Physical Assessment

PHYSICAL ASSESSMENT The assessment to Ms. Haji Maymona Jaire was conducted last February 21, 2009, Saturday at 1:00 pm in Intensive Care Unit, cubicle 14 of San Pedro Hospital, Davao City. I- General Surveys Received lying on bed, asleep; responsive to speech stimulation; not in respiratory distress. With symmetrical lung expansion. With IVF of PNSS 1 liter + 60 meqs KCl @ 80cc/ hour, infusing well at left cephalic vein at 800 cc level. With side drip in soluset of PNSS 90cc + 10cc of dopamine @ 20cc/ hour at 70 cc level. With NGT @ right nostril for feeding and medication purposes, closed distal end. Attached to mechanical ventilator with the set up of RR= 14, Tidal Volume= 475, Mode= assist control, FiO2= 60%. With endotrachel tube at right side at 22 level. Attached to cardiac monitor with sinus rhythm. With foley catheter fr. 14 draining to urobag with yellowish urine at 380 cc urine output. Her body built is endomorphic and looked according to her age. Hygiene was well maintained and grooming was good. No body odor was noted. Distress noted on her facial expression. II- Vital Signs Upon taking his vital signs, Ms. Jaire has an axillary temperature of 37oC (35.6-37.4oC), a pulse rate of 84 bpm, a cardiac rate of 90 bpm (70-90 bpm), a respiratory rate of 15 cpm (20-25 cpm), and a blood pressure of 140/90 mmHg (110/70-130/90). III- Skin He has a light brown-toned skin and uniformed skin color to those exposed to the sun and there are no signs of edema and/or lesions noted. Skin was warm to touch and has good skin turgor with a good capillary

circulation of 3-4 seconds. Dry skin not noted. Scars were noted on the lower extremities. IV- Head Head is rounded and normocephalic and symmetrical to the body parts. Has a smooth skull contour. He has evenly distributed hair. With dressing on left frontal side, dry and intact. No presence of infection or lesions noted upon palpation.

No nodules or masses noted. His facial

movements a symmetric as evidenced by elevating and lowering the eyebrows, closing of the eyes tightly. No dandruffs noted on his scalp. VI. Eyes Eyebrows symmetrically aligned; equal in movement. Hair is evenly distributed and skin intact. Have equally distributed and normal curl of eyelashes. Eyelids close symmetrically, with normal blinking. When lids open, no visible sclera above cornea and upper and lower borders of cornea are slightly covered. Has normal symmetry of the eye. Pupils are black in color, equal in size, with 3 mm in diameter and reacts to any stimuli. Pupils equally round and briskly reacting to light. Iris is flat and round. No tenderness or edema on the lacrimal duct upon palpation. Both eyes move coordinate and in unison with parallel alignment. VII. Ears Both pinna are same in color as facial skin and aligned with outer canthus of eye upon inspection. Pinna are mobile, firm and non tender upon palpation. Pinna recoils after it is folded. Presence of discharges was not observed on external canal. Pinna is also free from lesions, swelling, and masses. Hearing acuity is well. He was able to hear normal voice tones and whispering on both ears.

VIII. Nose Nose is symmetric and straight with no presence of discharges, swelling, and flaring upon inspection and with uniform color. It is also non tender and with no lesions upon palpation. Air moves freely as the client breathes through the nares. Mucosa is pink, with clear watery discharge and no lesions. Nasal septum is intact and in midline upon inspection. Maxillary and frontal sinuses are not tender upon palpation. IX. Mouth Lips and buccal mucosa are uniformly pink in color. It was also soft, moist and smooth in texture. The tongue is midline and pink in color. It is also moist with thin whitish coating upon inspection. The base of the tongue is smooth with prominent veins. Palate is soft, smooth and lighter pink in color. Hard palate is lighter pink and has a regular texture than the soft palate. Gag reflex is present. X. Neck No lymph nodes upon palpation. There is symmetry of posterior and anterior portions of neck. Lesions were not noted. Thyroid gland is not palpable. Neck muscles are equal in size and head is centered. Head movement is coordinated and smooth movements were done with no discomfort. Can flex head 45 degrees and can move chin to the chest. The head can hyperextend up to 60 degrees and can move it backwards. Head flexes laterally 40 degrees, and can rotate 70 degrees. Head has equal strength. Shoulders have no equal strength; in the right side is weak while in the left side is strong. The trachea is in central placement in midline of the neck upon palpation.

XI. Breast and Axilla His breasts are both symmetrical in shape and size and even with the chest wall. Skin smooth and intact and in uniform color. His areola is round and light brown in color with irregular replacement of sebaceous glands on the surface upon inspection with no discharges noted and no masses were noted upon palpation. The nipples are round, everted and equal in size, similar in color, soft, smooth and both points in the same direction. No discharges were noted. No tenderness or masses noted upon palpation. XII. Chest and Lungs Chest is symmetric and spine was vertically aligned with straight spinal column. Skin is intact with uniform temperature upon palpation. The posterior chest has a full and symmetric chest expansion. He has a bilateral symmetry of vocal fremitus. Fremitus is heard most clearly at the apex of the heart. Vesicular and bronchovesicular breath sound were heard upon auscultation. Anterior thorax is quiet and rhythmic and effortless to respirations. Has a full symmetric lung excursion upon palpation. With nitroglycewrin patch noted at left side of the chest. XIII. Heart He has a regular cardiac rhythm. Point of maximal impulse was auscultated at the left intercostal space, left midclavicular line. His apical, aortic, pulmonic and tricuspid pulses are clearly audible. Carotid arteries has symmetric pulse volume and no bruit was heard upon auscultation. Jugular veins were not visible upon inspection. XIV. Abdomen Abdomen is unblemish and has a uniform skin color. No striae noted. No dilated veins visible. Abdomen is soft, round and not distended. Bowel sounds is normal.

XV. Genito-Urinary Genitals are free from lesions and warts. She is with clean diaper. Pubic hair is free from dandruff and lice. No abnormalities were noted. XVI. Extremities There is symmetry on both arms and legs in size and are appropriate for body proportion. Also have symmetrical and strong pulses. Muscle strength is not equal on both hands. The right hand and foot is weak while in the left hand and foot is strong. Fingers and toes are complete. Fingernails and toenails are properly trimmed. XVII. Neurological Assessment The client’s neurological function is RLS score of 1-2 and GCS score of 11. Cranial Nerve Assessment: Cranial Nerve I: Olfactory Not applicable. Patient cannot talk because she is intubated. Cranial Nerve II: Optic She can see us even in the distance of 5 meters. Cranial Nerve III: Oculomotor Extraocular eye movement was good because when we ask her to follow the procedure, she has a good result. The pupil constricts upon the introduction of light and has a diameter of 3 mm. Cranial Nerve IV: Trochlear She can move the eyeball downward and laterally. Cranial Nerve V: Trigeminal

She elicit blink reflex upon light touch to the lateral sclera. She can feel sensation on the skin of face while she closes his eyes. Cranial NerveVI: Abducens She can move his eyeball laterally and be able to see his periphery. Cranial Nerve VII: Facial Facial expression like smiling, raising eyebrows, frowning and closing the eyes tightly were well done. Where not able to assess identifying various tastes because she is intubated. Cranial Nerve VIII: Auditory She was able to hear spoken words and whispers while her eyes were closed. Cranial Nerve IX: Glossophayngeal She cannot move tongue side to side and up and down. Cranial Nerve X: Vagus We cannot assess the swallowing capacity of the patient because she is intubated. Cranial Nerve XI: Accessory He can do head movement and can shrug his shoulders against resistance of hands in the left side only. Cranial Nerve XII: Hypoglossal Not applicable. Patient cannot talk because she is intubated.