22960163 physical assessment

8/6/2019 22960163 Physical Assessment

1/22

PHYSICAL ASSESSMENT

BODY PARTS TECH-NIQUE NORMAL

FINDINGS

ACTUAL FINDINGS ANALYSIS

Skin

Hair and

Scalp

Nails

Inspection,

Palpation

Inspection,

Inspection

-light to dark

brown & feels

warm

-no swelling,

-smooth and

soft

-color black-properly

distributed

-no presence

of parasites

(lice)

-fine texture

-light to dark brown &

feels warm

-mild skin rashes

-smooth and soft

- smooth and soft

-round nail with

160degrees nail base

-pink nail bed

-abnormal

-normal

-normal


2/22

-no masses

-round nail

with

160degrees

nail base

-pink nail bed

Head

Neck

Inspection

Inspection

-face is

symmetrical,

centered-

head position

-smooth andcontrolled

movements

-face is symmetrical,

centered-head position

-smooth and controlled

movements

-normal

-normal

Eyes

Eye brows

Eye lashes

Eye lids

Inspection -blinking

symmetrical,

involuntary &

approximately

15 blinks/min-evenly

distributed

-eye lashes

are short

-eye lid

margins moist

-blinking symmetrical,

involuntary &

approximately 15

blinks/min

-evenly distributed

-eye lashes are short

-eye lid margins moist &

pink

-pupil is equally round

and reactivated to light

-normal


3/22

Pupil

Iris

& pink

-pupil is

equally round

and

reactivated to

light

accommodati

on

-uniform in

color

-transparent,

smooth, moist

accommodation

-uniform in color

-transparent, smooth,

moist

Ears Palpation ,

Inspection

-Ears of equal

size & similar

appearance

-Skin in the

external ear is

-Ears of equal size &

similar appearance

-Skin in the external ear

is smooth and color pink

-normal


4/22

smooth and

color pink

Nose

Mouth

Lips

Buccal

mucosa

Tongue

Gums

Inspection

Inspection

Palpation

Inspection

-color is same

as face

-symmetricalappearance

-no redness in

the nasal

mucosa

-pink in color

-dry

-smooth,

moist with no

lesions

-moist with no

lesions

-pink and

moist

-no dental

carries

-color is same as face

-symmetrical appearance

-no redness in the nasal

mucosa

-pink in color

-moist

-smooth, moist with no

lesions

-moist with no lesions

-pink and moist

-no dental carries

-32 total no. of teeth

-normal

-normal

-normal


5/22

Teeth

-32 complete

no. of teeth

-normal

Thoracic &

Lungs

Inspection

Palpation,

Auscultation

-position of

sternum is

level with ribs

-no masses

-lungs clear

uponauscultation

-position of sternum is

level with ribs

-no masses

- lungs clear upon

auscultation

-normal

-normal

Breast Inspection

Palpation

-smooth skin

surface

-flat areola

-no masses

-smooth skin surface

-flat areola

-no masses

-normal

Heart Palpation,Inspection

-PMI is feltupon

pulsation

-Rhythm:

regular

-PMI is felt uponpulsation

-Rhythm: regular

-normal

Upper

Extremities

Palpation,

Inspection

-bilateral

pulses strong

-bilateral pulses strong &

equal (radial pulse)

-normal


6/22

(right and

left)

& equal

(radial pulse)

-mobile

-intact

condition ofthe skin in

arms

-no lesions, no

swelling

-mobile

- intact condition of the

skin in arms

-no lesions, no swelling

-normal

-normal

Abdomen Inspection,

Auscultation

Percussion

Palpation

-no rashes or

lesions

-umbilicus is

centrally

located

-rounded

abdomen

-symmetrical

-high pitched,

irregular

gurgles 5-

35times/min

-abdomen

rises with

inspiration in

-no rashes or lesions

-umbilicus is centrallylocated

-rounded abdomen

-symmetrical

-high pitched, irregulargurgles 5-35times/min

-abdomen rises with

inspiration in synchrony

with chest

-normal


7/22

synchrony

with chest

Genitourinary (The patient

refused to

assess hisgenitourinary

organs.)

(The patient refused to

assess his genitourinary

organs.)

Lower

Extremities

(right and

left)

Inspection -bilaterally

symmetrical

and equal

-right foot hasno lesions, no

swelling

-left foot has no

lesions, no

swelling

-skin color isthe same as

the other part

of the body

-bilaterally symmetrical

and equal

-right foot has no lesions,

no swelling

-left foot has no

abrasions

- skin color is the same

as the other part of the

body

-normal

- normal

-normal


8/22

A. Biographical Data

Name: J.E Reyes

Age : 17yrs old

Gender: Female

Birth Date: June 7, 1992

Birth place: Manila

Residence: 844-4 Hamabar St. Dagupan Tondo Mla.

Religion: Catholic

Civil Status: Child

Nationality: Filipino

Date of Admission: November 15, 2009

Admission Number: 96879

Room Number: 102 B

Discharge Date: Still in the hospital

Admitting Diagnosis: DHF

Attending Medical Doctor: Dr. GAN

II.Chief Complaint


9/22

Fever (39-40 C) w/ cough and whitish phlegm.

III.History

Present health history

5 days prior to admission patient had a high grade fever intermittent 39-40 c

associated with cough and whitish phlegm, took paracetamol 500 mg. tablet which afforded

some relief. No consult done, no associated signs and symptoms of diffuculty of

breathing,Dysuria abdominal pain and bleeding episode.

Past health history

J.E was born June 7, 1992 , the first daughter of Mr. and Mrs. Reyes. She was well

taken care of her parents starting her intrauterine life. J.E had already illness like Measles,

Chicken Pox, Mumps, Diarrhea.This was J.E. first confinment to the hospital As Sheverbalized First time ko pong na confined sa hospital ngayon lang po talaga.

IV. Hospitalization

Complete immunizations were given to her accordingly. Mild illnesses includehaving cold, cough and flu are treated by medication over the counter. Present

hospitalization at MHMC because of DHF. She havent undergone any surgery. As the

mother explained to us.. Oo, kumpleto naman ang bakuna. Kapag may lagnat, ubo at

sipon ang gamot na binibili naming over the counter.


10/22

V. Family History

J.E came from a nuclear type of family. Both of his parents are healthy. She is the first

daughter of Mr. and Mrs. R. She has her younger sister that is not yet admitted at the

hospital. As the mother verbalized Wala namang sakit ang pamilya namin. Yung kapatid

niya malakas din kita mo naman sa katawan nila

VI. Lifestyle

The patient usually have regular hours of sleep. Allergies from any kinds of foods or

medicines are not common to her. but due to her illness she has no appetite of eating well.

VII. Social Data

She have many friends around her and she is always with her friends as she

verbalized marami akong friends samin mahilig kasi ako lumabas pag hapon

VIII.Psychological Data

Patient is resting well and improving as she verbalized mejo ok n pakiramdam ko

hindi tulad nung unang araw na confined ako dito

IX. Patterns of Health Care

J.E was supported by her parents emotionally, physically and financially. She is under Dr.

Gan As she verbalized lagging andito sila mama at kapatid ko pati lola ko di nila ako

pinapabayaan pati narin si Dr. Gan


11/22

X. Review of System

Integumentary System

As she verbalized Ok naman ako wala rashes.

Excretory System

As she verbalized Hindi naman ako pinagpapawisan

Respiratory System

As she verbalized Hindi naman ako nahihiraang huminga.

Cardiovascular System

As she verbalized Wala naman kaming sakit sa puso

Gastrointestinal System

As she verbalized Hindi naman ako nahihirapang dumumi, regular naman

Genitourinary System


12/22

As she verbalized Hindi naman ako nahihirapang umihi.

Musculoskeletal System

As she verbalized Naigagalaw ko naman ng maayos ang mga kamay at paa ko

Neurologic System

As she verbalized Nakaka-sunod naman ako sa mga bagay na pamilyar sakin

Endocrine System

As she verbalized Wala naman akong sakit na nahawa lang.

5 PRIORITIZE PROBLEMS;

1.) Bleeding


13/22

2.) Hyperthermia

3.) Activity intolerance related to body weakness secondary to DHF

4.) Alteration in comfort

5.) Skin impairment

NURSING CARE PLAN(BLEEDING)

ASSESSME DIAGNOSIS INFERENCE PLANNING INTERVENTI RATIONALE EVALUATIO


14/22

NT ON N

Subjective:

Dumudug

o ang ilongko

as

verbalized

by the

client

Objective:

Weakness

and

irritability.

Restlessn

ess.V/S taken

as follows:

T: 38.1

P:70

R:19

Injury, risk

for

hemorrhage related to

altered

clotting

factor.

This

infectious

disease ismanifested

by a

sudden

onset of

fever, with

severe

headache,

muscle and

joint pains

(myalgias

and

arthralgias

severe

pain givesit the name

break-bone

fever or

bonecrushe

r disease)

and rashes

and usually

After 1 hr.

Of nursing

interventions, the

client will

be able to

demonstrat

e behaviors

that reduce

the risk for

bleeding.

Independen

t:

Assess for

signs and

symptoms

of G.I

bleeding.

Check for

secretions.

Observe

color and

consistency

of stools or

vomitus.

Observe

for

presence of

petechiae,

ecchymosis

, bleeding

from one

The G.I

tract

(esophagus

and

rectum) is

the most

usual

source of

bleeding of

its mucosal

fragility.

Sub-acute

disseminat

ed

intravascul

ar

coagulation

After 1 hr.

Of nursing

interventions, the

client was

able to

demonstrat

e behaviors

that reduce

the risk for

bleeding.


15/22

CR:73

BP:110/80

appears

first on the

lower limbs

and the

chest.

There mayalso be

gastritis

and some

times

bleeding.

more sites.

Monitor

pulse, Blood

pressure.

Note

changes inmentation

and level of

consciousne

ss.

(DIC) may

develop

secondary

to altered

clotting

factors.

An

increase in

pulse with

decreased

Blood

pressure

can

indicate

loss of

circulating

blood

volume.

Changes

may

indicate

cerebral

perfusion

secondary


16/22

Avoid

rectal

temperatur

e, be gentle

with GI tube

insertions.

Encourage

use of soft

toothbrush,

avoiding

straining for

stool, and

forceful

nose

blowing.

Use small

needles for

injections.

Apply

pressure to

venipunctur

to

hypovolemi

a,

hypoxemia.

Rectal and

esophageal

vessels are

most

vulnerable

to rupture.

In the

presence of

clotting

factor

disturbance

s, minimal

trauma cancause

mucosal

bleeding.

Minimizes

damage to


17/22

e sites for

longer than

usual.

Recommend

avoidance

of aspirin

containing

products.

Collaborativ

e:

Monitor Hb

and Hct andclotting

factors.

tissues,

reducing

risk for

bleeding

and

hematoma.

Prolongs

coagulation

,

potentiatin

g risk of

hemorrhag

e.

Indicators

of anemia,

active

bleeding,

or


18/22

impending

complicatio

ns.


19/22

NURSING CARE PLAN(HYPERTHERMIA)

Cues Nursing Rationale Nursing Intervention Rationale Evaluation


20/22

Cues Nursing

diagnosis

Rationale Nursing

objectives

Intervention

s

Rationale Evaluation

Objective

cues:

>skin is

warm to

touch

>flushed

skin

>increased body

temp.

Above

normal

range

(36.5C-

37.5C)

Temp

taken.

38.1

P:

alteration

in

thermoregu

lation

(hyperther

mia)

E:related to

infection s/t

DFS

S/Sx:

>skin is

warm to

touch

>flushed

skin

>increased

body temp.Above

normal

Body

temperatu

re

increases

(fever)as a

protective

response

to

infection

and injury.

Theelevated

body

temperatu

re

enhances

the bodys

defense

mechanis

m

although it

can cause

discomfort

for the

person. A

true feverresults

from an

Short term

goal:

After 10-

15mins of

nursing

interventio

n the body

temperatu

re willdecrease

from

38.1C to

a range of

37.8C-

37.6C

As will besupported

by skin

slightly

warm to

touch,

lessen

flushedskin.

Independent

:

1. Monitor

temperature

especially

during

episodes of

chills. Note

heart rateand rhythm.

2. If the

client is not

in chillingstage render

continuous

tepid sponge

bath.

1. Chills is

an

indication of

a rising

temperatur

e.

Hypertherm

ia can causedysrhythmia

s.

2. To

replaceartificially

the bodys

sweating

mechanism

by cooling

the skins

surface

Short term

goal:

After 10-

15mins of

nursing

intervention

the body

temperature

wasdecreased

from 38.1C

to a range

of 37.8C

As will be

supported

by skinslightly

warm to

touch,

lessen

flushed skin.

Goal met


21/22

Health History

Physical

assessment


22/22

NursingCare PlanRon Chan III- I4

Mam. Correa

22960163 physical assessment

Documents