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GUYS, HERE’S THE DISTRIBUTION OF TASKS..

KINDLY REVISE AS
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NA LANG MGA CUES… SEND THEM ASAP..TNX..:)

TXT ME PAG NASEND NYU NA..:)

I. BIOGRAPHIC DATA (narrative)


Name:
Address:
Age: Gender:
Civil Status:
Religious affiliation:
Occupation:
Room & bed #:
Chief complaint:
Provisional Diagnosis:
Attending Physician:

II. NURSING HISTORY (narrative)

A. Past Health History


B. History of present illness
C. Family History
D. Obstetric History (for OB cases only)
E. Developmental History (for Pediatric cases only)

III. PATTERNS OF FUNCTIONING (PERSON model)

A. (Den)Psychosocial
Interpretation:
Analysis:
B. (Ryan)Elimination
Interpretation:
Analysis:
C. (Nikka)Rest and Sleep
Interpretation:
Analysis:
D. (Jae)Safe Environment
Interpretation:
Analysis:
E. (Aya)Oxygenation
Interpretation:
Analysis:
F. (Jae)Nutrition Metabolic
Interpretation:
Analysis:
IV. ACTIVITIES OF DAILY LIVING (Darwin and zhar)

Before During
Interpretation
ADL Hospitalizatio Hospitalizatio
and Analysis
n n
Nutrition
Elimination
Exercise
Hygiene
Substance Abuse
Sleep and Rest
Sexual Activity

V. PHYSICAL ASSESSMENT (MArben)

Interpret
Actual
Norms ation and
Findings
Analysis
General Appearance
1. Posture/Gait
2. Skin color
3. Personal
Hygiene/ Grooming
4. Nutritional
status
5. Age
appropriateness
6. Verbal
behavior
7. Non-verbal
behavior
Measurements
1. Temperature
2. Pulse rate
3. Respiratory
rate
4. Blood pressure
5. Weight
6. Height
Interpret
Body Part Actual
Norms ation and
(Technique used) findings
Analysis
General Survey
1. Body built, Proportionate, varies with lifestyle
height and weight
2. Posture, gait , Relaxed, erect posture; coordinated
standing, sitting movement
and walking
3. Overall hygiene Clean, neat
and grooming
4. Body and No body odor or minor body odor
breathe odor relative to work or exercise; no breath
color
5. Sign of distress No signs of distress
in posture of facial
expression
6. Obvious signs Healthy appearance
of health or illness
7. Clients attitude Cooperative, able to follow
instructions
8. Clients Appropriate to situation
affect /mood ;
appropriateness
9. Quality and Understandable, moderate pace; clear
Quantity of speech tone and inflection; exhibits thought
association
10. Relevance and Logical sequence; makes sense; has
organization of sense of reality
thought
Skin
11. Skin color and Varies from light to deep brown; from
uniformity ruddy pink to light pink; from yellow
overtones to olive. Uniform
12. Presence of No edema
edema
13. Skin lesion Freckles, some birthmarks, some flat
according to and raised nevi; no abrasions or other
location, lesions
distribution, color,
configuration, size
shape, type of
structure
14. Skin moisture Moisture in skin folds and the axillae
(varies with environmental
temperature and humidity, body
temperature, and activity)
15. Skin Uniform; within normal range
temperature
16. Skin turgor When pinched, skin springs back to
previous state; may be slower in
elders
Fingernails
17. Fingernail Convex curvature; angle of nail plate
plate shape, about 160°
curvatures and
angle
18. Fingernail and Highly vascular and pink in light-
toe nail bed color skinned clients; dark-skinned clients
may have brown or black
pigmentation in longitudinal streaks
19. Fingernail and Smooth texture
toenail texture
20. Tissues Intact epidermis
surrounding the
nails
21. Blanch test Prompt return of pink or usual color
capillary refill (generally less than 4 seconds)
Skull
22. Skull size, Rounded (normocephalic and
shape or symmetry symmetric, with frontal, parietal, and
occipital prominences); smooth skull
contour
23. Nodules, Smooth, uniform consistency; absence
masses and of nodules or masses
depression
Scalp
24. Color and Uniform in color (light brown)
appearance
25. Areas of No tenderness
tenderness
Hair
26. Hair evenness Thick hair, Evenly distributed
of growth, thickness
or thinness
27. Hair texture Silky Resilient hair
and oiliness over
the scalp
Face
28. Facial features, Coordinated movement, Symmetric or
symmetry of facial slightly asymmetric facial features;
movement palpebral fissures equal in size;
symmetric nasolabial folds
Eyebrows
29. Hair Hair evenly distributed; skin intact,
distribution, eyebrows symmetrically aligned;
alignment , skin equal movement
quality and
movement
Eyelashes
30. Hair equally distributed; curled slightly
distribution and outward
direction of curl
Eyelids
31. Surface Skin intact; no discharge; no
characteristic, discoloration,
position in relation Lids close symmetrically,
to cornea, ability to Approximately 15 to 20 involuntary
blink and frequency blinks per minute; bilateral blinking,
of blinking When lids open, no visible sclera
above corneas, and upper and lower
borders of cornea are slightly covered
Conjunctiva
32. Bulbar Transparent; capillaries sometimes
conjunctivae (lying evident; sclera appears white (darker
over the cornea ) or yellowish and with small brown
for color, texture macules in dark-skinned clients)
and presence of
lesion
33. Palpebral Shiny, smooth, and pink or red
conjunctivae (lying
over the cornea for
color, texture, and
presence of lesion
Sclera
34. Color and
clarity White in color
Cornea
35. Clarity and Smooth, transparent, details of the iris
texture is visible

