Notre Dame of Jolo College

HEALTH SCIENCES DEPARTMENT

Jolo, Sulu

FORMAT FOR THE NURSING PROCESS

I. ASSESSMENT

A. Personal Data
Name:
Address:
Age:
Sex:
Status:
Occupation:
Educational Attainment:
Ethnic Group:
Dialect/Language Spoken:
Religion:
Chief Complaint:
Medical Impression:

B. Nursing History
1. History of Past Illness
Includes childhood diseases, immunizations, allergies, previous
hospitalization, previous surgery, serious injuries or accidents,
previous medications taken.

2. History of Present Illness

Reason for hospitalization, when the illness started, how it started,
symptoms felt by the patient, if hospitalization is planned or
unexpected emergency, if experiencing pain or if it is part of a
progressive, ongoing, or long term problem.

C. Gordon’s 11 Functional Health Patterns

1. Health Perception-Health Management Pattern
Describes the clients’ perception and understanding of the health
status. This includes the clients’ lifestyle and behaviors to maintain
and restore health and well-being.
a. How has your general health been?
b. What causes your illness?
c. What have you done to solve the problem?
d. Was the action effective?
e. Most important things done to keep healthy (include family
folk if appropriate).
f. Immunization Status (if appropriate).

2. Nutritional-Metabolic Pattern
Describes the clients’ food and fluid consumption in relationship to
the body’s metabolic needs. Adequacy of nutrient supply to local
tissues is included in this pattern.
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a. Typical daily food intake? (describe) Food supplements?
b. Typical daily fluid intake? (describe) Time?
c. Weight loss? Gain? (Amount)
d. Foods or eating discomforts? Diet restriction? Religious belief?
e. Skin Problems: Lesions and dryness? General ability to heal?
f. Dental problems?
g. Height?
h. Food preferences, use of nutrients or vitamin supplement?

3. Elimination Pattern
Focuses on the clients’ patterns of excretory function, including the
bowel, bladder, and skin. Habits for excretory regularity and
perceived difficulties in this pattern are assessed.
a. Bowel elimination pattern? (describe) Frequency? Discomfort?
Character?
b. Urinary elimination pattern? (describe) Frequency?
Discomfort? Character?
c. Excess perspiration? Odor problems?
d. Any discharges (wound)
e. Use of laxatives or any aid for bowel elimination?

4. Activity-Exercise Pattern
Describes the clients’ activities of daily living requiring energy
expenditure. These include self-care measures, physical exercise,
stamina, and leisure and recreational activities.
a. Sufficient energy for completing desired/required activities?
b. Exercise pattern? Type? Regularity?
c. Spare time (leisure) activities? Child play activities?
d. Perceive ability for: [Code for level]
Feeding ___ Dressing ___ Cooking ___
Bathing ___ Grooming ___ Toileting ___
Home Maintenance ___ Shopping ___
General Mobility ___ Bed Mobility ___

Functional Level Code:

Level 0: Full self-care
Level 1: Requires use of equipment or device
Level 3: Requires assistance or supervision from another
person
Level 4: Is independent and does not participate

5. Sleep-Rest Pattern
Refers to the clients’ usual habits for sleep, rest, relaxation, and
energy level. Patterns are assessed for 24-hour period to consider
circadian rhythmicity.
a. How many hours of sleep/rest per day?
b. Generally rested and ready for daily activities after sleep?
c. Sleep onset problems? (Nightmares, Somnambulism?) Early
awakening?
d. Time of sleep? Awakening?

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e. Aids to sleep such as medication or right time routine that the
individual employs?

6. Cognitive-Perceptual Pattern
Describes the clients’ ability to perceive, comprehend, and use
information as well as the sensory functions.
a. Hearing difficulty? (include hearing aid if there is any)
b. Visions? (Eye glasses? Contact lenses? Allergies?)
c. Any changes in memory lately?
d. Any difficulty in hearing?
e. Any discomforts? Pains? How do you manage it?

7. Self-Perception-Self-Concept Pattern
Includes the clients’ view of self, including attitudes, identity, body
image, sense of self-worth, and self-esteem.
a. How do you describe yourself? Moods? Perception towards
self?
b. Changes in the body or things you can do?
c. Changes in the way you feel about yourself or your body?
(since illness started)
d. Things that frequently make you angry? (depressed, anxious?
What helps)
e. Are you happy/contented about yourself?

8. Role-Relationship Pattern
Describes the clients’ roles in society and interpersonal
relationships.
a. Family Structure? How many members in the family? How do
you describe the interpersonal relationship among family
members? Language spoken?
b. Live alone? Family Type?
c. How does the family usually handle problems?
d. Who is the breadwinner?
e. Problems with children? Difficulty handling?
f. How family feels (or others) about your illness?
g. Belongs to social groups? Close friends? Feel lonely
(Frequency)
h. Do things generally go well with you at work? (school/college)
i. If appropriate, include family income. Is income sufficient for
needs?
j. Feel part or isolated in neighborhood where residing?

