Lanuza Demo Lab

A CASE OF:
A Pregnant Mother
PRESENTED BY:
BSN 205
Group 3
Magliba, Shannon Kimberly

Nuestro, Shella Mae C.
PRESENTED TO:
Ma’am Dancil
SUBMITTED ON:
NOVEMBER 19,2019
I. DEMOGRAPHIC PROFILE
Gender: Female
Name: Patient AA Birth Date: September 19, 1989
Address: Quiricada Street, Santa Cruz, Manila Race/ Ethnic Origin: Filipino
Age: 30 years old Educational Attainment:
Birth Place: Fabella, Manila Elementary Graduate
Religion: Roman Catholic Name of Live-in partner: NA
Occupation: NONE Financial Support: NA who
Civil Status: Single works at a Call Center
Number of Children: 3 GTPALM: 430030 Monthly Income: 15,000
Chief Complaints: Prenatal check-up
Date of Admission: N/A Room & Bed: N/A
Medical Insurance: N/A Physician: N/A
Admitting/ Final Diagnosis: Intrauterine

pregnancy in cephalic presentation
II. NURSING HEALTH HISTORY
A. History of Present Condition

Patient AA has mentioned that she has been wanting to get a prenatal checkup since
she found out she was pregnant with her fourth child; however, her first ultrasound was burned
in a fire and it was hard for them to get another one because they lacked money. AA
verbalized: ““Di pa ako nagpapacheck up kasi nasunog yung kailangan ko para sa
healthcenter nuon. Kulang din kami sa pambayad nuon para sa panglawang lab
assessments”. She was able to acquire another ultrasound and other lab assessments but
could not go to her local health center due to schedule conflicts. AA stated: ““Pabalik-balik ako
sa health center pero di pa ako nakapagcheck up ulit dahil sa nag-iiba na iskedul duon, ayoko
ko na bumalik duon.”
B. Past Health History

In regards to her past health history, patient AA mentioned that she has no allergies to
food, drugs, to objects, or other living creatures. She has no childhood illnesses and had the
following immunizations: hepatitis B, polio, and Tdap. AA has had no accidents or injuries
recently. In 2018, she was admitted in the hospital for a week due to a urinary tract infection.
AA mentions that she was given medication but is no longer aware of the name during the
interview. On the other hand, she mentions drinking buko juice to help with her urinary tract
infection. For the most part, AA mentions that she self- medicates. Specifically, AA said she
takes paracetamol if she has a fever.
C. Family History
Patient AA’s parents are both deceased due to a heart attack and died at the age of 56
and 57, respectively. She is the third eldest out of her seven siblings and has mentioned they
do not have any current illnesses. Her partner is 24 years old, and has no current illnesses or
past health conditions. AA and her partner have three children ages 13, 10, and 2,
respectively. She has stated no pregnancy complications with any of her currently living
children.
(FAMILY GENOGRAM)
56 57 Unknown Unknown
30 28 Unknown Unknown Unknown 24

34 30 27 23 22
LEGEND
Male Heart Attack
Female 13 10 2
Deceased
Client
D. OBSTETRICAL HISTORY
The patient is multigravida with an obstetrical score of Gravida 2 Para 1 (216). In March
2018 during her first pregnancy, curettage was done due to miscarriage that may be caused
by stress. For her second pregnancy, she had undergone checkup thrice in Jose Reyes
Memorial Medical Center. This February 27, episiotomy was done on the perineum area
during delivery. She was also given a local anesthesia to lessen the pain she felt. She was
also given Oxytocin, Tetanus Toxoid and Ferrous Sulfate while her child was given Hepa B
vaccine, BCG, OPV, Penta Hib and Measles immunization. Overall, she delivered a full-term
baby girl in cephalic presentation, with an apgar score of 8 and birth weight of 2300 grams
(SGA), in normal delivery with episiotomy in Jose Reyes Memorial Medical Center.
COMPUTATION:
LMP: May 19, 2019
EDC: February 26, 2020 (Based on Ultrasound)
AOG: ?
May 31-19 = 12
June 30
July 31
August 31
September 30
October 31
November 30
December 31
January 31
February 12- 22
281/ 7= 40.14
.14 x 7= 0.98
AOG:
40 weeks/ 1 day
III. GORDON’S HEALTH ASSESSMENT
A. Health Perception – Health Management Pattern
AA mentioned that she rates her health as 7/10. She mentioned, “Nag-iiba itsura ko
dahil sa pagbubuntis ko ngayon”, for the reason for her rating. She considers a healthy person
as someone who does not have any illness. Her usual health management routine for when
she is sick includes using her community resources or just medicating on her own. AA would
visit an albularyo, take medicine, and then rest. AA would just go to the hospital for
emergencies, like in 2018 for her UTI. She doesn’t have a routine for physical examination and
she does not perform routine self-breast exams. She doesn’t usually go to a health care
provider because she only goes when she is very sick. For her pregnancy checkups, it’s
difficult for her to go to the health care provider because they can only go when she has a
scheduled checkup. Her personal hygiene includes: brushing three times a day, trimming her
fingernails, and showering once a day during nighttime. She changes her clothes once she
showers but does not change it during the day. In addition, the client goes to her dentist only
during her prenatal checkups. Her last dental checkup was two years ago wherein she was
able to have dentures.Before her fourth pregnancy, the patient would drink 10 bottles of San
Miguel during occasions and smoke at least 5 sticks of Marlboro black every day. Since her
fourth pregnancy, she’s avoided these vices. To keep herself healthy, the patient doesn’t drink
anymore alcohol and doesn’t smoke cigarettes. On the other hand, she also doesn’t take any
vitamins for her and her baby.
INTERPRETATION: Deviation from Normal
ANALYSIS:
Health perception – health management pattern, describes patient’s self-report of health and
well-being, how patient manages health (e.g. frequency of health care provider visits,
adherence to therapies at home), knowledge of preventive health practices.
Some pregnancy problems arise, even in the healthiest of women. Prenatal care can help
prevent complications during pregnancy, helping to keep both the mother and the baby safe.
Tests done during pregnancy can help prevent problems or catch them early on. Getting early
and regular prenatal care can help you have a healthy and full-term pregnancy.
References: Hall, A., Perry, A.G., Potter, P., Stockert, P. (2018). Fundamentals of Nursing
Volume I (9th ed., page 212).
Singapore: Elsevier.
White Rose Women’s Center (Dec., 2017) Retrieved from:
https://whiterosewomenscenter.org/importance-of-prenatal-care/
B. Nutritional/ Metabolic
3-Day Diet Recall
Saturday (November 9, 2019)

Time Foods and Beverages Amount
6:00 AM Instant Coffee ½ cup
Pancit 1 serving
Water 1 ½ glass
1:00 pm Rice ½ cup
Meatloaf 1 piece
Water 1 ½ glass
8:00 PM Rice ½ cup
Meatloaf 1 piece
Water 1 ½ glass
Sunday (November 10, 2019)

Pandesal 2 pieces
Water 1 ½ glass
1:00 pm Rice ½ cup
Adobong Manok (Neck Part) 2 pieces
Water 1 ½ glass
8:00 PM Rice ½ cup
Adobong Manok (Neck Part) 2 pieces
Water 1 ½ glass
Monday (November 11, 2019)

Pandesal 4 pieces
Egg 1 piece
Water 1 ½ glass
1:00 pm Rice ½ cup
Sinigang na Pata 1 serving
Water 1 ½ glass
5:00 PM Rice ½ cup
Sinigang na Pata 1 serving
Water 1 ½ glass
According to the patient, she has a good appetite, though she only eats small portions
of food. Usually their food can last until dinner because they need to save it in order for them to
eat at least three times a day. In the past three days, the patient eats canned goods, bread,
adobong manok (neck part) and ½ cup of rice. The patient hasn’t been able to eat sinigang na
pata since they went in Valenzuela, in the house of her partner for the 40 th death anniversary
of his relative. The patient can take her food and drinks easily without experiencing any
discomfort. Aside from this, she mentioned that she doesn’t have any food allergies. With
regards to her fluid intake, the patient usually drinks 4 ½ glasses of water each day. Also, the
client mentioned that their water source is “mineral water” even though they live temporary in
“basketball court” as evacuation center because their house was burned by fire. With regards
to the food preparation, the patient is the one who is responsible in preparing the food for the
family and responsible for budgeting.
ANALYSIS:
During pregnancy, a woman must eat adequately to not only support her own nutrition
but also to supply enough nutrients so the fetus can grow. Adequate protein and calcium
intake is vital because so much of these are needed by the fetus to build a strong body
framework. Adequate protein may also help prevent complications of pregnancy such as
gestational hypertension or preterm birth. In addition, extra amounts of water are needed
during pregnancy to promote kidney function because a woman must excrete waste products
for two. Eight glasses of fluid daily is a common recommendation.
Reference: Pillitteri, A. (2014) Maternal and Child Health Nursing Vol.1 (7 th ed., pages 304 &
310)
C. Elimination
In the matter of bowel elimination, the patient eliminates three times a week. It is always
solid that somewhat soft and its color ranges from brown to dark brown, no matter what food
she eats. Along with this, she mentioned that there are no changes in her bowel habits, except
she felt pain in her hip area wherein she didn't know why it occurs whenever she was going to
eliminate. Other than that, she doesn’t experience any problems or difficulties when doing it.
Also, she doesn’t use any medications such as laxatives to enhance her bowel movement. In
terms of urinating, the patient usually urinates frequently meaning she usually felt the urge of
urinating time to time. The patient reports pain upon urinating with a pain scale of 5/10. In
addition, she reports discomfort and lower back pain especially when she was tired always
going back to comfort room just to urinate with a little amount of urine. With regards to its color,
it is yellow. As per laboratory exam, last November 9, 2019, she was positive for Urinary tract
infection which was also the cause of her confinement last 2018. Therefore, her partner bought
some buko juice because according to them it is the only thing that can help to treat her. Also,
the client doesn’t use any medication to enhance her urine output nor to relieve discomfort
during urination. On the other hand, the patient does not suffer from any body odor problems
or excessive perspiration.
ANALYSIS:
A UTI typically manifest as frequency and pain on urination. In pregnant woman
because the ureters dilated from the effort of progesterone, stasis of urine can occur. The
minimal presence of abnormal amounts of glucose that also occurs with pregnancy provides
an ideal medium for growth for any organism present. Combined, these factors cause
asymptomatic urinary tract infections and these asymptomatic infections are potentially
dangerous because they can progress to pyelonephritis and are associated with preterm labor
and premature rupture of membranes.
Reference: Pillitteri, A. (2014) Maternal and Child Health Nursing Vol.1 (7 th ed., pages 525)
D. Activity and Exercise

