NCP (Nicole Tandayu)
-
Upload
gladys-joy-pena -
Category
Documents
-
view
226 -
download
0
Transcript of NCP (Nicole Tandayu)
-
8/14/2019 NCP (Nicole Tandayu)
1/42
I. Biographic Data
Name: Ms. NAST
Age: 18 Sex: Female
Date of Birth: September 13, 1989 Place of Birth: Ilagan, Isabela
Ethnic Group:
Primary Language Spoken: Filipino
Other Dialect Spoken: Ilocano, Ibanag
Civil Status: Single
Highest Educational Attainment:Second Year College, BS Nursing
Religion: Methodist
Health Care Financing and Usual Source:
II. Nursing History
A. Past Health History
According to the client, she had chicken pox and measles when she was 9 years old. She had no allergies occurred
yet. She has not met any accident. She had been hospitalized due to pneumonia when she was 8 years old for a
week. She has a complete set of immunization such as BCG, DPT, OPV, Hepatitis B vaccine, and AMV aside from
an ongoing adult immunization of Hepatitis B vaccine.
B. Present Health History
The client is taking ferrous sulfate 2 times a week but sometimes she told to us that she forget to take her vitamins.
She encountered pyrexia a high fever with 380 degree Celsius last semester and she takes biogesic every 4 hours.
C. Family Medical History
III.Patterns of Functioning
A. PSYCHOLOGICAL PATTERN
The major stressors in the clients life right now are the school requirements that are needed to be
passed. The major stress that she had experience was when she had a problem regarding her relationships with
significant people in her life. Like when she had a fight with her best friend, Broke up with her boyfriend and when
her mother went to states to work. Her usual coping pattern with a serious problem or a high level of stress is
travelling to an unfamiliar place and she really enjoys it and she tends to forget her problems. She verbalized
appropriate emotions and even the non-verbal ones.
-
8/14/2019 NCP (Nicole Tandayu)
2/42
She is very optimistic person. She always looks at situations positively and maintains a positive outlook
in her life. Her most problematic mood is depression because she really feels down when she has problems. She gets
hurt when her ego is really harmed, But most of the time she tries to be patient with whats going on in her life. Her
previous patterns of handling stress, she plays guitar and sings a song to relieve pain.
Analysis:
Individuals with positive concept are better to develop and maintain warm interpersonal relationship and
resist psychological and physical illness. Adaptive coping helps the person to deal effectively in stressful events and
minimize distress associate with them.
Fundamentals of Nursing 5th ed., Taylor, pg. 802,832
Interpretation:
The client has a positive outlook in life and maintains a constant communication with the significant
person in her life.
B. SOCIOCULTURAL PATTERN
The clients support system are her family, friends and bible study group mates in times of stress his
father has diabetes and now her fathers kidneys are not as healthy as before it really affects her because her father is
important in her life & she feels sad whenever they talk about it.
She believes that health is very important to human so she takes good care of her health. Her highest
level of education is second Year College & she hasnt experienced any difficulty in learning. She doesnt have any
physical disability so she can work efficiently. She goes to school everyday and considers it as her activities of her
daily living. Her neighborhood & community services are available to meet her needs.
Analysis:
Family has functions that are important in how individual members meet their needs and maintain their
health. The family provides an individual with the necessary environment for discomfort and social interactions.
Fundamentals of Nursing, 5th edition, Taylor, pg.29
Interpretation:
The client has a good relationship with her family, friends and society where she belongs.
-
8/14/2019 NCP (Nicole Tandayu)
3/42
C. SPIRITUAL PATTERN
With regards to the spiritual pattern of the client, she has a good relation with god. She has a bible and
she enjoys reading it. She goes to the university chapel before meals and at other times of her life. She goes to the
university chapel before she attends the class everyday. She belongs to the Christian family. Her parents raised her
as a God fearing person and to be active in church services.
She views life as a sacred blessing from God. Life really means a lot to her & she lives it wisely &
fruitfully. For her, she must make the most out of her life, and live a life with deep meaning. She fears death because
shes still young and she plans to do more in her life. She still needs to improve herself for her parents & society
around her. She believes that God is the Supreme Being and she strongly believes that every person needs his
guidance.
Analysis:
Spiritual and religious beliefs are important in many peoples lives. They can influence lifestyle, attitudesand feelings about illness. Religions have central beliefs, rituals and practices usually related to death, marriage and
salvation. Many people satisfy their spiritual needs through a specific or religious framework.
Fundamentals of Nursing, 5th ed., Taylor, 311-322
Interpretation:
The client is a Methodist who has a personal relationship with God. She attend Bible study every week
and follows her religion faithfully.
D. ACTIVITY OF DAILY LIVING
Health Perception and Management
According to the client, health is a complete well being, can functions property everyday and does not
suffer from any illness or a disease that alters her daily routine. She describes herself as healthy and she function
well and she does not feel anything wrong with herself. She maintains her health by making sure that she eats three
times a day. She does not smoke and take drugs but she drinks alcohol beverages occasionally. She also eats fruits
and considers herself not a soda drinker. According to her, current medications she takes ferrous sulfate for her
anemia and if she has menstrual period she takes mefenamic acid to ease or relieve the pain she feels because of
dysmenorrhea. She has no allergies. Before and after menstrual period, she does self-breast examination to check if
theres any tenderness in her breast. Her father has diabetes and undergone operation for his gal stones and kidney
stones. She is aware that they have history of hypertension. As she describes her environment at home, she
verbalized malinis naman kung saan ako nakatira. I live with my cousin, the house caretaker and her son. Apat
kami sa bahay, komportable naman kung saan kami nakatira at sinisiguro naming na malinis ang bahay. Araw-araw
-
8/14/2019 NCP (Nicole Tandayu)
4/42
kami nagwawalis at hindi kami nagtatambak ng hugasing plato. According to the client, she takes a bathe three
times a day, brushes her teeth two times a day. After my breakfast and before ako matulog ako nagto-toohtbrush.
Nagsusuot ako ng slippers, I also use hygienic products like shampoo, soap and other kikay condiments.
Analysis:
Health is defined as state of complete physical, mental, emotional, and social well-being, and not merely
the absence of disease. (WHO, 1948)
Health is defined as in terms of role and performance health is the ability to maintain normal roles,
according to Talcott Parson. (1951)
Fundamentals of Nursing, Kozier, pg. 171
Interpretation:
Based on the clients statements, the client fully understands the meaning of health. The client also
knows the proper ways on how to keep herself healthy and clean. She also knows what type of medications shewould take for her illness. The client also has a tendency of acquiring hypertension because they have a history of
hypertension in their family. The client also has knowledge on self-breast examination. Overall, the client is aware
about her health.
E. Nutrition and Metabolic Pattern
When asked regarding the nutrition and metabolic pattern, the client verbalized, I usually eat thrice a
day, as in umagahan, tanghalian and hapunan. Starting ngayong summer class (2008) namin sa FEU (Far Eastern
University -- Manila), nadedelay na ako sa time ng pagkain dahil sa hectic class schedule ko pero I still make it to a
point na thrice a day pa din ako kung kumain. Two meals lang ako kung kumain ng rice, usually breakfast and lunch
tapos hindi ako nagra-rice kapag dinner kasi more on coffee lang ako. Feeling ko din super unhealthy nung mga
kinakain ko kasi usually mga galing sa fastfood chains (Mc Donalds), except sa dinner ko kasi nagluluto naman tita
ko sa bahay. Laging burgers saka pasta yung ino-order ko dun. Kapag nasa apartment naman ako, I usually eat fruits
and veggies, siguro mga 5 meals a week. Sa fluid intake naman, hindi ko namomonitor, eh kasi I drink when
everytime I feel thirsty saka every after meals. I am a coffee lover, nakaka two to three cups ako sa isang araw. She
also verbalized Gusto kong baguhin yung eating patterns at saka yung quality ng food na kinakaen ko. Mas
maganda sana kung healthy yung kinakaen ko araw-araw para ma-improve yung health ko. The client also said
that she has no eating disorder because she can eat properly. and she is also taking Ferrous Sulfate as her food
supplement. Nutrition, according to her, is simply eating healthy foods. She also verbalized I like to eat foods na
hindi masabaw kasi nakakatamad kainin, e. I dont like to eat oily foods naman lalo na yung mga taba ng kahit
anong karne. Kahit madalas karne yung kinakain ko saka mga burger. Hindi ako kumakain ng ampalaya, labanos
saka talong. Tapos yung mga iba nang mga gulay, yun na yung mga kinakain ko. According to her, she is not the
-
8/14/2019 NCP (Nicole Tandayu)
5/42
one who prepares her food. It is her auntie who cooks her meals when she eats at home. She usually eats with her
auntie and their housekeeper. When she is at school, she eats in fastfood chains with her friends. Her typical food
intakes are fried foods. I gained weight, 2 lbs. to be exact, hindi ako nawawalan ng gana kumain. Theres no
problem with my skin and I dont have skin allergy due to foods, she added. She wears dental braces that she
started wearing when she was in her third year high school, which is three years ago from now. According to her,
she does not feel any eating discomforts.
