N ewE r Univeit

a rs y
No. 9 Central Avenue, New Era, Quezon City 1107, Philippines
College of Nursing
Second Semester A.Y. 2020-2021

CASE PRESENTATION:

Headache

A Compilation Presented to the College of Nursing

By:

Allyza Trixia Joyce V. Villasoto

BACHELOR OF SCIENCE IN NURSING BATCH 2021

Submitted by: Allyza Trixia Joyce V. Villasoto

Submitted to: Dr. Lambert F. Valera, Jr.

Date: July 05, 2021

I. INTRODUCTION
This is the case of a Filipino male, 23 years old, who lives in San Iledfonso,
Bulacan together with his family. He was complaining about his headache that he was
started experiencing suddenly since last week of June. During the interview, the client
was cooperative and attentive answering all of the questions asked. The client was all
over fine despite of his headache. Moreover, the client’s nutritional status is normal.
A. BACKGROUND OF THE STUDY
Headache is one of the most common illness experienced by humans. In
which, 95% of the general population of the world have experienced headache at
some stages in their life (Stovner L, Hagen K, Jensen R, et. al. 2007). This condition
does not select its particular host, everyone in this world can be affected by it whether
children or adult even people in different races. It is included in top 10 list of the World
Health Organization as one of the usual effects of other health conditions such as
depression, dengue, hypertension, fever, and so on (WHO, 2001).
Headache occurs in many reasons, in particular, if a person is dehydrated,
experiencing too much stress from work or school, lack of sleep, head injury, effects
of medications, brain freeze, dental or sinus issues, and many others that’s when
headache is likely to take place (Mayo Clinic, 2019). However, headache can be
classified into two which is primary and secondary (Cecilia Y, 2012). Primary
headaches are mild headaches that people usually experience such as migraines and
tension-type of headaches (Clinch C, et. al. 2011). While secondary headaches are
more severe since it is caused by various diseases like infections, head injury, brain
bleed, vascular disorders, and tumors (Goadsby PH, et. al. 2012).
B. OBJECTIVES General
To provide appropriate nursing care to male adult whose experiencing
headache by teaching him, to enhance his knowledge regarding his condition for the
possible interventions that he can apply to improve his health.
Specific:
Knowledge:
a. Identify interventions that can be done in their home to treat his headache, changes
in his body, and how changes affect his health.
b. Classify and differentiate medications given to male client including their effects.
Skills:
c. Develop skills for the client with headache while going through clinical
manifestations.
d. Perform interventions that is appropriate and related to the condition of the male
client.

Attitude:
e. Develop empathy to the client as well as understanding what he’s going through
due to the pain he was experiencing.
f. Develop inquisitive attitude regarding to the state of the client to gather information
along with having an idea in promoting health.
 C. SCOPE AND LIMITATIONS
Headache has two classifications, which is the primary and secondary
headaches. Most common headaches experienced by most of the people is included
in primary headaches. This are the mild headaches such as migraines and
tensiontype headaches. However, the client stated that his headache suddenly
appeared during the day. Data was gathered by observing the client, personal
interview, and by performing physical assessment of the patient.

I. BIOGRAPHIC DATA Name: V.V.V.

Birthday: December 20, 1995
Age: 21 years old
Marital Status: Single

Occupation: Student

Religion: Iglesia Ni Cristo

Address: 172 Pulong Tamo, San Ildefonso, Bulacan
Healthcare Financing and usual source of Medical Care: PhilHealth

II. CHIEF COMPLAINT

The client stated that he was experiencing suddenly occurrence of
headache since last week of June.

III. Nursing Health History

A. History of Present Illness

The client was experiencing pain at the top of his head since last week of June .
The client has recently experiencing headache that appears suddenly. He rated the
pain as 5/10 based on the pain rating scale. For him to ease the pain he was
experiencing, he was taking up pain killers together with getting enough rest.
B. Past History
The client has been admitted to Señor Sto, Niño Hospital before, due to the
allergic reaction he experienced from an insect bite after his mother washed it with
water that lead to a large open wound and later on had undergone surgery to remove
the tumor. Other than that, there is no cases that the client has been admitted nor
admitted or go
going through clinical manifestations in relation to headache.
C. FAMILY HISTORY OF ILLNESS
The common illness or disease within the family is high blood and diabetes. There is
one member in the family that has an illness. His father, age 47, has been recently quit
smoking. His mother, age 46, has currently having a thyroid cyst. He is the eldest among
his 2 siblings that is currently alive and healthy.