3- Day Activity/Diary Recall
Saturday (November 9, Activities

2019)
6:00 am Woke up
7:00 am Ate breakfast
9:00 am Went to market
10:00 am Cook for the family
10:30 am Clean the house
1:00 pm Ate lunch and washing of dishes
1:30- 4:00 pm Sleeping (Naps)
6:00 pm Cook for the family
8:00 pm Ate dinner
8:30 pm Washing of dishes
9:00 pm Took a bath
9:30 pm Scrolling on Facebook
10:00 pm Went to bed
Sunday (November 10, Activities
2019)
6:00 am Woke up
9:00 am Went to market/ Cook for the family
10:00 am Went to church
1:30 pm Watching children
8:00 pm Ate dinner
8:30 pm Washing of dishes
9:00 pm Took a bath
9:30 pm Went to Valenzuela
11:00 pm Arrived and Went to bed
Monday (November 11,

2019) Activities
6:00 am Woke up
10:00 am Cook for the family
1:30 pm Watching children
5:00 pm Ate dinner
7:00 pm Took a bath
8:00 pm Went back to Manila
11:00 pm Went to bed
In a typical day, the patient’s activities include: cooking, washing dishes, cleaning,
watching her and her siblings’ children and surfing the net. As verbalized by the client, she still
able to travel despite her condition. In fact, last Sunday, November 10, 2019, the client and her
partner went to Valenzuela for the 40 th death anniversary of the relative of her partner. Before
the client got pregnant, she is physically active and does not have any difficulties upon
performing these activities except for the time she got pregnant but, as said by the patient, she
can still manage to do her daily activities.
INTERPRETATION: Normal
ANALYSIS:
Regular activity and exercise contribute to patient's physical and emotional wellbeing. It
also has the potential to enhance all aspects of patient’s health. An active lifestyle is important
for maintaining and promoting health; it is also an essential treatment for chronic illness.
Regular physical activity and exercise enhance functioning of all body systems, including
cardiopulmonary functioning, musculoskeletal fitness, weight control and maintenance, and
psychological well-being.
Reference: Hall, A., Perry, A.G., Potter, P., Stockert, P. (2018). Fundamentals of Nursing
Volume II (9th Ed.). Singapore: Elsevier.. Page 787-788.
E. Cognitive/ Perceptual
The client doesn’t wear eyeglasses and she doesn’t experience any problems in
regards to her vision. However, the patient has trouble when it comes to hearing. According to
her, she has difficulty in comprehending what other people are saying even if she is face- to-
face with that person. As a result, she often misunderstands what people are telling her and
needs them to repeat what they are saying. The patient has no report of using any hearing
aids and she doesn’t experience any ringing or any noise in her ears. However, she feels like
the right side of her ear is filled with water. AA also mentioned that she knows that she is hard
of hearing. She verbalized that she does not make any move just to resolve this problem like
paying check up to it. In addition, the client stated that she becomes forgetful and sometimes,
she experiences difficulties in processing her thoughts and remembering events.
ANALYSIS:
Clients with impaired hearing have difficulty understanding speech. Factors that
influence this difficulty are the environment, the rate of speech, and presence of accent.
Research indicates that the ability to process the fast verbal information is lower and that rapid
speech allows for less time to recognize the auditory cues of speech. In addition, mental status
is critical to any evaluation of the sensory perceptual process. Usually data on mental status
including level of consciousness, orientation, memory and attention span. It is important to
note the sensory alterations can cause changes in cognitive functioning.
Reference: Kozier & Erbs (2008) Fundamentals of Nursing Vol. 2 (8 th ed., page, 984, 992-993.
F. Sleep and Rest
3-Day Sleep Diary
SATURDAY SUNDAY MONDAY

Time went to bed 10:00 pm 11:00 pm 11:00 pm
Approximate time 10:30 pm 11:15 pm 11:15 pm
feel asleep
Wake up period/ It depends when she It depends when she It depends when
sleep interruptions felt to urinate felt to urinate she felt to
(How long) urinate
Time woke up the 6:00 am 6:00 am 6:00 am
next morning
Feeling after waking Relaxed and Relaxed and Relaxed and
up sometimes restless sometimes restless sometimes
restless
Naps ( time slept & 1:30 pm- 4:00 pm NONE NONE
woke up; duration) Total of 2 hours and
30 minutes
Activities done before Took a bath Took a bath Took a bath
bedtime
Bedtime rituals Scrolling on NONE NONE
Facebook (went to Valenzuela) (Went back to
Manila)
As reported by the client, she usually sleeps around 10:00 or 11:00 in the evening and
wakes up at 6 o’ clock in the morning with the total sleep of 7-8 hours. Between her sleep, she
feels a sleep disturbance because of an urge to urinate. She finds it difficult to have a heavy
sleep, especially since she is pregnant. The patient usually experiences having dreams during
her sleep and she doesn’t able to recall what her dream is all about. As verbalized by the
client, she felt restless and sometimes relaxed when she woke up in the morning. The patient
also reported that sometimes, she takes afternoon naps when she was not busy. Usually
around 1:30 to 4:00 pm. The patient doesn’t use any medications to enhance her sleeping
pattern.
ANALYSIS:
According to Potter and Perry young adults sleeps at an average of 6-8 1/2. hours.
Pregnancy increases the need for sleep and rest. However, a majority of pregnant women
describes variations in sleep habits. Increase in Estrogen and progesterone during pregnancy
affects sleep. Insomnia, periodic limb movements, RLS and sleep disordered breathing are
common problems during the third trimester of pregnancy. In addition, Sleep deprivation during
pregnancy is associated not only with fatigue in the woman but also with the possibility of
growth restriction in her fetus. To obtain enough sleep and rest during pregnancy, pregnant
women may need to begin to sleep earlier in the evening as well as schedule a rest period
during the afternoon.
Reference: Pillitteri, A. (2014) Maternal and Child Health Nursing Vol.1 (7 th ed., pages 280)
Hall, A., Perry, A.G., Potter, P., Stockert, P. (2018). Fundamentals of Nursing Volume II (9 th
ed., page 998)
G. Self-Perception/ Self Concept
The client says that she is not content with herself because of other people especially
when she feels people judging her. She says that she often feels jealous of others because
they have the things that she doesn’t have. AA stated, “Nararamdaman ko na jinijudge ako
ng ibang tao. Tapos nagseselos ako na naiirita kasi may mga bagay sila na wala ako ”. She
perceives that she will able to have a normal pregnancy since she’s had three prior normal
pregnancies with three healthy babies.
ANALYSIS:
Self-concept is an individual’s view of self. It is subjective and involves a complex
mixture of unconscious and conscious thoughts, attitudes, and perceptions. Self-concept, or
how a person thinks about oneself, directly affects self-esteem, or how one feels about
oneself. A positive self-concept gives a sense of meaning, wholeness, and consistency to a
person. A healthy self-concept has a high degree of stability, which generates positive
feelings toward self.
Volume II (9th ed., page 701&703). Singapore: Elsevier.
H. Role/ Relationship
The client stated that she is living with her family, particularly with her partner and their
children. Also, the client stated that she was living under one roof with her siblings. The
patient’s role in the family is to take care of her children, budgeting for her family’s groceries,
and cooking for the family. She doesn’t have much problems with her family members, aside
from when there are arguments. In those cases, she tends to go to her siblings or her
partner and asks for their help. On the other hand, they usually bond by eating with each
other or taking care of each other’s children. She does not often feel lonely or sad and she
has close friends as well. Despite having close friends and siblings, she usually prefers
being on her own although she understands that she needs others especially during times of
difficulties.
ANALYSIS:
Role performance relates what a person in a particular role does to the behaviors
expected of that role. Role mastery means that a person’s behaviors meet social
expectations. Expectations, or standards of behavior of a role, are set by society, or a
smaller group to which a person belongs. Each person has several roles, such as husband,
parent, brother, son, and etc. To act appropriately, people need to know who they are in
relation to others and what society expects for the positions they hold. Role conflicts arise
from opposing or incompatible expectations. Role conflict can lead to tension, decrease in
self-esteem, and embarrassment if needs for achievement, independence, and recognition
are unmet.
References: Berman, A. Snyder, S. Kozier, B. & Erb, G. (2007). Fundamentals of Nursing

volume II (8th ed., page 1006). Pearson.
I. Sexuality- Reproductive Pattern

The patient is a heterosexual female. She had her menarche at the age of 14 years old.
Prior to her pregnancies, she would have a 30- day menstrual cycle. Her menses last for
about 3 days, which are heavy in flow, and consume about 5 pads a day with no associated
dysmenorrhea. The patient mentioned that her last menstrual period was July 1st of 2019.
During her pregnancy, she has been experienced bleeding for 3 times without knowing the
cause. She had her coitarche at age 16 and had 1 sexual partner. Her current partner is her
live-in partner, who’s had 1 sexual partner before her. AA mentioned that prior to her
pregnancy, her and her partner would engage in intercourse once every month. She used to
use condoms and was on the pill during this time. The patient is multigravida with an
obstetrical score of (430030). Her previous pregnancies were all normal spontaneous delivery
and occurred when the baby was full term. She mentioned no pregnancy complications for
her 3 prior children.
ANALYSIS:
Sexuality is part of a person’s personality and is important for overall health. People
who are sexually healthy have a positive and respectful approach to sexuality and sexual
relationships. On low young adults have matured physically, they continue to explore and
mature emotionally in relationships. intimacy and sexuality are tissues for all young adults
whether they are in a sexual relationship, choose to abstain from sex, remain single by
choice, are homosexual, or are widow. People are socially healthy in numerous ways. Sexual
activity is often defined as a basic need, and healthy sexual desire is channeled into forms of
intimacy throughout a lifetime. At times young adults require support and education or therapy
to achieve mutually satisfying sexual relationships.
Volume II (9th ed., page 716 and 717). Singapore: Elsevier.
J. Coping – Stress Tolerance Pattern

