I.

DEMOGRAPHIC DATA
A. Initials of Clients’ Name Date of Admission:
B. Address: Time of Admission:
C. Age:
D. Birth Date: Date of Interview:
E. BirthPlace: Primary Informant:
F. Sex: Secondary Informant:
G. Civil Status: Other Data Sources:
H. Religion:
I. Highest Educational Attainment:
J. Occupation:
K. Monthly Income / Budget : PHP
Monthly Family Expenses
Food
Bills
Other needs of the family
Total

II. REASON FOR SEEKING HEALTH CARE

III. HISTORY OF PRESENT ILLNESS

IV. PAST MEDICAL HISTORY

V. OBSTETRIC-GYNECOLOGICAL HISTORY (if applicable)
A. Menarche:
B. Menstruation
- LMP:

C. AOG

VI. HEREDO-FAMILIAL HISTORY

A. Genogram
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

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)
B. E. Erikson’s Psychosocial Development
Stage Specific Task(s) Evidences of Milestone Achievement
Infancy Trust vs. Mistrust .
(birth to 18 Starting from birth
months) to 12-18months old
wherein infants
must learn to trust
others, especially
those who care for
their needs.
Early Autonomy vs.
Childhood Shame and Doubt
Starting from 2-3
years old children
develop a sense of
control on physical
skills and a sense
of independence.
Pre-school Initiative vs. Guilt
Starting from 3-5
years old children
interact socially
and play with
others and take
initiative and control
what happens.
School Age Industry vs.
Inferiority
 Starting from 5- 12
years old children
go to school where
they learn new
skills also where
their circle of
influence widens.
Adolescence Identity vs. Role
Confusion
Children 12-19y/o
facing the
challenge of
developing
oneself. They form
their identity by
examining their
beliefs, goals, and
values.
Young Intimacy vs.
Adulthood Isolation
This time 18-40 y/o
invest in
commitment to
others. Build long
term loving
relationships that
feel safe.
Middle Generativity vs.
Adulthood Stagnation
Adults (40-65 yrs.
old) need to create
or nurture things
that will outlast
them, often by
having children or
creating a positive
change that
benefits other
people. Success
leads to feelings of
usefulness and
accomplishment,
while failure results
in shallow
involvement in the
world.

C. S. Freud’s Psychosexual Development

Stage Specific Task(s) Evidences of Milestone Achievement
Oral Weaning
The libido is
centered in the
baby’s mouth.
Baby gets much
satisfaction by
putting all sorts of
things in its mouth
to satisfy the libido
Anal Toilet training
Development of
libido becomes
focused on the
anus, and the child
derives great
pleasure from
defecating.
Phallic Oedipus & Electra
Complexes
Infant libido
centers upon
genetalia as the
erogenous zone,
the child becomes
aware of
anatomical sex
differences.
Latency Development of
defense
mechanism
At this stage the
libido is dormant
and no further
psychosexual
development takes
place (latent
means “Hidden”)
Genital Mature sexual
intimacy
Begins in puberty, it
is the time of sexual
experimentation,
the successful
resolution of which
is settling down in
loving one to one
relationship with
another person.
VIII. GORDON’S 11 FUNCTIONAL HEALTH PATTERNS

A. Health Perception – Health Management

B. Nutritional – Metabolic

*3-day Diet Recall

MEALS Date & Day Date & Day Date & Day
Breakfast (time)

Snacks (if any)

Lunch (time)

Snacks (if any)

Dinner (time)

Snacks (if any)

Total Fluid Intake

C. Elimination
D. Activity – Exercise

*7-Day Activity Table

Time Days of the Week & Date
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
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

*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
Dressing
Toileting
Transferring
Continence
Feeding
TOTAL POINTS:

E. Sleep – Rest
 *7-Day Sleep Diary
Constructs Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Hours of Sleep

Sleeping Time

Waking Time

Bedtime Rituals

Feeling upon
waking up
Problem
Encountered

F. Cognitive – Perceptual

G. Self-Perception – Self-Concept

H. Role-Relationship
I. Ecomap

J. Sexuality – Reproductive
 K. Coping-Stress

K. Value-Belief

IX. COMPREHENSIVE PHYSICAL EXAMINATION

A. Vital Signs Date / Time of Exam:
T =
PR =
RR =
BP =

Normal Finding:
T=
Range
PR=
RR=
BP=
B. Anthropometric Data (only those applicable)
Height = BMI =
 Weight = IBW =

