HEALTH

ASSESMENT
(OBJECTIVE DATA)

SUBMITTED BY : DENISSE SHAZZ MAE O. MARET

SUBMITTED TO : MRS.CARMELA PEREZ
SECTION : BSN 1A2-1
NAME OF PATIENT: Maiso,Nelson B.
AGE: 19
5th Vital Sign (Pain)
Questions
General Observations
1. Observe posture.
2. Observe facial expression.
3. Inspect joints and muscles.
4. Observe skin for scars, lesions, rashes,
changes, or discoloration.
Vital Signs
1. Measure heart rate.
2. Measure respiratory rate.
3. Measure blood pressure.
BIRTHDAY: October 19,1999
GENDER: Male
Findings
He comportable,attentive and without
excessive changes in position and posture.
He always maintaining eye contact and
conversation .While I’m asking a question he
answering, my question with appropriate
facial expression.
There is no edema in his joints and his muscles
was relaxed.
His skin was no scars,lesions,rashes or any
discolorations and also there’s no
inconsistency ,wounds or bruising .
67 beats/minute
17 breaths/minute
Systolic: 130
Diastolic: 60 = 130/60 his systolic was
high,his diastolic is 60 due to the lack of sleep
and it is a not normal because, his baseline
was 120/90.
NAME OF PATIENT: Maiso,Nelson B. BIRTHDAY: October 19,1999
AGE: 19 GENDER: Male

Nutritional Status
Questions Findings
Current symptoms
1. Gather equipment (balance beam scale
with height attachment, metric
measuring tape, marking pencil, and
skin fold calipers).
2. Measure height
3. Measure weight (1 kg= 2.205 lb).
4. Determine BODY MASS INDEX 95
(BMI=weight in kilograms/height in
meters squared or use the NIH
website.
Compare the results to BMI in table 13-
3 on page 218 in the textbook
5. Measure waist circumference and
compare findings to table 13-5 on page
230 in the text book.
6. Measure MID-ARM CIRCUMFERENCE
(MAC) and compare findings to Table
13-6 on page 231 in the textbook.
7. Measure TRICEPS SKINFOLD THICKNESS
(TSF) and compare to table 13-7 on
page 232 in the textbook.
8. Calculate the MID-ARM MUSCLE
CIRCUMFERENCE (MAMC), MAMC (cm)
= MAC (cm) – (0.314 x TSF). Refer to
the table 13-8 on page 233 in the
textbook for interpretation
Analysis of Data
1. Formulate nursing diagnoses. The patient is normal because his BMI is
accurate to his height ,weight,waist
circumference,mid-arm circumference,triceps
circumference and also mid arm muscle
circumference to his appearance.
2. Formulate collaborative problems. There is no any collaborative problems.
3. Make necessary referrals Mr.Maiso needs to be seen to get a
information on how to maintain healthy
lifestyle.
NAME OF PATIENT: Maiso,Nelson B.
AGE: 19
Head and Neck
Questions
1. Gather equipments (gloves, penlight
or flashlight, small glass of water,
stethoscope).
2. Explain procedure to client.
Head and Face
1. Inspect head for size, shape and
configuration.
2. Palpate head for consistency while
wearing gloves.
3. Inspect face for symmetry, features,
movement, expression, and skin
condition.
4. Palpate temporal artery for
tenderness and elasticity.
5. Palpate temporomandibular joint for
range of motion, swelling, tenderness,
or crepitation by placing index finger
over the front of each and asking
client to open mouth. Ask if client has
history of frequent headaches.
Neck
1. Inspect neck while it is in a slightly
extended position (and using a light)
for position, symmetry, and presence
of lumps and masses
2. Inspect movement of thyroid cartilage
and thyroid gland by having client
swallow a small sip of water.
3. Inspect cervical vertebrae by having
client flex neck.
4. Inspect neck range of motion by
having client turn chin to right and
left shoulder, touch each ear to the
shoulder, touch chin to chest, and lift
chin to ceiling
BIRTHDAY: October 19,1999
GENDER: Male
Findings
Complete equipment
Nurse explain it
His head size,shape is symmetrically round in
the midline and appropriate to his body size
and there is no visible lesions.
His head is normally hard and smooth
without lesions.
His Face is symmetric with a round
appearance and there is no abnormalities
movements.
his temporal artery is elastic and not tender.
His temporomandibular is no swelling ,
tenderness, or crepitation with movement
.his mouth is open and closes fully (3-6 cm
between the upper and lower teeth).The jaw
was move laterally 1-2 cm in each direction.
His Neck is symmetric with head centered
and without bulging.
His Thyroid cartilage and cricoid cartilage is
move upward symmetrically after I ask the
patient to swallow a small sip of water.
his c7 is visible and palpable
His neck movement is smooth and controlled
with 45°flexion, 55° extension,
40° abduction, 70° rotation.
 5. Palpate trachea by placing your finger his trachea is at the midline
in the sterna notch, feeling to each
side, and palpating the tracheal rings.
6. Palpate the thyroid gland. His thyroid gland are positioned at the
midline.
7. Auscultate thyroid gland for bruits if No bruit breath sounds
the gland is enlarged (use bell of
stethoscope).
8. Palpate lymph nodes for size/shape, There is no any swelling or enlargement and
delimitation, mobility, consistency, no tenderness,no hardness is present.
and tenderness (refer to display on
characteristics of lymph nodes).
a. Preauricular nodes (front of ears)
b. Postauricular nodes (behind the
ears)
c. Occipital nodes (posterior base of
the skull
d. Tonsillar nodes
e. Submandibular nodes
f. Submental nodes
g. Superficial cervical nodes
h. Posterior cervical nodes
i. Deep cervical chain nodes
j. Supraclavicular nodes.
Analysis of data
1. Formulate nursing diagnoses The patient is wellness because,everything
(wellness risk, actual) are normal,there is no any abnormalities that
seen in the patient while Im assessing him.
2. Formulate collaborative problems. There is no any collaborative problems
3. Make necessary referrals. Mr.Maiso needs to be seen for futher
confirmation/information and evaluation
about on his Head and neck.
NAME OF PATIENT: Maiso,Nelson B.
AGE: 19
Skin, Hair, and Nails.
Questions
1. Gather equipments (gloves, exam light,
penlight, magnifying glass, centimeter
ruler, Wood lamp if available).
2. Explain procedure to client
3. Ask client to gown.
Skin
1. Note distinctive odor.
2. Inspect for generalized color variations
(brownness, yellow, redness, cyanosis,
jaundice, erythema, vitiligo).
3. Inspect for skin breakdown (Use
staging criteria given in Chapter 13.
4. Inspect for primary, secondary, or
vascular lesions. (Note size, shape,
location, distribution and
configuration). Use wood lamp if
fungus is suspected
5. Palpate lesions.
6. Palpate texture (rough, smooth) of
skin, using palmar surface of three
middle fingers.
7. Palpate temperature (cool, warm, hot)
and moisture (dry, sweaty, oily) of skin,
using dorsal side of hand.
8. Palpate thickness of skin with
fingerpads.
9. Palpate mobility and turgor by
pinching up skin over sternum.
10. Palpate for edema, pressing thumbs
over feet or ankles
Scalp and Hair
1. Inspect color.
2. Inspect amount and distribution.
3. Inspect and palpate for thickness,
texture, oiliness, lesions, and parasites.
BIRTHDAY: October 19,1999
GENDER: Male
Findings
There is no any distinctive odor
His skin color is slightly darked brown and
reveals evenly and without unusual or
prominent discolorations.
His skin of the patient is intact,and there are
no reddened areas and ulcer.
His skin is smooth and there is no lesion but
he have a keloid in the elbow due to the
operation of removing 2 warts.
His skin was no lesions palpated
His skin is smooth and even
His skin was normally warm and his skin under
folds are moist.
His skin thickness is normal
His skin is mobile, with elasticity and returns
to original shape quickly.
His skin is no edema ,his skin rebounds and
does not remain indented when pressure is
released.
His hair is color black
His hair is evenly distributed
His hair was elastic and there is no lesion and
also smooth ,while the scalp was clean and
dry.
Nails
1. Inspect for grooming and cleanliness Nails are clean
2. Inspect for colors and markings. Color of the nail is pink tones
3. Inspect shape His nail shape is concave and its is < 160°.
4. Palpate texture and consistency. His nails are smooth and firm and the nail
plate is firmly attached to the nail bed.
5. Test for capillary refill His nail bed is immediately return into the
pink tone after the pressure is released
Analysis of Data
1. Formulate nursing diagnoses (wellness, The patient Skin, Hair, and Nails are normal
risk, actual) and there is no any problems that I seen and
all are functioning well.
2. Formulate collaborative problem. There is no collaborative problems.
3. Make necessary referral Mr.Maiso needs to be seen for futher
confirmation/information and evaluation
about on his Skin, Hair, and Nails
NAME OF PATIENT: Maiso,Nelson B.
AGE: 19
Eyes.
Questions
1. Gather equipment (Snellen chart,
handheld Snellen chart or near vision
screener, penlight, opaque card, and
opthalmoscope).
2. Explain the procedures to the client.
Perform Vision Tests
1. Distant visual acuity (with Snellen
chart, normal acuity is 20/20 with or
without corrective lens).
2. Near visual acuity (with a handheld
vision chart, normal acuity is 14/14
with or without corrective lenses).
3. Visual fields (use procedure discussed
in textbook to test peripheral vision).
Perform Extraocular Muscle Function Test
1. Corneal light reflex (using a penlight to
observe parallel alignment of light
reflection on corneas).
2. Cover test (using an opaque card to
cover an eye to observe for eye
movement).
3. Positions test (observing for eye
movement).
External Eye Structures
1. Inspect eyelids and lashes (width and
position of palpebral fissures, abilty to
close eyelids in comparison with
eyeballs, color, swelling, lesions or
discharge.
BIRTHDAY: October 19,1999
GENDER: Male
Findings
His distant visual are normal , with 20/20
acuity without using corrective lenses.
His eyes in near vision are normal , with 14/14
acuity without using corrective lenses.
His sees the ballpen while covering one
eye(Right/Left) by using a opaque card that
use to examine his visual fields and both eyes
are fine .the inferior is 70°,superior is 50°
,temporal is 90° and the nasal is 90°
He have a asymmetric position of the light
reflex, because on his left eye is theres a
slightly deviate alignment .
His Uncovered eye is remain fixed straight
ahead .the covered eye is remain fixed straight
ahead after I remove the opaque card.
His eye movement is smooth and symmetric
thoughout all six directions.
His upper lid margin is between upper margin
of the iris and the upper pupil. The lower lid
margin rests on the lower border of the iris.No
white scelra is seen above/below the
iris.Palpebral fissure is horizontal.
The upper and lower lids are close easily and
meet completely when closed.
The lower eyelids are upright with no inward

2. Inspect position of eyeballs (alignment
in sockets, protruding or sunken).
3. Inspect bulbar conjunctiva and sclera
(clarity, color and texture).
4. Inspect palpebral conjunctive (eversion
of upper eyelid is usually performed
only with complaints of eye pain or
sensation of something in eye).
5. Inspect the lacrimal apparatus over the
lacrimal glands (lateral aspect of upper
eyelid) and the puncta (medial aspect
of lower eyelid). Observe for swelling,
redness or drainage.
6. Palpate the lacrimal apparatus, noting
drainage from the puncta when
palpating the nasolacrimal duct.
7. Inspect the cornea and lens by shining
a light to determine transparency.
8. Inspect the iris and pupil for shape and
color of the iris and size and shape of
the pupil.
9. Test pupillary reaction to light (in a
darkened room, have client focus on a
distant object, shine a light obliquely
into the pupil, and observe the pupil’s
reaction to light- normally, pupils
constrict).
10.
11. Test accommodation of pupils by
shifting gaze from far to near
(normally, pupils constrict).
and outward turning. Eyelashes are evenly
distributed and curve outward along the lid
margins.
Skin in both eyelids is wihout lesions,redness
and swelling .
His Eyeballs are symmetrically algned in
sockets without protruding or sinking .
His Bulbar conjunctiva is clear ,moist and
smooth .Underlying structure are clearly
visible white and his Sclera is white.
His lower and upper palpebral conjunctiva are
clearly and free from swelling or
lesions,foreign bodies or trauma.
There is No swelling or reddiness appeard over
areas of the lacrimal gland.The puncta is
visible and without swelling or redness and is
turned slightly toward the eye.
There is no drainage from the puncta while
palpating the nasolacrimal duct.
His cornea is transparent,with no opacities
.The oblique view shows a smooth and overall
moist surface ,his lens is free of opacities.
His iris is typically round flat and evenly
colored.The pupil are round with a regular
border is centered in the iris .Pupils are
normally equal in size (3-5mm).
His pupillary are constrict
His pupilliary are constrict and the
convergence of his eyes are focusing while I
near an object .
Internal Eye Strcuture
1. Inspect the red reflex by using an
opthalmoscope to shine the light beam
toward the client’s pupil (normally, a
red reflex is easily seen and should
appear round with regular borders).
2. Inspect the optic disc by using the
opthalmoscope focused on the pupil
and moving very close to the eye.
Rotate the diopter setting until the
retinal structures are in sharp focus
(observe disc for shape, color, size, and
physiologic cup).
3. Inspect the retinal vessels using the
above technique (observe vessels for
number sets, color, diameter,
arteriovenous ration, and
arteriovenous crossings).
4. Inspect retinal background for color
and the presence of lesions.
5. Inspect the fovea and macula for
lesions.
6. Inspect the anterior chamber for
transparency
Analysis of Data
1. Formulate nursing diagnoses (health Patients eyes are normal except of the
promotion, risk, actual). reflection of light on the cornea .The Patient
risk for paralysis or muscle weakness(Left eye).
2. Formulate collaborative problems.  RC: muscle weakness or paralysis
3. Make necessary referrals. Mr.Maiso have a asymmetric position of the
light reflex, on his left eye theres a slightly
deviate alignment .He need to be seen for
futher confirmation/information.

 RC: muscle weakness or paralysis

NAME OF PATIENT: Maiso,Nelson B. BIRTHDAY: October 19,1999
AGE: 19 GENDER: Male

Ears
Questions
External Ear Structures
1. Inspect the auricle, tragus, and lobule
for size and shape, position,
lesions/discoloration, and discharge.
Findings
His ears are equal size bilaterally and the size
are 6 cm.
The auricle aligns with the corner of each eye
and within 10° angle of the vertical position.

His earlobes are free,attached or soldered.

The skin of his ears are smooth,with no

lesions,lumps or nodules .

The color is consistent with facial color and

there is no discharged.
2. Palpate the auricle and mastoid His auricle,tragus and mastoid are not tender.
process for tenderness.
Otoscopic Examination
1. Inspect the external auditory canal His canal walls is pink and smooth and there is
with the otoscope for discharge, color no nodules
and consistency of cerumen, color and
consistency of canal walls, and
nodules.
2. Inspect the tympanic membrane, using The tympanic membrane is gray,shiny and
the otoscope, for color and shape, translucent with no bulging or retraction. It is
consistency and landmarks. slightly concave,smooth and intact .
3. Have the client perform the vaslava the bulb is inflated and returns to the resting
maneuver, and observe the center of position after the air is released.
the tympanic membrane for a flutter.
(Do not do this procedure on an older
client, as it may interfere with
equilibrium and caouse dizziness.)
Hearing and Equilibrium Tests
1. Perform the whisper test by having the Correctly repeat the two syllable word after I
client place a finger on the tragus of whisper.
one ear. Whisper a two-syllable word
30.4-60.9 cm (1-2 ft) behind the client.
Repeat on the other ear
 2. Perform the Weber test by using a The vibrations are heard equally well in both
tuning fork placed on the center of the ears .No lateralization of sound to either ear.
head or forehead and asking whether
the client hear the sound better in one
ear or the same in both ears.
3. Perform the RInne test by using a The air conduction is longer heard than the
tuning fork and placing the base on the bone conduction.
client’s mastoid process. When the
client no longer hears the sound, note
the time interval, and move it in front
of the external ear. When the client no
longer hears a sound, note the time
interval.
4. Perform the Romberg test to evaluate He is not swaying or minimal swaying after 20
equilibrium. With feet together and seconds.
arms at the side, close eyes for 20
seconds. Observe for swaying. (Refer
to textbook, Chapter 16 and 26).
Analysis of Data
1. Formulate nursing diagnoses (wellness, Patient ears are normal ,there is no any
risk, actual). abnormalities that I seen while assessing the
patient his ears are all functioning well.
2. Formulate collaborative problems. There is no any collaborative problems
3. Make necessary referrals. Mr.Maiso needs to be seen for futher
confirmation/information and evaluation
about on his Ears.
NAME OF PATIENT: Maiso,Nelson B.
AGE: 19
Mouth, Throat, Nose, and Sinuses
Questions
Current symptoms
1. Gather equipment (gloves, cotton
gauze pads, penlight speculum
attached to the otoscope, tongue
blade).
2. Explain the procedure to client.
Mouth
1. Note any distinctive odors.
2. Inspect and palpate lips, buccal
mucosa, gums and tongue for color
variations (pallor, redness, white
patches, bluish hue), moisture, tissue
consistency, or lesions (induration,
roughness, vesicles, crusts, plaques,
nodules, ulcers, cracking, patches,
bleeding, Koplik spots, cancer sores),
Stensen and Wharton ducts.
3. Inspect gums for hyperplasia, blue-
black line.
4. Inspect teeth for number and shape,
color (white, brown, yellow, chalky
white areas), occlusion.
5. Inspec and palpate tongue for color,
texture, and consistency (black, hairy,
white patches, smooth, reddish, shiny
without papillae), moisture, and size
(enlarged or very small).
Throat
1. Inspect the throat for color,
consistency, torus palatines, uvula
(singular)
BIRTHDAY: October 19,1999
GENDER: Male
Findings
There is no any distint odor
His lips ,buccal mucosa, gums and tongue are
pink toned ,smooth and moist and without
lesions or swelling .
The stensen ducts are visible flow of saliva and
theres no redness,swelling,pain and moistness
in area
The Whartons ducts the frenulum is midline
and visible flow of saliva and theres no
redness,swelling,pain and moistness in area
The color and consistency of tissues along his
cheeks and gums are even.
He have a 32 teeth pearly whitish with smooth
surfaces and edges. There Is no missing teeth
Jaws are aligned and no deviation seen with
biting down .
The color of his tongue is pink tone,moist and
visible veins and there is no any lesions are
present the size of tongue is moderate with
papillae present.
His hard palate is pale or whitish with firm
transverse rugae
Palatine tissues are intact the soft palate is
pinkish movable and spongy and also smooth.
 The uvula is fleshy ,solid structure that hang
freely at the midline .no redness or exudate
from uvula/soft palate the elevation of uvula
is at the midline and symmetric elevation of
sorft palate
2. Inspect the tonsils for color and The color is pink and symmetric and the grade
consistency; grading scale (1+,2+, 3+, is 1 and there is no exudate, swelling ,lesions
4+) are present.
Nose
1. Inspect and palpate the external nose The color is the same as the rest of the face
for color, shape, consistency, the nasal structures are smooth and
tenderness, and patency of airflow. symmetric and there is no tenderness.
2. Inspect the internal nose for color, The nasal mucosa is dark pink and moist and
swelling, exudates, bleeding, ulcers, also there is no swelling, exudates, bleeding,
perforated septum, or polyps. ulcers, perforated septum, or polyps.
Sinuses
1. Palpate the sinuses for tenderness. Theres no tenderness and no crepitus at the
frontal and maxillary sinuses.
2. Percuss and transilluminate the sinuses His sinuses are not tender and percussion.
for air versus fluid or pus.
Analysis of Data
1. Formulate nursing diagnoses (wellness, The Patient Mouth, Throat, Nose, and Sinuses
risk, actual) are normal ,there is no any abnormalities that
I seen while assessing his Mouth, Throat,
Nose, and Sinuses are all functioning well.
2. Formulate collaborative problems There is no collaborative problems.
3. Make necessary referrals. Mr.Maiso needs to be seen for futher
confirmation/information and evaluation
about on his Mouth, Throat, Nose, and Sinuses
NAME OF PATIENT: Delos Santos,Nhorren P. BIRTHDAY: June 20,2000
AGE: 19 GENDER: Female

Thorax and Lungs

Questions Findings
Current symptoms
1. Gather equipment (gown and drape,
gloves, stethoscope, exam light, mask,
skin marker, metric ruler).
2. Explain the procedure to the client.
3. Ask the client to put on a gown.
Posterior Thorax
1. Inspect for shape and configuration of Her scapulae is symmetric and not
the chest wall and position of scapulae. protruding.Shoulders and scapulae are at
equal horizontal position.
2. Inspect for use of accessory muscles. There is no any using accessory muscle
3. Inspect the client’s positioning noting The patient position is relaxed ,breathing
posture and ability to support weight easily and her arms are in the lap.
while breathing.
4. Palpate for tenderness and sensation There is no any tenderness,pain or unusual
with gloved fingers. sensation the temperature is equal bilaterallly
5. Palpate for surface characteristics such Her skin is free from lesions and masses.
as lesions or masses with gloved
fingers.
6. Palpate for fremitus, using the ball or Her fremitus are symmetric and easily
ulnar edge of one hand while the client identified in the upper regions of the lungs
says “ninety-nine.” Assess for and symmetric bilateral positions
syemmetry and intensity of vibration.
7. Palpate for chest expansion. Place My thumbs move 5-10 cm apart symmetrically
hands on the posterior chest wall with
your thumbs at the level of T9 or T10,
and observe the movement of your
thumbs as the client takes a deep
breath.
8. Percuss for tone, starting at the apices The tone is resonance at the lung tissue while
above tha scapulae and across the tops flat tone over the scapulae
of both shoulders.
9. Percuss intercostals spaces across and The tone is resonance at the lung tissue while
down, comparing sides. flat tone over the scapulae
10. Percuss o the lateral aspects at the The tone is resonance at the lung tissue while
bases of the lungs, and compare sides. flat tone over the scapulae
11. Percuss for diaphragmatic excursion, Excursion are equal and bilaterally in left are
using the procedure in Chapter 18 of it measured 3-5 cm while at the right is 7 cm
 the textbook.
12. Auscultate for breath sounds (normal,
bronchial, bronchovesicular, and
vesicular), noting location
13. Auscultate for adventitious sounds
(crackles, fine or coarse, pleural friction
rub, wheeze, sibilant, or sonorous).
14. Auscultate for voice sounds over the
chest wall: Bronchophony- ask the
client to repeat the phrase “ninety-
nine” ; egophony- ask the client to
repeat the letter “E” ; whispered
pectoriloguy – ask the client to whisper
the phrase “one-two-three”
Anterior thorax
1. Inspect for shape and configuration to
determine the ratio of anteroposterior
diameter to transverse diameter
(normally 1:2)
2. Inspect for position of sternum from
anterior and lateral viewpoints.
3. Inspect for slope of the ribs from
anterior and lateral viewpoints
4. Inspect for quality and pattern of
respiration, noting breathing
characteristics, rate, rhythm and
depth.
5. Inspect intercostals spaces while client
breathes normally.
6. Inspect for use of accessory muscles.
7. Palpate for tenderness and sensation,
using fingers.
8. Palpate surface characteristics such as
lesion or masses, using fingers of
gloved hand.
9. Palpate for fremitus while the client
says “ninety-nine”
10. Palpate for chest expansion by placing
hands on anterolatereal wall with the
thumbs along the costal margins and
,in the right part is higher than the left are
because of the liver.
The breath sounds is normal I auscultate a
bronchial, bronchovesicular, and vesicular
sound
There is no any a adventitious sounds
The voice sound of the patient is normal at the
test of Bronchophony,Egophony,Pectoriloguy
the sounds are soft and muffled and
distinguished while Pectoriloguy test is very
faint and inaudible
The diameter of her anteroposterior is less
than in transverse diameter (1:2)
Her sternum is at the midline and straight
Her ribs are slope downward with symmetric
ICS the coatal angles is 90°
Her respiration is relaxed,effortless and quit
No retractions and bulging in the ICS.
There is no any accessory muscle she used
There is no any tenderness,pain or unusual
sensation the temperature is equal bilaterallly
Her skin is free from lesions and masses.
Her fremitus are symmetric and easily
identified in the upper regions of the lungs
and symmetric bilateral positions
My thumbs move outward 5-10 symmetrically
at the midline
 point toward the xiphoid process.
Observe the movement of the thumbs
as the client takes a deep breath.
11. Percuss for tone above the clavicles The tone is resonance at the lung tissue while
and then the intercostals spaces across flat tone over the scapulae .
and down, comparing sides.
12. Auscultate for breath sounds, The voice sound of the patient is normal at the
adventitious sounds, and voice sounds. test of Bronchophony,Egophony,Pectoriloguy
the sounds are soft and muffled and
distinguished while Pectoriloguy test is very
faint and inaudible
Analysis of data
1. Formulate nursing diagnoses (wellness, The Patient Thorax and Lungs are normal
risk, actual). ,there is no any abnormalities that I seen while
assessing his Thorax and Lungs are all
functioning well.
2. Formulate collaborative problems. There is no collaborative problems.
3. Make necessary referrals. Ms.Delos Santos needs to be seen for futher
confirmation/information and evaluation
about on his thorax and her lungs.
NAME OF PATIENT: Maiso,Nelson B.
AGE: 19
Abdomen
Questions
Current symptoms
1. Gather equipments (pillow/towel,
centimeter ruler, stethoscope, marking
pen).
2. Explain the procedure to client.
3. Ask the client to put on a gown.
Abdomen
1. Inspect the skin, noting color,
vascularity, striae, scars, and lesions
(wear gloves to inspect lesions).
2. Inspect the umbilicus, noting color,
location, and contour.
3. Inspect the contour of the abdomen.
4. Inspect the symmetry of the abdomen.
BIRTHDAY: October 19,1999
GENDER: Male
Findings
 His Abdominal skin may be paler than
the general skin tone because this skin
is so seldom exposed to the natural
elements.
 Scattered fine veins may be visible.
Blood in the veins located above the
umbilicus flows toward the head;
blood in the veins located below the
umbilicus flows toward the lower
body.
 New striae are pink or blush in color;
old striae are silvery, white, linear, and
uneven stretch marks from past
weight gain.
 Pale, smooth, minimally raised old
scars may be seen.
 Abdomen is free of lesions or rashes.
Flat or raised brown moles are normal
 His Umbilical skin tones are similar to
surrounding abdominal skin tones.
 Umbilicus is at the midline and lateral
line.
 It is recessed (inverted) or protruding
no more than 0.5 cm, and is round or
conical.
His Abdomen is flat, rounded, and scaphoid .
Abdomen should be evenly rounded.
His Abdomen is symmetric and Abdomen does
not bulge when client raises his head.
5. Inspect abdominal movement, noting
respiratory movement, aortic
pulsations, and/or peristaltic waves.
6. Auscultate for bowel sounds, noting
intensity, pitch, and frequency.
7. Auscultate for vascular sounds and
friction rubs.
8. Percuss the abdomen for tone.
9. Percuss the liver
10. Percuss the spleen.
11. Perform blunt percussion on the liver
and the kidneys.
12. Perform light palpation, noting
tenderness or guarding in all
quadrants.
13. Perform deep palpation, noting
tenderness or masses in all quadrants.
14. Palpate the umbilicus
15. Palpate the aorta.
Abdominal respiratory movement is seen,
A slight pulsation of the abdominal aorta,
which is visible in the epigastrium, extends full
length in thin people.
peristaltic waves are not seen, although they
may be visible in very thin people as slight
ripples on the abdominal wall.
The intermittent is, soft clicks and gurgles are
heard at a rate of 5-30 per minute.
Hyperactive bowel sounds referred to as
“borborygmus” may also be heard. These are
the loud, prolonged gurgles characteristics of
one’s “stomach growling.”
There is no Bruits heard over abdominal aorta
or renal, iliac, or femoral arteries.
No friction rub over liver or spleen is present.
Generalized tympany predominates over the
abdomen because of air in the stomach and
intestines. Dullness is heard over the liver and
spleen.
Dullness may also be elicited over a non-
evacuated descending colon .
The normal liver span is at the MSL is 4-8cm
His Spleen is oval area and dullness
approximately 7 wide near the left 10th rib and
slightly posterior to the MAL.
There is no tenderness or pain that elicit the
patient
The abdomen is not tender and soft and there
is a guarding.
There is a mild tenderness over the
xiphoid,aorta cecum,sigmoid colon and
ovaries and they are palpable ,the stuctures of
the abdomen is no palpable masses are
present
Umbilicus and surrounding area are free of
swelling bulges or any masses
The aorta is approximately 2.5-3.0 cm wide
with a moderately strong and regular pulse
and theres a possible mild tenderness
 16. Palpate the liver, noting consistency His liver is smooth and even there is a mild
and tenderness. tenderness
17. Palpate the spleen, noting consistency His Spleen is palpable at the left coastal
and tenderness margin.Rarely the tip is palpable in the
presence of a low ,flat diaphragm with deep
diaphragmatic descent on inspiration the
spleen is soft and non tender.
18. Palpate the kidneys. His kidney is usually palpable and there is no
smooth and rounded and should not be
slightly palpable
19. Palpate the urinary bladder An empty bladder is neither palpable or nor
tender
20. Perform the test for shifting dullness. Borders between tymphany and dullness
remail relatively constant throughout position
changes
21. Perform the fluid wave test. There is no fluid wave is transmitted
22. Perform the ballottement test. There is no fluid wave is transmitted
23. Perform the tests for appendicitis.  There is no rebound tenderness is
Rebound tenderness present
Rovsing sign  There is no rovsing sign
Referred rebound tenderness  No rebound pain is elicited
Psoas sign  No abdominal pain is present
Obturator sign  No abdominal pain is present
Hypersensitivity test  Patient feels is no pain and
exaggerated sensation.
24. Perform the test for cholecystitis No increase pain is present
(Murphy sign).
Analysis of Data
1. Formulate nursing diagnoses (wellness, The Patient Abdomen are normal ,there is no
risk , actual). any abnormalities that I seen while assessing
his Abdominal and all are all functioning well.
2. Formulate collaborative problems. There is no collaborative problems.
3. Make necessary referrals. Mr.Maiso needs to be seen for futher
confirmation/information and evaluation
about on his/her Abdominal.