C.

HEAD TO TOE ASSESSMENT BODY PARTS SKIN FINDINGS NORMS

INTERPRETATION

-deep brown color of the -generally skin uniform

The client has skin signs of

the

physical

-presence of wrinkles in in color the neck and face -presence of dry skin -skin slightly -no signs of acne. pimples ,

changes due to aging

loses edema birthmarks -no of presence skin

elasticity -no presence of edema

lesion(primary and secondary lessions)

NAILS

-convex shape -smooth texture

-convex shape(160

NORMAL

-nailbed of the fingers degree) and toenails are -smooth in

generally light pink in texture color -no sign of irregularity in the nail blood

circulation SKULL & FACE -rounded in shape -no local deformities -rounded shape in NORMAL

-no signs of difficulty in -no signs of facial movements. local deformities -asymmetric

facial movements EYES & VISIONS -has minute - has blurred vision 17 blinks per -no signs of visual defects -equal -the client has visual acuity

-can performed the six movements muscle movements and equal of

alignment eyebrows

-no edema or tenderness -15-20 blinks per minute EARS& HEARING (+)RINNE TEST -no signs of in the NORMAL

-can hear the sounds difficulty clearly hearing

-no lesions in the area of sounds ears -(+)RINNE TEST NOSE & SINUSES -no signs of redness -no signs of lessions -dark(outside part of the -no signs of -The client has poor MOUTH OROPHARYNX & lips) color of the lips gum bleeding oral hygiene.

with white spot in the -pink color of surface of the tongue -no signs of skin lesions the lips -complete set

-no signs of excessive of teeth in the gum bleeding (right and left) and

-has tooth decays in the lower left lower teeth -Loss of teeth upper part.

NECK

-no lesions

-no lesions

NORMAL

-palpable sternomastoid, -palpable trapezius -palpable supraclavicular nodes -thyroid glands sternomastoid trapezius lymph -palpable supraclavicular not lymph nodes

visible on inspection - no vocal enlargement

BREAST

-has everted nipple

- -no

sign

of

NORMAL

nipple is dark brown in lesions in breast color area

-no tenderness, swelling, -everted nipple lesions - rounded in shape -equal in size -no signs of and

tenderness swelling -equal rounded shape

and in

-skin uniform in color RESPIRATORY -no signs of -no signs of NORMAL

lordosis,scoliosis,kypho sis -symmetric thorax -chest wall is intact - no tenderness

lordosis,scoliosis ,kyphosis -symmetric thorax -chest intact -no tenderness wall is

CARDIAC

No

presence

of -symmetric pulse

NORMAL

abnormal pulsations -veins are not visible

volume -veins visible are not

ABDOMEN

-no visible veins -flat appearance

-no signs of liver of inflammation.palpable liver dullness when

NORMAL

abdomen -no pain palpated tenderness

when being with and no sound

Auscultated -uniform in color

URINARY

-has yellowish urine and -no difficulty in no sign of pus, blood in urinating the urine -no infections - no pus and blood urine in the

NORMAL

GENITALS

-no signs of discharges -no or suspected STD genital

signs

of

NORMAL

-has few genital/pubic abnormality hair (according to client)

MUSCULOSKELETAL

-muscle size is equal -no tremors -coordinated muscle -no swelling -no deformities

muscle size is equal -no tremors -coordinated muscle

NORMAL

MENTAL STATUS A.Orientation

-can able to identify the -mentally date&time(sept.22,2011 ) active.

B. Memory Immediate memory -can recall the set of -has numbers (3.5,7,) a good NORMAL

memory

 Recent memory Remote memory

-can recall what he ate - -can during breakfast -can identify recall the -no

able

to

signs

of in the

birthdates of his family difficulty members recalling events

CRANIAL NERVES Olfactory -can identify the normal -no difficulty in smell of the alcohol and identifying vinegar Optic smell The client has the problem in the optic nerve the NORMAL

- he cannot read the -no snellens chart clearly

sign

of

visual acquity

-coordinated Oculomotor movements

eye -coordinated eye movements (cranial nerve 3 is normally NORMAL

functioning) Troclear

-pupil

is

direct

and -the pupil reacts

consensual reaction to to the light light and can perform -can perform the six ocular movements six movement ocular NORMAL

Trigeminal

-the client blinks when -can able to blink the cornea is touched

NORMAL

Facial

- can perform the facial -can expressions

able

to the

NORMAL

perform facial movements

Abducens

-can identify the taste of -has no difficulty vinegar, coffee sugar and in identifying the different kinds of taste