In terms of stress, the client often becomes stressed because of her children when they
do not follow her commands. AA stated, “sinisigawan ko sila kapag di sila sumusunod sa utos
ko”. The patient is also stressed because they have recently lost their home to a fire. AA
mentions that this has been a big stressor in her and her family’s lives as of late and
mentions, “medyo stress nga ako sa nangyari saamin”. Her and her family are currently living
outside on a community sports area with other families who have also been affected by the
fire. They live in an open area. Despite the closeness of her living area to her past home, AA
mentions she hopes to have her family home rebuilt soon. AA verbalized, “hindi ako sanay na
natutulog dito sa court”. She does not take any stress pills and considers herself as an
introvert. Instead, she copes with her stress by sleeping or resting. Sometimes, she has
trouble sharing her problems because she’s afraid that she will be judged by others.
Otherwise, she confides in her partner, siblings, or deals with it on her own.
ANALYSIS:
Coping strategies vary among individuals and are often related to the individual's
perception of the stressful event. Short-term coping strategies can reduce stress to a tolerable
limit temporarily but are in the end ineffective ways to deal with reality. They may even have a
destructive or detrimental effect on the person. Examples of short-term strategies are using
alcoholic beverages or drugs, daydreaming and fantasizing, relying on the belief that
everything will work out, and giving in to others to avoid danger.
Volume II (9th ed., page 1014). Singapore: Elsevier.
K. Value – Belief Pattern
The patient is Roman Catholic and she stated that being part of it is important not only
to her but also to her family. She celebrates traditions and practices like Christmas, Holy
Week, All Saint’s Day, etc. She also goes to church however; she can’t comply to attend every
Sunday because of lack of time. Usually, she went to church at least two times in a month.
Having faith in their religion helps them a lot, especially during their hardships and struggles
wherein through their faith, they give them strength to surpass their challenges. In addition,
she has no beliefs that impede her quality of health. Prior to having their fourth child, she was
praying for a successful delivery and a healthy baby. She plans to live long enough and take
care of herself so that she can able to see her child to grow.
ANALYSIS:
Religion is associated with the state of doing, or a specific system of practices with a
particular denomination, sect, or form of worship. Faith allows people to have firm’s beliefs
despite lack of physical evidence. It enables them to believe in establish trans-personal
connections.
Reference: Hall, A., Perry, A.G., Potter, P., Stockert, P. (2018). Fundamentals of nursing
Volume II (9th Ed.). Singapore: Elsevier. 734-735.
IV. MEASUREMENTS (HEIGHT, WEIGHT, BMI, VITAL SIGNS)
Measurements
MEASUREMENTS NORMS FINDINGS INTERPRETATION
1. Weight 40- 50kg 45 kg
2. Height 146 cm 146 cm
NORMAL
≥ 18.5 –
3. BMI 21.1
24.9
NORMAL
According to Marple, K. (n.d.) the average

fetal height and weight of an 18 week fetus
is 14.2 cm long (from the crown to rump)
14 cm long
and weighs approximately 190 grams.
(for four (below
4. Fundic Height
months) umbilicus) Reference: Marple, K. “Growth chart: Fetal
length and weight, week by week”.
Retrieved from:
https://www.babycenter.com/average-fetal-
length-weight-chart
VITAL SIGNS
MEASUREMENTS NORMS FINDINGS INTERPRETATION

DEVIATION
“A pregnant woman's
core body temperature
will often rise to about
37.8°C, when it is
normally 37°C.”
Early pregnancy
symptoms: Blood flow.
1. Temperature 36– 37.5 °C 35.2°C
(2017, July 3). Retrieved
from
https://www.kidspot.com
.au/birth/pregnancy/sign
s-and-symptoms/early-
pregnancy-symptom-
blood-flow/news-
story/16ebd0a06cf161a
6a50f8807c72b10c1.
NORMAL
2. Pulse Rate 60-100 bpm 78bpm
3. Respiratory Rate 18 - 25 rpm NORMAL

17 rpm
4. O2 Saturation 95 – 100% 99% NORMAL
V. PHYSICAL ASSESSMENT
A. GENERAL SURVEY
Appearance and Mental Status
ASSESSME NORMS FINDINGS INTERPRETATION

NT
Sign of Sign of distress in facial DEVIATION FROM

distress in No distress noted expression, specifically: NORMAL
posture or “sometimes obvious
facial -frowning signs or symptoms
expressions Indicate pain, difficulty
-forehead wrinkling breathing, or anxiety”
(Potter and Perry,
2018, p. 541).
Body Built, Proportionate, varies with The patient’s body built is NORMAL
Height, and lifestyle mesomorph. Has a BMI
Weight in within normal range
relation to (21.1).
the client’s
age, lifestyle
and health
Client’s Relaxed, erect posture and The patients’ movement is NORMAL

Posture and coordinated movement coordinated, posture of
gait, straight upper back while
standing, shoulder and hip are “Posture is the
sitting and aligned position in which you
walking hold your body while
standing, sitting, or
lying down. Good
posture during
pregnancy involves
training your body to
stand, walk, sit, and lie
in positions where the
least strain is placed
on your back.To
counteract the
increased low back
curve, straighten
your upper back so
that your ear,
shoulder and hip are
aligned. Tuck your
pelvis under using
the pelvic tilt.”
(Posture During
Pregnancy. (n.d.).
Retrieved from
https://my.clevelandcli
nic.org/health/articles/6
913-pregnancy-
correct-posture--body-
mechanics.)
Overall Clean, neat The patient is dirty and DEVIATION FROM

hygiene and clothes are unkempt NORMAL
grooming during time of interview
(afternoon). “Grooming depends on
the patient’s cognitive
and emotional
function, daily or social
activities, and
occupation.” (Potter
and Perry, 2018, p.
542).
Body and No body/breath odor or minor There is no foul or unusual NORMAL

breath odor body odor relative to work or odor noted.
exercise
Signs of
health and Healthy Appearance The patient does not look DEVIATION FROM
illness healthy. NORMAL
“A general survey, or
appraisal, of the
patient’s presentation
and behavior provides
information about the
characteristics of an
illness, the patient’s
ability to function
independently, body
image, emotional,
state, recent changes
in weight, and
development status.”
(Potter and Perry,
2018, p. 541)
Client’s Cooperative The patient is cooperative NORMAL
Attitude
Client’s
affect/mood; Appropriate to situation The affect/mood of the DEVIATION FROM
assess the patient is not consistently NORMAL
appropriate appropriate to the
ness of the situation. “Affect is how a person
client’s appears to others.
responses Patient expresses
mood or emotional
state verbally and
nonverbally.” (Potter
and Perry, 2018, p.
541)
Quantity, Understandable, moderate The patient’s organization DEVIATION FROM

Quality, and pace, and exhibits thought of speech, quantity and NORMAL
organization association quality is only somewhat
of speech understandable, in slow “Normal speech is
pace and exhibits understandable and
occasional unclear moderately paced and
thought association. shows an Association
with the person’s
thoughts. However,
emotions or
neurological
impairment sometimes
cause rapid or slowed
speed” (Potter and
Perry, 2018, p. 541)
SKIN
ASSESSME NORMS FINDINGS INTERPRETATION

NT
Inspect skin Varies from light to deep Brown skin NORMAL
color brown, from ruddy pink to
light pink
Inspect Generally, uniform except in Skin color is uniform NORMAL

uniformity of areas exposed to sun; areas except to the area not
skin color. of lighter pigmentation in exposed to sun.
dark skinned
Inspect, Freckles, some birthmarks, Scar is present at right DEVIATION FROM

palpate, and some flat and raised nevi, no leg. Other than that, no NORMAL
describe skin abrasion or other lesion other skin lesions is seen
lesions “Scars are a natural
part of the healing
process. Most will fade
and become paler over
time, although they
never completely
disappear.”
Reference: (n.d.).
Retrieved from
https://www.nhsdirect.
wales.nhs.uk/
encyclopaedia/s/article
/scars.
Observe and Moisture in skin folds and the Smooth and dry. NORMAL
palpate skin axillae, affected by different
moisture. factors
Palpate skin Uniform; within normal range Skin temperature is NORMAL
temperature uniform.
Palpate to No edema No edema is seen. NORMAL
assess for
presence of
edema
Palpate to When pinched, skin springs It springs back after it NORMAL
assess for back to previous state pinched.
skin turgor
HAIR
Inspect the Evenly distributed hair Evenly distributed hair NORMAL
evenness of
growth over
the scalp
Inspect hair Thick hair Thin DEVIATION FROM
thickness or NORMAL
thinness
“Thinning hair refers to
minor to moderate hair
loss. Unlike
widespread hair loss,
thinning hair doesn’t
necessarily cause
baldness. It does,
however, give the
appearance of thinner
spots of hair on your
head.”
Reference: Cherney,
K. (2019, October 7).
Thinning Hair:
Treatment, Vitamins,
and More. Retrieved
from
https://www.healthline.
com/health/thinning-
hair.
Inspect hair Silky, resilient hair Hair is somewhat dry and DEVIATION FROM
texture and brittle NORMAL
oiliness “Poor nutrition causes
stringy, du, dry and
thin hair”. (Potter and
Perry, 2018, p. 551)
Note No infection or infestation Presence of dandruff DEVIATION FROM

presence of NORMAL
infections or “Dandruff or psoriasis
infestations frequently causes
scariness or dryness of
scalp” (Potter and
Perry, 2018, p. 551).
Inspect the Variable Variable NORMAL
amount of
body hair.
NAILS
Inspect Convex curvature; The fingernail has convex NORMAL
fingernail angle between nail and nail curvature with an angle of
plate shape bed usually 160° 160°
Inspect Highly vascular and pink in Fingernail is highly NORMAL
fingernail and light skinned; dark skinned vascular and bed color is
toenail bed may be brown or black pink
color
Inspect Smooth, Intact, no It is smooth, intact and no NORMAL
tissues inflammation inflammation
surrounding
nails
Palpate Smooth It is smooth NORMAL
fingernail and
toenail
texture
Perform Prompt return or pink or Prompt return to its usual NORMAL
blanch test of usual color, less than four color, less than four
capillary refill seconds seconds
HEAD AND NECK
ASSESSMENT NORMS FINDINGS INTERPRETATION
Inspect the Head Head size and shape Head is symmetric, NORMAL
size, shape, and vary, especially in accord round, erect, and in
configuration. with ethnicity. Usually the midline and
head is symmetric, round, normocephalic. No
erect, and in midline and lesions are visible.
appropriately related to
body size
(normocephalic). No
lesions are visible.
Inspect for Head should be held still No involuntary head NORMAL

involuntary and upright. movement observed.
movement.
Palpate the head The head is normally The head is hard, NORMAL
consistency. hard and smooth, without smooth, and free of
lesions. lesions.
Inspect the face, The face is symmetric The face is symmetric NORMAL
symmetry, with a round, oval, with a round appearance.
features, elongated, or square No abnormal movements
movement, appearance. No noted. Skin is intact.
expression, and abnormal movements
skin condition noted.
Palpate the The temporal artery is The temporal artery is NORMAL

Temporal Artery. elastic and not tender. elastic and not tender.
Palpate for the Normally there is no There is no swelling, NORMAL