Three Day Diet Recall
MONDAY TUESDAY WEDNESDAY
BREAKFAST 4 slices bread
300 ml of coffee
2 packs of Pancit
CantonChilimansi
300 ml of coffee
1 cup rice
1 fried egg1 burger patty
100 ml of coffee
LUNCH 1 cup rice
1 piece fried
chicken leg
250 ml iced tea
1 serving of
spaghetti
250 ml iced tea
1 chicken burger
250 ml iced tea
1 regular sized
French fries
DINNER 1 cup rice
4 matchbox cut
pork adobo
1000 ml of water
300 ml of ice cold
coffee
1 cup rice
1 serving of
chopsuey
1000 ml of water
200 ml of ice cold
coffee
1 cup rice
1 serving of Pork
Sinigang
750 ml of water
100 ml of ice cold
coffee
Analysis:
Certain lifestyles are linked to food-related behaviors. People who are always in a hurry probably buy
convenience grocery items or eat restaurant meals. People who spend many hours at home may take time to prepare
more meals from scratch.
Fundamentals of Nursing, Kozier, pg. 1176
Interpretation:
The client has an imbalanced nutrition due to her busy school activities. She is spending most of her
time in school than staying at home. Her main sources of food are fastfood chains whenever she has classes. She is
always eating burger and pasta. When she is at home, the housekeeper is the one preparing her meals.
F. Elimination Pattern
When the client asked regarding the frequency of her elimination, she verbalized, I defecate, siguro
mga 4 times a week. Tapos in a day, hindi ko matandaan kung ilang beses ako kung umihi, pero sa tancha ko mga 5
times a day, basta pagkagising saka bago ako matulog talagang naihi ako. She characterized her stool as soft,
purigent and color brown while her urine as amber, transparent and aromatic. With regards to her elimination
-
8/14/2019 NCP (Nicole Tandayu)
6/42
patterns, she also verbalized, Hindi naman ako nakakarmdam ng discomfort when Im doing these activities.
During the interview, the client is not sweating.
Analysis:
The act of defecation is usually painless. If the bowels move at regular intervals and the stools are
formed and soft, functional problems involving frequency of elimination seldom occur. Many people become
concerned if they do not have a daily bowel movement, but there is no normal frequency of bowel movements.
Although many adults pass one stool each day, other healthy people have more frequent or less frequent bowel
movements. Some people have a bowel movement two or three times a week; others, two or three times a day.
Fundamentals of Nursing, Taylor, pg. 1340
Interpretation:
Based on the clients statement, her elimination pattern is normal because she defecates four times aweek and urinates five times a day. In addition to this, she describes her feces as soft that is why she does not feel
any discomfort during elimination.
G. Activity Exercise Pattern
The client describes her weekly pattern of activities and leisure, exercise and recreation as satisfying in
the sense that she feels good about her weekly accomplishments. She verbalized, lagi akong pagod dahil sa school
activities ko, lakad ng lakad, walang time magpahinga. According to her, she has no disease that affects her cardio-
respiratory system or her musculo-skeletal system. She allots 30 minutes of her time every morning to stretch out or
have some exercise which makes her really feel good and refreshed. When asked if she has sufficient energy for
completing desired or required activity, she verbalized, hindi masyado, lagi kasing puyat at sobrang stressed out
ako. She plays computer games and guitar with spare time.
Activity Plan
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
6:00-6:30
Do morningexercise
Do morningexercise
Do morningexercise
Do morningexercise
Do morningexercise
Sleep Sleep
6:30-
7:30
Watch
television
Watch
television
Watch
television
Watch
television
Watch
television
7:30-
8:00
Eat breakfast Eat breakfast Eat breakfast Eat breakfast Eat breakfast Eat
breakfast
Eat
breakfast
8:00-
8:30
Read notes Read notes Read notes Read notes Read notes Take a
bath
Take a
bath
8:30- Take a bath Take a bath Take a bath Take a bath Take a bath Prepare Prepare for
-
8/14/2019 NCP (Nicole Tandayu)
7/42
9:00 for school school
9:00-
9:30
Prepare for
school
Prepare for
school
Prepare for
school
Prepare for
school
Prepare for
school
Attend
Bible
study
Attend
Bible study
9:30-10:00
Travel toschool
Travel toschool
Travel toschool
Travel toschool
Travel toschool
10:00-1:00 AttendMicrobiology
&
Parasitology
class
AttendMicrobiology
&
Parasitology
class
AttendMicrobiology
&
Parasitology
class
AttendMicrobiology
&
Parasitology
class
AttendMicrobiology
&
Parasitology
class
Watchtelevision
and
browse
the
internet
Watchtelevision
and browse
the internet
1:00-
1:30
Eat lunch Eat lunch Eat lunch Eat lunch Eat lunch Eat lunch Eat lunch
1:30-
3:20
Attend PSTL
class
Attend PSTL
class
Attend PSTL
class
Attend PSTL
class
Attend PSTL
class
Watch
DVD/TV
Watch
DVD/TV
3:20-
4:00
Read notes Read notes Read notes Read notes Read notes
4:00-
7:00
Attend NCM
101 class
Attend NCM
101 class
Attend NCM
101 class
Attend NCM
101 class
Attend NCM
101 class
Go to the
mall7:00-8:00
Travel home Travel home Travel home Travel home Travel home Rest
8:00-8:30
Rest Rest Rest Rest Rest Eat dinner
8:30-
9:00
Eat dinner Eat dinner Eat dinner Eat dinner Eat dinner Eat
dinner
Read
notes/Do
homework9:00-
12:00
Read
notes/Do
homeworks
Read
notes/Do
homeworks
Read
notes/Do
homeworks
Read
notes/Do
homeworks
Read
notes/Do
homeworks
Play
guitar
12:00-
6:00
Sleep Sleep Sleep Sleep Sleep Sleep
Analysis:
Exercise is a physical activity for the purpose of body conditioning, improving health and maintaining
fitness or it may be used as a therapeutic measure.
Fundamentals of Nursing 5th edition, Potter & Perry, pg. 941
Interpretation:
The client is satisfied with her everyday activities because she has many accomplishments that make her
feel good inspite of her busy schedule. The reason why she does not have any respiratory or circulatory diseases is
because she exercises daily. Based on the clients statement, because there is time allotted to exercise everyday and
there are no cardio-respiratory and musculo-skeletal diseases
H. Cognitive Pattern
When asked regarding to the clients learning abilities, she verbalized, I easily learn naman. Wala
naman akong problems with my mental function pero sa sight, meron. I have an astigmatism kaya nga I wear
-
8/14/2019 NCP (Nicole Tandayu)
8/42
eyeglass to correct this deficit. According to her, she had her last eye check-up last 2 months ago. Her easiest way
of learning things is through reading and understanding what she is reading. So far hindi pa naman ako nahihirapan
matuto, she added.
Analysis:
Cognitive awareness is the ability to perceive environmental stimuli and body reactions and to respond
appropriately through thought and action.
Fundamentals of Nursing, Kozier, pg. 671
Interpretation:
The client wears eyeglasses because she has a problem in her sight. She has astigmatism that is why she
has to wear eyeglasses to correct that deficit. She does not have any learning difficulty because she can acquire
things easily. Reading helps her in learning things because she can gather much information from it.
I. Self Perception/ Self Concept
The client describes herself as a simple individual who always feels good about herself. She said that
she is very much comfortable and contented with the way she looks. She is always happy and feels great all the time
despite of having busy schedule. She is quiet most of the time and gets tactless whenever she is angry. She gets
angry when she is pressured and tired. Her goals for the next 5 years are to finish her college, then pass the nursing
board and hopefully get a job so she can help her family. She would always want to be with her family and she also
wants to be with someone who could get along with her easily. She expresses herself when her mood changes by
being quiet and not talking at all.
Interpretation:
The client has a good perception and positive concept about herself despite of having a hectic schedule.
She has a great self- esteem and self- confidence.
Analysis:
A positive self- concept is essential to a persons physical and psychologic well- being. When
individuals are able to conceptualize the self, they begin a life long process of deciding whether and to what extent
they are valuable and worthy.