Iris
36. Shape Brown, Flat and oval

Pupil
37. Color, shape Black, Smooth border
and symmetry

38. Light reaction Illuminated pupil constricts (direct


and accommodation response) Non-illuminated pupil
also constricts (consensual response),
Pupils constrict when looking at near
object; pupils dilate when looking at
far object; pupils converge when near
object is moved toward nose
Visual Acuity
39. Near vision able to read the letter in the near
vision
40. Distance vision 20/20 vision on Snellen-type chart
Lacrimal Apparatus
No edema or tenderness over lacrimal
41. Lacrimal Gland gland
Visual fields
42. Peripheral able to see the object at his
fields periphery(90 , 50 and 70)
Extra ocular muscle
43. Alignment and Both eyes coordinated, move in
coordination unison, with parallel alignment
Ear
44. Color, Auricle is aligned with her outer
symmetry and cantus of the eye, Uniform in color
position (light Brown), Symmetrical

45. Texture, Not tender, Mobile, Firm, Elastic ,


elasticity and areas Pinned recoil when folds
for tenderness

External ear canal


46. Presence of Dry cerumen, No lesion, Hair follicles
cerumen, skin
lesion, pus and
blood

Hearing acuity test


47. Clients able to respond in normal voice tone
response to normal
voice
48. Watch Tick able to hear the ticking of watch on
Test both ears.
49. Weber’s Test not able to hear the vibration on both
ears (-)
50. Rinne’s Test AC>BC
Nose
51. Shape. Size or Straight, symmetrical,
color and flaring or
discharge from
nares
uniform in color (light brown), no
flaring, no discharge
52. Nasal cavities Mucosa pink, Clear, watery discharge,
no lesion

53. Nasal septum Nasal septum is intact in midline


between nasal
chambers
54. Patency Air moves freely as the client
breathes through the nares.
55. Tenderness, No tenderness or masses
masses
displacement of
bone and cartilage
Sinuses
56. Note for
tenderness Absence of tenderness
Mouth and lips
57. Symmetry of Uniform pink in color, soft, moist,
contour, color and smooth in texture, Symmetrical,
texture ability to purse lips

Buccal Mucosa
58. Color, Uniform in color, moist, smooth, soft,
moisture, texture glistening and elastic.
and presence of
lesions
Teeth
59. Color, number, White, smooth, shiny, tooth enamel
texture and
presence of
dentures
Gums
60. Color and Pink, moist, shiny, no retraction of
condition gums

Oropharynx and tonsils


61. Color and Pink, smooth posterior wall
texture
62. Shape of the Pink, smooth, no discharge, normal
tonsils, color and size-grade
discharge
Neck and Lymph nodes
63. Tenderness in Not palpable
the lymph nodes
Trachea
64. Placement of Central placement in the midline of
trachea the neck, spaces are on both sides
Thyroid Gland
65. Symmetry and Not visible on inspection
visible masses
66. Smoothness Smooth, painless, rise freely when
and areas of swallowing
enlargement ,
masses or nodules
Thorax
Posterior Thorax
67. Inspect the Antroposterior to transverse diameter
size, shape, has the ratio of 1:2, Chest symmetry
symmetry and
compare the
diameter of
anteroposterior
thorax to transverse
diameter
68. Inspect the Spine vertically alignment
spinal alignment
69. Palpate for No tenderness, no masses, uniform
temperature temperature
tenderness and
masses
70. Assess Full and symmetric chest,
respiratory
excursion the thumbs separate at about 3-
5cm(1.5inches-2inches)when the
clients take a deep respiration
71. Palpate for Bilateral symmetry of vocal fremitus,
vocal fremitus fremitus is hard clearly mostly at the
apex of lung
72. Percuss the Percussion notes resonate, except
posterior thorax over the scapula
73. Auscultate the Vesicular and bronchovesicular
posterior thorax breathe sounds
Anterior Thorax
74. Inspect Quite, rhythmic, effortless respiration
breathing pattern

