Health Assessment: Health assessment is an evaluation of the health status of an individual by performing a physical examination after obtaining a health

history. Various laboratory tests may also be ordered to confirm a clinical impression or to screen for dysfunction. The depth of investigation and the frequency of the assessment vary with the condition and age of the client and the facility in which the assessment is performed. The person's response to any dysfunction present is observed and noted. The techniques of the health assessment include inspection, palpation, percussion, and auscultation. It is performed using cephalo caudal approach INITIAL ASSESSMENT: A. Father Donald Duck Father Donald Duck is born on September 21, 1978, 34 years old, male. He works as a construction worker in Mabalacat, Pampanga. Due to working hours, he was not present during the entire home visits. B. Mother Daisy Duck General Appearance: Mother Daisy Duck is born on January 15, 1982, 30 years old. She is currently unemployed. During the initial assessment, she is wearing a sando and pajamas. She weighs 45Kg. Vital Signs: Temperature: 36.7 Pulse Rate: 87 bpm Respiratory rate: 20 bpm Blood Pressure: 90/60 mmHg

Physical Assessment: Skull and Face Mother Daisy Duck has a normocephalic skull; no masses were seen nor palpated during the assessment. Mother Daisy Duck has symmetrical facial features and facial movements. She was able to carry out facial expressions asked by the student nurses (Smile, frown, puff her cheeks and raise her eyebrows.) Hair and Scalp Mother Daisy Duck has a long straight hair, oily and evenly distributed with variations, the hair is black in color and not brittle. No pediculosis, lesions and other infestations noted. Skin and Nails Mother Daisy Ducks skin has a fair dark complexion with normal skin turgor. Fingernails are and toenails are convex in curvature, capillary refill test is 2 seconds (normal) and there is no brittleness of the nails noted. Blanch test is normal. Eyes and Vision Eyebrows and eyelashes were black in color and were evenly distributed. Eyelashes were long and were slightly curved outward. Pupils are black and exhibited PERRLA (Pupil Equally round, reactive to light and accommodation). Bulbar conjunctiva is transparent in color and Palpebral conjunctiva is pinkish in color. No discharges were seen on the eyelids and corneal sensitivity test resulted normal. No edema and tenderness were noted in the lacrimal area.

Ears and Hearing Mother Daisy Duck has symmetrical ears; color is equal with the general skin

color. No tenderness was noted. Pinna recoils after folding. Ears were clean; presence of dry cerumen is noted on Mother Daisy Ducks both ears. Nose Nose is located at the midline. The nose is symmetrical and straight, no difficulty of breathing is observed; nasal patency is normal as the Mother Daisy Duck was asked to inhale through the nose with mouth closed. No discharges or any infestations were noted. Mouth Mother Daisy Ducks Lips were slightly dark and pinkish in color. Gums and tongue is pinkish in color and tongue moves freely without difficulty. No lesions or masses were noted. Tongue is centrally located and uvula is at the midline. Cavities were present and the oral cavity is moist, and the soft palate and hard palate were intact Neck Mother Daisy Ducks Neck muscles were equal in size. Head is located at the center, no difficulty in range of motion were noted as Mother Daisy Duck was asked to raised her head up, down and side by side. Lymph nodes were not palpable. No infestations were noted during the assessment.

Thorax and Lungs Chest is symmetric in size and spine is vertically aligned. No adventitious sounds

were heard upon auscultation. Normal rise and fall of the chest was noted. Quiet and effortless breathing was also observed during the assessment.

Heart Heart rate is normal with a result of 20 bpm. No presences of murmors or

abnormal heart sounds were heard upon auscultation. Upper Extremities Mother Daisy Ducks extremities were symmetrical in size and length. Movement was not difficult and has coordination. Skin is fair dark in color and good skin turgor is noted. Lower Extremities Mother Daisy Ducks lower extremities can move without difficulty and with coordination. Mother Daisy Duck was able to walk unaided and maintains balance. There are no presences of engorged veins. Cranial Nerve Assessment: Mother Daisy Duck

Cranial Nerves

Function

Assessment Technique

Normal Response

Clients Response

Instruct the patient to Cranial Nerve #1 Olfactory Sense of Type: Sensory smell or identify an aromatic non-irritating odor with each nostril separately. Occlude one nostril at a time

The client will be able to identify the scent of perfume and alcohol when asked to smell it.

Mother Daisy Duck was able to identify the scent of perfume and alcohol when

Smell

while the other one, smells while the eyes are closed.

asked to smell it.

Instruct the client to Cranial Nerve #2 Optic Type: Sensory Sense of Sight Mother Daisy Ducks Cranial Nerve # 3 Oculomotor Type: Motor Pupil Constriction and rising of eyeballs. pupils must also constrict upon introduction of penlight. With the use of penlight, instruct the client to look upward and downward and direction of the movement of penlight Type: Motor Cranial Nerve #4 Trochlear Downward and inward movement of the eye. Diagonal eye movement. Instruct the client to follow an abject such as pen with the use of his/her eyes without moving the head. read a newspaper at a given distance of 14.

Client must be able to read and see clearly at a given distance of 14

Mother Daisy Duck was able to read and see clearly the words at a given distance.

With the introduction of light, the pupil will constrict and clients eyes will follow the direction of the movement of the penlight Mother Daisy Duck eyes must follow the movement of the object used with coordination.

Mother Daisy Duck pupil constricted and she was able to follow the movement of the penlight.