Fundamentals of Nursing, Barbara Kozier, pg. 970
J. Rest and Sleep Patterns
According to client, she usually spends 4-6 hours in sleeping. She verbalized, depende kasi, kung
matulog kasi ako, either 12 or 2 in the morning tapos kung magising naman mga 6 in the morning. I am well aware
that I have a sleeping disorder kasi nga I find it difficult to fall asleep. Kaya lang, I dont really have any idea kung
-
8/14/2019 NCP (Nicole Tandayu)
9/42
anong specific sleeping disorder ang mayroon ako. According to her, her usual bed routines are playing guitar and
reading science fictional books which helps her sleep. Her sleep is not interrupted at night but still does not feel
satisfied with the amount of sleep she gets and does not also feel refreshed and nice when waking up. When asked
regarding her naps, the client verbalized, wala no, di uso yun walang time umidlip saka kapag umidlip man ako,
hirap na ko makatulog sa gabi... Her sleeping environment is well-ventilated and has an adequate space as
observed. When asked regarding her sleeping environment, the she verbalized, double deck yung bed ko pero sa
babang deck ako natutulog. Foam yung hinihigaan ko with six pillows at isang blanket. Although very comfortable
it may seem, hindi pa din ako ganun kabilis makatulog.
Analysis:
8 hours of sleep a night has been the accepted standards for adults. It is important, however, that each
person follow a pattern of rest that maintains well-being.
Adults average sleep is 7 to 9 hours. Those who are able to relax and rest easily, even while awake,
often find that less sleep is needed, whereas others may find that more sleep is required to overcome fatigue.Sleep patterns of older adults vary. However, older people often need more time to fall asleep, wake
earlier, and more frequently during the night, and are less able to cope with changes in their usual sleep patterns than
younger people are.
Fundamentals of Nursing, Taylor, pgs. 1172-1173
Interpretation:
The client sleeps only for 4-6 hours only because she finds it hard to sleep at night due to excessive
amount of coffee intake and also because of too much school requirements. When she wakes up in the morning, she
does not feel refreshed because she did not get enough sleep which makes her feel sleepy during daytime.
K. Role-Relationship Pattern
The client belongs to nuclear family. It is composed of 5 family members. She is the eldest child and
has two younger siblings, a boy and a girl. She lives in Manila with her auntie, and the housekeeper. Her and her
family lives in the province of Isabela. The client verbalized, First time ko lang malayo with my family at yun ay
simula nung nag-college ako. The significant persons in her life are her family and friends. She has a good
relationship with her family because they are close to each other and talk about all matters. She plays the role of
being a good daughter to her parents and a good sister to her siblings. She actually fulfills her role by
communicating with them even though they are living apart. They have some family problems with regards to their
finances. There were times that their resources are insufficient because of high cost of tuition fee. Whenever they
have problems they talk about it and discuss it with the whole family so that they can solve it easily. Her relationship
with her family and friends are the most significant and important relationships in her life. Their usual activities are
going to church, eating together and having recreational activities. The client belongs to a bible study group that
serves as her support system.
-
8/14/2019 NCP (Nicole Tandayu)
10/42
Analysis:
Families that communicate effectively transmit messages clearly. Members are free to express their
feelings without fear of jeopardizing their standing in the family. Family members support one another and have the
ability to listen, emphatize, and reach out to one another in times of crisis.
Fundamentals of Nursing, Kozier, pg. 193
Interpretation:
Based on the relationship pattern of the client, she has a good relationship and open communication
with all her family members. One of the problems they encounter is about financial problem due to some payment in
her school like the tuition fee. When it comes to family problem, they discuss it with all of the members of the
family to be able for them to solve it.
L. Role Sexuality-Reproductive Pattern
The client expresses herself as a woman by just being simple with her acts and gestures. She doesnt
have any difficulty/ problems in expressing her sexuality because she is satisfied and contented of what she is. She
shows affection to other by showing them that they are loved and cared and by being with them all the time. With
regards to her reproductive system, she menstruates regularly and usually around 7 days but she experiences
dysmenorrhea every month. Pag meron ako, super sakit talaga ng puson ko, tapos nahihilo ako, pinagpapawisan ng
malamig, masakit ang ulo ko. Suffering talaga pag meron ako.
Analysis:
At day 28, menses, or the menstrual flow, begins as a result of the uterus, shedding the useless portion
of its endometrium. Menses lasts for 3 to 7 days, the average length of flow being 5 days.
Fundamentals of Nursing, Taylor, pg. 933
Interpretation:
Based on the clients statement, she menstruates regularly which is usually for about 7 days but she
experiences dysmenorrheal every month which is not normal among women.
M. Values And Belief
She was raised by her parents to become God-fearing person thats why she grow up to be a religious
person. She is a very religious person, she makes sure that she maintains a strong relationship with God and she
believes that by this practice shell have a great flow of life. According to her, she practiced to be always prepared in
everything that she might encounter, this is very important for her before, now and in the future. She joins a bible
-
8/14/2019 NCP (Nicole Tandayu)
11/42
study every Thursday and she considers it as her support system. She sees herself as a good citizen in the society.
She makes sure that she follows the rules properly.
Analysis:
Spirituality shapes the self-becoming and is reflected in ones being, knowing and doing. Spirituality
permeates life, providing purpose, strength and guidance and shaping the journey. Cultivate wisdom and helps us
find meaning in life, be in relationship with others, be true to ourselves, live in uncertainty and mystery, deal with
suffering, sickness, and honor life transitions. Cultivate awareness of the sacred dimension of life through practices
such as worship prayer, meditation and singing. Help us be generous in service to others. Respect our
connectedness as fellow human being.
Interpretation:
The client has her own values and beliefs in accordance on how she deals with her life.
N. Coping Stress
According to the client, her most stressful event is when theres too many school works and
requirements. She copes with her problem by playing the guitar, singing and travelling to different places where she
has never been before. These activities really help her a lot and she doesnt take any medication for emotional
distress. She doesnt feel any tension at all. Her best friend is the one who helps her in taking things over. According
to the client, she and her best friend are only one call away from each other. The big change she considers in her life
tooks place last year during her first year in college, it was her first time to live in Manila. It was very hard for her to
adjust which took her 1 year and another big change was when her mother decided to wok in United States of
America.
Analysis:
Stress is a part of life: everyone feels stress at one time or another. Feeling stressed out is common,
and taking stress breaks to do physical exercise is recommended in many work settings. The experience of stress
and the ways have responds to it are unique to each individual. The process of responding to stress is constant and
dynamic and is essential to the persons physical, emotional, and social well-being. Stress and adaption are major
components in health and illness.
Fundamentals of Nursing, Taylor, pg. 849
Interpretation:
The client is not that much stressed because the one that she is experiencing is common among students.
A major factor causing her stress was the change in environment. She was used in living at the province of Isabela
and had to move in Manila because of her studies. Basically, a student in distress needs to unwind in order to be
refreshed. On the case of the client, her ways of freeing herself of hassle and bustle were to play the guitar, to sing
-
8/14/2019 NCP (Nicole Tandayu)
12/42
and to go to places she has never been before. She is the kind of person, who would stick to her peers, specifically
her bestfriend unlike other students who would undergo medications just to cope up with stress.
. PHYSICAL ASSESMENT
Client: Nicolle Ann S. Tandayu
Vital signs:
Behavior Actual Findings Normal Findings Analysis Interpretation
Temperature 36.90 C 36.50 37.50 C normal Her temperature is
within the normalrange.
Pulse Rate 75 beats per minute 60 100 bpm normal Her pulse rate is
within the normal
range.
Respiratory Rate 19 breaths per minute
Blood Pressure 110/80 mmHg 120/80mmHg abnormal Her blood pressuredoes not meet the
normal findings. She
has a low blood
pressure.
Temperature: 36.90 C
Pulse Rate:
Respiratory Rate:Blood Pressure: 110/80 mmHg
Behavior Actual Findings Normal Findings Analysis Interpretation
Height 168.92 cm. BMI : 21
Weight 59 kg.
General Survey
Describe the body built,
height & weight inrelation to the clients
age, lifestyle and health.
Proportionate weight to
height. BMI is 21.
Proportionate weight to
height.(Fundamentals of
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 571)
normal Her BMI is in normal
range which is from 18-24.5.
Describe the client'sposture, gait, standing,
sitting & walking.
Relax and erect postureCoordinated movements
Relax and erect posturewith Coordinated
movements.
(Fundamentals of
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 571)
normal The client stands inerect posture, she sits
relax and walks
coordinately.
Describe the client over
all hygiene andgrooming.
Clean and neat Clean and neat
(Fundamentals ofNursing by Kozier p.
normal The client doesnt have
stain or any kind of dirtin her dress.
