DERMOID CYST FINAL Na

ASIA PACIFIC COLLEGE OF ADVANCED STUDIES
A.H. Banzon St., Ibayo, Balanga City, Bataan
COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES
\

BIOGRAPHIC DATA
PERSONAL DATA
Name: Patient X
Age: 23 years old
Gender: Female
Birthday: May 23, 1997
Religion: Catholic
Marital Status: Single
Address: Zamora St. Poblacion, Pilar Bataan
Nationality: Filipino
Education Level: College
Weight:75.6 kg
Height: 5’4
OB History: N/A
Menarche: 14 years old
Days of menstruation: N/A
Coitarche: once (23 years old)
Menopausal Age: N/A
CLINICAL DATA
CHIEF COMPLAINT: Abdominal Pain For A Few Days

DATE OF ADMISSION: 06/11/2020
ADMITTING DIAGNOSIS: Abdominal Pain For Exlap
ATTENDING PHYSICIAN: Dra. Flores/Dr. Chan
WARD: Ob-Gyne Ward
FINAL DIAGNOSIS: Dermoid Right Cyst S/P Exlap Right Oophorectomy
NURSING HISTORY
A. History of Present Illness
While patient is cooking

↓
June 6- Patient feel pain in lower abdomen
↓
June-7 Patient can’t handle the pain
↓
June 8- Laboratory Examination (Blood test, Urinalysis)
↓
June 9- Diagnostic Test (MRI)
↓
June 10- Presence of cyst in the right ovary
↓
June 11- Admission at Isaac & Catalina Medical Center (7:30am)
↓
June 11- Signing of consent for surgery
↓
June 11- Explore lap Oophorectomy (11 am)
B. Past Health History
● Childhood Illness: Chickenpox, Amoebiasis, Fever.

● Immunization: Flu Vaccine, Hepa B
● Allergies: No known allergy.
● Accidents: No accidents.
● Hospitalization: PCOS
● Surgical History: No surgical history.
● Medication: Paracetamol, diatabs,Neozep, Multivitamins
● Foreign and Domestic Travel: No indicated foreign and domestic travel.
C. Present Health History
Patient X is a 23-year-old woman who was currently admitted to the hospital on June 11, 2020 with
a chief complaint of abdominal pain in a few days under the service of Dra. Nuque. She also added that
sometimes she felt a painful urination. She is diagnosed with dermoid cyst status post ex lap right
oophorectomy. She said that she had a PCOS back then. According to her, when she is in pain, she applies
a hot water bottle or heating pad to her lower abdomen or lower back to help ease the pain. She and her ex-
boyfriend broke up last 5 month. So, her mother takes care of her when she is in pain and her father works
as a teacher in public school. She and her mother decided to go to the hospital for laboratory exam and
diagnostic test to know her condition and on the next day the diagnosis is dermoid cyst and on June 11,
2020 she is scheduled for her surgery called Explore lap Oophorectomy.
ACTIVITIES OF DAILY LIVING
ADL Before Hospitalization Analysis During Analysis Nursing

Hospitalization Diagnosis
Nutrition Breakfast: Abdominal June 11, 2020 Present Fatigue r/t to
-coffee, bread Pain -NPO Condition change in
Lunch: ↓ ↓ appetite
- rice, pork, water Lack of Preparation for
Dinner appetite June 11, 2020 ex-lap
- No appetite ↓ *Post-anesthesia ↓
Decreased -NPO then may to prevent
Breakfast: food intake have clear liquid, aspiration
-coffee ↓ tea, crackers;
Lunch: 8hours post-op the
Insufficient
-rice, fish, water soft diet once with
energy
Dinner: flatus
↓
- rice, chicken, water
Fatigue
Breakfast:
-No appetite
Lunch:
-rice, Frozen food, water
Dinner
-no appetite
Elimination DEFECATION Abdominal Subjective Data: Present

Subjective Data: pain “Nung naoperahan Condition Constipation
“Sa isang araw minsan ↓ ako medyo (Post- related to
hindi ako makadumi Changes in nahihirapan akong Surgery) abdominal
paminsan pa nga after 3 appetite makadumi kaya ↓ muscle
days pa dahil sobrang ↓ naman nagbigay administratio weakness
constipated ako dahil din Hard formed yung doctor sakin n of laxative
sa ” -as verbalized by the stool ng gamot para stimulant
patient ↓ makadumi ako ng ↓
Consistency: Brown in maayos ” -as normal
difficulty to
color, hard stool verbalized by the defecation
defecate
patient
URINATION
Subjective data Consistency:
“Binabawasan ko kasi Abdominal Brown in color, Impaired
yung pag inom ko ng pain soft and moist urinary
tubig kaya naman ↓ Frequency: 1 times elimination
nahihirapan akong umihi Decrease a day related to
at masakit sa tuwing iihi fluid intake decreased urine
ako kaya naman minsan ↓ URINATION output
pinipilit ko na lang atleast pain in -IFC Decreased
3-4 na beses lang ako ihi urination urine output
sa isang araw” -as ↓ ↓
verbalized by the patient decreased urinary
urine output retention
↓
insertion of
IFC
Exercise Subjective Data: Physical “Nung pagkatapos Bed rest Activity

“naglalakad lakad ako activity kong operahan ↓ intolerance
minsan sa bakuran namin, ↓ nahihirapan akong no physical related to
ako rin ang gumagawa ng increased gumalaw dahil activities/ prolonged bed
gawaing bahay tulad ng physical kumikirot ang tahi exercise rest
paghuhugas ng plato, exertion ko at limited lang
pagluluto, nagwawalis” ↓ kasi yung
-as verbalized by the fatigue movements na
patient pwede kong gawin
dahil nga sa tahi ko
at mas
pinapayuhan akong
magpahinga sa bed
ko”
-as verbalized by
the patient
Hygiene Subjective Data: low risk of Subjective Data Patient is on Self-care deficit
“Naliligo ako isa o developing “simula ng bed rest related to bed
dalawang beses sa isang infections maadmit ako lagi ↓ rest as
araw lalo na sa ngayon ↓ na akong Limit physical evidenced by
dahil sobrang init at low risk for tinutulungan ni activities inability to
mabilis din kasi akong dental mama, ↓ perform self-
pagpawisan kaya naman problem pinupunasan lang Inability to care
minamabuti ko talagang ↓ ako ni mama ng perform self-
maligo sa araw-araw ” Practices bimpo sa katawan, care
perineal care: good hygiene inaabutan niya ako
“araw araw ginagawa ko ng tubig at maliit na
yun habang naliligo” palanggana para
makapag sipilyo
“Nagsisipilyo din ako 3 ako habang hindi
beses sa isang araw” pa ako
-as verbalized by the nadidischarge” -as
patient verbalized by the
patient
Substance use Subjective Data: Presence of Subjective Data: Hospitalizatio Readiness to

“Noon parati akong PCOS Medication: n enhanced health
umiinom ng alak at ↓ ↓ management
nakaka 4-5 ng stick ng diminished ● IV Fluid Administered related to ability

sigarilyo sa isang araw cigarette D5NR medication to control the
pero ngayon nung smoking ● Mefenamic use of substance
malaman na may pcos ako ↓ (Pain
tinigil ko ang bisyo ko to limits alcohol reliever)
recover then nung use ● Domperido
namamanage ko na yung ↓ ne
pcos ko i can occasionally ability to (Antiemetic
drink na. Nagtake din ako control the )
ng contraceptive pills use of ● Profurex
dahil active ang sexual substance (Prophylaxi
life namin ng boyfriend s)
ko noon tsaka para sa pcos ● Dulcolax
ko” as verbalized by the suppository
patient (stimulant
laxatives)
● Cefuroxime
(Anti-
infective)
● Keterolac
(Pain
reliever)
Sleep and Rest Subjective Data: Abdominal Subjective Data: Hospitalizatio Disturbed sleep
“nahihirapan at paputol Pain “after ako n pattern related
putol lagi ang tulog ko ↓ mabigyan ng pain ↓ to non
dahil pasumpong discomfort reliever nung nasa Administer restorative sleep
sumpong ang ang tiyan ↓ ospital ako mas pain reliever pattern as
ko, apat hanggang limang disturbed nakaginhawa at ↓ evidenced by
oras lang ang tulog ko sleeping nakapag pahinga Cessation of not enough
minsan masakit siya pattern ako bago isalang sa pain sleep
kapag madaling araw operation” as ↓
kaya sobrang sira yung verbalized by the
Effective
sleeping pattern ko tapos patient
sleeping
minsan nahihirapan na
pattern
ako makuha yung tulog ko
pero natutulog naman ako
sa tanghali at hindi na ako
masyadong gumagalaw
kaya nakakapagpahinga
ako sa bahay” as
verbalized by the patient
Sexuality Subjective Data: Quality family “masaya ako at Quality family Good coping
“Sobrang close ko sa care nagpapasalamat care mechanism
mama ko dahil palagi niya ↓ dahil nandyan ang ↓ related to
akong inaasikaso at well magulang ko para improves quality family
ginaguide sa mga organized alagaan ako sa coping care
decisions ko sa buhay. family panahon na mahina mechanism
Supportive din naman ↓ ako alam ko na
sakin yung boyfriend ko nahihirapan din sila
noon kaya maayos naman sa kalagayan ko
yung paghihiwalay namin improves kaya sobrang

dahil maunawain din coping thankful ako na
naman siya pero kasi mechanism nandyan sila ” -as
hindi kami compatible verbalized by the
that’s why we broke up” patient
as verbalized by the
patient
PATHOPHYSIOLOGY