NORMAL

Glossopharyngeal

-can able to move the -no eyeballs laterally -can identify

signs

of in the

NORMAL

difficulty the moving eyeballs

different taste of foods -can move the tongue

from side to side and up -can identify the and down different taste of foods -can hear he spoken -can move the Auditory words clearly (-) Romberg test tongue from side to side and up and down -(-)Romberg test NORMAL

Vagus

-can swallow the small -has no signs of amount of rice difficulty in

NORMAL

swallowing NORMAL

Accesories

-has equal strength of -has

an

equal of

shrugging of shoulder strength and head movement

shoulder and can move the head freely NORMAL

Hypoglossal

-can protrude the tongue

-has no signs of difficulty protruding tongue in the

REFLEXES BICEP - slight flexion of the -normally slight elbow flexion elbow( of the NORMAL

normal

response +2) TRICEP -slight extension of the -normally slight elbow extension of the elbows.
BRACHIORADIALIS

NORMAL

-flexion and supination -flexion of the forearm

and

NORMAL

supination of the forearm and

fingers may also extend slightly PATELLAR

-kicking out of the legs

-normal extension or

NORMAL

kicking out of the legs.

ACHILLES

-flexion of the feet

-normal of

flexion

NORMAL

feet(downward jerk) PLANTAR -all five toes bend -negative Babinski NORMAL

downward

MOTOR FUNTION GROSS ROMBERG TEST -may sway and able to -can able to sway maintain upright posture both hands and foot stance NORMAL

WALKING GAIT

-has upright posture and -has stable gait

upright

NORMAL

with posture and foot stance

opposing arm swing

-are able to close eyes -can STAND AT ONE FOOT WITH ONE EYE CLOSE HEAL TO TOE WALKING -maintain heel to toe -no walking in straight line and stand on one foot

able

to

NORMAL

stand on one foot with close eyes

signs

of in the toe

NORMAL

difficulty maintaining heel walking to

TOE TO HEAL -are WALKING

able

to

walk -can

able

to

NORMAL

several steps on the toes perform the toe and then to heels to heal walking without difficulty

-can able to touch the -can FINGER NOSE TEST TO nose

able

to

NORMAL

touch the nose

FINGER NOSE NURSES CLIENT

TO OF

-there is coordination -there

is

NORMAL

and rapidly can locate coordination and the nose rapidly can

locate the nose

FINGER THUMB

TO

- touches each finger to - touches each the thumb finger thumb to the

NORMAL

-can alternately supinate -can

ALTERNATE SUPINATION & PRONATION

able

to the & of

NORMAL

and pronate both hands

perform supination pronation both hands

SENSATION PAIN -can able to define the -can tip of the pen able to NORMAL

define the sharp objects

LIGHT TOUCH

-can define the light -can objects(cotton balls)

able

to

NORMAL

define the light objects

-can TEMPERATURE

able

to -can

able

to

NORMAL

differentiates the hot and differentiates the cold temperature(hot& hot and cold

cold water)

temperature

TACTILE DESCRIMINATION ONE TO TWO -can distinguish between -can distinguish POINT DISCRIMINATI ON

NORMAL

one or two stimulus

between one or two stimulus

STEREOGNOCIS

-can able to identify -can letters written in the identify palm

able

to the

NORMAL

letters written in the palm

EXTINCTION PHENOMENOM -both point are felt

-both point are felt

NORMAL

PRIORITIZATION I Cigarette Smoking 1.Nature of the Problem Health Threat 2 2/3 X1= 0.67

2.Modifiability

Easy

1 2/2 X 2= 2

3.Prevantive/Potential

High

2 3/3 x 1 = 1

4.Salience

Problem but not need immediate attention TOTAL

1 1/2 x 1 =1

4. 67

II. Poor Oral Hygiene

1.Nature of the Problem

Health Threat

3 2/3 x1 =0.67

2.Modifiability

Easy

2 2/2 x 2 =2

3.Preventive/Potential

High

3 3/3 X 1=0.67

4.Salience

Not considered as the problem

2 0/2 X 1=0

3.34 TOTAL

lll. Visual Acuity

1.Nature of the Problem

Health Threat

2 2/3 X 1 =0.67

2.Modifiability

Easy

2 2/2 X =2

3.Preventive/Potential

Moderate

2 2/3 X 1 =0.67

4.Salience

Problem but not need immediate attention

1 1/2 X 1 = 0.5

TOTAL

3.84

GORDON COLLEGE COLLEGE OF NURSING CITY OF OLONGAPO

CASE STUDY (ADOLTHOOD)

SUBMITTED BY: ERVY JEAN ABELON MICHELLE ANN PAMINTUAN

SUBMITTED TO: MARY ANN D. APACIBLE RN MAN