Mother Daisy Duck was able to follow the direction of the pen.

Cranial Nerve #5 Type: Sensory and Trigeminal motor

Instruct the client to move the jaw while applying force on it.

Mother Daisy Duck must be able to move the jaw even with presence of force

Mother Daisy Duck was able to move her jaw with resistance. She also verbalized the sharpness of the tip of the fork and a corneal reflex was elicited.

-Jaw movement - Skin and face sensation - cornea - instruct the client to verbalize sharp sensation when the tip and handle of the fork was used.

The client will verbalize the sharp sensation of the tip and the handle of the fork. Corneal reflex is

- use the tip of the cotton to swipe the corneal surface of the eye.

present upon touching the cornea with cotton.

Type: Cranial Nerve # 6 Abducens Motor Lateral movements of the eye.

Instruct the client to follow the examiners finger as it moves from side to side.

Client must be able to follow the direction of the finger without difficulty.

Mother Daisy Duck was able to follow the movement of the finger smoothly.

-Instruct the client make Cranial Nerve # 7 Facial Type: both Sensory and Motor -Movement of the face different facial expressions, puff cheeks, raise eyebrows. - provide food with various tastes.

Client must be able to show different facial expressions.

Mother Daisy Duck was able to puff her cheeks, raise her eyebrows and show

-Sense of Taste - Identify different taste of the given food. (sugar and salt)

different expressions. - Mother Daisy Duck was able to identify the correct taste of sugar and salt

Type: Cranial Nerve # 8 Vestibulocochl Sense of ear Hearing and Balance. Sensory and Motor

Let the client listen to the ticking of the wrist watch on each ear. Allow the client to stand with feet together and arms resting at sides with eyes closed.

Client must be able to hear the ticking sound on each ear. Client must maintain an upright posture and balance.

Mother Daisy Duck was able to hear the ticking off the clock and she was able to maintain balance and posture.

Type: Cranial Nerve # 9 Glossopharyn geal Pharyngeal / movement / swallowing. Type: Cranial Nerve # 10 Vagus Speaking Sensory and Motor Sensory and Motor

Ask the client to swallow. Observed pharyngeal movement

Client must be able to swallow without difficulty.

Mother Daisy Duck was able to swallow without difficulty.

Ask the client to speak or say one sentence.

Client must be able to speak without difficulty.

Mother Daisy Duck was able to speak without difficulty.

Type: Motor

Ask the client to move

Client must be

Mother Daisy

Cranial Nerve # 11 Accessory

Head Movement and shoulder muscles

his/her head in different directions. Ask the client to raise shoulder even with force against it.

able to perform the movement and shrug shoulders.

Duck was able to moved in different directions and shrug her shoulders.

Cranial Nerve # 12 Hypoglossal

Type: Motor Movement of the tongue.

Ask the client to show his/her tongue and move side to side.

Client must be able to move his/her tongue without difficulty.

Mother Daisy Duck was able to move her tongue smoothly.

Obstetrical History: Mother Daisy Duck has a obstetrical history of G6P6(T6P0A0L6M0). She had her menarche when she was 11 years old. All her children were delivered via normal spontaneous delivery in the hospital. According to Mother Daisy Duck, she had not experienced any complications after giving birth. History of Past and Present Illness: According to Mother Daisy Duck, she hasnt experienced any serious illnesses except for fever, coughs and colds. She was never hospitalized due to certain illnesses. She had acquired chickenpox, measles and mumps when she was young. Mother Daisy Duck manages these health problems by using Over-the-counter medications such as Paracetamol and Diphenhydramine. She also uses herbal medications such as oregano and lagundi for managing coughs and colds. She then visits the hospitals when she was unable to manage the illnesses.

Activities of Daily Living Mother Daisy Duck usually stays at home to take care of her children. She usually wakes up at dawn about 5:00 in the morning. She cooks their breakfast at 6:00 in the morning. She baths her children for school. She then cooks lunch at 11:30 and will usually spend her time caring for Baby Huey Duck. She spends time with the children after schooling and usually cooks dinner at 6:00 Pm and usually sleeps at 9:00PM. B. Baby Gustave Duck General Appearance: Baby Gustave Duck is born on November 14, 2001, 11 years old. He is studying at Mauaque Elementary School, currently at Grade 5. During the initial assessment, he is wearing a shorts and he has no shirt. He weighs 25Kg and his height is 128cm. Due to his studying, he was not present with the entire home visits.

C. Baby Roast Duck General Appearance: Baby Roast Duck is born on November 14, 2002, 10 years old. He is also studying at Mauaque Elementary School, currently at Grade 4. He is wearing a sando and a blue shorts. He weighs 24Kg and his height is 127cm. He was not present with the entire home visits.

D. Baby Daphne Duck General Appearance: Baby Daphne Duck is born on August 10, 2005, 7 years old. She is studying at Mauaque Elementary School, currently at Grade 2. On the initial assessment, she is wearing a red sando and black shorts. She weighs 20Kg and her height is 110cm. At her past illness Mother Daisy Duck told us that she had Pneumonia last 2006. Vital Signs: Temperature: 36.1 Pulse Rate: 72 bpm Respiratory rate: 17 bpm Physical Assessment: Skull and Face Baby Daphne Duck has a normocephalic skull; no masses were seen nor palpated during the assessment. Baby Daphne Duck has symmetrical facial features and facial movements. She was able to carry out facial expressions asked by the student nurses (Smile, frown, puff her cheeks and raise her eyebrows.) Hair and Scalp Baby Daphne Duck has a long straight hair, oily and evenly distributed with variations, the hair is dark brown in color and not brittle. No pediculosis, lesions and other infestations noted.

