VISION MISSION

Republic of the Philippines Cavite State University shall provide

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

College of Nursing global competitiveness.

INDIVIDUAL ASSESSMENT

Presented by:
Dizon, Diana A.

BSN / 2-3 /
Members

Presented to:

Prof. _________________ , RN, MAN

Prof. _________________ , RN, MAN
Prof. _________________ , RN, MAN

Clinical Instructors, Level II or III

Date:

July 17, 2021

In Partial Fulfillment of the Requirement in NURS 50/55 or NURS 60/65 for the Degree Bachelor of
Science in Nursing

TABLE OF CONTENTS
I. Demographic

Data………………………………………………………………………………….1

II. Reason for Seeking Health

Care…………………………………………………………………1

III. History of Present

Illness…………………………………………………………………………..1

IV. Past Medical

History………………………………………………………………………………...1

V. OB-Gynecological

History………………………………………………………………………….1

VI. Heredo-familia

History…………………………………………………………………………...1-2

VII. Developmental History……………………………………………………………………………...2

VIII.Gordon’s Functional Health Patterns…………………………………………………………..2-5

IX. Physical Examination…………………………………………………………………………….5-

12

X. Diagnostic Test…………………………………………………………………………………..12-

13

XI. Review of System……………………………………………………………………………………

13

XII. Concept

Maps………………………………………………………………………………………..13

XIII.Case

Management…………………………………………………………………………………..14

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

14
 B. Surgical……………………………………………………………………………………………

14

C. Nursing…………………………………………………………………………………………15-

16

XIV. Ongoing

Appraisal………………………………………………………………………………….16

I. DEMOGRAPHIC DATA
A. Initials of Clients’ Name: ADD Date of Interview:July 17, 2021
B. Address:
00025 Brgy. Pascam I General Trias Cavite
C. Age: 52 yrs. old
D. Birth Date: Sept. 26, 1968
E. Birth Place: Masbate City Primary Informant: Client
F. Gender: Female Secondary Informant: N/A
G. Civil Status: Married Other Data Sources: N/A
H. Religion: Roman Catholic
I. Highest Educational Attainment: High School Graduate
J. Occupation: Housewife
K. Monthly Income / Budget : 5,000-10,000 pesos

II. REASON FOR SEEKING HEALTH CARE:

Client ADD was interviewed because of the student’s activity of home seeking information
by doing assessments, identification of nursing problems, and implementation of family nursing
intervention that will be evaluated after implementation. 

III. HISTORY OF PRESENT ILLNESS:

Upon doing the interview, the client is complained that these past few days she is constantly
experiencing stinging sensation in her legs. The client stated “Tuwing nagbabasa ako ng paa pag
gabi dun sya sumasakit, tsaka pag tumatayo ako ng matagal dahil nagtitinda ako sa sari-sari
store”. She did not go to a doctor for checkup because she believed that it’s just a common muscle
pain, she uses ointments and essential oils such as (efficascent oil and omega pain killer) as a
form of medication.

IV. PAST MEDICAL HISTORY

Upon doing the assessment, the client stated that she doesn't remember having any childhood
diseases. She has not been into accidents. She didn't have any injuries. Upon assessing a
surgical scar is recognizable in her sternum. The client stated that she has been confined in the
hospital for the removal of a benign cyst in her sternum in year 2009. She also stated that she has
 no allergies in any food or medicine. She stated that she takes Vitamin C and herbal tea for her
immune system and she doesn't go to the doctor for checkup because she believed that she is
well and doesn't have any illness. The client stated that she was fully immunized when she was a
child.

V. OBSTETRIC-GYNECOLOGICAL HISTORY:
The menarche started when she was 13 years old, she wasn't able to remember the amount of her
menstrual flow. According to her it usually lasts for 3-4 days with no presence of dysmenorrhea or back
pain. She once goes for a checkup with an ob gynecologist in year 2012 and received a normal finding. At
the age of 50 she reached her menopausal stage. She experienced high fever and aching of muscles in
her thighs, she stated “Alam ko ng menopause ako dahil ang nanay ko ganito din ang naramdaman nung
nawalan sya ng dalaw.” She had an OB score of Gravida 2, Para 2, T2, P0, A0 and L2. Both of her children
were born in normal delivery.

C. EDC, AOG, GP-TPALM

VI. HEREDO-FAMILIAL HISTORY
Genogram

Interpretation of the Genogram:

The client’s mother and father are both an only child. They were raised in the province of Masbate
and was treated by their extended family very well that they were almost claimed as the children of
the whole clan. In the maternal side of the client, her grandparents suffered from hypertension and
lung cancer. The client stated that “Sobrang dalas magtabako ng lolo ko noon, inaasar pa namin
syang tren ng mga pinsan ko dahil pag palapit na ito ay napaka-kapal na ng usok.” While her
grandmother used to believe in different superstitious beliefs and amulets “Yung lola ko hindi yun
matablan tablan ng sakit dahil may iniingatang amigat, pero nagkasakit ang mamay ko kaya
napilitan syang ipasa.” While on the paternal side of the client, she stated that his grandfather is a
well-known fisherman in their barrio. He sails all the time with a cigarette on his lip even when
there’s a storm, he eventually developed pneumonia and died at the age of 58 while her
grandmother died due to heart attack. The client’s father and mother trained them to eat fresh
 seafoods and vegetables and avoid processed foods/with preservatives. In March 2021, his father
died due to kidney failure the client stated that his father developed this disease when he used to
work as a security guard and factory worker before.

