VISION MISSION

Republic of the Philippines Cavite State University shall provide

A premier university in historic
Cavite recognized for CAVITE STATE UNIVERSITY excellent, equitable and relevant
excellence in the development Don Severino Delas Alas Campus educational opportunities in the arts,
of morally upright and globally science and technology through
competitive individuals. Indang, Cavite quality instruction and relevant
research and development activities.
It shall produce professional, skilled
and morally upright individuals for
global competitiveness.
College of Nursing

TDDLER ASSESSMENT

Presented by:

BSN 2-3 GROUP # 4:

Viernes, Jemalyn

Presented to:

Prof. Ivan Derek Villena Wycoco, RN, MAN

Clinical Instructors, Level II

Date:

October 29, 2019

In Partial Fulfillment of the Requirement in NURS 05 for the Degree Bachelor of Science in Nursing
 TABLE OF CONTENTS

I. Demographic Data.......................................................................................................................3

II. Reason for Seeking Healthcare................................................................................................3

III. Past Medical History....................................................................................................................3

IV. OB-Gynecological History........................................................................................................3-4

V. Heredo-Familial History...............................................................................................................4

VI. Family APGAR............................................................................................................................5

VII. Gordon’s Functional Health Patterns.....................................................................................6-11

VIII. Physical Examination...........................................................................................................12-32

IX. Review of System.................................................................................................................33-34

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I. DEMOGRAPHIC DATA
A. Initials of Clients’ Name S.R.C Date of Interview: 10 24 2019
B. Address AGUS-OS, Indang, Cavite Time of Interview: 10:00 am
C. Age 1 y/o
D. Birth Date February 20, 2018 Primary Informant: Client
E. Birth Place Indang, Cavite Secondary Informant: Client’s Mother
F. Gender Female
G. Civil Status Single
H. Religion Catholic
I. Highest Educational Attainment N/A
J. Occupation N/A
K. Monthly Income / Budget N/A

II. REASON FOR SEEKING HEALTH CARE

III. PAST MEDICAL HISTORY

The client’s mother mentioned that her child never had chickenpox, mumps or measles.
Moreover, the client has no history of injury/accident, hospitalization or operation. She has no known
allergies and is not taking any medications. The client’s mother stated that her child is fully
immunized. Apart from this, the client’s mother cannot remember when the last examination of her
child was.

IV. HEREDO-FAMILIAL HISTORY

A. Genogram

RS RR
AC SC
32 27
33 y/o 28 y/o

SC SC SC

11 y/o 9 y/o 1 y/o

3
Diseased Male Female

Alive and Well Male Female

Interpretation:

The genogram shows the family history of the client. Her grandparents from both sides are
dead. The client’s mother mentioned that she did not know the reason behind the deaths of her
parents on both sides. Her mother is a 28 year old woman while her father is a 33 year old man, who
are both alive and well. She is a 1 year old toddler that has two siblings. Her eldest sibling is 11 years
old while her second sibling is 9 years old. They are alive and well.

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V. GORDON’S 11 FUNCTIONAL HEALTH PATTERNS
A. Health Perception – Health Management
Toddlers have little, if any, understanding of the meaning of health. They depend on their
parents for health management.

The client’s mother verbalized, that her child is current on her immunizations. The client only
experiences minor upper respiratory infections like colds and cough. Their passive immunity o
communicable diseases acquired from breast milk has disappeared and active immunity through the
initial immunization series is usually completed by 18 months. A potential problem for the toddler can
occur when their parents do not model healthybehaviors such as eating a balanced diet.

Whenever she feels sick or is sick, she said that she seeks help to the Health Care Unit. She
said that she is satisfied with it and believes it meets her needs adequately. She believes that it is
important to adhere to any recommendation or treatment administered by the doctor or health care
worker.

B. Nutritional – Metabolic
During a 24 hour period the client usually consumes three main meals and has snacks in
between. While breastfeeding, a healthy woman should consume approximately 500 calories/day. If
maternal intake is poor, which can occur when a lactating woman is not eating the right amount of
foods, the nutrient intake in her breast milk may become inadequate (Williams & Wilkins 2008, p.
435).

She usually eats a cup of rice with various viands that has some fat, proteins and vegetables
every meal. Protein is important for postpartum recovery and for the growth and repair of cells (Armul,
2015). She also eats fruits like apple, orange or banana.

The client is currently taking Ferrous Sulfate once a day. She was instructed by her doctor to
take it for a month after her childbirth. This medication is an iron supplement used to treat or prevent
low blood levels of iron (such as those caused by anemia or pregnancy). Iron is an important mineral
that the body needs to produce red blood cells and keep you in good health (WebMD, 2016).

