A case of a 79-year-old male who has

Acute Infarc at right Frontal Area

Submitted by:
BSN301- Group 3
Rapisora, Catleya
Raquedan, Michele Angela
Raymundo, Geo
Sacasas, John Ezekiel
Sagisi, Maria Victoria
Saway, Vien Dianne
Tala, Al Christian
Taong, Alexa Airha
Tividad, April Gean
Valdez, Monica Mae
Vito, Liberlyn Anne

Submitted to:
Mrs. Jennifer Padual

2nd Semester
April 4, 2016

TABLE OF CONTENTS
Page
I.
II.
III.

IV.
V.
VI.
VII.
VIII.
IX.
X.
XI.
XII.
XIII.

Introduction
Demographic Data
Nursing Health History
a) History of Present Illness
b) Past Health History
c) Occupational History
d) Family History
e) Genogram
Gordons Functional Pattern
8 - 11
Physical Assessment (Cephalocaudal)
12-24
Laboratory Examinations
A, B, C
Drug study
Pathophysiology
A, B
Ecologic Model
Problem Identification and Prioritization
25-26
Nursing Care Plan
Evidence Based Nursing
Discharge Plan

3-4
5
5
5
6
6
6
7

24
24
2425

I.

INTRODUCTION
Philippine Diabetes Statistics1

The incidence of diabetes is growing around the world. It is in the top ten
leading causes of deaths. Filipinos are not an exemption to this incidence as the
disease affects more and more Filipinos. In fact, the last 2008 survey was alarming
enough to conclude that one out of every five Filipinos have diabetes. That means
that around 20% of the population have diabetes and this has significantly increase
from only 4% in 1998. Another cause for alarm is that Filipinos diagnosed with
diabetes are getting younger. Children as young as 5-years old have been
diagnosed with type 2 diabetes. With this trend, the Philippines is expected to
belong on the top 10 countries with the most people with diabetes 15 years from
now.
While the diabetic statistics in the Philippines is relatively low compared to
Scandinavian countries, it nevertheless featured a drastic increase that is alarming.
Over 7 million Filipinos will have diabetes by 2030. Some experts attribute the
increase of diabetic incidence in the Philippines to the lifestyle and culture of
Filipinos. For one, Filipinos love to eat. Rice is the Filipinos staple food. Filipinos are
fond of holding celebrations from fiestas, chrisms, weddings, and different holidays
in which food indulgence is inherent and a crucial part of the celebrations.
Filipinos has the best fatty, risky exotic foods such as batsoy, liver and other
organ meat (papaitan), sisig, street foods (isaw, adidas), Lechon (split-roasted
meat), the best condiments such as bagoong (red and brown), patis (fish sauce),
the best steaks Bistek coated with sebo oil, Menudo and other menu. Filipinos also
have the best and sweetest native delicacies and cakes (puto, palitaw, biko,
bibingka, among many others. Finally, the Philippines is also the most free country
where people are allowed to indulge in vices such as alcohols and cigarettes. It has
the cheapest cigarettes and liquors in the world, which are practically available in
every nook and corner of a town and even at the most rural areas of the nation.
Under these premises, it is no wonder the diabetics in the Philippines will get worse
in the next years to come.
According to the latest WHO data published in may 2014 Diabetes Mellitus
Deaths in Philippines reached 33,656 or 6.46% of total deaths. The age adjusted
Death Rate is 60.44 per 100,000 of population ranks Philippines #20 in the world.
Review other causes of death by clicking the links below or choose the full health
profile.2

1 http://www.allaboutdiabetes.net/philippine-diabetes-statistics/
2 http://www.worldlifeexpectancy.com/philippines-diabetes-mellitus
3

Philippine Stroke Statistics3

Strokes are increasingly hitting younger people and the incidence of the
crippling condition worldwide could double by 2030, warns the first global analysis
of the problem.4
Though the chances of a stroke jump dramatically with age, the growing
number of younger people with worrying risk factors such as bulging waistlines,
diabetes and high blood pressure means they are becoming increasingly
susceptible.
Worldwide, stroke is the second-leading cause of death after heart disease and is
also a big contributor to disability.
Most strokes occur when a clot blocks the blood supply to the brain. Patients
often experience symptoms including a droopy face, the inability to lift their arms
and garbled speech. If not treated quickly, patients can be left with long-term side
effects, including speech and memory problems, paralysis and the loss of some
vision.
According to the latest WHO data published in may 2014 Stroke Deaths in
Philippines reached 63,261 or 12.14% of total deaths. The age adjusted Death Rate
is 119.21 per 100,000 of population ranks Philippines #54 in the world. Review
other causes of death by clicking the links below or choose the full health profile.

3 http://www.worldlifeexpectancy.com/philippines-stroke
4 http://www.philstar.com/world/2013/10/25/1249283/strokes-affecting-moreyounger-people
4

II.