Temporal swelling, tenderness, or tenderness, or crepitation
Mandibular Joint crepitation with with movement. Mouth
(TMJ). movement. Mouth opens opens and closes fully (3
and closes fully (3 to 6 cm between upper and
cm between upper and lower teeth). Lower jaw
lower teeth). Lower jaw moves laterally 1 cm in
moves laterally 1 to 2 cm each direction.
in each direction.
NECK
Inspect the neck Neck is symmetric, with Neck is symmetric to NORMAL

position, head centered and head. No bulging masses
symmetry, and for without bulging masses. found.
lumps or masses.
Inspect The thyroid cartilage, The thyroid cartilage, NORMAL
movement of the cricoid cartilage moves cricoid cartilage moves
neck structures. upward symmetrically as upward symmetrically as
the client swallows. the client swallows.
Inspect the C7 (vertebrae prominent) C7 is visible and NORMAL

cervical is usually visible and palpable.
vertebrae. palpable.
Inspect range of Normally neck movement Neck movement is DEVIATION FROM

motion. should be smooth and smooth and controlled NORMAL
controlled with 45-degree with 45-degree flexion,
flexion, 55-degree 35-degree Neck pain is relatively
hyperextension, 40- hyperextension, 30- common and usually
degree lateral abduction, degree lateral abduction, presumed to be
70-degree rotation. 60-degree rotation. musculoskeletal in
origin. A patient
presented with an
usual and serious
cause of neck pain-
malignant
hypertension.
(Stockwell & George,
1997).
Palpate the Trachea is midline. Trachea is midline. NORMAL

trachea.
Palpate the Landmarks are Landmarks are NORMAL

thyroid gland. positioned midline. positioned midline.
Glandular thyroid tissues Glandular thyroid tissues
may be felt rising may be felt rising
underneath your fingers. underneath your fingers.
Lobes should feel Lobes should feel
smooth, rubbery, and free smooth, rubbery, and free
of nodules. of nodules
Auscultate the No bruits are auscultated. No bruits auscultated. NORMAL

thyroid only if you
find an enlarged
thyroid
Palpate the lymph There is no swelling or There is no swelling or NORMAL

nodes. enlargement and no enlargement and no
tenderness. tenderness.
EYES
Test distant visual Normal distant visual Normal distant visual NORMAL
Acuity. acuity is 20/20 with or acuity is 20/20 with and
without corrective without corrective lenses
lenses. This means that on both eyes. Client
the client can distinguish wears no glasses.
what the person with
normal vision can
distinguish from 20 feet
away.
Test near visual Normal near visual Normal near visual NORMAL
Acuity. acuity is 14/14 (with or acuity is 14/14 (with or
without corrective without corrective
lenses). This means that lenses) on both eyes.
the client can read what Client wears no glasses.
the normal eye can read
from a distance of 14
inches.
Test visual fields for With normal peripheral Client sees the NORMAL
gross peripheral vision, the client should examiner’s finger at the
vision. see the examiner’s same time the examiner
finger at the same time sees it approximately as
the examiner sees it. follows:
Normal visual field • Inferior: 70 degrees
degrees are • Superior: 50 degrees
approximately as • Temporal: 90 degrees
follows:
• Nasal: 60 degrees
• Inferior: 70 degrees
• Superior: 50 degrees
• Temporal: 90 degrees
• Nasal: 60 degrees
NORMAL
Perform corneal The reflection of light on The reflection of light is
light reflex test. the corneas should be in symmetric on both sides
the exact same spot on of each eye.
each eye, which
indicates parallel
alignment.
NORMAL
Perform cover test. The uncovered eye The uncovered eye
should remain fixed remained fixed straight
straight ahead. The ahead. While the
covered eye should covered eye remained
remain fixed straight fixed straight ahead after
ahead after being being uncovered.
uncovered.
NORMAL
Perform the Eye movement should Eye movement is
positions test be smooth and smooth and symmetric
symmetric throughout all throughout all six
six directions. directions.
Inspect the eyelids The upper lid margin The upper lid margin is NORMAL
and eyelashes for should be between the between the upper
width and position upper margin of the iris margin of the iris and the
of palpebral and the upper margin of upper margin of the
fissures. the pupil. The lower lid pupil. The lower lid
margin rests on the margin rests on the
lower border of the iris. lower border of the iris.
No white sclera is seen No white sclera is seen
above or below the iris. above or below the iris.
Palpebral fissures may Palpebral fissures are
be horizontal.
horizontal.
The upper and lower The upper and lower lids
Assess ability of lids close easily and close easily and meet NORMAL
eyelids to close. meet completely when completely when closed.
closed.
Note the position of The lower eyelid is The lower eyelid is NORMAL
the eyelids in upright with no inward or upright with no inward or
Comparison with outward turning. outward turning.
the eyeballs. Eyelashes are evenly Eyelashes are evenly
distributed and curve distributed and curve
Also note any
outward along the lid outward along the lid
unusual
margins. margins. No unusual
• Turnings turnings, color, swelling,
• Color lesions, or discharge.
• Swelling
• Lesions
• Discharge
Observe for Skin on both eyelids is Skin on both eyelids is NORMAL

redness, swelling, without redness, without redness,
discharge, or swelling, or lesions. swelling, or lesions.
lesions.
Observe the Eyeballs are Eyeballs are NORMAL

position and symmetrically aligned in symmetrically aligned in
alignment of the sockets without sockets. Eyeballs are
eyeball in the eye protruding or sinking. neither protruding or
socket. sinking.
Inspect the bulbar Bulbar conjunctiva is Bulbar conjunctiva is NORMAL

conjunctiva and clear, moist, and clear, moist, and
sclera for clarity, smooth. Underlying smooth. Underlying
color, and texture. structures are clearly structures are clearly
visible. Sclera is white. visible. Sclera is white.
Inspect the The lower and upper The lower and upper NORMAL
palpebral palpebral conjunctivae palpebral conjunctivae
conjunctiva. are clear and free of are clear and free of
swelling or lesions. swelling or lesions.
Evert the upper Palpebral conjunctiva is Palpebral conjunctiva is NORMAL

eyelid. free of swelling, foreign free of swelling, foreign
bodies, or trauma. bodies, or trauma.
Inspect the lacrimal No swelling or redness No swelling or redness NORMAL

apparatus. should appear over appear over areas of the
areas of the lacrimal lacrimal gland. The
gland. The puncta are puncta are visible
visible without swelling without swelling or
or redness and is turned redness and is turned
slightly toward the eye. slightly toward the eye.
Palpate the lacrimal No drainage should be No drainage observed. NORMAL

apparatus. noted from the puncta
when palpating the
nasolacrimal duct.
NORMAL
Inspect the cornea The cornea is The cornea is
and lens. transparent, with no transparent. Cornea and
opacities. The oblique lens have no opacities
view shows a smooth and are smooth.
and overall moist
surface; the lens is free
of opacities.
NORMAL
Inspect the iris The iris is typically The iris is round, flat,
shape and color round, flat, and evenly and dark brown. The
and pupil for size colored. The pupil, pupil is round with a
and shape. round with a regular regular border, is
border, is centered in centered in the iris.
the iris. Pupils are Pupils are size (3 mm)
normally equal in size (3 equally.
to 5 mm). An inequality
in pupil size of less than
0.5 mm occurs in 20%
of clients. This
condition, called
anisocoria, is normal.
Test pupillary The normal direct Direct pupillary response NORMAL

reaction to light. pupillary response is is constriction.
Test for direct constriction.
response by
darkening the room
and asking the
client to focus on a
distant object
Assess consensual The normal consensual Consensual response is NORMAL

response at the pupillary response is constriction.
same time as direct constriction.
response
Test The normal pupillary Pupillary response is NORMAL

accommodation of response is constriction constriction of the pupils
pupils. of the pupils and and convergence of the
convergence of the eyes eyes when focusing on a
when focusing on a near near object.
object (accommodation
and convergence).
EARS
Inspect the auricle, Ears are equal in size Ears are equal in size NORMAL
tragus, and lobule bilaterally (normally 4– bilaterally (4cm). The
for size shape and 10 cm). The auricle auricle aligns with the
position. aligns with the corner of corner of each eye and
each eye and within a within a 10-degree angle
10-degree angle of the of the vertical position.
vertical position. Earlobes are attached.
Earlobes may be free,
attached, or soldered
(tightly attached to
adjacent skin with no
apparent lobe).
Continue inspecting
the auricle, tragus, The skin is smooth, with
and lobule. no lesions, lumps, or The skin is smooth, NORMAL
Observe for nodules. Color is without lesions, lumps,
lesions, consistent with facial or nodules. Color is
discolorations, and color. Darwin’s tubercle, consistent with facial
discharge. which is a clinically color. No Darwin’s
insignificant projection, tubercle. No discharge
may be seen on the present.
auricle.
No discharge should be
present.
Palpate the auricle Normally the auricle, Auricle, tragus, and NORMAL
and mastoid tragus, and mastoid mastoid process are not
process. process are not tender. tender.
Inspect the The tympanic The tympanic

tympanic membrane should be membrane is pearly, NORMAL
membrane pearly, gray, shiny, and gray, shiny, and
(eardrum) for color, translucent, with no translucent, with no
shape, consistency, bulging or retraction. It bulging or retraction. It is
and landmarks. is slightly concave, slightly concave,
smooth, and intact. A smooth, and intact.
cone-shaped reflection
of the otoscope light is
normally seen at 5
o’clock in the right ear
and 7 o’clock in the left
ear. The short process
and handle of the
malleus and the umbo
are clearly visible.
Inspect the external A small amount of No cerumen observed NORMAL

auditory canal for odorless cerumen after shining penlight in
discharge, color (Earwax) is the only ears.
and consistency of discharge normally
cerumen. present. Cerumen color
may be yellow, orange,
red, brown, gray, or
black. Consistency may
be soft, moist, dry, flaky,
or even hard.
Observe the color The canal walls should The canal walls are pink NORMAL
and consistency of be pink and smooth, and smooth, without
the ear canal walls without nodules. nodules.
and inspect the
character of any
nodules.
Perform the Able to correctly repeat With the grade of 0/6 DEVIATION FROM
Whisper Test. the two-syllable the patient can’t repeat NORMAL
Word as whispered. whispered words.
“A patient with hearing
loss often fails to
respond to
conversation. The 3
types of hearing loss
are conduction,
sensorineural, and
mixed.” (Potter and
Perry, 2018, p. 559)
Perform Weber’s Vibrations are heard Vibrations are not DEVIATION FROM
test equally well in both equally heard in both NORMAL
ears. No lateralization ears.
of sound to either ear. “Patient with normal
hearing hear sound
equally in both ears. In
conduction definite
sound is her best in
impaired year period in
sensorineural hearing
loss, sound is heard
better in normal ear.”
(Potter and Perry,
2018, p. 560)
Perform the Rinne’s Air conduction sound is Air conduction sound is DEVIATION FROM
test. normally heard longer shorter than bone NORMAL
than bone conduction conduction sound
sound R: (AC:2 > BC:8). “Patient should hear air
(AC > BC). L: (AC:5 > BC:10). conducted sound twice
as long as bone
conducted sound two to
one ratio”. (Potter and
Perry, 2018, p. 560).
Perform the Client maintains Client maintains position NORMAL

Romberg test. position for 20 seconds for 20 seconds with
without swaying or with minimal swaying.
minimal swaying.
MOUTH AND THROAT

