Fernando, April M.

BSN 1st Year – K

Pediatric Assessment
ASSESSMENT

A. Personal Data

Name: Arcega, Sven Oliver F.

Address: Callejon drive, Guiwan, Zamboanga City
Age: 6 years old
Sex: Male
Status: Single
Occupation: N/A
Educational Attainment: Pre-School Level
Ethnic Group: Zamboangueño
Religion: Roman Catholic
Chief Complaint:
Medical Impression:

B. Physical Examination

ACTUAL OBSERVATION DOCUMENT READINGS AND RESOURCES

Play/Socialization

The child enjoys playing outdoor games like
hide and seeks and touch ball. He is enjoying indoor
games, too. Like playing video games with some
neighborhood friends. He does whatever someone
asks him to do.
Discovers environment with his own
inventiveness. He tries to set up himself
independently. He enjoys outdoor activities. He likes
sports, rules and cooperative play.

Fine Motor Skills

He responds well when he is being asked. He
is really talented at drawing: he can draw both simple
and complex figures. He understands what is being
instructed.
Printing skills are developed in later years.
Greater skills and competence for crafts are also
developed.
Focuses on specific understanding. Organized
thoughts. Reasons and read better.

Gross Motor Skills

He likes toy cars for his collection. He can Skills obtained during this year include roller
balance well. The child can move from one place to skating, bicycling, rollerblading and skateboarding.
another and he can run fast, walk, identify objects and Running and jumping at this year improve
jump as high as he wanted to. increasingly.
 Assessment and Techniques Used Findings/Implications

Skin, Hair and Nails

Palpation and Inspection Skin – generally uniform except in areas exposed to

the sun; no abrasions and other lesions
Hair – evenly distributed hair, thick and silky
Nails – convex curvature; correct angle of nail plate;
smooth texture
Head

Palpation
Scalp – hard; dandruff free
Inspection
Shape – rounded; smooth skull contour
Eyes

Inspection
No swellings, no discharge, blinking symmetrically

Iris and Pupil – normal Iris, Pupils are black in color

and equal in size

Sclera – appears white

Ears
Inspection
No excessive Cerumen, no discharges and lesions
Inspection and Palpation
Auricles – color same as facial skin, symmetrical,
mobile, firm and not tender
Hearing Acuity
Normal voice tones audible, able to hear in both ears

Nose

Inspection
Nose – symmetric and straight, no discharge or
flaring, uniform in color
Palpation
Not tender; no lesions

Mouth

Inspection
Upper Lip – uniform light red color, moist,
symmetry of contour
Inspection and Palpation
Lower Lip – uniform light red color

Buccal Mucosa – moist, smooth, soft, glistening and

elastic texture
Neck and Lymph Nodes

Inspection Neck Muscles – no swellings or masses, muscles

equal in size

Palpation Lymph Nodes – not palpable

Palpation Trachea – central placement in midline of neck,

spaces are equal on both sides

Chest and Lungs

Inspection and Percussion Thorax – chest symmetric, spine vertically aligned,

percussion notes resonate

Auscultation Breath Sounds – vesicular and bronchovesicular

Hyperresonance – normal

Heart

Inspection and Palpation Apical Pulse – proper location

Auscultation Heart – normal rate

Abdomen

Inspection Skin Integrity – unblemished skin, uniform color

Contour and Symmetry – flat and rounded,

symmetric contour

Bowel Sounds – audible bowel sounds

Auscultation
Masses and Tenderness – relaxed abdomen with
Palpation
smooth, consistent tension
Fernando, April M. BSN 1st Year – K

Adult Assessment
ASSESSMENT

A. Personal Data

Name: Arvin Fernando

Address: Callejon drive, Guiwan, Zamboanga City
Age: 20 years old
Sex: Male
Status: Single
Occupation: Student
Educational Attainment: College Level
Ethnic Group: Zamboangueño
Dialect/Language Spoken: Chavacano, English
Religion: Roman Catholic
Chief Complaint:
Medical Impression:

B. Nursing History

1. Health Perception – Health Management Pattern

My client believes that he is healthy. Physically, he looks healthy and not weak. He
verbalized that he never had serious illnesses. He hasn’t got present illnesses. He says
that he enjoys reading books and going out.

2. Nutritional – Metabolic Pattern

He usually eats nutritious foods such as vegetables and fruits. He drinks water about 6 to
8 glasses a day. He is not having difficulty or discomforts in food. He is currently
wearing teeth braces.

3. Elimination Pattern

He expressed that he eliminates everyday. According to him, he eliminates yellow-

brown, understandably odorous stool 2 times a day.

4. Activity – Exercise Pattern

He has sufficient energy in every thing he does. His daily exercises include walking and
works out in a gym. He reads books and listens to music in his spare time. He can do
things by himself like feeding, drinking, grooming, toileting, and shopping; general
mobility and bed mobility.

5. Sleep – Rest Pattern

He sleeps 6 to 8 hours daily. He has no onset problems regarding sleep pattern. He is not
complaining about suffering from insomnia. He usually sleeps at 10 PM and wakes up at
6 AM.

6. Cognitive – Perceptual Pattern

 He said that he is not having difficulty about his senses. He is not experiencing any
discomforts and pain.

7. Self-Perception-Self-Concept Pattern

He is contented in his life now. He got friends who can help him if he has problem and a
family that can be there when he needs them. He describes himself as a simple guy with
simple dreams.

8. Role – Relationship Pattern

His family is a nuclear type with 5 members. They speak Chavacano at home. Just like
other families, they can handle problems by themselves by helping each other. They
handle these problems by discussing among themselves.

9. Sexuality – Reproductive Pattern

He hasn’t got any problems regarding this pattern for he is not having monthly
menstruations and he is not married.

10. Coping – Stress Tolerance Pattern

My client said that if his family is having problems financially, he and his siblings know
how to be thrifty. He is the eldest among the 3 children, so his parents trust him so much.
His life in his family doesn’t have any changes.

11. Value – Belief Pattern

His family is Roman Catholic. They go to church together once a week. God is with them
ever since and he couldn’t live without Him. He asks help from Him and he believes that
God is really helping him and his family.

Vital Signs:

BP: 120/80 mmHg

RR: 15 bpm
PR: 88 bpm
AP: 85 bpm

Temperature: 37.1 °C
 C. Physical Examination

Assessment and Techniques Used Findings/Implications

Skin, Hair and Nails

Inspection Skin – varies from light to deep brown, generally

uniform except areas exposed to the
sun, lesion free

Hair – evenly distributed hair, no signs of

parasites

Nails – tissues around are intact, convex

curvature

Palpation Skin – moist in skin folds

Temperature – uniform; within normal range

Scalp – no signs of dandruff

Nails – prompt return of pink color (when blanch

test was performed)

Head and Neck

Inspection Skull – rounded; smooth skull contour

Face – symmetric and balanced, symmetric facial

movements

Neck - symmetric

Palpation Trachea – midline

Thyroid – midline

Lymph Nodes – not palpable

Eyes

Inspection Eyebrows – hair evenly distributed, skin intact

Eyelashes – not-too-long but equally distributed

Eyelids – skin intact; no discoloration; no

discharge; lids close symmetrically

Bulbar Conjunctiva – transparent; capillaries

sometimes evident

Sclera – appears white

Palpebral Conjunctiva – shiny and pink

Cornea – transparent, shiny and smooth

 Iris and Pupil – Pupils are black in color, contract
in light, round and equal

Inspection and Palpation Lacrimal Sac and Nasolacrimal Duct – no edema

or tearing

Ears

Inspection Auricles

Color – same as facial skin

Symmetry – symmetrical
Position – aligned with outer canthus of eye

Palpation Auricles – mobile, firm and not tender, lesion free

Nose and Sinuses

Inspection and Palpation Nose

External – symmetric and straight, no
discharge, not tender, no lesions

Inspection Internal – mucosa pink, no lesions, clear,

watery discharge

Mouth and Oropharynx

Inspection and Palpation Upper Lip and Lower Lip – uniform pink color,
soft and moist, smooth texture, symmetry
of contour

Buccal Mucosa – soft, moist, smooth, gleaming

Thorax and Lungs

Inspection Chest – symmetric

Spinal Column – vertically aligned, straight

Palpation Posterior Thorax

Temperature and Integrity – skin intact;
uniform temperature

Chest – chest wall intact; no masses and no

tenderness

Posterior Chest – full and symmetric chest

expansion

Percussion Thorax – lowest point of resonance is at the

diaphragm

Auscultation Breath Sound – low-pitched, vesicular and

bronchovesicular breath sounds
 Lung sounds – clear inspirations and expirations

Heart rate – normal

Abdomen

Inspection Abdomen

Skin Integrity – presence of rash, uniform color

Contour and symmetry – flat and rounded

When asked to take deep breath – no evidence of

enlargement of liver or spleen

Auscultation Abdomen – audible bowel sounds, absence of

arterial bruits, absence of friction rub

Palpation

Light Palpation No tenderness, relaxed abdomen with consistent

tension

Deep Palpation Tenderness present near xiphoid process

Fernando, April M. BSN 1st Year – K

Geriatric Assessment

ASSESSMENT

A. Personal Data
 Name: Domingo Fernando
Address: Guiwan, Zamboanga City
Age: 69 years old
Sex: Male
Status: Married
Occupation: Retired Policeman
Educational Attainment: College Graduate
Ethnic Group: Zamboangueño
Dialect/Language Spoken: Chavacano
Religion: Roman Catholic
Chief complaint: Increase of heart rate
Medical Impression:

B. Nursing History

1. Health Perception – Health Management Pattern

My client verbalized that he is feeling well lately. His health accordingly is okay. No
illnesses occurred in his health. In his old age, he drinks vitamins and increase water
intake and exercise.

2. Nutritional – Metabolic Pattern

He mentioned that he is taking vitamins to maintain his good health. He loves to eat
health foods such as vegetables and fruits. His water intake is 6 to 7 glasses a day. He
avoids eating too much meat because it’s not good for his health.

3. Elimination Pattern

He urinates about 5 times daily and he hasn’t got any difficulty in urinating as well in
defecating. He eliminates bowel at least once a day. He described his stool as yellow-
brown and he mentioned that it smells, just like what normal stools are.

4. Activity – Exercise Pattern

He has activities that are done everyday. He loves working when he is bored. He loves
walking a lot. He can go to any places and that is one of the exercises he makes. He has
the ability to self-care.

5. Sleep – Rest Pattern

He sleeps early and wakes up early, too. He usually sleeps at 9 o’clock at night and
wakes up at 6 in the morning. He is not having nightmares and he sleeps soundly.

6. Cognitive – Perceptual Pattern

He doesn’t have any difficulties in hearing. He wears glasses everyday. He has no

discomforts except his vision.

7. Self-Perception-Self-Concept Pattern
 He said that he’s happy when his family is happy, too. He is quite high-tempered. He
loves children, especially his grandsons and granddaughters. He is outgoing and he easily
gets bored at home.

8. Role – Relationship Pattern

My client has an extended type of family because he lives with his wife and his son. He
has 3 daughters and 2 sons. He speaks Chavacano with his family at home. He and his
wife go to church every Sunday.

9. Sexuality – Reproductive Pattern

He has 5 children. All are professionals. No problems perceived in sexual relationship.

10. Coping – Stress Tolerance Pattern

When there are problems, he and his wife discuss it firmly. Sometimes he discusses it
with his son, too. They always pray when this happens.

11. Value – Belief Pattern

Religion, for him, is very important. He wants that his family will be religious like him.
He praises God and he always pray to him.

Vital Signs:

BP: 130/80 mmHg

RR: 14 bpm
PR: 88 bpm
AP: 77 bpm

Temperature: 37.1 °C

C. Physical Examination

Assessment and Techniques Used Findings/Implications

Skin, Hair and Nails

 Inspection Skin – varies from light to deep brown;
spots and wrinkles visible

Hair – clean and groomed, fairly

distributed dominant silver hair

Palpation Skin – no swellings

Scalp – no dandruff visible, lesion free

Temperature – normal range

Nails – firm and hard

Head

Inspection Shape – rounded, symmetrical

Palpation Scalp – lesion free

Eyes

Inspection Eyebrows – unequal alignment

Eyelids – no discharge, skin intact

Sclera – yellowish

Bulbar Conjunctiva – transparent

Palpebral Conjunctiva – shiny, smooth

Iris and Pupil – symmetrical, pupils

contrict to light

Ears

Inspection No nodules, no discharges

Auricles – color same as facial skin,

symmetrical, aligned with outer canthus of
eye

Palpation Auricles – scaly skin, tenderness when

pressed

Hearing Acuity Responds and answers correctly when

being asked in a whisper

Nose

Inspection External Nose – the color is same as face,

 symmetrical, smooth

Internal Nose – pink mucosa, moist with

uniform color, no lesions

Palpation Tenderness of sinuses

Mouth

Inspection Lips, Tongue and Buccal Mucosa – moist

and pinkish

Tonsils – easily seen

Neck and Lymph Nodes

Inspection Trachea – midline

Palpation Lymph Nodes – not palpable

Chest and Lungs

Inspection Chest - normal and relaxed

Percussion Resonance

Auscultation Breath sounds – low-pitched

Heart

Auscultation Normal heart rates

Abdomen

Inspection Abdomen – slightly protuberant

Umbilicus – pinkish, no odor, no

discharges and redness

Auscultation Bowel Sounds – normal sounds

Palpation No masses and tenderness

 Health Assessment

Pediatrics
Adult
Geriatrics

Submitted by:

Fernando, April M.