C. General Appearance

D. Focused Assessment
Body Part Examined Actual Finding Normal Finding Clinical Significance
INTEGUMENT
Skin
I: color, uniformity, The color of the skin Skin dryness indicates
edema, lesions should vary on the skin possible dehydration.
P: moisture, temp. tone of the client. The According to Kozier-
Turgor skin should moisturize fundamentals of
with normal nursing-10th-edition by
temperature and Edz Balendez
absence of turgor
Equivalent conveyance
Hair of hair. No diseases.
I: evenness of growth Even distribution of hair
thickness, texture, Smooth and delivers with no wounds
oiliness, infection produce natural oil indicated normal
or infestation, body findings as stated in
hair health assessment
P: smoothness page 528 Kozier-
fundamentals of
nursing-10th-edition by
 Edz Balendez

Nail The condition of client

I: plate shape, texture, nails is normal findings
bed color, Normal nails are in accordance with
surrounding tissues translucent, shiny and Kozier-fundamentals of
P: Blanch test firm in texture nursing-10th-edition by
Regain to natural color Edz Balendez page
within 2 seconds. 528.
HEAD Symmetric in shape
Skull and Face with no sign of edema,
I: size, shape, Face is symmetric, no hollowness, nodules,
symmetry edema, nodules, masses, depressions
: facial features masses, depressions. are indications of
: eyes for edema normal finding
and hollowness according to Kozier-
P: nodules, masses, fundamentals of
depressions nursing-10th-edition by
Edz Balendez page
532
Eyes and Vision
I: eyebrows for The client assessment
distribution & Equal distribution of in eyebrows and
alignment, quality & eyebrows. eyelashes showed
movement normal findings as
: eyelashes for stated in Kozier-
evenness of Equal distribution of fundamentals of
distribution & eyelashes. nursing-10th-edition by
direction of curl Edz Balendez page
535
: eyelids for surface
characteristics, No uncontrollable Yellowish-white lumps
position in relation to movement and lumps. of fatty under skin of
cornea, ability to blink eyelids may be an
 & frequency indication of
abnormality as stated in
Health Assessment:
incredibly Visual 2nd
edition page 33.
: bulbar & palpebral
conjunctiva for color, Redness in conjunctiva
texture, and lesion They should be white may result conjunctivitis
without any redness according to Kozier-
and any lesions fundamentals of
detected. nursing-10th-edition by
Edz Balendez page
I/P: lacrimal gland 533
sac, nasolacrimal
duct for edema, No edema, The condition of the
tenderness / tearing tenderness / tearing indicates normal finding
in the relevance stated
by Kozier-fundamentals
of nursing-10th-edition
by Edz Balendez page
I: cornea for clarity, 533
texture & sensitivity
Cornea should be clear. The assessment result
as normal findings as
reported by Kozier-
fundamentals of
nursing-10th-edition by
I: pupils for color, Edz Balendez page
shape, symmetry of 535
size, direct and Normal typical size of
consensual reaction pupils in adults’ The actual finding of
to light, & changes from 2 to 4 client pupil results as
accommodation mm in diameter in normal finding in
bright light to 4 to 8 mm relevance as reported
in dark. Pupils constrict by Kozier-fundamentals
to direct illumination of nursing-10th-edition
(direct response) and to by Edz Balendez page
 illumination of the 534
opposite eye
(consensual response).
The pupil dilates in the
dark.