B. Family APGAR

Constructs Questions Almost Some of Hardy

Always the Time Ever
(2) (1) (0)
Adaptation I am satisfied with the help that I receive
from my family when something is ✔️
troubling me.
Partnership I am satisfied with the way my family
discusses items of common interest and ✔️
shares problem-solving with me
Growth I find that my family accepts my wishes
to take on new activities or make ✔️
changes in my lifestyle.
Affection I am satisfied with the way my family
expresses affection and responds to my ✔️
feelings such as anger, sorrow and love.
Resolve I am satisfied with the way my family and ✔️
I spend time together.
TOTAL 8

VII. DEVELOPMENTAL HISTORY (Determine the exact stage based on client’s age and his
milestone and provide some justifications that would be most applicable to the specified
developmental stage)

A. J. Piaget’s Cognitive Development

Stage Specific Task(s) Evidences of Milestone
Achievement
Sensorimotor During this stage, According to the client’s
Stage (ages 0-24 infants are only aware mother she was able to
months) of what is right in front observe different reflexes
of them. They focus on mentioned during this
what they see, what stage. The client always
they are doing, and grasps and sucks her toes
physical interactions and fingers since toys are
with their immediate not available for them and
environment. They hold things that she was
shake or throw things, able to. During seven to
put things in eight months the client was
their mouth, and learn already able to notice
about the world through changes with reactions
trial and error. Between especially when feeding.
ages 7 and 9 months,
infants begin to realize
that an object exists
even though they can
no longer see it.
 Pre- operational During this stage, According to the client her
Stage (ages 2-7) children are able to mother always tells her that
think about things she has a very good
symbolically. Their imagination and sharp
language use becomes memory since she can still
more mature. They also remember some of her
develop memory and playmates and childhood
imagination, which friends in their island. The
allows them to client was also curious
understand the about a lot of things and
difference between past always asks a lot of
and future, and engage questions to her mother
in make-believe. when she was little.

Concrete Children's thinking During this stage, the client

Operational Stage becomes less focused was already aware of
(ages 7-11) on themselves. They're different things. She also
increasingly aware of shows interest on earning
external events. They money at an early age, she
begin to realize that went with her father to
their own thoughts and catch some fish after school
feelings are unique and so she can have her
may not be shared by allowance because they
others or may not even don't have enough money
be part of reality. to sustain their education.

G. Williams’ Metro Manila Developmental Screening Test (MMDST)

Personal-Social Score Justification

1. Task for a particular month Passed /
2. Failed /
3. Refused /
No Opportunity

Fine-Motor Adaptive Score Justification

1. Task for a particular month Passed /
2. Failed /
3. Refused /
No Opportunity

Language Score Justification

1. Task for a particular month Passed /
2. Failed /
3. Refused /
 No Opportunity

Gross-Motor Behavior Score Justification

1. Task for a particular month Passed /
2. Failed /
3. Refused /
No Opportunity

VIII. GORDON’S 11 FUNCTIONAL HEALTH PATTERNS

A. Health Perception – Health Management
According to the client her general health has been well since she doesn't get sick very often aside
from her legs aching under a cold weather. She doesn't take any medications aside from vitamins
and herbal coffee/ tea. Furthermore, she said that being hydrated, eating fruit and vegetables and
sleeping early improves her wellness during the pandemic. Whenever the client gets sick, she will
drink over the counter medications and use herbal/ essential oils.

B. Nutritional – Metabolic

According to the client, she eats three times a day. Rice, vegetables meat and coffee are her
typical food intake and her approximate fluid intake ranges from 7-8 glasses of water a day and 2
cups of decaffeinated coffee. In addition, the client gained weight during the pandemic from 57kg
to 65kg. She claims that she eats lot of vegetables and root crops such as sweet potato. Moreover,
in terms of healing the patient declared that it takes 3-4 days before she can completely heal from
sickness. She doesn't have any dental problems.

*3-day Diet Recall

MEALS July 29, 2021 July 30, 2021 July 31, 2021
Breakfast (time) 3 slices of bread (200 2 pcs. sweet potato, toasted bread, 200 mL
mL) of coffee 200 mL of coffee of coffee
Snacks (if any) Water (250 mL) Water (300 mL) Water (300 mL)
Lunch (time) 1 cup of rice, 1 chicken 1 cup of rice, Ginisang 1 cup of rice, Ginisang
adobo, 300mL of water toge, 500mL of water gulay, 500 mL of water
Snacks (if any) Coffee (250 mL) Coffee (250 mL) Coffee (250 mL)
Dinner (time) 2 sweet potatoes, 4 1 cup of rice, 5 1 cup of rice, ginisang
nilagang okra, 400 mL nilagang talong w/ soy gulay, 500 mL of water
of water sauce, 500 mL of water
Snacks (if any)
Total Fluid Intake 1,400 mL 1,750 mL 1,750 mL

According to the 3-day diet recall of the client, on July 29-31, 2021 she had coffee and slices of
bread for her breakfast, water for snacks. 3 cups of rice, chicken adobo, ginisang toge and
ginisang gulay for lunch, for dinner 2 cups of rice, 2 sweet potatoes, nilagang okra and nilagang
talong. Her fluid intake ranges from 1400-1750 mL per day,

C. Elimination
 According to the client, she usually defecates twice a day. She claimed that her stool was brown in
color but turns green when she ate vegetables, it has a lumpy and sausage like consistency.
Furthermore, she urinates approximately 5-6 times a day with a yellow to whitish color of urine with
slight odor and doesn't have any discomfort while urinating. There are no excessive perspiration
and odor problems as well.

D. Activity – Exercise
According to the client's activity table she usually spends her time running/managing her sari-sari
store, she uses her free time communicating with her mother through video call and watching
movies/ telenovela. She didn't include any physical activities aside from letting the dogs out for a
walk but aside from that she barely goes out of the house because of the pandemic. She asserted
that cleaning or doing house hold chores takes some of her stress away.

*7-Day Activity Table

Time Days of the Week & Date
July 25, July 26, July 27, July 28, July 29, July 30, July 31,
2021 2021 2021 2021 2021 2021 2021
1 am
2 am
3 am
4 am
5 am

6 am

7 am

8 am

9 am

10
am

11
am
12 nn

1 pm

2 pm
3 pm
 4 pm
5 pm

6 pm

7 pm

8 pm
9 pm
10
pm
11
pm
12
mn

LEGENDS:

Sleeping/Naps

Preparing to open/close
the store
Walking the dogs

Opening/managing the
store
Leisure:Watching/Using
phone

Interpretation:

*Katz Index of Independence in Activities of Daily Living

Activities Independence = 1 point Dependence = 0 point
Points (1 or 0) No supervision, direction or personal With supervision, direction or
assistance needed personal assistance or total care
Bathing (1) (1 point) Client bathes self completely
Dressing(1) (1 point) Client gets clother from her
cabinet on her own
Toileting (1 point) Client can go to toilet and
cleans genitalia without assistance.
Transferring Client can move freely with no guidance.
Continence (1 point) Client has self control over
urinatiin and defecation.
Feeding Client can eat in her win without
assistance
 TOTAL POINTS: 6= High (Client is independent)

According to the client’s Katz ADL, she obtained a score of 6 which indicates full function or
independence, she can properly take care of herself. She was able to meet one's physical needs in six
areas: eating, dressing, bathing, toileting, continence and mobility.

E. Sleep – Rest
Client ADD, her sleep ranges 8-9 hours. When she wakes up, she usually first check on her pets
and immediately prepare for the opening of her sari- sari store. After her morning routine she would
nap around 1-2 hours to regain her energy back from running the store. Client stated that she
doesn’t have trouble sleeping at night except when her legs hurt due to the cold weather.

*7-Day Sleep Diary

Constructs Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Hours of Sleep 9 hrs. 8 hrs. 7 hrs. 9 hrs 9 hrs 9 hrs 7 hrs
Sleeping Time 9:00 pm 10:00 10:00 9:00 pm 9:30 pm 9:25 pm 10:00 pm
pm pm
Waking Time 5:00 am 5:00 am 4:00 am 5:00 am 5:00 am 5:00 am 4:30 am
Bedtime Rituals Praying Watchin Talking Praying Watchin Praying Praying
g TV over the the g the TV the
phone rosary rosary
Feeling upon Energeti Energeti Lethargic Energeti Energeti Energeti Lethargic
waking up c c c c c
Problem None None Barking Exhaust None None Noisy
Encountered of dogs ed from neighbor
work s

F. Cognitive – Perceptual
Client A.D is attentive during the interview. She claimed that she is looking forward for the results
and she understands the concept. She declared that doesn't have any trouble with hearing but she
has a poor eyesight and wear reading glasses. in addition, the client also said that her memory and
concentration are not that sharp compared when she was younger. The client also learns by visual
and auditory the idea remains when she sees or hears it repeatedly.

G. Self-Perception – Self-Concept
The client asserted that she feels good but she also feels old most of the time about herself but she
actively participated and interact and said that she can do almost the things asked during the
interview. Also, she stated that she gets annoyed easily by naught kids and customers who buys at
her store while losing a loved one is her greatest fear.

H. Role-Relationship

According to client ADD, she doesn't have any family problems at all aside from being sad with the
passing of her father recently. She describes herself as honest, good listener and someone who can
give good advices coming from her own life experiences. She doesn't feel alone because she knows
she have her family with her.

Ecomap
 Interpretation of Ecomap
The client is married with her husband and has 2 kids. They rent an apartment his husband work as
a contractor while she manages a convenience store at their home. She didn’t mention any conflicts
in their family but she stated that his husband works from afar and she worries about his health
because of the pandemic.
The client is self-employed and manages her business by herself. The social group she belonged in
to are her friends, family and her extended family. She stated that she developed the aching of her
legs in managing the store. Health services is not much of the client’s priority, she said that she
most likely spends all her income from the store with utility services and groceries in mall/market.
She doesn’t like getting admitted in hospitals.

I. Sexuality - Reproductive
The client is not engaged in any sexual intercourse after giving birth to her second child. She had
undergone menopause on year 2020 and doesn't have any sexual problems.

J. Coping-Stress
According to the client, getting old and handling many problems is one of the reasons of her stress.
She noticed that her wrinkles started to show up together with white hairs. Her husband usually
helps her in terms of problems which helped her to cope up. The client doesn’t use any drugs or
alcohol. Whenever she has problems she would pray and think of immediate ways on how to solve
it by telling her husband.

K. Value-Belief
The client stated that you need to work hard for you to get what you need; she also wanted her
children to succeed in life and finish their studies. Moreover, religion for her is very important since
she was strictly raised by her Catholic parents, she has strong faith with the Lord and beliefs that
anything is possible with God.

IX. COMPREHENSIVE PHYSICAL EXAMINATION

A. Vital Signs Date / Time of Exam:July 27, 2021 7:09 pm
T = 36.5 C
PR = 93 bpm
RR = 28 cpm
 BP =110/70 mmHg
Pain- There are no signs of pain upon the interview.
B. Anthropometric Data (only those applicable)
Height = 149.8 cm (for both adult & pedia) BMI = 11.9 (for adult)
Weight = 59 Kg (for both adult & pedia) IBW =40- 59kg (for adult & pedia)
Head Circumference = __ cm (for pedia)
Chest Circumference = __ cm (for pedia)
Abdominal Circumference = __ cm (for pedia)

C. General Appearance
1. Body build and height-weight proportionality
- The client has a normal height for her age it doesn't affect her height-weight
proportionality since she has a normal body index.
2. Posture and Gait
- The client has a good posture and gait.
3. Over-all hygiene and grooming
- The client is well groomed and dresses appropriately.
4. Body and breath odor
- There is no presence of foul odors.
5. Obvious signs of distress / illness
- There are no signs of distress/ illness during the interview.
6. Mental status
- Client is attentive and respond well to the tasks.
7. Attitude
- The client answers the questions with respect and not rude to the interviewee.
8. Affect/mood; appropriateness of responses
- Client responds well to the interview.
9. Quantity and quality of speech
- Client speaks well and answers the questions directly.
10. Relevance and organization of thoughts
- The client gives relevant information about herself to the interviewee.

D. Focused Assessment

Body Part Examined Actual Finding Normal Finding Clinical

Significance
INTEGUMENTARY    
I: Inspection reveals
Skin evenly colored skin
I: Skin has a consistent fair complexion, no tones without unusual
I:   color, presence of lesions and edema. or prominent
uniformity, edema,   discolorations, skin is
lesions P: Skin is smooth, dry, warm to touch, has smoot hand even,
good elasticity and mobile. without lesions, warm, 
P: moisture, temp.    
  P: Skin is smooth and
    turgor   even, normally thin,
  dry, and intact.
   
 
HAIR I: hair is black and shiny, evenly I: Natural hair color,
distributed, has no presence of lesions, scalp is clean and dry,
I:  evenness of growth lice, or dandruff. no evidence of alopecia or has no infestations, 
lumps.  
   thickness, texture,    P: hair is smooth and
firm, somewhat elastic.
   oiliness, infection  
 
   or infestation, body P: has thick and smooth texture.  
 
   hair I: Nails are clean, pink
I: Nail shape is convex, has smooth and tones should be seen,
P: smoothness firm texture with pinkish color. hard and immobile.
 
 NAIL P: has good capillary refill time P: Pink tone returns
of 1 second. immediately to
I: plate shape, texture,   
blanched nail beds
 
  bed color, when pressure is
 
  released.
   surrounding tissues
 
P: Blanch test

I: Head shape is round, normocephalic and

symmetrical; face is square, smooth and
has uniform consistency.  I: Head should be
 HEAD
  symmetric, round, and
Skull and Face in midline and
appropriately related
I:  size, shape,     to body size.
   symmetry
P: has no presence of lesions, nodules or
 : facial features edema.
  P: Hard and smooth,
 : eyes for edema    without lesions.
 
   and hollowness

P: nodules, masses,

   depressions

I: eyebrows are symmetrical and in line

with each other, has black color and evenly
distributed.
 
I: no hair loss, curved
Eyelashes are evenly distributed, turned
outward and has a black color. eyelashes, evenly
EYES AND VISION distributed, eyelid
 
Eyelids are symmetrical, lids close open and close
I: eyebrows for 
symmetrically with involuntary blinks completely,
  distribution &  approximately 15-20 times per minute, no spontaneous blinking,
presence of discharge. eye shape is
  alignment, quality &   
symmetrical.
  movement
: bulbar conjunctiva is
: eyelashes for  transparent, smooth,
no lesions.
  evenness of   
I/P: no edema,
  distribution &  Bulbar & palpebral conjunctiva  tenderness or trauma.
Bulbar conjunctiva appeared to be
  direction of curl transparent with few capillaries. I: smooth, lens is
 
transparent, sclera is
:  eyelids for surface Palpebral conjunctiva appeared shiny,
clear and white,
characteristics, position in smooth, and pink. Has no swelling or
relation to cornea, ability exudates.
  I: pupil is black,
to blink & frequency
I/P: lacrimal gland sac, nasolacrimal PERRLA.
:  bulbar & duct
palpebral conjunctiva for Visual Acuity normal
I: has no swelling or redness,
color, texture, and lesion  near vision: 14/14
puncta are visible and turned slightly
toward the eye. Normal far vision:
  20/20
P: no drainage was found in the puncta
while palpating the nasolacrimal duct. Visual field test
  With normal peripheral
  vision, the client
I/P: lacrimal gland I: cornea is transparent, smooth and
should see the
sac, nasolacrimal duct for shiny. No irregularities found, there is examiner’s finger at
positive corneal reflex.
edema, tenderness /   the same time the
tearing I: pupils equally round, reactive to light examiner sees it.
and accommodation.
I: cornea for clarity,   EOM Test
texture & sensitivity Near visual acuity:
Client has normal near visual acuity
I: pupils for color, shape, (14/14) Corneal light reflex
symmetry of size, direct   The reflection of light
and consensual reaction Distant visual acuity: Client has 20/70 on the corneas should
to light, & distant visual acuity. (with the use of be in the exact same
accommodation  reading glasses) spot on each eye,
  which indicates
* Visual Acuity (near & far Visual field test: parallel alignment.
vision test) Client has normal peripheral vision.
 
EOM Test Cover test
* Visual Field Test
: corneal light reflex, light reflected in The uncovered eye
* EOM Test same spot on each eye. should remain fixed
  straight ahead. The
  Cover test covered eye should
Both covered and uncovered eye remain remain fixed straight
  fixed straight ahead even after being
ahead after being
uncovered. 
    uncovered.
Positions test
  Eye movement is smooth and symmetric to Positions test
all six directions. Eye movement should
    be smooth and
  symmetric throughout
   
  all six directions.
  I: auricles are
symmetrical and has
  same color with facial
skin, aligned with inner
 
canthus of eyes.
I: skin is the same in color as in the
  complexion, bean-shaped, parallel, and
P: mobile, firm, and
    symmetrical. not tender.
 
: external canal no presence of cerumen, Gross hearing acuity
lesions pus or blood test:
 
P: firm, has no presence of lumps or Able to correctly
tenderness. repeat the two-syllable
  word as whispered.
Gross hearing acuity test:
Client was able to correctly repeat the two- Tuning fork test:
syllable word whispered. (Weber for bone
 
EARS AND HEARING conduction)
Vibrations are heard
I: auricles for color, equally well in both
Tuning fork test:
symmetry and position (Weber for bone conduction) ears. No lateralization
of sound to either ear.
: external canal for Vibrations are heard equally in both ears.
cerumen, lesions, pus or (Rinne’s to compare air and bone (Rinne’s to compare
blood conductions) air and bone
conductions)
P: auricles for texture, Air conduction is heard longer than bone
elasticity and areas of conduction sound. Air conduction sound
tenderness  
  is normally heard
  longer than bone
* Gross Hearing Acuity
I: nose is in midline, no flaring alae nasi,no conduction sound
Tests: normal voice tone
discharge
and whispered voice  
: nasal mucosa mucosa is pink, no
* Watch Tick Test
lesions no swelling, no redness
 
* Tuning Fork Tests:
Pa: no tenderness, nares are patent, no
  - Weber for bone bone cartilage deviation noted, no Nose
tenderness palpated on paranasal sinuses. I: nose is symmetrical,
conduction  
midline, smooth
  - Rinne’s to compare air without lesions, no
and bone conductions discharge

  : no redness, no
swelling
 
Transillumination test Pa: no masses, no
 
Red light was seen in maxillary and frontal tenderness
NOSE AND SINUSES sinuses.
  : sinus areas are
I: nose deviation in shape   symmetrical with no
  redness or swelling,
size, color, flaring,
I: lips are symmetrical with visible margin, no tenderness
discharge; has pinkish color, smooth and moist.
  Transillumination test
: nasal mucosa for : 28 yellowish color teeth, no presence of Red light should be
redness, swelling, growth dental caries or dental filings, no halitosis.
or discharge visible.
 
:no gum bleeding, no receding gums,
Pa: tenderness, masses, pinkish in color.
displacements;  
: pinkish, no lesions, gag reflex is present,
: nasal patency able to move tongue freely and with
: maxillary and frontal strength, surface is rough.
sinuses for tenderness  
: no swelling or redness found.
Pe: the above sinuses for  
tenderness : palate is whitish with firm rugae.
  I: symmetrical, lips are
: uvula is in midline, pinkish, no swelling, pink and moist, no
Transillumination Test 
moves upward and backward when asked lesion
 MOUTH / to say “ah” : complete teeth, no
OROPHARYNX   dental filings, no caries
: throat is normally pink, with no lesions or : no bleeding, pink, no
I: lips for symmetry of exudate.
lesion and no swelling
contour, color, texture,  
: tonsil is present, with no discharge, 1+ : tongue is pink,
moisture, lesion smooth and midline,
 
no tumors or lesion
: teeth for alignment, loss, : gag reflex is present.
  present
dental filings and caries;  P: no presence of nodules.
  : no swelling, no
: gums for bleeding, color,
 
retraction, lesions, redness
 
swelling
: palates are pink with
: tongue for position, color no inflammation,
& texture; movement, as smooth and intact
well as the base of the I: no swelling, no masses, coordinated, : uvula rises
tongue, mouth floor and with equal strength. symmetrically with “ah”
frenulum  
P: non-palpable, non-tender.
: tissue is pink and
: salivary gland ducts for  
P: trachea is palpable. moist with symmetrical
swelling, redness
I: non-palpable, not visible on inspection, margins. No
: palates for color, shape, rise during swallowing enlargement or lesion,
  tonsils are absent or
texture, presence of bony
P: smooth 1+
prominences I: no bruits
P: no nodules, lumps
 
: uvula for position &  
mobility  
: oropharynx for color &
texture

: tonsils for color,
discharge, and size
I: no swelling, no
Test for Gag Reflex masses

P: nodules, lump and  P: lymph nodes are

I: Chest is symmetrical, spine vertically symmetrical, soft and
excoriated areas aligned, spinal column is straight, left and non-tender
right shoulders and hips are at the same
  height. I: symmetrical, rise
  during swallowing
NECK Pa: warm to touch, no bulges, no
tenderness, no abnormal movements P: smooth
Neck Muscles
Pe: lung resonant
I: abnormal swelling or A: no bruits
masses, head movement, A: breath sounds vesicular without
adventitious sounds
and muscle strength  

Lymph Nodes  I: chest is symmetrical, no barrel chest

Pa: fremitus symmetrical
P: enlargement
Pe: lung resonant
Trachea
A: lung sound clear, no egophony,
P: lateral deviation bronchophony or whispered pectoriloquy
I: Chest expansion is
 
Thyroid Gland   symmetric. Chest wall
  is cone shaped,
I: symmetry and visible   symmetric and oval,
masses, rise during   no spinal deformities
swallowing  
  Pa: warm to touch, no
P: smoothness   bulges, tenderness, no
  abnormal movements
A: bruit  
I: Pulsation of the apical is visible, no lifts Pe: lung is resonant.
 THORAX & LUNGS or heaves.
  A: breath sounds
Posterior Thorax A: S1 & S2 are heard at all anatomic sites. vesicular without
Normal heart rate, no presence of
I: shape & symmetry from murmurs. adventitious sounds
posterior-lateral views;  
spinal alignment for  
deformities I: no chest deformity.
 
Chest shape oval and
Pa: temperature, bulges,
symmetrical. Costal
tenderness, abnormal
angle less than 90
movements, respiratory
degrees. No barrel
excursion, vocal fremitus
chest
Pe: for symmetry of
Pa: excursion 3-5 cm
resonance; diaphragmatic P: carotid pulse 2+/4+ scale bilaterally
symmetrical. Fremitus
excursion
A: no bruit sounds symmetrical
A: breath sounds I: no distention
Pe: lung resonant
  I: no presence of superficial veins, no signs
of phlebitis A: lung sound clear,
  no egophony,
: capillary refill is less than seconds
bronchophony or
Anterior Thorax       whispered
pectoriloquy
I: breathing
pattern, coastal and
costovertebral angle 
I: Pulsation of the
Pa: respiratory apical impulse may be
excursion, tactile fremitus visible, no lifts or
heaves.
Pe: symmetry of
resonance
A: S1 & S2 can be
A: breath sounds heard at all anatomic
I: breast is symmetrical, no discoloration, site.
  contour is uninterrupted, no swelling, no : No abnormal heart
edema.
   sounds are heard
: areola is round, with equal brown color, (Murmurs, S3 & S4).
Heart same size, no lesions, no masses. : Cardiac rate ranges
 
from 60 – 100 bpm.
I: precordium for : nipples are rounded, everted, equal in
pulsations & lifts or color, no discharge.
  P: carotid pulse 2+/4+
heaves 
scale bilaterally
A: heart sounds (S1, S2, A: no bruit sounds
etc.) I: no distention

