OBJECTIVES - VALENZUELA

• General
• Specific

INTRODUCTION - MONDELO

NORMAL ANATOMY AND PHYSIOLOGY – MAMOSACA AND SALONG

ASSESSMENT – SAM, MAMOSACA, MONTES

• Vital Information
• Source of Information
• Chief Complaints
• Physical Assessment
• History of Present Illness
• History of Past Illness
• Allergies
• Previous Hospitalization
• Medication and Drug Study

PHYSICAL ASSESSMENT AND REVIEW OF SYSTEMS – MEJIA AND MEDINA

GORDON’S FUNCTIONAL HEALTH PATTERNS – TALAROC AND MANGUBAT

CONCEPT MAP – MANGUBAT, MEDINA, MEJIA

6 NURSING CARE PLAN – MONTES, SALVAN, SALONG, TALAROC

HEALTH TEACHINGS – SAM AND VALENZUELA

PROGNOSIS – MONDELO
 PEROS (Physical Assessment and Review of Systems)

Note: Assessment should follow IPPA / IAPP fashion if applicable. This serves as guide in
performing assessment thoroughly

In writing your PEROS requirement, please draw your own table following this format in a clean
sheet of long bond paper so that you can utilize more space for your assessment findings.

Areas Subjective Findings Objective Findings Problem Identified

Assessed

General -Have you been Inspection

Health feeling well?
Inspect overall appearance noting appropriate The following may be
Survey
-Have you lost or growth and development according to age (for applicable:
gained weight children).
-Anxiety (specify level)
recently?
-Describe the posture, body size and type, height,
-Body Image Disturbance
-Check patient’s weight and grooming (dress and hygiene).
orientation and -Altered Comfort
-How does the pt. smell?
intactness of
memory. -Impaired Verbal
-Watch signs of distress and check facial
Communication
characteristics.
-Acute Confusion
-Inspect level of alertness (alert, lethargic or
stuporous), memory, coherence and speech. -Risk for Acute Confusion
-Assess the client’s attitude, affect and mood. -Ineffective Individual
Coping
-Note for any deformities, check coordination of
movements when sitting, standing and walking. -Ineffective Denial
-Describe gait (does the patient need assistance in -Risk for Developmental
walking? If so – describe. Delay
-Describe the strides upon walking, is the gait -Delayed Growth and
steady?) If client is bedridden, describe the level Development
and kind of assistance the client needs.
-Impaired Memory

-Risk for Injury

-Powerlessness

-Social Isolation
 -Fear

-Imbalanced Nutrition: Less

than Body Requirements

-Imbalanced Nutrition: More

than Body Requirements

-Disturbed Thought Process

-Self Care Deficit

Integumenta -Do you have skin Inspection -Altered Body Temperature:

ry System rashes or lesions? Hyperthermia
-Inspect skin color and uniformity.
-Do you have -Injury
-Inspect skin for intactness. Note location of any
excessive itching?
break in skin integrity and describe its appearance. -Impaired Skin Integrity
-Do you sweat a
-Note distribution of hair all over the body and note -Risk for Impaired Skin
lot? Any odor
location of unevenness of hair distribution. Integrity
problems?
-Note hair distribution on the head, texture, color -Ineffective
-Are you exposed
and length of hair. Thermoregulation
to the sun?
-Note presence of lice, nits, dandruff, and condition -Self Care Deficit
-Do you use
of the scalp.
sunblock? -Impaired Tissue Integrity
-Describe nail condition on both upper and lower
-Body Image Disturbance
extremities giving emphasis on its shape, curvature
and angle, color and texture. Also inspect the -Pain, Acute or Chronic
tissues surrounding the nail.
-Allergy Response, Latex
Palpation
-Hypothermia
-Palpate skin and note its turgor, mobility and
moisture. -Infection

-If there’s presence of edema, apply pressure on -Risk for Infection

skin surface and note for pitting.