LEGEND:

= Male
D: Prostate D: Dog Rabies
Cancer
=Female

=Deceased
Thyroid Cyst
= Client

D: = Cause of Death
A+W = Alive and Well

A+W A+W

IV. GORDON’S FUNCTIONAL HEALTH PATTERN

1. Health Perception and Health Management Pattern

The client is cooperative in the whole interview and was able to answer all of
the questions attentively. During the interview, the client is comfortable together with
being able to coordinate despite of the pain he was experiencing. The client doesn’t
have any vices as well as he is having a right diet. He also stated that he is taking
pain killers along with getting enough rest to ease the pain he was experiencing.
Interpretation: The client values his health by keeping himself to be in a good health
as he stated that he don’t have any vices as well as having a right diet. He also have
a few knowledge on how to relieve the pain from his left knee temporarily by taking
up pain killers and getting enough rest.
Analysis: Pain control is important in the management of patients because untreated
pain has a detrimental impact on the patient's quality of life. (Bartoszczyk DA,
Gilbertson-White S. Interventions for nurse-related barriers in cancer pain
management. Oncol Nurs Forum. 2015;42:634–41.)
 2. Nutrition and Metabolic Pattern
The client has a good appetite in which he eats three times a day with a meal
containing rice with vegetables together with fish, pork, or chicken. He also drinks a
lot of water for about 2 liters a day. The client’s height is 5’7 and has a maintaining
weight of 55 kg and his computed BMI is 19.0 which is considered as normal.

Interpretation: The client has a normal weight since he’s eating in a right time and
also for having a control and discipline on what he eats for a day to maintain his
weight.
Analysis: A healthy diet is essential for good health and nutrition. It protects you
against many chronic noncommunicable diseases, such as heart disease, diabetes
and cancer. Eating a variety of foods and consuming less salt, sugars and saturated
and industrially-produced trans- fats, are essential for healthy diet. (World Health
Organization, 2021)
3. Elimination Pattern
The client is able to eliminate regularly which is at least once a day without
feeling of discomfort. He describes his stool as formed and brown in color. The client
urinates more than 6 times a day and describe it as odorless and clear to yellow in
color.

Interpretation: The client doesn’t have any problem with his elimination process.
Analysis: Maintaining good colon health is easy, and important, because not only
can it help you avoid preventable colon issues, but the things that are good for your
colon are also good for your heart, brain, kidneys, liver, skin, hair, and overall
wellbeing. (Holt, J. (2016, March 24). Potty Talk: What is a Normal Bowel Movement –
And Why Is This Important For Your
Health?.https://intermountainhealthcare.org/blogs/topics/live-
well/2016/03/normalbowel- movement-why-it-is-important-for-your-health/)
4. Activity-Exercise Pattern
The client has the energy to complete his daily tasks such as doing the house
chores together with doing his school activities and resting right after. The client is
also performing his daily exercises in the morning. His spare time was to play online
games and watching movies.
Interpretation: The client is productive since he is able to perform multiple tasks.
Analysis: Promotion of physical activity and healthy nutritional behavior at the
workplace could be an integrated initiative that improves worker health and enhances
business performance. ( Grimani, A., Aboagye, E. & Kwak, L. (2019). The effectiveness
of workplace nutrition and physical activity interventions in improving productivity, work
performance and workability: a systematic review.
https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-
80331#citeas)
Assessing for Self-care Deficit

BARTHEL INDEX OF ACTIVITIES OF DAILY LIVING

Score
ASSESSMENT CRITERIA :
 0 = incontinent (or needs to be
given enemata)
Bowels 2
1 = occasional accident

(once/week)2 = continent

2= continent
0 = incontinent, or catheterized
and unable to manage
Bladder 1 = occasional accident (max. 2
onceper 24 hours)
2 = continent (for over 7 days)

0 = needs help with personal care

Grooming 1 = independent 1
face/hair/teeth/shaving
(implementsprovided)

0 = dependent

1 = needs some help, but can do

Toilet Use something alone 2

2 = independent (on and off,

dressing, wiping)

0 = unable

1 = needs help cutting, spreading

Feeding butter, etc. 2

2 = independent (food provided

within reach)

0 = unable – no sitting balance

Transfer 3
1 = major help (one or two
people, physical), can sit

2 = minor help (verbal or physical)

3 = independent
3 = Independent
0 = immobile

1 = wheelchair independent,
including corners, etc.
Mobility 3
2 = walks with help of one person
(verbal or physical)

3 = independent (but may use

anyaid, e.g., stick)
 0 = dependent

1 = needs help, but can do about

Dressing 2
half unaided
2 = independent (including
buttons,zips, laces, etc.)
0 = unable

1 = needs help (verbal, physical,

Stairs 2
carrying aid)
2 = independent up and down
0 = dependent

Bathing 1 = independent (or in shower) 1

TOTAL: 20

Interpretation: The client scored a total of 20 out of a maximum of 20 points.