DEMOGRAPHIC DATA

Name: H.T.T
Address: Quezon City
Age: 79 years old
Birth Date: November 16, 1936

Birth Place: Kalibo, Aklan

Gender: Male
Religion: Roman Catholic

Race/Ethnic Origin: Cebuano

Occupation before admission: None

Attainment: High school Graduate

Educational

Marital Status: Married

Name of Spouse:

Number of children: 3
Chief Complaint: The patient experience dizziness.
Date of Admission: March 29, 2016
Room and Bed Number: 506 A
Attending/ Admitting Physician: Dr. Catalan, Dr. Andor, Dr. Pablo and Dr.
Rondilla
Admitting/Final Diagnosis: Acute Infarct, Right Frontal Area
Medical Insurance: Phil health

III.

NURSING HEALTH HISTORY

A. History of Present Illness:

The history of present illness started 6 hours prior to admission, the patient
experienced sudden dizziness described as umiikot ang paligid accompanied by
blurring of vision while standing outside his house waiting under the sunlight. No
other associated symptoms such as headache, nausea, vomiting, loss of
consciousness. 2hrs prior to admission, the patient still had persisntence of
dizziness aggravated by movement, few hours prior to admission, till with
persistence above symptoms now accompanied by 3 episodes of vomiting of post
ingested food, consult at the ER of FEU NRMF and was admitted.

B. Past Health History

Childhood diseases were chicken pox, mumps and measles. Patient had unrecalled
immunization. No allergies to foods or drugs. Patient is a known hypertensive since
1990 with highest blood pressure at 180/100 mmhg and usual blood pressure of
140/80 mmHg. He claims to take herbal medication as maintenance. The patient
had previous history of cerebrovascular accident where he was confined for 15 days
at QCGH. The patient is known diabetic since 2004. He have previous surgeries
include Lasik surgery for cataract removal for both eyes on 2011 in FEU-NRMF, and
again on march 2016 at Chinese general Hospital in the right eye.
C. Occupational History
Inclusive Dates/Years

Occupation
Retired warehouse salesman

D. Family History
Family Health History:
Father: deceased at age 83, known hypertensive, died due to complications
from infection
Mother: deceased at 64, died due to Stroke complications
Patient: Eldest among 4 siblings; all apparently well.
Has 3 children; all are apparently well.
The patients has heredofamilial history of maliganancy-bone on the maternal side,
hypertension and diabetes on both sides with no other history of lung, liver, kidney
and thyroid disease.

E. Genogram:

Patient

Genogram Key:
Male
Female
Marriage
Child
Patient
Dead

IV.

Gordons Functional Pattern

Note: All responses, except patterns about own perception, were provided by the
client's grandson (client's guardian during the time of interview).
A. Health Perception- Health Management Pattern
> The client stated that, "6 lang kasi madami akong nararamdaman at
nanghihina din"
Interpretation: Deviation from Normal
Analysis: During illness, changes may occur in the structure and function of a
human's body and mind (Miller, Stoeckel 2015)
B. Cognitive Perceptual Pattern
> "Nakakabasa at nakakasulat naman siya. May salamin na siya ngayon, pero
hindi niya masyado sinusuot dito. Sa pandinig naman, nagkaproblema siya
dun sa kaliwang tenga niya, hirap makarinig kasi parang barado daw".
Interpretation: Deviation from Normal
Analysis: Blockage in the ear always involve some degree of hearing loss and
a feeling of aural fullness (Lynch, 2008)
C. Self-perception Self-Concept Pattern
> The client stated that, "Ahh mabait siguro hehe. Medyo madami din kasi
akong kasundo dun sa may amin".
Interpretation: Normal
Analysis: Developing good self-esteem involves encouraging a positive (but
realistic) attitude toward yourself and the world around you and appreciating
your worth, while at the same time behaving responsibly towards others.
-mtstcil.org
D. Role-Relationship Pattern
> "Masaya naman sila sa bahay. Kasama niya yung asawa at dalawang anak
niya sa bahay. Yung isa kasi may pamilya na"
The client stated that "Okay naman kami ng asawa ko, kapag nagkakagalit
kami, pinag uusapan namin yung problema, sinusuyo ko din agad siya, tapos
minsan, okay na".
Interpretation: Normal
Analysis: Interpersonal harmony among family members is deemed very
important. In addition to the function of maintaining social order,

interpersonal harmony is also essential for maintaining individuals well-being

(Chuang, 2005)
E. Sexuality-Reproductive Pattern
> The client stated that, "Medyo matanda na din ako, wala na din time
magpa pogi hehe. Inilalaan ko nalang yung oras ko sa asawa at mga anak ko"
Interpretation: Normal
Analysis: The aging process involves many normal physical changes, some of
which naturally affect the sexual response. -wikibooks.org
F. Coping-Stress Tolerance Pattern
> The client stated that, " Kapag nai-stress ako, tinutulog ko nalang,
pagkagising ko naman, mas relax na yung utak ko at nakakapag isip na ng
ayos"
Interpretation: Normal
Analysis: During REM sleep, memories are being reactivated, put in
perspective and connected and integrated, but in a state where stress
neurochemicals are beneficially suppressed (Helm, 2012).
G. Value-Belief Pattern
> "Wala naman siyang pinaniniwalaang kasabihan o practices. Pero dati,
sinubukan niya atang gumamit ng herbal medicines para sa sakit niya"
Interpretation: Normal
Analysis: It is acceptable to use herbal medicine because the most common
reasons for using such is that it is more affordable, more closely corresponds
to the patients ideology, allays concerns about the adverse effects of
chemical (synthetic) medicines, satisfies a desire for more personalized
health care, and allows greater public access to health information (Benzie,
2011)
H. Nutritional-Metabolic Pattern
BEFORE
> "Pasaway siya sa mga pagkain. Hindi siya mahilig mag gulay tapos
malakas siya mag kape tapos yung juice na tang"
DURING
> "Mahina siya kumain. Yung mga pagkain dito sa ospital, halos hindi niya
masyado nababawasan".
Interpretation: Deviation from Normal