* Visual Acuity (near &

far vision test) Far Vision Test
(Snellen chart 20 ft Client far vision test
away) resulted 20/150 left eye
20/20 grade is normal 20/140 right eye and
20/100 both eyes for
Near Vision Test near vision test which
Rosenbaum Pocket indicated poor vision of
Screener (14 inches client. According to
away) Kozier-fundamentals of
Normal vision is 20/20. nursing-10th-edition by
Edz Balendez page
538
* Visual Field Test
Capable decide the
quantity of fingers
presented by the nurse The Visual Field Test
while one eye is and EOM Test that
covered client performed
* EOM Test resulted in a normal
Able to follow the finding. According to
direction of the finger Kozier-fundamentals of
correctly. nursing-10th-edition by
Edz Balendez page
Ears and Hearing 536
I: auricles for color,
symmetry and Symmetric in color, size
position and in the right position.
: external canal for
cerumen, lesions, pus No cerumen, lesions, The client assessment
or blood in auricles and external
 pus or blood canal resulted as
P: auricles for texture, symmetric in color, size
elasticity and areas of The ear cartilage is firm and in the right position
tenderness and movable. with no any signs of
redness cerumen,
lesions, pus and blood
this are indications of
normal finding as
stated in Assessment
of Ear in Kozier-
* Gross Hearing Acuity fundamentals of
Tests: normal voice Able to hear the voice nursing-10th-edition by
tone and whispered sound clearly. Edz Balendez, page
voice 541
The test resulted the
client hear the sound
The client should be make by the nurse,
able hear the tick sound according to Kozier-
* Watch Tick Test coming from the watch fundamentals of
nursing-10th-edition by
Edz Balendez, page
Able to hear or feel the 542
* Tunning Fork Tests: vibration in both ears.
- Weber for bone
conduction
- Rinne’s to compare
air and bone The client test for
conductions Weber’s and Rinne’s
test negative in having
impaired hearing in
Symmetric in shape, relevance of Kozier-
Nose and Sinuses size and color. No fundamentals of
I: nose deviation in unusual discharge. nursing-10th-edition by
shape size, color, Edz Balendez, page
flaring, discharge; 542

The client nose is

 symmetric in size and
shape that indicates
normal findings as
stated by Kozier-
fundamentals of
No redness, swelling, nursing-10th-edition by
growth and discharge in Edz Balendez, page
: nasal mucosa for nasal mucosa. 544
redness, swelling,
growth or discharge No visible masses,
lesions. Presence of lesions in
Pa: tenderness, client nasal mucosa
masses, displacements; (polyps) is considered
abnormal findings
No tenderness on according to Kozier-
: nasal patency frontal sinuses fundamentals of
: maxillary and frontal nursing-10th-edition by
sinuses for Edz Balendez, page
tenderness 545
Pe: the above sinuses No tenderness showed
for tenderness normal finding as
Transillumination Test reported by Kozier-
\Mouth / Oropharynx Normal lip tissue ought fundamentals of
I: lips for symmetry of to be versatile, smooth nursing-10th-edition by
contour, color, texture, and have a Edz Balendez, page
moisture, lesion homogenous pink tone, 545
moisturized with no
lesions. Client lips is uniform
pink color soft, moist,
smooth texture
Symmetry of contour
indicates normal
findings stated by
Teeth ought to be Kozier-fundamentals of
: teeth for alignment, perfect with no decay, nursing-10th-edition by
loss, dental fillings white with glossy polish Edz Balendez, page
and smooth surfaces
 and caries; and edges. Adults to 546
have a sum of 32 teeth
and children have a Client has 8 missing
total of 20 deciduous teeth and has 4 dental
teeth filling resulted as
Gums should look pink abnormal findings as
and firm, not red and reported by Kozier-
: gums for bleeding, swollen. fundamentals of
color, retraction, nursing-10th-edition by
lesions, swelling Edz Balendez, page
547
No retraction of gum is
Tongue is symmetrical, a normal finding in
pink, moist, slightly relevance of Kozier-
: tongue for position, rough from the papillae, fundamentals of
color & texture; perhaps with a slender, nursing-10th-edition by
movement, as well as whitish covering Edz Balendez, page
the base of the 547
tongue, mouth floor Normal findings Central
and frenulum position
Pink color (some brown
pigmentation on
tongue borders in dark-
skinned clients);
moist; slightly rough;
thin whitish coating
Smooth, lateral
margins; no lesions
Raised papillae (taste
No swelling and buds) as stated in
redness in the gland Kozier-fundamentals of
: salivary gland ducts nursing-10th-edition by
for swelling, redness Edz Balendez, page
547