Skin and Nails Baby Daphne Ducks skin has a fair complexion with normal skin turgor.

Fingernails are and toenails are convex in curvature, capillary refill test is 2 seconds (normal) and there is no brittleness of the nails noted. Blanch test is normal. Eyes and Vision Baby Daphne Ducks eyebrows and eyelashes were black in color and were evenly distributed. Eyelashes were long and were slightly curved outward. Pupils are black and exhibited PERRLA (Pupil Equally round, reactive to light and accommodation). Bulbar conjunctiva is transparent in color and Palpebral conjunctiva is pinkish in color. No discharges were seen on the eyelids and corneal sensitivity test resulted normal. No edema and tenderness were noted in the lacrimal area. Ears and Hearing Baby Daphne Duck has symmetrical ears; color is equal with the general skin color. No tenderness was noted. Pinna recoils after folding. Ears were clean; presence of dry cerumen is noted. Nose Nose is located at the midline. The nose is symmetrical and straight, no difficulty of breathing is observed; nasal patency is normal as the Baby Daphne Duck was asked to inhale through the nose with mouth closed. Clear secretions were noted. Mouth Baby Daphne Ducks Lips were slightly dark and pinkish in color. Gums and tongue is pinkish in color and tongue moves freely without difficulty. No lesions or masses were noted. Tongue is centrally located and uvula is at the midline. Cavities

were present and the oral cavity is moist, and the soft palate and hard palate were intact Neck Baby Daphne Ducks neck muscles were equal in size. Head is located at the center, no difficulty in range of motion were noted as Baby Daphne Duck was asked to raised her head up, down and side by side. Lymph nodes were not palpable. No infestations were noted during the assessment. Thorax and Lungs Chest is symmetric in size and spine is vertically aligned. No adventitious sounds were heard upon auscultation. Normal rise and fall of the chest was noted. Quiet and effortless breathing was also observed during the assessment. Heart Heart rate is normal with a result of 17 bpm. No presences of murmors or abnormal heart sounds were heard upon auscultation. Upper Extremities Baby Daphne Ducks extremities were symmetrical in size and length. Movement was not difficult and has coordination. Skin is fair dark in color and good skin turgor is noted. Lower Extremities Baby Daphne Ducks lower extremities can move without difficulty and with coordination. Baby Daphne Duck was able to walk unaided and maintains balance. There is a presence of wound on the Left lower extremity.

Cranial Nerve Assessment: Baby Daphne Duck

Cranial Nerves

Function

Assessment Technique

Normal Response

Clients Response

Instruct the patient to Cranial Nerve #1 Olfactory Sense of Smell Type: Sensory smell or identify an aromatic non-irritating odor with each nostril separately. Occlude one nostril at a time while the other one, smells while the eyes are closed. Instruct the client to Cranial Nerve #2 Optic Type: Sensory Sense of Sight Baby Daphne Ducks Cranial Nerve # 3 Oculomotor Type: Motor Pupil Constriction and rising of eyeballs. pupils must also constrict upon introduction of penlight. With the use of penlight, instruct the client to look upward and downward and direction of the movement of penlight read a newspaper at a given distance of 14.

The client will be able to identify the scent of perfume and alcohol when asked to smell it.

Baby Daphne Duck was able to identify the scent of perfume and alcohol when asked to smell it.

Client must be able to read and see clearly at a given distance of 14

Baby Daphne Duck was able to read and see clearly the words at a given distance.

With the introduction of light, the pupil will constrict and clients eyes will follow the direction of the movement of the penlight

Baby Daphne Ducks pupil constricted and she was able to follow the movement of the penlight.

Type: Motor Cranial Nerve #4 Trochlear Downward and inward movement of the eye. Diagonal eye movement. Cranial Nerve #5 Type: Sensory and Trigeminal motor

Instruct the client to follow an abject such as pen with the use of his/her eyes without moving the head.

Baby Daphne Duck eyes must follow the movement of the object used with coordination.

Baby Daphne Duck was able to follow the direction of the pen.

Instruct the client to move the jaw while applying force on it.

Baby Daphne Duck must be able to move the jaw even with presence of force

Baby Daphne Duck was able to move her jaw with resistance. She also verbalized the sharpness of the tip of the fork and a corneal reflex was elicited.

-Jaw movement - Skin and face sensation - cornea - instruct the client to verbalize sharp sensation when the tip and handle of the fork was used.

The client will verbalize the sharp sensation of the tip and the handle of the fork. Corneal reflex is

- use the tip of the cotton to swipe the corneal surface of the eye.

present upon touching the cornea with cotton.

Type: Cranial Nerve # 6 Abducens Motor Lateral movements of the eye.

Instruct the client to follow the examiners finger as it moves from side to side.

Client must be able to follow the direction of the finger without difficulty.

Baby Daphne Duck was able to follow the movement of the finger smoothly.

-Instruct the client make Cranial Nerve # 7 Facial Type: both Sensory and Motor -Movement of the face -Sense of Taste different facial expressions, puff cheeks, raise eyebrows. - provide food with various tastes.

Client must be able to show different facial expressions.

