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. BIRTHDAY: October 19,1999
AGE: 19 GENDER: Male
5th Vital Sign (Pain)
Questions Findings
General Observations
1. Observe posture. He comportable,attentive and without
excessive changes in position and posture.
2. Observe facial expression. He always maintaining eye contact and
conversation .While I’m asking a question he
answering, my question with appropriate
facial expression.
3. Inspect joints and muscles. There is no edema in his joints and his muscles
was relaxed.
4. Observe skin for scars, lesions, rashes, His skin was no scars,lesions,rashes or any
changes, or discoloration. discolorations and also there’s no
inconsistency ,wounds or bruising .
Vital Signs
1. Measure heart rate. 67 beats/minute
2. Measure respiratory rate. 17 breaths/minute
3. Measure blood pressure. 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. BIRTHDAY: October 19,1999
AGE: 19 GENDER: Male

Head and Neck

Questions Findings
1. Gather equipments (gloves, penlight Complete equipment
or flashlight, small glass of water,
stethoscope).
2. Explain procedure to client. Nurse explain it
Head and Face
1. Inspect head for size, shape and His head size,shape is symmetrically round in
configuration. the midline and appropriate to his body size
and there is no visible lesions.

2. Palpate head for consistency while His head is normally hard and smooth
wearing gloves. without lesions.
3. Inspect face for symmetry, features, His Face is symmetric with a round
movement, expression, and skin appearance and there is no abnormalities
condition. movements.
4. Palpate temporal artery for his temporal artery is elastic and not tender.
tenderness and elasticity.
5. Palpate temporomandibular joint for His temporomandibular is no swelling ,
range of motion, swelling, tenderness, tenderness, or crepitation with movement
or crepitation by placing index finger .his mouth is open and closes fully (3-6 cm
over the front of each and asking between the upper and lower teeth).The jaw
client to open mouth. Ask if client has was move laterally 1-2 cm in each direction.
history of frequent headaches.
Neck
1. Inspect neck while it is in a slightly His Neck is symmetric with head centered
extended position (and using a light) and without bulging.
for position, symmetry, and presence
of lumps and masses
2. Inspect movement of thyroid cartilage His Thyroid cartilage and cricoid cartilage is
and thyroid gland by having client move upward symmetrically after I ask the
swallow a small sip of water. patient to swallow a small sip of water.

3. Inspect cervical vertebrae by having his c7 is visible and palpable

client flex neck.
4. Inspect neck range of motion by His neck movement is smooth and controlled
having client turn chin to right and with 45°flexion, 55° extension,
left shoulder, touch each ear to the 40° abduction, 70° rotation.
shoulder, touch chin to chest, and lift
chin to ceiling
 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. BIRTHDAY: October 19,1999
AGE: 19 GENDER: Male

Skin, Hair, and Nails.

Questions Findings
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. There is no any distinctive odor
2. Inspect for generalized color variations His skin color is slightly darked brown and
(brownness, yellow, redness, cyanosis, reveals evenly and without unusual or
jaundice, erythema, vitiligo). prominent discolorations.
3. Inspect for skin breakdown (Use His skin of the patient is intact,and there are
staging criteria given in Chapter 13. no reddened areas and ulcer.
4. Inspect for primary, secondary, or His skin is smooth and there is no lesion but
vascular lesions. (Note size, shape, he have a keloid in the elbow due to the
location, distribution and operation of removing 2 warts.
configuration). Use wood lamp if
fungus is suspected
5. Palpate lesions. His skin was no lesions palpated
6. Palpate texture (rough, smooth) of His skin is smooth and even
skin, using palmar surface of three
middle fingers.
7. Palpate temperature (cool, warm, hot) His skin was normally warm and his skin under
and moisture (dry, sweaty, oily) of skin, folds are moist.
using dorsal side of hand.
8. Palpate thickness of skin with His skin thickness is normal
fingerpads.
9. Palpate mobility and turgor by His skin is mobile, with elasticity and returns
pinching up skin over sternum. to original shape quickly.
10. Palpate for edema, pressing thumbs His skin is no edema ,his skin rebounds and
over feet or ankles does not remain indented when pressure is
released.
Scalp and Hair
1. Inspect color. His hair is color black
2. Inspect amount and distribution. His hair is evenly distributed
3. Inspect and palpate for thickness, His hair was elastic and there is no lesion and
texture, oiliness, lesions, and parasites. 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. BIRTHDAY: October 19,1999
AGE: 19 GENDER: Male