Analysis: Loss of appetite, medically referred to as anorexia, can be caused

by a variety of conditions and diseases. Some of the conditions can be
temporary and reversible, such as loss of appetite from the effects of
medications. Some of the conditions can be more serious which should be
evaluated by a health care professional (Shiel, 2008)
I. Elimination Pattern
Stool
BEFORE
> "Regular naman siguro yung pagdumi niya nung nasa bahay pa. Wala pa
kasing masyadong komplikasyon nun".
DURING
> " Simula nung nagbantay ako kaninang umaga, hindi pa siya dumudumi".
Interpretation: Deviation from Normal
Analysis: Fecal Impaction in hospitalized client is an unfortunate consequence
of severe constipation often seen in geriatric population. Predisposing factors
includes decreased rectal sensation, poor diet, inadequate toilet access an
decrease colonic motility (Williams, 2007).
Urine
BEFORE
> "Wala naman siyang problema sa pag ihi nung hindi pa siya naoospital".
DURING
> "Pero ihi, lagi naman kaso pakunti-kunti lang. Masakit yung pantog niya
kapag umiihi siya. Namimilipit siya sa sakit dahil nilagyan siya nung catheter"

"Kulay dilaw yung ihi niya, mapanghi syempre. Hehe. Kapag nililipat na dun
sa pangsukat na container, palaging hanggang dun lang sa unang guhit (100
ml).
Interpretation: Deviation from Normal
Analysis: Bladder spasms, which feel like stomach cramps, are also quite
common when you have a catheter in your bladder. The pain is caused by the
bladder trying to squeeze out the balloon, which contributes to decreased
urine output. -nhs.uk
J. Activity-Exercise Pattern
BEFORE

10

> "Wala, taong bahay lang. Nanunuod lang ng T.V, wala siyang exercise. Pero
nung bago siya naospital, nakakapag drive pa siya".
DURING
> "Palagi lang siyang nakahiga dito, umuupo lang kapag gusto niyang
dumumi o umihi".
Interpretation: Deviation from Normal
Analysis: Mobility and activity tolerance are affected by any disorder that
impairs the ability of the nervous system, musculoskeletal system,
cardiovascular system, respiratory system and vestibular apparatus (Kozier
and Erb's Fundamental of Nursing p1117)
K. Sleep-Rest Pattern
BEFORE
> "Ganun din naman, nagpapahinga lang siya, natutulog siya sa tanghali.
Okay naman yung tulog niya noon, hindi nakukulangan".
DURING
> " Palagi siya natutulog dito pero pagka-gising niya parang kulang pa din
kaya tinutulog niya nalang ulet".
Interpretation: Deviation from Normal
Analysis: Illness that causes pain or physical distress can result in sleep
problems. People who are ill require more sleep that normal (Kozier and Erb's
Fundamental of Nursing p1169-1170)

11

V.

PHYSICAL ASSESSMENT (CEPHALO CAUDAL)

Findings

Norms

Interpretation

Vital Signs
- Temperature

36.5 C

36.5C 37.7C

Normal

Medical-Surgical
Brunner Suddarths
12th edition
- Pulse Rate

79 bpm

60 100 beats/min
Medical-Surgical
Brunner Suddarths
12th edition

-Respiratory
Rate
- Blood Pressure

Deviation from
normal
An excessive fast
rate is referred to
as tachycardia
(Kozier&Erbs
Fundamental of
Nursing 8th edition
vol.1 pg. 540)

20cpm

12-20 cpm

Normal

150/80 mmHg

120/80

Abnormal

Medical-Surgical
Brunner Suddarths
12th edition

Hypertension is the
most common
symptoms in
patients with
Diabetic Patients.
(Medical-Surgical
Nursing by Brunner
pg. 1911)

SKIN
(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 579-580)
AREA TO BE ASSESSED
Inspect for color,
uniformity of color

NORMAL
FINDINGS

ACTUAL FINDINGS

Light to deep
brown, generally

12

Brown, the rest of

the skin is uniform in

ANALYSIS
Normal

uniform except in
areas exposed to
the sun.

color.

Inspect for presence of

edema

No presence of
edema on any part
of the body.

No presence of
edema on any part
of the body.

Normal

Inspect, palpate, and

describe lesions.

Some birthmarks,
some flat and
raised nevi; no
abrasions or other
lesions.

Some black spots on

the skin.

Normal

Observe and palpate skin

moisture

Moisture in skin
folds.

Moist.

Normal

Palpate skin Temperature

Uniform and within

normal range.

Warm to touch and

uniform skin
temperature

Normal

Palpate skin turgor

When pinched,
skin springs back
to previous state.