Mother Daisy Duck was able to puff her cheeks, raise her eyebrows and show different expressions. - Mother Daisy Duck was able to identify the correct taste of sugar and salt

- Identify different taste of the given food. (sugar and salt)

Type: Cranial Nerve # 8 Vestibulocochl Sense of ear Hearing and Balance. Sensory and Motor

Let the client listen to the ticking of the wrist watch on each ear. Allow the client to stand with feet together and arms resting at sides with eyes closed.

Client must be able to hear the ticking sound on each ear. Client must maintain an upright posture and balance.

Baby Daphne Duck was able to hear the ticking off the clock and she was able to maintain balance and posture.

Type: Cranial Nerve Sensory and

Ask the client to swallow. Observed pharyngeal

Client must be able to swallow

Baby Daphne Duck was able

# 9 Glossopharyn geal

Motor

movement

without difficulty.

to swallow without difficulty.

Pharyngeal / movement / swallowing. Type: Ask the client to speak or say one sentence. Client must be able to speak without difficulty.

Baby Daphne Duck was able to speak without difficulty.

Cranial Nerve # 10 Vagus

Sensory and Motor

Speaking

Type: Motor Cranial Nerve # 11 Accessory Head Movement and shoulder muscles

Ask the client to move his/her head in different directions. Ask the client to raise shoulder even with force against it.

Client must be able to perform the movement and shrug shoulders.

Baby Daphne Duck was able to moved in different directions and shrug her shoulders.

Cranial Nerve # 12 Hypoglossal

Type: Motor Movement of the tongue.

Ask the client to show his/her tongue and move side to side.

Client must be able to move his/her tongue without difficulty.

Baby Daphne Duck was able to move her tongue smoothly.

E. Baby Louie Duck General Appearance: Baby Louie Duck is born on May 10, 2007, 5 years old. He is not yet studying. On the initial assessment, he is wearing a blue sando and a basketball shorts. He weighs 17Kg and his height is 103cm. He had Pneumonia last December 19, 2008. Vital Signs: Temperature: 36.3 Pulse Rate: 82 bpm Respiratory rate: 19 bpm Physical Assessment: Skull and Face Baby Louie Duck has a normocephalic skull; no masses were seen nor palpated during the assessment. Baby Louie Duck has symmetrical facial features and facial movements. He was able to carry out facial expressions asked by the student nurses (Smile, frown, puff her cheeks and raise his eyebrows.) Hair and Scalp Baby Louie Duck has a short hair and evenly distributed with variations, the hair is dark brown in color and not brittle. No pediculosis, lesions and other infestations noted. Skin and Nails Baby Louie Ducks skin has a dark complexion with normal skin turgor. Fingernails are and toenails are convex in curvature, capillary refill test is 2 seconds (normal) and there is no brittleness of the nails noted. Blanch test is normal.

Eyes and Vision Baby Louie Ducks eyebrows and eyelashes were black in color and were evenly

distributed. Eyelashes were long and were slightly curved outward. Pupils are black and exhibited PERRLA (Pupil Equally round, reactive to light and accommodation). Bulbar conjunctiva is transparent in color and Palpebral conjunctiva is pinkish in color. No discharges were seen on the eyelids and corneal sensitivity test resulted normal. No edema and tenderness were noted in the lacrimal area. Ears and Hearing Baby Louie Ducks has symmetrical ears; color is equal with the general skin color. No tenderness was noted. Pinna recoils after folding. Ears were clean; presence of dry cerumen is noted. Nose Nose is located at the midline. The nose is symmetrical and straight, no difficulty of breathing is observed; nasal patency is normal as the Baby Louie Duck was asked to inhale through the nose with mouth closed. No presences of colds were noted. Mouth Baby Louie Ducks lips were slightly dark and pinkish in color. Gums and tongue is pinkish in color and tongue moves freely without difficulty. No lesions or masses were noted. Tongue is centrally located and uvula is at the midline. Cavities were present and the oral cavity is moist, and the soft palate and hard palate were intact. Neck Baby Louie Ducks neck muscles were equal in size. Head is located at the center, no difficulty in range of motion were noted as Baby Louie Duck was asked to raised his head up, down and side by side. Lymph nodes were not palpable. No infestations were noted during the assessment.

Thorax and Lungs Chest is symmetric in size and spine is vertically aligned. No adventitious sounds

were heard upon auscultation. Normal rise and fall of the chest was noted. Quiet and effortless breathing was also observed during the assessment. Heart Heart rate is normal with a result of 19 bpm. No presences of murmors or abnormal heart sounds were heard upon auscultation. Upper Extremities Baby Louie Ducks extremities were symmetrical in size and length. Movement was not difficult and has coordination. Skin is fair dark in color and good skin turgor is noted. Lower Extremities Baby Louie Ducks lower extremities can move without difficulty and with coordination. Baby Louie Duck was able to walk unaided and maintains balance. No presences of wounds were noted.

F. Baby Dewey Duck General Appearance: Baby Dewey Duck is born on June 9, 2008, 3 years old. He is not yet studying. His weight is 13Kg. During the assessment, Baby Dewey Duck was not able to assess by the student nurses because he is afraid due to this he was not assessed during the assessment. G. Baby Huey Duck General Appearance: Baby Huey Duck is born May 12, 2011; he is 1 year and 5 months. He is 10Kg. He is wearing a white shirt sando and he is not wearing underwear. During the assessment, Baby Dewey has a two boils on the head. Vital Signs: Temperature: 36.1 Pulse Rate: 98 bpm Respiratory rate: 20 bpm Physical Assessment: Skull and Face Baby Huey Duck has a normocephalic skull; two boils were seen during the assessment. Baby Huey Duck has symmetrical facial features and facial movements. He was able to carry out facial expressions asked by the student nurses (Smile, frown, puff her cheeks and raise her eyebrows.)

