Physical Examination Sa

PHYSICAL EXAMINATION Name: Hilario, Susan M. Age: 33 years old Date of assessment: august 27, 2009 General survey: 1. Physical appearance/ grooming: The patient was awake in a supine position during the assessment. She looks restless and pale. 2. Facial Expression: When we enter, the patient is sad. She experience pain in the suture site(facial grimace). 3. Attitude: The patient participates on the assessment done. She doesn’t talk about her baby and feels discomfort upon the assessment. Baseline Data: * Temp. : * PR : * RR : * CR : * BP :

0625H 36.4˚C 55 22 58 110/70

HEAD-TO TOE ASSESSMENT Body Parts Technique Normal Findings skin

Inspection and Palpation

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• • • Head

Symmetric (rounded) or slightly asymmetric facial features: papebral fissure, equal in size, symmetric nasolabial folds, free from wrinkles. Sus-tanned areas No moist Pinched-up skin returns immediately

Actual Findings • • •

Generalized pale warm and dry poor skin turgor

Remarks ABNORMAL Due to decrease fluid volume and temperature attempts to evaporate the body’s water.

a. Skull

b. Scalp

Inspection Palpation

Inspection Palpation

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Smooth and soft

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Generally round, with prominences in the frontal and occipital area. (Normocephalic) No tenderness upon palpation

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Lighter in color than the complexion Can be moist or oily No scars noted Free from lice, nits and dandruff No lesions should be noted No tenderness nor masses on palpation

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c. Hair

Inspection

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Hearing Acuity

Inspection Inspection

Visual Acuity

Nose

Inspection

Inspection

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generally round no tenderness upon palpation

NORMAL

NORMAL

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free from dandruff, lice, and nits no lesions, tenderness, masses no scars noted NORMAL

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black, evenly distributed and covers the whole scalp thin smooth and not dry has no lice

Can be black, brown, or • burgundy • depending on race • Evenly • distributed and covers the whole scalp (no evidences of alopecia) • Maybe thick or Able to respond thin, coarse or correctly on the smooth questions asks. • Neither brittle nor dry. Able to see the Able to hear voice person coming near equally at both ears as to her. evidenced by eye movements towards nurse that’s speaking. • in the midline Able to hear whisper • no discharge voice. • no tenderness

Normal

NORMAL

NORMAL

Able to visualize things as evidenced by irises following hand movements of nurse Mouth and Lips

Tongue

Inspection

Inspection

Nose is in the midline • No discharges • Both nares are patent • Nasal septum is in the midline • The nasal mucosa is pinkish to red in color • •

Neck

Palpation

• • • • •

Lymph Nodes

Thorax

Inspection

Inspection

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Breasts

Inspection

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• •

Symmetrical in appearance and movement With visible margin Pinkish in color No edema Moist

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Gag reflex is present Able to move the tongue freely and with strength

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The neck is straight No visible mass or lumps Symmetrical No jugular venous distension May not be palpable May be normally palpable in thin clients

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upon palpation nasal septum is in the midline nasal mucosa is pinkish in color

with visible margin slightly pink in color no edema cracking of lips

Abnormal Due to fluid volume deficit

NORMAL

pinkish with yellow taste buds on the surface no lesions palpated

NORMAL

Not inflamed straight with no visible lumps or masses

NORMAL

NORMAL

Not Palpable

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Symmetrical chest excursion moves symmetrically normal breath sounds

NORMAL

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Abdomen

Inspection

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No crepitus noted The chest contour is symmetrical. Moves symmetrically on breathing with no obvious masses Equal thoracic expansion on both sides Variable in size depending on body build, round shape, symmetrical. No lumps, masses, or tenderness upon palpation No retractions or dimpling

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Trunk and Gluteus

Inspection Palpation

Upper Extremities (arms)

Lower Extremities (legs)

Inspection

inspection

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darkened areola nipples and more darkened are select.

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no masses no swelling, atrophy or redness stitches on the lower segment due to caesarean. Post op dressing

Skin the same in color of abdomen • Contour may be flat, rounded, or scapoid • Some clients may have striae or scar • Skin color is uniform • symmetrical • Thin clients may • same color as have visible skin peristalsis complexion • In extremely thin • no tenderness clients but upon otherwise healthy palpation individuals, it may be felt at costal margins symmetriacal; no tenderness Skin is flesh in color has size proportion with no lesions. body cyanosis absent Muscle flaccidity and pressure sore- absent no tenderness

NORMAL

NORMAL

NORMAL

ABNORMAL Due to poor blood circulation.

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Symmetrical Equal color and no discoloration No tenderness noted on palpation Symmetrical Equal color and no discoloration No tenderness noted on palpation

symmetrical edema on both sides of the extremities