APPENDIX C

Assessment Tools

a. Dillon’s Physical Assessment Tool

GENERAL NORMS ACTUAL INTERPRETATIO

APPEARANCE FINDINGS N/ANALYSIS
Posture/Gait Posture is erect and
position is relaxed
Skin Color “Normal” varies
depending on race
or ethnic
background,
complexion, sun
exposure,
pigmentation
tendencies.
Personal Hair well-trimmed,
Hygiene/Groomin well brushed, no
g foul body odor,
takes a bath at least
once per day, does
oral care after
meals.
Nutritional Status

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Verbal Behavior Words of choice are
in relation to each
other to form one
common idea.
TPR Temperature:36.5 –
B/P 37.5 oC
Weight Pulse: 60 – 100
Height beats per minute
Respirations: 15
-20 breaths per
minute
Blood Pressure:
Systole
90>&<120mmHg
Diastole 60>&<80
mmHg

Hair Evenly distributed,

silky, resilient, no
infection or
infestation
Face and Skull Skull round,
smooth skull
contour, absence of
nodules and
masses.

Facial feature is
symmetric or
slightly
asymmetric. Facial
movements

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 symmetrical.
Eyebrows Hair evenly
distributed; skin
intact. Eyebrows
symmetrically
aligned; equal
movement.
Eyelashes Equally distributed
eyelashes; curled
slightly outward.
Eyelids Skin intact; no .
discharge; no
discoloration. Lids
close
symmetrically.
When lids open, no
visible sclera above
corneas, and upper
and lower and
borders of the
cornea are slightly
covered
Lid Margins Shiny smooth with
no signs of
inflammation.
Sclera White in color.
Yellow in white-
skinned people.
Capillaries
sometimes
evident.VA=20/20
Eye Movement Both eyes
coordinated, move

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 in unison, with
parallel alignment.
Ears Color same as
facial skin.
Symmetrical.
Auricle aligned
with outer canthus
of eye. Pinna is
mobile, firm, and
not tender; pinna
recoils after it is
folded.
Ear canal Distal third
contains hair
follicles and glands.
Sticky wet cerumen
in various shades of
brown.
Hearing Acuity Sound in heard in .
both ears.
Nose Symmetric and
straight. No
discharge or flaring.
Air moves freely as
the client breaths
through the nares.
Mouth (lips) Pink in color. Soft,
moist and smooth
texture of the lips.
Ability to purse
lips.
Gums Pink gums, moist,
firm texture of

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 gums.
Teeth Smooth, white,
shiny tooth enamel.
Smooth intact
dentures.
Tongue Central position.
Pink color. Smooth
lateral margins; no
lesions. Moist,
moves freely, no
tenderness.
Neck Neck muscles are
equal in size and
head is centered.
When asked to
move head it is
coordinated.
Trachea is in
central placement
in midline of the
neck and spaces are
equal on both.
Thyroid gland is
not visible upon
inspection and
ascends during
swallowing.
Neck ROM Coordinated
smooth movements
with no discomfort.
Head flexes 45
degrees;

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 hyperextend 60
degrees; laterally
flexes 40 degrees
and laterally rotates
70 degrees. Equal
strength when
turning head to one
side against the
resistance of a
hand.
Thorax/ lungs Anteroposterior
diameter of the
thorax in relation to
the lateral diameter
is approximately
1:2. Chest is
symmetric. Spinal
column is straight,
right and left
shoulders and hips
are the same height.
Skin intact and
uniform in
temperature. Full
and symmetric
chest expansion.
Bilateral symmetry
vocal fremitus.
Clear breath
sounds.
Heart Heart sounds
indicate of S1 and

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 S2 and no other
murmurs upon
auscultation. EKG
reading shows
regular rhythm, no
prolongation in
waves P, R, S, T,
no prominent Q
wave and no PVC.
Abdomen Unblemished skin,
uniform color, flat
rounded; no
evidence of
enlargement of
liver, symmetric
countour,
abdominal,
movements
symmetric caused
by respiration.
Audible bowel
sounds at 5-30/per
minute.
Upper Extremities Skin color
generally uniform
except in areas
exposed to sun.
Skin intact and no
edema. Evenly
distributed hair,
flexing 45 degrees
and extending,