Analysis: A score of 20 shows the maximum amount for independence. As the score
gets lower, the level to participate dissipates and a disability becomes clearer. A score of
18 shows independence towards care for one’s self. (Ian Mcdowell, Measuring
Health: A Guide to Rating Scales and Questionnaires, 3rd Edition, Page 67)
5. Sleep-Rest Pattern
The client sleeps for about 7 to 8 hours without interruption. He is also taking a
nap in the afternoon sometimes for 1 to 2 hours. The client does not have any problem
with his sleep- rest pattern as well as not taking medications such as sleeping pills.
Interpretation: The client was not experiencing any difficulties with his sleep and rest
pattern.
Analysis: Research shows that most people need at least 7 to 8 hours of sleep to
function optimally. Sleeping less and being awake for several hours during the day is
not a testament to your physical strength and endurance but a silent indication that
your health is deteriorating. (Kokilaben Dhirubhai Ambani Hospital, 2015)
6. Cognitive-Perceptual Pattern
The client has a blurry vision and is nearsighted. He is wearing eyeglasses with
400/465 grade. The client was able to hear clearly and doesn’t have any problem with
it along with his memory. He learns the best in both listening to his professor and
reading about the subject.
Interpretation: The client was able to answer all of the questions asked. The client is
nearsighted and wearing eyeglasses for better vision.
Analysis: Glasses or contact lenses correct vision because they allow the eye to
focus light in the right spot on the retina — the spot that produces the clearest image.
Because everyone's eyes are different, a pair of glasses that makes one person see
wonderfully may look terribly blurry to someone else. (The Nemours Foundation,
2017)
7. Self-Perception and Self-Control Pattern
The client views his self as a body conscious person and is having a lack of
confidence due to his physical appearance but this feeling doesn’t affect his
relationship with others. The client is happy with his height and weight.
Analysis: Low self-esteem can lead to depression. A negative mindset undermines
your success and also your relationships as you don't show up as the best version
of yourself. In some cases, you may not even know what that best self looks like.
(Marcus, B. (2017, October 17). How Does A Lack Of Confidence
Affect Your Life And Career?.
https://www.forbes.com/sites/bonniemarcus/2017/10/17/how-does-a-lack-
ofconfidence- affect-your-life-and-career/?sh=2b3986401ac4)
8. Role-Relationship Pattern
The client is living with his family and stated that they are having a happy family
since they get along very well. All of the problems they encountered are usually
handled by talking to each other, for them to find for a solution. The client’s friends
are also there for him every time he needs them.
Interpretation: The client has a good relationship with his family together with his
friends.
Analysis: A family's social support is one of the main ways that family positively
impacts health. Social relationships, such as those found in close families, have been
demonstrated to decrease the likelihood of the onset of chronic disease, disability,
mental illness, and death. (George, L. K., & Durham, N. C. (2016). The health-
promoting effects of social bonds.)
9. Sexuality-Reproductive Pattern
The client doesn’t have any problem regarding to his sexual-reproductive
relations.
Interpretation: The client is okay with his sexual and reproductive relations and
doesn’t have encountered any problems with it.
Analysis: Male reproductive health challenges are a range of disorders that affect
the male reproductive system. These include penile disorders, erectile dysfunction,
balanitis (swelling of the foreskin or penis), prostate cancer, genital ulcers, testicular
disorders, low sperm count, painful or premature ejaculation, loss of libido, urethral
discharge, and sexually transmitted infections. ( Amoo, E.O., Omideyi, A.K.,
Fadayomi, T.O. et al. Male reproductive health challenges: appraisal of wives coping
strategies. Reprod Health 14, 90 (2017). https://doi.org/10.1186/s12978-0170341-2)
10. Coping-stress Tolerance Pattern
The client is able to cope up with the stress he is experiencing by letting out all
of his feelings through crying. The client sometimes talk to his family when he has a
problem and come up with a solution. But most of the time he is expressing his true
feelings towards his friends as he is comfortable with them.
Interpretation: The client has his own way of coping his stress but also comfortable
with his family and friends when it comes into this kind of situations. He feels relieved
every time his loved ones is there for him.
Analysis: Those receiving support from their family members may feel a greater
sense of self- worth, and this enhanced self-esteem may be a psychological resource,
encouraging optimism, positive affect, and better mental health. (Symister P., &
Friend R (2003). The influence of social support and problematic support on optimism
and depression in chronic illness: A prospective study evaluating selfesteem as a
mediator. Health Psychology, 22, 123–129.)
11. Value-Belief Pattern
The client respect and values his beliefs. His religion is one of the important in
his life other than his family.
Interpretation: The client follows his beliefs and gives high importance to his religion.
Analysis: Most studies have shown that religious involvement and spirituality are
associated with better health outcomes, including greater longevity, coping skills, and
health-related quality of life (even during terminal illness) and less anxiety,
depression, and suicide. (Paul S.
Mueller,David J. Plevak,Teresa A. Rummans. (2001, December). Religious
Involvement, Spirituality, and Medicine: Implications for Clinical Practice.
https://www.mayoclinicproceedings.org/article/S0025-6196(11)62799-7/fulltext)
12. Emotional Pattern
The client stated that he is mostly neutral and doesn’t want to say how he feels
at first but later on when he can no longer bear the heaviness he feels in his chest,
that’s when he expresses his feelings to others.
Interpretation: The client is both verbal and nonverbal when it comes to his emotions.
Analysis: Emotions and the ability to express emotions gives us the ability to connect
deeper with ourselves, thereby improving communication and relationships with
others. (Alston, T. (2020, August 6). Why Expressing Emotions Is Beneficial?.
https://tracyalston.com/why- expressing-emotions-is-beneficial/)
13. Cultural Pattern
The client was raised by his parents by teaching him to value their religion and
to be respectful. The client also celebrates New Year and his birthday every year with
his family and friends.
Interpretation: The client gives high importance to their religion as well as being a
respectful to others. The client has been also accustomed in celebrating events every
year such as New Year and birthdays.
Analysis: Cultural, social, and family influences shape attitudes and beliefs and
therefore influence health literacy. Social determinants of health are well documented
regarding the conditions over which the individual has little or no control but that affect
his or her ability to participate fully in a health-literate society. (Institute of Medicine
(US) Committee on Health Literacy; Nielsen-Bohlman L, Panzer AM, Kindig DA,
editors. Health Literacy: A Prescription to End Confusion. Washington (DC): National
Academies Press (US); 2004. 4, Culture and Society. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK216037/)
14. Recreation Pattern
The client stated that he spends his spare time in playing online games and
watching movies. The client also know how to dance and learning the steps by
watching tutorials in youtube.
Interpretation: The client is enjoying spending his spare time by doing the stuffs he
loves.