Spring back
immediately

Normal

HAIR
(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 582)
AREA TO BE ASSESSED

NORMAL
FINDINGS

ACTUAL
FINDINGS

ANALYSIS

Inspect the hair for color,

texture, and evenness

Hair evenly
distributed,
resilient.

Black and balding

Normal

Inspect the scalp

No flaking, no
infestations.

No dandruff, no
lice.

Normal

Palpate the scalp for

lesions, tenderness,
bruises, masses, or
nodules

No tenderness,
tenderness, no
bruises, no lesions,
no masses, or
nodules.

No tenderness, no
lesions.

Normal

13

Amount of body hair

Variable

Variable

Normal

NAILS
(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 583- 584)
AREA TO BE ASSESSED

NORMAL
FINDINGS

ACTUAL
FINDINGS

Inspect fingernail plate

shape to determine its
curvature and angle

Convex, angle of
nail plate about
160 degrees.

Inspect fingernail and toe

nail bed color

Highly vascular,
pink.

Palpate fingernail and

toenail texture

Smooth texture.

Inspect tissues
surrounding nails
Perform blanch test of
capillary refill

Intact epidermis
Capillary refill goes
back immediately
or less than 2
seconds

ANALYSIS

Nail shape is
convex and has an
angle of 160
degrees.
Fingernail is pink in
color and its nail
bed is also pink.
Fingernail and
toenail are both
smooth.
Intact epidermis

Normal

Capillary refill goes

back 2 seconds.*

Normal

Normal
Normal
Normal

SKULL AND FACE

(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 585)
AREA TO BE ASSESSED

NORMAL
FINDINGS

ACTUAL
FINDINGS

ANALYSIS

Inspect the skull for size,

shape, and symmetry

Rounded and
symmetric, with
frontal, parietal,
occipital
prominences;
smooth skull
contour.

Has smooth, round

and symmetric
contour

Normal

Palpate the skull for

nodules or masses and
depressions

Smooth, uniform
consistency;
absence of
nodules or masses.

No tenderness, no
rebound
tenderness, and no
presence of
nodules, masses, or

Normal

14

depressions.
Inspect the facial features

Symmetric or
slightly
asymmetric facial
features; palpebral
features equal in
size.

Facial features are

symmetric,
palpebral fissures
are equal

Normal

Note symmetry of facial

movements.

Symmetric facial
movements.

Facial movements
are symmetric, no
involuntary
movements.

Normal

EYE STRUCTUTRES AND VISUAL ACUITY

(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 588- 593)
AREA TO BE ASSESSED

NORMAL
FINDINGS

ACTUAL
FINDINGS

ANALYSIS

Inspect the eyebrows for

hair distribution and
alignment and skin quality
and movement

Hair evenly
distributed; skin
intact; eyebrows
symmetrically
aligned; equal
movement.

Skin is intact; hair is

evenly distributed;
eyebrows are
symmetrically
aligned; has equal
movements.

Normal

Inspect the eyelashes for

evenness of distribution
and direction of curl

Hair is evenly
distributed; curled
slightly outward.

Equally distributed;
curled slightly
outward.

Normal

Inspect the eyelids for

surface characteristics

Skin is intact; no
discharge; no
discoloration of
eyelids surface.
Lids close
symmetrically, no
pain as the lids
close, blinks
bilaterally.

Skin intact; no
discharge
,frequently
blinking , eyelids
close symmetrically

Normal

Inspect the bulbar

conjunctiva for color,
texture, and the presence
of lesions.

Transparent;
capillaries are
evident, pinkish in
color; sclera

Transparent; sclera
appears white.

Normal

15

appears white.
Inspect the palpebral
conjunctiva

Pinkish in color,
shiny, moist, and
smooth.

Shiny, smooth,
moist, and pink in
color.

Normal

Inspect and palpate the

lacrimal gland

No tenderness,
edema and
swelling.

No edema or
tenderness over
lacrimal gland.

Normal

Inspect and palpate the

lacrimal sac and
nasolacrimal duct

No tearing, edema,
and tenderness.

No edema or
tearing.

Normal

Inspect the cornea for

clarity and texture

Surface is smooth,
and shiny; details
of iris are visible.

Transparent, shiny,
and smooth; details
of iris are visible.

Normal

Perform corneal sensitivity

test

Client will blinks

when the cornea is
touch, indicating
that the trigeminal
nerve is intact.

Client blinks as the

gauze touches the
cornea.

Normal

Inspect the anterior

chamber for transparency
and depth

Transparent, no
shadow of light on
iris, has 3mm
depth.

Transparent; no
shadow of light on
iris

Normal

Inspect the pupils for color,

shape, and symmetry of
size

Black in color,
round, and equal
in size, symmetric,
has a diameter of
3mm. Iris is flat
and round.

Black in color; equal

size; round, smooth
border

Normal

Assess each pupils direct

and consensual reaction to
light

Illuminated pupil
constrict (direct
response);
Nonilluminated
pupil constrict
(consensual
respone)

The pupil constrict

in direct response
and still constrict in
consensual
response

Normal

Assess each pupil reaction

to accommodation

Pupil constricts
when looking at
near object; pupil
dilates when
looking at far
object; pupils
converges when

Constriction of the
pupil when looking
at near object,
dilation of pupil
when looking far
object;
convergence of the

Normal

16

near object is
moved toward the
nose.

pupils.

