BODY PART & INSPECTION PALPATION PERCUSSION AUSCULTATI INTERPRETATION

HISTORY ON

SKIN Fair skin color no Skin is NOT APPLICAPLE NOT A scar results from
unusual odor, smooth, warm APPLICABLE the biologic process
History of moderately dry skin, and firm, no of wound repair in
vehicular presence of scar in the tenderness the skin and other
accident right arm at 1 ½ inch in tissues. Most
length and ½ in width, wounds, except for
on the left arm very minor
presence of scar 2 ones, result
inch length and 1 inch in some degree
width, on the left lower of scarring. Scars
extremities presence can result from
of scar 1 inch length accidents, diseases,
and ½ width, presence skin conditions such
of tattoo at left upper as acne, or
extremities, presence surgeries. (Gardner,
of tinea versicolor on S., 2017,
the face WebMD.com)

Tinea versicolor is a
fungal infection of
the skin. It's also
called pityriasis
versicolor and is
caused by a type of
yeast that naturally
lives on your skin.
 When the yeast
grows out of control,
the skin disease,
which appears as a
rash, is the result.
(Gardner, S., 2018,
WebMD.com)

According to D,
Amico And Barbarito
Tattoos can cause
skin irritation, and
the process of
tattooing puts an
individual at risk for
infection, hepatitis c
and HIV. (Physical
Assessment, 2nd
edition.)

HAIR Hair is evenly Hair is soft, NOT APPLICAPLE NOT No Abnormalities.

distributed, hair is scalp mobile APPLICAPLE
black, fine body hair is non-tender
noted over the body,
no lice or dandruff,
presence of hair in the
axillary
NAILS Nail beds is pinkish, Nails are NOT APPLICAPLE NOT Slightly dirty nails
shape is convex, finger firmed, APPLICAPLE may indicate poor
nails and feet nails are capillary refill hygiene according to
not properly trimmed return after 2 (D’Amico, Barbarito.
and slightly dirty, no seconds, the Physical
clubbing, no lesions cuticles are Assessment 2nd
smooth and edition).
flat, no
tenderness

HEAD Head is symmetrical No NOT APPLICAPLE NOT No Abnormalities.

and contour rounded, tenderness APPLICAPLE
facial appearance is and masses,
symmetrical in features smooth and
and movement, no no bulges
lesions

EYES 20/20 visual acuity, no Pupil constrict NOT APPLICAPLE NOT No Abnormalities.
bulges and lesions, when light is APPLICAPLE
symmetrical eye shape in and pupil
and eye brows, good dilate when
distribution of eye light is out.
lashes and brows Pupils are
equal in
shape and
good
accommodati
on
EARS Symmetrical in size No NOT APPLICAPLE NOT Piercing of any body
and shape consistent, tenderness, APPLICAPLE part puts an
no discharges, no when individual at risk for
redness, no swelling, palpating the infection and
presence of piercing in mastoid no hepatitis c and can
both ears. lesions, pain result in
and swelling development of scar
tissue at the site.
Most commonly on
the ears (D’Amico &
barbarito. Physical
Assessment 2nd
edition.)

NOSE Symmetric in shape, Soft, mobile, Tympanic sound is NOT No Abnormalities.

midline without no produce upon APPLICAPLE
deformities, skin is tenderness percussing the
intact, no discharge when sinuses.
and no inflammation palpating the
present, presence of sinus
hair inside the nose

MOUTH AND Lips are slightly brown, Lips is soft, (-) NOT APPLICAPLE NOT Presence of dental
THROAT ability to purse lips, tenderness APPLICAPLE carries and
presence of dental and swelling, yellowish teeth
caries at lower teeth (-) masses. maybe a deviation
second molar, tongue is soft, from normal and can
yellowish teeth, pink (-) nodules
 gums, tongue moves affects personal
freely hygiene

Kozier, Blais, E.,

Wilkinson (5th
edition)
Fundamentals of
Nursing

NECK Midline with no lumps, (-) NOT APPLICAPLE No bruits, no No abnormal

bulges or masses, tenderness, abnormal findings.
neck is erect, the no masses, sound
thyroid is not visible, lymph nodes detected. Kozier, Blais, E.,
with no masses or are not Wilkinson (5th
swelling, thyroid gland palpable, edition)
moves superiorly when trachea is in Fundamentals of
patient swallow midline, Nursing
generally
thyroid is not
palpable

THORAX AND Chest symmetric, (-) tenderness Percussion note (-) abnormal No abnormal
BACK supine vertically and masses, resonate in chest breath sound, findings
aligned, chest wall normal rate heart rate of
intact, full and and rhythm 86 bpm Kozier, Blais, E.,
symmetric chest Wilkinson (5th
expansion, apical edition)
 pulse not visible, Fundamentals of
respiratory rate of 20 Nursing
cycles per minute

BREAST Breast even with the Skin smooth NOT APPLICABLE NOT No abnormal
chest wall, areola and and intact, (- APPLICAPLE findings
nipple are slightly )tenderness
brown, nipples are and masses Kozier, Blais, E.,
everted, no lesions Wilkinson (5th
edition)
Fundamentals of
Nursing

ABDOMEN Abdomen is flat, (-) Tympanic sound Presence of incision

symmetric movements tenderness, when percussed and pain may
caused by respirations, moderately indicate surgical
presence of incision at soft and operation or
lower sternum 3 inch rounded. Pain discomfort.
long and presence of upon
opening below the palpating the
incision approximately 4 quadrant of Kozier, Blais, E.,
25 centavo, umbilicus abdomen. Wilkinson (5th
is in midline. Presence edition)
of pain when moving. Fundamentals of
Nursing
GENITO- No unusual odor or Not assess NOT APPLICAPLE NOT No abnormalities,
URINARY drainage, (-) catheter, APPLICAPLE
equally distributed of Kozier, Blais, E.,
pubic hair and Wilkinson (5th
triangular distribution, edition)
often spreading up the Fundamentals of
abdomen, penile skin Nursing
intact,

MUSCULOSKEL Upper and lower (-) tenderness Not assess NOT No Abnormalities.
ETAL/EXTREMI extremities are and masses, APPLICAPLE
TIES symmetrical, no vertebral Kozier, Blais, E.,
contractures, smooth processes are Wilkinson (5th
coordinated aligned, edition)
movements. Cervical uniform in Fundamentals of
and lumbar curves are size, firm and Nursing
concave and the stable.
thoracic curve is
convex.
 GORDON’S FUNCTIONAL HEALTH PATTERNS

HEALTH PRIOR TO DURING ADMISSION IDENTIFIED PRIORITY JUSTIFICATION

PATTERN ADMISSION NURSING
PROBLEM

Health perception- “Nagapacheck-up “kung unsa gina ingon Non-compliance 7 (D) According to
Health mana sya sa health sa doctor og sa nurse related to Financial Maslow’s
management center ika tatlo na paliton og kaunon Barriers hierarchy of needs
kabeses sa isa niya kay ginatabangan financial is
kabulan kay naa man man namo mag pamilya needed in order to
gud na syay diabetes na mapalit pero meet Physiologic
tulo na katuig unya pangitaonon pod lagi needs which
naa mana syay ang kwarta labi na sa includes food and
maintenance na iyang mga tambal og water that must be
metformin, usahay mga laboratory” as met at least
maka inom siya verbalized by the wife minimally to
usahay dili pod kay maintain life and
kulang ang kwarta” as the most essential
verbalized by the wife and therefore
have the highest
priority.
 Reference:

Taylor, C., Lillis,

C., Lemone, P.,
Lynn, P.,
Fundamentals of
Nursing (6th
editon).

Nutritional- “katong wala pa sya “katong naa na sya diri Imbalanced 2 (B) According to
Metabolic na admit sa hospital sa hospital wala kaayo nutrition: Less than Maslow’s
ang iyang ginakaon siyay gana magkaon body requirements hierarchy of needs
kay isa lang kacup sa mga upat lang ka related to inability that Physiologic
rice tapos ang sud.an kutsara pero muinom to absorb nutrients needs include
kay gulay parehas man siyag tubig mga water and food,
anang mga duha lang ka baso kay must be met at
malunngay, kalabasa, dili man daw pwede siya least minimally to
talong na sinabawan pwede mag inom og maintain life and
panagsa kay naga daghan tubig” as the most essential
manok sad mi unya verbalized by the wife and therefore
mag meryenda na have the highest
sya sa buntag og priority.
hapon paryas anang IVF= PNSS1LxKVO
skyflakes tas parisan
na sad og kape Intake= 500ml Reference:
usahay tubig . Pag
Output= 1000ml
mata ana niya sa
 buntag adlaw adlaw Taylor, C., Lillis,
jud na sya mangapi C., Lemone, P.,
anang 3in1 na kape Lynn, P.,
unya pandesal. Sa is Fundamentals of
aka adlaw upat Nursing (6th
kabaso iyang mahurot editon).
na tubig mga 840ml
tanan. 5years naman
sya nag stop sa iyang
pag inom pero
makahurot na syag 5
kabutilya na tanduay
sa isa ka simana,
3years na pud na sya
nag stop sa iyang
panigarilyo pero
makahurot na syag 5
pud ka kaha sa isa
kasimana. ” as
verbalized by the wife

Elimination “ikalima sya mag ihi “maka tae man sya pero No identified
sa isa ka adlaw unya alternate lang giyapon, nursing problem
light yellow ang color dili man sad daw sakit
usahay dark pero dili og parehas lang man
man pud daw sakit sad ang color” as
mag ihi. Tapos ang verbalized by the wife
iyahang pag bawas,
 sa isa ka simana kay
ika upat yellow ang
color”as verbalized by
the wife

Activity- Exercise “katong wala pako “dili ko katindog tindog Impaired physical 6 (B) According to
sakit kay dili man pud diri sa hospital kay mobility related to Maslow’s
ko kaexercise kay hubag man akong tiil physical hierarchy of needs
naga panagat ko pero unya lisod mag lihok kay deconditioning that safety and
katong nag sugod bug.at akong lawas” as security include
nag kahanap akong verbalized by the physical safety
panan.aw kay ang patient. and security
akong anak na nag means being
puli og panagat. protected from
Katong naa nako sa potential or actual
balay, sa adlaw adlaw harm.
nakong ginabuhat kay
mag lingkod lang ko
habang gapaminaw Reference:
sa radyo” as
verbalized by the Taylor, C., Lillis,
patient C., Lemone, P.,
Lynn, P.,
Fundamentals of
Nursing (6th
editon).
Sleep-Rest “katong naa pako sa “dili kaayo ko katulog Disturbed sleep 3 (C) According to
balay makatulog man diri sa hospital hastang pattern related to Maslow’s
kog tarong, wala ko daghanag tao unya ambient noise hierarchy of needs
naga tulog og udto sa saba kaayo” as that Physiologic
gabii lang mga walo verbalized by the patient needs include rest
pod ka oras akong and must be met
tulog kay alas 10 man at least minimally
ko matulog tapos alas to maintain life
6 ko mag mata” as and the most
verbalized by the essential and
patient therefore have the
highest priority.

Reference:

Taylor, C., Lillis,

C., Lemone, P.,
Lynn, P.,
Fundamentals of
Nursing (6th
editon).

Cognitive- “wala man problem sa “karong naa nako dire Impaired comfort 1 (A) According to
Perceptual akong pandungog sa hospital dili man pud related to pain Maslow’s
pero dili na jud ko sakit akong tiyan og tiil hierarchy of needs
kakita, dili man pod pero dili ko komportable that Physiologic
sakit gunitan akong kay ang akong liog sakit need include rest
tiyan og akong tiil” ilihok og gunitan ambot and freedom from
na unsa ni” as pain and must be
verbalized by the patient met at least
minimally to
Pain scale of 5/10 maintain life and
the most essential
and therefore
have the highest
priority. If this
need are not met
the other needs
will not follow.

Reference:

Taylor, C., Lillis,

C., Lemone, P.,
Lynn, P.,
Fundamentals of
Nursing (6th
editon).
Self-Perception- “Minsan mag baba “maulaw ko kay mura Disturbed body 5 According to
Self Concept ang pagtingin ko sa kog buntis dako akong image related to Maslow’s
sarili ko kasi ako ang tiyan tapos ako pod mga illness hierarchy of needs
tatay sa pamilya pero tiil” as verbalized by the that self- esteem
di ako maka tulong patient needs include the
kay wala man koy need for a person
trabaho, kis.a to feel good about
malisdan mi sa himself or herself,
among pagkaon” as to feel pride and a
verbalized by the sense of
patient accomplishment,
and to believe that
others also
respect and
appreciate those
accomplishments.

Reference:

Taylor, C., Lillis,

C., Lemone, P.,
Lynn, P.,
Fundamentals of
Nursing (6th
editon).
Role-Relationship “Mag kasama kami sa “karong na admit sya No identified
bahay ng asawa ko at diri sa hospital bisag isa nursing problem
ng mga anak ko, okay ka adlaw palang sya diri
lang man ang daghan na kaayo mig
relasyon namo mag kamag-anak na nag
pamilya bisag lisod bisita para mag alaga sa
ang kinabuhi mag iyaha” as verbalized by
tinabangay man sad the wife
mi” as verbalized by
the patient

Sexuality- “Gituli ko kay nwebe “wala nami naga No identified

Reproductive anyos ko tapos nagka contact sa akong asawa nursing problem
buhok ko sa akong ari mga duha na ka bulan
kay katorse (14) kay nag dako naman
anyos ko, katong nag gud akong tiyan og
asawa nako kuan akong tiil”- as verbalized
akong edad bente by the patient
otso ko unya unom na
akong anak, duh aka
babae tapos upat ka
lalaki” as verbalized
by the patient

Coping-Stress “kung ma stress ko sa “katong naa nako diri sa Stress overload 4 (A) According to
Tolerance balay kay maminaw hospital first day pa man related to stressors Maslow’s
lang kog radio mga ni nako, nag guol ko sa hierarchy of needs
music kay dili naman akong hupong mafeel that safety and
ko kakita” as man sad nako na nag security needs
 verbalized by the hubag akong tiil unya involves trusting
patient sakit pud akong liog others and being
unya mahadlok jud ko free of fear,
kung unsa mahitabo sa anxiety and
akoa. Kung mastress ko apprehension.
diri kay matulog lang ko”
as verbalized by the
patient. Reference:

Taylor, C., Lillis,

C., Lemone, P.,
Lynn, P.,
Fundamentals of
Nursing (6th
editon).

Values-Belief “Katong wala pako na “Gusto man nako mag No identified

admit og nag kasakit simba pero dili naman nursing problem
kay perminti jud ko gud nako kaya kay
nagasimba, pero malisudan na jud ko,
katong nag sugod na pero everyday dyapon
kaguba akong mata ko naga pray” as
og kadako akong verbalized by the
tiyan kay wala na jud patient.
ko kasimba pero dili
jud magstop ang
akong pagtuo kay
allah” as verbalized
by the patient