75. Palpate for Uniform temperature, no tenderness,


temperature, no masses
tenderness and
masses
76. Asses the Full and symmetric chest, the thumb
respiratory separates at about 3-5cm when the
excursion client takes a deep breathe
77. Palpate the Bilateral symmetry of vocal fremitus,
vocal fremitus fremitus heard clearly mostly at the
apex of the lung, fremitus normally
decreased over the heart
78. Auscultate the Bronchial breathe sounds
trachea
79. Auscultate the Vesicular and bronchovesicular
anterior thorax breathe sounds
80. Percuss the Percussion notes resonance, down to
anterior thorax the sixth ICS at the level of the
diaphragm, flat over the areas of
heavy muscle and bone, dull over
areas of the heart and liver, tympanic
over the underlying stomach
Cardiovascular
81. Aortic and No pulsation, no lifts, no heaves
pulmonic areas
82. Tricuspid area No pulsation, no lifts, no heaves
83. Apical area Pulsation is visible, palpable in most
PMI in 5th LICS at or medical to MCL,
diameter of 1-2cm, no lifts, no heaves
84. Auscultate the S1 usually heard at all sites
aortic, pulmonic,
tricuspid and apical
areas
Carotid arteries
85. Palpate for the Symmetric pulse volumes, full
carotid arteries pulsation, thrusting quality
86. Auscultate the No sound heard on auscultation
carotid arteries
Jugular veins
87. Inspect the Veins are not visible
jugular veins
Breast and axillae
88. Inspect the Slightly unequal, generally symmetric
breast for size
symmetry, contour
while the client is I
n sitting position
89. Inspect the Skin intact, uniform in color , no
skin of the breast discoloration, no dimpling, no edema
for localized
discolorations,
retraction, dimpling
edema
90. Inspect the Round bilaterally the same, color
areola for size, varies from light dark brown, no
shape, symmetry, masses
color, surface
characteristic and
any masses
91. Inspect the Round, everted, equal size, both point
nipples for size, in same direction, no discharge, no
shape, symmetry, lesion
color, discharge and
lesion
92. Palpate the No tenderness, no masses, no
breast for nodules, no nipple discharge
tenderness, masses
nodules and
discharge
93. Palpate nipple No tenderness, no masses, no
for discharge and nodules, no nipple discharge
tenderness
Abdomen
94. Inspect the Uniform in color, unblemished
abdomen for
integrity of the skin

95. Inspect the Flat, rounded


abdominal contour
while standing at
the clients side
while the clients is
in dorsal position
96. Inspect for an No visible enlargement of the liver or
enlarged liver or spleen
spleen
97. Assess the Symmetric contour
symmetry of
contour while
standing at the foot
of the bed
98. Inspect the Symmetric movement caused by the
abdominal respiration
movement s
associated with
respirations,
peristalsis or aortic
pulsation
99. Observe No visible vascular pattern
vascular pattern
100. Auscultate the Audible bowel sounds, absence of
abdomen for bowel arterial bruits, absence of friction rub
sounds, vascular
sounds and
peritoneal friction
rub
101. Percuss Tympanic over stomach, gas –filled
several areas in bowels, dullness over the liver and
each 4 quadrants spleen
102. Perform light No tenderness, relaxed abdomen
palpation followed smooth with consistent tension,
by deep palpation tenderness may be present over
of all four quadrants sigmoid colon
Musculoskeletal system
Muscle
103. Inspect the Equal in size
muscles for size
and compare the
muscle of one of
the body to the
same muscle of the
other side of body
104. Inspect the No contractures or shortening
muscle and tendons
for contractures
105. Inspect the No tremors, no fasciculation
muscle for
fasciculation and
tremors. Inspect
any tremors of the
hands and arms out
in front of the body
106. Palpate muscle Normally firm
tonicity
107. test for Full resistance, Grade 5
strength (neck)
108. test for Full resistance, Grade 5
strength (upper
extremities )
109. test for Full resistance, Grade 5
strength (lower
extremities)
Bones
110. Inspect the No deformities
skeleton for normal
structures and
deformities
111. Palpate the No tenderness, no swelling
bones to locate
any areas of edema
or tenderness
Joints
112. Inspect the No swelling
joint for swelling
113. Palpate each No tenderness, no swelling, no
joint for tenderness, crepitation, no nodules, joint moves
smoothness of smoothly
movement,
swelling, crepitation
and presence of
nodule
114. Assess range Varies to some degree in accordance
of motion with person’s genetic make –up and
degree of physical activity
115. Upper No tenderness
extremities
(shoulder and
scapula)
116. Upper No tenderness
extremities(elbows)
117. Upper No tenderness
extremities(hands)
118. Lower No tenderness
extremities
( inguinal area)
119. Lower No tenderness
extremities
(popliteal)
120. Lower No tenderness
extremities (ankle)
VI. PATHOPHYSIOLOGY (Kiko and caryl)
VII. ECOLOGIC MODEL (Kiko and caryl)
A. Hypothesis
B. Predisposing factors
1. Host
a. Age
b. Sex
c. Race
d. Nationality
e. Behavior
f. Customs
g. Heredity
2. Agent
a. Mechanical
b. Physical
c. Chemical
3. Environment
a. Physical
b. Biologic
c. Socio-economic
C. Ecologic Model
D. Analysis (with reference)
E. Conclusions and Recommendations