Analysis: “When people engage in leisure activity, they have lower stress levels,
better mood, a lower heart rate and more psychological engagement — that means
less boredom, which can help avoid unhealthy behaviors,” Zawadzki said. (Leonard,
J. (2015, March 19). Relax: Benefits of Leisure Go Beyond the Moment.)
15. Environment
 The client lives in the province of Tarlac and he was contented to their place
due to having a fresh air and peaceful neighborhood. He is living in a bungalow
house that is just right for their family. They don’t have any pets and doesn’t have
any bad odor and noise to their place.

Interpretation: The client’s home is just right for their family. The client is happy and
comfortable to their place since this is the place where he grew up.
He doesn’t have any problem to the place where he lives.
Analysis: Research suggests that biodiversity may hold a key to the prevention and
treatment of many diseases (Lovejoy, 2001). An even more direct connection
between the environment and health is the potential enhancement of our physical,
mental, and social well-being through our daily exposure to the natural environment.
(Institute of Medicine (US) Roundtable on Environmental Health Sciences,
Research, and Medicine; Frumkin H, Jackson RJ, Coussens CM, editors. Health
and the Environment in the Southeastern United States. Washington (DC): National
Academies Press (US); 2002. 4, Human Health and the Natural Environment.
Available from: https://www.ncbi.nlm.nih.gov/books/NBK221127/)

16. Hygiene
The client is taking a bath every morning and takes a shower every night before
going to bed. He also brushes his teeth two to three times a day after eating lunch
and dinner. The clients last visit to dentist was already a year ago due to the
pandemic.
Interpretation: The client is neat since he is taking a shower everyday and brushing his
teeth 2 to 3 times a day after meals.
Analysis: Good personal hygiene involves keeping all parts of the external body
clean and healthy. It is important for maintaining both physical and mental health.
(Ames, H. (2020, May 20). Why is personal hygiene
important?. https://www.medicalnewstoday.com/articles/personalhygiene)
17. Substance Use/Abuse The client stated that he doesn’t have any vices such
as drinking alcohol, smoking cigarette, nor using any prohibited drugs.
Interpretation: The client does not have any substance use/abuse.
Analysis: People with addiction often have one or more associated health issues,
which could include lung or heart disease, stroke, cancer, or mental health
conditions. Imaging scans, chest X-rays, and blood tests can show the damaging
effects of long-term drug use throughout the body. In other cases, drug use may
trigger or worsen those mental health conditions, particularly in people with
specific vulnerabilities. (NIDA. 2020, July 13.
Addiction and Health. Retrieved from
https://www.drugabuse.gov/publications/drugs- brains-behavior-
scienceaddiction/addiction-health on 2021, July 5)
V. PHYSICAL ASSESSMENT