Inspect the lip Lips are smooth and Lips are pale, dry DEVIATION FROM
consistency and moist without lesions or without lesions or NORMAL
color. swelling. swelling.
“Normally they are pink,
moist, symmetrical and
smooth. Lip color in
dark-skinned patients
varies from pink to
plum. (Potter and
Perry, 2018, pg. 562).
Inspect number, Thirty-two pearly whitish The client has 23 DEVIATION FROM
color, and condition teeth with smooth yellow-whitish teeth. NORMAL
of teeth, repairs, and surfaces and edges. Presence of tooth
the color and Upper molars should cavities (lower right “The formation of
consistency of rest directly on the molar, upper left molar dental caries is the
gums. lower molars and the teeth). result of the breakdown
front upper incisors Absence of teeth on of enamel by acids
should slightly override lower and upper gums. produced by bacteria
the lower incisors.
Client has six teeth that on the tooth surface.
Some clients normally
are dentures. Consequently, a dental
have only 28 teeth if the filling is necessary to
four wisdom teeth do prevent further
not erupt. No decayed damage.” (VanPutte,
areas; no missing teeth. C., Regan, J., Russo,
Client may have A., 2019, pg.443)
appliances on the teeth
(e.g., braces). Client
may have evidence of
repair work done on
teeth (e.g., fillings,
crowns, or cosmetics
such as veneers).
Gums are pink, moist,
and firm with tight
margins to the tooth. No
lesions or masses.
Inspect color and The buccal mucosa The buccal mucosa NORMAL
consistency of the should appear pink in appears pink in light-
buccal mucosa. light-skinned clients; skinned clients; tissue
tissue pigmentation pigmentation typically
typically increases in increases in dark
dark skinned clients. skinned clients.
Inspect color,
moisture, size, Tongue should be pink, Tongue is pink, moist, a NORMAL
texture, and moist, a moderate size moderate size with
fasciculations if with papillae (little papillae (little
present and palpate protuberances) present. protuberances) present.
for lesions. A common variation is a No lesions are present.
fissured, topographic
map–
Like tongue, which is
not unusual in older
clients. No lesions are
present.
Assess the ventral The tongue’s ventral The tongue’s ventral NORMAL
surface of the surface is smooth, surface is smooth,
tongue. shiny, pink, or slightly shiny, pink, or slightly
pale, with visible veins pale, with visible veins
and no lesions. and no lesions.
Palpate the area if The older client may N/A

you see lesions, if have varicose veins on
the client is over age the ventral surface of
50, or if the client the tongue
uses tobacco or
alcohol. Note any
induration.
Check also for a
short frenulum that
limits tongue motion
(the origin of
“tongue-tied”).
Inspect for The frenulum is midline; The frenulum is midline; NORMAL

Wharton’s ducts— Wharton’s ducts are Wharton’s ducts are
openings from the visible, with salivary visible, with salivary flow
submandibular flow or moistness in the or moistness in the
Salivary glands— area. The client has no area. The client has no
located on either Swelling, redness, or swelling, redness, or
side of the frenulum pain. pain.
on the floor of the
mouth.
Observe the sides of No lesions, ulcers, or No lesions, ulcers, or NORMAL

the tongue and nodules are apparent. nodules are apparent.
palpate for any
lesions, ulcers, or
nodules.
Check the strength The tongue offers The tongue offers NORMAL
of the tongue. strong resistance. strong resistance.
The hard palate is pale The hard palate is pale NORMAL
or whitish with firm, with firm, transverse
transverse rugae rugae. Palatine tissues
(wrinkle-like folds). are intact; the soft
Palatine tissues are palate is pinkish,
intact; the soft palate movable, spongy, and
should be pinkish, smooth
movable, spongy, and
smooth
Note odor. No unusual or foul odor No unusual or foul odor NORMAL

is noted is noted
Assess the uvula. The uvula is a fleshy, The uvula is a fleshy, NORMAL
solid structure that solid structure that
hangs freely in the hangs freely in the
midline. No redness of midline. No redness of
or exudate from uvula or exudate noted.
or soft palate. Midline
elevation of uvula and
symmetric elevation of
the soft palate.
A bifid uvula, common
in Native Americans,
looks like it is split in
two or partially severed
Inspect the tonsils. Tonsils may be present Tonsils are present. NORMAL
or absent. They are They are pink and
normally pink and symmetric and enlarged
symmetric and may be to 1+. No exudate,
enlarged to 1+ in swelling, or lesions are
healthy clients. No present.
exudate, swelling, or
lesions should be
present.
Inspect the posterior Throat is normally pink, Throat is pink, without NORMAL
pharyngeal wall. without exudate or exudate and lesions.
lesions.
NOSE

Inspect and palpate Color is the same as Color is the same as the NORMAL
the external nose for the rest of the face; the rest of the face; the
nasal color, shape, nasal structure is nasal structure is
consistency, and smooth and symmetric; smooth and symmetric;
tenderness. the client reports no the client reports no
tenderness. tenderness.
Check patency of air Client is able to sniff Client is able to sniff NORMAL
flow through the through each nostril through each nostril
nostrils while other is occluded. while other is occluded.
The nasal mucosa is The nasal mucosa is

Inspect the internal dark pink, moist, and dark pink, moist, and NORMAL
nose. free of exudate. The free of exudate. The
nasal septum is intact nasal septum is intact
and free of ulcers or and free of ulcers or
perforations. perforations.
Turbinate are dark pink Turbinate are dark pink,
(redder than oral moist, and free of
mucosa), moist, and lesions.
free of lesions.
SINUSES

Frontal and maxillary Frontal and maxillary
Palpate the sinuses. sinuses are non-tender sinuses are non-tender NORMAL
to palpation, and no to palpation, and no
crepitus is evident. crepitus is evident.
Percuss the sinuses. The sinuses are not The sinuses are not NORMAL
tender on percussion. tender on percussion.
POSTERIOR THORAX
Inspect Scapulae are symmetric Scapulae are symmetric NORMAL

configuration. and non-protruding. and non-protruding.
Shoulders and scapulae Shoulders and scapulae
are at equal horizontal are at equal horizontal
positions. The ratio of positions. The ratio of
anteroposterior to anteroposterior to
transverse diameter is transverse diameter is
1:2. Spinous processes 1:2. Spinous processes
appear straight, and appear straight, and
thorax appears thorax appears
symmetric, with ribs
sloping downward at symmetric, with ribs
approximately a 45- sloping downward at
degree angle in relation approximately a 45-
to the spine. degree angle in relation
to the spine.
Observe use of The client does not use The client does not use NORMAL
accessory accessory (trapezius/ accessory muscles to
muscles. shoulder) muscles to assist breathing.
assist breathing. The
diaphragm is the major
muscle at work. This is
evidenced by expansion
of the lower chest during
inspiration.
Inspect the Client should be sitting Client is sitting up NORMAL

client’s up and relaxed, breathing straight and relaxed,
positioning, easily with arms at sides breathing easily with
posture and or in lap. arms at sides or in lap.
ability to support
weight while
breathing
comfortably.
Palpate for Client reports no Client reports no

tenderness and tenderness, pain, or tenderness, pain, or NORMAL
sensation. unusual sensations. unusual sensations.
Temperature should be
equal bilaterally. Temperature is equal
bilaterally.
Palpate for The examiner finds no The examiner finds no NORMAL

crepitus. palpable crepitus. palpable crepitus.
Palpate surface Skin and subcutaneous Skin and subcutaneous NORMAL

characteristics. tissue are free of lesions tissue are free of lesions
and masses. and masses.
Palpate for Fremitus is symmetric Fremitus is symmetric NORMAL

fremitus. and easily identified in and easily identified in
the upper regions of the the upper regions of the
lungs. If fremitus is not lungs.
palpable on either side,
the client may need to
speak louder. A decrease
in the intensity of fremitus
is normal as the
examiner moves toward
the base of the lungs.
However, fremitus should
remain symmetric for
bilateral positions.
Assess chest When the client takes a When the client takes a
expansion. deep breath, the deep breath, the NORMAL
examiner’s thumbs examiner’s thumbs move
should move 5 to 10 cm 5 to 10 cm apart
apart symmetrically. symmetrically.
Percuss for tone. Resonance is the Resonance is the NORMAL

percussion tone elicited percussion tone elicited
over normal lung tissue. over normal lung tissue.
Percussion elicits flat Percussion elicits flat
tones over the scapula. tones over the scapula.
Excursion should be Excursion is equal
Percuss for equal bilaterally and bilaterally and measure 4
diaphragmatic measure 3–5 cm in cm. NORMAL
excursion. adults. The level of the
diaphragm may be higher
on the right because of
the position of the liver.
In well-conditioned
clients, excursion can
measure up to 7 or 8
cm.
Auscultate for Three types of normal Three types of normal

breath breath sounds may be breath sounds may be NORMAL
sounds. auscultated— bronchial, auscultated— bronchial,
bronchovesicular, and
vesicular bronchovesicular, and
vesicular
Auscultate for No adventitious sounds, No adventitious sounds, NORMAL

adventitious such as crackles such as crackles
sounds. (discrete and (discrete and
discontinuous sounds) or discontinuous sounds) or
wheezes (musical and wheezes (musical and
continuous), are continuous), are
auscultated. auscultated.
Auscultate voice Voice transmission is Voice transmission is

sounds. soft, muffled, and soft, muffled, and NORMAL
indistinct. The sound of indistinct.
Bronchophony the voice may be
heard but the actual
phrase cannot be
distinguished.
Egophony Voice transmission will Voice transmission is NORMAL

be soft and muffled but muffled but the letter “E”
the letter “E” should be is distinguishable
distinguishable
Whispered Transmission of sound is Transmission of sound is NORMAL

pectoriloquy very faint and muffled. It faint.
may be inaudible.
ANTERIOR THORAX
Inspect for shape The anteroposterior The anteroposterior NORMAL

and diameter is less than the diameter is less than the
configuration. transverse diameter. The transverse diameter. The
ratio of anteroposterior ratio of anteroposterior
diameter to the diameter to the
transverse diameter is transverse diameter is
1:2. 1:2.
Inspect position Sternum is positioned at Sternum is positioned at NORMAL

of the sternum. midline and straight. midline and straight.
Watch for sternal Retractions not Retractions not NORMAL

retractions. observed. observed.
Inspect slope of Ribs slope downward Ribs slope downward NORMAL

the ribs. with symmetric with symmetric
. intercostal spaces. intercostal spaces.
Costal angle is within 90 Costal angle is within 90
degrees. degrees.
Observe quality Respirations are relaxed, Respirations are relaxed, NORMAL

and effortless, and quiet. effortless, and quiet.
pattern of They are of a regular They are of a regular
respiration. rhythm and normal depth rhythm and normal depth
Note breathing at a rate of 10–20 per at a rate of 17 per
characteristics as minute in adults. minute.
well as rate, Tachypnea and
rhythm, and bradypnea may be
depth. normal in some clients.
Inspect No retractions or bulging No retractions or bulging NORMAL

intercostal of intercostal spaces are of intercostal spaces are
spaces. noted. noted.
Observe for use Use of accessory Use of accessory NORMAL

of accessory Muscles (sternomastoid muscles is not seen with
muscles. and normal respiratory effort.
rectus abdominis) is not
seen with normal
respiratory effort. After
strenuous exercise or
activity, clients with
normal respiratory status
may use neck muscles
for a short time to
enhance breathing.
Palpate for No tenderness or pain is No tenderness or pain is NORMAL

tenderness, palpated over the lung palpated over the lung
sensation, and area with respirations. area with respirations.
surface masses.
Palpate for Palpation does not elicit Palpation does not elicit NORMAL
tenderness at tenderness. tenderness.
costochondral
junctions of ribs.
Palpate for No crepitus is palpated. No crepitus is palpated. NORMAL

