Physical Assessment

Health Assessment
This chapter contains the health assessment of each family member. A complete
health assessment may be conducted using cephalocaudal pattern (head-to-toe assesment).
It is the systematic and efficient manner of evaluating the body and its function. In assessing
the client, we are using the methods- INSPECTION, PALPATION, PERCUSSION, and
AUSCULTATION. But when assessing the abdomen, it is the other way around-
INSPECTION, AUSCULTATION, PERCUSSION, and, PALPATION.
The purpose of this physical assessment is to obtain data about the client’s functional
ability. It would also help the nurse to make a diagnosis and care plans for the client. It can
also help the nurse to evaluate the client’s health problem. The data would help the nurse in
determining appropriate interventions.
Mr. Black Amethyst is a 44 years old man, born on April 7, 1966 and a father of five children.
He used to smoke cigarettes. Black Amethyst general appearance was proportionate, has
coordinated walking. He wears casual clothes. He was slightly skinny . Black Amethyst was
cooperative in the assessment and his answer was appropriate in the given question ask. He has also
understandable speech and has a sense in his answer.
Vital Signs:
Temperature: 36.2° C
Pulse Rate: 84 beat per minute
Respiratory Rate:17 cycles per minute
Blood Pressure=110/90 mmHg
General Appearance:
During the final home visit, upon seeing Black Amethyst , he wears a white shirt and
dark blue pants. His hair is short and neat. His skin is brown and there were no lesions or
scars seen. Black Amethyst's facial expression is appropriate for his words. His responses to
questions are appropriate and his organization of thoughts is good and relevant. His posture
and gait, is good.
The Integument
Skin
Upon inspection, Black Amethyst has a dark complexion but uniform in color. There are
no signs of any discolorations. His skin was warm and soft to touch. He has a good skin
turgor, when his skin is pinched, it returned into its place immediately, and no presence of
edema. There is no foul odor and no excessive perspiration.
Hair
The color of his hair is black and evenly distributed. There are no infestations and
scaling.
Nails
Upon inspection, his nails are pinkish and have a convex curve. His nails are hard,
smooth, and immobile. It has a capillary refill of less than 4 seconds.
The Skull
Upon inspection of Black Amethyst's head, it is rounded and normocephalic. Upon
palpation, there is no presence of lumps.
The Face
Upon inspection, Black Amethyst has a symmetrical face and her facial feature is
symmetrical also. His skin is intact and there is no presence of edema.
The Eyes and Vision

Upon inspection, Black Amethyst 's eyebrows are aligned and the hair is evenly
distributed. His eyebrows’ movement is equal.
His eyelashes are evenly distributed and are curled slightly outward. Upon inspection
of the eyelids, skin is intact, moist and pink, and no discharge. His involuntary blinks are
approximately 15-20 blinks per minute.
In assessing the bulbar conjunctiva, the eyelids are retracted with thumb and index
finger. The bulbar conjunctiva is transparent and there is no presence of lesions. While the
palpebral conjunctiva, lower lids are everted. The palpebral conjunctiva is shiny, smooth, pink,
and there is no presence of lesions.
Upon inspection of the lacrimal sac and nasolacrimal duct, there is no edema or
tearing. And upon palpation of the lacrimal gland, Itay felt no tenderness.
Upon inspection of Itay’s cornea, it is observed to be transparent, smooth, moist, and
shiny.
In assessing the pupils, it is seen to be black in color, smooth border, and size of
around 3 millimeters.
The Ear and Hearing

Upon inspection, Itay’s auricles have a color same as facial skin. His auricles are
aligned with the outer cantus of the eye. Upon palpation, his auricles are mobile, firm, and
non tender. The pinna recoils after being folded.
• In assessing the external ear canal, there is presence of excessive cerumen.
The Nose and Sinuses
Upon inspection, Black Amethyst 's nose has same color of his face. The nasal septum
is in the midline. In assessing the patency of nasal cavities, the air moves freely when the
client breaths though each nares. There is no difficulty of breathing as observed by the
student nurse and as stated by Black Amethyst And upon palpation, no tenderness in the
maxillary and frontal sinuses.
The Mouth and Oropharynx
Upon inspection, the lips are dark in color. The gums are dark in color. Black
Amethyst has complete set of teeth, yellow in color.
The tongue is in the center, it is pink in color, moist, slightly rough, and has no lesions.
He does not have difficulty in moving his tongue. The uvula is located in the midline of the soft
palate.
Upon inspection of oropharynx and tonsils, it is observed to be pink, smooth and no

discharge noted, and no inflammation. There is presence of halitosis and discoloration of
teeth.
Neck
The head is centered in the neck. Movements of the neck are coordinated, smooth
movements with no discomfort observed. No swelling and masses noted. Coordinated head
movements; able to move freely and able to turn head from left to right. He was able to turn
his head on one side against the resistance and the same with the other side. He was able to
shrug his shoulders against the resistance of the hands of student nurse.
The Lymphnodes
Upon inspection of the entire neck, there is no enlargement and lymph nodes are not
palpable.
The Trachea
Upon palpation, the trachea is located at the midline of the neck.
The Thyroid Gland

Upon inspection and palpation, the thyroid gland ascends when swallowing.
The Thorax and Lungs

Upon inspection, full and symmetric chest expansion noted while the client is
breathing. No adventitious breath sounds noted upon auscultation. Breathing pattern is quiet,
rhythmic and effortless respiration.
Upon chest auscultation, no adventitious sounds heard on both lung fields.
The Heart
Upon assessing the heart, there is no any abnormal pulsation. The jugular veins are
not distended.
Breast and Axillae