BIOGRAPHIC DATA

Client’s Initial: V.V.V.

Age: 23 years old
Sex: Male
Address: 172 Pulong Tamo, San Ildefonso, Bulacan
 Date of Assessment: June 22, 2021 General
Assessment:
The client is a 23-year-old male. The client has light skin tone and has a normal
gait and posture standing at 5’7 and 55 kg. Client is cooperative and oriented to time,
place, person, and situation.

Interpretation:

The client has a normal general appearance and orientation.

Analysis:

The general appearance of a patient may provide diagnostic clues to the illness,
severity of disease, and the patient's values, social status, and personality. (Berk SL,
Verghese A. General Appearance. In: Walker HK, Hall WD, Hurst JW, editors. Clinical
Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston:
Butterworths; 1990. Chapter 217. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK330/)

Vital Signs:

NORMAL ACTUAL ANALYSIS

FINDINGS FINDINGS
BLOOD PRESSURE 110/70 100/70 mmHg NORMAL
120/80 FINDINGS
mmHg
PULSE RATE 60-100 beats per 79 bpm NORMAL
minute FINDINGS
RESPIRATORY 12-20 breaths per 20 bpm NORMAL
RATE minute FINDINGS
TEMPERATURE 36 ⁰C – 37.5 ⁰C 36.5⁰C NORMAL
FINDINGS
HEAD, FACE, and NECK

BODY PART NORMAL ACTUAL ANALYSIS

FINDINGS FINDINGS
Skull Proportional to
the size of the
body, round with Normocephalic,
prominences in symmetrical in all
the frontal and planes, gently NORMAL
the occipital curved without any FINDINGS
area, areas of masses,
symmetrical in all lumps and
planes, gently tenderness.
curved. No
masses, lumps,
or areas of
tenderness
 Scalp Clean, free from Scalp is clean,
scars, nits, lice, no scars, nits,
dandruff, lesions, lice, dandruff, NORMAL
masses, lumps, lesions, masses, FINDINGS
and areas of lumps, and areas
tenderness of tenderness
noted.
Hair Black, evenly Hair is black and
distributed & evenly
covers the whole distributed. Has NORMAL
scalp, thick, shiny, a fine texture, FINDINGS
and with fine thick, shiny,
texture and covers
the whole
scalp.
Face Symmetrical Face is symmetric NORMAL
facial and doesn’t have FINDINGS
movements and any deformities.
no deformities
Eyes Parallel and
evenly placed, Eyes are not dry,
symmetrical, symmetrical, NORMAL
nonprotruding, with black, and clear. FINDINGS
scant amount of
secretions, both
eyes are black
and clear
Eyebrows Black, evenly Hair of the
distributed, thick, eyebrows are
parallel to each evenly distributed, NORMAL
other, and can slightly thick, FINDINGS
be raised and parallel to each
lowered other, and equal
symmetrically movement.
Eyelashes Black, evenly Evenly
distributed, and distributed, NORMAL
directed slightly curled FINDINGS
outwards outward,
and black
in color.
Eyelids Upper lids cover a Eyelids meets
small portion of completely when
the iris, cornea eyes are closed NORMAL
and the sclera and upper lid FINDINGS
when the eyes are covers small
open. When the portion of the iris.
lids closed, the
lids meet
completely.
Lid Margins Clear; without Clear and no NORMAL
scaling and signs of scaling FINDINGS
secretions and
secretions.
Lower palpebral Salmon pink, Shiny, moist, NORMAL
conjunctiva shiny, and and pinkish in FINDINGS
moist color.
 Sclera White in color and Sclera is white NORMAL
clear FINDINGS
Iris Round, Black, round,
symmetrical to and NORMAL
each other, symmetrical to FINDINGS
black/brown in each other.
color, and
proportional to the
size of the eyes
Pupils From pinpoint to
almost the size of
the iris, round, Round, NORMAL
symmetrical, symmetrical, and FINDINGS
constrict with constrict with light.
increasing
light
accommodati
on
Eye Movement Able to move in all Moved eyes NORMAL
directions and full freely in all FINDINGS
of motion directions and full
of motion.
Field of Vision Able to see 60 Able to see 60
degrees degrees NORMAL
superiorly, 90 superiorly, 90 FINDINGS
degrees, degrees,
temporally, and temporally, and
70 degrees 70 degrees
inferiorly inferiorly.
Visual Acuity 20-distance from Blurred vision
the chart 20- refers to a lack of
distance at which Only able to read sharpness of vision
a normal eye can the largest resulting in the
read. Visual acuity letter. inability to see fine
of 20/20. Able to detail. Blurred
read small vision may result
newspaper print at from abnormalities
a distance of 14 such
inches
 as
nearsightedness,
farsightedness,
presbyopia, or
astigmatism that
can be improved
with corrective
lenses
(eyeglasses) or it
may signal the
presence of eye
disease.
(Stoppler,
M.C. (2019,
September 10).
Blurred
Vision:
Symptoms &
Signs)
Ear Parallel and symmetrical
to each other, in lined Symmetrical and NORMAL
with the outer canthus of aligned with the FINDINGS
the eyes outer canthus of the
eyes.
Ear Canal Distal third contains hair
follicles and glands, dry Hair follicles and dry
cerumen, grayish tan cerumen are
color, or sticky, wet present and NORMAL
cerumen in various tympanic FINDINGS
shades of brown. For the membrane is pearly
tympanic membrane, gray in color.
pearly gray color,
semitransparent