9. Sexually-Reproductive Pattern
Refers to the clients’ satisfaction or dissatisfaction with sexuality
and reproductive functions. These includes sex role behavior and
identification, physiologic and biologic functions, and sociocultural
aspects of sexual behavior.
a. How many children? History of abortions? Stillbirths?
Premature?
b. Any changes or problems in sexual relationships?
c. Use of contraceptives? Problems?
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d. Females: When menstruation started? Last menstrual period?
Menstrual problems? Para? Gravida?
e. Describe the client to the 3 major component of human
sexuality:
- Reproductive sexuality
- Gender sexuality
- Erotic sexuality

10. Coping-Stress Tolerance Pattern

Describes the clients’ general coping strategies and their
effectiveness in managing stress. Included are the clients’ perception
of stressors and their effect on the client.
a. How does the family cope in time of crisis?
b. Tense a lot of time? What helps? Use of many
medicines/drugs?
c. Any big changes in your life in the last year or two?
d. When you have a big problem, how do you handle them?
Successful in handling them?

11. Value-Belief Pattern

Includes the values, beliefs, (including spiritual), and goals that
guide the clients’ choices and decisions, particularly in health care.
Sources of strength and meaning for the client is identified.
a. What do you consider as the most valuable/important in life?
b. Generally get things you like? Most important things?
c. Is religion important in your life? Does it help you when a
difficulty arises?
d. Does illness/hospitalization interferes with any religious
practices?

12. Others
a. Any things we have talked about that you’d like to mention?
b. Questions?

13. Growth/Development Milestone (for PEDIATRIC PATIENT)

a. Theories: Erik Erikson, Sigmund Freud, Jean Piaget
b. Gross Motor Skills
c. Fine Motor Skills
d. Play/Socialization

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Example of Nursing Assessment
1. Past health history
It was not his first time to be hospitalized. He was first admitted to IPHO-
Sulu last 1997 due to appendicitis. He underwent appendectomy with colostomy
on the same year. His physician Dr. Che-che Laruh Savor Mogyeh told him that
the colostomy would be surgically closed after 3-4 months but he did not comply
and return to IPHO due to financial constraints. Accordingly, he was a chain
smoker and engaged in strenuous activities such as mountain climbing aand
diving but he stopped those after he had undergone apendectomy. His diet was
altered. He experienced anorexia and ate lesser than before. On 2002, he
consulted a quack doctor because he suffered from abodominal pain and he
found out that he has a peptic ulcer it he did not submit for medical check-up
due to financial constraints. He just restricted sour and salty foods. Aside from
these, he also experienced a minor discomforts such as headachs, fever,
abdominal pain but he did not bother to seek medical attention because the pain
is still bearable. He just took over-the-counter drugs (OTC drugs) such as
biogesic and mefenamic acid. he also utilized herbal medicine such as "haggut".
1. Present health history
My patient was admitted to IPHO-Sulu on June 22, 2008 at exactly 3
o'clock in the afternoon because of frequent vomiting and generalized abdominal.
I have learned that he actually suffered from those symptoms five days prior to
admission (PTA). He accordingly, had eaten mango, banana, and panyam the
night before the admission and these triggered him to vomiting nine times the
following day accompanied with generalized abdominal pain. Since he could not
anymore bear the pain, he agreed to be brought to the hospital for further
medical management. At present, he complains of body weakness, loss of
appetite, and constipation. He is scheduled for exploratory laparotomy on June
24, 2008 to 8 o'clock in the morning under spinal anesthesia. He will be on NPO
@12MN.

11 HEALTH FUNCTIONAL HEALTH PATTERN

1. HEALTH PERCEPTION - Health management pattern
The family of my patient considers health is very important the fact that
he was admitted to the hospital for proper management of his illness. They
somewhat place a high value on their health and they are very sensitive when
one's health is impaired. However, because of financial constraints and their
house is distal to the hospital, they can hardly seek medical attention
immediately. They just consulted a quack doctor or utilized herbal medicine
since there were so many herbal plants near their house. They also brought OTC
drugs to alleviate discomfrots. These methods seem to be effective on their part.
Currently, he is confined at surgical awards due to intestinal obstruction with
adhesion and is subjected for Exploratory Lapatrotomy aand closure of
colostomy. This time, he needs suchmsdical assistance to avoid complications
that is why we was rushed to the IPHO-Sulu.