Black Amethyst 's breasts were even with the chest wall. Upon assessing, there was no
presence of tenderness, lumps, and lesions.
The Abdomen
Upon inspection of the abdomen, the skin of the abdomen is uniform in color.
The Muscle
Upon inspection, Black Amethyst 's muscles are equal in size on both sides of his body.
Bones and Joints
There are no deformities on the bones and the joints can move freely without pain.
Cranial Nerves Assessment
Cranial Nerve Test Performed Expected Result Actual Result
I.OLFACTORY With both eyes close, Correctly identifies Black Amethyst was
ask the client to smell scent presented to able to identify the
Type: Sensory the different scents like each nostril even if scents which are
perfume, and vinegar. his eyes were both perfume, and vinegar.
Function: Sense of smell
closed.
Materials used: perfume,

and vinegar
II.OPTIC At a given distance At a given distance, Black Amethyst was

of 1 meter, ask the the client must be able to read the
Type: Sensory
client to read the able to read the newsprint clearly.
newsprint without
Function: Sense of Vision newsprint.
difficulty.
Materials used: newsprint
III.OCULOMOTOR Instruct the client to Eyes must move in a Pupils are equally round
open and close the smooth, coordinated reactive to light and
Type: Motor eyelids and follow the motion in all accommodation. He
directions of penlight. directions. The pupils was able to open and
Function: constricts
This is a test for of eyes are dilated close his eyelids and
pupils when exposed to
papillary reaction. without the light and follow the directions of
lights and ability to open constricts in the penlight.
and close eyelids. response to light.
Extraocular movement.
Material used: penlight
IV.TROCHLEAR Instruct the client to Without any Black Amethyst was

look upward and difficulty, the client able to move his eyes
Type: Motor downward. To assess must be able to upward and
direction of gaze.
Function: Upward and move his eyes downward without
downward movement of the upward and difficulty.
eyes. downward.
V.TRIGEMINAL Ask the client to The clients must be Black Amethyst was
open and clench jaw. able to clench jaw able to clench jaw and
Type: Motor and Sensory
and chew properly. chew without difficulty.
The cotton is gently
Function: Jaw movement, placed into lateral side
Must be able to elicit Black Amethyst was
chewing, and of the client’s eyes. blinking reflex. able to elicit blinking
mastication; blinking reflex when cotton was
reflex placed at the side of his
eyes.
Materials used: cotton
VI.ABDUCENS Ask the client to move Client must be able Black Amethyst was
the eyes laterally. to move eyes able to move eyes
Type: Motor laterally. laterally.
Function: Lateral movement

of the eye.
VII.FACIAL Instruct client to Facial muscles of Black Amethyst was

smile, frown, and the client must able to perform the
raise eyebrows. work as he test properly.
Function: Facial muscle performs the
movement; sense of taste procedure.
on the anterior two thirds of Make use of different Black Amethyst was
the tongue.
The client must be
seasonings like vinegar able to identify the
and salt to test taste of
able to identify the
different taste
sensation. different taste. presented.
VIII.ACOUSTIC Ask the client to repeat The client must be Black Amethyst was
the whispered words, able to repeat the able to repeat the
Type: Sensory “gwapo ako”. whispered words. whispered words which
are “gwapo ako”.
Function: Sense of hearing
IX.GLOSSOPHARYNGEAL Instruct the client to The client must be Black Amethyst was
Type: Motor and Sensory swallow or move able to swallow and able to swallow and
mouth in chewing chew properly move his mouth in a
Function: Pharyngeal chewing movement
motion. without difficulty.
movement and without difficulty.
swallowing; sense of Make use of different
Black Amethyst was
taste on the posterior one taste and ask he client
Client must be able able to identify the
thirds of the tongue to identify each.
to identify the taste tastes which are vinegar
being presented. and salt.
Materials used: vinegar and

salt
Black Amethyst was

X.VAGUS Ask the client to say The client must be
able to swallow properly
“ah” to swallow. able to swallow
Type: Motor and Sensory and elicit gag reflex.
Using a tongue properly and elicit
gag reflex upon
Function: For speaking depressor stimulate
pressing the tongue.
and swallowing and the posterior part of
sensation on the the tongue.
posterior one-third of the
tongue
Material used: tongue

depressor
Black Amethyst was

XI. ACCESSORY Against the resistance The client must be
able to shrug her
from the student able to shrug his
Type: Motor shoulders against
nurses’ hands, ask the shoulders against
resistance from the
client to shrug his resistance from the
Function: Shoulder muscle student nurse.
shoulder. student nurses’
movement
hands
Black Amethyst was

XII.HYPOGLOSSAL Ask the client to move Client must be able
able to move his tongue
or protrude tongue in to move tongue in
Type: Motor in different directions
different directions. different directions.
without difficulty.
Function: Movement of
the tongue
Nutritional Status
Black Amethyst is 44 years old, weighs 65 kilograms and stands 61 inches.
BMI = 65kg / (1.55m)2
= 65 kg / 2.40m2
= 27.08 kg/m2
BMI Range
Below 15 = emaciated
15-18.9 = underweight
19-24.9 = normal
25-29.9 = overweight
30-39.9 = obese
40-above = morbidly obese
Black Amethyst is considered to be overweight

History of Past and Present Illness
Black Amethyst of hospitalization. He hasn’t suffered from any serious diseases

