output (health assessment) nursing

8/8/2019 Output (Health Assessment) NURSING

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Fernando, April M. BSN 1st Year K

Pediatric Assessment

ASSESSMENT

A. Personal DataName: Arcega, Sven Oliver F.Address: Callejon drive, Guiwan, Zamboanga CityAge: 6 years old

Sex: Male

Status: SingleOccupation: N/A

Educational Attainment: Pre-School LevelEthnic Group: Zamboangueo

Religion: Roman Catholic

Chief Complaint:Medical Impression:

B. Physical ExaminationACTUAL OBSERVATION DOCUMENT READINGS AND RESOURCES

Play/Socialization

The child enjoys playing outdoor games like

hide and seeks and touch ball. He is enjoying indoorgames, too. Like playing video games with some

neighborhood friends. He does whatever someoneasks him to do.

Fine Motor Skills

He responds well when he is being asked. Heis really talented at drawing: he can draw both simpleand complex figures. He understands what is being

instructed.

Gross Motor Skills

He likes toy cars for his collection. He can

balance well. The child can move from one place toanother and he can run fast, walk, identify objects and

jump as high as he wanted to.

Discovers environment with his own

inventiveness. He tries to set up himselfindependently. He enjoys outdoor activities. He likes

sports, rules and cooperative play.

Printing skills are developed in later years.Greater skills and competence for crafts are also

developed.

Focuses on specific understanding. Organizedthoughts. Reasons and read better.

Skills obtained during this year include roller

skating, bicycling, rollerblading and skateboarding.

Running and jumping at this year improveincreasingly.


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Assessment and Techniques Used Findings/Implications

Skin, Hair and Nails

Palpation and Inspection

Head

Palpation

Inspection

Eyes

Inspection

Ears

Inspection

Inspection and Palpation

Hearing Acuity

Nose

Inspection

Palpation

Mouth

Inspection


Skin generally uniform except in areas exposed tothe sun; no abrasions and other lesions

Hair evenly distributed hair, thick and silky

Nails convex curvature; correct angle of nail plate;

smooth texture

Scalp hard; dandruff free

Shape rounded; smooth skull contour

No swellings, no discharge, blinking symmetrically

Iris and Pupil normal Iris, Pupils are black in color

and equal in size

Sclera appears white

No excessive Cerumen, no discharges and lesions

Auricles color same as facial skin, symmetrical,

mobile, firm and not tender

Normal voice tones audible, able to hear in both ears

Nose symmetric and straight, no discharge orflaring, uniform in color

Not tender; no lesions

Upper Lip uniform light red color, moist,symmetry of contour

Lower Lip uniform light red color

Buccal Mucosa moist, smooth, soft, glistening andelastic texture


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Neck and Lymph Nodes

Inspection

Palpation

Palpation

Chest and Lungs

Inspection and Percussion

Auscultation

Heart


Auscultation

Abdomen

Inspection

Auscultation

Palpation

Neck Muscles no swellings or masses, muscles

equal in size

Lymph Nodes not palpable

Trachea central placement in midline of neck,

spaces are equal on both sides

Thorax chest symmetric, spine vertically aligned,

percussion notes resonate

Breath Sounds vesicular and bronchovesicular

Hyperresonance normal

Apical Pulse proper location

Heart normal rate

Skin Integrity unblemished skin, uniform color

Contour and Symmetry flat and rounded,symmetric contour

Bowel Sounds audible bowel sounds

Masses and Tenderness relaxed abdomen withsmooth, consistent tension


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Fernando, April M. BSN 1st

Year K

Adult Assessment

ASSESSMENT

A. Personal DataName: Arvin FernandoAddress: Callejon drive, Guiwan, Zamboanga City

Age: 20 years old

Sex: MaleStatus: SingleOccupation: Student

Educational Attainment: College Level

Ethnic Group: ZamboangueoDialect/Language Spoken: Chavacano, English

Religion: Roman CatholicChief Complaint:

Medical Impression:

B.Nursing History1. Health Perception Health Management Pattern

My client believes that he is healthy. Physically, he looks healthy and not weak. Heverbalized that he never had serious illnesses. He hasnt got present illnesses. He says

that he enjoys reading books and going out.

2. Nutritional Metabolic PatternHe usually eats nutritious foods such as vegetables and fruits. He drinks water about 6 to8 glasses a day. He is not having difficulty or discomforts in food. He is currently

wearing teeth braces.

