NURSINGPROCESS

I HEALTH HISTORY

A. BIOGRAPHIC DATA

1. Name: JBL
2. Address: 70 Cleofer St. Sta. Queteria, Caloocan City
3. Age: 4 years old
4. Gender: Male
5. Date of Birth: May 2, 2006
6. Place of Birth: PGH
7. Ethic Group: None
8. Primary Language Spoken: Filipino, English
9. Education: Preschool
10. Religious Orientation: Roman Catholic
11. Health Financing/Source of Medical Care: None
12. Manner of Admission: Ambulatory

B. PAST HEALTH HISTORY

1. Child Disease: Asthama

2. Immunuzation: Complete but unrecalled dates
3. Allergies:
a. drugs:
b. foods:
c. Others: dogs, cats
4. Accident and Injuries: none
5. Hospitalization: July 6, 2010
6. Medication:Ceferoxine 750 mg/15cc, Paracetamol, 4.4 IVF q8, Gentamycin 80
mg/2cc,
7. Prescription:
a. Prescribed: Doctor’s Prescription
b. Self Prescribed:

C. FAMILY HISTORY OF ILLNESS

II. GORDON’ FUNCTIONAL HEALTH PATTERNS

D. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN

1. How has the general health been? Informant verbalizes that “J seldom get
sick so far twice pa lang siya na admit”
2. What do you consider healthy about you? Questions can’t be answered by
informant since “I am not the owner of the clients body” as informant stated
3. What are traditional concepts of health and illness? None
4. Do you have routine Physical Examination? The informant stated that she
does not take the child for Physical examination as far as she can remember
5. Perform self breast Examination? Question is not applicable for the child
6. In the past, year how many time have you seen health care provider? For
what reason? Informant stated that his grandson see his pediatric last month
7. In the past, has it been easy to find ways to follow things nurse/ doctors
suggest? Informant stated that its not easy to let his grandson follow things
especially medication
8. What safety practices do you follow? Informant stated that his grandson
always wanted to wash his hands before eating, put a towel on his back, he is
particular in cleanliness
9. Most Important things to keep healthy? Do You think these things will make a
difference to health/ family/ folks remedies if appropriate? Informant stated
that always wanted to wash his hands before eating, put a towel on his back,
he is particular in cleanliness
10. Personal Hygiene practices. Describe how do you have take care of your
body? Bath, hand washing, trimming of fingernails, wearing of slippers, use of
deodorant/ cologne, brush teeth, flossing, dental visit? Informant stated that
the client brushes his teeth four times a day, trim his nails once a week, wears
slippers all the time, uses cologne, does not floss and had seen a dentist twice
a year.
11. Substance use, Use of cigarette, alcohol, drugs? Kind, amount, frequency?
Reasons? Aware of the effects, Passive smoking? Questions are still not
answerable by client
12. Environmental condition sanitation practices, water supply, toilet facilities,
waste management and food preparation, presence of vectors, health hazards?
Informant stated and described that water for them and the client is safe, they
buy wilkins mineral water, and NAWASA water supply for bathing and others,
automatic toilet facilities, garbage is collected twice a week by the dump truck,
absence of vectors, and one health hazard particularly the bare wire in the
kitchen which is still not fixed.
E. NUTRITIONAL AND METABOLIC PATTERN

1. Typical Food intake? Describe. Supplements? Informant stated that the client
had clusivol, PedZinc vitamin supplements, eats three to four time a day.
a. 3 day Diets Recall

Breakfast Lunch
Dinner
1st Day milk, bacon, bread, water, water, squash, rice,chicken rice,
fish,water,milk,
banana apple
2nd Day milk, chicken nuggets, adobo, rice, water, rice, beef,
water, milk
banana, rice
3rd Day milk, hotdog, chicken bread, water rice,
chicken, water,
nuggets, bread, orange carrots,
beans,
vegetables,milk

2. Typical daily Fuid intake, Describe? Informant stated that the client drinks
210 ml of milk twice a day, morning and evening before he goes to bed, client
cant consume 2L of water the whole day
3. What is your knowledge of proper Nutrition? Client still does not have a
complete knowledge of proper nutrition, and still dependent on his guardians
4. Food likes and dislikes? Informant stated that the client had a strong dislike
to ampalaya, mallunggay.
5. Food Preparation? Informant stated that the client likes his food to be served
in a lunch box even he is at home
6. Where do you eat? Informant stated that the client does not like to eat much
at the restaurant he does not like too much people and noise, so they often eat
at home
7. Whom do you eat? Informant stated that the client like to eat with his
grandfather
8. Food Budgeting? Informant stated that her food budget for the kid a day is
400 pesos.
9. Weight loss? Gain? Amount? Informant stated that the client loss weight by 2
this month.
10. Appetite? Informant stated that the client is in to eating almost everything
she served except for the food that the client dislike
11. Food or eating discomfort? Informant stated that the client does not like to
eat when hospitalized
12. Heal wounds well or poorly? Informant stated that that client’s wound heal
easily
13. Skin Problems, lesions, dryness? Informant stated that the client does not
have skin problems
14. Dental Problems? Informant stated that the client had some decayed front
teeth.

F. ELIMINATION PATTERN

1. Bowel elimination pattern, Describe frequency? Characteristics?

Discomfort/pain? Informant stated that the client void once or twice a day,
depending on how much he eats, he sometimes hold his urge to poop when he
is very much interested on what he is watching, no bowel discomfort, formed,
stool, soft stool.
2. Urinary Elimination pattern. Describe its frequency, Characteristics,
Discomfort/pain? Informant stated that the client void 7 times a day but its still
dependent on how much fluid he takes during the day, amber in color and does
not have discomfort when urinating.
3. Practice to achieve normal elimination pattern? Informant stated that the
client is placed on top of the bowl for 15 to 20 minutes to feel the urge to void,
4. Excess perspiration? Informant stated that the client perspire a lot and
change t shirt 4 times a day because of his excessive perspiration.

G. ACTIVITY- EXERCISE PATTERN

1. Describe your usual activities in a day? Informant stated that the client likes
to watch TV after he wakes up in the morning and before he sleeps at night.
2. Kind of physical activity do you engage in? excercise pattern, Type?
Regularity? Client does not have any physical exercise pattern yet
3. Are you satisfied with the amount with the exercise do you get? Question
can’t still not answerable by the client
4. What type of work do you do for a living? Not applicable question for the
client at his age
5. Sufficient energy for completing desired required activities?Not applicable
question for the client at his age
6. Spare time(leisure activities)? Enough resources for leisure activities?
Satisfaction?Informant stated that the client spends his day watching
educational movie, coloring and adding and writing numbers
H. SLEEP-REST PATTERN

1. Describe sleep pattern, number of hours, continuity, satisfied? Informant

stated that the client sleeps only at night specifically 10 PM, continues and
satisfied.
2. Usual time to sleep? usual time for waking up? Do you wake up at night?
Informant stated that the client sleeps by 10 PM and wakes up in the morning
by 8:00 AM usually and continues
3. Do you feel refreshed when you wake up? Informant stated that the client
often had tantrums when he wakes up in the morning
4. Describe sleeping Environment, Any problem? Concerns? Informant stated
that the client sleeping environment is quite, he likes to sleep when the room is
dark
5. Describe bed routine? Informant stated that the client likes to watch Lotto on
TV reading the numbers of the balls with a bottled milk with him.
6. Any problem falling asleep? Informant stated that the client cannot sleep
when there is still light inside the house.
7. What helps you sleep? Informant stated that the client sleeps when he had
milk
8. Takes nap? When?Informant stated that the client does not take a nap during
day time
9. What do you do for relaxation? Question is not answered by the informant

I. COGNITIVE- PERCEPTUAL PATTERN

1. Can read and write? Any difficulty? Informant stated that the clientcan read
and write, add numbers, subtract and recognize almost all colors,shapes.
2. How is your hearing? hearing difficulty?Informant stated that the client had
no hearing impairment
3. How is your vission? Do you wear glasses? Last Checked?Informant stated
that the client had a clear vission and not wearing glasses.
4. Any change in the memory lately? Informant stated that the client memory is
far more advance than of a regular child.
5. Easiest way to learn things? Any difficulty learning?Informant stated that the
client can pick up line easily, learn thing easly with visual aids, and wayching
TV.
6. Do you have any problems with speaking, reading or writing?Informant
stated that the client is very good in reading, writing, but speaks less to people.
7. Any changes in smell or taste?Informant stated that the client does not have
smell or taste lately
8. How are you doing school?Informant stated that the client is placed in a
special shool for authistic children and he is doing good in school.

J. SELF- PERPCEPTION AND SELF-CONCEPT PATTERN

1. How do you describe yourself? Most of the time, feel good 9not good) about
yourself?
2. Changes in your body or the things you can do? Problem to you?
3. Any physical alterartions? Changes in ways you feel about yourself or your
body? Difficulty in acceptance of changes? How it affects the relationship
between you and your famil, friends and how you see yourself?
4. How do you see yourself in relation to other people?
5. How do you express your thoughts and feelings to others
6. What are your goals in the next five years? How do uou plan to achieve
them?
7. Describe chataracheristics of type of person you would most like to be? Do
you see yourself as that person?
8. What type of mood you usally in?
9. Find things that make you angry?
How do you express your self during mood changes? Do your relation with
otherschanges with your mood? How?
10. Are you satisfied with your usual mood? Why?

KROLE- RELATIONSHIP PATTERN

1. Live alone? Family? family Structure? Significant people in life? Informant

stated that the client is living with them and his parents are overseas.
Extended family and his significant persons are them, (grandmother and
grandfather)
2. Describe relationship for each member of the family? Informant stated that
the client is doing fine but sometimes its hard for them to communicate with
him since he had autism
3. Roles assumed in the family, Fulfilled? why?Informant stated that the client is
the only child and still does not have a concept of fulfillmet with his role.
4. Are family problems you have difficultly handling? Question is not
answerable yet
5. How does your family usualy handle problem? Question is not answerable yet
6. Family dependent on you for thing? If appropriate how do you manage?
Question is not applicable at his age
7. What do you think of voicing opinon of family? Friends?Question is not
applicable at his age
8. What iniates activities with the family?Question is not applicable at his age
9. What are usual family activities? Informant stated that client and them
usually stays at home and watch TV and seldom go out.
10. Belong to social group? Close friends? Feel lonely frequently?How do you
express your feelings or thoughts to others? Question is not applicable at his
age
11. Are things generally go well with school? Are there any problem that
influence to health? Informant stated that client is doing good with his school,
and they are thingking of putting him in a regular school if his authism gets
less
12. Inome/allowance sufficient for need? Any financial problems or concers?
Question is not applicable at his age
13. Feel part of the nieghborhood where living? Informant stated that client had
his own world and he does not much care of his nieghbors

L. SEXUALITY-REPRODUCTIVE PATTERN
 * Questions are still not applicable for his age.

M. COPING- STRESS TOLERANCE PATTERN

* Questions are still not applicable for his age.

N. VALU-BELIEFS PATTER

* Questions are still inappropriate for his age.

O. OTHERS

PHYSICAL ASSESSMENT FINDINGS

Body Part Examined Actual Findings

BODY MEASUREMENT
Hieght 112 cm
Weight 20 kg
Body Build ectomorphic
Body Mass Index (BMI) 17.7 (49%)
GENERAL APPEARANCE
 Posture and Gait * Erect

Standing, Sitting, Walking * coordinated movement

Hygiene and Grooming * Clean and neat

Body Odor * No body odor
Breath Odor * presence of breath odor
Signs of distress in posture or facial * No signs of distress
expression
Signs of health or illness * Healthy appearance
MENTAL HEALTH STATUS
Attitude * Cooperative
Mood * Appropriate to the situation
Quality and organization of speech * Understandable and exhibits thought
organization
Relevance * Have sense of reality
INTEGUMENTARY SYSTEM

NAILS: * Convex curvature; angle of nail plate

about 160˚
* Smooth texture

* Intact epidermis
* positive capillary refill test

SKULL and FACE (hair and scalp)

SKULL: * size appropriate to the body
* Round and symmterical in shape
* absence of masses/nodules
SCALP: * color similar to that of facial skin
*No foul odor
*No presence of lesions and no masses
HAIR: * Evenly distributed and thin
* No infection or infestation
FACE: * Symmetric facial features
* Palpebral features equal in size
* Symmetric nasolabial folds
* Symmetric facial movements
EYE STRUCTURE and VISUAL ACUITY
EYES:
Eyebrows * Hair evenly distributed
* Skin intact
* symmetrically aligned
* Equal movement
Eyelashes * Equally distributed
* Curled slightly outward
 Eyelids * Skin intact
* No discharges
* No discoloration
* Lids close symmetrically
* 16 involuntary blinks per minute
* Bilateral blinking
* When lids open, no visible sclera above
corneas, and upper and lower borders of
cornea are slightly covered

Bulbar Conjunctiva * Transparent

* Capillaries sometimes evident
* Sclera appears white
Palpebral Conjunctiva * Shiny
* Smooth
* Color pink
Lacrimal Gland * No edema or tenderness
Lacromal Sac and Nasolacrimal Gland * No edema or tearing
Cornea * Transparent
* Shiny and smooth
* Details of the iris are visible
* Client blinks when the cornea is touched
Pupil * Black in color
* Equal in size
* Normally 3 mm in diameter
* Round, smooth border, iris flat and round
* The illuminated pupil constricts and the
non illuminated pupil also constricts
* Pupils constrict when looking to the near
object: pupils dilate when looking to the
far object and pupils converge when near
object is moved towards nose
VISUAL FIELDS:
Peripheral visual field * When looking straight ahead, client can
see objects in the periphery
Temporal: 90˚
Upward field: 50˚
Downward field: 70˚
Nasal: 50˚

EXTRAOCULAR EYE MUSCLE:

Six Ocular Movement
* Parallel
* Move in unison/ coordinated
VISUAL AQUITY:
Near vission * Able to see newsprint at a distance of 1
ft.
EARS and HEARING
EARS:
 Auricles * Color is same as facial skin
* Symmetrical
* Auricle aligned with outer canthus of the
eye
* Mobile, firm and not tender
* Pinna recoils when folded
External Ear Canal * Dry cerumen
* Grayish color
HEARING ACUITY:
Hearing normal voice * Normal voice tones audible
Watch tick test * Able to hear ticking on both ears

Weber test * Sound is heard in both ears or is localized

at the center of the head (weber
negative)
Rinne’s test * Air conduction is greater than the bone
conduction
NOSE and SINUSES
NOSE:
External Nose * Symmetric and straight
* No discharge or flaring
* Uniform color
* Not tender; no lesions
Nasal Cavities * Air moves freely as the client breathes
through the nare
* Mucosa pink
* yellowish, watery discharge
* No lesions
* Nasal septum intact and in midline
SINUSES:
Facial Sinuses * No tenderness

MOUTH and OROPHARYNX

Lips * Pink color

* Smooth texture
* Symmetry of contour
* Ability to purse lips

Buccal mucosa * Pink color

* Moist, smooth, soft, glistening, and elastic
texture

Teeth * 23 teeth with cavities, yellowish in color

Gums * Pink
* Moist, firm texture to gums
* No retraction of gums
Tongue * Central position
* Pink color
* Moist, slightly rough
* Thin whitish coating smooth lateral
margins
* No lesions
* Raised papillae
 Hard Palate * Lighter pink
* More irregular texture
Soft Palate * Light pink
* Smooth
Uvula * Positioned in midline of soft palate
Oropharynx * Pink in color
* Smooth posterior wall
Tonsils * Pink and smooth
* No discharge
* Grade 1
* Gag reflex- present
NECK
Neck Muscle * Muscles equal in size; head centered
* Coordinated, smooth movements with no
discomfort

Lymph Nodes
* Not palpable
1. Submental * palpable
2. Submandibular * palpable
3. Postauricular * Not palpable
4. Occipital * Not palpable
5. Superficial * Not palpable
6. Superclavicular

Trachea * Central placement in midline of neck

* Spaces are equal on both sides

Thyroid Glands * No visible on inspection

* Gland ascends during swallowing but is
not visible
* Lobes may not be palpated
* Absence of bruit
THORAX and LUNGS
 * Anteroposterior (7 cm) to transverse (14
Posterior cm) diameter in ratio of 1:2
* chest symmetric
* spine curved to the left
* spinal column is not straight, right and
* left shoulders are not in the same height
but hips are at same height
* skin intact
* uniform temperature
* chest wall intact
* no tenderness and masses
* full and symmetric chest excursion
* bilateral symmetric vibration felt on the
* * vocal fremitus
* percussion notes
-resonate, except over scapula
* breath sounds:
-vesicular and bronchovesicular sounds
on chest
Anterior * irregular breathing andrespirations
* costal angle less than 90˚ and the ribs
insert into the spine at approximately a 45˚
angle

* full symmetric excursion

* bilateral symmetric vibration felt on the
vocal fremitus
* percussion notes:
-resonate down to the sixth rib at the
level of the diaphragm
-flat over areas of heavy muscle and
bone
-dull on areas over the heart and the
liver
-tympanic over the underlying stomach
* breath sounds:
-bronchial and tubular sounds over the
trachea
-bronchovesicular and vesicular sounds
over the anterior chest

HEART and CENTRAL VESSELS

 Heart * no pulsations over:
-aortic
-pulmonic
-tricuspid
* no lift or heaves over:
-tricuspid area
-apical area
* pulsations visible in apical area and
palpable in most PMI in fifth at or medial to
MCL
* aortic pulsations is palpable in epigastric
area
* S1 and S2 heart sounds, precense of
crackles and whizz sound
* Systole: silent interval; slightly shorter
duration than diastole at normal heart rate

* Diastole: silent interval; slightly longer

duration than systole at normal heart rates

Carotid Arteries * Symmetric pulse volumes

* Full pulsations, thrusting quality
* Quality remains same when client
breathes, turns head, and changes from
sitting to supine position
* Elastic and arterial wall
* No sound heard on auscultation
Jugular Veins * Veins not visible
BREASTS and AXILLAE
Breasts Males:
breasts even with the chest wall;
* Skin uniform in color
* Skin smooth and intact
* No tenderness, masses, nodules or nipple
discharge

Areola * Round in shape

* Bilaterally the same
* Light pink in color
* No tenderness, masses, nodules or nipple
discharge
Nipple * Round, everted, and equal in size
* Similar in color
* Soft and smooth
* Both nipples point in same direction
* No discharge
* Inversion of one or both nipples
* No tenderness, masses, nodules or nipple
discharge

Axillary, subclavicular, and supraclavicular * No tenderness, masses and nodules

lymph nodes
ABDOMEN
 Abdomen * Unblemished skin
* Uniform color
* concave abdominal contour
* No evidence of enlargement of liver or
spleen
* Symmetric contour while standing
* Abdominal movements:
-Symmetric movements caused by
respiration
- No visible vascular patterns
* bowel sounds heard in 5-20 seconds/
bowel sound
* Absence of arterial bruits
* Absence of friction rub
* Percussion notes:
-dullness over the stomach and gas-
filled bowels
-dullness, especially over the liver and
spleen, or a full bladder
* No tenderness
* Relaxed abdomen with smooth,
consistent tension
* Tenderness may be present near xiphoid
process, over cecum, and over sigmoid
colon

Liver * Less than 6 to 12 cm in the midclavicular

line; 4 to 8 cm at the midsternal line
* Liver may not be palpable
* Border feels smooth
* Not palpable
Bladder * Not palpable
MUSCULOSKELETAL
Muscles * Equal size on both sides of the body
* No contractures
* No tremors
* Normally firm
* Smooth coordinated movements

* Equal strength on each body side

1. Sternocleidomastoid * Grade5
2. Trapezius * Grade 4
3. Deltoid * Grade 5
4. Biceps * Grade 5
5. Triceps * Grade 5
6. Whist and finger muscle * Grade 5
7. Grip strength * Grade 3
8. Hip muscles * Grade 5
9. Hip Abduction * Grade 3
10. Hip Adduction * Grade 5
11. Hamstrings * Grade5
12. Quadriceps * Grade 5
13. Muscles of the ankles and feet * Grade 5
Bones * No deformities
* No tenderness or swelling
Joints * No swelling
* No tenderness, swelling, crepitation or
nodules
* Joints move smoothly
* Normal range of motion
Joints Movements
1. Neck
a. Flexion * 45˚ from midline
b. Extension * 45˚ from midline
c. Hyperextension * 45˚ from midline
d. Lateral Flexion * 40˚ from midline
e. Rotation
1. Shoulder
a. Flexion * 180˚ from the side
b. Extension * 180˚ from vertical
c. Hyperextension * 50˚ from side position
* 180˚
d. Abduction * 50˚
e. Adduction * 360˚
f. Circumduction * 90˚
g. External Rotation * 90˚
h. Internal Rotation
1. Elbow
a. Flexion * 150˚
b. Extension * 150˚
c. Rotation for Supination * 70˚ to 90˚
d. Rotation for Pronation * 70˚ to 90˚
1. Wrist
a. Flexion * 80˚ to 90˚
b. Extension * 80˚ to 90˚
c. Hyperextension * 0˚ to 20˚
d. Radial flexion (abduction) * 30˚ to 50˚
e. Ulnar (adduction) * 80˚ to 90˚

1. Hand and fingers

a. Flexion * 90˚
b. Extension * 90˚
c. Hyperextension * 30˚
d. Abduction * 20˚
e. Adduction * 20˚
 1. Thumb
a. Flexion * 90˚
b. Extension * 90˚
c. Abduction * 30˚
d. Adduction * 20˚
e. Opposition * 20˚

1. Hip
a. Flexion * Knee extended 90˚
b. Extension * 90˚ to 120˚
c. Hyperextension * 30˚ to 50˚
d. Abduction * 45˚ to 50˚
e. Adduction * 20˚ to 30˚ beyond other leg
f. Circumduction * 45˚
g. Internal rotation * 45˚
h. External rotation

1. Knee
a. Flexion * 120˚ to 130˚
b. Extension * 120˚ to 130˚
1. Ankle
a. Extension * 20˚
b. Flexion * 45˚ to 50˚
1. Foot
a. Extension * 5˚
b. Inversion * 5˚
1. Toes
a. Flexion * 35˚ to 60˚
b. Extension * 35˚ to 60˚
1. Trunk
a. Flexion * 70˚ to 90˚
b. Extension * 70˚ to 90˚
c. Hyperextension * 20˚ to 30˚
d. Lateral flexion * 35˚ on each side
e. Rotation * 30˚ to 45˚

NEUROLOGIC SYSTEM

Gross Motor and Balance Test
* Walking gait: has upright posture and
steady gait with opposing arm swing; walks
unaided, maintaining balance
* Romberg Test: Negative Romberg
* Standing on One foot with Eyes Closed:
Maintain stance for 11 seconds
* Heel-Toe Walking: Maintains heel-toe
walking along a straight line
* Toe or Heel Walking: Able to walk several
steps on toes or heels
Fine Motor Tests for the Upper Extremities* Finger-to-Nose Test: repeatedly and
Fine Motor Tests for the Lower Extremities* Heel Down Opposite Shin: demonstrates
Light Touch Sensation
Pain Sensation
Temperature Sensation
Position or Kinesthetic Sensation
Tactile Discrimination
rhythmically touches the nose
* Alternating Supination and Pronation of
Hands on Knees: Can alternately supinate
and pronate hands at rapid pace
* Finger to nose and to the Nurse’s Finger:
performs with coordination and rapidity
* Fingers to Fingers: performs with
accuracy and rapidity
* Fingers to thumb: rapidly touches each
finger to thumb with each hand
bilateral equal coordination
* Toe or Ball of Foot to the Nurse’s Finger:
moves smoothly, with coordination
* Light tickling or touch sensation
* Able to discriminate “sharp” and “dull”
sensations
* Able to discriminate between “hot” and
“cold” sensations
* Can readily determine the position of
fingers and toes
* One- and Two-Point Discrimination: She
can distinguish between a one- and two-
point stimulus within the following
minimum distances:
a. Fingertips- 2.8 mm
b. Palms of hands- 10 mm
c. chest,forearm- 40 mm
d. Back- 59 mm
e. Upper arm, tigh- 76 mm
f. Toes- 4 mm
* Stereognosis: recognizes common
objects; able to identify numbers or letters
written on palm
* Extinction Phenomenon: both points of
stimulus are felt