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2. NUTRITIONAL - Metabolic Pattern
The daily food intake of my patient PTA were 1 half cup of porridge, fish
and soup with vegetables and his fluid intake were five glasses of wate. During
hospitalization, he experienced loss of appetite and was ordered to have liquid
diet. He took at least 3-4 cups of water a day. since illness started he lost much
weight. Before he weighs about 120 pounds but at present, he weighs 100
pounds. His height is 5'6". He has a dry mucous membrane poor asking turgor.
Teeth are incomplete. First and second lower left molars are decayed and
removed by him. His central and lateral molars were extracted by the dentist. He
is taking vitamin B-complex once a day which serves as nutrient or vitamin
supplement to him.
3. ELIMINATION - Pattern
My patient is with sigmoid colostomy because he could not defecate
through his anus due to obstruct on the lower colonproximal to the anal area.
His stool is semi-formed moderate in amount and yellowish. Enema was done to
him on June 4, sat 9:34 in the evening to cleanse the colon area and facilitate
defecation but the solution did not pass through the colostomy site (a possible
indication of internal obstruction). With this, he was ordered to undergo rectal
examinations following day. He voids five times a day. The characteristics of his
urine are Amber in color, hazy in transparency and scant in amount.
4. ACTIVITY - EXERCISE PATTERN
Prior to admission, his daily activities were helping his wife in doing
household chores, constructing their porch and jogged in the morning.
accordingly, these served as his daily exercise. at present, changing of position,
sitting up on bed, initiating full range of motion and ambulating were his form
of exercise in tee hospital. His feeding, dressing, bathing, groooming , and
toileting are in level two because he requires assistance or supervision from his
wife or nurse.
5. SLEEP-REST PATTERN
My patient has sleeping difficulty. He sleeps at 1:30 am and wakes up at
3:30 in the morning. He experienced insomnia even before his hospitalization
but he did not take any sleeping pills to aid such. Accordingly, during his
confinement his wife asked for sleeping tablet from the nurse so that her
husband could relax and take enough sleep but the nurse refused to Grant her
because it was not included in the doctor's orders accodingly. He also takes a
nap in the morning especially after being checked-up by the physician.
6. COGNITIVE-PERCEPTUAL PATTERN
My patient doesn't have learning difficulties. I stood two feet away from
him to listen to me, and then he said that he heard me. He is clear-sighted too.
I stood 5 feet away from him and asked him to look and name the object I was
hoping which was ballpen, and then he said that he clearly saw the ballpen. He
still has a good memory. He can still remember what had happened to him. He
sometimes feels pain on the wounded area especially when changing the
dressing.

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7. SELF PERCEPTION-SELF CONCEPT PATTERN
Mr. Wadji, as I assessed, is consciously aware of is condition. He perceives
himself as a simple individual created by Almighty God. Because of this
condition, there are of things that change. He became weak aand he cannot
perform the things that he used to do like taking a bath himself, ambulating and
praying. He feels bad and sometimes becomes depressed but late he realizes that
he cannot do anything about it. He just accepts it.
8. ROLE-RELATIONSHIP PATTERN
Accordingly, they are aa patriarchal type of family because he is the head
and the breadwinner of the family. He dominates in making desicions. They
speak in bahasa-sug and they have a harmoniums relationship as a couple.
Although sometimes, they experienced minute misunderstanding, they
immediately patch it up. He has no difficulty in handling him. His family and
relatives cannot still believe about what had happened to him. They were very
sad. They just extended their moral support and also financial support the him.
9. SEXUALITY-REPRODUCTIVE PATTERN
My patient is a male and has only one child. At present, his sexual
relationship with his wife is impeded because of his condition. His wife also stays
at Pata to take Care of their child and their house.
10. COPING-STRESS TOLERANCE PATTERN
According to my patieent, every time they encountered problems within
the family, they talked it over and then with each other's help, they patched it
up. Currently, he had a hard time coping up with stress brought about by his
confinement especially on his first week of admission in IPHO-Sulu. Her was very
depressed because of his condition especially when is right arm was amputated.
Another stressor is was the pain on the wounded area aand fractured paart. He
cannot move freely. Consequently, he realizes that he cannot did anything about
it, so he just accepted aand get used to it. Thee moral support given by the
relaated and his family helped relieve his stress and anxiety.
11. VALUE-BELIEF PATTERN
Mr. Wadji embraces Islam religion and Tausug culture. He observes prayer
every Friday and performs Duwa'a every time they have problems. But now he
cannot perform prayer becaause his condition does not permit him to do.

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PHYSICAL ASSESSMENT
(CEPHALO-CAUDAL ASSESSMENT)

GENERAL APPEARANCE
My patient looks weak, and pale. With regardss to his mental state, he is
well oriented with the time, environment and the people around him. He is
responsive enough to answer questions.
1. HEAD is normocephalic and proportional to the body size.
2. HAIR is black in color, dry, and infested with few nits. It evenly distributed
and no signs of alopecia noted.
3. SCALP is white, dry and there is a presence of dandruff noted. Upon palpation,
there is no tenderness and pain noted.
4. FACE is symmetricaal , slightly rough and pale. There is a presence of
blackheads. Cheekbones are prominent. He has a short mustache and beard.
5. EYES globes of the eyes are symmetrical. Conjunctiva over eyeball is slightly
pale and under eyelids is slightly pink. Sclera is white and Iris is brown
throughout. Utilizing the penlight. I saw that the pupils are equal, round, aand
reactive to light and accomodation. Pupils constricted as I shine the penlight on
it and dilated as I removed it. Eyeballs move equally. Patient can still see far
objects but they seem blurry. He saw the scissor I was holding six feet away from
him.
6. EARS. Pinna is symmetrical to each other and there is lesion and deformities
noted. There is as minimal amount of dry, brown eaarwaax in the ear canal.
7. NOSE is proportional to the face. It is slightly pointed. No deformities or
deviated septum noted. Using the penlight, I ascertained that the nasal mucous
membrane is pink, dry and no discharges. There is no swelling or perforation
noted.
8. ORAL CAVITY. Upper and lower lips are asymmetrical to each other. they are
thick, dry and slightly pale. First and second lower left and right molars were
extracted. Gums aand rogue aare slightly pale and dry. tonsils are symmetrical,
visible and the uvula is at its midline.
9. NECK is slightly rough and dry. Upon palpation, there is no enlargement of
the thyroid aand cervical lymph nodes noted. Larynx move when swallowing.
10. CHEST is symmetrical and moves equally when breathing. Patient
productively coughs at times. His respiration rate is 23 breaths/minute.
11. BREAST. It is flat slightly smooth non-render aand symmetrical bilaterally.
No masses noted upon palpation.
12. BACK. There is no decubitus ulcer (bedsore) noted. The vertebral column is
able to flex and extend with no pain and tenderness.
13. ABDOMEN is sslightly rough, distended and tenderness when palpated. The
umbilical ring is regular and round. Umbilicus is centered. Upon auscultation
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on all quadrants of abdomen, bowel sounds can be heard but stop at times.
Patient somewhere complains off abdominal pain. There's is a scar on the R
lumbar because of he was accidentally stabbed by his playmates when he was
still a child. There is also an induction scar at the RIF (Right Iliac Fossa) due to
appendectomy 7 years ago. Currently, a sigmoid colostomy is present at the Left
Iliac region where he defecates.
14. UPPER EXTREMITIES. They are equal and symmetrical to each other. Skin
has a poor skin turgor after pinleft , the skin at the Left hand is dry too. Arms
can initiate full range of motion with no pain felt. Fingernails are short but dirty.
Nailbeds are slightly pink.
15. LOWER EXTREMITIES. Legs are symmetrical and emaciated. There is no
deformity noted. Feet are slightly warmer and dry. Calloused are present in both
feet. Toenails are short but dirty. Nailbeds are slightly pink.
16. GENITALIA
I was not given a chance to assess but I have learned that he was circumcised.
Accordingly, his R scrotum is bigger than his left. It is asymmetrical. He has a
Benign Prostatic Hypertrophy. He void 5 times a day. The characteristics of his
urine aare yellow, hazy in transparency and scanty in amount.
17. ANUS AND RECTUM
I was not also given a chance to assess but I learned that he has also a perforated
anus, but he cannot pass stool through it because he has an obstruction on his
lower colon. He defecates through his colostomy. He lastly defecated on his first
and second day in the hospital, after that he experienced constipation. Enema
was done to him on Thursday at 9:55 PM but there was no return flow from
colostomy site. The characteristics of his last stool were semi-formed, yellow
aand moderate in amount.

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PHYSIOLOGIC EXAMINATION

1. CENTRAL NERVOUS SYSTEM

After asking the patient the place where he is in, the time and watchers
around him, I learned that he is well-oriented because he answers my questions
correctly. He is alert and responds to my questions immediately. He has a good
attention span. He focused well and is not easily distracted by any noise around
him. He has no speech abnormalities. He enunciates Sinug and even some
English words well. His non-verbal communication is congruent to what he is
saying. He has coordinated movements too. I asked him to hold my ballpen and
there was no tremor noted.
2. SPECIAL SENSES
A. AUDITORY PERCEPTION
Aeg has no hearing difficulties. I stood 2 feet away from him and
asked him to listen to me with his right ear closed and then he said he
heard me. Then I tried the left ear using the same procedure, and then he
told me that he clearly hear me.
B. PUPILLARYPERCEPTION
Upon shining the penlight directly to the left side of the pupil, the
pupil constricted and when I turned off the light, it dilated. He has a good
accommodation too. I asked him to focus on a distant object (my ballpen)
and refocused on the near object. He clearly saw it and his pupils are
round and equal too as they constrict and dilates.
C. SPEECH PERCEPTION
He has no speech abnormalities. During one interview, I assessed
that he pronounced Sinug and even some English words well.
D. GUSTATORY PERCEPTION
I was not able to assess sense of taste since he is in liquid diet. He
just told us that PTA, foods like rice tasted a little bit bitter for him since
he has anorexia.
E. VISUAL PERCEPTION
He is clear-sighted. I stood approximately 6 feet away from him and
asked him to look at the name of the object I am holding which is a ballpen,
and then he told me that he can see it and named it correctly.
F. TACTILE PERCEPTION
His tactile perception is intact. Jacqueline rubbed a cotton ball
above the skin surface of his left hand and asked him if he feels it.
Fortunately, he felt it. I also pinched the skin to test if he is reactive to
pain, then I found out he is because of his facial grimace.
G. OLFACTORY PERCEPTION

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He can smell well. I closed his one nose and introduce a fragrant of
cologne on the left nose then I asked him the fragrance or odor, he said,
“Mahamut”. Then I do it on the other side and he uttered the same.
3. RESPIRATORY SYSTEM
His respiratory rate is written normal level which is 23 breaths per minute.
It is regular and effortless. Breath sound is noiseless.

4. CARDIOVASCULAR SYSTEM
Heart rate is 82 beats per minute and is normal in depth. It is regular.
Blood pressure is 130/90mmHg and is slightly above the normal value which is
120/80mmHg.
5. NUTRITIONAL STATUS
Skin is dry and slightly rough. Nasal mucous membrane is dry too. Nails
have slightly surface and pink in color. Height is 5’6 ft and lost much weight
since illness started. His weight before was 120 lbs but now he is only 100 lbs.
Body temperature is 37.1 C.
6. ELIMINATION STATUS
My patient defecated last Tuesday and Wednesday through the colostomy
site. The characteristics of his stool were yellow in color, semi-formed and
moderate in amount. After that, he did not anymore pass stool. Enema was done
to him but there wa no return flow from the colostomy site which is an indication
that there was an obstruction. He voids 5 times a day. The characteristics of his
urine are yellow, hazy in transparency and scanty in amount. He does not
perspire much.
7. MOTOR ABILITY STATUS
My patient has well-coordinated body movements. His posture is good and
he is ambulatory. He needs assistance when ambulating to the comfort room.

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Notre Dame of Jolo College
NURSING DEPARTMENT
Jolo, Sulu

PEDIATRIC NURSING ASSESSMENT GUIDE

Name of Patient:__________________ Age: _____ Date of Birth: _________ Sex: ____

Address: ____________________________________ Birthplace: ____________________
Religion: ____________ Height: __________ Weight: _______
Father’s Name: _________________________ Age: _________ Occupation: _________
Mother’s Name: _________________________ Age: ________ Occupation: _________
No. of Siblings: _______ Male: _____ Female: ______ Ordinal Position in the Family:
_______

Diagnosis:
____________________________________________________________________
I. CHIEF COMPLAINTS. The reason the parents have brought the child to the
health care aganecy.
Describe at least six aspects of the problem.
1. Duration – determines when a child was last well to determine when he or she
became ill.
2. Intensity and Frequency – refers to kind of illness the child is having. Is it
drooling, spitting up or actual vomiting? How many times?
3. Description – describes the amount and color
4. Associated Symptoms
5. Action taken – helps to know whether anything a parent has been doing, has
been making the illness worse. What the parent has previously tried but found
ineffective.
II. CURRENT HEALTH STATUS
- Who is the child’s primary health care provider?
- How often is the child seen for routine health examinations?
- Are the child’s immunizations up to date? If no, state the reason why not
up to date.
- What is the child’s general state of health? How does it compare to the
child’s health 1 and 5 years ago? (If appropriate).
- Does the child have any known allergies?
- Does the child have a chronic illness or disability.
- Is the child taking any prescription medications? Over-the-counter
medications? Home or folk remedies, such as herbal remedies?
- Is the child undergoing any treatments?

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III. PAST HEALTH STATUS
 Birth history (complications during pregnancy, where delivered, who
delivered, how delivered, complications during birth process).
 Previous illness, injuries, surgeries
IV. HABIT
- Patterns of sleeping and waking

V. FAMILY HISTORY
 Composition: Other members living with the family.
( ) Grandfather ( ) Grandmother ( ) Aunt ( ) Uncle ( ) Yaya
( ) Others _______________________________
 Health History: (Check when appropriate)
( ) PTB ( ) Heart Disease ( ) Renal ( ) Asthma ( ) Allergies
( ) CA ( ) Congenital Defects ( ) DM ( ) Mental Disorder
Remarks: ________________________________
VI. KNOWLEDGE OF HEALTH NEEDS (According to S.O/Mother)
 Beliefs: Practices during illness
VII. GENERAL ASSESSMENT
A. Vital signs: T:_____ HR:_____ PR:_____ BP(Optional):______

B. GENERAL APPEARANCE
- The general appearance of the child is a cumulative subjective
impression of the child’s physical appearance, behavior, personality,
interaction with parents and nurse posture development and speech.
1. Face- the facial expression and appearance of the child. For example the
face may give clues to children who are in pain: have difficulty breathing:
feel frightened, discontented or happy: are mentally deficient or are
acutely ill.
2. Posture – position and types of body movement
- The child with hearing or vision loss may characteristically tilt the
head in an awkward position to hear or see better.
- The child in pain may favor a body part (assume in abnormal posture
for relief)
- A child with low self-esteem or a feeling of rejection may assume a
slumped careless and apathetic pose or posture. Likewise a child with
confidence a feeling of self-worth and a sense of security usually
demonstrate a tall, straight, well balanced.
- While observing such “body language” do not interpret too freely but
rather record objectively.
3. Hygiene
- Note in terms of cleanliness unusual body odor the condition of the
hair, neck, nails, teeth and feet and the condition of the clothing.

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- Such observations are excellent clues for possible instances of neglect
inadequate financial resources, housing difficulties (eg. No running
water) or lack of knowledge concerning children’s behavior.

4. Behavior
- Includes the child’s personality level of activity reaction to stress,
frustration interaction with others (primarily with parent and nurse)
degree of alertness and response to stimuli.
- What is the child’s overall personality? Does the child have a long
attention span or is he or she easily distracted? Can the child follow
two or three commands in succession without the need top repetition?
What is the response to delayed gratification or frustration? Is eye to
eye contact used during conversation? What is the child ‘s reaction to
the nurse and family member? Is the child;
- Development
- Can be assessed by carefully observing the child
- Record an overall estimate of the child’s speech development motor
skills degree of coordination and recent area of achievement.

C. PHYSICAL ASSESSMENT

1. Skin
- Is assessed for color, texture, temperature, moisture and turgor
presence of lesions
- Examination of the skin and its accessory organs primarily involves
inspection and palpation
- Several variations in skin color can occur some of which warrant
further investigation
a. Cyanosis – blush tone through skin reflects reduced
(deoxygenated) hemoglobin
b. Pallor – paleness may be a sign of anemia chronic disease edema
or shock
c. Erythema- Redness may be result of increased blood flow from
chronic conditions local caused by increased numbers of red blood
cells as a compensatory response chronic hemorrhage.
d. Ecchymosis – large diffuse areas usually black and blue its color
caused by hemorrhage or
e. Jaundice – yellow staining of the skin usually by bile pigments
- For Newborn.
a. Presence of Vernix Casiso – a white cream cheese like substance that
serves as a skin lubricant; usually noticeable on a newborn’s skin at
birth in a term neonate.
b. Lanugo – fine, downy hair that covers a newborn’s shoulders back and
upper arms
c. Acroanosis – cyanosis of hands and feet
d. Cutis marmorata – transient mottling when infant is exposed to
decreases temperature
e. Milia – Distended sebaceous glands that appear as tiny white papules on
cheeks, chin and nose
f. Miliara or Sudamina – distended sweat eccrine glands that appear as
minute vesicles especially on face
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g. Erythema Toxicum – pink popular rash with vesicles superimposed on
thorax, back, buttocks and abdomen, may appear in 24 to 48 hours and
resolve after several days.
h. Harlequin color change – clearly outlined color change as infant lies on
side lower half of body becomes pink, and upper half is pale
i. Mongolian spots – irregular areas of deep blue pigmentation usually in
sacral and gluteal regions.
j. Telangiectatic Nevi (Stork bites”) – flat, deep pink localized areas usually
seen in back of neck
k. Café – au- ait spots – light brown spots
l. Neveus flammeus – pott wine stain
- Normally the skin texture of young children is smooth, slightly dry
and not only or clammy
- Determine the skin turgor or the amount of elasticity in the skin by
grasping the skin of the abdomen between the thumb and index finger
pulling it taut and quickly releasing it. Elastic tissue immediately
assumes its normal position without residual marks or creases
- In children with poor skin turgor the skin remains suspended or
tented for a few seconds before slowly falling back on the abdomen.
- Skin turgor is one of the best estimates of adequate hydration and
nutrition

2. Accessory Structures
a. Hair
- Assess for texture, color, quality distribution and elasticity
- Genetic factors affect the appearance of the hair
- Record any bald or thinning spots, loss of hair in infants may indicate
lying in the same position and may be a clue for a counseling parents
concerning the child’s stimulation needs
- Various ethnic groups condition their hair with oils or lubricants
when if not thoroughly
- Also examine for lesions scaliness, evidence of infestation such as lice
or ticks and signs of trauma such as ecchymosis, masses or scats.
- In children who are approaching puberty look for growth of secondary
hair as assign of normally progressing pubertal changes. Note
precocious or delayes appearance of hair growth because although not
always suggestive of hormonal dysfuntion it may be of great
concerned the early or late-maturing adolescent.
b. Nails
- Inspect the nails for color, shape, texture and quality. Normally the
nails are pink convex smooth and hard but flexible (not brittle). The
edges which are usually white should extend over the fingers.
- Dark skinned individuals may have more deeply pigmented nail beds.
Short, ragged nails are typical of habitual biting. Uncut, dirty nails
are sign of poor hygiene.

3. Lymph Nodes
- Lymph nodes are usually assessed when the part of the body in which
they are located in examined

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- Palpate nodes by using the distal portion of the fingers and gently but
firmly pressing in a circular motion along the regions where nodes are
normally present
- During assessment of the nodes in the head and neck tilt the child’s
neck upward slightly but without tensing the
STERNOCLEIDOMASTROID or TRAPEZIUS MUSCLES. This position
facilitates palpation of the SUMENTAL, SUBMAXILLARY, TONSILLAR
and CERVICAL NODES.
- Note size, mobility, temperature and tenderness as well as reports by
the parents regarding any visible change of enlkarged nodes.
- In children, small, no tender, moveable nodes are usually normal
- Tender, enlarged, warm lymph nodes generally indicate infection or
inflammation close to their location

4. Head and Neck

- Observe the head for general shape and symmetry
- A flattening of one part of the head such as the occiput may indicate
that the child _______ lies in this position. Marked asymmetry is
usually abnormal and may indicate premature closure of the sutures
(CRANIOSYNOTOSIS).
- Note the head control in infants and head posture in older children.
Most infants ______ age should be able to hold the head arect and in
midline when in vertical position
- Evaluate range of motion by asking the older child to look in each
direction (to ____ ____ ____ and down) or manually putting the
younger child through each position.
- Limited range of motion may indicate WRYNECK or TORTICOLLIS a
result of injury to the sternocleidomastoid muscle in which the child
holds the heads to one with the ______ toward the opposite side.
- Palpate the skull for patent sutures, fontanels, fractures and
swellings.
- Normally the posterior fontanel closes by the second month of life and
the anterior fontanel fuses between 12 and 18 months of age. Early or
late closure is noted since either may be a sign of pathologic condition
- While examining the head, observe the FACE for symmetry movement
and general appearance.
- Ask the child to “make a face” to assess symmetric movement and
disclose any degree of paralysis. Note any unusual facial proportion
such as an unusually high or low forehead wide or close-set eyes or
small receding chin.
- In addition to assessment of the head and neck for movement inspect
the neck for size and palpate it for associated structures.
- The neck is normally short with skinfolds between the head and
shoulders during infant however, it lengthens during the next 3 to 4
years. Presence of perspiration ________.