Hearing acuity Normal voice tones Able to hear and NORMAL

audible at a distance of repeat the word FINDINGS
2 feet the examiner that
has been said.

Nose Midline, patent and Nose in in the NORMAL

symmetrical midline. FINDINGS
Internal Nares Clean, pinkish, with Cilia is present, NORMAL
presence of cilia clean, and pinkish FINDINGS
Nasal Septum Straight Straight NORMAL
FINDINGS
Lips Pinkish lips, Visible margins,
symmetrical, well smooth, moist, and NORMAL
pinkish in color. FINDINGS

defined lip
margins smooth
and moist
 Gums Pinkish, smooth, Pinkish in color, NORMAL
moist, no smooth, moist, FINDINGS
swelling and no swelling.
Teeth 32 permanent Complete 32
teeth, Well permanent teeth NORMAL
aligned, free from and has slight FINDINGS
dental caries and dental caries.
no halitosis No halitosis
Tongue Central position,
pink color, moist, In the midline,
slightly rough, thin moist, presence of NORMAL
whitish thin whitish FINDINGS
coating, smooth, coating, and no
lateral margins, signs of lesions.
no lesions, raised
papillae, moves
freely, no
tenderness,
smooth tongue
base with
prominent veins,
smooth with no
palpable
nodules
Soft and Hard Pinkish, moist and Moist, smooth, NORMAL
Palate smooth and pinkish in FINDINGS
Slightly pinkish color.
Uvula At the center, In the midline and NORMAL
symmetrical, able to move FINDINGS
and freely movable freely.

Tonsils Pinkish, non- No signs of NORMAL

inflamed, no inflammation and FINDINGS
exudates exudates. Pinkish
in color.
Voice No hoarseness No hoarseness NORMAL
and well- of voice and FINDINGS
modulated well- modulated.

Neck Proportional to the

size of the Neck is in the
body and head, midline of the
symmetrical and body, able to NORMAL
straight. Freely move freely, and FINDINGS
movable without no palpable
difficulty. No masses and areas
palpable masses of tenderness.
or areas of
tenderness
Range of Motion Freely movable Able to move NORMAL
without difficulty freely. FINDINGS

Muscular Strength Symmetrical Able to resist NORMAL

and able to resist applied force and FINDINGS
applied force symmetrical.
(both muscles).
 PHYSICAL ASSESSMENT II

BODY PARTS NORMAL FINDINGS ACTUAL FINDINGS

Posterior Thorax INSPECTION
Contour is symmetrical;
color is the same as
general complexion, free
from scars or bruises, hair
evenly distributed. The
spine is straight.
Anteroposterior to
transverse diameter in ratio
of 1:2

PALPATION
No lumps, masses, areas of
tenderness. Sides of the
thorax expand
symmetrically Full and
symmetric thorax expansion

Bilateral symmetry of vocal

fremitus
Fremitus is heard most
clearly at the apex of the NOT PERFORMED
lungs

PERCUSSION
Percussion Note Left &
Right Supraclavicular flat,
lungs are resonance and
downward is dull because of
bodily organs.

