PHYSICAL ASSESSMENT

When skin is pinched it goes to previous state after 3 seconds.

With fair complexion.
 Skin With dry skin

Evenly distributed hair.

With short, dry, black and some grey hair at the top of the
 Hair head.
With no presence of pediculosis Capitis.

Smooth and has intact epidermis

With short and clean fingernails and toenails.
 Nails
Convex and with good capillary refill time of 2 seconds.

Rounded, normocephalic and symmetrical, smooth and has

Skull
uniform consistency.Absence of nodules or masses.

Symmetrical facial movement, palpebral fissures equal in size,

Face
symmetric nasolabial folds.

Eyes and Vision

Hair evenly distributed with skin intact.

Eyebrows are symmetrically aligned and have equal
 Eyebrows
movement.

Equally distributed
 Eyelashes

Skin intact with no discharges and no discoloration.

Lids close symmetrically and blinks involuntary.
 Eyelids
Presence of eye bags

 Bulbar Transparent with capillaries slightly visible

 conjunctiva

 Palpebral Shiny, smooth, pink

Conjunctiva
Appears white.
 Sclera

 Lacrimal gland,
No edema or tenderness over the lacrimal gland and no
Lacrimal sac,
Nasolacrimal tearing.
duct
Cornea

Transparent, smooth and shiny upon inspection by the use of a

penlight which is held in an oblique angle of the eye and
 Clarity and
texture moving the light slowly across the eye.
Have [brown] eyes.

Blinks when the cornea is touched through a cotton ball from

 Corneal
sensitivity the back of the client.

Black, equal in size with consensual and direct reaction, pupils

Pupils
equally rounded and reactive to light and accommodation.

When looking straight ahead, the client can see objects at the
periphery which is done by having the client sit directly facing
the nurse at a distance of 2-3 feet.
Visual Fields
The right eye is covered with a card and asked to look directly
at the student nurse’s nose. Hold penlight in the periphery and
ask the client when the moving object is spotted.

Ear and Hearing

Color of the auricles is same as facial skin, symmetrical, auricle

is aligned with the outer canthus of the eye, mobile, firm, non-
 Auricles
tender, and pinna recoils after it is being folded.

 External Ear Without impacted cerumen.

Canal
 Whisper Test Was not able to hear whispering on both ears at a distance of
 one feet

Nose and sinuses

Symmetric and straight, no flaring, uniform in color, air moves

 External Nose freely as the clients breathes through the nares.

 Nasal Cavity

Mucosa is pink, no lesions and nasal septum intact and in

middle with no tenderness. She can smell kind of scent

Mouth and Oropharynx Symmetrical, pink lips and gums

With decayed lower molars in the gums. She is using a

 Teeth prosthetic teeth in the upper gum.

 Tongue and Central position, pink but with whitish coating which is normal,
floor of the with veins prominent in the floor of the mouth.
mouth
Moves when asked to move without difficulty and without
 Tongue
movement tenderness upon palpation.

Uvula Positioned midline of soft palate.

Positioned at the midline without tenderness and flexes easily.

Neck
No masses palpated.

Coordinated, smooth movement with no discomfort, head

Head movement
laterally flexes, head laterally rotates and hyperextends.

Muscle strength With equal strength

Lymph Nodes Non-palpable, non tender

 Not visible on inspection, glands ascend but not visible in
 Thyroid Gland female during swallowing and visible in males.

Thorax and lungs

Posterior thorax Chest symmetrical

Spine vertically aligned, spinal column is straight, left and right

 Spinal
alignment shoulders and hips are at the same height.

Breath Sounds With normal breath sounds without dyspnea.

Quiet, rhythmic and effortless respiration

 Anterior Thorax

Unblemished skin, uniform in color, symmetric contour, not

Abdomen
distended.

Abdominal movements Symmetrical movements cause by respirations.

 Auscultation of With audible sounds

bowel sounds
Upper Extremities Without scars and lesions on both extremities.

With minimal scars on lower extremities. With no presence of

Lower Extremities
edema in legs.

Equal in size both sides of the body, smooth coordinated

Muscles movements, 100% of normal full movement against gravity
and full resistance.

Presence of deformities in hands and swelling in the knee joint

Bones and Joints
(right side)

Mental Status

Language Can express oneself by speech or sign.

Orientation Oriented to a person, place, date or time.

Attention span Able to concentrate as evidence by answering the questions

 appropriately.

