PEROS SUBJECTIVE

DAY 1 OBJECTIVE PROBLEM IDENTIFIED OBJECTIVE

DAY 2 PROBLEM IDENTIFIED OBJECTIVE

DAY 3 PROBLEM IDENTIFIED

General Health Survey

malipong ko usahay. As verbalized by the patient

66 years old male, weighs 51.3 kgs Conversant yet weak, no signs of distress. Patient has symmetrical facial features, posture erect, and head midline, both feet point straight ahead with Grade 1 pitting edema on both lower extremities, all movements coordinated and smooth. Patient feels weak yet responds appropriately. Speech is clear but not loud. Patient is in proper dress and grooming. Unusual odors noted. Patient is alert and is oriented to time, place and person. Height is 5 feet 6 inches. Patient cannot recall past weight.

Body Image Disturbance Fluid Volume Excess

66 years old male, weighs 51.3 kgs Conversant yet weak, no signs of distress. Patient has symmetrical facial features, posture erect, and head midline, both feet point straight ahead with Grade 2 pitting edema on both lower extremities, all movements coordinated and smooth. Patient feels weak yet responds appropriately. Speech is clear but not loud. Patient is in proper dress and grooming. No usual odors noted. Patient is alert and is oriented to time, place and person. Height is 5 feet 6 inches. Patient cannot

Body Image Disturbance Fluid Volume Excess

66 years old male, weighs 51.3 kgs Conversant yet weak, no signs of distress. Patient has symmetrical facial features, posture erect, and head midline, both feet point straight ahead with Grade 2 pitting edema on both lower extremities, all movements coordinated and smooth. Patient feels weak yet responds appropriately. Speech is clear but not loud. Patient is in proper dress and grooming. No usual odors noted. Patient is alert and is oriented to time, place and person. Height is 5 feet 6 inches. Patient cannot

Body Image Disturbance Fluid Volume Excess

recall past weight. Integumentary System wala man koy rashes, dili pod ko magkatolkatol og singtanon. Usahay kay mainitan ko kanang mag gardengarden ko. Dili man pod ko nag-gamit anang sunblock. As verbalized by the patient Skin color is tan and is uniform with slightly darker exposed areas. Senile skin turgor, skin scaly and dry on both upper and lower extremities. Hair is evenly distributed to all over the body. Hair in the head is evenly distributed, in gray color, short and nonbrittle, smooth and shiny, no presence of lice and dandruff. Scalp is intact and no lesions or masses as palpated. Nails on fingers and toes are yellow, dry, and brittle with longitudinal ridges. Skin warm to touch. Edema is observed on right metacarpal and both and both lower extremities Grade 1 pitting edema, Axilliary temperature is 36.0 C. Skin color is tan and is uniform with slightly darker exposed areas. Senile skin turgor, skin scaly and dry on both upper and lower extremities. Hair is evenly distributed to all over the body. Hair in the head is evenly distributed, in gray color, short and nonbrittle, smooth and shiny, no presence of lice and dandruff. Scalp is intact and no lesions or masses as palpated. Nails on fingers and toes are yellow, dry, and brittle with longitudinal ridges. Skin warm to touch. Edema is observed on both upper extremities Garde 1 and lower extremities Grade 2 pitting edema, Axilliary temperature is 36.9 C.

recall past weight. Skin color is tan and is uniform with slightly darker exposed areas. Senile skin turgor, skin scaly and dry on both upper and lower extremities. Hair is evenly distributed to all over the body. Hair in the head is evenly distributed, in gray color, short and nonbrittle, smooth and shiny, no presence of lice and dandruff. Scalp is intact and no lesions or masses as palpated. Nails on fingers and toes are yellow, dry, and brittle with longitudinal ridges. Skin warm to touch. Edema is observed on both lower extremities Grade 2 pitting edema, Axilliary temperature is 37.0 C. Impaired skin integrity Impaired tissue integrity Fluid Volume Excess

Impaired skin integrity Impaired tissue integrity Fluid Volume Excess

Impaired skin integrity Impaired tissue integrity Fluid Volume Excess

HEENT a. Head and

Face

dili man sakit akong ulo og nawong kung imong hikapon. As verbalized by the patient

Head is normocephalic, symmetrical and facial movements and features are symmetrical, no lesions and pigmentations, scaliness and lump on scalp.