------------------ Head and face – Head and face – (Inspection) note symmetry, size, -Body Image Disturbance
------------------ (Palpation) proportion and contours of the head.
-Pain, Acute or Chronic
------------------
-Palpate the head -Note symmetry of facial movements
------------------
and face for any
------------------
------------------ tenderness or pain. (Palpation) -Impaired Verbal
------------------ If there is, ask Communication
-Palpate for presence of any masses.
------------------ COLDSPA.
-Impaired Dentition
----------- Eyes – (inspection) Inspect eyebrows and eye
HEENT lashes for shape, size and evenness of hair -Impaired Swallowing
(Percussion) distribution. (Eye lashes may be pointing internally
a. Head -Altered Sensory Perception
– a phenomenon called trichiasis)
and face -Percuss sinuses for
b. Eyes -Impaired Oral Mucous
any tenderness -Inspect pupils and note if PERRLA (pupils that does
c. Ears Membrane
(COLDSPA). not assume a circular shape is called coloboma),
d. Nose determine color of sclera, describe corneal size, -Ineffective Airway
e. Oral Eyes – Do you have
light reflex and color (corneal scars may appear Clearance
Cavity any visual
white over the cornea and may impede vision).
problem?
-Inspect for presence of redness, swelling and
-Do you wear
discharges.
glasses? If yes, do
you wear them -Note presence of periorbital edema.
consistently,
-Test muscle strength of the eyes (note presence of
specially while at
nystagmus and strabismus) using cardinal fields of
school/work?
gaze test, cover and uncover test and corneal light
-Do you wear reflex test.
contact lenses?
-Check corneal sensitivity using a wisp of cotton.
-When was your
Ears –(Inspection) Note symmetry, size and
last eye
position of ears, assess for presence of discharges
examination? What
and note odor and color.
was the result?
(Palpation)
-Do you use any
eye medications? If -Palpate auricles for texture, elasticity and areas of
yes, identify. tenderness.

Nose – (Inspection) describe symmetry, size and

distribution of hair within the nostrils.
Inspection
-Note presence of discharges, if there is, describe
-Check the vision
color, consistency, quantity and odor.
using Snellen’s
chart or -Note patency of nares, color of nasal mucosa and
Rosenbaum card. check for flaring.
-Describe -Lightly palpate the external nose for presence of
peripheral vision masses and displacement of bone and cartilage.
and any limitations.
Oral cavity–(inspection). Describe contour,
Palpation symmetry, moisture, color and intactness of lips.
-Palpate the -Describe texture, color and intactness of gums,
periorbital area for oral mucosa as well as the tonsils and uvula.
presence of
-Describe color, presence of carries, decays and
tenderness
number of teeth.
(COLDSPA).
-Inspect tongue color, symmetry, size, shape and
Ears – Do you have
position.
any hearing
problem? -Assess swallowing ability and ability to determine
taste (anterior and posterior).
-Do you listen to
loud music? (Palpation)
-When was your
last hearing exam?

-Check hearing
acuity using
whisper test, watch
tick test, Weber
test and Rinne test.

Nose.

–Do you use any

inhalers or
nebulization? How
often?

-Check ability to
distinguish
different scents.

(Palpation)

-Palpate externally
for any tenderness
(COLDSPA).

Oral cavity – How

many second teeth
do you have?
When was your last
visit to the dentist?

- Do you see an
orthodontist?
 -Note presence of
tooth and gum
pain.

-Assess presence of
pain on tonsils and
uvula.

Neck -Note for presence -Palpate tongue and check for strength, nodules -Impaired Mobility
of pain, always and lumps.
-Body Image Disturbance
take the COLDSPA.
Inspection
-Risk for Ineffective Airway
-Do you experience
-Note symmetry of appearance including size, Clearance
stiff neck? How
contours, and presence of distended veins.
often? -Infection
- Note the location and symmetry of the trachea.
Palpation -Risk for Infection
-Inspect the neck muscles (sternocleidomastoid and
-Palpate for any
trapezius muscle).
tenderness
(COLDSPA). -Observe head movement in all directions.

Palpation

-Palpate for enlargement of cervical nodes and

enlargement of thyroid gland of the neck.

-Palpate the trachea for any deviation.

-Palpate neck muscle for tone, strength, deviation

and presence of lumps or masses.

-Check shoulder strength by instructing the client to

shrug shoulders with or without resistance.

Auscultation

-Auscultate carotid artery for bruit sounds.

Respiratory -Do you have Inspection -Ineffective Airway

System asthma? Clearance
-Inspect shape and symmetry of the thorax from
-Do you ever have posterior and lateral views, Inspect the spinal -Risk for Ineffective Airway
trouble breathing alignment for deformities. Clearance
or do you wheeze
-Note symmetry of chest expansion, any abnormal -Risk for Aspiration
when exercising /
retractions of the ribcage, supraclavicular
running? -Impaired Gas Exchange
retractions, rate, depth and rhythm of respirations.
-Are you exposed -Impaired Spontaneous
Palpation
to air pollutants, Ventilation
 smoke, or second- -Palpate for vocal (tactile) fremitus on the entire -Dysfunctional Ventilator
hand smoke? chest while the patient says “99” noting its Weaning Response
symmetry of vibrations with the other lung and
-Do you feel any -Infection
area of diminishing vibrations.
discomforts or pain
-Pain
when breathing? Percussion

Palpation -Percuss each intercostal spaces for resonance –

normal sound (never percuss over a bone as this
-Palpate for any
will create flat sounds).
tenderness on both
anterior and -Note the hyper-resonance of the left lower
posterior chest anterior chest due to air filled stomach. Normally,
wall. the rest of the lung fields are resonant.

-Abnormal (dullness – decreased air in lungs such

as atelectasis, pulmonary edema and hemothorax;
hyperresonance – pneumothorax, acute asthma.

-Percuss for diaphragmatic excursion – point where

resonance changes to dullness. (Normal
diaphragmatic excursion is 5-6 cm.).

Auscultation

-Auscultate for breathing / lung sounds and

describe (note any adventitious lung sounds).

-Normal sounds: bronchial sound – main bronchus,

bronchovesicular sounds – lower part of the
bronchial tree, vesicular sounds – lung field.

Cardio- -Do you have any Inspection -Decreased Cardiac Output

chest pain? If yes,
vascular -Inspect for presence of edema on other body parts -Ineffective Tissue Perfusion
identify COLDSPA.
System
-Inspect jugular vein for distention and identify the -Fluid Volume Excess
-Does your heart
highest point a.k.a point of maximal impulse- PMI
ever skip -Fluid Volume Deficit
(at which pulsations can be seen or palpated).

Palpation

-Check capillary refill time and record, palpate

peripheral pulses and compare them in all four

-Pain
a beat? -Altered Comfort

-Anxiety
 -Fear

extremities and count in one full minute. Describe -Knowledge Deficit

strength of each pulse whether thready or strong
bounding.

-Palpate carotid artery with extreme caution.

-Palpate pulsations on the anterior chest wall

(sternoclavicular area, aortic area, pulmonic area
and left clavicular area) and note any lifts, heaves
or vibrations.

Auscultation

-Auscultate heart rate, rhythm, or presence of

adventitious and extra heart sounds, bruits of thrills
using both bell and diaphragm of the stethoscope
in the following areas:

(APe To Man and Erbs point –mnemonics)

Aortic – 2nd intercostal space near right sternum

Pulmonic – 2nd intercostal space near left sternum

Tricuspid – 5th intercostal space near left sternum

Mitral – 5th intercostal space mid clavicular line left

thorax

Erbs point – 3rd intercostals space near left sternum

Breast and -Do you perform Inspection -Ineffective Breastfeeding

axilla breast self-
-Inspect the breast for size, symmetry, contour -Interrupted Breast Feeding
examination? How
(dimpling), shape, color, presence of lesions and
often? -Pain
discharges (including areola and nipples).
-Have you -Impaired Skin Integrity
Palpation
undergone
mammography -Body Image Disturbed
-Using spiral/circular, wedge, vertical/ lateral,
procedures? horizontal / transverse technique, palpate the
whole breast area including tail of Spence.
-Have you had any
breast surgery? -Palpate the axillary, sub clavicular, and
supraclavicular lymph nodes while the client sits.
-Do you experience
breast tenderness?
How often?
COLDSPA.
 Palpation

-Note presence of
pain / tenderness
upon breast
palpation.

Gastro- -Do you have any Note: Order of abdominal assessment should -Bowel Incontinence
intestinal stomach problems? always be inspection, auscultation, percussion and
-Constipation
System and Vomiting? palpation.
the abdomen -Perceived Constipation
-How often do you Warning: it may cause death for the ff reasons:
have a bowel -Risk for constipation
Adults – Abdominal Aortic Aneurysm
movement?
-Diarrhea
Children – Wilms Tumor
-Do you feel any
pulsations in your -Risk for Diarrhea
Inspection:
abdomen? -Ineffective Infant Feeding
-Assess ability to swallow.
Inspection Pattern
-Inspect contour, size and shape of abdominal area.
-Check sensitivity -Risk for Impaired Liver
of the abdomen -Inspect umbilicus noting position, contour, color Function
using open safety and discharge.
-Nausea
pin – noting its -Ask client to raise head off bed and any bulges or
sensitivity to dull or hernias.
sharp object.
-Observe abdominal movements and pulsations.
Palpation
-Stroke the abdomen upward using a tongue blade
-Palpate for any and toward the umbilicus in each quadrant and
pain starting with note reflexes.
light palpation to
deep palpation. Auscultation

-Auscultate bowel sounds in all four quadrants of

the abdomen and note each of them.

-Auscultate for presence of pulsations on the

abdomen.

Percussion

-Percuss for presence of distention caused by gas,

size of liver and spleen.
 Palpation

-Palpate for presence of masses (from light to deep

palpation).

Genito- -Do you have Inspection -Fluid Volume Deficit

urinary / bladder control?
(Female and Male) -Risk for Fluid Volume
Reproductive
-Do you wet the Deficit
system -Inspect genitalia and note its color, intactness,
bed?
lesions and discharges. -Fluid Volume Excess
Palpation
-Note the smell. -Risk for Fluid Volume
-Palpate genitalia Excess
(Male)
for presence of
-Sexual Dysfunction
tenderness and -Shine a light on the posterior part of the scrotum
note COLDSPA. and visualize the testicles. -Ineffective Sexuality
Pattern
Percussion Palpation
-Situational Low Self Esteem
-Ask pt to sit and (Female)
place non-
dominant hand -Palpate for presence of masses.
over kidney. Make (Male)
a fist with the
dominant hand and -Palpate scrotum and note its descend and
strike non presence of hernias.
dominant hand
noting any pain.

M -Do you have any Inspection - Activity Intolerance

back problems?
U -Inspect posture, symmetry, body size and -Risk for Activity
-Have you ever irregularity in shape of the whole musculoskeletal Intolerance
S
been told you had system as well as any limitation in movement.
-Risk for Falls
C a spinal problem?
-Neck muscle symmetry, range of motion and size.
-Fatigue
U -Assess for pain
-Arm muscle measurement and compare with
upon movement -Impaired Physical Mobility
L other arm, also test range of motion.
(COPLDSPA).
-Risk for Injury
O -Leg muscle measurement and compare with other
leg.
S Palpation
-Inspect curvature of the spine.
K -Assess tenderness
-Inspect joint for any deformities.
E upon palpation.
Palpation
L
-Palpate all joins for any joint deformities.
E -Palpate for any abnormal growth/protrusion of
bone, crepitus in the whole system.
T
-Check the range of motion in all joints and note for
A
any limitation of movement.
L
-Palpate muscle `for presence of any masses.
System
-Note muscle strength of all four limbs (5/5),
including fingers or phalanges / tarsals and
metatarsals and elbows or knees, neck, waist.
Indicate muscle strength with and without applying
resistance.

Neurologic -How would you Cerebellar, motor -Unilateral Neglect

System describe your
a. Balance -Impaired Physical Mobility
mood?
-Let the patient do heel to toe walking. -Disturbed Sensory
-Do you feel any
Perception
numbness? -Let the patient stand closing the eyes and observe
for swaying of arms. -Risk for Injury

-Let the patient hop in one foot then the other -Risk for Fall

finger to nose alternate with other arm (open and

close eyes).

-From my hand to nose.

-Pronation and supination of both hands.

-Fingers to thumb.

-Feet to my hand.

-Heel move from anterior knee to feet.

b. Strength

-Arm strength with and without resistance.

-Squeeze fingers.

-Leg strength with and without resistance.

Sensory (comparing with other side of body).

-Soft cotton sensation all over body moving from

distal to proximal.

-Sharp and dull sensation

-Vibration feeling of a tuning fork. Tell when it

stops.

-Moving fingers up and down. Identify direction

while eyes are closed.

-Identifying numbers of pricking pins.

-Identifying number of hands holding.

-Identifying objects whether coin or pencil.

Reflexes

-Biceps tendons (clenched teeth).

-Triceps tendons.

-Brachioradialis tendon.

-Patellar tendons (grasp hands).

-Achilles tendon.

-Babinski reflex.

-Abdominal reflex.

Cranial nerves

I – Olfactory – identify different scents

II – optic – visual acuity, visual field, fundoscopic

exam

III – Oculomotor, IV – trochlear and VI – abducens -

eye movement , pupillary reflexes (PERRLA),

V – Trigeminal – sensations of face using soft and

sharp objects, corneal reflexes with wisp of cotton

VII – Facial – make faces, open eyes against

resistance

VIII – Acoustic – test hearing acuity using tuning

fork and whisper test
 IX – Glossopharyngeal and X vagus – taste buds test
- test bitter taste last as this interferes with the
different tastes, watch uvula rising, check gag reflex

XI – Spinal accessory muscle shoulder strength,

tongue

XII – Hypoglossal – tongue strength

Lymphatic / -Have you been Inspection -Infection

Hemato-logic tired?
-Inspect any enlargement of the limb due to -Risk for Infection
System
-Do you have any lymphatic obstruction.
-Risk for Fluid Volume
lumps in your neck,
-Inspect skin for signs of paleness or flushed Deficit
underarms or
appearance.
groin? -Body Image Disturbance
-Assess for signs of bleeding in the different areas
Palpation
of the body including the oral mucosa, nose and
-Palpate nodes for rectal bleeding by noting the stool color. Also
presence of pain. inspect the skin for easy bruising, petechial rashes,
ecchymosis and other bleeding tendencies.

Palpation

-Palpate for enlargement of the lymph nodes.

 GORDON'S FUNCTIONAL HEALTH PATTERNS

#1 HEALTH MAINTENANCE MGMT. #5 COGNITIVE/PERCEPTUAL

• Admit Date • Pain (scale, characteristics)

• Medical Diagnosis • Glasgow Score

• Pertinent Medical History • Sensory Aids

• Pertinent Psychosocial History • Level of Consciousness

• Insurance • Circulation, Motion, Sensation

(CMS)
• Age

• Allergies-Food and Medicines

#6 SLEEP/REST
• Erikson's Developmental Level
SUBJECTIVE
• Tendency Toward which Pole OBJECTIVE

• Perception of Health Status • Pattern of Sleep

• Immunization Status • Quality/Quantity

• Risk Behaviors

• Discharge Needs #7 SELF-PERCEPTION/SELF-ESTEEM

• Medications Prior to Admission

• Describes Attitudes about Self and
Perception of Abilities.

• Attitudes about Self

#2 NUTRITION/METABOLIC
• Impact of Illness on Self

• Desire to Change Self

• Diet
• Nervous or Relaxed: rate 1-5
• Recent Intake (% of meals)
• Perceived Powerlessness
• Food Preferences
• Body Posture
• Abdomen
• Eye Contact
• Bowel Sounds
• Assertive or Passive: rate 1-5
 • Nausea • Nonverbal Cues to Altered Self-
esteem
• NG Tube
• Facial Expressions
• IV Fluids

• Intake/Output (no. of hours)

#8 ROLE/RELATIONSHIP
• Temperature

• Edema
• Occupation
• Height, Weight
• Recent change in Role
• Body Mass Index
• Comfort with Change

• Marital Status
#3 ELIMINATION
• Family Structure

• Bladder
#9 SEXUALITY
• Bowel Patterns

• Last BM
• Menstrual History: Children
• Skin
• Self-breast/Testicular Exams
• Braden Scale Score
• Impact of Illness on Sexuality

• Birth Control
#4 ACTIVITY/EXERCISE

#10 COPING/STRESS
• Respiratory – Rate

• Character of Respirations
• Expression of Stress
• Color
• Stressors
• Breath Sounds
• Usual Coping Mechanisms
• SpO2
• Support Systems
• Cardiac
• Family Support
• Apical Pulse (rate, rhythm, sounds)
• Community Resources
• Peripheral Pulses

• Capillary Refill Time

• Blood Pressure #11 VALUE/BELIEF

• Homan's Sign
• Religious Preference
• ROM
• Spirituality
• Mobility (Describe extent)
• Cultural Beliefs and Practices
• Assistive Equipment
• Practice of Values/Beliefs
• ADL Performance
• Advanced Directives
• Leisure and Recreation