crepitus
Palpate for any No unusual surface No unusual surface NORMAL

surface masses masses or lesions are masses or lesions are
or lesions. palpated. palpated.
Palpate for Fremitus is symmetric Fremitus is bilaterally NORMAL

fremitus. and easily identified in symmetric and easily
the upper regions of the identified in the upper
lungs. A decreased regions of the lungs.
intensity of fremitus is There is a decreased
expected toward the intensity of fremitus
base of the lungs. toward the base of the
However, fremitus lungs.
should be symmetric
bilaterally.
Palpate anterior Thumbs move outward in

chest expansion. a symmetric fashion from Thumbs move outward in NORMAL
the midline. a symmetric fashion from
the midline.
Percuss for tone. Resonance is the Resonance is the NORMAL

percussion tone elicited percussion tone elicited
over normal lung tissue. over normal lung tissue.
Percussion elicits Percussion elicits
dullness over breast dullness over breast
tissue, the heart, and the tissue, the heart, and the
liver. Tympany is liver. Tympany is
detected over the detected over the
stomach, and flatness is stomach, and flatness is
detected over the detected over the
muscles and bones. muscles and bones.
Auscultate for Refer to text in the Normal breath and voice NORMAL
anterior posterior thorax section sounds heard.
breath sounds, for normal voice sounds.
adventitious
sounds,
and voice
sounds.
BREAST
ASSESSMENT NORM FINDINGS INTERPRETATION
FOR FEMALE Breasts can be a variety Breasts are small and NORMAL
BREASTS: of sizes and are symmetrical.
Inspect size and somewhat round and
symmetry. pendulous. One breast
may normally be larger
than the other.
NORMAL
Inspect color and Color varies depending Color is brown. Texture
texture and overall on the client’s skin tone. is
skin tone and Texture is smooth, with no edema.
lesions. smooth, with no edema.
Linear stretch marks
may be seen during and
after pregnancy or with
significant weight gain
or loss.
NORMAL
Inspect superficial Veins radiate either Veins are seen. It is
venous pattern for horizontally and toward horizontally and toward
visibility and the axilla (transverse) or the axilla
pattern of breast vertically with a lateral
veins. flare (longitudinal).
Veins are more
prominent during
pregnancy.
NORMAL
Inspect the areolas Areolas vary from dark Areolas are dark brown,
for color, size, pink to dark brown, round, and small. Small
shape, and texture. depending on the Montgomery tubercles
client’s skin tones. They are present
are round and may vary
in size. Small
Montgomery tubercles
are present.
Inspect the nipples Nipples are nearly Nipples are nearly equal NORMAL
for size and equal bilaterally in size bilaterally in size and
direction of the and are in the same are in the same location
nipples of both location on each breast. on each breast.
breasts. Also Nipples are usually
note any dryness, everted, but
lesions, bleeding, they may be inverted or
or discharge. flat.
Supernumerary nipples
may appear along the
embryonic “milk line.”
No discharge should be
present.
Inspect for The client’s breasts The patient’s breast has
retraction and should rise no signs of dimpling or NORMAL
dimpling. symmetrically, with no retraction.
sign of dimpling or
retraction.
Ask the client to Breasts should hang Breasts hang freely and NORMAL
lean forward from freely and symmetrically.
the waist. symmetrically.
Palpate texture and Palpation reveals Upon palpation, it NORMAL

Elasticity smooth, firm, elastic reveals smooth, firm,
tissue. elastic tissue.
Palpate for A generalized increase Breasts are slightly NORMAL

tenderness and in nodularity and tender. Temperature is “Typical changes are a
temperature. tenderness may be a normal body feeling of fullness,
normal finding temperature. tingling, or tenderness
associated with the that occurs because of
menstrual cycle or the increased
hormonal medications. stimulation of breast
Breasts should be a tissue by the high
normal body estrogen level in her
temperature. body. (Silbert-Flagg &
Pilitteri, 2018, page.
216).
Palpate for masses No masses should be No masses palpated. NORMAL

for location, size, palpated. However, a
shape, mobility, firm inframammary
consistency, and transverse ridge may
tenderness. Also normally be palpated at
note the condition the lower base of the
of the skin over the breasts.
mass.
If you detect any Fibrocystic breast tissue N/A -

lump, refer the that feels ropy, lumpy,
client for further or bumpy in texture is
evaluation. referred to as “nodular”
or “glandular” breast
tissue. Benign breast
disease consists of
bilateral, multiple, firm,
regular, rubbery, mobile
nodules with well-
demarcated borders.
Pain and fullness
occurs just before
menses.
Palpate the The nipple may become The patient’s nipple is NORMAL
nipples. erect and the areola erect and the areola
. may pucker in may pucker to
response to stimulation. stimulation.
A milky
discharge is usually
normal only during
pregnancy and
lactation. However,
some women may
normally have a clear
discharge.
Inspect and palpate No rash or infection No rash or infection NORMAL

the axillae for noted. noted.
rashes or infection.
Hold the client’s No palpable nodes or No palpable nodes. NORMAL

elbow with one one to two small (less
hand, and use the than 1 cm), discrete,
three finger pads of nontender, movable
your other hand to nodes in the central
palpate firmly the area.
axillary lymph
nodes
Ask the client to Client may request The patient isn’t aware DEVIATION FROM
demonstrate how instructions on how to about BSE (Breast self- NORMAL
she performs BSE perform the exam or Examination) “women need to be
choose not to learn how taught to know how the
to perform the exam. rest usually look and
Either choice feel and report changes
needs to be accepted to a healthcare
by the examiner professional. In addition,
they need to know ….re
performing a systematic
BSE”. (Potter and Perry,
2018, page 581).
HEART
Observe the jugular The jugular venous The jugular venous NORMAL
venous pulse. pulse is not normally pulse is not visible with
visible with the client the client sitting upright.
sitting upright. This
position fully distends
the vein, and pulsations
may or may not be
discernible.
Evaluate jugular The jugular vein should The jugular vein is not NORMAL
venous pressure. not be distended, distended, bulging, or
bulging, or protruding at protruding.
45 degrees or greater.
Auscultate the No blowing or swishing No blowing or swishing NORMAL

carotid arteries or other sounds are or other sounds are
heard. Pulses are heard. Pulses are
equally strong; a 2+ or equally strong; a 2+ or
normal with no variation normal with no variation
in strength from beat to in strength from beat to
beat. Contour is beat. Contour is smooth
normally smooth and and rapid on the
rapid on the upstroke upstroke and slower
and slower and less and less abrupt on the
abrupt on the downstroke. The
downstroke. The strength of the pulse is
strength of the pulse is 4.
evaluated on a scale
from 0 to 4
Palpate the carotid Arteries are elastic and Arteries are elastic and NORMAL
arteries. no thrills are noted. no thrills are noted.
Inspect pulsations. The apical impulse may Apical impulse is not NORMAL
or may not be visible. If visible.
apparent, it would be in
the mitral area. The
apical impulse is a
result of the left
ventricle moving
outward during systole.
NORMAL
Palpate the apical The apical impulse is The apical impulse is
impulse. palpated in the mitral palpated in the mitral
area and may be the area and is 2cm in size.
size of a nickel (1-2 Amplitude is small. The
cm). Amplitude is duration is brief, lasting
usually small - like a through the 1st 2/3 of
gentle tap. The duration systole and often less.
is brief, lasting through
the 1st 2/3 of systole
and often less. In obese
clients or clients with
large breasts, the apical
impulse may not be
palpable.
Palpate for No pulsations or No pulsations or NORMAL

abnormal vibrations are palpated vibrations are palpated
pulsations. in the areas of the in the areas of the apex,
apex, left sternal left sternal border, or
border, or base. base.
Rate should be 60-100 Rate is 78 bpm with a NORMAL

Auscultate heart bpm with a regular regular rhythm.
rate and rhythm. rhythm. A regularly
irregular rhythm, such
as sinus arrhythmia
when the heart rate
increases with
inspiration and
decreases with
expiration, may be
normal in young adults.
Auscultate to S1 corresponds with S1 corresponds with NORMAL
identify S1 and S2. each carotid pulsation each carotid pulsation
and is loudest at the and is loudest at the
apex of the heart. S2 apex of the heart. S2
immediately follows immediately follows
after S1 and is loudest after S1 and is loudest
at the base of the heart. at the base of the heart.
A A NORMAL
Listen to S1 distinct sound is heard distinct sound is heard
in each area but loudest in each area but loudest
at the apex. May at the apex. Becomes
become softer with softer with inspiration.
inspiration. A split S1
may be heard normally
in young adults at the
left lateral sternal
border.
Distinct sound is heard Distinct sound is heard NORMAL
Listen to S2. in each area but is in each area but is
loudest at the base. loudest at the base.
Auscultate for extra Normally no sounds are No extra sounds heard. NORMAL
heart sounds. Heard A physiologic S3
heart sound is a benign
finding commonly heard
at the beginning of the
diastolic pause in
children,
adolescents and young
adults (rare after age
40) A physiologic S4
heart sound may be
heard near the end of
diastole in a well-
conditioned athletes
and adults older than
age 40 or
50 with no evidence of
heart disease
Auscultate for Normally no murmurs No murmurs are heard. NORMAL

murmurs. are heard.
ABDOMEN
Observe the Abdominal skin may Abdominal skin is paler NORMAL

coloration of the be paler than the than the general skin
skin. general skin tone tone because this skin
because this skin is so is so seldom exposed
seldom exposed to the to the natural elements.
natural elements.
Scattered fine veins are
Note the vascularity Scattered fine veins quite visible
of the abdominal may be visible. Blood NORMAL
skin. in the veins located
above the umbilicus
flows toward the head;
blood in the veins
located below the
Umbilicus flows toward
the lower body.
NORMAL
Note any striae New striae are pink or
(stretch marks) bluish in color; old “Striae gravidarum are
striae are silvery, formed because as the
white, linear, and uterus increases in size
uneven stretch marks during pregnancy, the
From past Has presence of striae abdominal wall stretches
pregnancies or weight and Striae gravidarum to accommodate it,
gain. are visible on the sides wherein this stretching
of the abdominal wall. can cause rupture and
atrophy of small
segments of the
connective layer of the
skin leading to these
streaks that can still be
visible during
postpartum” (Silbert-
Flagg & Pillitteri, 2018).
Inspect for scars. Pale, smooth, No scars are seen. NORMAL

minimally raised old
scars may be seen.
Non Healing wounds,
redness, inflammation.
Deep, irregular scars
may result from burns.
Assess for lesions Abdomen is free of Abdomen is free of NORMAL

and rashes. lesions or rashes. Flat lesions, rashes, and
or raised brown moles,
however, are normal moles.
and may be apparent.
Inspect the Umbilical skin tones Umbilical skin tones are NORMAL
umbilicus for color. are similar to similar to surrounding
surrounding abdominal
skin tones or even
pinkish.
Observe umbilical Umbilicus is midline at Umbilicus is midline at NORMAL
location. lateral line. lateral line.
Assess contour of It is recessed It is inverted NORMAL

umbilicus. (inverted) or protruding
no more than 0.5 cm,
and is round or
conical.
Inspect abdominal Abdomen is flat, Abdomen is rounded NORMAL
contour. rounded, or scaphoid
(usually seen in thin “In the early days of
adults; Abdomen pregnancy, your uterus
should be evenly is the shape of a pear.
rounded. Over the first 12 weeks,
it gradually becomes
more rounded until it is
about the size of a
grapefruit.”
Reference: When will I

look pregnant?
(n.d.). Retrieved from

https://www.babycentre.
co.uk/x25006275
/when-will-i-look-
pregnant.
Assess abdominal Abdomen is Abdomen is symmetric. NORMAL

symmetry. symmetric.
Inspect abdominal Abdominal respiratory Abdominal respiratory NORMAL

movement when the movement may be movement is seen
client breathes seen, especially in
(respiratory male clients.
movements).
Observe aortic A slight pulsation of No pulsation observed NORMAL
pulsations. the abdominal aorta,
which is visible in the
epigastrium, extends
full length in thin
people.
Peristaltic waves are NORMAL