No problem identified

b. Eyes

Makakita man japon ko, pero pag magbasa k okay mag gamit ko og antepara. As verbalized by the patient

Eyes clear and bright, in proper alignment, eye lashes are present, evenly distributed and curving outward, sclera is white. Not able to assess visual acuity due to lack of equipments (Snellen Eye Chart). Peripheral vision in both eyes and all fields. Light is symmetrical on each cornea when assessed corneal light reflex. Gaze is steady when eye is covered and uncovered. No drifting noted. Parallel movements of eyes in all directions. No presence of redness, swelling and discharges noted. No periorbital

No problem identified

Head is No problem identified normocephalic, symmetrical and facial movements and features are symmetrical, no lesions and pigmentations, scaliness and lump on scalp. Eyes clear and bright, No problem identified in proper alignment, eye lashes are present, evenly distributed and curving outward, sclera is white. Not able to assess visual acuity due to lack of equipments (Snellen Eye Chart). Peripheral vision in both eyes and all fields. Light is symmetrical on each cornea when assessed corneal light reflex. Gaze is steady when eye is covered and uncovered. No drifting noted. Parallel movements of eyes in all directions. No presence of redness,

Head is normocephalic, symmetrical and facial movements and features are symmetrical, no lesions and pigmentations, scaliness and lump on scalp. Eyes clear and bright, in proper alignment, eye lashes are present, evenly distributed and curving outward, sclera is white. Not able to assess visual acuity due to lack of equipments (Snellen Eye Chart). Peripheral vision in both eyes and all fields. Light is symmetrical on each cornea when assessed corneal light reflex. Gaze is steady when eye is covered and uncovered. No drifting noted. Parallel movements of eyes in all directions. No presence of redness,

No problem identified

No problem identified

edema.

swelling and discharges noted. No periorbital edema. No problem identified Helix of ear is level with inner and outer canthus of eye. Ears are intact, no lesions and discharges noted. Consistent with skin color. Ears are soft and pliable. Shape is symmetrical, midline. No presence of masses and displacement of bone and cartilage. Can distinguish scent. O2 inhalation 2L/min via nasal cannula. No problem identified

swelling and discharges noted. No periorbital edema. Helix of ear is level with inner and outer canthus of eye. Ears are intact, no lesions and discharges noted. Consistent with skin color. Ears are soft and pliable. Shape is symmetrical, midline. No presence of masses and displacement of bone and cartilage. Can distinguish scent. O2 inhalation 2L/min via nasal cannula. No problem identified

c. Ears

makadungong man ko Helix of ear is level with og tarong. As verbalized inner and outer canthus by the patient of eye. Ears are intact, no lesions and discharges noted. Consistent with skin color. Ears are soft and pliable. wala may deperensya akong ilong, maglisod lng ko ginhawa sauna. As verbalized by the patient Shape is symmetrical, midline. NGT in place right nares with greenish black discharges. No presence of presence of masses and displacement of bone and cartilage. Can distinguish scent. Lips midline, symmetrical, dry and intact. Gums pinkish in color as well as the tonsils and uvula. There is presence of carries and decays. Oral mucosa and gums pink no bleeding noted. Tongue is midline and

d. Nose

Impaired swallowing

Ineffective airway clearance

Ineffective airway clearance

e. Oral Cavity

wala man ko pustiso, wala pod ka paycheckup og dentist. As verbalized by the patient

Body Image Disturbance

Lips midline, symmetrical, dry and intact. Gums pinkish in color as well as the tonsils and uvula. There is presence of carries and decays. Oral mucosa and gums pink no bleeding noted. Tongue is

Body Image Disturbance

Lips midline, symmetrical, dry and intact. Gums pinkish in color as well as the tonsils and uvula. There is presence of carries and decays. Oral mucosa and gums pink no bleeding noted. Tongue is

Body Image Disturbance

Neck

wala ra y burot-burot, dili pod sakit. As verbalized by the patient

can move up, down and in both sides. Patient is currently on NPO. Neck erect, midline, no lumps, bulges, or masses. Thyroid not visible. No distended veins. Trachea is midline. Head can move in all directions. Lymph nodes not palpable. Chest is symmetrical in appearance with symmetrical rise and fall when breathing, skin is intact. Patient rib cage is visible due to thin and senile skin. No sternal and intercostals retraction or bulging. Equal chest expansion, upon auscultation. Clear breath sounds, no crackles, wheezes or rubs. Respiratory rate is 14.