PATTERNS OF FUNCTIONING
(Can be in landscape format)
Psychological Assessment
Interpretation Relevant Theory Analysis
Health Must be subjective
Coping “isa sa pinakamalaking The client knows Stress and coping Ability to
Pattern problema ko na how she’ll cope theory developed handle stressor
naranasan, ay noong up with the by Lazarus and ↓
nalaman ko na may situation Folkman (1987)
Adequate level
PCOS ako at ang dami Explained coping as of knowledge
kong kinatakot lalo na’t a phenomenon that regarding the
babae ako, syempre involves both disease
pagdating ng panahon cognitive and
gusto ko din naman behavioral responses ↓
magkaanak, at lalo that individuals use Effective
akong nalungkot noong in an attempt to coping pattern
nalaman ko na may manage internal
dermoid cyst ako and/or external
andaming takot sa sarili stressors perceived
ko pero, kailangan ko to exceed their
lumaban para sa sarili personal resources.
at pamilya ko at
nanghihingi ako ng This theory is related
advice para gumaan to the patient’s
loob ko” situation where she
can handle her stress
“ilang way ko para by just breathing and
magcope up ay manuod thinking calmly
ng motivational videos which can
para gumaan loob ko” effectively manage
as verbalized by the what stressor she
patient has.
Interaction “okay lang naman yung the client can Hildegard Peplau’s healthy
Pattern relationship ko sa interact well Interpersonal relationship
family ko pero mas Relation Theory is ↓
close ako sa nanay ko about the nurse and
kasi lagi ko siyang client relationship
kasama sa bahay pati that must pass effective
sa ibang lakad. Then sa through three phases communication
friends ko maayos in order to be ↓
naman kaya lang since successful enhance
pandemic nabawasan interaction
yung communication pattern
namin kasi nga iyon This theory is related
limitado lang yung to the patient’s
paglabas and through situation because
chat na lang kami there’s a rapport
nagkakausap intact pa between the patient
rin. Sa hospital naman and the nurse and
nakakausap ko yung patient can interact
mga nurses kasi well with the people
nagtatanong tanong around her and even
ako saka pag there’s a pandemic
nakakaramdam ako ng her relationship with

sakit sinasabi ko sa her friends are still
kanila ” as verbalized intact
by the patient
Cognitive “Hindi naman ako The client is Cognitive pain
Pattern makakalimutin, sometimes out Development:The ↓
siguro out of focus of focus due to Theory of Jean client gets out
lang nung mga pain but still Piaget of focus
nakaraan dahil yung manage to ↓
pisikal na sakit ng make decision Cognition refers to
tyan ko yun lang” for herself thinking and But still
memory processes, manage to
“Sa decision making and cognitive make decision
minsan ako yung development refers
nagdedecide kase sila to long term
mama may kaedaran changes in these
na din” processes. Based
on what the patient
verbalized, her
thinking and
memory are being
affected due to her
pregnancy.
Self- Concept "Noon bago pa man The patient’s Sister Callista Unable to do
mag pandemic palagi self esteem is Roy’s Adaptation daily activities
akong nakikipagkita sa lower than Model Sister ↓
mga kaibigan ko lagi before because Callista Roy’s
kaming kumakain sa of her illness and Theory The patient
labas nag memake up her daily routine is open for adapting Accepting the
pa nga ako bago also changed. slowly in the present
umalis. Kaso dahil sa di changes of her daily situation
inaasahang pangyayari living even it is ↓
may mga daing na ako negative adjustment Adjusting
na sumasakit yung of her living daily
tagiliran ko ganun life
tapos syempre ↓
napapadalas ang
pagsakit kaya sinabi ng Disturb self –
mama ko na concept Related
magpacheck-up na ako to changes in
at iyon nga nalaman ko appearance
na meron akong cyst sa
ovary nalungkot ako
syempre bakit ako
nagkaroon ng ganon
yun yung iniisip ko
palagi tapos tinigyawat
na ako dahil sa sakit ko
kaya nahihiya na akong
lumabas at di na din
masyado nag aayos” as
verbalized by the
patient
Emotional “ayos naman ang the client’s James Lange dermoid cyst
Pattern nararamdaman ko pero emotion is Theory of Emotion ↓
nung nagkaroon ako unstable because is related to the
invasive
sakit, paminsan-minsan of her situation study because her
procedure
hindi ako nagiging condition as a
komportable kasi may stimulus triggered ↓
halong kaba’t takot her emotion to altered emotion
dahil iniisip ko yung become anxious
sakit ko. pagkatapos
naman ng surgery ko
nakaramdam parin ako
ng takot at kaba dahil
hindi pa magaling ang
sugat ko at magkaroon
ako ng ibang
komplikasyon.” as
verbalized by the
patient
Sexuality " nung nasa edad na 14 The patient had MASLOW’S 1st
yrs old ako okay naman a sexually active HIERARCHY OF Menstruation (
menstruation ko regular relationship NEEDS 14 yrs old) her
naman. Pero nung nag since she had a (ABRAHAM menstruation is
start nako sa college at boyfriend MASLOW) Regular
nagkaroon ako ng before. Her
boyfriend napansin ko menstruation is Is a theory of ↓
na hindi nako monthly irregular. motivation which
dinadatnan. Pero naisip states that five When she in
ko non na kaya naging categories of human start college her
irregular menstruation needs dictate an menstruation
ko dahil sa may individual's became
nangyari samin ng behavior. Those irregular
boyfriend ko. Nung needs are
naghiwalay na kami ng physiological needs, ↓
boyfriend ko 5 months safety needs, love inactive sexual
na kaming hiwalay and belonging needs, intercourse
irregular pa din mens esteem needs, and
ko at sabi ko kay mama self-actualization
sumasakit kako yung needs.
lower abdomen ko kaya
nagpa check up kami
agad at ang sabi ng
doktor samin ay may
dermoid cyst ako." As
verbalized by the
patient.
Socio
Assessment
Cultural Interpretation Relevant Theory Analysis
Must be subjective
Pattern
Cultural “bago ako maospital ay the client Madeleine cultural
Pattern madalas na rin akong. preserves what Leininger’s beliefs
umiinom ng mga herbal she’s been taught Transcultural ↓
tea itinuro ito ng aking and applies it to theory is related to
being passed
nanay para daw her own life. The the study because
to her
mabawasan ang sakit ng patient knows and she used herbal
tiyan ko. Naiintindihan ko understands the medications that she ↓
naman yung mga traditional way of believes can be a believing
pumupunta sa mga healing, and she remedy and can that the
albularyo pero kasi hindi doesn't consider beliefs
ako naniniwala sa mga faith healers or understand the taught to her

ganon kaya nung albularyo . diversity of culture can benefit
nakaramdam ako ng her
sunod sunod na pagsakit ↓
sa bandang tiyan ko ay
apply the
agad akong
beliefs to her
nagpakunsulta sa doktor.
daily living.
Then sa pagkain ko
naman lahat naman ↓
kinakain ko pwera lang decrease
sa foods na may allergy worries and
ako. ” as verbalized by symptoms of
the patient illness
↓
preserving
the beliefs
Significant “Sa mga kaibigan ko The patient Barker’s Tidal Ability to

Pattern very limited lang dahil preserves having Model of Mental socialize
mas okay sakin yung a small group of Health Recovery ↓
konti lang kaibigan ko friends that she is widely used in Good
pero kilalang kilala ko knows really mental health relationship
naman na sila at alam well. nursing. Focuses ↓
ko naman din kung on the
paano ko ako nakikipag fundamental care Effective
interact sa kanila” processes of significant
nursing, is pattern
“Minsan kapag may universally
bago ako applicable, and is
nakakasalamuha, kaya a practical guide
ko naman makisama sa for psychiatry and
kanila” mental health
nursing.
“Sa mga magulang ko, Draws on values
okay kami dahil sila about relating to
lang din kasama ko sa people and help
bahay e” other in their
moment of distress
So upon the
patient’s
verbalization she
had good
communication to
her significant
others.
Recreational “Dati, ang libangan ko The patient Kurt Lewin’s Present