Eyes.
Questions Findings
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 His distant visual are normal , with 20/20
chart, normal acuity is 20/20 with or acuity without using corrective lenses.
without corrective lens).
2. Near visual acuity (with a handheld His eyes in near vision are normal , with 14/14
vision chart, normal acuity is 14/14 acuity without using corrective lenses.
with or without corrective lenses).
3. Visual fields (use procedure discussed His sees the ballpen while covering one
in textbook to test peripheral vision). 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°

Perform Extraocular Muscle Function Test

1. Corneal light reflex (using a penlight to He have a asymmetric position of the light
observe parallel alignment of light reflex, because on his left eye is theres a
reflection on corneas). slightly deviate alignment .
2. Cover test (using an opaque card to His Uncovered eye is remain fixed straight
cover an eye to observe for eye ahead .the covered eye is remain fixed straight
movement). ahead after I remove the opaque card.
3. Positions test (observing for eye His eye movement is smooth and symmetric
movement). thoughout all six directions.
External Eye Structures
1. Inspect eyelids and lashes (width and His upper lid margin is between upper margin
position of palpebral fissures, abilty to of the iris and the upper pupil. The lower lid
close eyelids in comparison with margin rests on the lower border of the iris.No
eyeballs, color, swelling, lesions or white scelra is seen above/below the
discharge. 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

 and outward turning. Eyelashes are evenly
distributed and curve outward along the lid
margins.

Skin in both eyelids is wihout lesions,redness

and swelling .
2. Inspect position of eyeballs (alignment His Eyeballs are symmetrically algned in
in sockets, protruding or sunken). sockets without protruding or sinking .
3. Inspect bulbar conjunctiva and sclera His Bulbar conjunctiva is clear ,moist and
(clarity, color and texture). smooth .Underlying structure are clearly
visible white and his Sclera is white.
4. Inspect palpebral conjunctive (eversion His lower and upper palpebral conjunctiva are
of upper eyelid is usually performed clearly and free from swelling or
only with complaints of eye pain or lesions,foreign bodies or trauma.
sensation of something in eye).
5. Inspect the lacrimal apparatus over the There is No swelling or reddiness appeard over
lacrimal glands (lateral aspect of upper areas of the lacrimal gland.The puncta is
eyelid) and the puncta (medial aspect visible and without swelling or redness and is
of lower eyelid). Observe for swelling, turned slightly toward the eye.
redness or drainage.
6. Palpate the lacrimal apparatus, noting There is no drainage from the puncta while
drainage from the puncta when palpating the nasolacrimal duct.
palpating the nasolacrimal duct.
7. Inspect the cornea and lens by shining His cornea is transparent,with no opacities
a light to determine transparency. .The oblique view shows a smooth and overall
moist surface ,his lens is free of opacities.

8. Inspect the iris and pupil for shape and His iris is typically round flat and evenly
color of the iris and size and shape of colored.The pupil are round with a regular
the pupil. border is centered in the iris .Pupils are
normally equal in size (3-5mm).

9. Test pupillary reaction to light (in a His pupillary are constrict

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 His pupilliary are constrict and the
shifting gaze from far to near convergence of his eyes are focusing while I
(normally, pupils constrict). 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 Findings
External Ear Structures
1. Inspect the auricle, tragus, and lobule His ears are equal size bilaterally and the size
for size and shape, position, are 6 cm.
lesions/discoloration, and discharge.
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. BIRTHDAY: October 19,1999
AGE: 19 GENDER: Male

Mouth, Throat, Nose, and Sinuses

Questions Findings
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. There is no any distint odor
2. Inspect and palpate lips, buccal His lips ,buccal mucosa, gums and tongue are
mucosa, gums and tongue for color pink toned ,smooth and moist and without
variations (pallor, redness, white lesions or swelling .
patches, bluish hue), moisture, tissue
consistency, or lesions (induration,
roughness, vesicles, crusts, plaques,
nodules, ulcers, cracking, patches, The stensen ducts are visible flow of saliva and
bleeding, Koplik spots, cancer sores), theres no redness,swelling,pain and moistness
Stensen and Wharton ducts. in area

The Whartons ducts the frenulum is midline

and visible flow of saliva and theres no
redness,swelling,pain and moistness in area
3. Inspect gums for hyperplasia, blue- The color and consistency of tissues along his
black line. cheeks and gums are even.
4. Inspect teeth for number and shape, He have a 32 teeth pearly whitish with smooth
color (white, brown, yellow, chalky surfaces and edges. There Is no missing teeth
white areas), occlusion. Jaws are aligned and no deviation seen with
biting down .
5. Inspec and palpate tongue for color, The color of his tongue is pink tone,moist and
texture, and consistency (black, hairy, visible veins and there is no any lesions are
white patches, smooth, reddish, shiny present the size of tongue is moderate with
without papillae), moisture, and size papillae present.
(enlarged or very small).
Throat
1. Inspect the throat for color, His hard palate is pale or whitish with firm
consistency, torus palatines, uvula transverse rugae
(singular) 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. ,in the right part is higher than the left are
because of the liver.
12. Auscultate for breath sounds (normal, The breath sounds is normal I auscultate a
bronchial, bronchovesicular, and bronchial, bronchovesicular, and vesicular
vesicular), noting location sound
13. Auscultate for adventitious sounds There is no any a adventitious sounds
(crackles, fine or coarse, pleural friction
rub, wheeze, sibilant, or sonorous).
14. Auscultate for voice sounds over the The voice sound of the patient is normal at the
chest wall: Bronchophony- ask the test of Bronchophony,Egophony,Pectoriloguy
client to repeat the phrase “ninety- the sounds are soft and muffled and
nine” ; egophony- ask the client to distinguished while Pectoriloguy test is very
repeat the letter “E” ; whispered faint and inaudible
pectoriloguy – ask the client to whisper
the phrase “one-two-three”
Anterior thorax
1. Inspect for shape and configuration to The diameter of her anteroposterior is less
determine the ratio of anteroposterior than in transverse diameter (1:2)
diameter to transverse diameter
(normally 1:2)
2. Inspect for position of sternum from Her sternum is at the midline and straight
anterior and lateral viewpoints.
3. Inspect for slope of the ribs from Her ribs are slope downward with symmetric
anterior and lateral viewpoints ICS the coatal angles is 90°
4. Inspect for quality and pattern of Her respiration is relaxed,effortless and quit
respiration, noting breathing
characteristics, rate, rhythm and
depth.
5. Inspect intercostals spaces while client No retractions and bulging in the ICS.
breathes normally.

6. Inspect for use of accessory muscles. There is no any accessory muscle she used
7. Palpate for tenderness and sensation, There is no any tenderness,pain or unusual
using fingers. sensation the temperature is equal bilaterallly
8. Palpate surface characteristics such as Her skin is free from lesions and masses.
lesion or masses, using fingers of
gloved hand.
9. Palpate for fremitus while the client Her fremitus are symmetric and easily
says “ninety-nine” identified in the upper regions of the lungs
and symmetric bilateral positions
10. Palpate for chest expansion by placing My thumbs move outward 5-10 symmetrically
hands on anterolatereal wall with the at the midline
thumbs along the costal margins and
 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. BIRTHDAY: October 19,1999
AGE: 19 GENDER: Male

Abdomen
Questions Findings
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,  His Abdominal skin may be paler than
vascularity, striae, scars, and lesions the general skin tone because this skin
(wear gloves to inspect lesions). 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

2. Inspect the umbilicus, noting color,  His Umbilical skin tones are similar to
location, and contour. 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.

3. Inspect the contour of the abdomen. His Abdomen is flat, rounded, and scaphoid .
Abdomen should be evenly rounded.
4. Inspect the symmetry of the abdomen. His Abdomen is symmetric and Abdomen does
not bulge when client raises his head.
5. Inspect abdominal movement, noting Abdominal respiratory movement is seen,
respiratory movement, aortic
pulsations, and/or peristaltic waves. 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.
6. Auscultate for bowel sounds, noting The intermittent is, soft clicks and gurgles are
intensity, pitch, and frequency. 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.”
7. Auscultate for vascular sounds and There is no Bruits heard over abdominal aorta
friction rubs. or renal, iliac, or femoral arteries.
No friction rub over liver or spleen is present.
8. Percuss the abdomen for tone. 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 .
9. Percuss the liver The normal liver span is at the MSL is 4-8cm
10. Percuss the spleen. His Spleen is oval area and dullness
approximately 7 wide near the left 10th rib and
slightly posterior to the MAL.
11. Perform blunt percussion on the liver There is no tenderness or pain that elicit the
and the kidneys. patient
12. Perform light palpation, noting The abdomen is not tender and soft and there
tenderness or guarding in all is a guarding.
quadrants.
13. Perform deep palpation, noting There is a mild tenderness over the
tenderness or masses in all quadrants. xiphoid,aorta cecum,sigmoid colon and
ovaries and they are palpable ,the stuctures of
the abdomen is no palpable masses are
present
14. Palpate the umbilicus Umbilicus and surrounding area are free of
swelling bulges or any masses
15. Palpate the aorta. 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.