No problem identified

Respiratory System

sauna atong wla pko na admit, sakit akong dughan inig ginhawa. Karon kay dili naman. As verbalized by the patient

Ineffective airway clearance Impaired gas exchange

midline and can move up, down and in both sides. Neck erect, midline, no lumps, bulges, or masses. Thyroid not visible. No distended veins. Trachea is midline. Head can move in all directions. Lymph nodes not palpable. Chest is symmetrical in appearance with symmetrical rise and fall when breathing, skin is intact. Patient rib cage is visible due to thin and senile skin. No sternal and intercostals retraction or bulging. Equal chest expansion, upon auscultation. Clear breath sounds, no crackles, wheezes or rubs. Respiratory rate is 16.

No problem identified

Ineffective airway clearance Impaired gas exchange

midline and can move up, down and in both sides. Neck erect, midline, no lumps, bulges, or masses. Thyroid not visible. No distended veins. Trachea is midline. Head can move in all directions. Lymph nodes not palpable. Chest is symmetrical in appearance with symmetrical rise and fall when breathing, skin is intact. Patient rib cage is visible due to thin and senile skin. No sternal and intercostals retraction or bulging. Equal chest expansion, upon auscultation. Clear breath sounds, no crackles, wheezes or rubs. Respiratory rate is 16.

No problem identified

Ineffective airway clearance Impaired gas exchange

Cardiovascular System

sauna atong wla pko na admit, sakit akong dughan inig ginhawa. Karon kay dili naman. As verbalized by the patient

Edema not present on other parts of body except for upper and lower extremities. No jugular vein distention, capillary refill time is less than 2 sec. Pulses on upper extremities are strong and bounding with 65 bpm. Pulses on lower extremities are not assessed due to edema. No adventitious and extra heart sounds, regular rhythm, no bruit and thrills. BP- 90/60 P65bpm

Fluid Volume Excess

Breast and Axilla

wala may burot og sakit. As verbalized by the patient

Breast symmetrical, consistent with color, nipples pointing on direction, no lesions and discharges and is midclavicular line. Areola and nipple darker than breast tissue.

No problem identified

Edema not present on other parts of body except for upper and lower extremities. No jugular vein distention, capillary refill time is less than 2 sec. Pulses on upper extremities are strong and bounding with 62 bpm. Pulses on lower extremities are not assessed due to edema. No adventitious and extra heart sounds, regular rhythm, no bruit and thrills. BP- 100/80 P- 62bpm Breast symmetrical, consistent with color, nipples pointing on direction, no lesions and discharges and is midclavicular line. Areola and nipple darker than breast tissue.

Fluid Volume Excess

No problem identified

Edema not present on other parts of body except for upper and lower extremities. No jugular vein distention, capillary refill time is less than 2 sec. Pulses on upper extremities are strong and bounding with 65 bpm. Pulses on lower extremities are not assessed due to edema. No adventitious and extra heart sounds, regular rhythm, no bruit and thrills. BP- 90/60 P65bpm Breast symmetrical, consistent with color, nipples pointing on direction, no lesions and discharges and is midclavicular line. Areola and nipple darker than breast tissue.

Fluid Volume Excess

No problem identified

Gastointestinal System/ Abdomen

sauna kay taga 3 araw ko makalibang. Kron kay maglisod ko og libang. As verbalized by the patient

Can t assess if patient can swallow due to NPO status, globular abdomen and round contour, umbilicus in midline, inward and no herniation noted. No abdominal movements, no bruit sounds, normoactive bowel sounds. RUQ- 10 LUO- 10 RLQ- 12 LLQ- 13 Suprapubic catheter in place draining yelloworange output. Patient complains pain in site of incision.

Bowel Incontinence Pain Impaired skin integrity

Patient can swallow globular abdomen and round contour, umbilicus in midline, inward and no herniation noted. No abdominal movements, no bruit sounds, normoactive bowel sounds. RUQ- 11 LUO- 11 RLQ- 12 LLQ- 13 Suprapubic catheter in place draining straw yellow output.

