CHAPTER III REVIEW OF SYSTEM

a. Physical Assessment

Vital signs

The client’s pulse rate is 90 beats per minute, his respiratory rate is 21 breaths per minute, temperature is 36.8°c.

General appearance

The client is in medium frame with stooped posture, the client is bedridden since he was admitted to the hospital last may 8, 2009. Well groomed and has no body odor. He doesn’t have any deformity.

Mental status

The client is conscious and cooperative. The client can’t talk because he was stroke.

Skin

The client’s skin is of normal racial tone which is brown. It is dry and smooth. The skin turgor is wrinkled and loss of elasticity. The body hair is evenly distributed. He doesn’t have any edema. But he has a skin lesion on his right elbow.

Nail

The client’s nail shape is convex clubbing, the nail is rough and the nail bed is pink. The capillary refill is within 3 seconds and thise is an absence of beau’s line.

Head and Face

The client’s skull is proportionate to the body size, Thise were no tenderness in the scalp. Thise were no presence of nodules, and infestation. His hair is evenly distributed and the strands are thin and brittle. The color of his hair is a mixture of white and black. His head is round and symmetrical its consistency is hard. He can’t control his head and the shape of his face is round and asymmetrical and its consistency is soft.

Eyes

The condition of his eyes is straight normal; the eye brows are evenly distributed. Eyelids have effectively closure. The blink response is bilateral, eye balls are symmetrical, bulbar conjunctiva is clear, the palpebral conjunctiva is pink and the sclera is white. The palpebral slant is aligning with the tip of the pinna. The corneal sensitivity reflex is present cornea is transparent, the color of his eyes are brown, the shape are equal, it is uniform in color. Pupils are equal in size. Pupils are equally round and reactive to light and accommodation. He can execute the occular movements. He can recognize objects within 12-14 inches away. The lacrimal apparatus are moist.

Ear

The color of the ear is of normal racial tone which is brown, it is symmetrical. The alignment of the pinna is symmetrical. The pinnas are elastic and recoil when folded. The mastoid process is tender. The auditory canal contains some cerumen, the color is brown and there is an absent of discharges.

Nose

The color of the client’s nose is of racial tone which is brown. His septum is in the midline. The mucosa is pink, nostrils are both patent, nasal flaring is absent. Landmarks are visible. Sinuses are non-tender. There is an NGT in his right nostrils.

Mouth and Oropharynx

The lips is symmetrical and pink, the consistency is smooth, buccal mucosa is pink, the gum is pink, the tongue is in the midline, the color is pink and it is smooth. The tongue movements are not that smooth. Its texture is rough. The color of the hard and soft palate is pink. And it is intact. The tonsils are inflamed grade of + 2. Ther is presence of mucous. Uvula is in the midline, gag reflex is absent. The teeth are incomplete.

Neck

The neck has involuntary movement and with resistance, the muscle strength 3/5. The trachea is in the midline, thyroid is in the midline and it is smooth. Maxillary lymph nodes are palpable.

Breast

The breasts are symmetrical with flat contour. Shape is flat, the skin surface is smooth. Lympnodes are not palpable. The areola is color brown, shape is round and the nipple is everted, there are no discharges and there are no Lympnodes and no tenderness.

Chest and Lungs

The color of the chest is of normal racial tone which is brown, the shape is AP to lateral ratio 1:2. There are absence of intercoastal retraction, costal angle is 45° chest wall are symmetrical, and the chest expansion is symmetrical. Rib slope is less than 90. Respiratory rhythm is regular. The respiratory depth is shallow. Respiratory pattern is normal. When palpated he doesn’t feet any tenderness. The vocal fremitus is normal, tactile fremitus is symmetrical. The lung expansion is normal. When percussed the sound is resonance. When

auscultated brondual is absent. No adrentition sound. Respiratory rate is 21 breaths per minute.

Heart

The rhythm is regular. PMI is located in the apical pulse. Heart rate is 90 beats per minute.

Abdomen

Skin is of normal racial tone which is brown, the contour is flat. Peristalsis is non-visible. The color of his stool is brown, it is solid and formed. The bowel sound is normo active and no bruits. When percussed the sound is tympany. When palpated he doesn’t have any tenderness and when light palpation is done muscle guarding is absent. The liver is not palpable.

Upper extremities

The client cannot resist force when asked to resist. Muscle strength is 3/5. He have a skin lesion in his right elbow, The peripheral pulses are equal. Lympnodes are not palpable. The IV site is in his left arm.

Lower extremities

The client cannot resist force when asked to resist. Muscle strength is 2/5. He doesn’t have any deformity. The peripheral pulses are equal. Lympnodes are non-palpable.

Genital(according to the client)

The client is circumcised and his genitals are fully developed