AUSCULTATION
Breath sounds
characterized in cervical are
as bronchial, in the
lungs as bronchi vesicular
and downward as vesicular.
Anterior Thorax
INSPECTION
Contour is symmetrical;
color is the same as
general complexion, free
from scars or bruises, hair
evenly distributed. The NOT PERFORMED
chest wall moves
systematically during
respiration
 PALPATION
No lumps, masses, areas of
tenderness

PERCUSSION
Percussion Note Left &
Right Supraclavicular flat,
lungs are resonance and
downward is dull because of
bodily organs.

AUSCULTATION
Breath sounds
characterized in cervical are
as bronchial, in the
lungs as bronchovesicular
and downward as vesicular
Heart Pulsation of the apical
impulse may be visible

There should be no lift or

heaves

No masses and area of

tenderness NOT PERFORMED
Systolic; silent interval,
Slightly shorter duration
than diastole at normal
heart rate

Diastolic; silent interval.

Slightly longer duration than
systole at normal heart
rates
Carotid Arteries Symmetric pulse volumes
Full pulsations, thrusting

Quality remains
same when client breathes, NOT PERFORMED
turn head and changes from
sitting to supine position

no sound heard on
auscultation
Jugular Veins Veins not visible
(indicating right side of NOT PERFORMED
heart is functioning
normally)
Breast Symmetrical, no palpable
mass, NOT PERFORMED
 no tenderness

No abnormal nipple
discharges
Abdomen INSPECTION
Skin color is lighter than
the extremities, no lesions,
scars or moles
AUSCULTATION
Average of 5-32 bowel
sounds

PERCUSSION
Organs are tympanic and NOT PERFORMED

the liver is dull.

PALPATION
No tenderness, no
muscles guarding and with
smooth and consistent
tension notes.
For liver palpation, the liver
edges can be felt by the
examiner. Smooth, regular
in contour, firm and non-
tender
 PHYSICAL ASSESSMENT III

BODY PARTS NORMAL ACTUAL INTERPRETATION

FINDINGS FINDINGS AND ANALYSIS
Inspection Shoulder Even in color with no
to Wrist (Dorsal discoloration like Hair is evenly
Aspect) rashes or marks or distributed, light
scars. Color same brown in color and NORMAL
as general no presence of FINDINGS
complexion, hair discoloration.
evenly distributed
Shoulder to Wrist Lighter in color than
(Ventral Aspect) skin exposed to the There is no
sun. Should still be presence of scar NORMAL
uniform in color. No FINDINGS
presence of scars.
Hands Complete number of -Fingernail edges
5 fingers on each are parallel
hand. Nails are -There are complete
transparent, 10 fingers
smooth, and convex -Nail plate is
with pink nail beds colorless and has a
and white convex curve
translucent tips. -Nail bed returns to NORMAL
Good capillary refill. its usual color or
FINDINGS
Has no pink color when
edema pressed are
released. -Palms
don’t have any
lesions or any
signs of bumpy
nodules
-There’s a multiple
presence of creases
Palpation Shoulder No lumps or No presence of pain,
to Finger Tips masses. Check for lumps, or masses.
areas of pain which NORMAL
should be absent. FINDINGS

RANGE OF MOTION
BODY PARTS NORMAL ACTUAL FINDINGS INTERPRETATION
FINDINGS AND ANALYSIS
Upper Extremities Motion is smooth No complaint of pain
and able to lift the and able to do the NORMAL
arms up and bring movement FINDINGS
them down with
control and ease.
Shoulders Be able to rotate No complaint of pain NORMAL
shoulders without and able to do the FINDINGS
issue pain movement
Elbow Be able to open and No complaint of pain NORMAL
close elbow with and able to do FINDINGS
ease and smooth movement
movement
Wrist Wrist is able to be No complaint of pain NORMAL
moved and swing and able to do FINDINGS
 without pain the movement
Hands Hands can close No complaint of pain NORMAL
and open with and able to do the FINDINGS
control and no pain movement
Lower Extremities Uniform skin
color with slightly
darker Light brown in color NORMAL
exposure and no presence of FINDINGS
area. No jaundice, jaundice and
cyanosis, cyanosis
Legs pallor or erythema

No presence of Smooth, firm, and no NORMAL

edema areas of tenderness FINDINGS

Smooth, firm and

non – tender
Ventral Aspect Darker in color than
the dorsal aspect.
Complete number -Hair is evenly
of 5 toes on each distributed and skin
is smooth
foot, pink nails -There is complete
beds and convex in 5 toes on each foot
- Nail bed returns to NORMAL
shape with good its usual color or FINDINGS
capillary refill, pink color when
pressed are
presence of released
veins, and -There is presence
of veins
smooth skin with
fine hair
evenly distributed