No problem identified

Genitourinary System

sakit og lisod inig pangihi sauna pero karon kay naka catheter naman ko. As verbalized by the patient

Input: Output: Genitalia light brown in color. Edema is present in scrotum. Appears red and is swelling. Foley bag catheter draining yellow colored urine.

Pain Fluid volume excess Sexual dysfunction

Input: Output: Genitalia light brown in color. Edema is present in scrotum. Appears red and is swelling. Foley bag catheter draining yellow colored urine.

Pain Fluid volume excess Sexual dysfunction

Patient can swallow globular abdomen and round contour, umbilicus in midline, inward and no herniation noted. No abdominal movements, no bruit sounds, normoactive bowel sounds. RUQ- 11 LUO- 11 RLQ- 12 LLQ- 13 Suprapubic catheter in place draining straw yellow output and patient was able to have bowel elimination with yellow colored stool, watery and is moderate in amount. Patient complains pain in site of incision. Input: Output: Genitalia light brown in color. Edema is present in scrotum. Appears red and is swelling. Foley bag catheter draining yellow colored urine.

Pain Impaired skin integrity

Pain Fluid volume excess Sexual dysfunction

Musculoskeletal System

sakit man to akong luyo saw ala pko na admit. As verbalized by the patient

Posture erect, head midline with ectomorph nody. Pitting edema Grade 1 on right ulnar hand and both lower extremities. Patient can move legs up and down. Can perform pronation and supination of hand, finger to thumb and is able to identify sharp and dull objects. weak

Fatigue Risk for fall Activity Intolerance Fluid Volume Excess

Neurologic System

kapoy man ako lawas kron. As verbalized by the patient

A. Balance Patient can t perform the heel-to-toe walking, tandem walking, Romberg s test, hop in one foot and heel tracing due to weakness of the body. Patient can perform accurately touching examiner s finger and his nose, can alternately touch his own fingers but can t perform rapidly. B. Strength Left arm muscle

Fatigue

No problem identified

Posture erect, head midline with ectomorph nody. Pitting edema Grade 1 on upper extremity and Grade 2 pitting edema on both lower extremities. Patient can move legs up and down. Can perform pronation and supination of hand, finger to thumb and is able to identify sharp and dull objects. weak A. Balance Patient can t perform the heel-to-toe walking, tandem walking, Romberg s test, hop in one foot and heel tracing due to weakness of the body. Patient can perform accurately touching examiner s finger and his nose, can alternately touch his own fingers but can t perform rapidly. B. Strength Left arm muscle

Fatigue Risk for fall Activity Intolerance Fluid Volume Excess

Posture erect, head midline with ectomorph nody. Grade 2 pitting edema on both lower extremities. Patient can move legs up and down. Can perform pronation and supination of hand, finger to thumb and is able to identify sharp and dull objects. weak

Fatigue Risk for fall Activity Intolerance Fluid Volume Excess

Fatigue

No problem identified

A. Balance Patient can t perform the heel-to-toe walking, tandem walking, Romberg s test, hop in one foot and heel tracing due to weakness of the body. Patient can perform accurately touching examiner s finger and his nose, can alternately touch his own fingers but can t perform rapidly. B. Strength Left arm muscle

Fatigue

No problem identified

strength is 5/5 in active motion with some resistance, right arm muscle strength 3/5. Left leg muscle strength 4/5, right leg muscle strength is 4/5 due to edema, active motion with some resistance. C. Sensory Patient can feel soft brush from the forehead towards the whole extremities. Can detect dull and sharp sensation. Patient can detect number of hands holding him; can identify objects such as coin or ballpen. D. Cranial Nerves Cranial Nerve I.Olfactory Can identify scents such as alcohol and perfume. Cranial Nerve II.- Optic Not able to assess visual acuity due to lack of equipment (Snellen Eye Chart). Peripheral vision intact in both eyes and all fields. Cranial Nerve IIIOcculomotor, IV-

No problem identified

strength is 5/5 in active motion with some resistance, right arm muscle strength 3/5. Left leg muscle strength 4/5, right leg muscle strength is 4/5 due to edema, active motion with some resistance. C. Sensory Patient can feel soft brush from the forehead towards the whole extremities. Can detect dull and sharp sensation. Patient can detect number of hands holding him; can identify objects such as coin or ballpen. D. Cranial Nerves Cranial Nerve I.Olfactory Can identify scents such as alcohol and perfume. Cranial Nerve II.Optic Not able to assess visual acuity due to lack of equipment (Snellen Eye Chart).