Assess peripheral visual

fields

Able to see the

objects in
periphery when
looking straight.

When looking
straight ahead, the
clients can see
objects in
periphery.

Normal

Assess six ocular

movements

Eyes have
coordinated
movements.

Both eyes
coordinated, moves
symmetrically with
parallel alignment.

Normal

Assess distance vision

20/20 vision on
Snellen-type chart.

The clients eye

vision is 20/20
without correction.

Normal

EARS AND HEARING

(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 595- 598)
AREA TO BE ASSESSED

NORMAL
FINDINGS

ACTUAL
FINDINGS

ANALYSIS

Inspect the auricles for

color, symmetry, position

Color same as
facial skin;
symmetry; ;
auricle is aligned
with the outer
canthus of the eye
about 10 degree

Auricles has same

color as the face;
symmetrical;
auricle is aligned
with the outer
canthus of the eye
about 10 degree

Normal

Palpate the auricles for

texture, elasticity, and
areas of tenderness

Firm, mobile, no
tenderness; pinna
recoils
immediately after
folding.
Distal third
contains hair
follicles and
glands; dry
cerumen, grayishtan color; or sticky,

Mobile, firm, and

not tender; pinna
recoils after it is
folded.

Normal

Presence of tissue
blockage on left ear
to prevent fluid
discharge

Sound is heard in

Sound travels

Deviation:
Analysis
Otitis media
causes fluid
buildup in the
middle ear.
Ref: Fundamentals
of Nursing 8th
Edition by Kozier
and Erb, page 600610
Deviation:

Inspect the external ear

canal for cerumen, skin
lesions, pus, and blood

Perform Webers test to

17

assess the bone

conduction by examining
the lateralization of sounds

both ears or is
localized at the
center of the head
(Weber Negative).

towards the left ear.

Analysis
Conductive loss
will indicate the
sound travels
towards the poor
ear.
Ref: Fundamentals
of Nursing 8th
Edition by Kozier
and Erb, page 597598

Conduct the Rinnes test to

compare air conduction to
bone conduction

Air-conducted (AC)
hearing is greater
than boneconducted (BC).

AC > BC
5s > 8s

Deviation:
Analysis
If a patient has
conductive hearing
loss, the bone
conduction sound
is longer than or
equal to the air
conduction sound.
Ref: Fundamentals
of Nursing 8th
Edition by Kozier
and Erb, page 597598

NOSE AND SINUSES

(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 599- 601)
AREA TO BE ASSESSED

NORMAL
FINDINGS

ACTUAL
FINDINGS

18

ANALYSIS

Inspect the external nose

for any deviations in
shape, size, color, flaring,
discharge from the nares

Symmetric and
straight; no
discharge or
flaring; uniform
color.

Straight; same with

skin color; no
discharge

Normal

Lightly palpate the

external nose

No tenderness and
lesions.

Not tender, no
lesions.

Normal

Determine the patency of

both nasal cavities

Symmetric,
straight; pinkish in
color; no discharge

As the clients
breathes the air
moves freely

Normal

Observe for the presence

of redness, swelling,
growths, and discharge

Mucosa pink, clear

watery discharge,
no lesions.

No lesions, mucosa
is pink and clear
watery discharge

Normal

Inspect the nasal septum

between the nasal
chambers

Nasal septum
intact and is in
midline.

Nasal septum
located at the
center.

Normal

Palpate the maxillary and

frontal sinuses

Not tender

Not tender

Normal

MOUTH AND OROPHARYNX

(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 601- 605)
AREA TO BE ASSESSED
Inspect the nasal septum
between the nasal
chambers
Inspect the outer lips for
symmetry of contour,
color, and texture

NORMAL
FINDINGS
Nasal septum
intact and is in
midline.
Pinkish in color,
dry, has elastic
texture, able to
purse the lips.

Inspect the teeth and

gums

32 adult teeth,
smooth, white,
shiny tooth
enamel, pink
gums.

Inspect the surface of the

tongue for position, color,

Central position,
pink color, moist,

19

ACTUAL
FINDINGS
Nasal septum
located at the
center.
Uniform dark
brownish red in
color, moist,
smooth, soft, and
elastic.
28 teeth and has
white, shiny tooth
enamel. Gums are
pinkish and have no
retractions. 2
dental caries on the
lower left and right
end molar. (no
wisdom tooth yet
-4)
Tongue is located at
the center. It is

ANALYSIS
Normal
Normal

Normal

Normal

and texture

Inspect the salivary duct

opening for any swelling or
redness
Inspect the hard and soft
palate for color, shape,
texture, and presence of
bony prominences

slightly rough, thin

whitish coating, no
lesions, raised
papillae.
Moves freely
without
tenderness.
Smooth tongue
base with
prominent veins.
No tenderness and
rebound
tenderness, no
swelling, no
nodules, no lumps.
Same as color of
buccal mucosa and
floor of the mouth.
Soft palate is light
pink, and smooth.
Hard palate has
lighter pink color.

Inspect the uvula for

position and mobility while
examining the palates
Inspect the oropharynx for
color and texture
Inspect the tonsils for
color, discharge, and size

Uvula positioned in
the middle of soft
palate.
Pink and smooth
posterior wall.
Pink and smooth;
no discharge.

Light pink, smooth,

soft palate; lighter
pink hard palate,
more irregular
texture.
Positioned in
midline of soft
palate.
Pink and smooth
posterior wall.
Reddish in color, no
discharge

Elicit the gag reflex by

pressing the posterior
tongue with a tongue
depressor

Present

Present

Inspect the tongue

movement
Inspect the base of the
tongue, the mouth floor,
and the frenulum
Palpate the tongue and
floor of the mouth for any
nodules, lumps, or
excoriated area

moist, has raised

papillae, has
slightly rough
surface, no lesions.
Moves freely.

Normal

Tongue base is
smooth, presence
of prominent veins.
Smooth with no
palpable nodules.

Normal

No inflammation.

Normal
Normal

Normal

Normal

Normal
Normal
Normal

NECK
(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 607- 610)
AREA TO BE ASSESSED
Observe head movement

Palpate the entire neck for

enlarged lymph nodes

NORMAL
FINDINGS
Smooth, has
coordinated
movements with
no discomfort, no
stiffness, no pain,
no limited range in
motion, no
involuntary
movements.
No enlargements,
lymph nodes

20

ACTUAL
FINDINGS
Coordinated,
smooth
movements.

ANALYSIS

Not palpable lymph

nodes

Normal

Normal

Palpate the trachea for

lateral deviation

Central placement
in midline of neck;
spaces are equal
on both sides

Located in the
midline of neck,

Normal

Inspect the thyroid gland

Not visible on
inspection
Lobes mat not be
palpated, if
palpated, lobes are
small, smooth,
centrally located,
painless, and rise
freely with
swallowing

Not visible on
inspection
Rise freely when
swallowing, no
tenderness

Normal

Palpate the thyroid gland

for smoothness

THORAX and LUNGS, HEART

(Ref: Fundamentals of Nursing 8th Edition by Kozier
AREA TO BE ASSESSED NORMAL FINDINGS
Posterior thorax
Inspect the shape and
Anteroposterior is
symmetry of the thorax
twice the size of the
from posterior and
transverse diameter
lateral views.
in ratio of 1:2.
Compare the
Chest symmetric.
anteroposterior diameter
to the transverse
diameter.
Inspect the spinal
Spine is vertically
alignment for
aligned. Hips and
deformities.
shoulders are
symmetric.
Palpate the posterior
Skin intact; has
thorax.
uniform temperature;
chest wall intact; no
tenderness; no
masses.
Palpate the posterior
chest for respiratory
excursion.
Palpate the chest for
vocal fremitus.

Percuss the thorax

Auscultate the chest

Normal

and Erb, page 614-618)

ACTUAL FINDINGS
1:2

ANALYSIS
Normal

Chest symmetric.

Spine vertically
aligned.

Normal

Skin intact; uniform

temperature; chest
wall intact; no
tenderness; no
masses

Normal

3 to 5 cm expansion,
full and symmetric.

Full and symmetric

chest expansion.

Normal

Bilateral symmetry of
vocal fremitus.
Fremitus is heard
most clearly at the
apex of the lungs
Percussion notes
resonate, except over
scapula.
Lowest point of
resonance is at the
diaphragm
Vesicular and

Bilaterally symmetric.

Normal

Resonant.

Normal

Vesicular and

Normal

21

using the flat-disc

diaphragm of the
stethoscope
Inspect breathing
patterns
Inspect the costal angle
and the angle at which
ribs enter the spine

Palpate the anterior

chest

Palpate the anterior

chest for respiratory
excursion
Palpate tactile fremitus

bronchiovesicularbre
ath sounds.

bronchiovesicularbre
ath sounds.

Quiet, rhythmic, and

effortless
respirations.
Costal angle is less
than 90 degrees, and
the ribs insert into
the spine at
approximately at 45
degrees angle.
Skin intact; has
uniform temperature;
no lesions; no
tenderness; no
masses; no abnormal
movements
3 to 5 cm. Has full
and symmetric
excursion
Same as posterior
vocal fremitus;

Quiet, rhythmic, and

effortless
respirations.
Costal angle is less
than 90 degrees.

Normal

Skin intact; uniform

temperature; chest
wall is intact; there is
no tenderness,
bulges, and abnormal
movements
Full symmetric
excursion

Normal

Same as posterior
vocal fremitus;
fremitus is normally
decreased over heart
and breast tissue
Symmetric in
percussion notes.

Normal

Bronchial and tubular

breath sounds
Bronchiovesicular
and vesicular breath
sounds

Normal

Percuss the anterior

chest systematically

Percussion notes
resonate down to the
sixth rib at the level
of the diaphragm but
are flat over areas of
heavy muscle and
bone, dull on areas
over the heart and
the liver, and
tympanic over the
underlying stomach

Auscultate the trachea

Bronchial and tubular

breath sounds
Bronchiovesicular
and vesicular breath
sounds

Auscultate the anterior

chest

Normal

Normal

Normal

Normal

HEART and CENTRAL VESSELS

(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 621-623)
AREA TO BE
NORMAL FINDINGS
ACTUAL
ANALYSIS
ASSESSED
FINDINGS
Inspect and palpate the
Normal
precordium for the
presence of abnormal
pulsations, lifts, or
heaves:
No pulsations
No pulsations

22

Inspect and palpate the

aortic and pulmonic
areas, observing
them at an angle and
to the side
Inspect and palpate the
tricuspid area for
pulsations and
heaves or lifts
Inspect and palpate the
apical area for
pulsation
Inspect and palpate the
epigastric area at the
base of the sternum
for abdominal aortic
pulsations
Auscultate the heart in
all four anatomic sites:
aortic, pulmonic,
tricuspid, and apical
(mitral)

Palpate the carotid

artery.
Auscultate the carotid
artery.
Inspect the jugular veins
for distention.

No pulsations
No lifts or heaves

No pulsations
No lift or heave

Palpable in 5th ICS and

medial MCL.
Diameter of 1 to 2 cm.
No lift or heave.
Aortic pulsations.

No lifts or heaves.
Have palpable
pulsations.
Palpable in 5th ICS
and No lift or
heave.
Aortic pulsations

S1 Usually heard at all

sites.
Usually louder at apical
area.
S2 Usually heard at all
sites.
Usually louder at base
of the heart.
S3 in children and
young adults
S4 in many older adults

S1 and S2 is heard at
all sites.

Normal

Full pulsations have

symmetric volumes.

Symmetric pulse
volumes.

Normal

Elastic arterial wall.

No sound.

No sound heard

Normal

Veins not visible.

Veins not visible.

Normal

BREAST and AXILLAE

(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 628-630)
AREA TO BE
NORMAL FINDINGS
ACTUAL FINDINGS
ASSESSED
Inspect the breasts for
Round Shape: slightly
Equal in size,
size, symmetry, and
unequal in size:
symmetric, round in
contour or shape while
generally symmetric
shape
the client is in a sitting
position.
Inspect the skin of the
Skin uniform in color
Skin is uniform in
breast for localized
(same in appearance
color; skin smooth
discolorations or
as skin of abdomen or
and intact; no
hyperpigmentation,
back).
presence of striae

23

ANALYSIS
Normal

Normal

retraction or dimpling,
localized hypervascular
areas, swelling or
edema
Inspect the areola area
for size, shape,
symmetry, color,
surface characteristics,
and any masses or
lesions
Inspect the nipples for
size, shape, position,
color, discharge, and
lesions

Skin smooth and intact

Palpate the axillary,

subclavicular, and
supraclavicular lymph
nodes.
Palpate the breast for
masses, tenderness,
and any discharge from
the nipples.
Palpate the areola and
the nipples for masses.

No presence of
tenderness, masses or
nodules

Round or oval and

bilaterally the same;
color varies from light
pink to dark brown

Round and bilaterally

the same.
Color dark brown.

Normal

Round, everted, and

equal in size; similar in
color; soft and smooth;
both nipples point in
same direction.

Round, everted, and

equal in size; similar
in color; soft and
smooth; both nipples
point in same
direction.
No tenderness,
masses, or nodules

Normal

No presence of
tenderness, masses or
nipple discharge

No tenderness,
masses, nodules, or
nipple discharge

Normal

No presence of
tenderness, masses,
nodules or nipple
discharge

No tenderness,
masses, nodules, or
nipple discharge.

Normal

ABDOMEN
(Ref: Fundamentals of Nursing 8th Edition by Kozier
AREA TO BE
NORMAL FINDINGS
ASSESSED
Inspect the abdomen for Skin is intact; uniform
skin integrity.
in color.
Inspect the abdomen for Flat rounded
contour and symmetry.
No evidence of
enlargement of liver or
spleen.
Symmetric contour.
Observe abdominal
Symmetric
movements associated
movements.
with respiration,
caused by respirations
peristalsis, or aortic
pulsations.
Observe the vascular
No visible vascular
pattern.
pattern.
Auscultate abdomen.
Bowel sounds are
audible. No bruits, and
friction rub.
Percuss abdomen.
Tympanic on the
stomach and dull on
the liver.

24

and Erb, page 633-638)

ACTUAL FINDINGS

Normal

ANALYSIS

Unblemished skin.
Uniform color.
Protruded, No
evidence of
enlargement of liver
or spleen.
Symmetric contour.
Symmetric
movements

Normal

No visible vascular
pattern.
Bowel sounds are
audible. No bruits,
and friction rub.
Tympanic on the
stomach and gasfilled bowels; dullness
over the liver and

Normal

Normal

Normal

Normal
Normal

Percuss liver to
determine its size.

10 cm in the MCL; 6 cm
at the midsternal line.

Palpate abdomen.

No tenderness; relaxed
abdomen with smooth,
consistent tension.

Deep palpation over all

four quadrants.

Tenderness present
near xiphoid process,
over cecum, and over
sigmoid colon.

Palpate liver.
Palpate bladder.

Border feels smooth.