She usually consumes 6-7 glasses of water and two glasses of milk every day. Getting enough
water not only supports breastfeeding but helps all moms avoid constipation. Apart from this, calcium
is also important after pregnancy because estrogen is low when a mother is nursing, so she is at risk
for osteoporosis. No issues were identified in terms of allergy or difficulty when eating, drinking or
swallowing. The client has an elastic skin turgor.

*3-day Diet Recall

MEALS 10/15/19 10/16/19 10/17/19
(Tuesday) (Wednesday) (Thursday)
Breakfast 1 pc. fried egg, 1 cup 2 pcs. Tuyo, 1 cup of 1 pc. hotdog, 1 pc.
of rice, 1 glass of milk rice, 1 glass of milk fried egg, 1 cup of rice,

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 1 pc. pandesal, 1 glass
of milk
Snacks 2 Breads, 1 glass of Biscuits, 1 glass of 1 Pandesal, 1 glass of
water water water
Lunch 1 serving of nilagang 1 serving of chicken 1 serving of Pakbet, 1
baka, 1 cup of rice, 2 curry, 1 cup of rice, 2 pc. fish, 1 cup of rice, 2
glasses of water glasses of water glasses of water
Snacks 3 buns of bread w/ 3 Biscuits, 1 glass of Turon, 1 glass of milk
tbsp. of strawberry milk
jam, 1 glass of milk
Dinner 1 serving of nilagang 1 serving of chicken 1 serving of Pakbet, 1
baka, 1 cup of rice, 2 curry, 1 cup of rice, 2 pc. fish, 1 cup of rice, 2
glasses of water glasses of water glasses of water
Snacks Apple, 1 glass of Banana, 1 glass of Orange, 1 glass of
water water water
Total Fluid Intake 1,183 ml 1,183 ml 1,183 ml

C. Elimination
When reflecting on her voiding pattern the client stated that she voided approximately seven
times per day. The color of her urine is light yellow. She feels no discomfort in urinating. During
pregnancy, as much as 2,000-3,000 ml of excess fluid accumulates in the body so extensive
diaphoresis (excessive sweating) and diuresis (excess urine production) begin immediately after birth
to rid the body of this fluid (Pillitteri 2018, p. 405).

The client has never utilized suppositories, supplements or other medication for either
constipation or diarrhea. She defecates 1-2 times, everyday. The color of her usual stool is brown.
She stated that the consistency of her stool is a sausage-shaped but with cracks on surface which is
type 3 according to Bristol Stool Chart. She has no hemorrhoids.

D. Activity – Exercise
The client stated that she barely goes out. Mothers need time for rest and recover before
resuming normal activities. Exercise after pregnancy helps to lose weight you gained during
pregnancy, reduce backaches, constipation, and bloating, improves posture, helps build muscle tone
and strength, and promotes better sleep.

Below is a 7-Day activity table and table for Katz Index of Independence in Activities of Daily
living for measuring the usual activities and independency of the client.
*7-Day Activity Table

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 Time Days of the Week & Date
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
1 am
2 am
Sleeping
3 am Breakfast; Feeding Baby; Change of Diaper
4 am
5 am
6 am Sleeping
7 am Breakfast; Feeding Baby; Change of Diaper
8 am
9 am Takes care of baby: bathing, breastfeeding baby
10 am
11 am Sleeping
12 am Lunch
1 pm Breastfeeding Baby; Change of Diaper
2 pm
3 pm Sleeping
4 pm Meryenda; Breastfeeding Baby; Change of Diaper
5 pm
6 pm Prepares Dinner
7 pm Breastfeeding Baby; Change of Diaper
8 pm
9 pm Sleeping
10 pm Breastfeeding Baby; Change of Diaper
11 pm Sleeping
12 pm Breastfeeding Baby; Change of Diaper

Interpretation:
This table gives us a generalize routine of the client for her activities of daily living.
*Katz Index of Independence in Activities of Daily Living
Activities Independence = 1 point Dependence = 0 point

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 Points (1 or 0) No supervision, direction or personal With supervision, direction or
assistance needed personal assistance or total care
Bathing 1
Dressing 1
Toileting 1
Transferring 1
Continence 1
Feeding 1
TOTAL POINTS: 6

Interpretation:
The table shows that the patient has sense of independency in doing her activities of daily
living. As stated by the patient, she can move easily and does not experience any discomforts
while doing these activities.

E. Sleep – Rest
*7-Day Sleep Diary
Constructs Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Hours of Sleep 11 hours
Sleeping Time 8pm,11pm, 1 am, 5 am, 10 am, 2 pm,
Waking Time 6pm, 10 pm, 12 am, 3 am, 7 am, 11 am, 4 pm
Bedtime Rituals None-
Feeling upon normal Normal normal Normal normal tired normal
waking up
Problem Shallow sleep and Sleep interruptions due to breastfeeding to newborn.
Encountered

The client mentioned that she sleeps for 11 hours every day. Mothers need time for rest and
recover before resuming normal activities. However, she is experiencing shallow sleep and sleep
interruptions due to breastfeeding a newborn. Breastfed newborns need to nurse every 2-3 hours,
that is 8-12 times in 24 hours. This means that, due to the short duration of their sleep, new
breastfeeding moms tend to lack REM sleep. REM starts about 90 minutes into sleep cycle and a
lack of this type of sleep can affect how moms think and cope in their daily lives.

Breast milk contains a hormone called Prolactin which helps to induce sleep. It also helps
soothe and calm our nerves which allows for a more peaceful postpartum period. Sleep deprivation
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can affect how a mother can able to cope with the stress of new motherhood but breastfeeding
mothers tend to be able to cope with this stress easier (Babymori, 2015).

F. Cognitive – Perceptual

The client is having deficit in her eye vision. Whenever she is having check-up for her eyes,
the health care provider does not identify it because she memorizes the snellen chart. She is not
having any problems with her other sensory perception. Furthermore, she is able to read and
write and has no difficulty in learning.

The postpartum period or puerperium, refers to the 6-8 week period after delivery during which
the mother’s body returns to its prepregnant state. The mother also undergoes psychological changes
during this time in addition to the changes that are occurring in her body. In the classic work on
maternal behavior of Reva Rubin, a nurse, she divided the puerperium into three separate phases—
taking-in phase, taking-hold phase and letting-go phase (Pillitteri 2018, p. 398)

The client is in her taking-hold phase wherein after a time of passive dependence, she begins
to initiate action in self-care. She has a strong interest in caring for the neonate that’s often
accompanied by a lack of confidence about her ability to care (Williams & Wilkins 2008, p. 420).

She mentioned that the time during labor and birth is stressful but since it is for her child she
overcome it successfully. The client is happy with the appearance of her baby. She is glad to be
through with pregnancy. She holds and talks to the infant. When a woman has successfully linked
with her newborn, it is termed effective attachment. (Pillitteri 2018, p. 400).

G. Self-Perception – Self-Concept
The client believes that she looks fresher now. A woman who feels good about herself, even
though she is exhausted from childbirth, usually will try to maintain her appearance (Pillitteri 2018, p.
397).

The client mentioned that she wants to return to her normal body shape. Experts warn that when
it comes to getting that post-pregnancy body back in shape, neither crash dieting nor a stringent
exercise program is the way to go. The worst thing a woman can do is try too hard to do too much too
soon -- if you do, you're likely to find yourself exhausted and discouraged and less likely to continue,
and you'll wind up carrying that baby weight a lot longer (Fleming, 2015). Breastfeeding burns
calories. It can help mothers lose extra weight gained during pregnancy (Somer, 2015).

H. Role-Relationship

The patient speaks Filipino. She speaks in a medium-pitched tone. When asked about if there
are any complaints with her family, she said that she has none. The family structure of the client is a
cohabitating family. She is the 7th among the eight siblings. She lives with her family at Oriental
Mindoro before and is living in Tanza, Cavite now with his live-in partner and daughter. Her sister is

9
temporarily staying with her now to help her do the activities at home such as cooking, washing
clothes, washing plates and cleaning. Her husband is at work every morning.

She mentioned that her partner is a loving and supporting man. Although sometimes, they are
having some problems but they make sure that they fix and talk about it immediately. Also, she is
being visited by her mother-in-law every month. She mentioned that she is actively communicating
with her other family members, relatives and friends.

I. Sexuality - Reproductive
The client had her first menstruation when she was 14. She said that she has a medium flow
during her menstruation. She uses a regular pad which she change for three times a day when full.
She has a regular period that lasts up to 3-4 days. She barely experiences abdominal cramps with a
pain scale of 6 out of 10. The client is not taking any medication for it, aside from putting some
ointment (Efiicascent Oil) and just by simply lying down and resting. She has had two pregnancies,
has delivered them at term and is all alive and well.

The client mentioned that she does not want to have sex with his partner. It is normal to have a
decreased sex drive after giving birth. This feeling can last for months. Sex drive has to compete with
the overwhelming fatigue that resulted from taking care of a newborn. Also, major hormonal shifts are
taking place that can make you feel off balance. Most women report that this decrease in libido is
temporary. With time and patience, you and your partner can rebuild a satisfying sexual relationship.
(McKain, 2015). She also stated that she explained it well with her husband.

She also said that she wants to know what method in family planning can be applicable to her
and her partner. Furthermore, the client mentioned that she is aware about Sexually Transmitted
Diseases.

J. Coping-Stress
The client said that at 27, she is now capable of making her own decision with regards to the
things about herself like wanting to take care of her second child. She failed to be with her first child
because she has to work at that time. Now, she wants to see her second child grow and to be with
her, verbalizing “Dapat matutukan at maalagaan lalo at babae”.
She stated that stress is a normal part of a mother life. She said that whenever she feels stress
and exhausted, she just thinks that it is for the sake of her baby.

K. Value-Belief
An individual’s sense of spirituality can be influenced by culture, life experiences and religious
beliefs (Brush 2000). The client is Protestant. She said that there are no influences from her spiritual
views on her postpartum stage. She added that she seldom goes to church because there are no
available nearby but prays every night. Moreover, she believes that her baby is a blessing.

The client did some “pausok” once at their home that was advised to her by the elderly in their
province to get rid of bad spirits. She also let her child wear a bracelet and pin some “anting-anting”
on her baby’s clothes that serves as “pangontra”.

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VI. COMPREHENSIVE PHYSICAL EXAMINATION
A. Vital Signs Date / Time of Exam: October 18, 2019, 1:00 pm
T = 36° C
PR = 83 bpm
RR = 19 bpm
BP = 120/80 mmHg
B. Anthropometric Data
Height = 168 cm BMI = 23.1 Normal)
Weight = 65 kg IBW = 53-70 kg
C. General Appearance
1. Body build and height-weight proportionality
The client’s body build is proportional to her height and weight.
2. Posture and Gait
The client has normal posture and gait.
3. Over-all hygiene and grooming
The client is properly groomed and has a good hygiene.
4. Body and breath odor
The client doesn't have body odor or bad breath.
5. Obvious signs of distress / illness
There are no obvious signs of distress/ illness.
6. Mental status
The client was able to communicate well with the interviewer, can understand language
and is oriented on time, people and place.
7. Attitude
The client participates well on the interview.
8. Affect/mood; appropriateness of responses
The client answers all the questions appropriately.
9. Quantity and quality of speech
The client speaks well and comfortably talks about her labor and childbirth.
10. Relevance and organization of thoughts
The client’s answers are organized and relevant to the questions that were asked by the
interviewer.
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 D. Focused Assessment
Body Part Normal Findings Actual Findings Clinical Significance
Examined

Skin Inspection Inspection

 Skin colour with  No bruising,  Bruise is an injury

no areas of pallor, erythema, appearing as an area
jaundice, or edema, lesions of discolored skin on
cyanosis or any skin the body, caused by
 No bruising, abnormalities a blow or impact
erythema, or  No problems rupturing underlying
areas of with facial blood vessels;
discoloration are blemishes Erythema suggests
apparent inflammation. Edema
 No presence of is characterized by
edema an excess of watery
 No presence of fluid collecting in the
lesions or any cavities or tissues of
skin abnormalities the body; Lesions

 Possible suggests local or

increased feeling systemic problems.

of warmth and  The client is not

sweating due to experiencing any of
increased activity those skin
of the sweat abnormalities which
glands are a normal finding.
 Possible
problems with
facial blemishes
due to increased
activity of
sebaceous glands

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  Chloasma/
Hyperpigmentatio
n (brown patches)
seen on forehead,
cheeks, and
bridge of nose,
known as the
“mask of
pregnancy”
Palpation Palpation

 Skin immediately  Skin immediately  Decreased mobility is

back to its original back to its original seen with edema.
position after position after gentle Poor skin turgor is
gentle pitch pitch (turgor) seen in dehydration
(turgor)  Skin is warm, clients.
 Skin feels smooth smooth and intact  Rough, flaky, dry skin
and warm without is seen in
broken areas hypothyroidism.
 Cold skin may
accompany shock or
hypotension. Cool
skin may accompany
arterial disease. Very
warm skin may
indicate a febrile
state or
hyperthyroidism.
 The clients is not
experiencing any of
those abnormalities,
and therefore has a
normal finding.

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Hair Inspection Inspection

 Equally  Natural Hair Color  The color is

distribution of (Black) determined by the
hair thickness  Equally distribution amount of melanin
 No presence of of hair thickness present. Nutritional
any infestations  Hair Loss deficiencies may
or infection  No presence of cause patchy gray
any infestations or hair in some clients.
infections  Many women begin
to lose a quantity of
hair in the
postpartum period
because, during
pregnancy, their
increased
metabolism caused
hair to grow rapidly
and many hairs to
reach maturity at the
same time. As the
woman’s body
returns to a normal
metabolism level
following birth, this
rapid-growth hair will
be lost, especially
around 6-12 weeks
postpartum. That is
why moderate hair
loss is a common
finding in a
postpartum woman.

14
  No presence of any
infestations or
infections is a normal
finding.

Palpation Palpation  Brittle or broken hair

shafts may indicate
 Hair is smooth  Hair is smooth
endocrine or
metabolic
dysfunction.
 Smooth hair is a
normal finding.

Nail Inspection Inspection

 Color of nail bed  Color of the nail  Discoloration of nail

ranges from light bed is light pink bed may indicate
pink to brown,  Nails are slightly trauma, fungal
depending on skin curve (160-degree infection, or
color angle) b/w the nail melanoma.
base and the skin.  Early clubbing and
 Nail bed is slightly
 Round in shape late clubbing can
curve or flat
and is hard. occur from hypoxia.
Spoon nails may be
present with iron
deficiency anemia.
 Thickened nails may
be caused by
decreased
circulation.
 The client is not
experiencing any of
those abnormalities.

15
 Palpation Palpation

 Capillary refill in less  Capillary refill is 1  A slow capillary nail

than 3 seconds second bed refill is seen in
clients with
respiratory or
cardiovascular
disease that causes
hypoxia.
 Pink tone returns
immediately to
blanched nailbeds of
the client when
pressure is released,
and therefore, a
normal finding.

HEAD Inspection Inspection

Skull and  Head is symmetrical  Head is  The skull and facial

Face to the body symmetrical to the bones are larger and
body thicker in
acromegaly, which
occurs when there is
an increased
production of growth
hormone.

Palpation Palpation

 Absence of  Absence of  Presence of

edema, nodules, edema edema, lesions,
masses nodules, or or masses may
masses indicate

16
 problems, trauma
or cancer.

EYES AND Inspection Inspection

VISION
 Equally  Hairs were  Loss of hair in the
Eyebrows distribution of equally eyebrows and
hairs distributed alignment and motility
 Proper  Eyebrows were of it will affect the
alignment and proper aligned amount of light,
movement and moved moisture or dirt that
freely gets into our eyes.

Eyelashes Inspection Inspection

 Equally  Hairs were equally  Madarosis is the loss

distribution of distributed of eyelashes;
hairs  Direction of curls Blepharitis is the
 Outwards were outward irritation of the lid
direction of margin, where
curls eyelashes join the
eyelid. The eyelids
are red and itching,
the skin often
becomes flaky, and
the lashes may fall
out; Distichiasis is the
abnormal growth of
lashes from certain
areas of eyelid;
Trichiasis refers to
ingrown eyelashes.

17
  Eyelashes may
become infested with
parasitic crab louse.
 Direction of the curls
will affect how it
keeps organisms
from the eyes.

Eyes Inspection Inspection

 No problems on  The client has  Myopia is present

visual acuity problem on when the second
 Symmetrical, sclera visual acuity number in the test
is clear  The eyes were result is larger than
 Eyes follows symmetrical and the first (20/40). The
movements sclera is clear higher the second
 PERRLA  Eyes follows number, the poorer
movements the vision.
 Conjunctiva is  Preshyopia is
clear, moist, and indicated when the
smooth. client moves the
 PERRLA chart away from the
eyes to focus on the
print. It is caused by
decrease
accommodation.
 Any client with vision
worse than 20/30
should be referred for
further evaluation.
 Asymmetrical
position of eyes can
be genetics or can
due to muscle

18
 weakness or
paralysis.
 Scleral Icterus
(Yellow Eyes) is
associated with
hepatitis and other
liver disease; Blue
Sclera can be caused
by iron deficiency
anemia; Episcleritis is
a local noninfectious
inflammation of the
sclera.
 Failure eyes to follow
movement
symmetrically in any
or all directions
indicates a weakness
in one or more
xtraocular
movements or
dysfunction of the
cranial nerve that
innervates the
particular muscle;
Nystagmus, an
oscillating movement
of the eye may be
associated with an
inner ear disorder,
multiple sclerosis,
brain lesions, or
narcotics use.

19
  Generalized redness
of the conjunctiva
suggests
conjunctivitis; Areas
of dryness are
associated with
allergies or trauma;
 The pupil is abnormal
if it fails to dilate to
the dark or fails to
constrict to light or
accommodation.

EARS Inspection Inspection

AND
 Symmetrical, eye  Ears were  Malaligned ears may
HEARING
level position symmetrical and in be seen with
 No lesions and eye level genitourinary
discharges  No lesions and disorders or
 Color is consistent discharges chromosomal
with facial color.  Prearicular pits on defects.
 Romberg Test: Client both ears  Tophi (nontender,
maintains position for  Color is consistent hard, cream-colored
20 seconds without with facial color. nodules on the helix
swaying or with  Romberg Test: or antihelix,
minimal swaying Client maintains containing uric acid
position for 20 crystals)-gout
seconds without  Blocked sebaceous
swaying or with glands-postauricular
minimal swaying cysts
 Ulcerated, crusted
nodules that bleed-
skin cancer

20
  Preauricular pits
occur during the
development of an
embryo. It most likely
occurs during the
formation of the
auricle during the first
two months of
gestation. It does not
cause any symptoms,
however sometimes
they become
infected.
 Redness or swelling,
scalin or itching- otitis
externa.
 Pale blue ear color-
frostbite
 Romberg Test
(Abnormal Finding):
Client moves feet
apart to prevent falls
or starts to fall from
loss of balance. This
may indicate a
vestibular disorder

Palpation Palpation

 Smooth in texture,  The rest are  Enlarged

has elasticity, no smooth in preauricular and
areas of tenderness texture, has postauricular
elasticity, no lymph nodes-

21
 areas of infection.
tenderness

NOSE Inspection Inspection

AND
 Color is the same as  Color is the same  Rhinophyma is a skin
SINUSES
the rest of the face as the rest of the disorder that causes
Nose  Nose is symmetrical face the nose to become
and is in midline  Symmetrical and enlarged and
located in midline bulbous. The nose
may look red,
swollen, and
distorted.

Palpation Palpation

 No swelling and  No swelling and  Nasal tenderness on

discharges discharges palpation
 Absence of masses  Absence of masses accompanies a local
and tenderness and tenderness infection.
 Client is able to sniff  Client is able to  Cannot sniff through
through each nostril sniff through each a nostril that is not
while other is nostril while other is occluded, nor can he
occluded occluded or she sniff or blow
air through the
nostrils. This may be
a sign of swelling,
rhinitis, or a foreign
object obstructing the
nostrils.
 A line across the tip
of the nose just
above the fleshy tip is
common in clients

22
 with chronic allergies.

Nasal Inspection Inspection

mucosa
 Absence of redness,  Absence of  Nasal mucosa is
swelling, growth or redness, swelling, swollen and pale pink
discharge growth or discharge or bluish gray in
clients with allergies.
Nasal mucosa is red
and swollen with
upper respiratory
infection.

MOUTH Inspection Inspection

Lips  Lips should be pink  Pink in color  Pallor around the lips
in color, varies in skin  Lips look smooth is seen in anemia
color and moist and shock. Bluish lips
 Lips should look may result from cold
smooth and moist or hypoxia. Reddish
lips are seen in
clients with
ketoacidosis, carbon
monoxide poisoning,
and COPD with
polycytemia.
 Swelling of the lips is
common in local or
systemic allergy.

Teeth Inspection Inspection

 Clients who smoke,
 Absence of dental  No dental caries
drink large quantities

23
 caries  Teeth in proper of coffee or tea or
 Teeth should be in alignment have an excessive
proper alignment intake of fluoride may
have yellow or
brownish teeth.
 Tooth decay (caries)
may appear as brown
dots or cover more
extensive areas of
chewing surfaces.
 A chalky white area
in the tooth surface is
a cavity that will turn
darker with time.
 Malocclusion of teeth
is seen when upper
or lower incisors
protrude.
 White spots on teeth
may result from
antibiotic therapy.

Gums Inspection Inspection

 Red, swollen gums
 No bleeding, swelling  Gums sometimes
that bleed easily are
or lesions bleed during
seen in gingivitis,
 Color should be in brushing her teeth
scurvy (vitamin C
light pink or pink  No swelling or
deficiency), and
lesions
leukemia. Receding
 Gums are pink in
red gums with loss of
color
teeth are seen in
periodontitis.
 Enlarged reddened

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 gums (hyperplasia)
that may cover some
of the normally
exposed teeth may
be seen in
pregnancy, puberty,
leukemia, and use of
some medications,
such as phenytoin.
 A bluish-black or
grey-white line along
the gum line is seen
in lead poisoning

Tongue Inspection Inspection

● Tongue moves ● Tongue moves  Decreased tongue

normally normally strength may occur
● Tongue is in midline ● Tongue is in with a defect of the
● Color of the tongue midline twelfth cranial
should be pink ● Pink in color with nerve—
● Have adequate some white in the hypoglossal—or with
salivation middle a shortened frenulum
● The tongue’s ventral ● Have adequate that limits motion.
surface is smooth, salivation ● Among possible
shiny, pink or slightly ● The tongue’s abnormalities are
pale with visible ventral surface is deep longitudinal
veins and no lesions. smooth, shiny, pink fissures seen in
● The client can or slightly pale with dehydration;
distinguish between visible veins and no ● A black tongue
sweet and salty. lesions. indicative of bismuth
● The client can (PeptoBismol) toxicity
distinguish between ● black, hairy tongue;
sweet and salty. a smooth, reddish,

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 shiny tongue without
papillae indicative of
niacin or vitamin B12
deficiencies, certain
anemias, and
antineoplastic
therapy.
● An enlarged tongue
suggests
hypothyroidism,
acromegaly, or
Down’s syndrome,
and angioneurotic
edema of
anaphylaxis.
● A very small tongue
suggests
malnutrition. An
atrophied tongue or
fasciculations point to
cranial nerve
(hypoglossal, CN 12)
damage.
● Leukoplakia,
persistent lesions,
ulcers, or nodules
may indicate cancer
and should be
referred. Induration
increases the
likelihood of cancer.
● Loss of taste
discrimination occurs

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 with zinc deficiency, a
seventh cranial nerve
(facial) defect, and
certain medication
use.

NECK Inspection Inspection

 Swelling, enlarged
 No abnormal swelling  No abnormal
masses, or nodules
or masses swelling or
may indicate an
 Can freely move the masses
enlarged thyroid
head in any direction  Can freely move
gland , inflammation
 Thyroid is the head in any
of lymph nodes, or a
symmetrical and direction
tumor
visible, rise during  Thyroid is
 Limited range of
swallowing symmetrical and
motion, swelling,
 No signs of visible, rise during
ten- derness, or
weakness of neck swallowing
crepitation may
muscles  No signs of
indicate TMJ
weakness of neck
syndrome.
muscles
 Asymmetric
movement or
generalized
enlargement of the
thyroid gland is
considered
abnormal.

THORAX Inspection Inspection

AND
 Shape of the chest is  Shape of the chest  Skeletal scoliosis and
LUNGS
1:2, symmetrical to is 1:2, symmetrical kyphosis
the body and aligned to the body and

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 with the spine with no aligned with the
deformities spine with no
deformities
Auscultation Auscultation
 Coarse breath
 Clear lung sounds;  Clear lung sounds;
sounds
absence of absence of
 Decreased or
wheezing, rhonchi, wheezing, rhonchi,
diminished lung
etc. etc.
sounds
 Respiratory rate  Has respiratory  Absent breath
increases rate of 19 breaths sounds
per minute  Adventitious breath
sounds
 Crackles
 Wheezes
 Rhonchi
 Respiration rate
under 12 or over 25
breaths per minute
while resting is
consideredabnormal.

HEART Auscultate Auscultate

 Regular rhythm (S1  Regular rhythm (S1  S1: Fixed split

and S2) and S2) Wide splitting
 Heart rate is 60-100  Has pulse rate of Paradoxical split
beats/min and 79 beats per minute S2: Split S2 may
regular  No S3 and S4 occur from pulmonic
 No S3 and S4  No murmurs, valve closing slightly
 No murmurs, gallops gallops or rubs after the aortic’ it may
or rubs  Blood pressure is be heard in the
120/80 mmHg pulmonic valve area
during inspiration in
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  Normal Blood children
pressure is 120/80  Rhythm is irregular
mmHg  S3 and S4 is heard
 murmur is heard
 Postpartum
Preeclampsia’s blood
pressure is (140/90
mmHg)
 Postpartum
Hemorrhage

BREAST Inspection Inspection

AND  Erythema: infection
● Increased size of ● Increased size of
AXILLAE  Hypermpigmention –
breast breast
cancer
● No discoloration, ● No discoloration,  Unilateral vascular
retraction, swelling, retraction, swelling, appearance could
edema, lesions, edema, lesions, indicate increased
masses and masses and blood flow to a
discharges discharges malignancy
 Mastitis: inflammation
● Areola may darken ● Areolas are darker
and nipples are more ● Nipples are more  Nipples have cracks,

erectile and becomes erectile and larger sores or fissures

enlarge ● Breast 

engorgement

ABDOMEN Inspection Inspection

 No lesions, hernia,  No lesions, hernia,  Asymmetry may be

distention (girth) distention (girth) seen with organ
 Symmetrical  Symmetrical enlargement, large
 Linea Nigra:  Presence of striae masses, hernia,
 Striae Gravidarum/ gravidarum and diastasis recti, or
Stretch marks on the linea nigra bowel obstruction.

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 abdomen, thighs,  Bluish or purple
discoloration around
the umbilicus
(Cullen’s sign)
indicates intra-
abdominal bleeding.

MUSCULO Inspection Inspection

SKELETA
 Absence of tremors,  Absence of  Presence of tremors,
L
swelling or atrophy of tremors, swelling or swelling or atrophy of
muscles atrophy of muscles muscles, deformities,
 Absence of  Absence of edema and
deformities, edema deformities, edema tenderness in bones
and tenderness in and tenderness in and swelling in joints
bones bones
 No swelling in joints  No swelling in joints
Palpation Palpation
 Difficulty to move
 Movements are  Movements are
 Muscles are flaccid,
smooth smooth
tenderness and
 Muscles are not  Muscles are not
swelling on bones
flaccid, no flaccid, no
and joints
tenderness and tenderness and
 Not able to move
swelling on bones swelling on bones
against resistance
and joints and joints
 Able to move against  Able to move
resistance against resistance

NEUROLO Mental Status

GIC  Able to
● Able to  Patients generally
communicate,
communicate, lose orientation in
understands
understands time first, then in

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 language, oriented in language, oriented place, and finally
time, place and in time, place and person. Asking about
people, can people, can situation may also
remember recent and remember recent show development,
remote memories and remote memory, and
memories judgment.
 Uterus is  The bladder should
nonpalpable be nonpalpable
 Bladdr is above the symphysis
nonpalpapble pubis.

Consciousness Level

 A comatose client
● Score ranges from 8  Scores 15 points
scores 7 or less
and above for
Glasgow Coma
Scale
Cranial Nerves
● Absence of problems  Absence of
 Abnormal findings
on 12 Cranial nerves problems on 11
include difficulty
Cranial nerves
reading Snellen
 Presence of
chart, missing
Problems in
letters, and
Cranial Nerve II
squinting.
 Client reads print by
holding closer than
14 in or holds print
farther away as in
presbyopia, which
occurs with aging.

Reflexes

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 ● Positive brachial and  Positive brachial  Negative brachial
patellar reflexes and patellar and patellar reflexes
reflexes

Gross Motor/Balance
● Normal walking gait  Normal walking
 Abnormal walking
gait
gait

GENITALS Inspection (has to asked

the client)
 According to the  Redness is
● Equally distribution of client, pubic hairs considered normal
pubic hairs, no were equally with episiotomies
infestations, lesions, distributed, no and lacerations;
nodules, swelling, infestations, however, if there is
inflammation, lesions, nodules, significant pain
abnormal discharges swelling, present, further
● White lochia inflammation, and assessment is
abnormal necessary.
discharges Furthermore,
 White lochia excessive edema
can delay wound
healing.

RECTUM Inspection (has to asked .

AND the client)
 Client doesn’t have  Presence of
ANUS
 May have hemorrhoids hemorrohoids
hemorrhoids  No lesions,  Presence of lesions,
 No lesions, nodules, nodules, masses nodules, masses
masses and and tenderness and tenderness
tenderness  There is no pain in  Pain in defecating
defecating

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VII. Review of System
General health

Neurologic  The client cited that she does not have headache, head injury,
seizures, dizziness or fainting.
Eyes  She does not wear any eye glasses but has a problem with her
vision. She said that she does not have glaucoma or cataract. She
added that she has no infection, pain or any recent changes in the
eyes.
Ears  The client mentioned no infection, tinnitus, vertigo or earache.
 The client said that she has no nose bleeds, discharge, allergies,
Nose postnatal drainage, or sinus pain. She also reported that she rarely
have colds a year.
 The client is not wearing dentures. Her teeth is complete and in
Mouth and Pharynx good condition. She said that she is not experiencing toothache,
bleeding of gums, hoarseness, or difficulty in swallowing. Also, she
does not undergo tonsillectomy. She cannot remember her last
dental exam
Pulmonary  She mentioned no cough, wheezing pain, or serious chest illness.
Cardiovascular  She said she has no history of heart murmur, history of heart
Hematologic disease, hypertension, pain, palpitations, or anemia. She
mentioned that she is aware of her blood pressure because of her
prenatal check-ups. She said that she never had blood
transfusion.
Gastrointestinal  She defecates every other day. She said that she has no rectal
pruritus, hemorrhoids, pain, ulcer, gallbladder disease, hepatits, or
appendicitis.
Renal  She reported no hematuria, STI’s, pelvic inflammatory disease,
Hepatitis B, HIV, subfertility concern or problem getting pregnant.
Musculoskeletal  She has no varicose veins, pain, and stiffness of joints, fractures,
or dislocations.
Reproductive  She said that she has no lumps, secretion, pain, tenderness in the

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 breasts.
Integumentary  She has no rashes, acne, or psoriasis.

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