-
8/14/2019 NCP (Nicole Tandayu)
13/42
531)
Describe body and
breath odor
No body odor and
breath odor
No body odor and
breath odor
(Fundamentals of
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 571)
normal The clients breath
doesnt smell like
acetone.
Identify signs of
distress, in posture of
facial expression
No distress noted No signs of distress.
(Fundamentals of
Nursing by Kozier p.
531)
normal The patient is not
bending and no labored
breating.
Identify obvious signs
of heath or illness
Healthy appearance; no
signs of illness.
Healthy appearance
(Fundamentals of
Nursing by Kozier p.
531)
normal The clients color is not
pallor. She looks alive
during the assessment.
Describe the client's
attitude
cooperative Cooperative
Healthy appearance
(Fundamentals of
Nursing by Kozier p.531)
normal The client is cooperative
during the activity/
assessment.
Describe the client'saffect/mood; assess the
appropriateness of the
client's response
Responses appropriately Appropriate response tothe situation
Healthy appearance
(Fundamentals of
Nursing by Kozier p.
531)
normal The client responsesappropriately to the
questions asked to her.
Describe the quantity
and quality of speech
voice is clear and
understandable;
moderate pace
Understandable,
moderate pace; exhibits
thought association
Healthy appearance
(Fundamentals of
Nursing by Kozier p.
531)
normal The clients voice is in
moderate pace. She
speaks clearly and
understandable.
Listen for relevance and
organization of thoughts
The response has sense
and relevant to thequestion.
Logical sequence;
makes sense and hassense of realty
Healthy appearance
(Fundamentals of
Nursing by Kozier p.
531)
normal The clients responses
have sense and there isno confusion.
Integumentary
SKIN
Inspect for color;uniformity of color.
Fair skin complexion,uniform. Skins that are
normally expose is a
little darker.
Ranging from pinkishwhite to various shades
of brown. Skin color
relatively constant
except skin ares that are
normally exposed.
(Fundamentals of
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 572)
normal The clients skin color islight brown and she
doesnt have
discolorization.
Inspect for presence of
edema.
No edema No edema
(Fundamentals of
normal The client doesnt have
a presence of edema.
-
8/14/2019 NCP (Nicole Tandayu)
14/42
Nursing by Kozier p.
538)
There is no are that
appears swollen, shiny
and taut.
Inspect for lesions
according to location,
color, size and shape
No lesions, has birth
mark on left shin.
Freckles, some birth
marks, some flat and
raised nevi; no
abrasions or otherlesions.
(Fundamentals of
Nursing by Kozier p.
538)
normal The client doesnt have
an alteration in her
normal skin appearance.
Palpate skin moisture No excessive moisture
and no excessivedryness.
Moisture in skin folds
and the axillae.(Fundamentals of
Nursing by Kozier p.
539)
normal The client doesnt have
excessive moisture inher ski folds or
excessive dryness.
Palpate skin temperature Warm and uniform Uniform temperature
within normal range.
(Fundamentals of
Nursing by Kozier p.
539)
normal The temperature of her
skin is warm and
uniform.
Palpate skin turgor When pinched skin
springs back on its
original state
When pinched skin
springs back to previous
state.
(Fundamentals of
Nursing by Kozier p.
539)
normal The clients skin springs
back immediately when
pinched.
Nails
Inspect fingernails plate
shape to determine its
curvature and angle
Convex curvature; angle
of nail plate is about
160 degrees
Convex and should
follow the natural curve
of the finger. Angle
between the nail and
base of the finger shouldbe about 160 degrees.
(Fundamentals of
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 574)
normal The clients fingernail
shows a convex shape
and the nail plate angle
is about 160 degrees.
Inspect fingernails and
toenail bed color
Pink in color and highly
vascular
Highly vascular and
pink in light skinned
people; dark skinned
people may have brownor black pigmentation.
(Fundamentals ofNursing by Kozier p.
543)
normal The clients fingernails
and toenail bed is pink
in color highly vascular.
Palpate fingernail and
toenail texture
Smooth and firm Smooth firm and
nontender.
(Fundamentals of
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 574)
normal Her fingernails and
toenails texture is
smooth and firm
because
-
8/14/2019 NCP (Nicole Tandayu)
15/42
-
8/14/2019 NCP (Nicole Tandayu)
16/42
Inspect the facial
feature, symmetry of
facial movements
Symmetrical feature and
movement; moles are
present. Uniform in on
color
Symmetrical' even
distribution of facial
hair and uniform in
color.
(Fundamentals of
Nursing: The Art of
Nursing Care by Tayloret. al. P. 576)
normal The clients facial
feature and facial
movements is
symmetrical. There is a
presence of moles. She
has uniform facial color.
Eyes
Eyebrows
Inspect of hair
distribution, alignment,
skin and quality and
movement
Symmetrical, evenly
distributed, black in
color, equal movement
Equal distribution;
parallel alignment.
(Fundamentals of
Nursing: The Art of
Nursing Care by Tayloret. al. P. 577)
normal The hair in clients
eyebrows is evenly
distributed, black in
color and equal in
movement.
Eyelashes
Inspect for hair
distribution and
direction of curl
Evenly distributed,
curled outward
Equal distribution,
curled outward.
(Fundamentals ofNursing: The Art ofNursing Care by Taylor
et. al. P. 577)
normal The clients eyelashes is
evenly distributed and
curled outward.
Eyelids
Inspect for the surface
characteristics, position,
in relation to the cornea,ability to blink and
frequency of blinking
Skin intact, no
discharges and
discoloration,symmetrically 15-20
blinks per minute. Close
symmetrically
Skin intact, no
discharges and
discoloration,symmetrically 15-20
blinks;lids close
symmetrically; upper
and lower boundaries of
cornea are slightly
covered.
(Fundamentals of
Nursing by Kozier p.548)
normal Her eyelids skin is
intact, no discharge and
discolorization. It issymmetrically blinks
15-20 times per minute.
It is close
symmetrically.
Conjunctiva
Inspect the bulbar
conjunctiva for color,
texture, and presence of
lesions
Transparent with minute
capillaries, no presence
of lesions
Transparent; capillaries
sometimes evident.
(Fundamentals of
Nursing by Kozier p.548)
normal The clients bulbar
conjunctiva is
transparent in color with
minute capillaries, andthere is no presence of
lesions.
Inspect the palpebral
conjunctiva for color,
texture, and presence of
lesions
Pink in color, no lesions
and shiny.
Shiny, smooth, pink or
red.
(Fundamentals of
Nursing by Kozier p.
548)
normal Her palpebral
conjunctiva is color
pink, smooth and shiny.
There is no presence of
lesions.
Sclera
Inspect the color and
clarity
White in color, clear White in color, clear.
(Fundamentals of
Nursing by Kozier p.
550)
normal The clients sclera is
white in color and clear.
Cornea
Inspect for clarity and Transparent, smooth and Transparent, smooth and normal The clients cornea is
-
8/14/2019 NCP (Nicole Tandayu)
17/42
texture shiny clear, no
irregularities
shiny, details of the iris
are visible.
(Fundamentals of
Nursing by Kozier p.
550)
transparent, smooth,
shiny and clear. There
are no irregularities.
Iris
Inspect for color andshape Brown in color, roundand flat. Flat and round(Fundamentals of
Nursing by Kozier p.
550)
normal The clients iris is brownin color, round and flat.
Pupils
Inspect for color, shape
and symmetry of size
Black in color; they are
equal in size
Black in color; equal in
size
(Fundamentals of
Nursing by Kozier p.
550)
normal The clients pupils are
black in color and they
are equal in size.
Visual Acuity
Test near vision Able to read newsprint. Able to read newsprint.
(Fundamentals of
Nursing by Kozier p.552)
normal The client was able to
read newsprints.
Test distant vision 20/20 vision without
glasses
20/20 vision
(Fundamentals of
Nursing by Kozier p.
552)
normal The clients vision is
20/20 without glasses.
Pupils
Test each pupil for light
reaction and
accommodation
Illuminated constrict;
non illuminated dilate;
viewing nearer object
constrict; viewing
farther object dilate
Pupil Equal Round and
reactaed to Light and
Accommodation
(Fundamentals of
Nursing by Kozier p.
550)
normal The clients pupils
constrict when
illuminated and dilate
when non-illuminated.
Lacrimal Gland,Lacrimal sac,
Lacrimal duct
Inspect and palpate the
lacrimal gland
No excessive tearing
and no edema
no edema or tearing.
(Fundamentals ofNursing by Kozier p.
550)
normal The client has no
excessive tearing and noedema.
Extraocular Muscle
Test for each eye for
alignment and
coordination
Coordinated movements
of the eye.
Both eyes coordinated,
move in unison,with
parallel alignment.(Fundamentals of
Nursing by Kozier p.
552)
normal The clients both eye is
coordinated, move in
unison and with parallelalignment.
Visual Field
Test for peripheral fields When looking straight
ahead, the client can seethe object in periphery
When looking straight
ahead, the client can seethe object in periphery
(Fundamentals of
Nursing by Kozier p.
551)
normal When looking straight
ahead, the client can seeobjects in periphery.
Ears
Auricles
-
8/14/2019 NCP (Nicole Tandayu)
18/42
Inspect for color
symmetry and position
Color same as the facial
color, symmetrically
aligned the with outer
canthus of eye.
Color same as the facial
color, symmetrical
auricle aligned with
outer canthus of eye,
about to form vertical.
(Fundamentals of
Nursing by Kozier p.556)
normal The clients auricle is
with same color to her
face, symmetrically
aligned to the outer
canthus of her eyes.
Palpate for texture,
elasticity and areas of
tenderness
Mobile, firm and tender,
pinna recoils when it is
folded
Mobile, firm and tender,
pinna recoils when it is
folded(Fundamentals of
Nursing by Kozier p.
556)
normal Her auricles are mobile,
firm and tender. Her
pinna recoils when it isfolded.
External ear canal
Inspect ear canal for
cerumen, skin lesions,
pus and blood
Ear canal is pink and
shiny. has dry cerumen,
no skin lesions pus and
blood deposits, contains
hair follicles
Ear canal should be
smooth and pinkish.
Tympanic membrane
intact, translucent, shiny
and gray. No redness or
discharge.
(Fundamentals of
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 580)
normal The ear canal is pink
and shiny. It has a dry
cerumen, no skin
lesions, pus and blood
deposits. It contains hair
follicles.
Hearing Acuity test
Assess client's response
to normal voice tones
Voice is heard in both
ears.
Normal voice tones
audible.
(Fundamentals ofNursing by Kozier p.
558)
normal The client can hear
normal voice tones.
Perform watch tick test Able to hear ticking in
both ears.
Able to hear ticking in
both ears.(Fundamentals of
Nursing by Kozier p.
558)
normal The client able to hear
ticking in both ears.
Perform Weber's test Sound is heard on both
sides of the ears.
Sound is heard in both
ears or is localized at
the center of the head.
(Fundamentals of
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 582)
normal The client can hear the
sound from the tuning
fork that was localized
at the center of the head.
Perform Rinne's test Rinne Positive Air conduction is
greater to bone
conduction or Rinne
positive.(Fundamentals of
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 582)
normal The clients air-
conducting hearing is
greater than her bone-
conducting hearing.
Nose
Inspect for anydeviations in shape, size
and color and flaring or
In the midline of theface,symmetric and
straight no discharge
Symmetric and straightno discharge uniform in
color.
normal The clients nose is inthe midline of her face,
symmetric, straight, no
-
8/14/2019 NCP (Nicole Tandayu)
19/42
discharge from nares uniform in color. (Fundamentals of
Nursing by Kozier p.
560)
discharge and its color is
uniform to the color of
her face.
Inspect the nasal
cavities for the presence
of redness, swelling,
growths and discharge,using penlight
Reddish mucosa; watery
discharge and no
lesions.
Pink mucosa; watery
discharge, no lesions.
(Fundamentals of
Nursing by Kozier p.561)
Deviated from normal The clients nasal
cavities have a reddish
mucosa, watery
discharge but there is nolesion.
Inspect the nasal septum
between the nasal
chambers
Intact and in midline Intact and in midline
(Fundamentals of
Nursing by Kozier p.
561)
normal The clients nasal
septum is intact and
placed in the midline.
Test patency of both
nasal cavities
Air freely flows through
nares
Air flows freely as the
client breathes through
the nares.(Fundamentals of
Nursing by Kozier p.
560)
normal The air freely flows
through the nares of the
clients nose.
Palpate for anytenderness, masses
displacements of bone
and cartilage
No tenderness nolesions, no
displacements of bones
and cartilage
No tenderness nolesions, no lesions.
(Fundamentals of
Nursing by Kozier p.
560)
normal The clients nose has notenderness, no lesion, no
displacement of bones
and cartilage.
Sinuses
Locate/ palpate/ identifythe sinuses and note for
any tenderness
Non-tender Not painful whenpalpated.
(Fundamentals of
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 583)
normal The clients sinuses isnot painful when
palpated.
Mouth
Lips
Inspect for symmetry ofcontour, color and
texture
Pink in color, smooth,symmetrically aligned
and in movement
Symmetrical, pinkmoist, smooth and free
of swelling or lesions.
(Fundamentals of
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 583)
normal The lips of the client iscolor pink, it is smooth,
free of swelling or
lesion.
Buccal Mucosa
Inspect for color,
moisture, texture and
presence of lesions
Pink in color, moist, no
lesions,
Pink, moist, free of
swelling or lesions.
(Fundamentals of
Nursing: The Art of
Nursing Care by Taylor
et. al. P. 583)
normal The buccal mucosa of
the client is pink in
color, moist and has no
lesion.
Teeth
Inspect for color,
number and condition,
and presence of
dentures
28 numbers of teeth,
enamel in color, shiny
and smooth.
32 numbers of adult
teeth; shiny, smooth and
white.
(Fundamentals ofNursing by Kozier p.
564)
normal The client has 28 teeths.
It is enamel in color,
shiny and smooth.
Gums
Inspect for the color and Pink in color, no Pink in color, moist normal The clients gums is
-
8/14/2019 NCP (Nicole Tandayu)
20/42
condition bleeding, moist firm, no
retraction
firm.
(Fundamentals of
Nursing by Kozier p.
564)
pink in color, no
bleeding, it is moist, and
has no retraction.
Tongue/Floor of
Mouth
Inspect for color andtexture of the mouth
floor and frenelum
Pink in color, moist. Pink in color, moist,slightly rough, frenulum
is at the center
(Fundamentals of
Nursing by Kozier p.
564)
normal The tongue and floor of the mouth is color pink
and moist.
Inspect and palpate the
position, color and
texture, movement andbase of the tongue
Pink in color, slightly
rough, thin whitish
coated, no lesions
Moves freely no
tenderness
(Fundamentals ofNursing by Kozier p.
564)
normal The base of her tongue
is pink in color, slightly
rough, has a tin whitishcoated and has no
lesion.
Palpate for any nodules,
lumps or excoriatedareas
smooth, no lumps No palpable nodules
(Fundamentals ofNursing by Kozier p.
564)
normal There are no nodules,
lumps or any excoriatedareas.
Palates and Uvula
Inspect and palpate forcolor, shape, texture and
the presence of presenceof bony prominences
Light pink, smooth, softpalate, hard palate, more
irregular texture
Light pink, smooth, softpalate, hard palate, more
irregular texture(Fundamentals of
Nursing by Kozier p.
565)
normal The soft and hard palateof the client is color
light pink and moreirregular in texture.
Inspect for position of
the uvula and mobility
while examining the
palates
At the center and freely
movable.
Is normally centered
and freely movable.
(Fundamentals of
Nursing: the Art of
Nursing Care by Taylor
et. al. p. 583)
normal The uvula of the client is
placed at the center and
freely movable.
Oropharynx and
tonsils
Inspect and palpate for
color and texture
Pink, smooth, posterior
wall
Pink, smooth, posterior
wall.
(Fundamentals of
Nursing by Kozier p.
565)
normal The color of the clients
oropharynx is pink, and
it has a smooth posterior
wall.
Inspect the size of the
tonsils, color anddischarge
Pink and smooth, with
no discharge.
Pink, smooth, no
discharges of normalsize.
(Fundamentals of
Nursing: the Art of
Nursing Care by Taylor
et. al. p. 584)
Inflamed The color of the clients
tonsils is pink, it issmooth and with no
discharge.
Neck and Lymph
Nodes
Lymph nodes
Locate/palpate/identify
lymph nodes and note
for tenderness
Not palpable, no
tenderness
Normally not palpable;
if palpable it should be
small mobile, smooth
and nontender.
normal The lymph nodes of the
client is not palpable
and has no tenderness
-
8/14/2019 NCP (Nicole Tandayu)
21/42
(Fundamentals of
Nursing: the Art of
Nursing Care by Taylor
et. al. p. 584)
Trachea
Inspect and palpate for
placements
Midline of neck; spaces
are equal on both sides
Midline of neck at the
supresternal notch;spaces are equal on both
sides
(Fundamentals of
Nursing: the Art of
Nursing Care by Taylor
et. al. p. 584)
normal The trachea of the client
is placed in the midlineof her neck and it has
equal spaces on both
sides.