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 supinate and
pronate. When
pinched, skin
springs back to
previous state.
Nails Convex shape and
nail plate angle of
about 160 degrees.
Shoulders and Shoulders are
Arms symmetrically
round, no redness,
swelling, or
deformity or heat.
Clavicles and
scapulae are even
and symmetric.
Elbows Elbows are
symmetric without
deformities.
Redness or
swelling. No
nodules
Hands and wrist Hand and fingers
are symmetric, non-
tender, and without
nodules. Fingers lie
in straight line. No
swelling or
deformities.
Rounded
protuberance noted
next to the thumb

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 over the near
prominence.
Lower Extremities Both extremities
are equal size.
Have the same
contour with
prominences of
joints.
No involuntary
movements.
No edema.
Color is even.
Temperature is
warm and even.
Has equal
contraction and
even.
Can perform
complete range of
motion.
No crepitus must be
noted on joints.
Can counter act
gravity and
resistance on ROM.

b. Virginia Henderson’s 14 Components

VIRGINIA HENDERSON’S 14 Ability to Meet Needs

COMPONENTS
Physiological Components
1. Breathe Normally.

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 2. Eat and drink adequately.

3. Eliminates body waste.

4. Move and maintain desirable

postures.

5. Sleep and rest.

6. Select suitable clothes, dress

and undress.

7. Maintain body temperature

within normal range by
adjusting clothing and
modifying environment.

8. Keep the body clean and

well groomed and protect the
integument.

9. Avoid dangers in the

environment and avoid
injury to others.
Psychological Aspects of
Communicating and Learning
10. Communicate with others in
expressing:
- Emotions

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 - Needs
- Fears
- Opinions

14. Learn, discover, or satisfy

the curiosity that leads to normal
development and health and use the
available health facilities.
Spiritual and Moral
11. Worship according to one’s
faith.
Sociologically Oriented to
Occupation and Recreation
12. Work in such a way that
there is a sense of
accomplishment.

13. Play or participate in various

form of recreation.

c. Fatigue Severity Scale

During the past week, you found that: Disagree Agree Score
1. Your motivation is lower when you’re 1 2 3 4 5 6 7
fatigued.
2. Exercise brings on your fatigue. 1 2 3 4 5 6 7
3. You are easily fatigue. 1 2 3 4 5 6 7
4. Fatigue interferes with your physical 1 2 3 4 5 6 7
functioning.
5. Fatigue causes frequent problems to you. 1 2 3 4 5 6 7
6. Your fatigue prevents sustained physical 1 2 3 4 5 6 7
functioning.
7. Fatigue interferes with carrying out certain 1 2 3 4 5 6 7
duties and responsibilities.
8. Fatigue is among your three most disabling 1 2 3 4 5 6 7
symptoms.
9. Fatigue interferes with your work, family, or 1 2 3 4 5 6 7

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 social life.
Total Score:

d. Insomnia Severity Index

Insomnia Problem None Mild Moderate Severe Very

Severe
1. Difficulty falling asleep 0 1 2 3 4
2. Difficulty staying asleep 0 1 2 3 4
3. Problems waking up to early 0 1 2 3 4
4. How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern?
Very Satisfied Satisfied Moderately Satisfied Dissatisfied Very Dissatisfied
0 1 2 3 4
5. How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your
life?
Not at all Noticeable A Little Somewhat Much Very Much Noticeable
0 1 2 3 4
6. How WORRIED/DISTRESSED are you about your current sleep problem?
Not at all Worried A Little Somewhat Much Very Much Worried
0 1 2 3 4
7. To what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g.
daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, mood, etc.)
CURRENTLY?
Not at all Interfering A Little Somewhat Much Very Much Interfering
0 1 2 3 4

Total Score: 14/28 (Subthreshold insomnia)

Guidelines for Scoring/Interpretation:
0-7 = No clinically significant insomnia
8-14 = Subthreshold insomnia
15-21 = Clinical insomnia (moderate severity)
22-28 = Clinical insomnia (severe)

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