Pattern ay ang lumabas with my lifestyle was Change Theory condition
friends kasi dun ko changed by her ↓
nahahanap ang happiness condition in which
The patient is Changes in
ko pero simula nung she needs to adjust
adjusting slowly to lifestyle
nalaman ko na may sakit her actions.
ako, malimit nalang the changes in her ↓
akong lumabas at daily living.
Able to
makipagkwentuhan. Yung The three phases
cope the
mga dati kong (unfreeze,
changes in
kinawiwilihang gawin change, refreeze)
daily
noon ay hindi ko na of the theory is
magawa ngayon kaya
activity
doing by the
nasa bahay nalang ako at patient by limiting ↓
naglilibang mag isa o her actions due to Effective
minsan ay kasama ang her illnesses. recreational
aking pamilya. Ngayon, pattern
Kapag bored ako
The theory is related
nanunuod ako ng mga
to the patient
vlog sa youtube at
because her lifestyle
nagbabasa basa rin ako
was changed by her
ng mga libro about sa
condition in which
condition ko ngayon para
she needs to adjust
makakuha ako ng mga
her actions.
information na dapat
kong malaman at minsan
nanunuod ng mga movie
kasama ko ang family ko.
Yan na kasi yung
nakakapaglibang sakin
kapag bored ako and very
helpful naman para may
oras din ako sa sarili ko
at naipapahinga ko ang
katawan ko dahil nag iiba
iba ang mood ko.” As
verbalized by the patient.
Environment “yung lugar naman ng The client has a Environmental Enough

bahay peaceful naman peaceful and Theory (Florence space
siya at hindi naman clean Nightingale) ↓
sobrang ingay dahil surroundings. Believed that five Unpolluted
may kalayuan kami sa points were surrounding
highway sapat na yung essential in ↓
ingay at tahimik na achieving a
naririnig namin sa araw healthful house; Healthy
araw” “pure air, pure environmen
water, efficient t
“sa loob naman ng drainage, ↓
bahay, si mama kase cleanliness, and Effective
mahilig maglinis ng light. “A healthy environmen
bahay kaya environment is t pattern
napapanatili yung linis essential for
ng munti naming healing”
tahanan”
In this theory, the
patient needs a
healthy and safe
environment.
Based on what the
patient verbalized,
they have a fresh
air and has a quiet
place which we
can assure that it is
a healthy
environment for
their family.
Economic " okay naman yung buhay The patient Lubotsky and
naman pero madami kami economic status is Paxson 2002 Monthly
binabayaran katulad ng stable. This work showed salary for
tubig, ilaw at internet that the relationship father
namin. Kapag naman between family ↓
magpapahospital kami income and child
Stable
meron naman kami health grows
philhealth para kahit economic
stronger as children
papano maliit nalang age, likely in part ↓
binabayaran namin. Ayos due to the Effective
naman ang sahod ng mga cumulative effects economic
magulang ko para samin of living in low- pattern
pamilya. " as verbalized income households
by the patient. who face associated
stress, more
frequent health
shocks and limited
access to health
care.
Assessment
Spiritual Pattern Interpretation Relevant Theory Analysis
Must be subjective
Religious Belief “Catholic ang aking The patient has a Social theorist Émile present
religion noong hindi faith in God. Durkheim defined conditio
pa pandemic linggo religion as a “unified n
linggo kami system of beliefs and ↓
nagsisimba kasama practices relative to
Believe
ko ang aking pamilya sacred things” (1915).
in God
pero netong nag
pandemic hindi na ↓
Durkheim found that
kami naka kapag people tend to separate Trust
simba pero kahit religious symbols, and
ganun ay hindi objects, and rituals, Worship
nawala ang aking which are sacred, from ↓
pananampalataya at the daily symbols, Faithful
pananalig sa Diyos objects, and routines of
dahil siya ang ↓
existence referred to as
pinanghahawakan ko the profane. Effective
ng lakas lalo na This theory is related religious
ngayon na may to the patient because in pattern
nararamdaman ako” her religion, they
As verbalized by the believe in God.
patient.
Values and valuing “Noong nalaman ko The patient Jean Watson’s Have
na may sakit ako, beliefs is strong Theory of Caring Good
mas tumibay ang specially to Values
pananalig ko at mas God, she also The Patient is caring ↓
madalas ko siyang patronized saints for family and friends
kausapin dahil sa Uplifted
kalagayan ko. Dahil
in fiestas and is related to theory Spirit
naniniwala ako at for her family is because she cares not ↓
may takot ako sa the most only for herself but
She
panginoon. Dati may important thing also for other people
gave
mga tendencies in her life
more
akong nakakalimutan
ko ang magpray but
time to
my belief for God is god and
still intact. Pero her
ngayon masasabi family
kong mas tumibay at ↓
mas lalo akong effectiv
napalapit sa e values
panginoon. Kami ng
and
pamilya ko palagi
talaga kaming beliefs
nagsisimba kasa
kasama ko madalas
ang mama ko at
masaya ako na may
matibay kaming
pananalig lahat ng
problema namin ay
ipanagdarasal
namin. Nagiging
bonding na din kasi
namin ang
pagsisimba dahil
katoliko kasi tuwing
linggo nagiging
family day na din
namin iyon. Even the
celebrations ng mga
kristyano like fiesta
ay ipinagdiriwang
namin.” as verbalize
by the patient
PHYSICAL ASSESSMENT
I.Physical Assessment
a. General Assessment
Normal Actual Findings Analysis

Findings
Initial Assessment Final Assessment
1. Posture/Gait ■Bilateral/equa Normally, the Limited joint Ex lap
l 100% normal base is as wide range of ↓
strength; as the shoulder motion Incision pain
normal full width; foot ↓
movement; placement is Slightly slouched
against gravity accurate, the ↓
and against full walk is smooth, Limited joint
resistance eve and well range of motion
■ Has upright balanced; and
posture and associated
steady gait movements such
with opposing as symmetric
arm swing; arm swing are
walks unaided, present
maintaining
balance
1. Personal Women should Appears clean Unkept hair Discomfort
Hygiene wash her body and groomed and absent ↓
everyday with appropriately. make-up Unable to take a
clean water Hair is groomed indicate bath
especially her and brushed. malaise and ↓
genital area unable to take Poor personal
a bath hygiene
1. Verbal ■ Clear Articulation (the Words are Effects of
Behavior ■ Rate ability to form unclear, Anesthesia
consistent with words) is clear inaudible ↓
overall and tone and Groggy feeling
understandable. stuttering ↓
psychomotor Words unclear,

status inaudible tone
■ Volume and stuttering
audible,
normal
conversational
tone
■ Modulation
and fluid and
expressive
■Productionabl
e to produce
words
Deviations
from Normal
■ Incoherent,
rambling,
slurred,
stuttering
■ Monotone
■ Dysphasia,
aphasia
1. Vital Signs
a. PR 60-100 bpm 78 bpm 78 bpm NORMAL
b. RR 12-20 bpm 23 bpm 23 bpm Abdominal Pain

↓
Breathlessness
↓
Rapid RR
c. BP 120/80 mmHg 110/80mmHg 110/80mmHg NORMAL
d. Temp. 36-37.5 C
o
38.6 C
o
38.6 C
o
Dull pelvic
↓
Bloating/heaviness
in the abdomen
↓
Elevated body
temperature
e. Pain
1. Body Built
a. Height 5’4 5’4 Overweight
b. Weight 75.6kg 75.6kg ↓
c. BMI 32.59 = Obese High BMI (Obese)
b. Integumentary System
Body Technique Normal Findings Actual findings
Parts used
Initial Final Analysis /
Assessment Assessment Nsg.
diagnosis
Skin
Skin Color Inspection Varies from light to Skin is brown Skin is brown NORMAL
deep brown; from
ruddy pink to light
pink; from yellow
overtones to olive.
Uniformity Inspection Generally uniform Uniform color of Uniform color of NORMAL

of except in areas areas exposed to areas exposed to
Skin color exposed to the sun, the sun the sun
areas of lighter
pigmentation (palm,
lip, nail, beds in dark
skin)
When pinched, skin When skin is When skin is

Skin NORMAL
springs back to pinched it goes pinched it goes
Turgor Inspection
previous state (is to previous state to previous state
elastic; may be immediately immediately
slower in older (3 seconds) (3 seconds)
adults)
Presence of
Skin Inspection Freckles, some Presence NORMAL
of birthmark in
Lesion birthmarks that have birthmark in thigh
not changed since thigh
childhood, and some .
long standing
vascular birthmarks,
such as strawberry or
port wine,
hemangiomas, some
flat and raised nevi
no abrasion or other
lesion.
Hair Inspection The hair is thick, No infestation No infestation NORMAL
silky, evenly observed. Hair observed. Hair
distributed and has is thick, is thick and
a variable amount straight and evenly
of body hair. There evenly distributed.
is no infestation distributed
observed.
Nails Inspection The nail has a light Smooth and Smooth and NORMAL
brown color and has intact has intact
has the shape of a epidermis. epidermis.
convex curve. It is short and clean short and clean
smooth and intact fingernails and fingernails and
with the epidermis. toenails. toenails.
When nails are Convex and Convex and
pressed between with good with good

the fingers (Blanch capillary refill capillary refill
Test), the nails time of 2 time of 2
return to usual seconds seconds
color in less than 4
seconds.
c. Cephalo – Caudal Assessment
Actual Findings
Normal Analysis /
Body Parts Techni Findings Initial Assessment Latest Nsg.
que Assessment Diagnosis
used
Head
Skull and Inspecti The head is Her skull is normocephalic Her skull is NORMAL
Face on and rounded; and symmetrical, normocephalic
Skull palpatio normocephalic No masses and tender felt and
n and upon palpation. symmetrical,
symmetrical. No masses and
There are no tender felt upon
nodules or palpation.
masses and
depressions
when palpated.
Symmetric Facial feature was normal, NORMAL

Facial feature
Facial inspecti
nasolabial folds, Without congenital. was normal,
on
features symmetric Without
facial features, congenital.
palpebral
fissures equal in
size
Symmetrical Symmetrical facial Symmetrical NORMAL

inspecti facial movement and non facial
Facial on movement and drooping movement and
Movements non drooping non drooping
And voluntary
facial
movement
Inspecti
Eyes and on and No tenderness
Vision when palpated NORMAL
palpatio Lacrimal gland No tenderness when