Thyroid gland
Inspect symmetry and
visible masses
Not visible, glands
ascends during
swallowing
Not visible, glands
ascends during
swallowing
(Fundamentals of
Nursing ny Kozier p.569)
normal The thyroid gland of the
client is not visible and
its gland ascends during
swallowing.
Palpate for smoothnessand areas of
enlargement, masses
and nodules
Not palpable, centrallylocated, no tenderness
Normally not palpable;if palpable it should feel
soft bur elastic, non
tender and should have
no enlargements, masses
or nodules.
(Fundamentals of
Nursing: The Art of
Nursing Care by Tayloret. al. P. 572)
normal Her thyroid gland is notpalpable, centrally
located and has no
tenderness.
Thorax Normal Findings Actual Findings Analysis Interpretation
Posterior Thorax
a. size, shape,
symmetry, diameter of
anteroposterior thoraxand transverse
diameter.
Anteroposterior to
transverse diameter
diameter in ratio of 1:2
Chest symmetric
(Fundamentals ofNursing by Kozier p.
576)
Anteroposterior
diameter to the
transverse diameter bya ratio of 2:1 (17:34)
Chest symmetric
Within normal range.
-
8/14/2019 NCP (Nicole Tandayu)
22/42
b. spinal alignment Spine Vertically aligned
(Fundamentals of
Nursing by Kozier p.
576)
Spine is vertically
aligned
Within normal range. The spinal column of
the client is vertically
aligned.
c. temperature,tenderness and masses
Uniform temperature
No tenderness
No masses
(Fundamentals of
Nursing by Kozier p.
576)
Uniform temperature
No tenderness
No masses
Within normal range. The posterior thorax of
the client has a uniform
temperature, has no
tenderness and no
masses
d. respiratory excursion Full symmetric chest
expansion during deep
inspiration
(Fundamentals of
Nursing by Kozier p.576)
Has full and
symmetrical chest
expansion
Within normal range. During the deep
inspiration of the client,
her chest has a full
symmetric expansion.
e. vocal fremitus Bilateral symmetry ofvocal fremitus
Fremitus is heard most
clearly at the apex of
the lungs
(Fundamentals of
Nursing by Kozier p.
577)
Bilateral symmetry ofvocal fremitus
The vibrations diminish
from superior to
inferior thorax.
Within normal range. The vocal fremitus of
the client has a bilateral
symmetry, and its
fremitus is heard most
clearly at the apex of
her lungs.
-
8/14/2019 NCP (Nicole Tandayu)
23/42
f.percuss posterior
thorax
Percussion notes
resonate, except over
scapula
(Fundamentals of
Nursing by Kozier p.
577)
There is a resonant
sound over lung field
and dullness over the
ares of the liver and
spleen
Within normal range. On the posterior thorax
of the client, the
percussion notes
resonate, except over
scapula.
g. auscultate posterior
thorax
Vesicular and
bronchovesicular breath
sounds
(Fundamentals of
Nursing by Kozier p.
577)
Has bronchovesicular
breath sound in the
apex of lungs and
vesicular breath sound
base of the lungs.
Within normal range. In the auscultation of
the posterior thorax of
the client, it notes
vesicular and
bronchovesicular breath
sounds
Anterior Thorax
a. breathing patterns Quiet, rhythmic, and
effortless respirations
(Fundamentals of
Nursing by Kozier p.
578)
Has quiet, rhythmic and
effortless respirations
or has eupnic
respiration.
Within normal range. The breathing pattern
of the client is quiet,
rhythmic and has a
eupnic respiration.
b. temperature,
tenderness and masses
Uniform temperature
No tenderness
No masses
(Fundamentals of
Nursing by Kozier p.
578)
Uniform temperature
No tenderness
No masses
Within normal range. On the anterior thorax
of the client, it has a
uniform temperature,
no tenderness, and no
masses
-
8/14/2019 NCP (Nicole Tandayu)
24/42
c. respiratory excursion Full and symmetric
chest expansion during
deep inspiration
(Fundamentals of
Nursing by Kozier p.
578)
Full and symmetric
chest expansion
Within normal range. During the deep
inspiration of the client,
her chest has a full
symmetric expansion.
d. vocal fremitus Bilateral symmetry of
vocal fremitus
(Fundamentals of
Nursing by Kozier p.
579)
Bilateral symmetry of
vocal fremitus.
Diminishing vibrations
from superior to
inferior thorax.
Within normal range. On the anterior thorax
of the client, it has a
bilateral symmetry of
vocal fremitus
e. percuss anterior
thorax
Percussion notes
resonate down to thesixth rib at the level of
diaphragm but flat over
areas of heavy muscles
and bone, dull over
areas over the heart and
the liver, tympanic over
the underlying stomach.
(Fundamentals of
Nursing by Kozier p.
579)
Has resonated sound. Within normal range. On the clients anterior
thorax, percussionnotes resonate down to
the sixth rib at the level
of the diaphragm, but
flat over areas of heavy
muscles and bone, dull
over areas over the
heart and the liver,
tympanic over theunderlying stomach.
f. auscultate trachea Bronchial and breath
sounds
(Fundamentals of
Nursing by Kozier p.
579)
Has bronchial breath
sounds
Within normal range. The clients trachea has
bronchial breath
sounds.
-
8/14/2019 NCP (Nicole Tandayu)
25/42
g. auscultate anterior
thorax
Bronchovesicular and
vesicular breath sounds
(Fundamentals of
Nursing by Kozier p.
579)
Has bronchovesicular
breath sound in the
apex of lungs and
vesicular breath sound
base of the lungs.
Within normal range. In the auscultation of
the clients anterior
thorax, it notes
bronchovesicular breath
sounds.
Cardiovascular
a. Inspect and Palpate
at the same time
aortic and
pulmonic areas
No Pulsations
(Fundamentals ofNursing by Kozier p.
583)
No pulsations felt Within normal range. There are no pulsations
on the clients aortic
and pulmonic areas.
Tricuspid areas No Pulsations
(Fundamentals of
Nursing by Kozier p.
583)
Light pulsations are feltWithin normal range. There are light
pulsations on the
clients aortic and
tricuspid areas.
Apical area Pulsations visible in the
5th LICS at medial to
MCL
(Fundamentals of
Nursing by Kozier p.
583)
Pulsations are felt
specifically in the fifth
intercostal space
Within normal range. There are pulsations
felt specifically in the
fifth intercostal space
of the clients apical
area.
b. Auscultation
-
8/14/2019 NCP (Nicole Tandayu)
26/42
aortic S1: usually heard at all
sites
S2: usually heard at all
sites
(Fundamentals ofNursing by Kozier p.
583)
S2 heart sounds is
heard.
Within normal range. In the aortic of the
client, heart sounds is
heard
pulmonic S1: usually heard at all
sites
S2: usually heard at allsite.
(Fundamentals of
Nursing by Kozier p.583)
S2 heart sounds is
heard
Within normal range. In the pulmonic of the
client, heart sound is
heard.
tricuspid S1: usually heard at all
sites
S2: usually heard at all
sites
(Fundamentals of
Nursing by Kozier p.
583)
S1 Heart sounds is
heard
Within normal range. In the tricuspid of the
client, heart sound is
heard.
-
8/14/2019 NCP (Nicole Tandayu)
27/42
apical valves S1: usually heard at all
sites
S2: usually heard at all
sites
(Fundamentals ofNursing by Kozier p.
583)
S1 heart sounds is
heard.
Within normal range. In the apical valves of
the client, heart sounds
is heard.
Carotid Arteries
a. palpation Symmetric pulse
volumes
(Fundamentals of
Nursing by Kozier p.
584)
Pulsation is full and has
a symmetric pulse
volume
Within normal range. In the carotid arteries of
the client, pulsation is
full and has a
symmetric pulse
volume
b. Auscultation No sound heard on
auscultation
(Fundamentals ofNursing by Kozier p.
584)
No sound heard. Within normal range. In the carotid arteries of
the client, auscultation
is no sound heard
Jugular Veins
a. inspect Veins not visible
(Fundamentals ofNursing by Kozier p.
584)
Veins not visible Within normal range. In the jugular veins of
the client, veins are not
visible.
-
8/14/2019 NCP (Nicole Tandayu)
28/42
Breast and Axillae
a. size, symmetry,
contour, shape
Round in shape;
slightly unequal in size;
generally symmetric
(Fundamentals of
Nursing by Kozier p.
589)
Flat, rounded shape,
slightly unequal in size,
right breast is slightly
bigger than the left.
Within normal range. The breast of the client
is flat, rounded shape,
slightly unequal in size;
her right breast is
slightly bigger than the
left.
b. discoloration of the
skin,
hypopigmentation,retraction,dimpling,
hypervascular areas,swelling or edema.