Dorsal Aspect Lighter in color. No Light brown in color NORMAL

signs of cyanosis and no signs of FINDINGS
cyanosis
Range of Motion No involuntary No complaint of pain NORMAL
movement and can and able to do the FINDINGS
move freely movement
Foot and Toes Five toes in each -There is complete
five toes on each
foot
foot
-Sole and dorsal NORMAL
surface is smooth FINDINGS
Sole and dorsal
- Nail bed is pink in
surface is smooth: color and has
with pink nail beds translucent tips
and translucent tips

VI. PHYSIOLOGY
 VII. PRIORITAZION OF NURSING DIAGNOSIS

NURSING PROBLEMS IDENTIFIED CUES JUSTIFICATION

Subjective: An individual’s assessment of their own lack of
knowledge is of interest in the context of risk
“Bigla nalang pong sumasakit yung ibabaw ng perception. Some studies have shown that
aking ulo” people can use their perceptions of their
ignorance to their advantage when dealing with
Objective: judgments and conclusions about their
knowledge (Son and Kornell 2010).
• W: 55kg
Deficient knowledge regarding disease condition
• H: 5’7= 170.18 cm

• BMI: 19.0 Kg/ m2

• BP: 100/70 mmHg
• PR: 79 bpm
• RR: 20 bpm
• T: 36.5⁰C
Subjective: Having blurred vision more than once or twice a
month has a detectable and significant impact on
“Hindi ko na po mabasa yung kasunod na letra” functional status and well-being, especially in
referring to Snellen Chart’s second to the largest role limitations due to physical health problems
Inability to read words or phrases in far direction letters (Lee, P. P., Spritzer, K., & Hays, R. D. (1997).
due to having a blurred vision
Objective:

• The client is wearing eyeglasses with a

thick lense.
• Squinching of eyes when reading the

Snellen Chart without the client’s

corrective lense.
• W: 55kg
• H: 5’7= 170.18 cm

• BMI: 19.0 Kg/ m2

• BP: 100/70 mmHg
• PR: 79 bpm
• RR: 20 bpm
• T: 36.5⁰C
 Subjective: Low self-esteem has been shown to lead to
mental and physical health issues like depression,
“May time na confident ako sa sarili ko pero anxiety, and anorexia. It can also lead to
kapag nasa isang lugar ako at nakakita ako ng unhealthy habits like smoking tobacco, alcohol
mas angat sa akin, doon bumababa ang abuse, or drug use (Dan B, 2020).
selfconfidence ko”

Objective:
Situational Low Self-Esteem • The client is avoiding eye contact.
• W: 55kg
• H: 5’7= 170.18 cm

• BMI: 19.0 Kg/ m2

• BP: 100/70 mmHg
• PR: 79 bpm
• RR: 20 bpm
• T: 36.5⁰C

VIII. NURSING CARE PLAN

CUES NURSING ANALYSIS/ PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INFERENCE INTERVENTIONS
Subjective: Deficient A lack of cognitive After 30 minutes of 1.Assess 1. Provide
knowledge information or nursing understanding of baseline data for
“Bigla nalang pong regarding disease psychomotor intervention, the cause of headache. teaching and Improvement of
sumasakit yung condition ability needed for client will be able evaluation of the client’s knowledge
ibabaw ng aking health restoration, to improve his 2. Provide clear interventions. 2. regarding to his
ulo” preservation, or knowledge explanation about Provide condition such as
health promotion regarding his the client’s understanding to knowing the
is identified as a condition. condition. client to improve causes together
Objective:
knowledge deficit. his knowledge with having an idea
• W: 55kg
Knowledge plays 3. Identify ways regarding the about the possible
• H: 5’7= an influential and client’s condition. preventive
to
170.18 cm significant part of a 3. Encourage
prevent measures about
• BMI: 19.0 client to provide
patient's life and experiencing his condition within
Kg/ m2 preventive
recovery headache as well 30 minutes of
• BP: 100/70
(Nurseslabs, as identifying ways measures at home Nursing
mmHg
2019). to relieve the to ease the client’s Interventions.
• PR: 79 bpm client’s pain. pain.
• RR: 20 bpm
• T: 36.5⁰C 4. Provide 4. Can be used by
written information client for
regarding the clarifications.
client’s condition.
BIBLIOGRAPHY