External n is normally non palpated
Eye palpable
Structures Hair is evenly
distributed.
Hair evenly
distributed with NORMAL
Inspecti Hair evenly distributed skin intact.
on Eyebrows are with skin intact. Eyebrows are
Eyebrows symmetrically Eyebrows are symmetrically
aligned and symmetrically aligned and aligned and
show equal have equal movement have equal
movement when movement
asked to raise
and lower
eyebrows. Equally
distributed and
Equally distributed and curled slightly NORMAL
Eyelashes Inspecti
on Eyelashes curled slightly outward outward
appeared to be
equally
distributed and
curled slightly
outward.
Skin intact with NORMAL
no discharges
Inspecti Skin intact with no and no
Eyelids There is no discharges and no discoloration
on and
presence of discoloration Lids close
palpatio
discharges, no Lids close symmetrically symmetrically
n
discoloration and blinks involuntary. and blinks
and lids lose Blinks 18 times per involuntary.
symmetrically minute. Blinks 18 times
with involuntary per minute.
blinks
approximately
15-20 times per
minute.
The patient NORMAL
conjunctiva is
Both are pinkish The patient conjunctiva is pinkish and has
Bulbar Inspecti to red in color, pinkish and has no ulcers no ulcers and
conjunctiv on no ulcers, with and has many min. has many min.
a presence of capillaries capillaries
many minutes
capillaries
The patient NORMAL

cornea is clear
Cornea. Inspecti Looks smooth, The patient cornea is clear and looks
on and the cornea is and looks smooth. No smooth. No
transparent irregularities observed. irregularities
there should be observed.
no irregularities
on the surface
Pupils are black
NORMAL
Pupils and equal in
size, dilate at
Inspecti Pupils are Pupils are black and equal far objects and
on PERRLA in size, dilate at far objects constrict when
and constrict when looking looking at
at nearby objects. nearby objects.
Moved toward the nose at Moved toward
four inches distance and the nose at four
using the penlight. inches distance
and using the
penlight.
The patient was

able to hold the NORMAL
position and no
When looking The patient was able to nystagmus was
CN 3 and straight ahead, hold the position and no observed.
CN4 Inspecti client can see nystagmus was observed.
on objects in the
periphery And
there should be
no nystagmus Patient could
see exactly NORMAL
what the
Patient could see exactly examiner
Accommodati Normally the what the examiner see at the exact
on client should see see at the exact same time. same time.
Inspecti
Visual Fields it the same time
on
[retina and the examiners
neuronal sees it.
visual
pathways to
the brain NORMAL
Client can read
snellen chart
Client can read snellen 30cm away
Second A client who chart 30cm away
(optic) can read the
largest letter on
cranial Inspecti NORMAL
the chart
nerve) on (20/200) The patient
auricles are
symmetrical,
The patient auricles are
and have the
The auricles are symmetrical, and have the same color with
Ears symmetrical and same color with her facial her facial skin,
Auricles have the same skin, and are firm. No and are firm No
Inspecti color as his tenderness felt when
tenderness felt
on and facial skin. The palpated.
when palpated.
palpatio auricles are Pinna recoil after it is being Pinna recoil
n aligned with the folded after it is being
outer canthus of folded
the eye. When
palpating for the
texture, the
auricles are
mobile, firm and No redness and NORMAL
not tender. no discharge
External Distal third No redness and no NORMAL

Ear contains hair discharge
Canal follicles
Inspecti
on semitransparen
t
Tympanic Pearly gray semitransparent
color,
Membran NORMAL
semitransparent.
e
Inspecti The patient
on Normally the identified the
Gross client can The patient identified the sound
Hearing identify the sound
Acuity sound and at
Test Inspecti what side it was
on heard
NORMAL
The patient
Nose nose is
Normally symmetrical
External The patient nose is
symmetrical, no symmetrical and no and no flaring,
Structure
masses, tender flaring, no masses, and no no masses, and
and no flaring no tenderness
Inspecti tenderness
on and NORMAL
palpatio
n The patient was
Patency able to breath
No difficulty in The patient was able to w/ out
breathing breath w/ out difficulties difficulties
Inspecti NORMAL
on
The patient
Nasal nasal mucosa is
Cavities No exudates and The patient nasal mucosa is pinkish to red
change in color pinkish to red in color and in color and no
no exudates
exudates
Inspecti NORMAL
on
Normally the The patient
septum Is in the septum is in the
Nasal midline and no The patient septum is in the midline and no
perforation midline and no perforation
Septum perforation
Inspecti NORMAL
on
Normally the The patient
sinuses Is no The patient frontal and frontal and
Facial Sinuses tender upon maxillary sinuses is no maxillary
palpation tender when palpated sinuses is no
tender when
palpated
Palpatio
n
The patient
The patient frontal and frontal and NORMAL
maxillary sinuses is no maxillary
Mouth With visible tender when palpated sinuses is no
margin tender when
Inner Lips symmetrical in palpated
and Inspecti appearance and
movement,
Bucccal on
pinkish in color
Mucosa
Slightly pale in Low level of
Slightly pale in color and color and moist Hemoglobin
moist ↓
Uniform pink Risk for
color and soft, anemia
Lips moist, smooth, ↓
glistening and
Inspecti Pale color of
elastic texture
on lips
The patient has
30 teeth
NORMAL
The patient has 30 teeth And no
And no dentures. dentures.
The patient has Gums color is pinkish and Gums color is
8 teeth in each no presence of lesions and pinkish and no
quadrant in both sores presence of
Teeth and mandibular and lesions and
Gums Inspecti maxillary sores
on and
palpatio
n
The patient has
The patient has no dentures no dentures NORMAL
NO
DENTURES
Dentures (if
applicable) Inspecti
on
Tongue is in central Tongue is in

position, pink but with central
whitish coating which is position, pink NORMAL
Tongue Pinkish with normal with veins but with
white taste buds prominent in the floor of whitish coating
Tongue on the surface, the mouth. which is
no lesions Tongue moves without normal with
movement
Inspecti noted, no difficulty veins
base of the prominent in
on varicosities on
tongue, ventral surface, the floor of the
the frenulum is thin mouth.
mouth attaches to the Tongue moves
floor, posterior 1/3 of without
and the the ventral difficulty
frenulum aspect of the
tongue. able to
move the tongue

freely and with
strength, surface
of the tongue is
rough The patient palates are pink
and smooth and her hard
palate has an irreg. texture. The patient
The smooth palates are pink
palates are light and smooth and NORMAL
pink and smooth her hard palate
while the hard has an irreg.
Palate palate has a texture.
Inspecti
more irregular
on
texture.
The patient uvula is in the
midline, pinkish in color,
no lesion upon inspection, The patient
moved upward and uvula is in the
Positioned in midline,
backward when asked to NORMAL
the midline, pinkish in
say “ah”
pinkish to red in color, no lesion
color, no upon
swelling or inspection,
Uvula Inspecti lesion noted, moved upward
on moves upward and backward
and backwards when asked to
when ask to say say “ah”
“ah”
Pink and no presence of

lesions
Pink and no NORMAL
Pink and presence of
smooth lesions
posterior wall Not inflamed, no presence
Inspecti of discharge and no
Oropharynx Not inflamed,
on swollen. And gag reflex
Pink color and no presence of NORMAL
smooth texture, discharge and
no discharge no swollen.
and normal size And gag reflex
Tonsils
Inspecti
on
Neck
Observe head Inspecti The neck Neck is palpated and Neck is

movement. on muscles are showed no tenderness andpalpated and NORMAL
And equal in size. flexes easily. No massesshowed no
palpatio The client is palpated. tenderness and
n showed Coordinated, smooth
flexes easily.
coordinated, movement with no
No masses
smooth, head discomfort. palpated.
movement with Coordinated,
no discomfort smooth
Inspecti Normally the The patient was able to movement with
Sternocleidom on client was follow all the commands no discomfort. NORMAL
astoid muscle fallow this and move without

Trapezius command: difficulties.
muscle. Move chin to The patient was
the able to follow
chest(sternoclei all the
domastoid), commands and
Move the head move without
so that the ear is difficulties.
moved toward
the shoulder on
each
side(sternocleid
omastoid),
Turn the head to
the right and to
the left
(sternocleidoma
stoid),
Move the head
back so that the
chin points
upward
(trapezius)
The patient
Inspecti Equals strength The patient Sternocleidoma
Muscle on on each side Sternocleidomastoid and stoid and
strength trapezius muscle is equals trapezius NORMAL
in strength. muscle is
equals in
strength.
May not be The patient

The patient lymph nodes
Lymph Nodes Inspecti palpable, maybe lymph nodes
is not palpable. Showed no
on normally is not palpable. NORMAL
signs of inflammation
And palpable in thin Showed no
palpatio clients, no signs of
n tender if inflammation
palpable,
slightly
movable
Trachea Inspecti Trachea is The patient trachea is in the The patient NORMAL
on palpable and is lined and straight trachea is in the
And in the lined and lined and
palpatio straight straight
n
Thyroid Inspecti Normally the The patient thyroid gland is The patient NORMAL
Gland on thyroid gland is non palpable when thyroid gland is
And non palpable, palpated, and no nodules. non palpable
palpatio Isthmus maybe when palpated,
n visible in a thin and no nodules.
neck, no
nodules are
palpable.
Upper
Extremities
Inspecti The skin is Skin is brown with dry Skin is brown NORMAL
Skin and nails on uniform in skin. And the nail is with dry skin.
And color, smooth and has intact And the nail is
palpatio unblemished epidermis. smooth and has
n and no presence short and clean fingernails intact
of any foul odor. and toe nails. epidermis.
Has a good skin Convex and with good short and clean
turgor and capillary refill time of 2 fingernails and
skin’s seconds toe nails.
temperature is Convex and
within normal. with good
The nails light capillary refill
brown color and time of 2
has the shape of seconds
convex curve. It
is smooth and
intact with the
epidermis.
When nails
pressed between
the fingers
(Blanch Test),
the nails return
to usual color in
less than 4
seconds
No deformities
There no No deformities or swelling or swelling, NORMAL
Bones presence of joint moves smoothly joints moves
Inspecti bone smoothly
on deformities,
And tenderness and
palpatio swelling.
n
The muscles are Equal size in both sides of Equal size in