Absence of swelling
and redness in the area
 of salivary gland as
stated in Kozier-
fundamentals of
Visual examination with nursing-10th-edition by
a penlight shows a solid Edz Balendez, page
: palates for color, sense of taste as 549
shape, texture, whitish in color, with a
presence of bony firm surface and
prominences unpredictable cross
over rugae. Light pink, smooth, soft
palate is a normal
finding in accordance
It should be light pink, with Kozier-
smooth and upwardly fundamentals of
: uvula for position & versatile. The uvula nursing-10th-edition by
mobility should resemble a Edz Balendez, page
pendant in the midline 548
and ascend along the
soft palate. Normal finding
positioned in midline of
soft palate, rises
during vocalization in
It is generally color pink accordance with
and smooth. Kozier-fundamentals of
: oropharynx for color nursing-10th-edition by
& texture Edz Balendez, page
548

The has Pink and

smooth posterior wall
indicated normal finding
Are generally about the in accordance with
same size and have a Kozier-fundamentals of
: tonsils for color, similar pink tone as the nursing-10th-edition by
discharge, and size encompassing region. Edz Balendez, page
Test for Gag Reflex Grade 1 (normal): The 548
P: nodules, lump and tonsils are behind
 excoriated areas the tonsillar pillars (the
soft structures Pink and smooth and
supporting the soft no discharge and
palate). No any Grade 1 is considered
discharge, nodules, normal finding as
lump and damage area. stated in Kozier-
fundamentals of
Determine if there is nursing-10th-edition by
discomfort on Edz Balendez, page
swallowing. 548

NECK No abnormal swelling

Neck Muscles or masses, head
I: abnormal swelling or movement and muscle
masses, head strength.
movement, and
muscle strength

Client neck muscle is

coordinated, smooth
movements with
No enlargement in no discomfort is a
lymph nodes. normal finding in
Lymph Nodes relevance of Kozier-
P: enlargement fundamentals of
nursing-10th-edition by
Edz Balendez, page
551

No palpable lymph
nodes on client
No deviation or the assessment is normal
Trachea trachea is not pushed in finding in accordance
P: lateral deviation one side. with Kozier-
fundamentals of
nursing-10th-edition by
 Edz Balendez, page
551

Central placement in
midline of neck;
spaces are equal on
Symmetric, no masses, both sides is a normal
Thyroid Gland bruit and rises during finding in relevance of
I: symmetry and visible swallowing. It is soft Kozier-fundamentals of
masses, rise during and non-tender. nursing-10th-edition by
swallowing Edz Balendez, page
P: smoothness 552
A: bruit
Not visible during the
inspection is normal
THORAX & LUNGS Symmetric in the finding as stated in
Posterior Thorax position of spinal cord. Kozier-fundamentals of
I: shape & symmetry No misalignment and nursing-10th-edition by
from posterior-lateral spinal deformities. Edz Balendez, page
views; spinal 552
alignment for
deformities
Anteroposterior to
transverse diameter in
ratio of 1:2 and thorax
No bulges, tenderness symmetric is normal
and abnormal finding according to
movement. Kozier-fundamentals of
Pa: temperature, Equal and moderate nursing-10th-edition by
bulges, tenderness, vibrations are noticed Edz Balendez, page
abnormal movements, during speech. 556
respiratory
excursion, vocal Normal finding skin
fremitus intact; uniform
temperature Chest wall
intact; no tenderness;
no masses. Bilateral
 symmetry of vocal
fremitus. Fremitus is
heard most clearly at
the apex of the lungs.
According to Kozier-
Diaphragmatic fundamentals of
excursion measure nursing-10th-edition by
should be 3–5 cm Edz Balendez, page
during Palpation. 557
Pe: for symmetry of
resonance;
diaphragmatic Diaphragmatic
excursion excursion of client
measures 4.5 cm is a
No abnormal sounds normal finding in
such as Rales, relevance of Kozier-
Rhonchi, Stridor, fundamentals of
Wheezing. Breath nursing-10th-edition by
A: breath sounds sound is present Edz Balendez, page
558
Normal finding Breath
sound is present as
Normal chest shape, stated in Kozier-
with no noticeable fundamentals of
Anterior Thorax deformations, like a nursing-10th-edition by
I: breathing pattern, barrel chest, kyphosis, Edz Balendez, page
coastal and or scoliosis. 558
costovertebral angle

No muscle withdrawals
when relaxing. Calm,
Pa: respiratory unlabored breaths
excursion, tactile without really any
fremitus utilization of
Pe: symmetry of embellishment, neck, Diaphragmatic
resonance shoulder, or abs. An excursion of client
ordinary respiratory measures 4 cm is a
 cadence, with lapse normal finding in
accepting with regards relevance of Kozier-
to twice the length fundamentals of
motivation. nursing-10th-edition by
Breath sound is present Edz Balendez, page
with no any abnormal 558
sound.
A: breath sounds

Normal finding Breath

sound is present as
stated in Kozier-
fundamentals of
No pulsations & lifts or nursing-10th-edition by
heaves. Edz Balendez, page
Heart 558
I: precordium for
pulsations & lifts or
heaves Client has no
pulsations & lifts or
heaves and has normal
finding as stated in
No additional heart Kozier-fundamentals of
sounds other than S1, nursing-10th-edition by
S2. Edz Balendez, page
A: heart sounds (S1, 563
S2, etc.)
S1 and S2 heard at all
sites is normal finding
as stated in Kozier-
fundamentals of
nursing-10th-edition by
Velocity of the common Edz Balendez, page
Central Vessels: carotid artery is 30-40 563
Carotid Arteries cm/sec. No bruit.
P: volume, quality
A: bruit
Normal findings Full
pulsations, thrusting
quality. Quality remains
same when client
breathes, turns head,
and changes from
sitting to supine
position. No sound
heard on auscultation
According to Kozier-
No distention. Vein is fundamentals of
not visible nursing-10th-edition by
Jugular Veins Edz Balendez, page
I: distention 564

Jugular vein of client is

not visible showed
normal finding.
According to Kozier-
fundamentals of
nursing-10th-edition by
No change of color Edz Balendez, page
presence or 565
appearance of
superficial veins during
Peripheral Vessels Bueger’s Test
I: presence or Normal finding
appearance of Symmetric in size
superficial veins, Regain to its natural Limbs not tender stated
signs of phlebitis color within 2 seconds. in Kozier-fundamentals
*Buerger’s Test of nursing-10th-edition
by Edz Balendez, page
566
*Capillary Refill Immediate return of
color is resulted as
normal finding in
 relevance of Kozier-
fundamentals of
Symmetric in size, nursing-10th-edition by
contour or shape. No Edz Balendez, page
discoloration, retraction, 567
Breast & Axillae hypervascularity,
I: breast for size, swelling, edema. Skin uniform in color.
symmetry, contour or Usually rounded shape; Rounded shape;
shape, discoloration, slightly unequal in slightly unequal in size
retraction, size; generally is normal finding as
hypervascularity, symmetric in female. stated in Kozier-
swelling, edema fundamentals of
Equal for size, shape, nursing-10th-edition by
symmetry, color. No Edz Balendez, page
masses, lesions 569

: areaola for size,

shape, symmetry, color, The client has round or
surface characteristics, oval and bilaterally the
masses, lesions same and color brown
areola which is normal
No lesions, discharge as reported by Kozier-
and swelling. Nipples fundamentals of
are everted nursing-10th-edition by
Edz Balendez, page
: nipples for size, 569
shape, position, color, The client has round,
discharge, lesion everted, and equal in
size; similar in
color; soft and smooth;
both nipples point
in same direction. No
discharge and lesion
showed normal finding
No tenderness, as stated in Kozier-
masses, nodules, fundamentals of
discharge nursing-10th-edition by
 Edz Balendez, page
569
P: lymph nodes, No tenderness,
breast, areola & masses, nodules, or
nipples for nipple. Discharge is a
tenderness, masses, normal finding as
nodules, discharge showed by Kozier-
fundamentals of
Symmetric in color and nursing-10th-edition by
skin integrity. No Edz Balendez, page
hernia, distention 570.
(girth), movements
ABDOMEN associated w/ The skin integrity of the
I: skin integrity, contour respiration, peristalsis & client is symmetric with
& symmetry, hernia, aortic pulsations no hernia, distention
distention (girth), and unusual movement
movements while respiration and
associated w/ aortic pulsation is
respiration, peristalsis considered normal as
& aortic pulsations stated in Kozier-
fundamentals of
Normal bowel sounds nursing-10th-edition by
are present in 2 minute Edz Balendez, page
of auscultation Normal 573-574
bowel sounds occur
approximately every 10 Audible bowel sounds,
A: bowel, vascular, & seconds present within 3
peritoneal friction rub minutes of auscultation.
sounds According to Kozier-
fundamentals of
nursing-10th-edition by
Edz Balendez, page
No pain felt during 574
palpation.
Pe: all quadrants / The abdominal
regions for tympany and assessment performed
deviations to the client showed
Pa: light to deep normal finding as
palpitations ALL represented in Kozier-
quadrants from least fundamentals of
painful to most painful nursing-10th-edition by
for masses, Edz Balendez, page
tenderness, muscle 575
guarding; liver
(bimanual) and
bladder palpation
* Leopold’s Maneuver
for OB clients for
presentation, lie, No contractures,
engagement, attitude, fasciculations, tremors
position
MUSCULOSKELETAL The assessment
Muscles resulted normal finding
I: size, contractures, in relevance of Kozier-
fasciculations, tremors fundamentals of
Muscle has nursing-10th-edition by
smoothness of Edz Balendez, page
movement, strength. 578
Absence of flaccidity, The assessment
spasticity. resulted normal finding
P: tonicity, flaccidity, in relevance of Kozier-
spasticity, smoothness fundamentals of
of movement, strength nursing-10th-edition by
Edz Balendez, page
Strong structure, no 578-579
deformities, edema and
tenderness.
Deformities and
Bones tenderness or
swellingis not present
I: structure, deformity as resulted normal
P: edema, tenderness finding as reported by
Kozier-fundamentals of
nursing-10th-edition by
Edz Balendez, page
579

No Crepitation on client
joints is an abnormal
No swelling and finding as stated in
Joints tenderness, crepitation Kozier-fundamentals of
I: swelling and nodules. nursing-10th-edition by
P: tenderness, Edz Balendez, page
smoothness of 579
movement, swelling,
crepitation, nodules The client mental status
is normal finding in
NEUROLOGIC Able to answer relevance stated in
Mental Status questions without any Kozier-fundamentals of
- Language confusion and have nursing-10th-edition by
- Orientation good attention in Edz Balendez, page
- Memory listening and 583-588
- Attention Span / answering. Able to The client is completely
Calculation remember the things oriented during the
being asked. assessment that
resulted normal finding
in relevance stated in
Normal finding grade is Kozier-fundamentals of
Consciousness Level E4V5M6 nursing-10th-edition by
Glassgow Coma Scale Edz Balendez, page
583-588

In the client
assessment showed
that client has poor
eyes that considered
Cranial Nerves abnormal to the II Optic
- I to XII nerve, but on the rest
Able to execute and cranial nerve
follow the test on assessment turns out
Cranial Nerves I to XII normal finding as
without any problems. stated in Kozier-
fundamentals of
nursing-10th-edition by
Edz Balendez, page
590
 The assessment of the
client tested normal
finding in relevance of
Kozier-fundamentals of
Reflexes The plantar and nursing-10th-edition by
- Deep, superficial & abdominal reflex should Edz Balendez, page
pathologic be reflexive to the 584-588
touch.

- Neonatal Reflexes
(For Pedia)

Gross Motor/Balance Maintain balance w/o

* Walking Gait any signs of swaying
* Romberg and dizziness felt.
* Standing on 1foot w/
eyes closed
* Heel-toe walking

The assessment of the

client tested normal
finding in relevance of
Kozier-fundamentals of
Fine Motor nursing-10th-edition by
- Upper Extremities: Edz Balendez, page
* Finger-Nose Test Able to follow the action 587
* Alternate Supination & without confusion and
Pronation of hands on hesitation. The
knees movement should not
* Finger to Nose & to be stiff.
RN finger
* Fingers-to-fingers
* Fingers-to-thumb
- Lower Extremities:
* Heel down opposite
skin
* Toe / Ball of Foot to
RN’s finger

The assessment of the

client tested normal
finding in relevance of
Kozier-fundamentals of
Sensory Function nursing-10th-edition by
* Light/Deep Touch Edz Balendez, page
* Pain Sensation Able to identify the 587-588
* Temperature sensation felt correctly.
* Position / Kinesthetic
* Tactile Discrimination
GENITALS
*For males:
I: pubic hair for
distribution, amount,
characteristics
: penis shaft and glans
for lesions, nodules,
swelling, inflammation
: urethral meatus for
swelling,
inflammation,
discharge
: inguinal areas for
bulges or swelling
P: penis for
tenderness,
thickening, nodules
: scrotum for
appearance, size and
symmetry, and
underlying testes,
epididymis and
spermatic cord
: inguinal areas for
palpable bulge
* For females:
I: pubic hair
distribution, amount,
characteristics; its
areas for parasites,
 inflammation,
swelling, lesions
: clitoris, urethral and
vaginal orifices for
inflammation or
discharge
P: bartholin’s glands,
lymph nodes for
enlargement,
tenderness, swelling
* Internal Exam for OB
clients for cervical
dilation, effacement
and AP pelvic
diameter
RECTUM & ANUS
I: anus and surrounding
tissue for color,
integrity, lesions
P: anal spinchter
tonicity, nodules,
masses and
tenderness
: if male, prostate
gland for tenderness
: if female, cervix
through the anterior
rectal wall for
tenderness

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
B. Pulmonary
C. Cardiovascular
D. Hematologic
E. Immunologic
F. Gastrointestinal
G. Renal
H. Musculoskeletal
I. Reproductive
J. Integumentary

XII. Concept Maps

A. Theory-based Physiology (for 2nd year) / Pathophysiology (for 3rd year)
B. Client-based (only those facts related to the case are included)

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 Desired Untoward
- Classification
- 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 (minimum of 5 for 2nd year; minimum of 10 for 3rd year)
a.
b.
c.
d.
e.
f.
 g.
h.
i.
j.

2. Prioritization of Nursing Problems

Criteria Weight Multiplier Computation Justification
Nature and 3 Actual Problem 1 3/3 x 1 Situational Urgency
Extent 2 Risk / Potential based on:
1 Wellness State - ABC Principle
- Maslow’s HON
- Nursing Concept
Modifiability 2 Easily Modifiable 2 2/2 x 2 Availability of
1 Partially Modifiable resources and
0 Not Modifiable interventions(financial)
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 1 2/2 x 1 Client’s perception
attention and recognition of the
action problem
1 Not needing immediate
attention
0 Not perceived as a
problem/
condition needing change
TOTAL 5 Priority # 1

3. Plans for Nursing Actions

a. Nursing Care Plan
Assessment Diagnosis Planning Implementation Evaluation
Subjective: Problem r/t At the end of After 4 hours of
The client Etiology, w/ 4 hours of nursing care,
verbalized, Sign/symptom rendering goal was met /
“_______” (defining nursing care, unmet / partially
 characteristics) the client will met, as
be able to: evidenced by:
Objective: *Choose the 1.________ 1.
● PE Findings applicable:

● Lab 1. Actual Independent Rationale &

2. Probable Dependent Reference
Findings
3. Risk 2.________ Collaborative 2.
4. Syndrome
5. Wellness Dx Independent Rationale &
Dependent Reference
3.________ Collaborative 3.

Independent Rationale &

Dependent Reference
Collaborative

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

c. Discharge Plan
Medication Exercise Treatment Health OPD Diet Signs and
Education Follow-up Symptoms
Generic/Brand - Type - Nebulization - Pertinent - What - Limits - Things that
- Dose - Frequency - Chest Knowledge, - W/ whom - Inclusion need to be
- Frequency physiotherapy Skill, or - When reported
Attitude immediately to
 - Route - Physical / - Where primary care
- Time Occupational / provider
- Side effects Speech /
Psychotherapy

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)