No problem identified

strength is 5/5 in active motion with some resistance, right arm muscle strength 3/5. Left leg muscle strength 4/5, right leg muscle strength is 4/5 due to edema, active motion with some resistance. C. Sensory Patient can feel soft brush from the forehead towards the whole extremities. Can detect dull and sharp sensation. Patient can detect number of hands holding him; can identify objects such as coin or ballpen. D. Cranial Nerves Cranial Nerve I.Olfactory Can identify scents such as alcohol and perfume. Cranial Nerve II.Optic Not able to assess visual acuity due to lack of equipment (Snellen Eye Chart).

No problem identified

Trochlear and VIAbducens Can move eyes up, down and both sides, equally round, reactive to light Cranial Nerve VTrigeminal Can sense brush on face using sharp and dull objects. Cranial Nerve VII- Facial Smiles coordinately, constructively and facial grimace appropriate, in coordinated facial structures. Cranial Nerve VIIIAcoustic Can hear examiner upon whisper test. Cranial Nerve IXGlossopharyngeal and X- Vagus Intact gag reflex, taste buds can taste sweet and bitter. Cranial Nerve XI- Spinal Accessory Muscle Ca move shoulder up but with resistance. Cranial Nerve XIIhyposglossal Tongue is midline and can move up, down and

Peripheral vision intact in both eyes and all fields. Cranial Nerve IIIOcculomotor, IVTrochlear and VIAbducens Can move eyes up, down and both sides, equally round, reactive to light Cranial Nerve VTrigeminal Can sense brush on face using sharp and dull objects. Cranial Nerve VIIFacial Smiles coordinately, constructively and facial grimace appropriate, in coordinated facial structures. Cranial Nerve VIIIAcoustic Can hear examiner upon whisper test. Cranial Nerve IXGlossopharyngeal and X- Vagus Intact gag reflex, taste buds can taste sweet and bitter.

Peripheral vision intact in both eyes and all fields. Cranial Nerve IIIOcculomotor, IVTrochlear and VIAbducens Can move eyes up, down and both sides, equally round, reactive to light Cranial Nerve VTrigeminal Can sense brush on face using sharp and dull objects. Cranial Nerve VIIFacial Smiles coordinately, constructively and facial grimace appropriate, in coordinated facial structures. Cranial Nerve VIIIAcoustic Can hear examiner upon whisper test. Cranial Nerve IXGlossopharyngeal and X- Vagus Intact gag reflex, taste buds can taste sweet and bitter.

in both sides. Patient is currently on NPO.

Cranial Nerve XISpinal Accessory Muscle Ca move shoulder up but with resistance. Cranial Nerve XIIhyposglossal Tongue is midline and can move up, down and in both sides. No limb enlargement, not pale nor flushed, no active bleeding No problem identified noted on oral mucusa, nose and rectum as observed. No lymph nodes palpated. No buffalo hump, no abnormal pigmentation, does No problem identified not sweat a lot or flushed. Grade 1 pitting edema is noted on both lower extremities.

Cranial Nerve XISpinal Accessory Muscle Ca move shoulder up but with resistance. Cranial Nerve XIIhyposglossal Tongue is midline and can move up, down and in both sides. No limb enlargement, not pale nor flushed, no active bleeding noted on oral mucusa, nose and rectum as observed. No lymph nodes palpated. No buffalo hump, no abnormal pigmentation, does not sweat a lot or flushed. Grade 1 pitting edema is noted on both lower extremities.

Lymphatic / Hematologic System

wala ra y burot-burot, dili pod sakit. As verbalized by the patient

Endocrine System

kalimot raba ko xa akong timbang sauna. as verbalized by the patient

No limb enlargement, not pale nor flushed, no active bleeding noted on oral mucusa, nose and rectum as observed. No lymph nodes palpated. No buffalo hump, no abnormal pigmentation, does not sweat a lot or flushed. Grade 1 pitting edema is noted on both lower extremities.

No problem identified

No problem identified

No problem identified

No problem identified