contour
& symmetry, hernia,
distention (girth),
movements
associated w/
respiration,
peristalsis & aortic
pulsations
A: bowel, vascular, &
peritoneal friction rub
sounds
Pe: all quadrants /
regions for tympany
and deviations
Pa: light to deep
palpations ALL
quadrants from least
painful to most
painful for masses,
tenderness, muscle
guarding; liver
(bimanual) and
bladder palpation
* Leopold’s Maneuver
for OB clients for
presentation, lie,
engagement,
attitude, position If necessary /
MUSCULOSKELETA applicable /
L significant
Muscles
I: size, contractures,
fasciculations,
tremors
P: tonicity, flaccidity,
spasticity,
smoothness of
movement, strength
Bones
I: structure, deformity
P: edema, tenderness
Joints
I: swelling
P: tenderness,
smoothness of
movement, swelling,
crepitation, nodules
NEUROLOGIC
Mental Status
- Language
- Orientation
- Memory
- Attention Span /
Calculation
Consciousness Level
Glassgow Coma Scale
Cranial Nerves
- I to XII
Reflexes
- Deep, superficial & For Adult
pathologic
- Neonatal Reflexes For Pedia
Gross Motor/Balance
* Walking Gait
* Romberg
* Standing on 1 foot w/
eyes closed
* Heel-toe walking
Fine Motor
- Upper Extremities:
* Finger-Nose Test
* Alternate Supination
& Pronation of hands
on knees
* Finger to Nose & to
RN finger
* Fingers-to-fingers
* Fingers-to-thumb
- Lower Extremities:
* Heel down opposite
skin
* Toe / Ball of Foot to
RN’s finger
Sensory Function
* Light/Deep Touch
* Pain Sensation
* Temperature
* Position / Kinesthetic
* Tactile Discrimination If necessary /
GENITALS applicable /
*For males: significant
I: pubic hair for
distribution, amount,
characteristics
: penis shaft and
glans for lesions,
nodules, swelling,
inflammation
: urethral meatus for
swelling,
inflammation,
discharge
: inguinal areas for
bulges or swelling
P: penis for
tenderness,
thickening, nodules
: scrotum for
appearance, size and
symmetry, and
underlying testes,
epididymis and
spermatic cord
: inguinal areas for
palpable bulge
* For females: If necessary /
applicable /
RECTUM & ANUS significant
I: anus and
surrounding tissue
for color, integrity,
lesions
P: anal spinchter
tonicity, nodules,
masses and
tenderness
: if male, prostate
gland for tenderness
: if female, cervix
through the anterior
rectal wall for
 tenderness

If necessary /
applicable /
significant

VIII. Diagnostic Test

A. Non-Invasive
Specific Test Actual Finding Normal Finding Clinical
Significance
Sputum
Microscopy
Urinalysis
Fecalysis
Radiology
Other: ECG, MRI,
CT
B. Invasive
Specific Test Actual Finding Normal Finding Clinical
Significance
Blood Chemistry
Hematology
Electrolytes
ABG
Visualization
procedures
(surgical approach)
Note: Please indicate ONLY those diagnostic tests that were actually performed
to confirm the identified pathology. For OB and Pedia clients, please utilize the
appropriate tools for labor and delivery as well newborn assessment.

*Client AD’s mother weren’t able to present laboratory results because their
files went missing when they transferred house few years ago.*
IX. Review of System (include only those that are significant to the case under study)
A. Neurologic
B. Pulmonary
C. Cardiovascular
D. Hematologic
E. Immunologic
F. Gastrointestinal
G. Renal
H. Musculoskeletal
 I. Reproductive
J. Integumentary
X. Concept Maps
A. Theory-based Physiology (for 2nd year) / Pathophysiology (for 3rd year)
Predisposing Factors: Precipitating Factors:
- Age, gender, family history, genetics - Lifestyle, diet, exercise, medication,
etc.

Main Etiology

Effect Effect

Sub-effect
Sub-effect Sub-effect
Sub-effect

Clinical manifestations:
Clinical manifestations: - s/sx
- s/sx - s/sx
- s/sx - s/sx

DISEASE CONDITION
B. Client-based (only those facts related to the case are included)

XI. CASE MANAGEMENT

A. Medical (present only those that are applicable and w/c have been done for the
patient)
1. Pharmacologic Intervention
Drug Features Therapeutic Effects Nursing
Responsibilit
- Brand / Generic Name Indication Contraindication Desire Untowar
- Classification d d
- Prescribed Dosage
- Route
- Frequency

C. Nursing Management
1. List of Nursing Problems (minimum of 5 for 2nd year; minimum of 10 for 3rd
year)
 a.
b.
c.
d.
e.
f.
g.
h.
i.
j.

2. Prioritization of Nursing Problems

Criteria Weight Multiplie Computatio Justification
r n
Nature and 3 Actual Problem 1 3/3 x 1 Situational
Extent 2 Risk / Potential Urgency
1 Wellness State based on:
- ABC
Principle
- Maslow’s
HON
- Nursing
Concept
Modifiabilit 2 Easily 2 2/2 x 2 Availability of
y Modifiable resources and
1 Partially interventions
Modifiable
0 Not Modifiable
Peventive 3 High 1 3/3 x 1 Likelihood of
Potential 2 Moderate occurrence of
1 Low complication
w/ respect to
measures
taken
Salience 2 Needs 1 2/2 x 1 Client’s
immediate perception and
attention recognition of
action the problem
1 Not needing
immediate
attention
0 Not perceived
as a problem/
 condition
needing change
TOTAL 5 Priority # 1
3. Plans for Nursing Actions
a. Nursing Care Plan
Assessment Diagnosis Planning Implementation Evaluation
Subjective: Problem r/t At the end After 4 hours o
The client Etiology, w/ of 4 hours nursing care,
verbalized, Sign/symptom of rendering goal was met /
“_______” (defining nursing unmet /
characteristics)
care, the partially met,
client will be as evidenced
Objective: *Choose the able to: by:
 PE applicable: 1.________ Independent Rationale & 1.
Findings 1. Actual Dependent Reference
 Lab 2. Probable Collaborativ
Findings 3. Risk e
4. Syndrome 2.________ Rationale & 2.
5. Wellness Dx Independent Reference
Dependent
Collaborativ
3.________ e Rationale & 3.
Reference
Independent
Dependent
Collaborativ
e

b. Teaching Plan
Intended Outcomes Content Strategies Resources Evaluation
1. Cognitive Topic Teaching Learning * Materials Pen and paper
2. Affective Subtopic Activity Activity * Human test
3. Psychomotor - concept Resources
- concept * Time Recitation
Subtopic
- concept Return
- concept demonstration

Observation