Pa Mamde La Cruz

Date of assessment: November 23, 2009 PHYSICAL EXAMINATION Name: Aireen Pama Age: 30 yrs old General survey: Physical appearance/ grooming: The client wake up and eat her breakfast. The patient looks restless. There was an IV fluid of PNSS1L in her right hand. Edema and Rashes are noticeable on her face. Her eyes were half open. Facial Expression: The patient looks restless. Attitude: The patient participates in the assessment done. she shows a positive attitude and interest by asking me the rationale of the assessment. Baseline Data: 8am * Temp. : * PR : * RR : * CR : * BP :

36.5˚C 65 bpm 19 bpm 68 120/90

Head to Toe Assessment Body Parts Skin

Technique Inspection Palpation

Head

Hair

Inspection

Normal Findings fair complexion

Actual Findings Analysis -rashes on face Due to signs of and arms infected lymph in the neck. nodules absent -not totally assess Normocephalic (size -generally round NORMAL & shape proportional to the body), symmetrical in all planes

Palpation

tenderness Absence of nodules -no upon palpation & masses

Inspection

long black straight -black,evenly

NORMAL

hair equally distributed

distributed and covers the whole scalp. Thin, Smooth, not dry and has no lice

Face

Inspection

Symmetrical, oval in -Edematous face Due to poor shape blood circulation Bean-shaped, -Bean-shaped, NORMAL parallel, parallel, symmetrical, symmetrical, proportional in size proportional in of the head & face size of the head & face

Ears

Inspection

Hearing Acuity

Inspection

Able to hear voice -The patient has equally at both ears able to hear as as evidenced by eye evidence by eye movements towards movement a nurse that’s speaking. Able to hear whisper voice.

NORMAL

Eyes

Inspection

Round and black in -Round and black color cornea. in color cornea. no Proportional in size abnormal of the face no involuntary abnormal involuntary movements.movements.

NORMAL

NORMAL Eye brows

Pupils

Inspection

Present bilaterally, -Present move symmetrically bilaterally, move as the facial symmetrically as expression changes, the facial no scaling & lesions; expression evenly distributed changes, no scaling & lesions; evenly distributed

Inspection (instrument: With normal -refuse to assess penlight, and pupillary resting size pupillary of 4mm on right eye measurement attach in ruler)

NORMAL

Eye Movement

Inspection

Visual Acuity Inspection

Has spontaneous 90 -Has spontaneous degrees eye 90 degrees eye movement movement Able to visualize -the patient saw things as evidenced the nurse moving by irises following closer to her. hand movements of nurse

NORMAL

NORMAL

Nose

Inspection

Midline, symmetrical -Midline, symmetrical

NORMAL

Mouth

Inspection

Proportional to the -Proportional to face, Ulcers absent, the face, Ulcers has complete set of absent, has teeth, dental caries complete set of absent teeth, dental caries absent

NORMAL

Lips

Inspection

lip margin well - lip margin welldefined moist, defined moist, smooth lips smooth lips

NORMAL

Gums

Inspection (using penlight)

Pink gums in most - Pink gums in areas; Ulcers most areas; Ulcers absent, pinkish in absent, pinkish in color color

NORMAL

Teeth

Inspection

Intact teeth; Without -Intact teeth; caries, complete set, Without caries, teeth are white in complete set, color teeth are white in color

NORMAL

Tongue

Inspection

Reddish lesions; movable

NORMAL

&

no -freely movable freely red in color.

NORMAL Voice

Inspection

Normal voice tone; -Normal voice Hoarseness absent tone; Hoarseness absent

Neck

Inspection

Head position is - Head position is Mass is present center to the midline, center to the on the neck due proportional to the midline, to systemic size of the body. proportional to the

size of the body.

Abdomen

Palpation

No palpable lumps & Palpable mass on masses the neck

Inspection

Flat -Flat No enlargement of the liver; no -normal distention abdominal bowel.

Auscultation

Dull sound, normal -Not assess abdominal bowel sounds of 15x borborygmi sound per minute

Percussion

Dull & soft sound -Not assess upon persussion

Palpation

Flabby, tender,

soft,

infection.

NORMAL

non- Flabby, soft, nontender,

Upper extremities Arms

Inspection

ROM

Hands fingers

and Inspection

Fingernails

Symmetrical; size Symmetrical; Due to poor proportional w/ body; size proportional blood circulation. edema absent w/ body; edema on right and upper arm left can flex & extend Has able to stamp freely; has full ROM her feet while crying.

Symmetrical; size Symmetrical; size proportional w/ body; proportional w/ Cyanosis absent body; Cyanosis absent

Normal

Hands & fingertips are warm to touch.

Palpation

-warm to touch

Inspection

Short & clean, Short & clean, capillary refill of less capillary refill of than 4 seconds, less than 4

NORMAL

absent bed.

bluish

nail seconds, absent bluish nail bed.

Lower Extremities Legs and feet

Inspection

Right & left leg are -Right & left leg symmetrical; size are symmetrical; proportional to body size proportional to size , with complete body set of toe nails size , with complete set of toe nails

Palpation

has good skin -no presence of turgor, warm skin, edema has no pitting edema on feet, Absence of bluish toe nails, has no pressure sores on both soles of feet

NORMAL