II.

NURSING ASSESSMENT
1. PERSONAL DATA
The patient is referred to as Patient X so as to ensure outmost confidentiality.
He and his parents were the primary source of information.
This is a case of a 14 year-old, Male, Born again Christian and natural-born
Filipino, named Patient X. He stands 5 feet and 2 inches and weighs 120 pounds. He
was born on August 12, 1997. In the family, there are 3 children and Patient X is the
eldest. He is currently a student in a school in Angeles City and he is also from Angeles
City.
It is noted from the patients medical records that on September 9, 2011 at 6:30
in the evening, he was admitted in Angeles University Foundation Medical Center due to
complaints of high fever and headache. The admitting physician assessed the patient
and has given an initial diagnosis of to consider pyelonephritis. He has the following
vital signs: BP: 90/70 mmHg, CR: 90 bpm, RR: 30 bpm and T: 39.9C.
2. PERTINENT FAMILY HISTORY
Patient X belongs to a nuclear family since he lives with his parents alone and
with his 2 siblings. Patient Xs mother gave birth to him via Normal Spontaneous
Delivery in Mabalacat, Pampanga. He has 2 siblings who were also born normally.
The patient is currently a 2 nd year high school student in one of the schools in
Angeles City, he is the 1st born child of his parents and a very good brother to his
siblings.
His parents own a business grocery somewhere in Angeles City and that serves
as the familys income. His parents didnt want to tell the average monthly income of the
family but they assured that the familys monthly budget is more than enough for their
living.
Patient X wakes up at around 6:00 in the morning. Sometimes, He cooks
breakfast for everybody in the house right after waking up when his parents leave the
house early to open their store. He then eats his breakfast, 30 minutes later. Most often,
He prefers rice and noodles. He rarely eats fish, vegetables and fruits. Also, he takes
care of his siblings and assists them with their homeworks. At round 7:15am he leaves
the house and goes to school. He gets home by 5:00 pm and rests for a while and eat

Page | 8

his merienda. At around 7:00 or 8:00 the family eats their dinner all together and
afterwards, patient X does his home works then takes a bath and gets a good night
sleepy by around 10-11pm.
Their housing condition, the mother has mentioned that their residence is owned
by Patient Xs grandmother and is handled to their care since his grandmother. It is
made of concrete materials and is full of wide windows. The mother described it as
having a backyard with mango, avocado and jackfruit trees planted. They have a toilet
facility with a mechanical flush. Their water supply is from Angeles Water System and
electric supply is from Angeles City Electric Company.
As with other Filipinos, the patient believes that he shouldnt take a bath after
school without resting his feet from socks he just worn also, he do not sleep when his
hair is still wet from shower and do not take a bath if he sweats a lot. His mother told the
student nurses that they dont believe on herbolarios and hilots. They also do not visit
the health center in their place but rather, they go straightly at AUFMC for thei medical
and health problems or issues.

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MATER

PATERN
father

Mother (+)
old age

Diabetes Mellitus

Sibling

Sibling 2

father (+)
Old age

Patient
Xs father

Mother (+)
Old age

Patient Xs

Sibling 1

Patient X
Pyelonephritis

mother

Sibling 3

(UTI)

Legend:
-Female
(+) -Deceased

-Male
-Patient

-Married

Page | 10

The family health illness history diagram above shows that on Patient Xs
paternal side, his grandfather has DM and his grandmother, died due to old age. All the
children of patient Xs paternal side, which includes patient Xs father, have no disease
condition diagnosed. Moving on the maternal side, both his grandparents died of an old
age. His mother had UTI when she was a child and his mothers siblings have no
diagnosed disease currently. Currently, Patient X is known to have Pyelonephritis.
3. PERSONAL HISTORY
Patient Xs mother has an obstetric history of G3P3 (T3P0A0L3). Similar to what has
been mentioned earlier, patient X was born via Normal Spontaneous Delivery in one of
the hospitals in Angeles City. He is the 1 st born child of his parents. Patient X was born
on his 9th month conceived by his mother.
4. HISTORY OF PAST ILLNESS
Patient X was noted to have been immunized during his childhood days making
him less prone to common childhood diseases but he already had chicken pox, measles
and mumps; his exact age when he acquired such cannot be remembered anymore both
by the patient and her mother. However, the two of them agreed that they did not consult
any health care provider because they thought of it as something that will eventually
disappear.
Not so often, he experiences fever, cough and colds, stomach ache and
headache. With these conditions, he is not much bothered and considered them as
ordinary. He takes over-the-counter medications such as paracetamol and mefenamic
acid as treatment along with simple home management like increasing oral fluid intake,
drinking kalamansi juice and having adequate rest. He was also hospitalized when he
was 4 years old because of convulsions.

5. HISTORY OF PRESENT ILLNESS

Two days prior to admission, the patient experienced fever and headache and
pain in urination with scanty amount, on the next day his temperature went up to 39.9
degrees so his parents decided to take him to the hospital. He was admitted at 6:30 in
the evening of September 9, 2011 in AUFMC. The doctor gave a diagnosis of to
Page | 11

consider pyelonephritis. With this, a urinalysis has been performed on the same day
and it was found out that the urine is dark yellow in color, is turbid, pus cells are too
numerous to count and there are 3-4/hpf RBCs. This confirms the presence of infection.
According to
6. PHYSICAL EXAMINATION
Date of Admission:
September 9, 2011
Initial physical examination (lifted from the chart, assessed and accomplished by the
Residence on Duty)
Vital signs:
BP: 90/70 mmHg
CR: 90 bpm
RR: 30 bpm
T: 39.9C
Respiratory: clear breath sounds
Gastrointestinal: (-) Ascites
Cardiovascular: (-) murmur
First Nurse-Patient Interaction:
Semptember 9, 2011
General Appearance:
Upon assessment, he was found out to have relaxed & coordinated movements,
with good over-all hygiene as seen with her tidy clothing. Patient X is cooperative, has
an appropriate affect, and speaks moderately and understandably in a logical sequence.
However, he feels nauseated.
Vital signs:
BP: 110/70 mmHg
CR: 86 bpm
RR: 27 bpm
T: 37.2C
INTEGUMENT
Skin: No odor; uniform color; unblemished skin; when pinched, skin go back to previous
state immediately; temperature is within normal limit
Hair: Evenly distributed; thin; silky; no sign of infection/ infestation
Nails: long with dirt on fingernails and toenails upon inspection; convex curve;
smooth, intact epidermis; prompt return to usual color in 2 seconds when nail beds are
pinched.
HEAD
Skull: rounded, normochepalic and symmetrical; absence of nodules or masses and
depressions; has uniform consistency upon palpation
Scalp: absence of lesions, dandruff, and pediculosis upon inspection.
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Face: symmetric facial features; no lesions or scar present; no edema noted

EYES AND VISION
Eyes: anicteric sclera, pupils equally round and reactive to light and accommodation
Eyebrows: symmetrically aligned, hair is evenly distributed and there is equal movement
upon inspection
Eyelashes: long and evenly distributed, curled slightly outward
Eyelids: skin is intact; lids close symmetrically, involuntary blinks approximately 15 per
minute
Bulbar conjuctiva: transparent; sclera appears white
Palpebral conjunctiva: shiny, smooth, pink in color
Cornea: transparent, smooth and shinny upon inspection; details of iris are visible
Pupils: Pupils equally round and reactive to light and accomodation
EARS
Auricles: color same as facial skin; symmetrical; auricle aligned with outer canthus of
eye; non tender; with presence of minimal amount of dry cerumen, no swelling, nodules
and pain. No scars or lesion present.
NOSE AND SINUSES
Nose: nares are symmetrical and are uniform in color; absence of redness and
tenderness noted, no lesions, airways are clear, intact nasal septum located in the
midline, no swelling, bleeding and discharge
Sinuses: non-tender frontal and maxillary sinuses
MOUTH AND THROAT
Teeth and gums: yellowish incomplete set of teeth (right upper molar and left upper
premolar missing); gums are pink, moist and has firm texture
Lips and buccal cavity: outer lips are uniform, pink in color; moist inner lips and buccal
mucosa is moist
Tongue: is in central position, pink in color, slightly rough, with raised papillae
Palates and uvula: light pink, smooth soft palate; lighter pink hard palate with more
irregular texture, uvula is in the midline
Oropharynx and tonsils: link and smooth posterior wall, tonsils are smooth and have no
discharge
NECK
Neck muscles: muscles are equal in size; head is centered; coordinated, smooth
movement with no discomfort
Lymph node: no enlargement and not palpable
Neck veins: not visible upon inspection, not distended upon palpation
Trachea: central placement in midline of neck; spaces are equal on both sides
Thyroid gland: not visible on inspection, ascends during swallowing but is not visible
CHEST AND THORAX
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Chest and thorax: skin is intact; no tenderness and masses noted; full and symmetric
chest expansion; normal rise and fall of chest when breathing; absence of crackles in
both lungs upon auscultation; bilateral symmetry of vocal fremitus; quiet rhytmic,
effortless respirations
Heart: normal heart rate and heart beat of 86 beats per minute, no murmurs, regular
rhythm
ABDOMEN
Abdomen: unblemished skin; uniform color; No evidence of enlargement of liver or
spleen, symmetric contour; symmetric movements caused by respirations; audible
normocative bowel sounds; absence of ascites, arterial bruits and friction rubs;
tenderness and pain on the epigatric and hypogastric area
EXTREMITIES
Upper and lower extremities: there are no signs of paralysis, able to move freely,
symmetrical in length; the muscle sizes are equal, no tremors noted, and no bone
deformities; without pitting edema
GENITOURINARY
Genitourinary: painful urination, dark yellow and turbid urine
NEUROLOGICAL EXAMINATION:
Mental assessment:
Level of consciousness: conscious and coherent, oriented with place and person
Mood and behavior: cooperative during assessment
Sensory function status:
Able to perceive and distinguish between dull and sharp sensation
Motor function:
Able to move both upper and lower extremities without difficulty
Cranial Nerves:
Cranial Nerve
I. OLFACTORY

II. OPTIC

Type and
Function
Sensory;
sense
smell

of

Sensory;
sense
vision

of

Assessment
Procedure

Expected
Result

Actual Result

Identify
the
smell
of
different
aromas
such
perfume
and
alcohol.
Read
printed
letters
from
newspaper 14
inches away

An individual
must identify
different
aromas.

Reena
identified
aromas such
as
perfume
and alcohol

Able to read
headers of a
newspaper
14
inches

Was able the

headers
of
newspaper at
14
inches
Page | 14

away.

away.

III. OCULOMOTOR

Motor;
pupillary
constriction
and rising of
the eyelids.

Make use of
penlight in order
to test pupillary
reaction
and
instruct client to
open and close
eyelids.

With the use

of penlight,
pupils
constrict to
light
while
dilates
without the
presence of
light.

Was able to
open & close
eyelids;
pupils
constrict
in
response to
presence of
light & dilate
in absence of
light.

IV. TROCHLEAR

Motor; ocular
movements

Instruct client to
look downward,
sideward,
upward,
laterally

Follow the
movement
of
the
penlight in 6
different
directions
with eyes.

The
patient
able to follow
the
movement of
the penlight in
6
different
directions
with eyes.

V. TRIGEMINAL
*opthalmic

Sensory;
sensation of
cornea, skin
of face and
nasal
mucosa

While
client
looks
upward
lightly;
touch
lateral sclera of
eye to elicit
blink reflex; to
test
light
Sensory;
sensation have
face and
client
close
anterior and
eyes; wipe a
cavity
wisp of cotton
over
the
Motor
and
forehead and
sensory
paranasal
muscle; skin
sinuses and ask
client to clench
teeth.

Must able to
blink; can
feel the wisp
of cotton to
the
forehead; be
able to feel
and
distinguish
sharp and
blunt objects
and clench
teeth.

She blinked,
distinguished
sharp & blunt
objects
&
clenched her
teeth.

Motor; lateral
movements
of the eye.

Must
be
able
to
move eyes
on
6
different

Smoothly
followed the
penlight, up,
down,
upright,
up

*maxillary branch

*mandibular branch

VI. ABDUCENS

Assess
direction
gaze.

of

Page | 15

VII. FACIAL

Motor; facial
express-ions

Sensory;
taste
(anterior 2/3
of
the
tongue)

directions.

left,
right,
left.

Ask client to
smile,
show
teeth, puff out
cheeks, purse
lips and raise
eyebrows.

Must
be
able to smile
show teeth,
puff
out
cheeks
purse
lip
and
raise
eyebrow.

Reena
was
able to smile
show teeth,
puff
out
cheeks purse
lip and raise
eyebrow.

Ask the client to

identify the
different taste
(sugar and salt)
placed on the
anterior 2/3 of
the tongue.

Must be
able to
identify the
different
taste (sugar
and salt)
placed on
the anterior
2/3 of the
tongue
Must
be
able to hear
the ticking
sound of the
second
hand of the
watch.

Also, she was

able to
identify the
different taste
(sugar and
salt) placed
on the
anterior 2/3 of
the tongue

Positive gag
reflex; able
to swallow
without pain;
able to taste
the sugar.

Gag reflex
has been
elicited with
the use of
tongue blade;
able to
swallow
without pain;
able to taste
the sugar.

VIII. VESTIBULOCOCHLEAR

Sensory;
Placed
wrist
hearing and watch near the
balance
ears and let
client hear the
second hand of
the watch.

IX.
GLOSSOPHARYNGE
AL

Motor;
pharyngeal
movement &
swallowing.
Sensory;
taste
(posterior 1/3
of
the
tongue)

Ask the client to

say ah. Ask
the client to
identify the
taste (sugar)
placed on the
posterior
tongue.
Elicit gag
response by
using tongue
blade; noted
ability to
swallow

down
down

Was able to
hear the
ticking sound
of the second
hand of the
watch.

Page | 16

X. VAGUS

Motor:
speaking
Sensory:
swallowing

Ask the client to

swallow and
speak

XI. ACCESSORY

Motor;
movement of
shoulder

Ask patient to
shrug shoulders
against
resistance from
the hand and
turn head to
side against
resistance from
the hand.

XII.HYPOGLOSSAL

Motor;
movement
and strength
of tongue

Ask the client to

protrude, retract
and move
tongue forward,
backward and
sideward.

Must be
able to
swallow
without pain
and speak
Must be
able to
shrug
shoulders
easily
against
resistance
from the
hand and
turn head to
side against
resistance
from the
hand.
Can
protrude,
retract and
move
tongue
forward,
backward
and
sideward.

Reena was
able to
swallow
without pain
and speak
She shrugged
her shoulders
easily against
resistance
from the hand
and turn head
to side
against
resistance
from the
hand.

She was able

to protrude,
retract and
move tongue
forward,
backward and
sideward.

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