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5. EYES
- Inspect the LIDS for proper placement on the eye. When the eye is open the
upper lid should fall near the upper iris. When the eyes are closed the lids should
completely cover the cornea and sclera.
- Inspect the inside of the lids. To examine the lower conjunctiva sac, pull the lid
down while the patient looks up. To avert the upper lid hold the upper lashes
and gently pull down and forward as the child looks down.
- Normally the CONJUNCTIVA appears pink and glossy. Vertical yellow striation
along the edge are the MEIBOMIAN or SEBACEOUS GLANDS near the hair
follicle.
- Located in the inner or medial canthus and situated on the inner edge of the
upper and lower lids is a tiny opening, the LACRIMAL PUNCTUM. Note any
excessive tearing discharge of inflammation of the lacrimal apparatus.
- The BULBAR CONJUNCTIVA, which covers the eye up to the limbus or junction
of the cornea and sclera should be transparent.
- The SCLERA or white covering of the eyeball, should be clear. Tiny black marks
in the sclera of heavily pigmented individuals are normal.
- The CORNEA or covering of the iris and pupils should be clear and transparent.
Record opacities because they can be signs of scarring or ulceration which can
interfere with vision. The best way to test for opacities is to illuminate the eyeball
by shining a light at an angle obliquely toward the cornea.
- Compare the PUPILS for the size, shape and movement. They should be round
clear and equal. Test their REACTION TO LIGHT by quickly shining a source of
light toward the eye and removing it. As the light approaches the pupils should
CONSTRICT, as the light fades the pupils should DILATE.
- Test the pupil/ any response of ACCOMODATION by having the child look at a
bright shiny object at a distance and quickly moving the subject toward the face.
The pupils should constrict as the object is brought near the eye. Normal findings
on examination of the pupils maybe recorded as PERRLA, which means “PUPILS
EQUAL, ROUND, REACT to LIGHT and ACCOMODATION.
- Inspect the IRIS and pupils for color, size, shape and clarity. Permanent eye
color is usually established by 6 to 12 months of age. As the iris and pupils are
inspected look for the LENS. Normally the lens is not visible through the pupils.

6. Ears
- The entire external earlobe is called the PINNA or AURICLE and is located on
each side of the head.
- Measure the HEIGHT alignment of the pinna by drawing an imaginary line from
the outer orbit of the eye to the occiput or most prominent protuberance of the
skull. The top of the pinna should meet or cross this line.
- Low set ears are commonly associated with renal anomalies or mental
retardation.

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- Normally the pinna extends slightly outward from the skull. Except in newborn
infants ears that are flat against the head or pronating away from the scalp may
indicate problem.
- Flattened ears in infants may suggest a frequent side-lying position and just as
with isolated areas of hair loss may be a clue to investigating parents
understanding of the child situation needs.
- Inspect the SKIN surface around the ear for small opening, extra tags of skin
or sinuses. If a sinus is found, note this because it may represent a fistula that
drains into some area of the neck or ear.
- Cutaneous tags represent no pathologic process but may cause parents
concern in terms of the child’s appearance.
- Also assess the ear for HYGIENE. An otoscope is not necessary for looking into
the external canal to note the presence of CERUMEN. A waxy substance
produced by the common glands in the outer portion of the canal. Cerumen is
usually yellow-brown and soft. If otoscope is used and any discharge is seen, its
color and odor are noted.
7. Nose
- The nose is located in the middle of the surface just below the eyes and above
the lips. Compare its placement and alignment by drawing an imaginary vertical
line from the center point between the eyes down to the notch of the upper lip.
- The nose should lie exactly vertical to this line, with each side exactly
symmetric.
- Notes its location, any deviation to one side and symmetry in overall size and
in diameter of nares (nostrils).
- The BRIDGE of the nose is sometimes flat in Asian and black children. Observe
the ALAE NASI for any sign of flaring, which indicates respiratory difficulty.
Always report any flaring of the alae nasi.
8. Mouth and Throat
- The major structure of the exterior of the mouth is the LIPS. The lips should be
moist, soft, smooth, and pink, the color of the deeper hue then the surrounding
skin.
- The lips should be symmetric when relaxed or tensed. Assess symmetry when
the child talks or cries.
- The major structures that are visible within the oral cavity and oropharynx are
the MUCOSAL lining of the lips and cheeks, gums or gingival teeth, tongue,
- Inspect all areas lined with MUCOUS MEMBRANES (inside the lips and cheeks,
gingival underside of the tongue, palate and the back of the pharynx) for the
color, any area of white patches or ulceration, bleeding, sensitivity, and moisture.
The membranes should be bright pink, smooth, glistening, uniform and moist.
- Inspect the TEETH for number in each dental arch. For hygiene and for
occlusion or bite. Discoloration of tooth enamel with obvious plaque (whitish
coating on the surface of the teeth) as a sign of poor dental hygiene and indicates
a need for counselling.
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- Brown spots in the crevices of the crown of the tooth or between the teeth may
be caries, (cavities).
- Chalky white to yellow or brown areas on the enamel may indicate fluorosis
(excessive fluoride indigestion).
- Teeth that appear greenish black may be stained temporarily from indigestion
of supplemental iron.
- Examine the GUMS (gingiva) surrounding the teeth. The color is normally coral
pink and the surface texture is tripled. Similar to the appearance of orange peel.
- In dark skinned children the gums are more deeply colored and brownish area
is often observed along the gum line.
- Inspect the TONGUE for the presence of papillae small projection that contain
several taste buds and give the tongue its characteristics rough appearance. Note
the size and mobility of the tongue. Normally the tip of the tongue should extend
to the lips or beyond.
9. Chest
- Inspect the chest for the size, shape, symmetry, movement, breast
development, and the presence of the bony landmarks formed by the ribs and
sternum.
- Measure the SIZE of the chest by placing the measuring tape around the rib
cage at the nipple line. Chest measurement is important mainly in comparison
with its relationship to head circumference.
- Note for any altered chest shape: BARREL CHEST (chest is round) or PIGEON
CHEST (sternum protrudes outward).
- During infancy the shape of the chest is almost circular, with the
anteroposterior (front-to back) diameter equaling the transverse or lateral (side
to side) diameter. As the child grows the chest normally increases in the
transverse direction, causing the anteroposterior diameter to be less than the
lateral diameter.
- MOVEMENT of the chest wall should be symmetric bilaterally and coordinated
with breathing. During inspiration the chest rises and expand the diaphragm
descend and the costal angle increases. During expiration the chest falls and
decreases in size the diaphragm rises and the costal angle narrows.
- In children under 6 or 7 years of age respiratory movement is principally
abdominal or diaphragmatic. In older children particularly girls respiration are
chiefly thoracic. In either type, the chest and abdomen should rise and fall
together. Note any asymmetry of movement 10 lungs.
- Inspection of the lungs primarily involves observation of respiratory
movements.
- Evaluate respirations for rate (number per minute), rhythm (regular irregular
or periodic) depth (deep or shallow) and quality (effortless, automatic, difficult or
labored).
- Note the character of breath sounds such as noisy, grunting, snoring or heavy.

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11. Heart
- Evaluate heart sound for
A) Quality – clear and distinct, not muffled, diffuse or distant
b) Intensity – should not be weak or pounding
C) Rate – should be the same as the radial pulse
D) Rhythm – regular and even

12. Abdomen
- Examination of the abdomen involves inspection, followed by auscultation and
then palpation.
- Perform palpation last because it may distort the normal abdominal sounds.
- Observe movement of the abdomen. Normally chest and abdominal movement
are synchronous. In infants and thin children PERISTALTIC WAVES maybe
visible through the abdominal wall they are best observed by standing at eye
level to and across from the abdomen.
- Examine the UMBILICUS for size, hygiene and evidence of any abnormalities
such as HERNIAS. The umbilicus should be flat or only slightly protruding.
- The most important finding to listen for is PERISTALSIS or BOWEL SOUNDS
which sound like short metallic clicks and gurgle. Bowel sounds may be
stimulated by stroking the abdominal surface with a fingernail.
- Absence of bowels sound or HYPERPERISTALSIS usually denotes as abdominal
disorder.
13. Genitalia
- Discharge or difficulty in the urinating
14. Back and Extremities:
A) Spine
- The general curvature of the spine is noted. Normally the back of newborn is
rounded or C shaped from the thoracic and pelvic curves.
- Marked curvatures in posture are abnormal
1) Scoliosis – lateral curvature of the spine, is an important childhood problem
especially in girls.
- Inspect the back especially along the spine for any tuft of hair, dimples or
discoloration.
B) Extremities
- Inspect each extremity for symmetry of length and size. Count the fingers and
toes to be certain of the normal number.
- Extra Digit (POLYDACTYLY)
- Fusion of digits (SYNDACTYLY)
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- Inspect the arms and legs for TEMPERATURE and COLOR which should be
equal in each extremity, although the feet may normally be colder than the
hands.
15. Nutritional Status
- Quantity and quality of food given
- Breastfeeding or bottle feed. How many bottles 24 hours dilution type of milk
- Describe a typical day meal. Listening what the child ate for each meal and
between meals as well.
16. Elimination Pattern
- Color, amount, odor, consistency and frequency
- Stool, urine and perspiration
17. Motor Ability Status: Gait, posture and body movements
18. Laboratory and Diagnostic Test Results
- Blood studies (CBC, hematocrit, FBS, Blood chemistry)
- Urinalysis tools analysis
- Sputum

GROWTH AND DEVELOPMENT MILESTONES

Actual Observation (or as related by Document Readings and Resources
S.O.)
Time started
Time ended

Motor Development
- Gross motor
- Fine Motor
- Play activity/ socialization

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