3. Elimination PatternHe expressed that he eliminates everyday. According to him, he eliminates yellow-

brown, understandably odorous stool 2 times a day.

4. Activity Exercise PatternHe has sufficient energy in every thing he does. His daily exercises include walking and

works out in a gym. He reads books and listens to music in his spare time. He can dothings by himself like feeding, drinking, grooming, toileting, and shopping; general

mobility and bed mobility.

5. Sleep Rest PatternHe sleeps 6 to 8 hours daily. He has no onset problems regarding sleep pattern. He is notcomplaining about suffering from insomnia. He usually sleeps at 10 PM and wakes up at

6 AM.

6. Cognitive Perceptual Pattern


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He said that he is not having difficulty about his senses. He is not experiencing anydiscomforts and pain.

7. Self-Perception-Self-Concept PatternHe is contented in his life now. He got friends who can help him if he has problem and afamily that can be there when he needs them. He describes himself as a simple guy with

simple dreams.

8. Role Relationship PatternHis family is a nuclear type with 5 members. They speak Chavacano at home. Just like

other families, they can handle problems by themselves by helping each other. Theyhandle these problems by discussing among themselves.

9. Sexuality Reproductive PatternHe hasnt got any problems regarding this pattern for he is not having monthly

menstruations and he is not married.

10.Coping Stress Tolerance PatternMy client said that if his family is having problems financially, he and his siblings know

how to be thrifty. He is the eldest among the 3 children, so his parents trust him so much.His life in his family doesnt have any changes.

11.Value BeliefPatternHis family is Roman Catholic. They go to church together once a week. God is with themever since and he couldnt live without Him. He asks help from Him and he believes that

God is really helping him and his family.

Vital Signs:

BP: 120/80 mmHg

RR: 15 bpm

PR: 88 bpm

AP: 85 bpm

Temperature: 37.1 C


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C. Physical ExaminationAssessment and Techniques Used Findings/Implications


Inspection

Palpation

Head and Neck

Inspection

Palpation

Eyes

Inspection

Skin varies from light to deep brown, generally

uniform except areas exposed to the

sun, lesion free

Hair evenly distributed hair, no signs of

parasites

Nails tissues around are intact, convexcurvature

Skin moist in skin folds

Temperature uniform; within normal range

Scalp no signs of dandruff

Nails prompt return of pink color (when blanch

test was performed)

Skull rounded; smooth skull contour

Face symmetric and balanced, symmetric facial

movements

Neck- symmetric

Trachea midline

Thyroid midline


Eyebrows hair evenly distributed, skin intact

Eyelashes not-too-long but equally distributed

Eyelids skin intact; no discoloration; no

discharge; lids close symmetrically

Bulbar Conjunctiva transparent; capillariessometimes evident

Sclera appears white

Palpebral Conjunctiva shiny and pink

Cornea transparent, shiny and smooth


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Ears

Inspection

Palpation

Nose and Sinuses


Inspection

Mouth and Oropharynx


Thorax and Lungs

Inspection

Palpation

Percussion

Auscultation

Iris and PupilPupils are black in color, contract

in light, round and equal

Lacrimal Sac and Nasolacrimal Duct no edema

or tearing

Auricles

Color same as facial skin

Symmetry symmetrical

Position aligned with outer canthus of eye

Auricles mobile, firm and not tender, lesion free

NoseExternal symmetric and straight, no

discharge, not tender, no lesions

Internal mucosa pink, no lesions, clear,watery discharge

Upper Lip and Lower Lip uniform pink color,soft and moist, smooth texture, symmetry

of contour

Buccal Mucosa soft, moist, smooth, gleaming

Chest symmetric

Spinal Column vertically aligned, straight

Posterior Thorax

Temperature and Integrity skin intact;uniform temperature

Chest chest wall intact; no masses and no

tenderness

Posterior Chest full and symmetric chestexpansion

Thorax lowest point of resonance is at thediaphragm

Breath Sound low-pitched, vesicular andbronchovesicular breath sounds


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Abdomen

Inspection

Auscultation

Palpation

Light Palpation

Deep Palpation

Lung sounds clear inspirations and expirations

Heart rate normal

Abdomen

Skin Integrity presence of rash, uniform colorContour and symmetry flat and rounded

When asked to take deep breath no evidence of

enlargement of liver or spleen

Abdomen audible bowel sounds, absence ofarterial bruits, absence of friction rub

No tenderness, relaxed abdomen with consistent

tension

Tenderness present near xiphoid process


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Fernando, April M. BSN 1st

Year K

Geriatric Assessment

ASSESSMENT

A. Personal DataName: Domingo Fernando

Address: Guiwan, Zamboanga CityAge: 69 years old

Sex: MaleStatus: Married

Occupation: Retired PolicemanEducational Attainment: College Graduate

Ethnic Group: ZamboangueoDialect/Language Spoken: Chavacano

Religion: Roman CatholicChief complaint: Increase of heart rate

Medical Impression:

B.Nursing History1. Health Perception Health Management Pattern

My client verbalized that he is feeling well lately. His health accordingly is okay. No

illnesses occurred in his health. In his old age, he drinks vitamins and increase waterintake and exercise.