Muscle not palpable NORMAL
Inspecti the body both sides of
strength and with the absence With limited movement the body
on of tremors. They
tone
And are normally
palpatio With limited
firm and
n No varicose movement
showed smooth,
And the tone there is the
coordinated
right amount of tension
movements.
inside the muscle at rest. No varicose
And the tone
And that the muscles And the tone
there is the right
inherently a to contract on there is the
amount of
command right amount of
tension inside
tension inside
the muscle at
the muscle at
rest. And that
rest. And that
the muscle is
the muscles
inherently a to
inherently a to
contract on
contract on
command
command
The client triceps smooth,

The client soft warm, dry. And good
Tricep Inspecti triceps smooth, poor skin turgor odor, The client NORMAL
on soft warm, dry. perspiration triceps smooth,
And good poor soft warm, dry.
And skin turgor odor, And good poor
palpatio perspiration skin turgor
n odor,
perspiration
The client bicep

Inspecti smooth, soft
on warm, dry. And The client bicep smooth,
Bicep good poor skin soft warm, dry. And good
turgor odor, poor skin turgor odor, The NORMAL
And client
palpatio perspiration perspiration bicep smooth,
n soft warm, dry.
And good poor
skin turgor
odor,
perspiration
Wrist is
symmetric The client’s wrists are
without redness symmetric without redness
Inspecti
Wrist and or swelling. or swelling. They are no The client’s NORMAL
on
finger They are no tender and free of nodules. wrists are
And
muscles tender and free And the fingers are symmetric
palpatio
of nodules. And symmetric, no tender and without redness
n
the fingers are without nodules. No or swelling.
symmetric, no swelling and deformities They are no
tender and tender and free
without of nodules. And
nodules. No the fingers are
swelling and symmetric, no
deformities tender and
without
nodules. No
swelling and
deformities
There were no
Inspecti swelling, No swelling, tenderness
on and tenderness and and joints moves smoothly
Joint palpatio joints moves No swelling, NORMAL
n smoothly tenderness and
joints moves
smoothly
The range of The client range of motion

motion are 160 are 160 degrees of flexion
Inspecti
degrees of 180 degrees of extension The client
Range of on NORMAL
flexion 180 90 degrees of pronation range of motion
motion degrees of and supination are 160 degrees
extension 90 of flexion 180
degrees of degrees of
pronation and extension 90
supination degrees of
pronation and
The patient brachial and supination
A normal pulse radial pulses is normal
Inspecti can be felt with pulse in each beat for 1
Brachial and on moderate minutes The patient
radial pulses And pressure and the brachial and
palpatio pressure is equal radial pulses NORMAL
n with each beat are normal
pulse in each
beat for 1
minute.
The client can The patient sensation is can

Inspecti identify light identify light and deep
Sensation on and deep touch, touch no tender
And no tender The patient NORMAL
palpatio sensation is can
n identify light
and deep touch
no tender
No tingling
numbers, The patient Phalen’s test
Inspecti burning or pain no tingling numbers,
on result in burning or pain result in The patient
Phalen’s test Phalen’s test Phalen’s test
NORMAL
And
Phalen’s Test palpatio no tingling
n numbers,
burning or pain
result in
No tingling or Phalen’s test
Inspecti shocking The patient Tinel’s test no
on sensation tingling or shocking
Tinel’s Sign experienced sensation experienced with The patient
with test for test for Tinel’s sign. Tinel’s test no
Tinel’s sign. tingling or NORMAL
shocking
sensation
experienced
Elbow flexes The patient deep tendon with test for
Inspecti and contraction reflexes absent or Tinel’s sign
on of the bicep hyperactive contraction of
Deep Tendon The patient
muscles is seen biceps
Reflexes or felt ranges 1 (0,4 +) deep tendon
+to 3 + reflexes absent NORMAL
or hyperactive
contraction of
The patient triceps absent biceps (0,4 +)
Elbow extends, or hyperactive elbow
triceps contracts extension (0,4 +)
Inspecti ranges from 1+ The patient
Tricep triceps absent NORMAL
on to 3+
or hyperactive
elbow
extension
(0,4 +)
Bicep muscles The patient biceps absent

is seen or felt or hyperactive contraction The patient NORMAL
Biceps ranges from of biceps biceps absent
Inspecti (0,4 +) or hyperactive
on 1 + to 3 + contraction of
biceps (0,4 +)
Forearm flexes The patient brachioradialis NORMAL

and supinates absent or hyperactive
ranges from 1 + flexion of elbow and The patient
Brachioradiali
Inspecti to 3 + forearm pronation brachioradialis
s
on (0,4 +) absent or
hyperactive
flexion of
elbow and
forearm
pronation
(0,4 +)
Chest
Posterior
Thorax
Respiratory Inspecti The 2 to 3 The The NORMAL

Excursion on inch symmetric patient posterior thorax 2 patient posteri
al thoracic exp to or thorax 2 to
ansion thumbs 3 inch symmetrical thora 3 inch symmet
move apart cic expansion thumbs rical thoracic e
equal distance move apart xpansion thum
in equal distance bs move apart
both direction equal distance
in
thorax for The patient

Bilateral The patient thorax for thorax for NORMAL
vocal
(tactile symmetry of vocal decreased or absence vocal
Inspecti vocal fremitus. fremitus associated with decreased or
fremitus) on Fremitus is pneumothorax. And absence
heard most increased fremitus fremitus
clearly at the associated with associated with
apex of the consolidated lung tissue as pneumothorax.
lungs in pneumonia And increased
fremitus
associated with
consolidated
lung tissue as
in pneumonia
Inspect
Respiratory ion and
Rate 23 breaths per min. 23 breaths per
min.
Palpati 15-21 breaths Abdominal

on per min Pain
↓
Breathlessnes
s
↓
Rapid RR
Anterior
Thorax
Inspecti The The patient symmetrical The
tactile on symmetrical expansion thumbs move patient symmet
fremitus expansion apart equal distance in rical expansion NORMAL
thumbs move both directions thumbs move
apart equal apart equal
distance in both distance in
directions. both directions
Heart Auscult S1 is louder no murmur sounds No murmur

ation than S2 sounds
Tricuspid NORMAL
area
Aortic area S2 is louder no murmur sounds No murmur

than S1 sounds
have a mild epigastric
Mild epigastric pain Have a mild
Epigastric
pain epigastric pain
area
Carotid Inspecti Symmetric The patient carotid arteries The patient NORMAL
Arteries on pulse volumes Thickening hard, carotid arteries
Full pulsations, Asymmetric volumes Thickening
thrusting hard,
quality Decreased pulsations Asymmetric
Quality remains Increased pulsations volumes
same when rigid, beaded, inelastic
client breaths, walls
turns, head, and Presence of bruit in one or Decreased
changes from both arteries. pulsations
sitting to supine Increased
position pulsations
Elastic arterial rigid, beaded
wall inelastic,
No sound heard Presence of
on auscultation bruit in one or
both arteries.
Jugular Veins Inspecti Veins not Veins not distended Veins not NORMAL
on visible distended
And indicating right
palpatio side of heart is
n functioning
normally.
Peripheral Inspecti Symmetric The patient peripheral The patient NORMAL
Pulses on pulse volume pulses symmetric volumes peripheral
full pulsation indicate impaired pulses
circulation symmetric
volumes
indicate
impaired
circulation
Peripheral Inspecti In dependent The patient peripheral The patient NORMAL