except for common coughs and colds.
Activities of Daily Living
Black Amethyst wakes up at 6:00 am and prepares his self to work (jueteng). At
around 9-10 a.m he goes home to rest. If he is bored he goes around their streets and chat
with his friends and he usually sleeps at 9 p.m.
Eating Habits
He normally eats 2-3x a day. He eats breakfast at wotk and usually eats lunch and
dinner with his family. He has no food preference, he eats whatever is served.
Sleeping Pattern
Black Amethyst usually sleeps at 9:00 pm and wakes at 6:00 am. He don't take short
naps at the afternoon because of his work.
Leisure Time
Black Amethyst usually has no leisure activities except for watching his children play
and taking care of his son. Other than that, he also chat with their neighbors.
Mrs. Sweet Pea is the mother of the five children and is born on June 6, 1970 and is now 40
years old. She is the one who takes care of the children. Mrs.Sweet Pea's body built is large due to
fat deposits in the body and also because of her pregnancy 8 months ago. Mrs. Sweet Pea was
cooperative in the assessment perform and has appropriate answers given in the questions asked.
She has also understandable speech and has a sense in her given answer.
Vital Signs:
Respiratory Rate: 21 cycles per minute
Blood Pressure: 90/60 mmHg
General Appearance:
During the initial home visit, upon seeing Sweet Pea, she wears a brown shirt and
black pants. Her hair is unkempt. Her skin is brown and there were no lesions or scars seen.
Mother’s facial expression is appropriate for her words.Her responses to questions are
appropriate and her organization of thoughts is good and relevant. Her posture and gait,
standing and walking is good.
The Integument
Skin
Upon inspection, Sweet Pea has a dark complexion but uniform in color. There are no
signs of any discolorations. Her skin was warm and soft to touch. She has a good skin turgor,
when her skin is pinched, it returned into its place immediately, and no presence of edema.
There is no foul odor and no excessive perspiration.
Hair
The color of her hair is black and evenly distributed. There are no infestations and
scaling.
Nails
Upon inspection, her nails are pinkish and have a convex curve. Her nails are hard,
The Skull
Upon inspection of Sweet Pea's head, it is rounded and normocephalic. Upon
The Face
Upon inspection, Sweet Pea has a symmetrical face and her facial feature is
symmetrical also. Her skin is intact and there is no presence of edema.
The Eyes and Vision

Upon inspection, Sweet Pea’s eyebrows are aligned and the hair is evenly distributed.
Her eyebrows’ movement is equal.
Sweet Pea's eyelashes are evenly distributed and are curled slightly outward. Upon
inspection of the eyelids, skin is intact, moist and pink, and no discharge. Her involuntary
blinks are approximately 15-20 blinks per minute.
tearing. And upon palpation of the lacrimal gland, Sweet Pea felt no tenderness.
Upon inspection of mother Ina’s cornea, it is observed to be transparent, smooth,
moist, and shiny.
The Ear and Hearing

Upon inspection, Sweet Pea's auricles have a color same as facial skin. Her auricles
are aligned with the outer cantus of the eye. Upon palpation, her auricles are mobile, firm, and
non tender. The pinna recoils after being folded.
In assessing the external ear canal, there are no discharges and lesions.
Upon inspection, Sweet Pea’s nose has same color of her face and no nasal
secretions. The nasal septum is in the midline. In assessing the patency of nasal cavities, the
air moves freely when the client breaths though each nares. There is no difficulty of breathing
as observed by the student nurse and as stated by Sweet Pea. And upon palpation, no
tenderness in the maxillary and frontal sinuses.
Upon inspection, the lips are slightly pinkish and uniform in color. The gums are
pinkish. Sweet Pea has complete set of teeth, yellow in color, and dental caries noted on
her teeth.
The tongue is in the center, it is pinkish, moist, slightly rough, and has no lesions. Does
not have difficulty in moving her tongue. The uvula is located in the midline of the soft palate.

discharge noted, and no inflammation.
Neck
movements; able to move freely and able to turn head from left to right. She was able to turn
her head on one side against the resistance and the same with the other side. She was able
to shrug her shoulders against the resistance of the hands of student nurse.
The Lymphnodes
palpable.
The Trachea
The Thyroid Gland


breathing. With adventitious breath sounds noted upon auscultation. Breathing pattern is
Upon chest auscultation, presence of adventitious sounds heard on both lung fields.
The Heart
Upon assessing the heart, there were no abnormal pulsations. The jugular veins are
not distended.
Breast and Axilla

Upon assessing the breast, they are round, and not engorged, generally symmetric.
The skin color of the breast is uniform, smooth and intact. No localized discoloration or hyper
pigmentation noted. The size of the areola is round and bilaterally the same. Color is brown,
no mass or lesion or discharge noted on the breast.
The Abdomen
Upon inspection of the abdomen, the skin of the abdomen is uniform in color. There
are presence stretch marks on the lateral side of the abdomen.
The Muscle
Upon inspection, Sweet Pea's muscles are equal in size on both sides of her body.
Bones and Joints
There are no deformities on the bones and the joints can move freely without
pain.
I.OLFACTORY With both eyes close, Correctly identifies Sweet Pea was able to
ask the client to smell scent presented to each identify the scents which
Type: Sensory the different scents like nostril even if her eyes are perfume and
perfume, and vinegar. were both closed. vinegar.
Function: Sense of
smell
Materials used:
perfume, and vinegar
II.OPTIC At a given distance of 1 At a given distance, the Sweet Pea was able to
meter, ask the client to client must be able to read the newsprint
Type: Sensory read the newsprint. read the newsprint clearly.
without difficulty.
Function: Sense of
Vision
Materials used:
newsprint
III.OCULOMOTOR Instruct the client to Eyes must move in a Pupils are equally round
open and close
the smooth, coordinated reactive to light and
Type: Motor eyelids and follow the motion in all accommodation. Sweet
directions of penlight. Pea was able to open
Function: constricts directions. The pupils
This is a test for and close her eyelids
pupils when exposed of eyes are dilated
papillary reaction. and follow the directions
to lights and ability to without the light and
of the penlight.
open and close constricts in response
eyelids. Extraocular to light.
movement.
Material used:
penlight
IV.TROCHLEAR Instruct the client to look Without any difficulty, Sweet Pea was able to
upward and downward. the client must be able move her eyes upward
Type: Motor To assess direction of to move her eyes and downward without
gaze. upward and downward. difficulty.
Function: Upward and
downward movement
of the eyes.
V.TRIGEMINAL Ask the client to open The clients must be Sweet Pea was able
and clench jaw. able to clench jaw and to clench jaw and
Type: Motor and
chew properly. chew without difficulty.
Sensory
Must be able to elicit Was able to elicit
Function: Jaw The cotton is gently blinking reflex. blinking reflex when
movement, chewing, placed into lateral side cotton was placed at the
and mastication; of the client’s eyes. side of her eyes.
blinking reflex
Materials used: cotton
VI.ABDUCENS Ask the client to move Client must be able to Sweet Pea was able to
the eyes laterally. move eyes laterally. move eyes laterally.
Type: Motor
Function: Lateral
movement of the eye.
VII.FACIAL Instruct client to smile, Facial muscles of the Sweet Pea was able
frown, and raise client must work as to perform he test
Type: Motor and
eyebrows. she performs the properly.
Sensory
procedure.
Function: Facial muscle
The client must be able
movement; sense of
to identify the different
taste on the anterior two
taste.
thirds of the tongue. Make use of different Sweet Pea was able to
seasonings like vinegar identify the different
and salt to test taste of taste presented.
sensation.
VIII.ACOUSTIC Ask the client to repeat The client must be able Sweet Pea was able to
the whispered words, to repeat the whispered repeat the whispered
Type: Sensory “maganda ako”. words. words which are
“maganda ako”.
Function: Sense of
hearing
IX.GLOSSOPHARYN Instruct the client to The client must be Sweet Pea was able
GEAL swallow or move able to swallow and to swallow and move
mouth in chewing chew properly without her mouth in a
Type: Motor and
motion. difficulty. chewing movement
Sensory
without difficulty.
Function: Pharyngeal
Sweet Pea was able to
movement and Make use of different Client must be able to identify the taste which
swallowing; sense of taste and ask her client identify the taste being is vinegar and salt.
presented.
taste on the posterior to identify each.
one thirds of the
tongue
Materials used: vinegar

and salt
X.VAGUS Ask the client to say The client must be able Sweet Pea was able to
“ah” to swallow. Using a to swallow properly and swallow properly and
Type: Motor and tongue depressor elicit gag reflex upon elicit gag reflex.
Sensory stimulate the posterior pressing the tongue.
part of the tongue.
Function: For
speaking and
swallowing and
sensation on the
posterior one-third of
the tongue

depressor
XI. ACCESSORY Against the resistance The client must be able Sweet Pea was able to
from the student nurses’ to shrug her shoulders shrug her shoulders
Type: Motor hands, ask the client to against resistance from against resistance from
shrug her shoulder. the student nurses’ the student nurse.
Function: Shoulder
hands.
muscle movement
XII.HYPOGLOSSAL Ask the client to move Client must be able to Sweet Pea was able to
or protrude tongue in move tongue in different move her tongue in
Type: Motor different directions. directions. different directions
without difficulty.
Function: Movement of
the tongue
Obstetrical History
Sweet Pea had her first menstruation when she was 13 years old. According to her, she has duration
of an average of ____ week. Her obstetrical history as of the present time is TPAL which means that
all her children are full term, none of them are premature, and there are no cases of spontaneous or
induced abortion, also her children are all living or there is no cases of mortality among her children.
She delivered all her children via normal spontaneous delivery. Also, mother stated that all of them are
delivered pass the age of viability. She has complete administration of her Tetanus Toxoid. During her
antepartum period, she regularly go to their health center for check-up. She verbalized that she
experienced no complications during her past pregnancies. She eats any kinds of food, she did not
crave, and though she experienced nausea during her past pregnancies for the first trimester. She
gave birth of all her children at home and a midwife attended her needs. She has never been
hospitalized.
Nutritional Status
Sweet Pea is 40years old, weighs 56 kilograms and stands 63 inches.

BMI = 56kg / (1.60m)2
= 56 kg / 2.56
= 21.875 kg/m2
BMI Range
19-24.9 = normal
30-39.9 = obese
Sweet Pea's body mass index is ranged as normal.
Sweet Pea has no history of hospitalization. She hasn’t suffered from any serious
diseases except for common cough and colds. She just waits for the cough and colds to
disappear or sometimes she goes to their health center to ask for medicines.
Eating Habits
Sweet Pea usually eats 2-3x a day.

Sleeping Pattern
Sweet Pea usually sleeps at 10:00 pm and wakes at 5:00 am. She sleeps beside her
youngest child. During afternoon, she will take nap for at least 2-3 hours.
Leisure Time
Sweet Pea usually has no leisure activities except for listening to music and arranging
their small room. Apart from that, there are no other leisure activities that she does in order to
relieve day to day stress
Cucumber Melon is the 3rd to the youngest son of the family, who is born on March 20, 1997
and is now 13 years of age. He is currently studying and he's on his first year high school. General
appearance was proportionate, has coordinated walking. He wears casual clothes. He was slightly
skinny. He was cooperative in the assessment and his answer was appropriate in the given question
ask. He has also understandable speech and has a sense in his answer.
Vital Signs:
General Appearance:
During the initial home visit, upon seeing Cucumber Melon , he was wearing a printed
sleeveless shirt and violet shorts. He has good posture and gait. He looks like a little tired. He
has unkempt appearance.
The Integument
Skin
Upon inspection, Cucumber Melon has a dark complexion but uniform in color. There
are no signs of any discolorations. His skin was warm and dry to touch. He has a good skin
turgor, when his skin is pinched, it returned into its place immediately, and no presence of
Hair
The color of his hair is black and evenly distributed. With infestations noted on his
hair.
Nails
Upon inspection, his nails are pinkish and have a convex curve. His nails are hard,
Dirty untrimmed nails

The Skull
Upon inspection of Cucumber Melon head, it is rounded and normocephalic. Upon
The Face
Upon inspection, Cucumber Melon has a symmetrical face and his facial feature is
The Eyes and Vision

Upon inspection, Cucumber Melon's eyebrows are aligned and the hair is evenly
distributed. His eyebrows’ movement is equal.
Cucumber Melon’s eyelashes are evenly distributed and are curled slightly outward.
Upon inspection of the eyelids, skin is intact, moist and pink, and no discharge. Her
involuntary blinks are approximately 15-20 blinks per minute.
tearing. And upon palpation of the lacrimal gland, Cucumber Melon felt no tenderness.
Upon inspection of Cucumber Melon’s cornea, it is observed to be transparent,
smooth, moist, and shiny.
around 3 millimetres.
The Ear and Hearing

Upon inspection, Cucumber Melon ’s auricles have a color same as facial skin. His
auricles are aligned with the outer cantus of the eye. Upon palpation, his auricles are mobile,
firm, and non tender. The pinna recoils after being folded.
Upon inspection, Cucumber Melon ’s nose has same color of his face and has a
whitish nasal secretions. The nasal septum is in the midline. In assessing the patency of
nasal cavities, the air moves freely when the client breaths through each nares. There is no
difficulty of breathing as observed by the student nurse and as stated by Cucumber Melon.
And upon palpation, no tenderness in the maxillary and frontal sinuses.
pinkish. Seven has complete set of teeth, yellow in color, and dental caries noted on the
teeth.
He does not have difficulty in moving her tongue. The uvula is located in the midline of the
soft palate.

Neck
movements; able to move freely and able to turn head from left to right. He was able to turn
his head on one side against the resistance and the same with the other side. He was able to
shrug his shoulders against the resistance of the hands of student nurse.
The Lymphnodes
palpable.
The Trachea
The Thyroid Gland

Upon chest auscultation, no adventitious sounds heard on both lung fields.
The Heart
not distended.
Breast and Axilla

Cucumber Melon's breasts were even with the chest wall. Upon assessing, there was
no presence of tenderness, lumps, and lesions.
The Abdomen
The Muscle
Upon inspection, seven’s muscles are equal in size on both sides of his body.
Bones and Joints
Cranial Nerve Test Expected Result Actual Result

Performed
I.OLFACTORY With both eyes Correctly identifies Cucumber Melon

close, ask the scent presented to was able to identify
Type: Sensory
client to smell each nostril even if the scents which are
Function: Sense of smell the different her eyes were both perfume, and
scents like closed. vinegar.
Materials used: perfume, perfume, and
alcohol, and vinegar vinegar.
II.OPTIC At a given At a given distance, Cucumber Melon

distance of 1 the client must be was able to read the
Type: Sensory
meter, ask the able to read the newsprint clearly.
Function: Sense of Vision client to read newsprint without

the newsprint. difficulty.
Materials used: newsprint
III.OCULOMOTOR Instruct the Eyes must move in Pupils are equally

client to open a smooth, round reactive to
Type: Motor
and close the coordinated motion light and
Function: constricts pupils eyelids and in all directions. The accommodation. He
when exposed to lights and follow the pupils of eyes are was able to open
ability to open and close directions of dilated without the and close his
eyelids. Extraocular penlight. This is light and constricts eyelids and follow
movement. a test for in response to light. the directions of the
papillary penlight.
Material used: penlight reaction.
IV.TROCHLEAR Instruct the Without any Cucumber Melon

client to look difficulty, the client was able to move
Type: Motor
upward and must be able to his eyes upward and
downward. To move her eyes downward without
Function: Upward and assess upward and difficulty.
downward movement of the direction of downward.
eyes. gaze.
V.TRIGEMINAL Ask the client to The clients must be Cucumber Melon

open and able to clench jaw was able to clench
clench jaw. and chew properly. jaw and chew
Function: Jaw movement, without difficulty.

The cotton is Must be able to
chewing, and mastication;
gently placed elicit blinking reflex. Cucumber Melon
blinking reflex
into lateral side was able to elicit
Materials used: cotton of the client’s blinking reflex when
eyes. cotton was placed at
the side of his eyes.
VI.ABDUCENS Ask the client to Client must be able Cucumber Melon

move the eyes to move eyes was able to move
Type: Motor
laterally. laterally. eyes laterally.
Function: Lateral movement

of the eye.
VII.FACIAL Instruct client to Facial muscles of Cucumber Melon

smile, frown, the client must work was able to perform
and raise as she performs the the test properly.
Function: Facial muscle eyebrows. procedure.
movement; sense of taste

The client must be
on the anterior two thirds of
the tongue.
different taste. Cucumber Melon
Make use of was able to identify
different the different taste
seasonings like presented.
vinegar and salt
to test taste of
sensation.
VIII.ACOUSTIC Ask the client to The client must be Cucumber Melon
repeat the able to repeat the was able to repeat
Type: Sensory
whispered whispered words. the whispered words
Function: Sense of hearing words, which are “gwapo

“maganda ako”. ako”.
IX.GLOSSOPHARYNGEAL Instruct the The client must be Cucumber Melon

client to able to swallow and was able to swallow
swallow or chew properly and move his mouth
Function: Pharyngeal move mouth in without difficulty. in a chewing
movement and swallowing; chewing movement without

Client must be able
sense of taste on the motion. difficulty.
to identify the taste
posterior one thirds of the
Make use of being presented. TzuCucumber
tongue
different taste Melon was able to
and ask he identify the tastes
client to identify which are vinegar
Materials used: vinegar and each. and salt.
salt
X.VAGUS Ask the client to The client must be Cucumber Melon

say “ah” to able to swallow was able to swallow
swallow. Using properly and elicit properly and elicit
Function: For speaking and a tongue gag reflex upon gag reflex.
swallowing and sensation depressor pressing the
on the posterior one-third of stimulate the tongue.
the tongue posterior part of

the tongue.
depressor
XI. ACCESSORY Against the The client must be Cucumber Melon

resistance from able to shrug her was able to shrug
Type: Motor
the student shoulders against his shoulders
Function: Shoulder muscle nurses’ hands, resistance from the against resistance
movement ask the client to student nurses’ from the student
shrug her hands. nurse.
shoulder.
XII.HYPOGLOSSAL Ask the client to Client must be able Cucumber Melon

move or to move tongue in was able to move
Type: Motor
protrude tongue different directions. his tongue in
Function: Movement of the in different different directions
tongue directions. without difficulty.
Nutritional Status
Cucumber Melon is 13 years old, weighs 32 kilograms and stands 56 inches.
BMI = 32kg / (1.42m)2
= 32 kg / 2.02m2
= 15.84 kg/m2
BMI Range
19-24.9 = normal
30-39.9 = obese
Cucumber Melon’s Body Mass Index is ranged as underweight.

Summary of Assessment (Day 2- Day 4)
From day 2 to day 4 of physical assessment, Cucumber Melon was still observed as
untidy of himself and his hair is still unkempt. He is cooperative when being asked and
answers appropriately to the question
Cucumber Melon has no history of hospitalization. He hasn’t suffered from any serious
diseases except for common cough and colds.
Cucumber Melon usually wakes up 6:30 a.m. or sometimes if his youngest brother
wakes up, he would be forced to wake up and take care of her brother. Cucumber Melon goes
to school.He plays with his siblings and most of the time he takes care of them all day when
her mother is doing some household chores . And at around 8 p.m., he sleeps.
Eating Habits
Cucumber Melon eats 2-3x a day. He eats lunch and dinner and as stated by him, he
doesn’t have any food preference, whatever his mother serves he eats.
Sleeping Pattern
Cucumber Melon usually sleeps at 8:00 pm at wakes at 6:30 am everyday. He

seldomly take a nap during afternoon because his class is up to 3:00 pm
Leisure Time
Cucumber Melon usually play with his siblings and neighbors. He sometimes chooses to do
his school works with his classmates in the afternoon after school.
Blushing Cherry is the 2nd youngest daughter of the family and he was born on May
3, 2007. She just stays at home with her youngest brother. Her general appearance was
proportionate, has coordinated walking. she wears casual clothes. she was slightly skinny.
she was cooperative in the assessment and her answer was appropriate in the given
question ask.
Vital Signs:
General Appearance:
Upon assessment, Blushing Cherry was wearing pair of pink shirt and brown shorts. She was
also wearing pair of slippers. She has proportionate and small body built, coordinated
movements and has dark complexion. She speaks not so clearly but can be easily
understood by the group and she also exhibits thought coordination, appears dirty. She is
cooperative when being asked and answers appropriately to the question.
The Integument
Skin
Upon inspection, Blushing Cherry has a dark complexion but uniform in color. There
are no signs of any discolorations. Her skin was warm and dry to touch. She has a good skin
turgor, when her skin is pinched, it returned into its place immediately, and no presence of
Hair
The color of her hair is black and evenly distributed. With infestations noted on her
hair.
Nails
Upon inspection, her nails are pinkish and have a convex curve. Her nails are hard,
smooth, and immobile. It has a capillary refill of less than 4 seconds. Dirty untrimmed nails
The Skull
Upon inspection of Blushing Cherry’s head, it is rounded and normocephalic. Upon
The Face
Upon inspection, Blushing Cherry has a symmetrical face and her facial feature is
symmetrical also. Her skin is intact and there is no presence of edema.
The Eyes and Vision

Upon inspection, Blushing Cherry’s eyebrows are aligned and the hair is evenly
distributed. Her eyebrows’ movement is equal.
Blushing Cherry’s eyelashes are evenly distributed and are curled slightly outward.
Upon inspection of the eyelids, skin is intact, moist and pink, and no discharge. Her
tearing. And upon palpation of the lacrimal gland, Blushing Cherry felt no tenderness.
Upon inspection of Blushing Cherry’s cornea, it is observed to be transparent, smooth,
moist, and shiny.
around 3 millimetres.
The Ear and Hearing

Upon inspection, Blushing Cherry’s auricles have a color same as facial skin. Her
auricles are aligned with the outer cantus of the eye. Upon palpation, her auricles are mobile,
Upon inspection, Blushing Cherry’s nose has same color of her face and has a
yellowish green. The nasal septum is in the midline. In assessing the patency of nasal
cavities, the air moves freely when the client breaths through each nares. There is difficulty
of breathing as observed by the student nurse and as stated by Blushing Cherry. And upon
palpation, no tenderness in the maxillary and frontal sinuses.
pinkish. Seven has complete set of teeth, yellow in color, and dental caries noted on the
teeth.
She does not have difficulty in moving her tongue. The uvula is located in the midline of the
soft palate.

Neck
movements; able to move freely and able to turn head from left to right. She was able to turn
her head on one side against the resistance and the same with the other side. She was able
to shrug her shoulders against the resistance of the hands of student nurse.
The Lymphnodes
palpable.
The Trachea
The Thyroid Gland

Upon chest auscultation, (+) rales on both lung fields.
The Heart
not distended.
Breast and Axilla

Blushing Cherry s breasts were even with the chest wall. Upon assessing, there was
no presence of tenderness, lumps, and lesions.
The Abdomen
The Muscle
Upon inspection, Blushing Cherry ’s muscles are equal in size on both sides of her
body.
Bones and Joints
I.OLFACTORY With both eyes Correctly identifies Blushing Cherry was

close, ask the client scent presented to able to identify the
Type: Sensory
to smell the each nostril even if scents which are
Function: Sense of different scents like her eyes were both perfume, and
smell perfume, and closed. vinegar.

vinegar.
Materials used:
perfume, alcohol, and
vinegar
II.OPTIC At a given distance At a given distance, Blushing Cherry was

of 1 meter, ask the the client must be able to read the
Type: Sensory
client to read the able to read the newsprint clearly.
Function: Sense of newsprint. newsprint without
Vision difficulty.
Materials used:
newsprint
III.OCULOMOTOR Instruct the client to Eyes must move in Pupils are equally
open and close the a smooth, round reactive to
Type: Motor
eyelids and follow coordinated motion light and
Function: constricts the directions of in all directions. The accommodation.

pupils when exposed to penlight. This is a pupils of eyes are She was able to
lights and ability to test for papillary dilated without the open and close her
open and close eyelids. reaction. light and constricts eyelids and follow
Extraocular movement. in response to light. the directions of the

penlight.
Material used: penlight
IV.TROCHLEAR Instruct the client to Without any Blushing Cherry was

look upward and difficulty, the client able to move her
Type: Motor
downward. To must be able to eyes upward and
Function: Upward and assess direction of move her eyes downward without
downward movement of gaze. upward and difficulty.
the eyes. downward.
V.TRIGEMINAL Ask the client to The clients must be Blushing Cherry was
open and clench able to clench jaw able to clench jaw
Type: Motor and
jaw. and chew properly. and chew without
Sensory
difficulty.
The cotton is gently Must be able to elicit
Function: Jaw
placed into lateral blinking reflex. Blushing Cherry was
movement, chewing,
side of the client’s able to elicit blinking
and mastication;
eyes. reflex when cotton
blinking reflex
was placed at the
Materials used: cotton side of her eyes.
VI.ABDUCENS Ask the client to Client must be able Blushing Cherry was
move the eyes to move eyes able to move eyes
Type: Motor
laterally. laterally. laterally.
Function: Lateral
movement of the eye.
VII.FACIAL Instruct client to Facial muscles of Blushing Cherry was

smile, frown, and the client must work able to perform the
Type: Motor and
raise eyebrows. as she performs the test properly.
Sensory
procedure.
Function: Facial muscle

The client must be
movement; sense of
taste on the anterior
Make use of different taste. Blushing Cherry was
two thirds of the
different able to identify the
tongue.
seasonings like different taste
vinegar and salt to presented.
test taste of
sensation.
VIII.ACOUSTIC Ask the client to The client must be Blushing Cherry was
Type: Sensory repeat the able to repeat the able to repeat the
whispered words, whispered words. whispered words
Function: Sense of
“maganda ako”. which are “maganda
hearing
ako”.
IX.GLOSSOPHARYNG Instruct the client to The client must be Blushing Cherry was
EAL swallow or move able to swallow and able to swallow and
mouth in chewing chew properly move her mouth in a
Type: Motor and
motion. without difficulty. chewing movement
Sensory
without difficulty.
Make use of Client must be able
Function: Pharyngeal
different taste and to identify the taste Blushing Cherry was
movement and
ask he client to being presented. able to identify the
swallowing; sense of
identify each. tastes which are
taste on the posterior
vinegar and salt.
one thirds of the tongue
Materials used: vinegar

and salt
X.VAGUS Ask the client to The client must be Blushing Cherry was
say “ah” to swallow. able to swallow able to swallow
Type: Motor and
Using a tongue properly and elicit properly and elicit
Sensory
depressor stimulate gag reflex upon gag reflex.
Function: For speaking the posterior part of pressing the tongue.

and swallowing and the tongue.
sensation on the
posterior one-third of
the tongue

depressor
XI. ACCESSORY Against the The client must be Blushing Cherry was
Type: Motor resistance from the able to shrug her able to shrug her
student nurses’ shoulders against shoulders against
Function: Shoulder
hands, ask the resistance from the resistance from the
muscle movement
client to shrug her student nurses’ student nurse.
shoulder. hands.
XII.HYPOGLOSSAL Ask the client to Client must be able Blushing Cherry was
move or protrude to move tongue in able to move her
Type: Motor
tongue in different different directions. tongue in different
Function: Movement of directions. directions without
the tongue difficulty.
Nutritional Status
Wt: 13kg
Ht: 105cm
IRS: below normal
Blushing Cherry’s IRS is ranged as underweight.
Summary of Assessment (Day 2- Day 4)
From day 2 to day 4 of physical assessment, Blushing Cherry was still observed as
untidy of herself has pediculosis.
Blushing Cherryhas no history of hospitalization. She hasn’t suffered from any serious
diseases except for common cough and colds.

Blushing Cherry usually wakes up 6:30 a.m. She does not go to school because she is
too young. She plays with her siblings. And at around 8 p.m., she sleeps.
Eating Habits
Blushing Cherry eats 3-4x a day. She eats lunch and dinner and as stated by her
mother, she doesn’t have any food preference, whatever her mother serves she eats. She
also choose to eat independently.
Sleeping Pattern
Blushing Cherry usually sleeps at 8:00 pm at wakes at 6:30 am everyday. She usually
sleep or take a nap in the afternoon while her youngest brother sleeps.
Leisure Time
Blushing Cherry usually play with her siblings and neighbours and listens and dances
to music.
Orange Sapphire is the youngest son of the family. He is a 9 month-old infant and was born on
September 19, 2009. General appearance was proportionate. He wears baby clothes and shorts.
Vital Signs:
Respiratory Rate:28 cycles per minute
General Appearance:
During the initial home visit, He wears a green shirt and a ragged short. His nails were
untidy and he keeps on biting them. He has an unkempt hair, dirt on his hands and feet
are present. He has a good posture.
The Integument
Skin
Upon inspection, has a light complexion but he has dry skin. There are no signs of
any discolorations. His skin was warm and soft to touch. He has a good skin turgor, when his
skin is pinched, it returns into its place immediately, no presence of edema noted, has a
wound on his right hand and lesions on his lower extremities. There is no foul odor and no
excessive perspiration.
Hair
The color of his hair is black and evenly distributed but is not well kept. There are no
infestations and scaling.
Nails
Upon inspection, his nails are pinkish in color and have a convex curve. His nails are
hard, smooth, and immobile. He has a capillary refill of less than 1 seconds.
The Skull
Upon inspection of Orange Sapphire's head, it is rounded and normocephalic. No
presence of elevations and depressions noted.
The Face
Upon inspection, Orange Sapphire has a symmetrical face and his facial features are
The Eyes and Vision

Upon inspection, Orange Sapphires eyebrows are aligned and evenly distributed. His
eyebrows’ movement are equal.
Orange Sapphire’s eyelashes are evenly distributed and are curled slightly outward.
Upon inspection of the eyelids, skin is intact, moist and pink, and no discharge. His
palpebral conjunctive, lower lids are everted. The palpebral conjunctiva is shiny, smooth, pink,
tearing. And upon palpation of the lacrimal gland, he felt no tenderness.
Upon inspection of Orange Sapphire' s cornea, it is observed to be transparent, smooth,
moist, and shiny.
The Ear and Hearing

Upon inspection, Orange Sapphire's auricles have a color same as facial skin. His
auricles are aligned with the outer cantus of the eye. Upon palpation, his auricles are mobile,
Upon inspection, Orange Sapphire’s nose has same color of his face and has whitish
nasal secretions. The nasal septum is in the midline. In assessing the patency of nasal
cavities, the air moves freely when the client breaths though each nares. There is difficulty of
breathing as observed by the student nurse. No tenderness in the maxillary and frontal
sinuses upon palpation.
Upon inspection, the lips are slightly pinkish and uniform in color. The gums are pinkish
in color. His teeth and gums was uniform slight dark pink; moist, soft, glistening, and elastic texture.
Does not have difficulty in moving his tongue. The uvula is located in the midline of the soft
palate.

Neck
movements; able to move freely and able to turn head from left to right.
The Lymphnodes
palpable.
The Trachea
The Thyroid Gland

Upon chest auscultation, (+) rales on both lung fields.
The Heart
Upon assessing the heart, there are no any abnormal pulsations. The jugular veins are
not distended.
Breast and Axillae

Orange Sapphire’s breasts were even with the chest wall. Upon assessing, there was no
presence of tenderness, lumps, and lesions.
The Abdomen
Upon inspection of the abdomen, the skin of the abdomen is uniform in color. There is
no presence of reddish striae or bulging part.
The Muscle
‘ Upon inspection, Orange Sapphire’s muscles are equal in size on both sides of his body.
Bones and Joints
• CRANIAL NERVE ASSESSMENT
Has no abnormalities present on his cranial nerves.

A. NUTRITIONAL STATUS
Ht: 58.42cm Wt.:7.6 kg.
FNRI: NORMAL
B. IMMUNIZATION STATUS
Orange Sapphire has an incomplete immunization status for his age, he

already had BCG, Hepatitis B 1,2&3 but he just received 2 doses for DPT and OPV.
C. GROWTH AND DEVELOPMENT
 Erik Erikson’s Psychosocial Stage
Trust vs. Mistrust (0-8 months old): Erikson also referred to infancy as the Oral Sensory
Stage (as anyone might who watches a baby put everything in her mouth) where the major
emphasis is on the mother's positive and loving care for the child, with a big emphasis on visual
contact and touch. Orange Sapphire looks at his mother more often than any people around him
and he is crying when anybody except her mother is cuddling him. He is obviously attached to his
mother.
 Sigmund Freud’s Psychosexual Development
Oral Stage (0 to 12 months). During the oral stage, the child if focused on oral pleasures
(sucking). Too much or too little gratification can result in an Oral Fixation or Oral Personality which
is evidenced by a preoccupation with oral activities.
A. HISTORY OF PAST AND PRESENT ILLNESSES

Orange Sapphire is recently suffering from recurrent coughs and colds characterized by lclear,
watery mucus for 3 days.
Dancing Water is not
seen on the whole
Family Case Analysis
Moonlight Path is not
seen on the whole
Family Case Analysis

Physical Assessment

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Physical Assessment

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Health Assessment

The Eyes and Vision

The Ear and Hearing

The Nose and Sinuses

The Mouth and Oropharynx

Upon inspection of oropharynx and tonsils, it is observed to be pink, smooth and no

The Thyroid Gland

The Thorax and Lungs

Breast and Axillae

Bones and Joints

Cranial Nerve Test Performed Expected Result Actual Result

Materials used: perfume,

II.OPTIC At a given distance At a given distance, Black Amethyst was

Materials used: newsprint

Material used: penlight

IV.TROCHLEAR Instruct the client to Without any Black Amethyst was

Function: Lateral movement

VII.FACIAL Instruct client to Facial muscles of Black Amethyst was

Materials used: vinegar and

Black Amethyst was

Material used: tongue

Black Amethyst was

Black Amethyst was

Black Amethyst is 44 years old, weighs 65 kilograms and stands 61 inches.

BMI = 65kg / (1.55m)2

40-above = morbidly obese

Black Amethyst is considered to be overweight

Black Amethyst of hospitalization. He hasn’t suffered from any serious diseases

Activities of Daily Living

The Eyes and Vision

The Ear and Hearing

The Nose and Sinuses

The Mouth and Oropharynx

Upon inspection of oropharynx and tonsils, it is observed to be pink, smooth and no

The Thyroid Gland

The Thorax and Lungs

Breast and Axilla

Bones and Joints

Cranial Nerve Test Performed Expected Result Actual Result

eyelids. Extraocular to light.

Materials used: cotton

Materials used: vinegar

Material used: tongue

Sweet Pea is 40years old, weighs 56 kilograms and stands 63 inches.

40-above = morbidly obese

Sweet Pea's body mass index is ranged as normal.

History of Past and Present Illness

Activities of Daily Living

Sweet Pea usually eats 2-3x a day.

Dirty untrimmed nails

The Eyes and Vision

The Ear and Hearing

The Mouth and Oropharynx

Upon inspection of oropharynx and tonsils, it is observed to be pink, smooth and no

The Thorax and Lungs

Breast and Axilla

Bones and Joints

Cranial Nerve Test Expected Result Actual Result

I.OLFACTORY With both eyes Correctly identifies Cucumber Melon

II.OPTIC At a given At a given distance, Cucumber Melon

Function: Sense of Vision client to read newsprint without

III.OCULOMOTOR Instruct the Eyes must move in Pupils are equally

Function: constricts pupils eyelids and in all directions. The accommodation. He