Not palpable.

spleen, or a full
bladder.
9 cm in the MCL; 6
cm at the midsternal
line.
No tenderness;
relaxed abdomen
with smooth,
consistent tension.
Tenderness may be
present near xiphoid
process, over cecum,
and over sigmoid
colon.
May not be palpable.
Border feels smooth.
Not palpable.

MUSCULOSKELETAL
(Ref: Fundamentals of Nursing 8th Edition by Kozier and
AREA TO BE
ACTUAL FINDINGS
ASSESSED
Inspect muscles and
Equal size on both sides
tendons.
of body. No contractures.
No tremors.
Palpate muscles for
tonicity, flaccidity,
spasticity and
smoothness of
movement.
Test muscle strength:
Sternocleidomastoid
Trapezius
Deltoid
Biceps
Triceps
Wrist
Grip strength
Hip muscles
Hip abduction
Hip adduction
Hamstrings
Quadriceps
Muscles of the ankles
and feet
Inspect skeleton for
structure.
Palpate bones.
Inspect joints.

Firm. Smooth coordinated

movements

Erb, page 640-641)

NORMS AND
STANDARDS
Equal size on both
sides of body. No
contractures. No
tremors.
Normally firm.
Smooth
coordinated
movements

Normal
Normal

Normal

Normal
Normal

ANALYSIS
Normal

Normal

Normal

Equal strength on each

body side.

Equal strength on
each body side.

No deformities.

No deformities.

Normal

No tenderness or swelling.

No tenderness or
swelling.
No tenderness or
swelling.

Normal

No tenderness or swelling.

25

Normal

Palpate joints.

VI.

No tenderness, swelling,
crepitation, or nodules.
Joints move smoothly.

Laboratory Results

(Other Paper)
VII.

DRUG STUDY

(Other Paper)
VIII.

Pathophysiology

(Other Paper)

26

No tenderness,
swelling,
crepitation, or
nodules. Joints
move smoothly.

Normal

IX.
X.

Ecologic Model
Problem Identification and Prioritization
Rank

Nursing Diagnosis
& Cues
Alteration in comfort :
Pain r/t increased
intracranial pressure
secondary to CVA
Objective cues:

- + dizziness (persistent)
- + episodes of vomiting
- blurring of vision
- BP : 160/90
- facial grimae
Disturbed sensory
perception (auditory) r/t
inflammation of the
middle ear
Subjective cues:
"sa pandinig naman,
nagkaproblema siya dun
sa kaliwang tenga niya.
Hirap makading kasi
parang barado daw."
Objective cues:
- presence of tissue
blockage

Altered nutrition r/t loss

of nutrients associated
with vomiting
Objective cues:

- + 2-3 episodes of
vomitting
- 1/2 cup per episode
Acute pain r/t presence of
urinary catheter
Subjective cues:
"pero ihi lagi naman pero
pakonti konti lang.

27

Justification
Pain affects the entire body. It can
increase heart rate and blood
pressure, alter mood and cause
stress and anxiety. Until the pain is
managed, it will be difficult to
proceed with other lower priority
nursing interventions. Everything
else comes to a halt until that pain
reaches a manageable level.
Actual Problem
Physiological needs (Maslows
Hierarchy of needs)
Blockage in the ear always involve
some degree of hearing loss and a
feeling of aural fullness (Lynch, 2008)
In nursing, there are actual and risk
diagnoses. An actual diagnosis
means the health concern is already
present. A risk diagnosis means the
nurse has reason to believe the
concern is imminent. Generally
speaking, the actual problem should
take priority over the risk, unless the
risk can cause injury or death.
Actual Problem
Physiological needs (Maslows
Hierarchy of needs)
Nausea and vomiting are symptoms
associated with a wide variety of
diseases and particular life conditions
Health Threatening
Physiological needs (Maslows
Hierarchy of needs)
Bladder spasms, which feel like
stomach cramps, are also quite
common when you have a catheter
in your bladder. The pain is caused
by the bladder trying to squeeze out
the balloon, which contributes to

Masakit yung pantog niya

kapag umiihi siya.
Namimilipit siya sa sakit
dahil nilagyan siya nung
catheter."

Objective cues :
- facial grimace
- guarding behavior on
the lower abdomen area
Impaired physical
mobility r/t decreased
muscle strength
Subjective cues:
-

" 6 lang kasi

madami akong
nararamdaman at
nanghihina din"
Activity intolerance r/t
generalized weakness
Subjective cues :
"palagi lang siya na
nakahiga dito, umuupo
lang kapag gusto niyang
dumumi o umihi"

decreased urine output. -nhs.uk

Health Threatening
Physiological needs (Maslows
Hierarchy of needs)

During illness, changes may occur in

the structure and function of a
human's body and mind (Miller,
Stoeckel 2015)
Health Threatening
Physiological needs (Maslows
Hierarchy of needs)
Mobility and activity tolerance are
affected by any disorder that impairs
the ability of the nervous system,
musculoskeletal system,
cardiovascular system, respiratory
system and vestibular apparatus.
Most activity intolerance is related to
generalized weakness and
debilitation secondary to acute or
chronic illness and disease. This is
especially apparent in patients with a
history of orthopedic,
cardiopulmonary, diabetic, or
pulmonary- related problems.
Health Threatening
Physiological needs (Maslows
Hierarchy of needs)

28