Central Vessels: P: no tenderness, no lumps,  

I: no presence of
 
  superficial veins, no
Carotid Arteries
  signs of phlebitis
P: volume, quality   : capillary refill is less
  than seconds
A: bruit  
 
Jugular Veins  
I: skin tone determines
 
I: distention   actual color,
  symmetrical, or a left
 Peripheral Vessels   breast slightly larger
  than the right breast,
I: presence or   contour is
appearance of superficial   uninterrupted, no
veins, signs of phlebitis
swelling, no edema,
I: Skin is uniform, not lesions, symmetric
*Berger’s Test contour, not distended, visible peristalsis no discoloration
and aortic pulsations.
*Capillary Refill   : no change in size,
A: bowel, vascular, peritoneal sounds are color, symmetry, or
  normal. contour of the breast
  or change in nipple
  Pe: no abnormal tympany, no bruits.
characteristic, no
 
  Pa: no masses, tenderness. Liver, spleen, masses and lesion, no
and kidneys are non-palpable. discharge on nipples
Breast & Axillae  
  P: one or more small,
I: breast for size,   soft, non-tender nodes
symmetry, contour or   are common, breast of
shape, discoloration,  
a nulliparous woman
retraction,  
  feels smooth, elastic
hypervascularity,
  and firm, no lumps
swelling, edema
  present, nipple smooth
: areola for size, shape,   without masses,
symmetry, color, surface   nodules or discharge
 
characteristics, masses,  
lesions  
 
: nipples for size, shape,   I: flat, symmetric, no
position, color, discharge,   scars, striae or
lesion   varicosity. Skin even-
  toned. Umbilicus
P: lymph nodes, breast,
midline and inverted.
areola & nipples for
No hernias noted. No
tenderness, masses, I: symmetrical, smooth, no tenderness, distention, visible
nodules, discharge contractures, fasciculation and tremors pulsation, or peristaltic
wave noted.
  P: move smoothly and quietly, able to Respirations even, no
perform full ROM against resistance
no muscle atrophies. use of accessory
 
  muscles
ABDOMEN  
A: bowel, vascular,
I: skin integrity, contour & peritoneal sounds
symmetry, hernia, should be normal.
distention (girth),
movements associated w/ I: symmetrical bone length, no deformity Pa: no tenderness,
respiration, peristalsis & abdomen without
aortic pulsations P: no edema no tenderness masses, palpable liver
edge against your
A: bowel, vascular, &
right-hand during
peritoneal friction rub
inspiration, normal
sounds
spleen is not palpable,
I: no swelling
Pe: all quadrants / P: non-tender, smooth movements are common to be unable
regions for tympany and visible, no swelling, nodules, crepitation. to palpate kidneys
deviations   except in slender
  patients, empty
Pa: light to deep bladder is neither
palpations ALL quadrants tender nor palpable.
from least painful to most
painful for masses,
: language is Tagalog, speech is clear,
tenderness, muscle fluent and articulate, has good memory
guarding; liver (bimanual) and attention span. I: symmetrical,
and bladder palpation   smooth, no
: client is alert; conscious. tenderness,
* Leopold’s Maneuver for  
contractures,
OB clients for Cranial nerves
fasciculation and
presentation, lie,
tremors
engagement, attitude,
P: move smoothly and
position
quietly, able to perform
  full ROM against
resistance
  no muscle atrophies.

 
I-XII is all present.
Reflexes are all present.
 
   

MUSCULOSKELETAL

Muscles I: symmetrical bone

length, no deformity
I: size, contractures, P: no edema no
fasciculations, tremors tenderness

P: tonicity, flaccidity,
spasticity, smoothness of
movement, strength

  : walks normally smooth and rhythmic; with

arms swinging in opposition I: no swelling
  : client maintains position without opening
the eyes P: non-tender, smooth
 BONES : able to stand on one foot with eyes movements are
closed visible, no swelling,
I: structure, deformity : walks smoothly without swaying nodules, crepitation.
: movements are well-coordinated 
P: edema, tenderness  
 
Joints     
 
I: swelling  
 
P: tenderness,
: identifies light/deep touch, pain
smoothness of sensation is present, temperature
movement, swelling, sensation is present, can identify warm and
crepitation, nodules cool appropriately, intact motion and
position sense.
   
  : language is Tagalog,
NEUROLOGIC   speech is clear, fluent
and articulate, has
Mental Status
good memory and
- Language attention span.