Veins on position veins not distended veins peripheral
presence of in the thigh and or lower veins not
distension and leg or on posterolateral distended veins
nodular bulges part of calf from knee to in the thigh and
at calves. When ankle or lower leg or
limbs elevated, on
veins collapse posterolateral
part of calf
from knee to
ankle
No swelling of
Symmetric in No swelling of one calf or one calf or leg NORMAL
size leg
NORMAL
No tenderness on No tenderness
Limbs not
palpation on palpation
tender
Capillary Inspecti Immediate Immediate return of Immediate NORMAL
Refill Test on return of color pink or usual color return of pink
or usual color
Breast
Size,symmetr Verbali Rounded shape Cup size:34A Cup size:34A Hormonal

y, contour or zed by slightly unequal -Increase size of the breast -Increase size change
shape the PT in size generally -The right breast is of the breast. ↓
symmetric & no tenderer than the left. -The right Breast
tenderness. breast is tenderness
tenderer than ↓
the left. increase in
sized
Verbali Presence of
Skin Skin uniform in Presence of striae (stretch striae (stretch
ze by Hormonal
the PT color (similar to mark) mark) changes
skin of ↓
abdomen if not
Increase size
tanned)
of breast
↓
Breast skin
stretches/
Thinning
↓
Striae (stretch
mark)
Verbali
Areola zed by Round or oval Round or oval
the PT and by laterally Round or oval and by and by laterally
the same colors laterally the same colors the same colors NORMAL
varies widely, varies widely, from dark varies widely,
from light pink color. from dark
to dark brown. color.
Verbali Round, everted

zed by Round, everted and equal in
Nipples size similar in
the PT and equal in Round, everted and equal NORMAL
size similar in in size similar in color, color, soft and
color, soft and soft and smooth, both smooth, both
smooth, both nipples point in same nipples point in
nipples point in direction. same direction.
same direction.
Abdomen
Skin Inspect The surface is Unblemished skin Presence of Abdominal
ion smooth and uniform color, silver- keloid in the surgery
even, with white striae or surgical abdomen due ↓
homogenous scars to surgery Midline
color. incision
↓
Rough and
uneven
abdominal
surface
Abdominal
movements
associated
with Symmetric
Rapid
respiration, Inspect movements
Limited movement due Marked respiration
ion caused by
peristalsis, or
to abdominal pain ↓
aortic respiration visible
peristalsis, Abdominal
pulsations. pain
together with
a distended ↓
abdomen , Asymmetric
indicates movement
intestinal
obstruction
No visible
Vascular vascular
pattern Inspect pattern
No visible venous No visible NORMAL
ion
pattern venous
pattern
Bowel sounds Audible bowel Hypoactive sounds

sounds indicate decreased Diminished
Auscul motility and are usually bowel sound Abdominal
tation associated with associated surgery
manipulation of the with ↓
bowel during surgery manipulation Decreased
of the bowel bowel
during motility
surgery ↓
Diminished
bowel sound
↓
Hypoactive
Vascular Absence of sound
sounds arterial bruits No arterial bruits
No arterial
Auscul bruits
tation NORMAL
Peritoneal
Friction Rubs Absence of No friction rub No friction
friction rub rub
Auscul NORMAL
tation
Not palpable
Urinary Distended and palpable Urethral
bladder as smooth, round, tense blockage Decreased
Palpati mass {indicates urinary associated urine output
on retention} with surgical ↓
swelling Urinary
Retention
↓
Insertion of
IFC
Musculoskeletal System
Muscles Inspecti Equal size of Symmetric size Symmetric size NORMAL
on both side of the
body
50% of normal Abdominal

Palpatio Equal strength 75% of normal strength, strength, but Pain
Muscle n on each body but there is weakness in need a support ↓
strength side lower extremities due to resistance due Lethargic
abdominal pain to her surgery ↓
Weakness of
some
extremities
Bones Inspecti No deformities No found bone misaligned No found bone NORMAL

on misaligned
Joints Palpatio No swelling, no No swollen joints and No swollen NORMAL

n tenderness or tenderness joints and
nodules tenderness
Female
Genitals and
Inguinal
Area
Pubic area Inspect Pubic skin Intact skin and no Intact skin NORMAL
ion intact, no presence of lesions and no
lesions presence of
lesions
Vulva slightly darker Vulva slightly

Skin of vulva than the rest of the body darker than NORMAL
area slightly the rest of the
darker than the body
rest of the
body
Labia are normally Labia are

Labia round, normally
symmetric, plump and NORMAL
full, and symmetric,
well formed. Also in
relatively plump and
dark pink and moist
symmetric in well formed.
adult females Also in dark
pink and
moist
clitoris,
Inspect Clitoris does Clitoris does
urethral Clitoris does not exceed NORMAL
ion not exceed not exceed
orifice, and 1cm in width and 2cm
1cm in width 1cm in width
vaginal in length
and 2cm in and 2cm in
orifice
length length
No Presence of vaginal
Increased growing size
inflammation, discharge
amount of of cyst
swelling or unusual ↓
discharge vaginal twisting
discharge, a and/or
brownish pressure in
vaginal ovary
discharge ↓
abdominal
pain
↓
vaginal
discharge
Palpati No No enlargement or No
on enlargement or tenderness enlargement
tenderness or tenderness NORMAL
Inguinal
lymph
nodes
Anus Inspecti Intact perianal No presence of fissures No presence of NORMAL
on skin. Anal skin fissures
is intact
Lower
Extremities
Inspecti Generally, No edema found on client No edema NORMAL

Skin and nails on and uniform except feet found on
palpatio in areas clients feet
n exposed to the
sun
Normal
No deformities, no No deformities,
Inspecti swelling, no swelling, no
Bones on and No deformities, no tenderness tenderness
palpatio no swelling, no
n tenderness
Able to resist
Inspecti Able to resist applied applied
Able to resist pressure symmetrically Normal
Muscle on and pressure
strength and palpatio applied pressure symmetrically
tone n symmetrically
Hip Muscles Inspecti Symmetric

on and Symmetric Symmetric muscle tone muscle tone Normal
palpatio muscle tone
n
Hip Equal strength on each Equal strength

Equal strength body side on each body Normal
Adduction
on each body side
side
Hip Equal strength

Equal strength Equal strength on each on each body Normal
Abduction on each body body side side
side
Equal strength Equal strength

on each body Equal strength on each on each body
Hamstring side body side side
Normal
Equal strength Equal strength on each Equal strength
on each body body side on each body
Quadriceps side side
Normal
No swelling
No swelling No tenderness
Equal strength No crepitation
Muscles of the No tenderness
on each body or nodules
ankles and feet No crepitation or nodules Normal
side
Equal strength
Equal strength
Equal strength on each on each body Normal
on each body
Joint body side. No swelling, no side. No
side
tenderness or nodules swelling, no
tenderness or
nodules
Light tickling
range of Equal strength or touch
Light tickling or touch
motion on each body sensation
sensation Normal
Popliteal, side. No
posterior tibial, swelling, no
and dorsalis tenderness or
pedis pulse nodules
Able to
Percuss Light tickling or discriminate
touch sensation Able to discriminate between
ion
Sensation between “sharp” and “sharp” and
“dull” Normal
“dull” sensations.
Able to sensations.
discriminate
between
“sharp” and
“dull”
sensations.
Grade 2+ Grade 2+ Grade 2+

Deep Tendon Grade 2+ Grade 2+ Grade 2+
Reflexes Normal
COURSE IN THE WARD

DATE MANAGEMENT INDICATION
Due to present condition
↓
● Please admit room of choice
under my service for observation, diagnosis and
treatment
Rights of patient when required for

medical care
↓
● Secure consent for ex-lap on Right for information and legal
June 11, 2020 (AM) purposes
↓
Secure Consent
Present Condition
↓
● Monitor v/s q shift and record Need for close observation and
frequent monitoring
Present Condition
↓
JUNE 11, 2021 Preparation for ex-lap
● NPO
↓
to prevent aspiration
recent condition
(Scheduled for ex-lap)
↓
Hypertonic solution
● IV Fluid D5NR for 10hrs
↓
Intravenous fluid and electrolyte
maintenance therapy
assess the patient’s general medical

condition
↓
● CP (cardiopulmonary) cleared optimize the patient’s state for the
procedure
↓
cleared patient for surgery
● Schedule for Ex-lap (11 am) Present condition(dermoid cyst)

↓
JUNE 11, 2021 Undergo Invasive procedure
(AM) ↓
To properly endorsed
● Dr. Lucas for Anesthesia Present condition(Dermoid Cyst)
↓
Undergo anesthesia
↓
Need specialized physician for
anesthesia care before surgery
● Profurex 1.5mg/ IV ANST 1 Present condition(Dermoid Cyst)

hour prior to OR.
↓
risk for infection
↓
prevention treatment before surgery
(prophylaxis)
↓
administer after negative skin test
status of patient after ex-lap
↓
reference for further assessment
● s/p explore-lap oophorectomy
↓
under spinal anesthesia
for diagnostic & therapeutic
procedure/treatment
Present Condition
↓
● to rr, O2 inhalation for 1 hour To maintain normal oxygen in blood
and increase perfusion in the body
increase pressure at the back (site of

anesthesia)
↓
to avoid complication to patient like
● flat on bed for 8 hours
ICP that can leads to seizure
↓
flat on bed for 8 hr
POST-
ANESTHESIA NPO
↓
s/p explore-lap oophorectomy
↓
Under anesthesia effect
↓
checking if the patient flatus
before introducing soft diet
● NPO then may have clear
↓
liquid, tea, crackers; 8 hours
post-op the soft diet once with working peristaltic movement
flatus
body has been weakened and finds it
difficult to digest solid foods
↓
Introduce liquids or soft foods
Present Condition
(explore-lap oophorectomy)
● IVF: D5NR 1L for 8hrs ↓

Administration of D5NR
↓
Hypertonic
↓
Used as an adjunct to restore a
decrease in circulatory volume in
patients with moderate blood loss
during surgery
class of medications called NSAIDs