Skin uniform in color
Skin smooth and intact
(Fundamentals of
Nursing by Kozier p.
589)
Skin uniform in color
Skin smooth and intact.
Has no stretch marks
Within normal range. The skin of the clients
breast is uniform in
color, it is smooth and
intact, and it has no
stretch marks.
c. areola for size, shape,
symmetry, color,
surface characteristics
and any mass or lesions
Round or oval and
bilaterally the same.
Color varies widely,
from light pink to dark
brown.
Irregular placement of
sebaceous glands on the
surface of the areola
(Fundamentals of
Nursing by Kozier p.
590)
Round and bilaterally
the same
Brown in color
Within normal range. The size of the areola
of the client is round
and bilaterally the
same. It is brown in
color.
-
8/14/2019 NCP (Nicole Tandayu)
29/42
d. nipples for size,
shape, position, color,
discgarge, and lesions
Round, everted, and
equal in size; similar in
color; both nipples
point in same direction.
No discharge
(Fundamentals of
Nursing by Kozier p.
590)
Everted nipple.
Pointing at the same
direction.
No discharge
Within normal range. The nipples of the
client is everted,
pointing at the same
direction, and it has no
discharge
e. Palpation
axillary,
subclavicular
and
superclavicular
lymph nodes
No tenderness, masses,
or nodules.
(Fundamentals ofNursing by Kozier p.
590)
Lymph node
not palpable
Within normal range. In the axillary,
subclavicular ans
superclavicular lymph
nodes of the client are
not palpable
breast formasses,
tenderness
No tenderness, masses,nodules, or nipple
discharge.
(Fundamentals of
Nursing by Kozier p.
590)
No tenderness, masses,nodules, or nipple
discharge
Within normal range. The breast of the client
has no tenderness,
masses, nodules, and it
doesnt have nipple
discharge.
-
8/14/2019 NCP (Nicole Tandayu)
30/42
nipples
tenderness and
masses
No tenderness, masses,
nodules, or nipple
discharge.
(Fundamentals of
Nursing by Kozier p.
590)
No tenderness, masses ,
nodules, or nipple
discharge
Within normal range. The nipples of the
client has no
tenderness, no nodules
and doesnt have nipple
discharge
Abdomen
a. inspection abdomenfor skin Unblemished skin
(Fundamentals of
Nursing by Kozier p.
594)
Unblemished skin,uniform in color. Nostretch marks.
Within normal range. The abdomen of the
client has unblemished
skin, it has uniform
color and doesnt have
stretch marks.
b. inspection abdomen
for contour and
symmetry
Flat, rounded (convex),
scaphoid (concave)
(Fundamentals of
Nursing by Kozier p.594)
Flat abdomen Within normal range. The abdomen of the
client is flat
c. inspection
enlargement of
abdomen/spleen.
No evidence of
enlargement of liver or
spleen (Fundamentals
of Nursing by Kozier p.
594)
No enlargement of
spleen or liver
Within normal range. The client has no
enlargement of spleen
or liver.
-
8/14/2019 NCP (Nicole Tandayu)
31/42
d. symmetry of contour
while standing at the
foot of the bed
Symmetric contour
(Fundamentals of
Nursing by Kozier p.
594)
Symmetric contour Within normal range. The client has a
symmetric contour
e. Abdominal
movement
Symmetric movements
caused by respirations.
(Fundamentals of
Nursing by Kozier p.
595)
Symmetric movements.Within normal range. The abdominal
movements of the client
is symmetric
f. vascular pattern No vascular pattern.
(Fundamentals of
Nursing by Kozier p.
595)
No visible vascularpattern
Within normal range. The client has no
visible vascular pattern
g. Auscultation Audible bowel sounds
Absence of arterialbruits
Absence of friction rub
(Fundamentals of
Nursing by Kozier p.595)
Audible bowel sounds
Absence of arterialbruits
Absence of friction rub
Within normal range. The abdomen of the
client has an audible
bowel sounds. There is
no presence of arterial
bruits, and no presence
of friction rub
-
8/14/2019 NCP (Nicole Tandayu)
32/42
h. Percuss each of the 4
quadrants
Tympany over the
stomach and gas-filled
bowels; dullness,
especially over the liver
and spleen, or full
bladder (Fundamentals
of Nursing by Kozier p.596)
Tympanic sound heard
in the stomach and
dullness in liver and
spleen.
Within normal range. In the percussion of the
4 quadrants of the
abdomen of the client,
tympanic sound is
heard in the stomach
and dullness in liver
and s leeni. Palpation No tenderness; relaxed
abdomen with smooth,
consistent tension.
(Fundamentals of
Nursing by Kozier p.596)
No tenderness; relaxed
abdomen with smooth,
consistent tension.
Within normal range. In the palpation of the
abdomen of the client,
it has no tenderness, her
abdomen was relaxed
and with smooth, and
has a consistent tension
Musculoskeletal
System
a. Size Equal size on both sides
of the body
(Fundamentals of
Nursing by Kozier p.600)
Equal size on both sidesWithin normal range. The musculoskeletal
system of the client is
equal in size on both
sides
b. Tendons for
contractures
No contractures
(Fundamentals of
Nursing by Kozier p.600)
No contractures Within normal range. The tendons of the
musculoskeletal system
of the client has no
contractures
-
8/14/2019 NCP (Nicole Tandayu)
33/42
c. Fasciculation and
tremors
No fasciculation and
tremors (Fundamentals
of Nursing by Kozier p.
600)
No fasciculations and
tremors
Within normal range. There are no
fasciculations and
tremors in the
d. Palpate muscletonicity
Normally firm
(Fundamentals of
Nursing by Kozier p.
600)
Tonicity is normallyfirm
Within normal range. The muscle tonicity of
the client is normally
firm
e. Test for musclestrength
(Fundamentals ofNursing by Kozier p.
600)
Neck Grade 5
Able to resist
Able to resist Within normal range. She can able to resist
her neck in normal
range.
Upper
extremities
Grade 5
able to resist
Able to resist Within normal range. The upper extremities
of the client can able to
resist.
lower
extremities
Grade 5
able to resist
Able to resist Within normal range. The lower extremities
of the client can able to
resist and it is in normal
range.
Bones
a. Deformities and
skeleton for normal
structures
No deformities
(Fundamentals ofNursing by Kozier p.
601)
No deformities Within normal range. Theres no deformity
on the clients bone
structure.
-
8/14/2019 NCP (Nicole Tandayu)
34/42
b. Palpation No tenderness or
swelling
(Fundamentals of
Nursing by Kozier p.
601)
No tenderness or
swelling
Within normal range. Theres no sign of
tenderness and
swelling.
Joints
a. Joint for swelling No swelling
(Fundamentals ofNursing by Kozier p.
601)
No swelling Within normal range. The joints of the client
has no swelling
b. Palpation No tenderness,
swelling, crepitation, ornodules.
(Fundamentals of
Nursing by Kozier p.
601)
No tenderness,
swelling, crepitation, ornodules
Within normal range. In the palpation of the
joints of the client,
there is no tenderness,
no swelling no
crepitation nor nodules
Upper
Extremities
(shoulder and
scapula)
Complete Complete Within normal range. Her upper extremities
are complete.
Elbows Complete complete Within normal range. The Elbows of the
client is complete.
Hands Complete complete Within normal range. The hand of the client
is complete and it is in
normal range without.
-
8/14/2019 NCP (Nicole Tandayu)
35/42
Lower
Extremities
(acetabalum/in
guinal area)
Complete complete Within normal range. The Lower Extremities
(acetabalum/inguinal
area) is complete.
Popliteal Complete complete Within normal range. The Popliteal of the
client is complete.
ankles complete complete Within normal range. Her ankle is complete
and in it is on the
normal range.
II. LIST OF NURSING PROBLEMS
Nursing Diagnosis Cues Justification
Sleep Deprivation related to
sustained inadequate sleep hygiene.
I
-I find it difficult to fall asleep
- I am well aware that I have a
sleeping problem, hindi ko lang
alam kung ano problem ko, gusto ko
sana mamodify yun.
O
- Dark circles around her eyes
- looks sleepy and tired.
M
- yawned 8x during the interview.
-Sleep is a physiologic need
according to Maslows hierarchy of
needs.
- actual problem
- recognizes it as a problem
- has a desire to modify the problem,
- If left untreated, may arise to
potential problems.
- resources like time and personnel
are available
-
8/14/2019 NCP (Nicole Tandayu)
36/42
Nursing
Diagnos
is
Cues Justificat
ion
Ineffecti
ve
coping
related
to
gender
differen
ces in
coping
strategie
s
specific
ally no
vacation
and too
many
deadline
s.
I
-
Monday Tuesday Wednesd
ay
Thursday Friday Saturd
ay
Sunday
6:00
-
6:30
Do
morning
exercise
Do
morning
exercise
Do
morning
exercise
Do
morning
exercise
Do
morning
exercise
Sleep Sleep
6:30
-
7:30
Watch
television
Watch
television
Watch
television
Watch
television
Watch
television
7:30
-
8:00
Eat
breakfast
Eat
breakfast
Eat
breakfast
Eat
breakfast
Eat
breakfast
Eat
breakf
ast
Eat
breakfa
st
8:00
-8:30
Read
notes
Read
notes
Read
notes
Read
notes
Read
notes
Take a
bath
Take a
bath
8:30
-
9:00
Take a
bath
Take a
bath
Take a
bath
Take a
bath
Take a
bath
Prepar
e for
school
Prepare
for
school
9:00
-
9:30
Prepare
for school
Prepare
for school
Prepare
for school
Prepare
for school
Prepare
for school
Attend
Bible
study
Attend
Bible
study
9:30
-10:0
0
Travel to
school
Travel to
school
Travel to
school
Travel to
school
Travel to
school
10:0
0-1:00
Attend
Microbiology &
Parasitolo
gy class
Attend
Microbiology &
Parasitolo
gy class
Attend
Microbiology &
Parasitolo
gy class
Attend
Microbiology &
Parasitolo
gy class
Attend
Microbiology &
Parasitolo
gy class
Watch
television and
browse
the
interne
t
Watch
television and
browse
the
internet
1:00
-
1:30
Eat lunch Eat lunch Eat lunch Eat lunch Eat lunch Eat
lunch
Eat
lunch
1:30
-
3:20
Attend
PSTL
class
Attend
PSTL
class
Attend
PSTL
class
Attend
PSTL
class
Attend
PSTL
class
Watch
DVD/
TV
Watch
DVD/T
V
3:20
-
4:00
Read
notes
Read
notes
Read
notes
Read
notes
Read
notes
4:00
-
7:00
Attend
NCM 101
class
Attend
NCM 101
class
Attend
NCM 101
class
Attend
NCM 101
class
Attend
NCM 101
class
Go to
the
mall
7:00
-
8:00
Travel
home
Travel
home
Travel
home
Travel
home
Travel
home
Rest
8:00
-
Rest Rest Rest Rest Rest Eat
dinner
- love
and
belongin
g needs
accordin
g to
Maslow
s
- an
actual
problem
-my
arise to
potential
problems
-
resource
s like
time and
personnel are
available
-
8/14/2019 NCP (Nicole Tandayu)
37/42
8:30
8:30
-
9:00
Eat dinner Eat dinner Eat dinner Eat dinner Eat dinner Eat
dinner
Read
notes/D
o
homework
9:00
-
12:00
Read
notes/Do
homeworks
Read
notes/Do
homeworks
Read
notes/Do
homeworks
Read
notes/Do
homeworks
Read
notes/Do
homeworks
Play
guitar
12:00-
6:00
Sleep Sleep Sleep Sleep Sleep Sleep
O
-yawns during the inerview
Nursing Diagnosis Cues Justification
Readiness for enhanced Nutrition I
-Gusto ko baguhin yung eating
patterns at saka yung quality ng food
na kinakain ko.
- mas maganda sana kapag healthy
yung kinakain ko araw-araw para
maimprove yung health ko.
- denotes no existing problem
- client has the desire for a
higher level of wellness
-resources like time and personnel
are available
Nursing Diagnosis Cues JustificationImbalanced Nutrition: less than body
requirements related to inability to
ingest food necessary for formation
of normal red blood cells. As
evidence by:
Istarting ngayong summer
class, nadedelay na yung time
ng pagkain dahil sa hectic
schedule ko.
feeling ko super unhealthy
nung mga kinakain ko kasi
usually mga galling sa fastfood
chains
I drink when I feel thirsty saka
every after meals.
According to her, she takes
ferrous sulfate for her anemia.
Gusto ko baguhin yung eating
patterns at saka yung quality ng
food na kinakain ko.
Nutrition is a physiologic need,
according to the Maslows Hierarchy
of Needs
- it is an actual problem
- if left untreated, may arise
to potential problems
- recognize it as a problem
- resources like time and
personnel are available
-
8/14/2019 NCP (Nicole Tandayu)
38/42
O
- pale
Nursing Diagnosis
-
8/14/2019 NCP (Nicole Tandayu)
39/42
VI- Nursing Care Plan
Nursing
Diagnosis
Analysis Outcomes Intervention Rationale Evaluation
Sleep
deprivation
related to
inadequate as
evidence by:
I
-I find it
difficult to fall
asleep
- I am well
aware that I
have a
sleeping
problem, hindi
ko lang alam
kung ano
problem ko,
gusto ko sanamamodify
yun.
O
- Dark circles
around her
eyes
- looks sleepy
and tired.
a. Situational
Analysis
The client is able
to achieve a longer
duration of sleep
because of the
elimination of thefactors such as
difficulty in falling
asleep, working
late etc.
b. Health
Implication
Sleep exerts
physiological
effects on both the
nervous system
and other body
structures. Sleep
on someway
restore normallevel of activity a
normal balance
among parts of the
nervous system.
Sleep also
necessary for
protein synthesis,
which allows
repair process to
occur.
Illness that causes
Goal:
After nursing
intervention,
the client will
be able to
achieve a
longer
duration ofsleep.
Objectives:
After the
nursing
intervention,
the client will
be able to:
1. Know the
importance of
eliminating
caffeine
intake before
sleep in 30
minutes of
discussion.
2. Choose an
alternative for
caffeine
intake in 20
minutes.
1. Discuss with the
client then
importance of
eliminating
caffeine intake
before sleep
2. Provide choices
of alternatives or
substitute for
caffeine.
1. Caffeine is a CNS stimulant.
For many people beverages
containing caffeine interfere of
the activity to fall asleep.
Example of beverage containing
caffeine, include coffee, tea and
most cola drinks(FON 5th edition
by Karol Taylor p. 1176)
2. Small protein containing snack
before bedtime used to be
recommended for patient with
insomnia. Protein may actually
increase alertness and
concentration whereas
carbohydrates appears to affect
brain serotonin level and promote
calmness and relaxation(FON 5th
edition by K. Taylor page 1175)
3. What they do to accomplish
Goal:
met
Partially met
not met
Objectives:
Effectiveness:
1. Was the client able to
decrease the amount of
caffeine intake before going
to sleep?
_yes
_No
Why? ___________
2. Was the client able to look
for substitute to coffee beforegoing to sleep?
_yes
_ no
Why?______
3. Was the client able to
manage her time properly?
-
8/14/2019 NCP (Nicole Tandayu)
40/42
M
- yawned 8x
during the
interview.
pain or physical
distress can result
on sleep problems.
People who are ill
require more sleep
than normal and
the normal rhythm
of sleep and
wakefulness is
often disturbed.
People deprived ofREM sleep
subsequently spend
more time than
normal in this
stage.
Kozier pp. 1115 to
1117
3. Manage her
time properliy
.
4. Engage in
relaxation
techniques,
such as
reading or
listening to
quiet music to
reduce
stimulation.
!
5. Gradually
increase theno. of hours
of sleep per
day.
3. Discuss with the
client proper time
arrangement:
3.1 provide a
sample activity
plan for a day
3.2 guide theclient in making
her own activity
plan.
4. Discuss
importance of
relaxation
techniques.
4.1 Provide list of
relaxation
techniques to
stimulate sleep.
5. Monitor the
sleep hours off the
client.
more at work and thereby reduce
stress.
4. Relaxation techniques are
useful in many situation such as
childbirth, pain, sleeplessness,
anxiety (FON 5th edition K.
Taylor page 864)
5. For no known reasons, 8 hours
of sleep a night has been the
accepted standards for adults,
despite obvious variations own in
the general population.
_yes
_no
why?___________
4. Was the client engageherself in relaxation
techniques?
_yes
_no
Why?____________
5. Was the client to prolong
the no. of hours of her sleep
per day?
_yes
_no
why?___________
Efficiency:
Were the time, materials and
human resources and used
economically?
__Ye
__No Why?
_______________
Appropriateness:
Were the intervention setting
and timetable realistic to
-
8/14/2019 NCP (Nicole Tandayu)
41/42
client situation?
Yes___
No___
Why?________
Acceptability:
Were the interventions
suitable to the clients
situation?
Yes_____No___
Why?___________
Adequacy:
Were the number of
intervention sufficient?
Yes____
No____ why?
_________________
-
8/14/2019 NCP (Nicole Tandayu)
42/42
VII. References