Observe for Normally, peristaltic not seen
peristaltic waves. waves are not seen,
although they may be
visible in very thin
people as slight ripples
on the abdominal wall.
Auscultate for bowel A series of A series of intermittent,
sounds. intermittent, soft clicks soft clicks and gurgles NORMAL
and gurgles are heard are heard at a rate of
at a rate of 5–30 per 10 per minute.
minute. Hyperactive
bowel sounds referred
to as
“Borborygmus” may
also be heard. These
are the loud,
prolonged gurgles
characteristic of one’s
“Stomach growling.”
Auscultate for Bruits are not normally Bruits are not heard NORMAL
vascular sounds. heard over abdominal over abdominal aorta or
aorta or renal, iliac, or renal, iliac, or
Femoral arteries. Femoral arteries.
However, bruits
confined to systole
may be normal in
some clients
depending on other
Differentiating factors.
Listen for venous Venous hum is not Venous hum is not NORMAL
hum. normally heard over heard over the
the epigastric and epigastric and umbilical
umbilical areas. areas.
Auscultate for a No friction rub over No friction rub over liver NORMAL
friction rub over the liver or spleen is or spleen is present.
liver and spleen. present.
.
Percuss for tone. Generalized tympani Generalized tympani NORMAL

predominate over the predominate over the
abdomen because of abdomen because of
air in the stomach and air in the stomach and
Intestines. Dullness is Intestines. Dullness is
heard over the liver heard over the liver and
and spleen. Dullness spleen. Dullness is
may also be elicited elicited over a non-
over a non-evacuated evacuated descending
descending colon colon
Percuss the span or On deep inspiration, On deep inspiration, the NORMAL

height of the liver by the lower border of lower border of liver
determining its lower liver dullness may dullness
and Descend from 1 to 4 descended from 2 cm
Upper borders. cm below the costal below the costal
margin. margin.
To assess the upper The upper border of The upper border of NORMAL
border, percuss over liver dullness is liver dullness is located
the upper right chest located between the between the left fifth
at the left fifth and seventh and seventh intercostal
MCL and percuss intercostal spaces. spaces.
downward, noting
the change from
lung resonance to
liver dullness. Mark
this point: It is the
upper border of liver
dullness.
Repeat percussion The normal liver span The normal liver span
of the liver at the at the MSL is 4 – 8 at the MSL is 4 cm. NORMAL
Midstream line cm.
(MSL).
Percuss the spleen. The spleen is an oval N/A -

area of dullness
approximately 7 cm
Wide near the left
tenth rib and slightly
posterior to the MAL.
Normally, tympani (or
resonance) is heard at
the last left interspace
Perform blunt Normally, no N/A
percussion on the tenderness is elicited. -
liver and the Tenderness elicited
kidneys. over the liver may be
associated
N/A
Perform blunt Normally, no -
percussion on the tenderness or pain is
kidneys at the elicited or reported by
costovertebral the client. The
angles examiner senses only
(CVA) over the a dull thud.
twelfth rib
N/A -
Abdomen is nontender
Perform light and soft. There is no
palpation. guarding.
-
Deeply palpate all Normal (mild) N/A
quadrants to tenderness is possible
Delineate abdominal over the xiphoid, aorta,
organs and detect cecum, sigmoid colon,
subtle masses. and
Ovaries with deep
palpation.
Palpate for masses No palpable masses No palpable masses NORMAL

for are present. are present.
Note their location,
size (cm), shape,
consistency,
demarcation,
plasticity,
tenderness, and
mobility.
Palpate the Umbilicus and Umbilicus and NORMAL

umbilicus and surrounding area are surrounding area are
surrounding area for free of swellings, free of swellings,
swellings, bulges, or bulges, or masses. bulges, or masses.
masses.
Palpate the aorta. The aorta is The aorta is NORMAL

approximately 2.5–3.0 approximately 2.5cm
cm wide with a wide with a moderately
moderately strong and strong and regular
regular pulse. Possibly pulse.
mild tenderness may
be elicited.
Palpate the liver for
tenderness and The liver is usually not N/A -
consistency. palpable, although it
may be felt in some
Thin clients. If the
lower edge is felt, it
should be firm,
smooth, and even.
Mild tenderness may
be normal.
Palpate the urinary An empty bladder is An empty bladder is NORMAL

bladder. neither palpable nor neither palpable nor
tender. tender.
Assess for rebound No rebound N/A -

tenderness. tenderness is present.
.
N/A
Test for referred No rebound pain is -
rebound tenderness. elicited.
MUSCULOSKELETAL

The patient’s
Equal size on
Inspect the muscles for muscles are in
both sides of the NORMAL
size. equal size on both
body.
sides of the body.
There are no
Inspect the muscles and contractures on the
No contractures. NORMAL
tendons for contractures. patient’s muscles
and tendons.
There are no
Inspect the muscles for No fasciculation fasciculation or
NORMAL
tremors. or tremors. tremors on the
patient’s muscles
Palpate muscles at rest The patient’s
to determine muscle Normally firm. muscles at rest are NORMAL
tonicity firm.
Palpate muscles while
There is a smooth
the client is active and
Smooth coordinated
passive for flaccidity,
coordinated movement while NORMAL
spasticity, and
movement. the patient is active
smoothness of
and passive.
movement
The patient’s
Test muscle strength.
Equal strength on muscle strength is
Compare the right side NORMAL
each body size. equal on each body
with left side
size.
Inspect the skeleton for There are no
normal structure and No deformities. deformities on the NORMAL
deformities patient’s skeleton.
Inspect the joint for No tenderness or There is no area of NORMAL
swelling. swelling. tenderness, no
edema or swelling
on the patient’s
bones.
VI. LABORATORY ASSESSMENTS
A. Urinalysis (11/09/19)
Routine Exam Result Normal Values Interpretation

Color YELLOW LIGHT YELLOW- NORMAL
YELLOW
Transparency TURBID CLEAR- S.L. HAZY DEVIATION
“normal urine
appears transparent
at the time of
voiding.’’(Potter and
Perry, 2018, page
1112).
Ph 7.0 4.6-8.0 NORMAL
Specific gravity 1.015 1.00053-1.030 NORMAL
Protein NEGATIVE NEGATIVE NORMAL
Glucose NEGATIVE NEGATIVE NORMAL
Pus Cells 50—55/HPF 1-3/HPF DEVIATION
“elevated numbers
indicate
inflammation or
infection.” (Potter
and Perry, 2018,
page 1112).
Red Blood Cells 1-3/ HPF 1-3HPF NORMAL
Epithelial Cells MODERATE DEVIATION
“Types include
hyaline, WBCs,
RBCs, granular
cells, and epithelial
cells. The presence
indicates renal
disease. '' (Potter
and Perry, 2018,
page 1112).
Bacteria MANY (not normally present) DEVIATION
“Bacteria in the urine
can mean infection
or colonization if the
patient shows no
symptoms.” (Potter
and Perry, 2018,
page 1112).
Amorphous Urates MODERATE (not normally present) DEVIATION
“crystals indicate
increased risk for the
development of renal
calculi or stone.
Patients with high
uric acid levels are
gout may develop
uric acid crystal.”
(Potter and Perry,
2018, page 1112).
Mucus Thread MODERATE (not normally present) DEVIATION
“Mucus is a slimy
substance produced
by membranes and
glands to lubricate
and protect certain
parts of the body.
Mucus coats and
protects the urinary
tract, so some
mucus in the urine is
normal. But too
much mucus, or
mucus that has
changed in color or
consistency, can
signify an underlying
condition that may
need addressing.”
(Medical News
Today).
B. Pelvic Ultrasound (11/09/19)
Measurements Age Estimate

Biparietal diameter 4.24cm 18 weeks 6 days
Head circumference 16.06 cm 18 weeks 6 days

Abdominal circumference 12.67 cm 18 weeks 0 days
Femur length 2.72 cm 18 weeks 2 days
Estimated fetal weight 249 grams -
IMPRESSION:
Single live intrauterine pregnancy in cephalic presentation with an average ultrasound age of
18 weeks and 3 days.
EDC: 08 APRIL 2020
C. Blood Chemistry (11/09/19)

S.I. UNIT INTERPRETATIONS CONVENTIONAL INTERPRETATION
S
TEST RESU NORMAL RESULT NORMAL
LT VALUE VALUE
FBS 4.76 3.89 NORMAL 86.5 70.7-106mg/dL NORMAL
-5.84mmo
l/L
First hour 5.88 4.40- NORMAL 106.9 80-140 mg/dL NORMAL
7.70mmol
/L
Second 5.55 - NORMAL 100.9
hour
Third 5.39 - NORMAL 98.0
hour
VII. PROBLEM PRIORITIZATION AND IDENTIFICATION
NURSING DIAGNOSIS
JUSTIFICATION
& RANK
CUES
1st According to Maslow’s Hierarchy of Needs, this
Impaired Urinary would fall under the physiological and biological
Elimination related to needs because included here is elimination.
urinary tract infection The act of elimination is also the last step in the
as evidenced by removal and elimination of excess water and
frequency of urination by-product of body metabolism. Inadequate
and urinalysis elimination would therefore impede proper
findings waste removal, affecting the kidneys and
urinary system.
Subjective Cues:
● 4 ½ fluid intake
daily
● “Kahit kakaihi ko
lang, naiihi na
naman ako kaya
Sources: (Potter and Perry, 2018, page. 1101)
tuwing gabi
Registered Nursing (n.d.)
bangon ako ng
Retrieved from:
bangon eh” https://www.registerednursing.org/nclex/establi
shing-priorities/
● “Nakakaramdam
ako ng sakit
kapag umiihi”, as
verbalized by the
client with pain
scale of 5/10
● discomfort and
lower back pain
when urinating
Objective Cues:
● eats canned
goods
● observed
holding lower
back during
interview
● frowning facial
expression
● Based from the

laboratory
results, the
following
deviations were
found:
- Transparency-
turbid
- Pus cells- 50-55/
HPF
- Epithelial cells-
Moderate
- Bacteria-many
- Amorphous
urates- moderate
- Mucous thread-
moderate
Risk for deficient