↓
to relieve moderately severe pain after
● Keterolac 30mg/IV q8 ANST
surgery
↓
administer after negative skin test
management of pain as analgesic
↓
● Nubain 5mg/IV PRN for severe
to supplement to balanced anesthesia
pain
for postoperative anesthesia
↓
given if needed
Present Condition
(post-anesthesia)
↓
to assess the pain present
● Monitor vs q1 till stable q4 ↓
Need for close observation and
frequent monitoring
↓
until stable
Present Condition
↓
Abdominal Pain
↓
● Moderate to high backrest Prevent dull ache in the lower back
and thighs
↓
Relaxes abdominal muscles
(JUNE 12,
Present Condition
2021)
(dermoid cyst)
↓
Abdominal Pain
● Mefenamic acid 500 mg q 8hrs ↓
Nonsteroidal anti-inflammatory drugs
↓
to relieve pain (prophylaxis)
● Diet as tolerated
(3:30AM) diet as tolerated
↓
to further monitor the peristaltic
movement of the patient
Present condition
(dermoid cyst)
↓
● IV as to consume Fluid support for the patient
↓
as to consume
Present condition
(dermoid cyst)
↓
Checking of Urine output
● Remove IFC now
↓
monitor the output of the patient after
surgery
Present condition
(Dermoid cyst)
↓
● Check voiding 6hrs after refer if monitor the output of the patient after
unable to void surgery
↓
peristaltic movement checking
Present condition
↓
to stimulate bowel muscles
● Insert Dulcolax suppository
↓
after removal of IFC
to soften the stool and make it pass
through more quickly
D receptor antagonist
2
↓
acts on GI tract
● Domperidone 10 mg q 8hrs
↓
antiemetic
Present condition
↓
Antibiotic
● Cefuroxime 500 mg q 8hrs
↓
treat bacterial infections
Present condition
↓
stimulates circulation
● Encourage ambulation ↓
promotes blood flow of oxygen
throughout the body
↓
stop the development of blood clots

↓
Quicker wound healing
● Refer Present condition

↓
Need close observation
↓
Continuity of care
↓
Refer accordingly
LABORATORY
DATE LABORATORY ACTUAL NORMAL ANALYSIS

RESULT RESULT
06-08-2020 Blood Urea Nitrogen 2.54 mmol/L 2.5-7 mmol/L NORMAL
Creatinine 55 umol/L 62-106 umol/L NORMAL
Fasting Blood Sugar 95.8 mg/dL 65-105 mg/Dl NORMAL
Serum Sodium 139.4 mEq/L 135-145 mEq/L NORMAL
Serum Potassium 3.96 mmol/L 3.5-5.1 mmol/L NORMAL
HBsAg 0.09 1.00 NORMAL
WBC Count 6.62 x109/L 4.00-10.00 x109/L NORMAL

Hematocrit 0.50 0.37-0.54 NORMAL
Hemoglobin 152 g/L 110-150 g/L PCOS
↓
↑ testosterone
and androgen
↓
↑RBC
↓
Increase in
hemoglobin
↓
Risk for clotting
DIFFERENTIAL
COUNT
Segmenters 0.58 0.500-0.700 NORMAL
Lymphocytes 0.33 0.200-0.400 NORMAL
Monocytes 0.06 0.030-0.120 NORMAL
Eosinophils 0.03 0.005-0.050 NORMAL
Basophils 0.00 0.000-0.010 NORMAL
Platelet Count 364 x109/L 150-450 x109/L NORMAL

Prothrombin Time 12.0 seconds 10-14 seconds NORMAL
(PT)
INR 0.92 Below 1.1 is NORMAL
normal
Percent Activity 110% NORMAL
Control Value 12.8 seconds NORMAL
Activated Partial 24.0 seconds 23-33 seconds NORMAL
Thromboplastin Time
(APTT)
Control Value 27.0 seconds NORMAL
DRUG STUDY
DRUG NAME INDICAITION MECHANISM OF ADVERSE EFFECTS NSG.

ACTION INTERVENTION
GENERIC NAME: Used to treat DOMPERIDONE - Dry mouth
DOMPERIDONE stomach pain ↓ - Abdominal INDEPENDENT
D2 RECEPTOR cramps NURSING
BRAND NAME: ANTAGONIST - Diarrhea INTERVENTION:
MOTILIUM ↓ - Drowsiness
RELIEVE - Headache - Double check
DRUG STOMACH PAIN the dosage if it
CLASSIFICATION: is accurate
D2 RECEPTOR before
ANTAGONIST administering
drugs
AVAILABLE DOSAGE:
- Monitor for pt
10mg q 8hrs body response
after
administration
- Monitor the
patient
condition if
adverse effects
appears
DEPENDENT
NURSING
INTERVENTION:
- Inform the
Doctor when
adverse effects
worsen or
become
bothersome
GENERIC NAME: Given as CEFUROXIME - Severe stomach

CEFUROXIME antimicrobial ↓ pain INDEPENDENT
prophylaxis ANTIBIOTIC - Nausea NURSING
BRAND NAME: ↓ - Diarrhea INTERVENTION:
ZINACEF TREAT & - Vomiting
PREVENT ● Double check
DRUG BACTERIAL the dosage
CLASSIFICATION: INFECTION before
ANTIBIOTIC administering
● Monitor for pt
DOSAGE: body response
after
500 mg q administration
● Monitor the
FREQUENCY: patient
condition if
Every 8hrs adverse effects

appears
DEPENDENT
NURSING
INTERVENTION:
- If any of the side

effects persist or
worsen, notify the
Doctor.
HEALTH
TEACHING:
- Teach the pt how to

avoid infection
Educate the pt about the

importance of proper
hygiene
GENERIC NAME: INSERT - Severe stomach INDEPENDENT

BISACODYL Used as stool softener DULCOLAX pain NURSING
SUPPOSITORY - Nausea INTERVENTION:
BRAND NAME: ↓ - Diarrhea
DULCOLAX STIMULATE - Vomiting - Monitor fluid
BOWEL MUSCLES - Burning feeling intake and output
DRUG WHILE in rectal area - Assess the
CLASSIFICATION: ACCUMULATING frequency of bowel
STIMULANT LAXATIVE WATER IN THE movements and stool
INTESTINE characteristic
DOSAGE: ↓ DEPENDENT
NURSING
SUPPOSITORY TO SOFTEN THE INTERVENTION:
STOOL AND - If the pt is still
MAKE IT PASS constipated for 3 days
THROUGH or more after using
QUICKLY bisacodyl notify the
Doctor
HEALTH
TEACHING:
- Advise the pt to
expect that
suppositories produces
bowel movements in
15 mins to 1 hour
- Advise the pt
that don’t hesitate to
inform their physician

or nurse if they feel
uncomfortable
GENERIC NAME: Used to relief pain Mefenamic Acid CNS: Drowsiness, INDEPENDENT
Mefenamic Acid ↓ insomnia, dizziness, NURSING
Prevent abdominal nervousness, confusion, INTERVENTION:
BRAND NAME: cramps headache. -Assess patients who
(ponstan, pontel) ↓ GI: Severe diarrhea, develop severe diarrhea
ulceration, and and vomiting for
DRUG to relieve moderate bleeding; nausea, dehydration and
CLASSIFICATION to severe pain vomiting ,abdominal electrolyte imbalance
ANALGESIC cramps
DEPENDENT
AVAILABLE DOSAGE: NURSING
500mg INTERVENTION:
Q8
- Monitor for patient
body response after
administration
HEALTH
TEACHING:
-Provide the client an
information why she
needs to take this
medications
GENERIC NAME: For severe NUBAIN * CNS: Sedation, INDEPENDENT

(NUBAIN) pain ↓ dizziness, vertigo, NURSING
ANALGESIC headache, INTERVENTION:
BRAND NAME: ↓ *CV: tachycardia
Nalbuphine
Hydrochloride TO RELIEVE ● Watch for
SEVERE TO allergic
MODERATE PAIN response in
DRUG persons with
CLASSIFICATION: sulfite
ANALGESIC sensitivity.
● Administer with
AVAILABLE DOSAGE: caution to
5mg patients with
Q6 hepatic or renal
impairment.
● Monitor
ambulatory
patients;
nalbuphine may
produce
drowsiness.
DEPENDENT
NURSING
INTERVENTION:
- Monitor for patient

body response after
administration
HEALTH
TEACHING:
-You should know that
nalbuphine may make
you drowsy. Do not
drive a car or walk
around until you know
how this medication
affects you.
GENERIC NAME: used for pain KETOROLAC CNS: Drowsiness, dizzi INDEPENDENT
I ness, headache. NURSING
KETOROLAC Reducing pain helps GI: Nausea, dyspepsia, INTERVENTION:
BRAND NAME: you recover more GI pain,
(Toradol) comfortably Other: Edema, ● Correct
I sweating, pain at hypovolemia
DRUG treat moderately injection site. prior to
CLASSIFICATION: severe pain and administration
ANALGESIC inflammation of ketorolac.
● Lab tests:
AVAILABLE DOSAGE: Periodic serum
30mg electrolytes and
Q8 liver functions;
urinalysis (for
hematuria and
proteinuria)
with long-term
use.
● Monitor for
S&S of GI
distress or
bleeding
including
nausea, GI pain,
diarrhea,
melena, or
hematemesis.
GI ulceration
with perforation
can occur
anytime during
treatment.
DEPENDENT
NURSING
INTERVENTION:
● Arrange for a
skin sensitivity
test before
administration
of medication, if
expected
response seen
● Monitor for
patient body
response after
administration
HEALTH
TEACHING:
● Explained the
side effects of
this medication.
●
DISCHARGE PLANNING
CATEGORY DISCHARGE PLAN