Hair and Scalp Baby Huey Duck is bald. He has a wound also in the scalp. Skin and Nails Baby Huey Ducks skin has a fair complexion with normal skin turgor. Fingernails

are and toenails are convex in curvature, capillary refill test is 2 seconds (normal) and there is no brittleness of the nails noted. Blanch test is normal. Eyes and Vision Baby Huey Ducks eyebrows and eyelashes were black in color and were evenly distributed. Eyelashes were long and were slightly curved outward. Pupils are black and exhibited PERRLA (Pupil Equally round, reactive to light and accommodation). Bulbar conjunctiva is transparent in color and Palpebral conjunctiva is pinkish in color. No discharges were seen on the eyelids and corneal sensitivity test resulted normal. No edema and tenderness were noted in the lacrimal area. Ears and Hearing Baby Huey Ducks has symmetrical ears; color is equal with the general skin color. No tenderness was noted. Pinna recoils after folding. Ears were clean; presence of dry cerumen is noted. Nose Nose is located at the midline. The nose is symmetrical and straight, no difficulty of breathing is observed; nasal patency is normal as the Baby Huey Duck was asked to inhale through the nose with mouth closed. Presences of colds were noted.

Mouth Baby Huey Ducks lips were slightly dark and pinkish in color. Gums and tongue is

pinkish in color and tongue moves freely without difficulty. No lesions or masses were noted. Tongue is centrally located and uvula is at the midline. Neck Baby Huey Ducks neck muscles were equal in size. Head is located at the center, no difficulty in range of motion were noted as Baby Huey Duck was asked to raised her head up, down and side by side. Lymph nodes were not palpable. No infestations were noted during the assessment. Thorax and Lungs Chest is symmetric in size and spine is vertically aligned. No adventitious sounds were heard upon auscultation. Normal rise and fall of the chest was noted. Quiet and effortless breathing was also observed during the assessment. Heart Heart rate is normal with a result of 20 bpm. No presences of murmors or abnormal heart sounds were heard upon auscultation. Upper Extremities Baby Huey Ducks extremities were symmetrical in size and length. Movement was not difficult and has coordination. Skin is fair in color and good skin turgor is noted. Lower Extremities Baby Huey Ducks lower extremities can move without difficulty and with coordination. Baby Huey Duck was able to walk unaided and maintains balance. Presence of mosquito bites.

Final Assessment B. Mother Daisy Duck General Appearance: Mother Daisy Duck is born on January 15, 1982, 30 years old. She is currently unemployed. During the final assessment, she is wearing a shirt and white shorts. She weighs 45Kg. Vital Signs: Temperature: 36.2 Pulse Rate: 89 bpm Respiratory rate: 18 bpm Blood Pressure: 100/60 mmHg Physical Assessment: Skull and Face Mother Daisy Duck has a normocephalic skull; no masses were seen nor palpated during the assessment. Mother Daisy Duck has symmetrical facial features and facial movements. She was able to carry out facial expressions asked by the student nurses (Smile, frown, puff her cheeks and raise her eyebrows.) Hair and Scalp Mother Daisy Duck has a long straight hair, oily and evenly distributed with variations, the hair is black in color and not brittle. No pediculosis, lesions and other infestations noted.

Skin and Nails Mother Daisy Ducks skin has a fair dark complexion with normal skin turgor.

Fingernails are and toenails are convex in curvature, capillary refill test is 2 seconds (normal) and there is no brittleness of the nails noted. Blanch test is normal. Eyes and Vision Eyebrows and eyelashes were black in color and were evenly distributed. Eyelashes were long and were slightly curved outward. Pupils are black and exhibited PERRLA (Pupil Equally round, reactive to light and accommodation). Bulbar conjunctiva is transparent in color and Palpebral conjunctiva is pinkish in color. No discharges were seen on the eyelids and corneal sensitivity test resulted normal. No edema and tenderness were noted in the lacrimal area. Ears and Hearing Mother Daisy Duck has symmetrical ears; color is equal with the general skin color. No tenderness was noted. Pinna recoils after folding. Ears were clean; presence of dry cerumen is noted on Mother Daisy Ducks both ears. Nose Nose is located at the midline. The nose is symmetrical and straight, no difficulty of breathing is observed; nasal patency is normal as the Mother Daisy Duck was asked to inhale through the nose with mouth closed. No discharges or any infestations were noted. Mouth Mother Daisy Ducks Lips were slightly dark and pinkish in color. Gums and tongue is pinkish in color and tongue moves freely without difficulty. No lesions or masses were noted. Tongue is centrally located and uvula is at the midline. Cavities

were present and the oral cavity is moist, and the soft palate and hard palate were intact Neck Mother Daisy Ducks Neck muscles were equal in size. Head is located at the center, no difficulty in range of motion were noted as Mother Daisy Duck was asked to raised her head up, down and side by side. Lymph nodes were not palpable. No infestations were noted during the assessment. Thorax and Lungs Chest is symmetric in size and spine is vertically aligned. No adventitious sounds were heard upon auscultation. Normal rise and fall of the chest was noted. Quiet and effortless breathing was also observed during the assessment.

Heart Heart rate is normal with a result of 20 bpm. No presences of murmors or

abnormal heart sounds were heard upon auscultation. Upper Extremities Mother Daisy Ducks extremities were symmetrical in size and length. Movement was not difficult and has coordination. Skin is fair dark in color and good skin turgor is noted. Lower Extremities Mother Daisy Ducks lower extremities can move without difficulty and with coordination. Mother Daisy Duck was able to walk unaided and maintains balance. There are no presences of engorged veins.

Cranial Nerve Assessment: Mother Daisy Duck

Cranial Nerves

Function

Assessment Technique

Normal Response

Clients Response

Instruct the patient to Cranial Nerve #1 Olfactory Sense of Smell Type: Sensory smell or identify an aromatic non-irritating odor with each nostril separately. Occlude one nostril at a time while the other one, smells while the eyes are closed. Instruct the client to Cranial Nerve #2 Optic Type: Sensory Sense of Sight Mother Daisy Ducks Cranial Nerve # 3 Oculomotor Type: Motor Pupil Constriction and rising of eyeballs. pupils must also constrict upon introduction of penlight. With the use of penlight, instruct the client to look upward and downward and direction of the movement of penlight read a newspaper at a given distance of 14.

The client will be able to identify the scent of perfume and alcohol when asked to smell it.

Mother Daisy Duck was able to identify the scent of perfume and alcohol when asked to smell it.

Client must be able to read and see clearly at a given distance of 14

Mother Daisy Duck was able to read and see clearly the words at a given distance.

With the introduction of light, the pupil will constrict and clients eyes will follow the direction of the movement of the penlight

Mother Daisy Duck pupil constricted and she was able to follow the movement of the penlight.

Type: Motor Cranial Nerve #4 Trochlear Downward and inward movement of the eye. Diagonal eye movement. Cranial Nerve #5 Type: Sensory and Trigeminal motor

Instruct the client to follow an abject such as pen with the use of his/her eyes without moving the head.

Mother Daisy Duck eyes must follow the movement of the object used with coordination.

Mother Daisy Duck was able to follow the direction of the pen.

Instruct the client to move the jaw while applying force on it.

Mother Daisy Duck must be able to move the jaw even with presence of force

Mother Daisy Duck was able to move her jaw with resistance. She also verbalized the sharpness of the tip of the fork and a corneal reflex was elicited.

-Jaw movement - Skin and face sensation - cornea - instruct the client to verbalize sharp sensation when the tip and handle of the fork was used.

The client will verbalize the sharp sensation of the tip and the handle of the fork. Corneal reflex is

- use the tip of the cotton to swipe the corneal surface of the eye.

present upon touching the cornea with cotton.

Type: Cranial Nerve # 6 Abducens Motor Lateral movements of the eye.

Instruct the client to follow the examiners finger as it moves from side to side.

Client must be able to follow the direction of the finger without difficulty.

Mother Daisy Duck was able to follow the movement of the finger smoothly.

-Instruct the client make Cranial Nerve # 7 Facial Type: both Sensory and Motor -Movement of the face -Sense of Taste different facial expressions, puff cheeks, raise eyebrows. - provide food with various tastes.

Client must be able to show different facial expressions.

Mother Daisy Duck was able to puff her cheeks, raise her eyebrows and show different expressions. - Mother Daisy Duck was able to identify the correct taste of sugar and salt

- Identify different taste of the given food. (sugar and salt)

Type: Cranial Nerve # 8 Vestibulocochl Sense of ear Hearing and Balance. Sensory and Motor

Let the client listen to the ticking of the wrist watch on each ear. Allow the client to stand with feet together and arms resting at sides with eyes closed.

Client must be able to hear the ticking sound on each ear. Client must maintain an upright posture and balance.

Mother Daisy Duck was able to hear the ticking off the clock and she was able to maintain balance and posture.

Type: Cranial Nerve Sensory and

Ask the client to swallow. Observed pharyngeal

Client must be able to swallow

Mother Daisy Duck was able

# 9 Glossopharyn geal

Motor

movement

without difficulty.

to swallow without difficulty.

Pharyngeal / movement / swallowing. Type: Ask the client to speak or say one sentence. Client must be able to speak without difficulty.

Mother Daisy Duck was able to speak without difficulty.

Cranial Nerve # 10 Vagus

Sensory and Motor

Speaking

Type: Motor Cranial Nerve # 11 Accessory Head Movement and shoulder muscles

Ask the client to move his/her head in different directions. Ask the client to raise shoulder even with force against it.

Client must be able to perform the movement and shrug shoulders.

Mother Daisy Duck was able to moved in different directions and shrug her shoulders.

Cranial Nerve # 12 Hypoglossal

Type: Motor Movement of the tongue.

Ask the client to show his/her tongue and move side to side.

Client must be able to move his/her tongue without difficulty.

Mother Daisy Duck was able to move her tongue smoothly.

H. Baby Daphne Duck General Appearance: Baby Daphne Duck is born on August 10, 2005, 7 years old. She is studying at Mauaque Elementary School, currently at Grade 2. On the final assessment, she is wearing her school uniform. She weighs 20Kg and her height is 110cm. Vital Signs: Temperature: 36.8 Pulse Rate: 76 bpm Respiratory rate: 18 bpm Physical Assessment: Skull and Face Baby Daphne Duck has a normocephalic skull; no masses were seen nor palpated during the assessment. Baby Daphne Duck has symmetrical facial features and facial movements. She was able to carry out facial expressions asked by the student nurses (Smile, frown, puff her cheeks and raise her eyebrows.) Hair and Scalp Baby Daphne Duck has a long straight hair, oily and evenly distributed with variations, the hair is dark brown in color and not brittle. No pediculosis, lesions and other infestations noted. Skin and Nails Baby Daphne Ducks skin has a fair complexion with normal skin turgor. Fingernails are and toenails are convex in curvature, capillary refill test is 2 seconds (normal) and there is no brittleness of the nails noted. Blanch test is normal.

Eyes and Vision Baby Daphne Ducks eyebrows and eyelashes were black in color and were

evenly distributed. Eyelashes were long and were slightly curved outward. Pupils are black and exhibited PERRLA (Pupil Equally round, reactive to light and accommodation). Bulbar conjunctiva is transparent in color and Palpebral conjunctiva is pinkish in color. No discharges were seen on the eyelids and corneal sensitivity test resulted normal. No edema and tenderness were noted in the lacrimal area. Ears and Hearing Baby Daphne Duck has symmetrical ears; color is equal with the general skin color. No tenderness was noted. Pinna recoils after folding. Ears were clean; presence of dry cerumen is noted. Nose Nose is located at the midline. The nose is symmetrical and straight, no difficulty of breathing is observed; nasal patency is normal as the Baby Daphne Duck was asked to inhale through the nose with mouth closed. No secretions were noted. Mouth Baby Daphne Ducks Lips were slightly dark and pinkish in color. Gums and tongue is pinkish in color and tongue moves freely without difficulty. No lesions or masses were noted. Tongue is centrally located and uvula is at the midline. Cavities were present and the oral cavity is moist, and the soft palate and hard palate were intact Neck Baby Daphne Ducks neck muscles were equal in size. Head is located at the center, no difficulty in range of motion were noted as Baby Daphne Duck was

asked to raised her head up, down and side by side. Lymph nodes were not palpable. No infestations were noted during the assessment. Thorax and Lungs Chest is symmetric in size and spine is vertically aligned. No adventitious sounds were heard upon auscultation. Normal rise and fall of the chest was noted. Quiet and effortless breathing was also observed during the assessment. Heart Heart rate is normal with a result of 17 bpm. No presences of murmors or abnormal heart sounds were heard upon auscultation. Upper Extremities Baby Daphne Ducks extremities were symmetrical in size and length. Movement was not difficult and has coordination. Skin is fair dark in color and good skin turgor is noted. Lower Extremities Baby Daphne Ducks lower extremities can move without difficulty and with coordination. Baby Daphne Duck was able to walk unaided and maintains balance. There is a presence of wound on the Left lower extremity.

Cranial Nerve Assessment: Baby Daphne Duck

Cranial Nerves

Function

Assessment Technique

Normal Response

Clients Response

Instruct the patient to Cranial Nerve #1 Olfactory Sense of Smell Type: Sensory smell or identify an aromatic non-irritating odor with each nostril separately. Occlude one nostril at a time while the other one, smells while the eyes are closed. Instruct the client to Cranial Nerve #2 Optic Type: Sensory Sense of Sight Baby Daphne Ducks Cranial Nerve # 3 Oculomotor Type: Motor Pupil Constriction and rising of eyeballs. pupils must also constrict upon introduction of penlight. With the use of penlight, instruct the client to look upward and downward and direction of the movement of penlight read a newspaper at a given distance of 14.

The client will be able to identify the scent of perfume and alcohol when asked to smell it.

Baby Daphne Duck was able to identify the scent of perfume and alcohol when asked to smell it.

Client must be able to read and see clearly at a given distance of 14

Baby Daphne Duck was able to read and see clearly the words at a given distance.

With the introduction of light, the pupil will constrict and clients eyes will follow the direction of the movement of the penlight

Baby Daphne Ducks pupil constricted and she was able to follow the movement of the penlight.

Type: Motor Cranial Nerve #4 Trochlear Downward and inward movement of the eye. Diagonal eye movement. Cranial Nerve #5 Type: Sensory and Trigeminal motor

Instruct the client to follow an abject such as pen with the use of his/her eyes without moving the head.

Baby Daphne Duck eyes must follow the movement of the object used with coordination.

Baby Daphne Duck was able to follow the direction of the pen.

Instruct the client to move the jaw while applying force on it.

Baby Daphne Duck must be able to move the jaw even with presence of force

Baby Daphne Duck was able to move her jaw with resistance. She also verbalized the sharpness of the tip of the fork and a corneal reflex was elicited.

-Jaw movement - Skin and face sensation - cornea - instruct the client to verbalize sharp sensation when the tip and handle of the fork was used.

The client will verbalize the sharp sensation of the tip and the handle of the fork. Corneal reflex is

- use the tip of the cotton to swipe the corneal surface of the eye.

present upon touching the cornea with cotton.

Type: Cranial Nerve # 6 Abducens Motor Lateral movements of the eye.

Instruct the client to follow the examiners finger as it moves from side to side.

Client must be able to follow the direction of the finger without difficulty.

Baby Daphne Duck was able to follow the movement of the finger smoothly.

-Instruct the client make Cranial Nerve # 7 Facial Type: both Sensory and Motor -Movement of the face -Sense of Taste different facial expressions, puff cheeks, raise eyebrows. - provide food with various tastes.

Client must be able to show different facial expressions.

Mother Daisy Duck was able to puff her cheeks, raise her eyebrows and show different expressions. - Mother Daisy Duck was able to identify the correct taste of sugar and salt

- Identify different taste of the given food. (sugar and salt)

Type: Cranial Nerve # 8 Vestibulocochl Sense of ear Hearing and Balance. Sensory and Motor

Let the client listen to the ticking of the wrist watch on each ear. Allow the client to stand with feet together and arms resting at sides with eyes closed.

Client must be able to hear the ticking sound on each ear. Client must maintain an upright posture and balance.

Baby Daphne Duck was able to hear the ticking off the clock and she was able to maintain balance and posture.

Type: Cranial Nerve Sensory and

Ask the client to swallow. Observed pharyngeal

Client must be able to swallow

Baby Daphne Duck was able

# 9 Glossopharyn geal

Motor

movement

without difficulty.

to swallow without difficulty.

Pharyngeal / movement / swallowing. Type: Ask the client to speak or say one sentence. Client must be able to speak without difficulty.

Baby Daphne Duck was able to speak without difficulty.

Cranial Nerve # 10 Vagus

Sensory and Motor

Speaking

Type: Motor Cranial Nerve # 11 Accessory Head Movement and shoulder muscles

Ask the client to move his/her head in different directions. Ask the client to raise shoulder even with force against it.

Client must be able to perform the movement and shrug shoulders.

Baby Daphne Duck was able to moved in different directions and shrug her shoulders.

Cranial Nerve # 12 Hypoglossal

Type: Motor Movement of the tongue.

Ask the client to show his/her tongue and move side to side.

Client must be able to move his/her tongue without difficulty.

Baby Daphne Duck was able to move her tongue smoothly.

I.

Baby Louie Duck

General Appearance: Baby Louie Duck is born on May 10, 2007, 5 years old. He is not yet studying. On the final assessment, he is wearing a sando and blue shorts. He weighs 17Kg and his height is 103cm. Vital Signs: Temperature: 36.5 Pulse Rate: 88 bpm Respiratory rate: 16 bpm Physical Assessment: Skull and Face Baby Louie Duck has a normocephalic skull; no masses were seen nor palpated during the assessment. Baby Louie Duck has symmetrical facial features and facial movements. He was able to carry out facial expressions asked by the student nurses (Smile, frown, puff her cheeks and raise his eyebrows.) Hair and Scalp Baby Louie Duck has a short hair and evenly distributed with variations, the hair is dark brown in color and not brittle. No pediculosis, lesions and other infestations noted. Skin and Nails Baby Louie Ducks skin has a dark complexion with normal skin turgor. Fingernails are and toenails are convex in curvature, capillary refill test is 2 seconds (normal) and there is no brittleness of the nails noted. Blanch test is normal.

Eyes and Vision Baby Louie Ducks eyebrows and eyelashes were black in color and were evenly

distributed. Eyelashes were long and were slightly curved outward. Pupils are black and exhibited PERRLA (Pupil Equally round, reactive to light and accommodation). Bulbar conjunctiva is transparent in color and Palpebral conjunctiva is pinkish in color. No discharges were seen on the eyelids and corneal sensitivity test resulted normal. No edema and tenderness were noted in the lacrimal area. Ears and Hearing Baby Louie Ducks has symmetrical ears; color is equal with the general skin color. No tenderness was noted. Pinna recoils after folding. Ears were clean; presence of dry cerumen is noted. Nose Nose is located at the midline. The nose is symmetrical and straight, no difficulty of breathing is observed; nasal patency is normal as the Baby Louie Duck was asked to inhale through the nose with mouth closed. Clear secretions were noted. Mouth Baby Louie Ducks lips were slightly dark and pinkish in color. Gums and tongue is pinkish in color and tongue moves freely without difficulty. No lesions or masses were noted. Tongue is centrally located and uvula is at the midline. Cavities were present and the oral cavity is moist, and the soft palate and hard palate were intact. Neck Baby Louie Ducks neck muscles were equal in size. Head is located at the center, no difficulty in range of motion were noted as Baby Louie Duck was asked to raised his head up, down and side by side. Lymph nodes were not palpable. No infestations were noted during the assessment.

Thorax and Lungs Chest is symmetric in size and spine is vertically aligned. No adventitious sounds

were heard upon auscultation. Normal rise and fall of the chest was noted. Quiet and effortless breathing was also observed during the assessment. Heart Heart rate is normal with a result of 19 bpm. No presences of murmors or abnormal heart sounds were heard upon auscultation. Upper Extremities Baby Louie Ducks extremities were symmetrical in size and length. Movement was not difficult and has coordination. Skin is fair dark in color and good skin turgor is noted. Lower Extremities Baby Louie Ducks lower extremities can move without difficulty and with coordination. Baby Louie Duck was able to walk unaided and maintains balance. No presences of wounds were noted. J. Baby Huey Duck General Appearance: Baby Huey Duck is born May 12, 2011; he is 1 year and 5 months. He is 10Kg. He is wearing a white and green lining shirt sando and wearing white shorts. During the assessment, Baby Huey Duck is sleeping; the two boils become one and have no abscess.