2. Nutritional Metabolic PatternHe mentioned that he is taking vitamins to maintain his good health. He loves to eathealth foods such as vegetables and fruits. His water intake is 6 to 7 glasses a day. He

avoids eating too much meat because its not good for his health.

3. Elimination PatternHe urinates about 5 times daily and he hasnt got any difficulty in urinating as well indefecating. He eliminates bowel at least once a day. He described his stool as yellow-

brown and he mentioned that it smells, just like what normal stools are.

4. Activity Exercise PatternHe has activities that are done everyday. He loves working when he is bored. He loves

walking a lot. He can go to any places and that is one of the exercises he makes. He hasthe ability to self-care.

5. Sleep Rest PatternHe sleeps early and wakes up early, too. He usually sleeps at 9 oclock at night andwakes up at 6 in the morning. He is not having nightmares and he sleeps soundly.


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6. Cognitive Perceptual PatternHe doesnt have any difficulties in hearing. He wears glasses everyday. He has nodiscomforts except his vision.

7. Self-Perception-Self-Concept PatternHe said that hes happy when his family is happy, too. He is quite high-tempered. Heloves children, especially his grandsons and granddaughters. He is outgoing and he easily

gets bored at home.

8. Role Relationship PatternMy client has an extended type of family because he lives with his wife and his son. He

has 3 daughters and 2 sons. He speaks Chavacano with his family at home. He and hiswife go to church every Sunday.

9. Sexuality Reproductive PatternHe has 5 children. All are professionals. No problems perceived in sexual relationship.

10.Coping Stress Tolerance PatternWhen there are problems, he and his wife discuss it firmly. Sometimes he discusses itwith his son, too. They always pray when this happens.

11.Value BeliefPatternReligion, for him, is very important. He wants that his family will be religious like him.He praises God and he always pray to him.

Vital Signs:

BP: 130/80 mmHg

RR: 14 bpm

PR: 88 bpmAP: 77 bpm

Temperature: 37.1 C


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C. Physical ExaminationAssessment and Techniques Used Findings/Implications


Inspection

Palpation

Head

Inspection

Palpation

Eyes

Inspection

Ears

Inspection

Palpation

Skin varies from light to deep brown;spots and wrinkles visible

Hair clean and groomed, fairly

distributed dominant silver hair

Skin no swellings

Scalp no dandruff visible, lesion free

Temperature normal range

Nails firm and hard

Shape rounded, symmetrical

Scalp lesion free

Eyebrows unequal alignment

Eyelids no discharge, skin intact

Sclera yellowish

Bulbar Conjunctiva transparent

Palpebral Conjunctiva shiny, smooth

Iris and Pupil symmetrical, pupils

contrict to light

No nodules, no discharges

Auricles color same as facial skin,

symmetrical, aligned with outer canthus of

eye

Auricles scaly skin, tenderness whenpressed


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Hearing Acuity

Nose

Inspection

Palpation

Mouth

Inspection

Neck and Lymph Nodes

Inspection

Palpation

Chest and Lungs

Inspection

Percussion

Auscultation

Heart

Auscultation

Abdomen

Inspection

Auscultation

Palpation

Responds and answers correctly whenbeing asked in a whisper

External Nose the color is same as face,

symmetrical, smooth

Internal Nose pink mucosa, moist withuniform color, no lesions

Tenderness of sinuses

Lips, Tongue and Buccal Mucosa moistand pinkish

Tonsils easily seen

Trachea midline


Chest- normal and relaxed

Resonance

Breath sounds low-pitched

Normal heart rates

Abdomen slightly protuberant

Umbilicus pinkish, no odor, no

discharges and redness

Bowel Sounds normal sounds

No masses and tenderness


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Health Assessment

Pediatrics

Adult

Geriatrics

Submitted by:

Fernando, April M.

output (health assessment) nursing

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