GORDON’S 11 FUNCTIONAL HEALTH PATTERN

GORDON’S 11 PRESENT HEALTH PATTERN

FUNCTIONAL HEALTH
PATTERN
HEALTH The client believes that health is important to an
PERCEPTION-HEALTH individual; she follows doctor’s order to improve her
MANAGEMENT health condition and complies with her medication
PATTERN regimen but there are times where she skips her
naproxen and take it only whenever pain occurs in the
joints of her knees. She also manage the pain by
massaging the body part involved.

NUTRITIONAL AND The client verbalized that she has no allergies to food
METABOLIC and drugs, she ate three times a day with snack in
PATTERN between. She typically consumes 7-8 glasses of water a
day and she state that she also drinks black coffee in the
morning and afternoon.
ELIMINATION The client usually urinates three times a day with light
PATTERN yellow color. She defecates once a day with golden
brown color, firm and soft consistency. She doesn’t
express any problem in voiding and defecating.
ACTIVITY-EXERCISE According to the client, she stretches her ankle every
PATTERN morning when she wakes up. She can still tolerate doing
household chores such as cleaning their backyard and
gardening which serves as her daily exercise. She even
reported “Haan nak sanay nu awan ti ububbraek, kasla
mandi ti rikriknaek nu awan ti ar aramidek.
SEXUALITY- The client claimed that she is sexually inactive due to her
REPRODUCTIVE age and aging process.
PATTERN
SLEEP-REST The client usually sleeps 5-6 hours; her earliest time in
PATTERN going to sleep was around 9-10 o’clock in the evening
just after she finished watching TV then wakes up at
around 2-3 am in the morning. According to her, she
experience difficulty in going to sleep and doesn’t use
any medication to promote sleep.
COGNITIVE- The client is oriented to people, time and place. She
PERCEPTUAL responses to stimuli verbally and physically. The client
PATTERN able to respond to questions asked by the student nurse.
 The client educational attainment is elementary
undergraduate but she is able to read and write.
ROLES- The client plays the role of a grandmother to her
RELATIONSHIP grandchildren and a wife to her husband. She is well
PATTERN supported by her family. Additionally, she maintains a
good relationship with her family. The client even stated,
“Mayat met ti komunikasyon mi a agkakabbalay pati
karrubak ngem mas pilyek lang umadayo nukwa ta adda
dagiti sao a sabali pagawawatak”. She also clarified that
there are no conflicts among them.
SELF-PERCEPTION- The client is experiencing negative behaviors toward
SELF CONCEPT herself primarily regarding her bone derformities. She
PATTERN stated,””. Seeing her family's support, love and care
makes her contented and also it serves as her distraction
to alleviate herself in her condition.
COPING-STRESS The client copes up with stress through watching
PATTERN television, cleaning their backyard and gardening. Every
time there's a problem in their family, they resolve it by
talking to each other with the people who are involve.
The client has a traumatic experience in the past wherein
they were almost attacked by terrorists which brought
fear to them and led them to transfer in another place.
VALUE BELIEF The client's religious affiliation is Roman Catholic. She
PATTERN seldom goes to church because of the pandemic and
also because of her condition but she never forgot to
pray. The client also believes in quack doctors and
sometimes, she consults to them.

NCP

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective Acute pain r/t At the end of Independendent Nursing GOAL MET:
Data joint 1hr of nursing Interventions After 1hr. of
(+)Swelling degeneration interventions, Assessed the To identify the nursing
knees the patient client’s appropriate interventions,
Pain scale: will report description of nursing the patient
4/10 pain is pain. intervention for reported pain
Subjective relieved from the patient. is relieved
Data 4/10 to 0/10 Assessed the To determine if from 4/10 to
“Nasakit nu client’s there are 0/10
ingatum ti previous practices being
takyag ku”, as experiences done that could
verbalized by with pain and exacerbate the
the patient pain relief. problem.
Emphasized to To raise
the patient the awareness
importance of regarding the
taking prescribed
medication medication that
accordingly. alleviates pain
occurrence.
Applied cold Cold reduces
pack in the pain,
knee of the inflammation,
patient and and muscle
instructed to spasticity by
do it whenever decreasing the
pain occurs. release of pain-
inducing
chemicals and
slowing the
conduction of
pain impulses.
Supported Flexion of the
Joints in a joints may
slightly flexed reduce muscle
position spasms and
through the other
use of pillows. discomforts.
Instructed the Limiting the
patient to rest factors that
in between could cause
activities. stress of the
joints may
reduce pain
occurrence.
Dependent Nursing Intervention
Instructed the This NSAID
patient to take drugs acts by
naproxen as reducing
prescribed prostaglandin
synthesis vie
the inhibition of
cyclooxygens e-
2 (COX-2)
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Objective Data Interrupted At the end of Independent Nursing After 30
(+) Eyebags sleep pattern 30 minutes. Of Interventions minutes. Of
Subjective r/t caffeine nursing Instructed the Caffeine intake nursing
Data intake and intervention, patient to specially in the intervention,
She states ineffective the patient will limit/avoid afternoon the patient
that she also coping demonstrate drinking could interfere demonstrated
drinks black techniques to coffee. the patient’s techniques to
coffee in the Traumatic improve sleep ability to relax improve sleep
morning and experience pattern and sleep. pattern
afternoon. Encouraged L-tryptophan is
patient to take a component
The client milk instead. of milk which
has a promotes
traumatic sleep.
experience Instruct the Consistent
in the past patient to schedules
follow a facilitate
consistent regulation of
daily schedule the circadian
for rest and rhythm and
sleep. decrease the
energy needed
for adaptation
to changes.
Introduced These
reading a book activities
or listening to provide
calm music relaxation and
before distraction to
bedtime. prepare mind
and body for
sleep.
Suggest patient To prevent
to get out of distracting
bed thoughts
temporarily
and perform
DBE for 30-45
minutes

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective Data Impaired At the end of Independendent Nursing
Whisper test verbal 1hr of Interventions
result as follows: communication nursing Instructed the To protect
Slight auditory r/t hearing intervention, patient to stay hearing
hearing disability the patient away from
impairment will interact noise
without
Subjective Data hesitation
“Mayat met ti and preserve
komunikasyon mi hearing.
a agkakabbalay
pati karrubak
ngem mas pilyek
lang umadayo
nukwa ta adda
dagiti sao a
sabali
pagawawatak”,a
s verbalized by
the patient
Reinforced to Too much build
the patient up can reduce
that earwax hearing while
removal should performing it
be done every frequently
two weeks impairs hearing
interval as well.
Involved the Enhances
S/Os in plan of participation
care as much and
as possible commitment of
the client
Used and Promoting the
encouraged quality of
S/Os to speak transmitting
to the client information
slowly and also promotes
with communication
appropriate
volume.
Dependent Nursing
Interventions
Referred to an To determine
ENT doctor for the extent of
further hearing
assessment impairment and
obtain
prescribed
 hearing aid, as
appropriate

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective Data Disturbed body At the end of Independent Nursing After 1hr of
(+) Bone image r/t bone 1hr of nursing Interventions nursing
deformities on features intervention, Encouraged Sharing their intervention,
both arms the patient will the patient to feelings the patient
Subjective demonstrate express provides demonstrated
Data strategies to feelings about excellent strategies to
“Kitam ne adjust to new body changes.  insight into the adjust to new
nakkung, reality. patient’s reality.
nagmandi nga insecurities
kitkitan tuy and helps the
imak”, as nurse in
verbalized by individualizing
the patient care.
Encouraged To become
the patient in used to the
self-care with a altered body
step-by-step part or
approach.  function
without
overwhelming
the patient. 
Assured the Reassurance of
patient about that bone
the normalcy deformity is
of undergoing part of aging
to this age- process may
related process be comforting
for the patient
and promotes
a normal
healing
process. 
Advised the Strengthening
patient to skills can boost
focus on the patient’s
remaining confidence and
abilities. distract from
feelings of
loss. 
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Objective Data Risk for At the end of Independendent Nursing After 30
(+)Minimal impaired skin 3o minutes of Interventions minutes of
scars integrity nursing Assessed Healthy skin nursing
(+) Dry Skin related to intervention, general varies from intervention,
Capillary refill aging process the Patient condition of individual to the patient
Time : 3 sec. describes skin. individual, but described
measures to should have measures to
protect skin good turgor protect skin
integrity (an indication integrity
of moisture),
feel warm and
dry to the
touch, be free
of impairment,
and have quick
capillary refill
(less than 4
seconds).
Encouraged the Position
patient to changes
change the pt's relieve
position pressure,
frequently restore blood
during bedtime. flow, and
promote skin
integrity .
Suggested using Rat: these
pressure- equipments
relieving beds, redistribute
mattress pressure when
overlays, and frequent
chair cushions. position
changes are
not possible.
Instructed to These prevent
apply lotion if friction and
not shear.
contraindicated
.
Encouraged to Skin friction
wear fabric caused by stiff
clothes or rough
clothes leads
to irritation
Emphasized the Improve
importance of nutrition and
adequate hydration will
nutrition and improve skin
oral fluid intake. condition.