Need for water falls under Maslow’s
volume as evidenced
physiological and biological needs. Water is
by lack of daily water
critical because all cell function depends on the
intake
fluid environment. Water makes up 60% to
70% of total body weight. We need our fluid
Subjective:
needs by drinking liquids and eating solid foods
● “Mga ½ na baso
high in water content such as in fresh fruits and
lang ng tubig
vegetables period digestion produces.
naiinom ko”
Digestion produces fluid during food oxidation.
2nd
And a healthy individual fluid intake from all
Objective:
sources equals fluid output through elimination,
● Lips are dry
respiration, and sweaty.
● Hair is somewhat
References: (Potter and Perry, 2018, page.
dry
1055).
● Presence of
Registered Nursing (n.d.)
dandruff
Retrieved from:
● Observed empty
https://www.registerednursing.org/nclex/establi
mineral bottle in
shing-priorities/
home
Imbalanced Nutrition:
less than body
requirements related
to inability to absorb
nutrients needed by
the body as evidenced
by food intake less
Nutrition is related to food intake which falls
than recommended
under the category of physiologic needs in
daily allowance
Maslow’s hierarchy of needs.
During pregnancy, a woman must eat
Subjective Cues:
adequately to not only support her own nutrition
● “Magana naman
but also to supply enough nutrients so the fetus
ako kumain
can grow. Adequate protein and calcium intake
kaso unti lang
is vital because so much of these are needed
kinakain ko”
by the fetus to build a strong body framework.
● “Yung pagkain
Proper nutrients must be obtained by the body.
namin abot
Along with this, it is vital
nayan hanggang
that one must obtain proper nutrition and
gabi kaya pare-
proper
pareho lang
diet to be able to function well.
kinakain ko
buong araw”
3rd Reference: Pilletteri, A. (2014) Maternal and
● “Madalas
Child Health Nursing Vol.1 (7th ed., page 304 )
kinakain ko ½
Henry, (2018-2020), Nursing
basong kanin
Diagnosis 11 th edition (page 162)
lang e tas unting
ulam”, as
verbalized by the
client.
Objective cues:
● no observation of
fruits or
vegetables in
home
● no variation in
meals
Ineffective 4th According to Maslow’s Hierarchy of Needs, this

childbearing process would fall under safety and security because
Related to lack of the client needs adequate resources in order to
prenatal visits as ensure her safety and her child’s safety during
evidenced by her pregnancy.
inappropriate prenatal
preparations Source: Registered Nursing (n.d.) Retrieved
from:
Subjective Cues:
● “Di pa ako
nagpapacheck
up kasi nasunog
yung kailangan
ko para sa
healthcenter
nuon”
● “Kulang din kami
sa pambayad
nuon para sa
panglawang lab
assessments”
● “Pabalik-balik
https://www.registerednursing.org/nclex/establi
ako sa health
shing-priorities/
center pero di pa
ako
nakapagcheck
up ulit dahil sa
nag-iiba na
iskedul duon”
Objective Cues:
● AA has not
acquired any
prenatal vitamins
or supplements
needed for her
pregnancy
● AA is not aware
of the most
recent health
status of her child
Self care deficit According to Maslow’s hierarchy of needs, poor
related to 5th hygiene falls under safety needs. Poor hygiene
environmental factors can be a sign of self-neglect, which is the
as evidenced by Poor inability or unwillingness to attend to one's
personal Hygiene personal needs. Poor hygiene often
accompanies certain mental or emotional
Subjective Cues: disorders, including severe depression and
● “Naliligo lang ako psychotic disorders.
ng isang beses
sa isang araw, Reference: Stöppler, M. C. (2019, September
madalas tuwing 10). Poor Hygiene: Symptoms, Signs, Causes
gabi” & Treatment. Retrieved from
● “Isang beses https://www.medicinenet.com/poor_hygiene/sy
lang din ako mptoms.htm.
magpalit ng
damit”, as
verbalized by the
client
Objective Cues:
● The patient is
dirty and clothes
are unkempt
● Presence of
dandruff
Ineffective coping
related to situational
crisis as evidence by
house on fire It is classified as physiologic needs according
to Maslow’s hierarchy of needs. Tiredness and
emotional stress can cause concentration for
Subjective Cues: most people. Hormonal changes, such as
● “Hindi ako sanay those experienced
dito kami sa court during menopause or pregnancy, can also
natutulog” affect how we think and concentrate.
● “Medyo stress
nga ako dahil sa Reference: Stöppler, M. C. (2019, September
6th
nangyari samin e 10).
,” as verbalized
by the client Difficulty Concentrating: Symptoms, Signs,
Causes & Treatment. Retrieved from
Objective Cues: https://www.medicinenet.com/difficulty_concent
● Facial expression rating/
of distress as symptoms.htm.
seen by
Frowning face of
client
Disturbed Sensory 7th Hearing impairment falls under the category of

Perception related to physiologic needs in Maslow’s hierarchy of
hearing impairment as needs. Hearing loss is a common problem
evidenced by poor caused by noise, aging, disease, and heredity.
concentration People with hearing loss/ impairment may find
it hard to have conversations with friends and
Subjective Cues: family. They may also have trouble
● “Madalas hindi ko understanding a doctor’s advice, responding to
maintindihan warnings, and hearing doorbells and alarms.
sinasabi ng
kausap ko kahit Reference: Hearing Loss: A Common Problem
katapat ko lang for Adults. (n.d.). Retrieved from
siya kaya https://www.nia.nih.gov/health/hearing-loss-
madalas din iba common-problem-adults.
pagkakaintindi ko
sa sinasabi nila”
● “Hindi pa ako
nagpapacheck
up tungkol dito at
wala rin akong
ginagmit na
hearing aid”
● “Wala akong
naririnig na tunog
pero feeling ko
may tubig yung
tenga ko, ditto sa
kaliwang tenga
ko,” s verbalized
by the client
Objective Cues:
● Wrinkled
forehead while
the interviewee is
talking
● Inappropriate
response to
questions
● Can’t repeat the

whispered words
with the grade of
0/6
● Vibrations are not

equally heard in
both ears (Weber
Test)
● Air conduction
sound is shorter
than bone
conduction sound
R: (AC:2 > BC:8).
L: (AC:5> BC:10).
Deficient Knowledge 8th According to Maslow’s Hierarchy of needs, this

As evidenced by lack falls under safety and security since acquiring
of knowledge about knowledge to take care of one’s body ensures
self- breast exam their safety and security in terms of their health.
related to lack of
exposure to topic as Reference: Registered Nursing (n.d.) Retrieved
evidenced by absence from:
of knowledge about https://www.registerednursing.org/nclex/establi
self- breast exam shing-priorities/
Subjective Cues:
● “Hindi ko alam na
dapat nagbre-
breast exam,” as
verbalized by the
patient
Objective:
● Was hesitant to
perform self-
breast exam
during demo
According to Maslow’s Hierarchy of Needs, this
falls into love and belongingness because this
deals with the relationship of the mother with
her children. Preschoolers have definite
Risk for Impaired
opinions on things which is what they want to
parenting related to
eat, where they want to go, and what they want
deficient knowledge
to wear, and these opinions may bring them
about parenting skills
into opposition with parents. A major parental
as evidenced by
responsibility when this happens is to guide a
inappropriate child
child through these struggles without
discipline 9th
discouraging the child’s right to have an
opinion. In time out is easy technique prepared
Subjective cues:
to correct behavior throughout the years.
● “sinigawan ko
Parents may also need to be reminded that
even the simplest of tasks of every day life
Objective cues:
require repeated practice before they can be
●
accomplished well.
Reference: Pillitteri, A. (2014) Maternal and
Child Health Nursing Vol.1 (7th ed., page 843
and 871 )

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A CASE OF:

Magliba, Shannon Kimberly

Admitting/ Final Diagnosis: Intrauterine

II. NURSING HEALTH HISTORY

A. History of Present Condition

B. Past Health History

30 28 Unknown Unknown Unknown 24

III. GORDON’S HEALTH ASSESSMENT

A. Health Perception – Health Management Pattern

INTERPRETATION: Deviation from Normal

3-Day Diet Recall

Saturday (November 9, 2019)

Sunday (November 10, 2019)

Monday (November 11, 2019)

INTERPRETATION: Deviation from Normal

INTERPRETATION: Deviation from Normal

D. Activity and Exercise

Saturday (November 9, Activities

Monday (November 11,

INTERPRETATION: Deviation from Normal

F. Sleep and Rest

3-Day Sleep Diary

SATURDAY SUNDAY MONDAY

INTERPRETATION: Deviation from Normal

G. Self-Perception/ Self Concept

INTERPRETATION: Deviation from Normal

References: Berman, A. Snyder, S. Kozier, B. & Erb, G. (2007). Fundamentals of Nursing

I. Sexuality- Reproductive Pattern

J. Coping – Stress Tolerance Pattern

K. Value – Belief Pattern

IV. MEASUREMENTS (HEIGHT, WEIGHT, BMI, VITAL SIGNS)

According to Marple, K. (n.d.) the average

MEASUREMENTS NORMS FINDINGS INTERPRETATION

3. Respiratory Rate 18 - 25 rpm NORMAL

Appearance and Mental Status

ASSESSME NORMS FINDINGS INTERPRETATION

Sign of Sign of distress in facial DEVIATION FROM

Client’s Relaxed, erect posture and The patients’ movement is NORMAL

Overall Clean, neat The patient is dirty and DEVIATION FROM

Body and No body/breath odor or minor There is no foul or unusual NORMAL

Quantity, Understandable, moderate The patient’s organization DEVIATION FROM

ASSESSME NORMS FINDINGS INTERPRETATION

Inspect Generally, uniform except in Skin color is uniform NORMAL

Inspect, Freckles, some birthmarks, Scar is present at right DEVIATION FROM

Note No infection or infestation Presence of dandruff DEVIATION FROM

HEAD AND NECK

ASSESSMENT NORMS FINDINGS INTERPRETATION

Inspect for Head should be held still No involuntary head NORMAL

Palpate the The temporal artery is The temporal artery is NORMAL

Palpate for the Normally there is no There is no swelling, NORMAL

ASSESSMENT NORMS FINDINGS INTERPRETATION

Inspect the neck Neck is symmetric, with Neck is symmetric to NORMAL

Inspect the C7 (vertebrae prominent) C7 is visible and NORMAL

Inspect range of Normally neck movement Neck movement is DEVIATION FROM

Palpate the Trachea is midline. Trachea is midline. NORMAL

Palpate the Landmarks are Landmarks are NORMAL

Auscultate the No bruits are auscultated. No bruits auscultated. NORMAL

Palpate the lymph There is no swelling or There is no swelling or NORMAL

ASSESSMENT NORMS FINDINGS INTERPRETATION

Observe for Skin on both eyelids is Skin on both eyelids is NORMAL

Observe the Eyeballs are Eyeballs are NORMAL

Inspect the bulbar Bulbar conjunctiva is Bulbar conjunctiva is NORMAL