- Orientation : client is alert;

conscious.
- Memory

- Attention Span / Cranial nerves I-XII

Calculation are all present.
Reflexes are all
Consciousness Level present.

Glasgow Coma Scale
: walks normally
 
smooth and rhythmic;
  with arms swinging in
opposition
Cranial Nerves : client maintains
position without
- I to XII
opening the eyes
Reflexes : able to stand on one
foot with eyes closed
- Deep, superficial & : walks smoothly
pathologic without swaying
: movements are well-
- Neonatal Reflexes
coordinated
 

Gross Motor/Balance
* Walking Gait

* Romberg

* Standing on 1-foot w/
eyes closed

* Heel-toe walking

Fine Motor
: identifies light/deep
- Upper Extremities: touch, pain sensation
is present,
* Finger-Nose Test temperature sensation
is present, can identify
* Alternate Supination &
warm and cool
Pronation of hands on
appropriately, intact
knees
motion and position
* Finger to Nose & to RN sense.
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

 
 

X. 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.

XI. Review of System (include only those that are significant to the case under study)

A. Neurologic
Client denies dizziness, weakness, numbness, tingling, tremors, fainting, depression, stress,
nervousness, headache, concussions, difficulty speaking, difficulty learning or memory
problems.

B. Pulmonary
Client stated shortness of breath especially when running. Denies wheezing, cough or
sputum, hemoptysis, orthopnea, respiratory infections.
 C. Cardiovascular
Client denies chest pain, tightness, paroxysmal nocturnal dyspnea, orthopnea, palpations,
edema.

D. Hematologic
Client denies ease of bruising or bleeding.

E. Immunologic
Client has no allergic rhinitis. Denies history of cancer, immunosuppression.

F. Gastrointestinal
Client denies swallowing difficulties, yellow eyes or skin, heartburn, change in appetite,
nausea.

G. Renal
Client has a daily bowel movement of well-formed brown stool. Denies change in bowel
habits, pain in defecation, constipation, diarrhea, hemorrhoids, rectal bleeding.

H. Musculoskeletal
Client is able to experience pain in the joints when cold but able to perform ADLs without
difficulty. Denies, stiffness, back pain, redness of joints, edema, trauma.

I. Reproductive
Age 13 at menarche, has been menopaused at the age 50. Denies itching or rash on
genitalia.

J. Integumentary
Client has presence of dandruff, skin itching especially in lower extremities. Denies lesions,
discolorations, lumps, nail changes.

XIII. 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
Responsibilities
- Brand / Generic Name Indication Contraindication Desire Untoward
- Classification d
- Prescribed Dosage
- Route
- Frequency
2. Dietary Prescription / Restriction
3. Procedures (If any)
a. Oxygenation by nasal prong, venture/face mask, mist-tent, ambubag, ventilator, T-
piece
b. Suctioning
c. Osteorized Feeding
d. Intravenous Fluids
e. Catheterization
- Gastric
- Urinary
 - Intravenous
Lavage
f. Enema
g. Diversional Ostomies
h. Drains i.e. Hemovac, Pleurovac, JP, Ventriculostomy, etc.
i. Others

B. Surgical (for 3rd year)

1. Pre-operative
2. Intra-Operative
3. Post-Operative

C. Nursing Management
1. List of Nursing Problems:
a. Arthritis as a health deficit (Rheumatoid arthritis)
b. Self-medication

2. Prioritization of Nursing Problems

Criteria Weight Multiplier Computatio Justification
n
Nature and 3 Actual Problem 1 3/3 x 1 Situational
Extent 2 Risk / Potential Urgency based
1 Wellness State on:
- ABC Principle
- Maslow’s HON
- Nursing Concept
Modifiabilit 2 Easily Modifiable 2 2/2 x 2 Availability of
y 1 Partially Modifiable resources and
0 Not Modifiable interventions
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 immediate attention 1 2/2 x 1 Client’s
action perception and
1 Not needing immediate recognition of the
attention problem
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: At the end After hours of
The client Inability to of hours of nursing care,
verbalized, provide rendering goal was met /
“Sumasakit adequate nursing unmet /
ang mga binti nursing care to care, the partially met,
ko pag the family client will be as evidenced
 malamig lalo member who able to: by:
nap ag has arthritis due 1.________ Independent Rationale & 1.
binabasa ko to: Dependent Reference
ito.” Collaborativ
Lack of adequat e
e knowledge 2.________ Rationale & 2.
Objective: about the Independent Reference
 Vital signs: disease arthritis, Dependent
its nature, Collaborativ
complications, 3.________ e Rationale & 3.
prognosis and Reference
management 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

XIV. ONGOING APPRAISAL

 Day 1
- Medical and Nursing Care provided for managing the case
- Significant conditions or improvements noted
 Day 2
- Medical and Nursing Care provided for managing the case
- Significant conditions or improvements noted
 Day 3 (last day of duty or encounter with the patient / day of discharge)
Prepared by: Noted by: