Nursing Systems Physical Assessment

Area Assessed Head: Hair distribution color texture Scalp Size and shape Motor portion of cranial nerves VII(facial nerve) Neck: Position,Symmetrical Range of motion Lymph nodes

Actual Findings Long and evenly distributed Black Smooth Clean and dry Symmetrical,rounded,head positioned at midline with no lumps,lesions and parasites Symmetrical smile,frown, and forehead wrinkles; Equal puffing out of cheeks Head centered symmetrical Smooth movements without discomfort Small,round,soft,mobile,non-tender lymph nodes

Area Assessed Eyes: Visual acuity

eyelids

eyelashes eyebrows Cornea Ears Ear canal opening Hearing acuity

Actual Findings Presence of eyebags Parallel to each other PERRLA-Pupils Equally Round React to light Accommodation Same color as the skin Eyelids close completely No lesions,scaling of inflammation Distributed evenly and curved outward Symmetrical in size,extension,hair texture and movement Clear transparent cornea Free of lesions, discharge or inflammation Canal walls pink Patient normally hears word when whispered

Area Assessed Nose Size,shape and skin color Nares Mouth and Pharynx

Actual Findings No bumps,lesions,edema or tenderness Smooth,symmetric with same color as face Oval,symmetric and without discharge. Flaring of nostrils. light pink,dry,symmetric

lips Buccal mucosa Gums tongue teeth Pink,moist Slightly pink color,moist and tightly fit against each other Moist,slightly rough tongue with a midline depression Firmly set,shiny with tooth decay

Area Assessed Anterior Thorax: Skin tone symmetry Clients position Percuss over the anterior thorax axillae Posterior Thorax: Skin tone Shoulder blades Palpate over the posterior thorax scapulae Symmetry of chest expansion Accessory muscle used during respiration

Actual Findings Even brown skin tone. Smooth surface,no lesions and lumps Symmetrical placement of all structures. Client sits up with arms in lap dull over the area Symmetrical axillae without hair, no lesions Even skin tone Bilaterally equal shoulder height firm, smooth surface, no lesions and lumps symmetrical Equal chest expansion Accessory muscle(shoulder) used during respiration

Area Assessed Upper Extremities: Skin tone Ask patient to extend the arms forward and then rapidly turn the palms up and down Fingers, wrist and elbow joints Color, shape of finger nails Place two fingers in each of the patients palms while the patient squeezes your fingers

Actual Findings Uniform color,texture without lesions, only a yellowish bruise on her right arm Steady arms without tremors or pronator drift Smooth. Freely movable joints without edema Pink nail beds with smooth rounded nails Bilaterally equal hands strength

Area Assessed Abdomen: Abdominal contour Skin characteristics Bowel sounds Palpate kidneys on each side of the abdomen Palpate the liver at the right intercostals border Palpate for spleen at the left costal border

Actual Findings rounded contour Symmetrical contour without lesions, rash; presence of stretch mark Normal bowel sounds in four quadrants; no bruits Non-palpable kidneys; or solid firm Non-palpable liver;or smooth firm Non-palpable spleen

Area Assessed Lower extremities: Skin tone Hair and nail growth edema Lesion and lumps

Actual Findings Pallor Symmetrical hair and nail growth Bilaterally pitting edema No lesions or lumps

Subjective:

Communication: Okay ra ako panan-aw og klaru ako pagdungog as verbalized by the patient Subjective: Oxygenation: Kailangan pa ko mugamit sa oxygen support as verbalized by the patient

Subjective: Circulation: osahay muhu.ot ako dughan as verbalized by the patient.

Subjective: Nutrition: daghan man ko makaun pero dili lang naho hutdon and sud.an sa platoas verbalized by the patient.

Subjective: Elimination: ok ra ako pagpangihi as stated by the patient. Subjective: Skin Integrity: wala man koy samad samad as verbalized by the patient. Subjective: Activity/Safety: malipong ko osahay as verbalized by the patient.

Objective: Pupil size : Right: 3cm Left: 3cm Reaction: Bilateral eyes are equally round black reactive to light accommodation. Patient was able to answer the questions well when interviewed. Objective: Describe: The patient has irregular respiration. RR= 35 cpm, PR=90 bpm. Having a normal breathing sound of bronchial. The patient denies the presence of coughing. Objective: Heart Rhythm: The patients heart rhythm is regular with the presence of discomfort and pain. The patient scores the pain with 6 and we scores 3 as moderate pain. Guarded movement of the heart BP= 100/70 mmHg, HR= 90 bpm Objective: The patient only takes 4-5 spoons of rice and drinks half water of the glass. The patient has complete upper teeth while she lost 1 bicuspid and 1 molar of her lower teeth. Objective: Patient has less fluid intake, urinates 3x a day and defecates only when she needs to. Color of urine is yellow. Consistency of stool is soft, and color yellow. Objective: Patient has moist skin with brown pigmented skin tone. She has a bruise on her right arm of a yellowish color. Objective: Patients activity was limited sitting on bed. Patient claims for dizziness and can take only to 2-3 steps without the oxygen support.

Sujective: Comfort/Sleep/Awake: maglisod ko matulog kung muhigda sa kama.mas ok maglingkod og porma As verbalized by the patient. Subjective: Coping: nakasabot man ko sa aho sitwasyon as verbalized by the patient

Objective: Patient claims to sleep for 4-5 hours at night and has a difficulty in breathing when lying on bed. Objective: She shares her problems to her father. She verbalizes her feelings. Patient is taking her medications religiously. Seen patient always smiling during nursing rounds.

LABORATORYEXAMINATIONS HEMATOLOGY REPORT EXAMINATION HEMOGLOBIN RESULT REFERENCE VALUE (M) 13.0-18.0gm/L (F) 12.0-16.0gm/L DATE: July 28, 2012 HEMATOCRIT 10.7 less than the normal range (M)0.40-0.54 (F) 0.37- 0.47 5-10x10g/L (M) 4.5-6.0 (F) 4.0-5.5x 10^/L 140-440x10/L less than the normal range Above the normal range less than the normal range SIGNIFICANT

0.31

WBC RBC

15.99 3.43

Thrombocytes (platelets) Differential Count Neutrophil

537

Above the normal range. less than the normal range Above the normal range Within the normal range Within the normal range

0.45

0.51-0.67

Lymphocyte Monocyte Eosinophils

0.46 0.06 0.03

0.25-0.40 0.02-0.08 0.01-0.06

Examination Mean Cell Vol. (MCV) Mean Cell Hgb. (MCH) Mean Cell Hgb. Conc.

Results 83.73 31.19 372.51

REFERENCE VALUE 80.0-100.0 fl 27.0-34.0 pg 330-350 g/l

SIGNIFICANT Within the normal range Within the normal range Above the normal range

Urinalysis Examination Macroscopic Color Transparency Reaction Specific gravity Glucose Protein Result yellow cloudy 6.0 1.020 Negative 2+ Reference Value Pale yellow to amber Clear to slightly hazy 4.5-8.0 1.015-1.025 Negative negative Significant Normal Abnormal Normal Normal Normal Abnormal