Chapter 22: Assessing Peripheral Vascular System

Activity E (p.157)

Nursing Interview Guide to Collect Subjective Data from the Client

Current symptoms Findings

1. Skin changes? There are no discoloration in skin of the

client. It is still the same as her
complexion.

2. Leg pain, heaviness, or “Minsan pag gabi nagigising ako pag

aching? Does it awaken you at pinupulikat, sobrang sakit baka dahil
night? din yun sa injury ko sa tuhod ko.
Napakasakit pag sumusumpong” as
verbalized by the client

3. Leg veins? There is no signs of varicosities present

in the lower extremities of the client but
since she has fair skin her veins are
visible in the poplitheal area.

4. Leg sores or open wounds? “Wala naman akong sugat o kaya

nararamdaman na masakit sa leg part
ko” as verbalized by the client

5. Swelling in legs or feet? The client does not feel any swelling in
legs or feet, she can walk and move
properly.

6. Men: Sexual activity changes? N/A. The client is a woman.

7. Swollen glands or nodules
(pain)?
Past History
1. Previous problems with
circulation in arms or legs?
2. Heart or blood vessel
surgeries or treatments?
Family History
1. Family history of varicose
veins, diabetes hypertension,
coronary heart disease, or
elevated cholesterol or
triglyceride levels?
Lifestyle and Health Practices
1. Cigarettes or other forms of
tobacco, past or present use?
“Wala naman akong nararamdaman na
masakit sa may leeg ko, minsan lang
pag may sipon nakakapa ko parang
may bukol sa gilid ng leeg” as
verbalized by the client.
 
“Wala naman hindi pa din ako
naooperahan or nag undergo sa
treatment kaya wala naming problema”
as verbalized by the client.
The patient did not undergo any of
these procedures or treatment.
 
The client does not have any family
history of varicose veins but have an
family history of diabetes milletus.
 
The client uses cigarette sometimes
due to the influence of her peers but not
regularly.
 2. Regular exercise? The client does not have a regular
routine of exercise but she perform
ADLs independently without any
problems.

3. Women: use of oral The client does use any contraceptives.

contraceptives?

4. Degree of stress? The recent stress event of the client

was an academic stress due to
excessive requirements.

5. Peripheral vascular problems “Wala naman, okay naman ako.

that interfere with ADLs? Nakakagalaw ako ng walang problema”
as verbalized by the client

6. Use of medications to improve The client does not take any medication
circulation or control blood for circulation and blood pressure. As
pressure? she said she only takes B-Complex,
Ascorbic Acid and Fish Oil.

7. Use of support hose? The client does not use support hose.

Activity F (p.158-159)

Physical Assessment Guide to Collect Objective Client Data

Current symptoms Findings

1. Gather equipment Before the physical assessment I

sanitized all the materials to be
used in the client and performed
 proper hand hygiene before
proceeding to the assessment. The
following materials that I will
particularly use are the ff:

a. Stethoscope

b. Tourniquet

c. Tape measure

d. Blood pressure apparatus

Also, I explained the rationale of

the procedure and asked for
consent to the client before
starting the assessment. I also
provided privacy and make sure
only the two of us are in the
examination area.

2. Ask client to put on a gown I do not have a gown so I asked

the client to wear a loose ‘daster’
so that I can assess easily her
legs and arms.

Assess Arms  

1. Inspect bilaterally for size, presence There are no signs pitting edema
of edema, and venous patterning.   in the arms area both left and
right. The arms are symmetrical to
the left and right as well.

2. Inspect bilaterally for skin color. The skin color is fair as per her
complexion. There are no signs of
discoloration in both arms.
3. Inspect fingertips for clubbing
4. Palpate fingers, hands and arms for
temperature using dorsal surface of
the fingers
5. Determine capillary time
6. Palpate radial, ulnar and brachial
pulses
7. Palpate epitrochlear lymph nodes
behind the elbow in the groove
between the biceps and triceps
muscles
8. Perform Allen test by occluding the
radial and ulnar arteries and observing
for palm pallor. Then, release the ulnar
artery and watch for color to return to
hand.
Assess Legs
The finger nails does not exhibit
signs of clubbing. The client’s
fingernails have pinkish red tone
color.
The hands of client is warm and
pinkish pale in color because of
her complexion as well as her
fingers. For the arms, I can also
feel the warmth of the client’s
body.
As I pressed the nailbed for the
capillary test for 2 secs, it the refill
times immediately returned.
As I palpated the pulses here are
the rates of the ff:
a. Radial  +2
b. Ulnar +1
c. Brachial +2
The epitrochlear lymph nodes has
not been felt during the palpation.
It means it is not swollen or
infected.
As I performed the Allen’s test in
the client, the pinkish color return
immediately in both radial and
ulnar artery.
 
1. Inspect bilaterally for skin color. For the legs of the client, there are
no signs of discoloration and
same only on her complexion.
There are no sign of hematoma or
color pigmentation as well.

2. Inspect bilaterally for distribution of The distribution of hair is

hair symmetrical to the left and right.
There are no signs of alopecia or
hair loss in the leg area of the
client.

3. Inspect for lesions or ulcers There are no signs of lesions and

ulceration in the lower extremities
of the client. There are no scars or
wounds present as well.

4. Inspect for edema, unilateral or As per inspection there are no

bilateral signs of pitting edema present.

5. If client has edema, determine Not applicable because the client

whether it is pitting or nonpitting. If does not have any edema present
client has pitting edema, rate on a +1 in the lower extremities.
to +4 scale.

6. Palpate skin temperature. Use The skin temperature of the client

dorsal surface of hands as I palpated her is warm and
does not elicit coldness in the
upper and lower extremities.

7. Palpate the superficial inguinal The superficial inguinal does not

lymph nodes while keeping the show implications of swelling and
genitals draped. If detected, note size, the client does not elicit pain as I
mobility or tenderness.
8. Palpate and auscultate femoral
pulses over artery. Listen for bruits.
9. Palpate popliteal, dorsalis pedis,
posterior tibial pulses
10. Inspect for varicosities and
thrombophlebitis by asking client to
stand
11. Perform position change test for
arterial insufficiency while client is in
supine position by placing hands
under both of the client’s ankles. Raise
legs 30.48 cm(12in) above heart level,
and ask client to pump feet up and
down for 1  min. Have a client sit up
and dangle legs. Note color of the feet.
Time the interval for color return.
12. If varicosities are present, perform
the manual compression test by
having client stand. Firmly compress
the lower portion of the varicose vein
with one hand. Place other hand 15.2
to 20.3 (6 to 8in) above hand. Feel for
pulsation in the upper hand.
palpated it.
The pulses in the femoral artery
are strong and rigid. It can easily
be identified and there are no
bruits present during auscultation.
The client does not elicit pain as I
palpated these areas. There are
no also signs of masses or
lesions. The posterior tibial pulse
have also a rigid and strong
pulsations felt.
 The veins can is visible in the
surface of the skin since the client
has fair complexion but it is not
distended and there is no signs of
bulging.
The skin changes in pink color
easily and seen during inspection
because as per her complexion it
can be easily identified. The fill of
veins are also fast in just 12
seconds.
As per examined in question
number 10, the client’s veins are
not distended or bulging so there is
no signs for varicosities. The filling
of the venous is also fast with 10-12
seconds in time. The pulsations of
the hands can be felt but with the
rate of +1.
 13. If varicosities are present, perform
the Trendelenburg test with client in
supine position. Elevate leg 90
degrees for 15 secs. With legs
elevated, apply a tourniquet to the
upper thigh. Assist client to a standing
position, and observe for venous
filling. Remove tourniquet after 30
secs and watch for sudden filling of the
varicose veins from above.
Analysis of Data
1. Formulate nursing diagnoses (well,
risk and actual)
2. Formulate collaborative problems
3. Make necessary referrals
Chapter 23: Assessing Abdomen
Activity F (p.167-168)
As per examined in question
number 10 and 12, the client’s
veins are not distended or bulging
so there is no signs for varicosities.
The filling of the venous is also fast
with 10-12 seconds in time.
 
Risk for ineffective therapeutic
regimen management related to
busy lifestyle and lack of exercise
Readiness for enhanced self-health
management to improve lifestyle
including exercises and
performance of ADL
Risk for complications of
thrombosis
Referral to see orthopedic specialist
to assess further client’s condition
and situation with the approval of
the attending physician.

Physical Assessment Guide to Collect Objective Client Data
Current Symptoms
1. Gather equipment
2. Explain the procedure to the client
3. Ask the client to put on a gown
Abdomen
1. Inspect the skin, noting
color,vascularity, striae, scars and
lesions
Findings
Before the physical assessment I
sanitized all the materials to be used
in the client and performed proper
hand hygiene before proceeding to the
assessment.
 I explained the rationale of the
procedure and asked for consent to
the client before starting the
assessment. I also provided privacy
and make sure only the two of us are
in the examination area.
 Since my client is a woman. I asked
her to wear a loose ‘daster’ so that I
can assess her abdomen easily. I also
prepared a clean cloth so I can place it
in a diamond position so I she will feel
comfortable and for her privacy as
well..
 
 There is no discoloration in the areas
of the abdomen. There are moles
present but it is does not shows
swelling or infection. The color of her
abdomen is lighter in her complexion
in the arms. There is also signs of
striae which appears to be linear and
uneven that is related to her weight
 loss. There is a sign of keloid scar on
her right lower quadrant due to a bike
accident when she was young as per
said by the client. Also, there are no
following lesions or wounds present in
the abdomen area.

2. Inspect the umbilicus, noting color,  The color of the umbilicus is same as
location, and contour the color of the abdomen, umbilicus is
not everted as well and located in the
midline anterior part of the body at
lateral line.

3. Inspect the contour of the  The client’s abdomen is flat and there
abdomen are no other signs of irregularities.

4. Inspect the symmetry of the  The abdomen of the client is

abdomen symmetrical to the left and the right.
There also no signs of distention.

5. Inspect abdominal movement,  There is also abdominal movement

noting respiratory movement, aortic but it is not pounding too obvious and
pulsations and/ or peristaltic waves it is due to peristaltic waves and aortic
pulsations.

6. Auscultate for bowel sounds,  As I auscultated the client’s 9 regions

noting intensity, pitch and frequency of the abdomen there are gurgles
present. Also I heard some growling in
the stomach of the client from time to
time.

7. Auscultate for vascular sounds  There are no vascular sounds present

and friction rubs or bruits in these areas.

8. Percuss the abdomen for tone  During percussion there is dull

 sounds and tympanic sounds heard in
the abdomen of the client.

9. Percuss the liver  The sounds in the liver while being

percussed is dull.

10. Percuss the spleen  The sounds in the spleen while being
percussed is dull as well.

11. Perform blunt percussion on the  The client does not elicit any pain
liver and the kidneys reaction as I performed blunt
percussion.

12. Perform light palpation, noting  During light palpation of the 9 regions
tenderness or guarding in all of the abdomen, there client does not
quadrants elicit any pain.

13. Perform deep palpation, noting  During deep palpation of the 9

tenderness or guarding in all regions of the abdomen, there client
quadrants does not elicit any pain as well.

14. Palpate the umbilicus  There are no masses, lesions or cyst

present in the umbilicus area. The
umbilicus is not also everted.

15. Palpate the aorta  The aorta have strong pulsations as I

performed light palpation.

16. Palpate the liver, noting  The client does felt some mild
consistency and tenderness tenderness during palpation of the
liver. The consistency is also soft and
no signs of masses or cyst as well.
17. Palpate the spleen, noting  The client did not elicit signs of pain
consistency and tenderness during palpation of the spleen.

18. Palpate the kidneys  The client’s kidneys can be described

as firm and smooth. Again, the client
did not elicit any signs of pain during
palpation.

19. Palpate the urinary bladder  I performed deep palpation in the

urinary bladder the client did not elicit
any pain reaction but said a bit of urine
came out because she did not empty
her bladder before the assessment.

20. Perform the test for shifting  The tympanic and dullness sounds
dullness are constant and does not change
much.

21. Perform the fluid wave test  There is no fluid wave transmitted
during the test.

22. Perform the ballottement test  There is no signs of swollen and

bulging the abdomen during the test.

23. Perform the test for appendicitis  The client is negative for rebound
tenderness.
Rebound tenderness
The client is negative for referred
Rovsing sign rebound tenderness.

Referred rebound tenderness The client is positive for rovsing sign.

Psoas sign The client is negative for psoas sign.

Obturator sign The client is negative for obturator

sign.
 Hypersensitivity test The client is negative for
hypersensitivity test.

24. Perform the test for cholencystitis  The client did not experience pain or
(Murphy sign) tenderness as I assess for the
Murphy’s sign.

Analysis of Data  

1. Formulate nursing diagnoses  Readiness for enhanced health

(well, risk and actual) management: request for health
education and improve the nutritional
status

Risk for imbalanced nutrition related

to imbalanced diet and lack of
nutritional food supply

2. Formulate collaborative problems  Risk for complications of peptic ulcer

disease

3. Make necessary referrals  Referral to see gastroenterologist and

dietitian specialist to assess further
client’s condition and situation with the
approval of the attending physician.

CHAPTER 23 - Assessing Musculoskeletal System

Activity E (pp.178)

 
 Nursing Interview Guide to Collect Subjective Data from the Client
QUESTIONS
Current Symptoms
1. Recent weight gain?
2. Difficulty chewing?
3. Joint, muscle, or bone throbbing?
Past History
1. Past problems or injuries to joints,
muscles, or bones?
2. Past treatment: surgery,
medications, physical therapy,
exercise, rest?
FINDINGS
 The client said she recently loose
weight due to fasting but gain again
another 3 kilos because of stress
eating due to academic stress.
 The client does not feel any difficulty
in chewing.
 ”Wala namang nasakit sa akin pero
minsan dahil nga dun sa injury ko sa
tuhod pag malamig sumasakit talaga
sya kaya nagsusuot ako ng knee
support” as verbalized by the client.
 ”Meron, yung knee injury ko nung
grade 9 dahil sa volleyball. Sabi ng
doctor ACL daw pero okay nanaman
ako ngayon hindi lang pwede ng
mabibigat na gawain” as verbalized
by the client.
 The client had her knee cast before
and after a several months she
undergo some physical therapy to
enhance her right leg. As per client
said, her doctor also advised her to

3. Tetanus and polio immunizations?
4. Diagnosed with diabetes mellitus,
lupus, or sickle cell anaemia?
5. How old at start of menstruation:
started menopause; estrogen
replacement therapy?
Family History
1. Family history of rheumatoid
arthritis, gout, osteoporosis,
psoriasis, infectious tuberculosis?
Lifestyle and Health Practices
1. Activities to promote
musculoskeletal health?
take a rest and do not make
extraneous movements.
 ”Yes meron akong tetanus vaccine
noon nung nagka-injury” as
verbalized by the client.
 The client was not diagnosed with
these diseases.
 ”Nagkaroon ako ng mens 13 years
old na and regular naman yung
periods ko ngayon pero nung simula
medyo hindi pa sya ganon ka
regular. Saka mahirap ako magka
mens, grabe ako saktan ng puson at
pms” as verbalized by the client.
 ”Meron lang yung Ina(grandmother)
at Tatay (grandfather) ko na arthritis
saka gout siguro dahil matanda na
din sila. Si Ina medyo ayos pa
naman umiinom sya lagi ng gatas
para daw di magka-osteoporosis” as
verbalized by the client.
 ”Lagi kaming nag wawalking sa
umaga kasama ang mga Ina saka
paminsan nag babasketball kaso di
pwedeng matagal at sumasakit ang
 tuhod ko” as verbalized by the client.

2. Home remedies to relieve  As per client said, she always wear
musculoskeletal problems? her knee support and have ice cold
compress or bath.

3. Assistive devices to promote  The client does not use any devices
mobility? to promote mobility such as
wheelchair or crane.

4. Smoking?  The client admitted that she seldom

smokes but with influence of her
peers only.

5. Alcohol or caffeinated beverages?  ”Mahilig ako sa kape saka mga

softdrinks, di ko kaya mawala yon sa
sistema ko eh” as verbalized by the
client.

6. Typical diet, drink milk, take  The client only takes B-complex,
calcium supplements? Ascorbic Acid and Fish Oil as her
supplements.

7. Occupation?  The client is a college student.

8. Time in sunlight?  ”Minsan umaga na talaga ako

matulog o kaya may araw na.
Nahihirapan ako matulog talaga di ko
din alam kung bakit” as verbalized by
the client.

9. Routine exercise?  The client does some walking as a

routine perform ADLs independently.
 10. Difficulty with ADL?  The client does not have any
problem in performing ADLs.

11. Typical posture?  The client is a bit slouching but

always straighten her back.

12. Interference with sexual  The client does not have any
activities? experience or engagement in any
sexual activities.

13. Ability to interact/socialize?  ”Kayang kaya ko naman, walang ka

proble-problema” as verbalized by
the client

14. Body Image?  ”Okay naman minsan naiilang lang

ako kase medyo chubby ako pero
okay lang yon, ganon talaga eh” as
verbalized by the client.

15. Stress?  The client only experiences

academic stress and peer pressure
but other than that her body image
does not give her stress as per said.

Activity F (p.179-180)

Physical Assessment Guide to Collect Objective Client Data

QUESTIONS FINDINGS

1. Gather equipment (tape  Before the physical assessment I

measure, goniometer). sanitized all the materials to be used
in the client and performed proper
hand hygiene before proceeding to the
assessment.

I explained the rationale of the

2. Explain the procedure to client. procedure and asked for consent to the
client before starting the assessment. I
also provided privacy and make sure
only the two of us are in the
examination area.

3. Ask the client to put on a gown.  Since my client is a woman. I asked

her to wear a loose ‘daster’ so that I
can assess her movements easily.

Gait

1. Observe gait for base, weight-
bearing stability, feet position,
stride, arm- swing, and
posture.
 The gait of the client is okay she can
stand and walk properly without any
problem. She is able to stand on heels
and toes. The feet are symmetrical to
the left and right. She can also swing
her arms forward, backward and
sideward without any problems or
pain.

Temporomandibular Joint  

1. Inspect, palpate, and test  The client can move the TMJ without
ROM. eliciting any pain. There are no heard
crepitus when I asked her to bite.
Sternoclavicular Joint
1. Inspect and palpate for midline
location, colour, swelling, and
masses.
Spine
1. Inspect and palpate cervical,
thoracic, and lumbar spine for
pain and tenderness
2. Test ROM of cervical spine.
3.. Test for leg and back pain.
4. Measure leg strength.
Shoulders
1. Inspect and palpate shoulders  During the palpation and inspection
for symmetry, colour, swelling, the shoulders don’t have indication of
and masses.
 
 The sternoclavicular joint is not tender
and free of masses, lesions or cysts..
Spasm is not also felt by the client.
 
 As I inspected the client’s posterior
part of the body, the spine appears to
be straight. For the cervical and
lumbar it appears to be concave. She
did not feel any as I palpated her back
area.
 The movement of flexion and
extension is done by the client without
any problems or existing pain during
the test.
  The client does not elicit pain as I
assess and test for the leg and back.
 The legs are symmetrical to the left
and right.
 
swelling and lesions. As well as the
clavicle and scapulae, it is also
symmetrical to the left and right. There

2. Test ROM of shoulders.
Elbows
1. Inspect and palpate elbow for
size, shape, symmetry, colour,
swelling, tenderness, and
nodules.
2. Test ROM of elbows.
Wrists
1. Inspect and palpate wrists for
size, shape, symmetry, colour,
swelling, tenderness, and
nodules.
2. Test ROM of wrists.
are no tenderness during palpation.
 The client can perform the ROM
which is flexion and hyperextension
also the adduction and abduction and
external rotation and internal rotation
without any problem and client does
not elicit pain during ROM test for
shoulders.
 
 During the palpation and inspection
the elbows don’t have indication of
swelling and tenderness. It is
symmetrical to the left and the right.
There are no discoloration as well.
 The client can perform the ROM
which is flexion and extension also the
supination and pronation without any
problem and client does not elicit pain
during ROM test for elbows.
 During the palpation and inspection
the wrist of the client it doesn’t have
indication of swelling and tenderness.
The wrist are symmetrical to the left
and the right. There are no
discoloration as well.
 The client can perform the ROM
which is flexion and extension, wrist

3. Test for carpal tunnel
syndrome.
Hands and Fingers
1. Inspect and palpate hands and
fingers for size, shape,
symmetry, colour, swelling,
tenderness, and nodules.
2. Test ROM of hand and fingers.
Hips
1. Inspect and palpate hips for
shape and symmetry.
rotation and ulnar deviation and radial
deviation without any problem and
client does not elicit pain during ROM
test for wrist.
 Upon the test, the client does not feel
numbness and tingling sensation after
the tests such as phalen, tinel, flick
and thumb weakness signal. There
are no indication of swelling and
redness or any discoloration.
 During the palpation and inspection
the hands and fingers of the client it
doesn’t have indication of swelling and
pain. The hands and fingers are
symmetrical to the left and the right.
There are no discoloration as well.
There are also no signs of clubbing in
the nailbeds.
 The client can do ROM test for fingers
without any intervention. She can do it
independently and fast as well. The
client does not elicit pain during the
ROM test for the hands and fingers.
 The client did not feel any tenderness
or pain as I palpated her hip area. It is
not distended as well and no signs of
masses and lesions.
 2. Test ROM of hips.
Knees
1. Inspect and palpate knees for
size, shape, symmetry,
deformities, pain, and
alignment.
2. Test knee for swelling. If small
amount of fluid present, do
“bulge test.” If large amount of
fluid present, do “ballottement
test.”
3. Test ROM of knees.
4. Perform McMurray test if client
complains of “clicking” in
knee.
Ankles and Feet
1. Inspect and palpate ankles and  The ankles and feet are symmetrical
 The client can perform the ROM for
the hips such as rotation, flexion and
extension and others without any
problem and pain.
 Upon palpation and inspection the
client’s knee is symmetrical to the left
and right. But there is a bulging in her
right knee due to her past injury. The
client does elicit pain while I palpated
her right knee but not on the left knee.
The right knee appears to be bigger
than the size of the left knee. There
are no crepitus sounds as well.
 The client did not elicit pain during the
bulge test. She said that she feels
numbness a bit on her right knee.
 The client can do the ROM for the
knees independently without any
problem and does not feel any pain or
swelling upon the test.
 There are no clicking sounds heard
upon the McMurray’s test.
 feet for position, alignment,
shape, skin, tenderness,
temperature, swelling, or
nodules.
2. Test ROM of ankles and toes.
Analysis of Data
1. Formulate nursing diagnoses.
2. Formulate collaborative
problems.
3. Make necessary referrals.
to the left and to the right. The client
can point and flatten her toes and
heels. There are no signs for calluses
and wounds present in the feet and
ankle. During palpation, there is no
tenderness and swelling as well. Her
feet is warm on the left area and for
the right it is also warm but the left is
warmer. There are no lumps or bumps
in the feet and ankles as well.
 The client can do the ROM test for the
ankles and toes freely and does not
feel any pain during the test.
Risk for injury to muscle, joints and
bones related to past bone fracture
during past injury
Readiness for enhanced health
management: activity for light
exercises to improve the condition
 Risk of Complication for Joint
dislocation
 Referral to see orthopedic specialist
to assess further client’s condition and
situation with the approval of the
attending physician.