M- Medication ✔ Cefuroxime 500mg (currently taking) 1 tab 3x a day for 7 days
HEALTH TEACHING:
o Tell the patient to take the drug as prescribed, even if he
feels better.
o Instruct the client to give the medication with food
o Instruct the patient to notify prescriber about rash, loose
stools, diarrhea, or evidence of superinfection
✔ Ponstan SF 500mg (currently taking) 1 tab 3x a day for 7 days

HEALTH TEACHING:
o Discontinue drug promptly if diarrhea, dark stools,
hematemesis, ecchymoses, epistaxis, or rash occur and do
not use again. Contact physician.
o Notify physicians if persistent GI discomfort, sore throat,
fever, or malaise occur.
o Do not drive or engage in potentially hazardous activities

until response to drugs is known. It may cause dizziness and
drowsiness.
o Monitor blood glucose for loss of glycemic control if
diabetic.
o Do not breast feed while taking this drug without consulting
a physician.
E- Exercise ✔ You will need to limit physical activities such as driving and heavy
lifting for 2-6 weeks,
✔ Encourage deep breathing exercise.
✔ Educate client on proper body mechanism to prevent muscle strain
and enable client to relax
✔ Although walking may be painful at first, it can help prevent the
formation of blood clots in the legs, strengthen the abdominal
muscles, and get your digestive system working again
T- Treatment ✔ Keep your incision clean and dry.
✔ If you have a dressing over your incision, change it as you were told.
Replace the dressing if it becomes wet or dirty.
✔ Don’t sit in a bathtub, pool, or hot tub until your incision is closed
✔ When coughing or sneezing, hold a pillow firmly against your
incision with both hands. Doing this helps protect your incision and
decreases belly discomfort.
✔ Avoid picking, scratching, or pulling at your incision.
✔ Don’t use oils, or creams on your incision. Ask your healthcare
provider before using lotions on your incision.
H- Health teaching ✔ It's important to avoid lifting while you are recovering so that you
can heal.
✔ Don't put anything in your vagina until your doctor says it's OK.
✔ Eat a healthy, well-balanced diet.
✔ Avoid constipation.
✔ Avoid standing for a long period.
✔ Check your temperature each day for 1 week after your surgery.
✔ Make sure to go to follow up treatments
✔ Take antibiotics as directed
✔ Shower as needed. Wash your incision gently with mild soap and
warm water.
✔ Wipe from front to back when going to the washroom
O- OPD follow-up ✔ Follow up on Thursday 1-3pm icmc June 12
D- Diet ✔ Eat vegetable and fruits rich in vitamin C such as spinach
strawberries and orange. Choose whole grains food and consume
more protein food such as egg, lean meat, seafood and dairy. For
fast wound healing.
✔ After surgery it is acceptable to eat normal diet. Bland, low fat foods
like rice, broiled chicken, toast and yogurt are suggested foods if the
stomach is upset. Drinking plenty of fluids is recommended unless
the doctor tells not to
NURSING CARE PLAN
Cues Nursing Analysis Planning Nursing Rationale Evaluation

Diagnosis Interventions
Subjective: Risk for explore lap STG: **Independent Goal met as

“kakaopera ko infection oophorectomy After 4 hours Nursing evidenced by
lang kaninang related to ↓ of nursing Intervention client showing
umaga as surgical Breaking in the intervention -Monitor vital -For baseline no
verbalized by incision as continuity of the client will sign data manifestation of
the patient” evidenced the skin be able to sign and
by: ↓ identify ways -Provide clean -To reduce the symptoms of
Objective: improper Exposure of the to reduce risk and well- risk of infection infection.
hygiene wound to for infection as ventilated
environment evidenced by environment
Improper ↓ the client
hygiene participation -Emphasize the -Its serve as the
exposure of
on therapeutic importance of first line
wound to
Swelling regimen proper hygiene defense against
bacteria
infection
↓ LTG:
Inflammation
process After 12 hours -Maintain strict -Aseptic
triggered of nursing asepsis for techniques
↓ intervention dressing changes reduce the
Improper the client will and wound care chances of
hygiene be free from transmitting/
↓ the risk as spreading of
Risk for evidenced by bacteria in
infection no wound
manifestation
of signs and
symptoms of -Monitor
infection. medication -To determine
regimen the
effectiveness of
therapy
-Discuss the -Inappropriate

importance of use can lead to
proper taking of development of
antibiotic drug resistance
and secondary
infection.
- Encourage
intake of protein- -Proper
rich food and nutrition places
vitamin A and C a part in
supporting the
immune
systems’
responsiveness.
**Dependent
Nursing
Intervention
-administered
cefuroxime as
doctor order
- to prevent
growth of
bacteria.
Cues Nursing Analysis Planning Nursing Rationale Evaluation

Diagnosis Interventions
Subjective: Risk for explore lap STG: **Independent Goal met as
“kakaopera bleeding oophorectomy After 6 hrs. of Nursing evidenced by
ko palang as related to ↓ Nursing Intervention absence of
verbalized by thinning of Removal ovary Intervention, spotting .
the patient “ endometrium ↓ the client will -monitor vital - for wide
secondary low Reduce be able to signs assessment
estrogen production of identify
Objective: hormone as estrogen individual -assess skin -to indicate blood
evidenced by hormone risks as color loss
Spotting spotting. ↓ evidenced by
engaging in -encourage to -to prevent
affect the
Weakness appropriate take a rest bleeding
stimulation of
behaviors or
endometrium
lifestyle - Encourage
↓ changes to intake of protein- - to help increase
Thinning of prevent rich food the estrogen
endometrium bleeding level.
↓ LTG: -Provide
Spotting opportunity to - Enhances
↓ After 12hrs of practice deep- learning and
NSG breathing, and continuation of
Risk for intervention muscular activity
bleeding the patient exercises. postoperatively.
will be free
from the risk
of bleeding as
evidenced by **Dependent
absence of Nursing
spotting Intervention
-administered
mefenamic acid -to treat moderate
to severe pain
and prevent
bleeding.
Nursing Analysis Planning Nursing Rationale Evaluation

Cues Diagnosis Interventions
Subjective: Acute pain STG: **Independent Goal met as
“sobrang related to explore lap After 4hrs of Nursing evidenced by
masakit po invasive oophorectomy NSG Intervention the patient
yung tiyan procedure intervention verbalizing
ko” as secondary to ↓ the patient relief of pain
verbalized by removal of will -monitor vital - to check if
the patient dermoid cyst Breaking in the experience signs there’s alteration
as evidence by continuity of gradual
Objective: pain of 8/10, reduction of
the skin
Restlessness facial grimace pain as -to know the
Facial and evidenced by -perform pain severity of pain
grimace restlessness ↓ absence of assessment
Pain: 8/10 restlessness
Guarding Inflammation and pain of
behavior process 8/10 to 5/10 -determine client -to know if the
triggered acceptable level client is
of pain and pain cooperating in
↓ LTG: control therapeutic
management.
After 12hrs of
Nerve ending
NSG
compression intervention
the patient -provide noise
↓ will manifest free environment -for relaxation of
relief of pain and proper the patient
Acute Pain as evidenced ventilation
by absence of -it provides
facial grimace -instruct calming effects to
and sense of breathing reduce stress and
comfort. exercise relieves muscle
tension
-Encourage
patient to do
diversional -to divert
activities (tv/ attention from
radio and pain.
socialization)
-position the -to facilitates the

patient into semi relaxing of
fowler’s position tension of the
abdominal
muscles,
allowing for
improved
breathing and
-provide hot or
warm compress.
-to reduce pain
reflex and
improve blood
**Dependent flow.
Nursing
Intervention
- administer
nubain as
doctors order.
- to treat pain

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ASIA PACIFIC COLLEGE OF ADVANCED STUDIES

A.H. Banzon St., Ibayo, Balanga City, Bataan

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

CHIEF COMPLAINT: Abdominal Pain For A Few Days

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

A. History of Present Illness

While patient is cooking

B. Past Health History

● Childhood Illness: Chickenpox, Amoebiasis, Fever.

C. Present Health History

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

ACTIVITIES OF DAILY LIVING

ADL Before Hospitalization Analysis During Analysis Nursing

Elimination DEFECATION Abdominal Subjective Data: Present

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

Exercise Subjective Data: Physical “Nung pagkatapos Bed rest Activity

Substance use Subjective Data: Presence of Subjective Data: Hospitalizatio Readiness to

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

nakaka 4-5 ng stick ng diminished ● IV Fluid Administered related to ability

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

yung paghihiwalay namin improves kaya sobrang

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

nakakaramdam ako ng her relationship with

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

ako naniniwala sa mga faith healers or understand the taught to her

Significant “Sa mga kaibigan ko The patient Barker’s Tidal Ability to

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

Recreational “Dati, ang libangan ko The patient Kurt Lewin’s Present

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

Environment “yung lugar naman ng The client has a Environmental Enough

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

Normal Actual Findings Analysis

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

psychomotor Words unclear,

b. RR 12-20 bpm 23 bpm 23 bpm Abdominal Pain

c. BP 120/80 mmHg 110/80mmHg 110/80mmHg NORMAL

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

Uniformity Inspection Generally uniform Uniform color of Uniform color of NORMAL

When pinched, skin When skin is When skin is

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

pressed between with good with good

c. Cephalo – Caudal Assessment

Symmetric Facial feature was normal, NORMAL

Symmetrical Symmetrical facial Symmetrical NORMAL

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

palpatio Lacrimal gland No tenderness when

The patient NORMAL

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

The patient was

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES