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A. Physical Assessment Upon Admission Date: September 19, 2008 GCS-15 oriented to 3 spheres-(E4M6V5) Height: 62 inches V/S: BP- 90/70 mmHg, CR: 84 bpm, RR: 36 cpm, T-37.5 C Weight: 31.5 kilograms LOC: Oriented BMI: 12.5 (Severe Malnutrition)
AREA TECHNIQUE NORMS FINDINGS ANALYSIS and INTERPRETATIONA. SKULL
1. Size, shape andsymmetry of the skull
InspectionPalpation
Rounded(normocephalic andsymmetrical, withfrontal, parietal, and
occipitalprominences);Smooth skull contour
Rounded(normocephalic); smooth skullcontour
Normal
2. Presence of nodules,masses, anddepressions
PalpationInspection
Smooth, uniformconsistence; absenceof nodules or masses
Has no tenderness; nomasses nor nodules
Normal
3. Facial Features InspectionPalpation
Symmetric or slightlyasymmetric facial
features; palpebralfissure equal in size;symmetric nasolabial
Symmetrical andpalpebral fissure equal
in size, nasolabial foldsare symmetrical
Normal
4. Presence of edemaand hollowness in theeye.
Inspection No edema andhollowness
Has Hollowness Abnormal, Volume deficiency of fat withinthe orbit (the space inside of the bony eyesocket). This condition of the patient isrelated to his nutritional status, she ismalnourished. Her BMI is 12.5.(http://www.drmeronk.com/hollowed/under-eye-hollows.html)
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C. HAIR
1. Evenness of growth,thickness, or thinness of
hair
InspectionPalpation
Evenly distributedand covers the whole
scalp; Maybe thick orthin
Evenly distributed withno patches of hair loss;
thick hair
Normal
2. Texture and oilinessover the scalp
InspectionPalpation
Silky; resilient hair Silky, smooth andresilient hair
Normal.
3. Presence of infectionand infestation
InspectionPalption
No infection andinfestation
Presence of lice Abnormal, There is pediculosis, a type of parasitic infection. Lice may be contractedfrom infcetd clothes and direct contact withan infected person. The idea is that an oilysubstance, such as oil, smothers the liceand they may die. (Kozier, Fundamentals of Nursing 7 th ed. Page 733)
D. FACE
Facial features,symmetry of facialmovements
Inspection Symmetric or slightlyasymmetric facialfeatures; palpebralfissures equal in size;symmetric nasolabialfolds
Symmetrical facialfeatures while talkingor elevating theeyebrow. Equalpalpebral fissure,symmetrical nasolabialfolds.
Normal
IV. EYES
A. EYEBROWS
Hair distribution,alignment, skin quality
Inspection Symmetrical and inline with each other;
Symmetrical andaligned with each
Normal
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and movement maybe black, brownor blond dependingon race; evenlydistributed
other; black; evenlydistributed. Movementsare symmetrical.
B. EYELASHES
Evenness of distributionand direction of curl
InspectionPalpation
Evenly distributed;turned outward
Turned outwardeyelashes; hair equallydistributed
Normal
C. EYELIDS
Surface characteristicsand position (in relationto the cornea, ability toblink, and frequency of blinking)
Inspection Upper eyelids coverthe small portion of the iris, cornea, andsclera when eyes areopen; eyelids meetcompletely when theeyes are closed;symmetrical
Able to close the eyesand has the ability toblink.
Normal
D. CONJUNCTIVA
1. Color, texture, and
the presence of lesionsin the bulbar conjunctiva
Inspection
Palapation
Pinkish or red in color;
with presence of small capillaries;moist; no foreignbodies; no ulcers
Pale color; smooth in
texture
Abnormal, pale conjunctiva may be related
to the low RBC level of the patient.(Fundamentals of Nursing 5 th edition byTaylor, page 642)
2. Color, texture, andthe presence of lesionsin the palpebralconjunctiva
InspectionPalpation
Pinkish or red in color;with presence of small capillaries;moist; no foreign
Pale Abnormal, pale conjunctiva may be relatedto the low RBC level of the patient.(Fundamentals of Nursing 5 th edition by
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bodies; no ulcers Taylor, page 642)
E. SCLERA
Color and clarity Inspection White in color; clear;no yellowishdiscoloration; somecapillaries maybevisible
White sclera with somevisible capillaries,anicteric sclera.
Normal
F. CORNEA
Clarity and texture Inspection No irregularities onthe surface; lookssmooth; clear ortransparent
Clear and smooth intexture
Normal
G. IRIS
Shape and color Inspection Anterior chamber istransparent; no notedvisible materials;color depends on thepersons race
Dark brown in color;transparent anteriorchamber
Normal
H. PUPILS
1. Color, shape, andsymmetry of size
Inspection Color depends on thepersons race; sizeranges from 3-7 mm,and are equal in size;equally round
Pupil size is 3mm. Normal
2. Light reaction and Inspection Constrict Dilates when looking at Normal
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accommodation briskly/sluggishlywhen light is directedto the eye, bothdirectly and
consensual
far objects andconstricts when lookingat near objects.Constricts when there
is light.
I. VISUAL ACUITY
1. Near vision Inspection Able to readnewsprint
Nearsightedness(Myopia)
Abnormal, it is a refractive defect of the eye in which collimated light produces imagefocus in front of the retina whenaccommodation is relaxed. It is caused byan eyeball that is longer than normal, whichmay be a familial trait. Transient mayopiaoccurs due to influenza, steroids, severdehydration and large intake of antacids.(Black, Medical Surgical Nursing7th edition, page1963).
J. LACRIMAL GLAND
Palpability andtenderness of thelacrimal gland
Palpation No edema ortenderness overlacrimal gland
No tenderness andedema noted.
Normal
K. EXTRAOCULARMUSCLES
Eye alignment andcoordination
Inspection Both eyescoordinated, move inunison, with parallelalignment
Moves in Unison Normal
L. VISUAL FIELDS
Peripheral visual fields Inspection When looking straightahead, client can see
Can see objects in the Normal
http://en.wikipedia.org/wiki/Refractive_errorhttp://en.wikipedia.org/wiki/Eyehttp://en.wikipedia.org/wiki/Collimated_lighthttp://en.wikipedia.org/wiki/Focus_(optics)http://en.wikipedia.org/wiki/Retinahttp://en.wikipedia.org/wiki/Accommodation_(eye)http://en.wikipedia.org/wiki/Refractive_errorhttp://en.wikipedia.org/wiki/Eyehttp://en.wikipedia.org/wiki/Collimated_lighthttp://en.wikipedia.org/wiki/Focus_(optics)http://en.wikipedia.org/wiki/Retinahttp://en.wikipedia.org/wiki/Accommodation_(eye)8/7/2019 dona mae rosalit
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objects in theperiphery
periphery.
V. EARS
A. AURICLES
1. Color, symmetry of size, and position
Inspection Color same as facialskin; symmetrical;auricle aligned withouter canthus of eye,about 10 degreesfrom vertical
Same color as thefacial skin; tip of auricle aligned at theouter canthus of theeye.
Normal
2. Texture, elasticity andareas of tenderness
Palpation Mobile, firm, and nottender; pinna recoilsafter it is folded
Smooth in texture,flexible and elasticpinna; no tenderness
Normal
C. HEARING ACUITY TESTS
1. Clients response tonormal voice tones
Inspection Normal voice tonesaudible
Can hear normalvolume tones or words.
Normal
VI. NOSE
1.Any deviations inshape, size, or color andflaring or discharge fromthe nares
Inspection Symmetric andstraight; no dischargeor flaring; Uniformcolor
Symmetric andstraight; Uniform colorwith nasal flaring .
Abnormal, Nasal flaring suggests airwayobstruction. Nasal discharge shows thepresence of mucus secretions in the airtract.
2. Nasal septum Inspection Nasal septum intact Nasal septum intact Normal
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(between the nasalchambers)
Palpation and in midline and in midline
3. Patency of both nasal
cavities
Inspection Air moves freely as
the client breathesthrough the nares
Only left nares is
patent. Right nares iswith secretion.
Abnormal, not patent right nares show the
presence of mucus secretions and wouldsuggest there is an infection in therespiratory system.
4. Tenderness, masses,and displacements of bone and cartilage
Palpation Not tender; no lesions Nor tenderness norlesions.
Normal
VII. SINUSES
Identification of thesinuses and fortenderness
Inspection Not tender Not painful whenpalpated
Normal
VIII. MOUTH
A. LIPS
Symmetry of contour,color and texture
InspectionPalpation
Uniform pink color;soft, moist, smoothtexture; symmetry of
contour; ability topurse lips
Pink in color, dry andcracked lips
Abnormal, May suggest cellular dehydration.(Black, Medical Surgical Nursing7th edition,page 208).
B. BUCCAL MUCOSA
Color, moisture, texture,and the presence of lesions
Inspection Uniform pink color;moist, smooth, soft,glistening, and elastictexture
Pink color and dry. Abnormal, May suggests dehydration.(Black, Medical Surgical Nursing7th edition,page 208).
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C. TEETH
Color, number andcondition and presenceof dentures
Inspection 32 adult teeth;smooth, white, shinytooth enamel;smooth, intactdentures
Has 31 adult teeth. Thepatient has yellowishteeth. Have badbreath. Have toothdecay in the lower rightsecond molars.
Abnormal, most unpleasant odors are knownto arise from proteins trapped in the mouthwhich are processed by oral bacteria. Themost common location for mouth-relatedhalitosis is the tongue .(http://en.wikipedia.org/wiki/Halitosis ). It isalso related to dental carries and frequencyof tooth brushing.
D. GUMS
Color and condition Inspection Pink gums; noretraction
Pink gums; has novisible retractions
Normal
E. TONGUE/FLOOR OFTHE MOUTH
1. Color and texture of the mouth floor and
frenulum.
Inspection pink color; moist;slightly rough; thin
whitish coating;moves freely; notenderness
Pink and moist. Tonguemoves freely and nopain felt.
Normal
2. Position, color andtexture, movement andbase of the tongue
Inspection Central position; pinkcolor; smooth tonguebase with prominentveins
Located and positionedin the center.
Normal
http://en.wikipedia.org/wiki/Odorhttp://en.wikipedia.org/wiki/Odorhttp://en.wikipedia.org/wiki/Proteinhttp://en.wikipedia.org/wiki/Tonguehttp://en.wikipedia.org/wiki/Halitosishttp://en.wikipedia.org/wiki/Odorhttp://en.wikipedia.org/wiki/Proteinhttp://en.wikipedia.org/wiki/Tonguehttp://en.wikipedia.org/wiki/Halitosis8/7/2019 dona mae rosalit
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3. Any nodules, lumps,or excoriated areas
PalpationInspection
Smooth with nopalpable nodules,lumps, or excoriatedareas
No tenderness normasses
Normal
F. PALATES andUVULA
1. Color, shape, textureand the presence of bony prominences
InspectionPalpation
Light pink, smooth,soft palate; lighterpink hard palate ,more irregular texture
The hard palate has alighter color than thesoft palate; has quiterough texture
Normal
2. Position of the uvulaand mobility (whileexamining the palates)
Inspection Positioned in midlineof soft palate
Positioned at thecenter of theoropharynx
Normal
G. OROPHARYNX andTONSILS
1. Color and texture Inspection Pink and smoothposterior wall
Dry, pinkish in color. Abnormal, May suggests dehydration.(Black, Medical Surgical Nursing7th edition,page 208).
2. Size, color, and
discharge of the tonsils
Inspection Pink and smooth; no
discharge; of normalsize
Has no discharge;
pinkish
Normal
3. Gag reflex Inspection Present Present Normal
X. THORAX
A. ANTERIOR THORAX
1. Breathing patterns Inspection Quiet, rhythmic, and Difficulty of breathing Abnormal, labored breathing is a common
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effortless respirations manifestation affecting clients with cardiacand pulmonary disorders. It is related toobstructed airway. It also related to thedecreased size of the lungs due to PTB.
(Black, Medical Surgical Nursing7th edition,page 1566).
2. Temperature,tenderness, masses
Palpation Skin intact; uniformtemperature; chestwall intact; notenderness; nomasses
Has an intact skin; hasequal warmth on bothsides. No masses.
Normal
3. Anterior thorax
auscultation
Auscultation Bronchovesicular and
vesicular breathsounds
Has crackles sounds on
the upper thorax &lower thorax
Abnormal, crackles or rales are audible
when there is a sudden opening of smallairways that contain fluid. It is usually heardduring inspiration. (Black, Medical SurgicalNursing7th edition, page 1756).
B. POSTERIORTHORAX
1. Shape, symmetry,and comparison of anteroposterior thoraxto transverse diameter
InspectionPalpation
Anteroposterior totransverse diameterin ratio 1:2; Chestsymmetric
Has a anteroposteriorto transverse diameterratio of 1:2, elliptical inshape and symmetricalchest
Normal
2. Spinal alignment Inspection Spine verticallyaligned
Has a verticalalignment
Normal
3. Temperature, Palpation Skin intact; uniform No masses nor Normal
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tenderness, and masses temperature; chestwall intact; notenderness; nomasses
tenderness; has equalwarmth on each side
7. Posterior thoraxauscultation
Auscultation Vesicular andbronchovesicularbreath sounds
Has crackles heard onthe anterior and middlepart of right and leftlungs. Diminishedlung sound on theposterior right lung.
Abnormal, the condition is related to thedecreased size of the right lung and poorinspiratory effort due to pain.(http://www.nurse411.com/Heart_Lung_Sounds.asp)
XI. CARDIOVASCULAR
A. AORTIC andPULMONIC AREAS
Auscultation No pulsations No pulsations felt Normal
B. TRICUSPID AREA Auscultation No pulsations; no liftor heave
No pulsations of lifts Normal
C. APICAL AREA Auscultation Pulsations visible in50% of adults andpalpable in most PMIin fifth LICS at ormedial to MCL
Has full pulsation Normal
D. EPIGASTRIC AREA Auscultation Aortic pulsations Has pulsation Normal
E. CARDIOVASCULARAREASAUSCULTATION
Auscultation S1: Usually heard atall sites
Usually louder at theapical area
Has full and rapidpulsation. 84bpm/minute.
Sounds on the aorticand pulmonic areas;
Normal
Normal
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S2: Usually heard atall sites
Usually louder at thebase of heart
Systole: silentinterval; slightlyshorter duration thandiastole at normalheart rate (60 to 90beats/min)
Diastole: silentinterval; slightlylonger duration thansystole at normalheart rates
S3: in children andyoung adults
S4: in many olderadults
has a lub sound on theapex and dub soundson the tricuspid area.
Blood pressure is 90/70mm Hg.
Normal
XII. CAROTIDARTERIES
1. Carotid arterypalpation
Palpation Symmetric pulsevolumes; fullpulsations, thrustingquality; qualityremains same whenthe client breathes,
Has weak pulsation.Symmetrical pulse.
Abnormal, decreased amount of bloodvolume passing the artery. (Black, MedicalSurgical Nursing7th edition, page 1574).
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peristalsis or aorticpulsations
peristalsis in verylean people; aorticpulsations in thinpersons at epigastric
area
6. Vascular pattern Inspection No visible vascularpattern
Has no blood vesselsvisible
Normal
XVI.MUSCULOSKELETALSYSTEM
A. MUSCLES
1. Muscle size andcomparison on the otherside
Inspection Proportionate to thebody; even in bothsides
Proportionate to thebody; even in bothsides
Normal
2. Fasciculation andtremors in the muscles
Inspection No fasciculation andtremors
Has no fasciculationand tremors
Normal
3. Muscle tonicity Palpation Even and firm muscletone
Weak muscle tone Abnormal, possibly related to the amount of food that patient is eating. Possible
exhaustion experienced by the patient whenshe coughs.(http://en.wikipedia.org/wiki/Muscle_weakness)
4. Muscle strength Palpation Has equal muscularstrength on bothsides
Weak muscle strength Abnormal, possibly related to the amount of food that patient is eating. Possibleexhaustion experienced by the patient whenshe coughs.(http://en.wikipedia.org/wiki/Muscle_weakness)
C. JOINTS
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1. Joint swelling Inspection No swelling, nowarmth, no redness,no pain, no crepitus
No swelling, nowarmth, no redness, nopain, no crepitus
Normal
EXTREMETIES Inspection,Palpation
No swelling, nowarmth, no redness,no pain.
No edema, no painwhen moved.
Normal
Neurologic Assessment:
Category Normal Findings Actual Findings Analysis and interpretation
Mental Status
Level of Consciousness
Orientation
Language test
Recall
Alert
Oriented
Coherent
Able to remember
Alert
Oriented to person, timeand place.Coherent
Able to state whathappened to her in thepast.
Normal
Normal
Normal
Normal
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Cranial Nerves
CN 1Olfactory
CN 11Optic
CN III, IV, VIOcculomotorTrochlearAbducens
CN VTrigeminal
CN VII
Facial
CN VIIIVestibulocochlear
CN IX, XGlossopharyngealVagus
Able to smell andrecognize stimuli
20x20 vision, able toread, 3-5 mm [pupilsize]
(+) ExtraoccularMovement (EOM);Lateral Upward anddownward; pupils
reactive to light.
Able to feel andclearly identifystimulus, withbilateral facialsensation. Withactive corneal reflex.
(+) Corneal reflex ,Facial asymmetry
Able to hear clearly,can maintain balance
(+) gag reflex, uvula
Able to identify the scentof the alcohol
Pupil size is 3 mm, able toread, myopia ornearsightedness.
Pupils react to light. Thereis constriction andconsensualaccommodation. Able to
move the eyes in anydirection in unison.
Able to feel my finger onher face while covering hereyes.
(+) Facial symmetry
Can hear clearly and canwalk.
Present gag reflex, able to
Normal
Abnormal, it is a refractive defect of the eye inwhich collimated light produces image focus in frontof the retina when accommodation is relaxed. It iscaused by an eyeball that is longer than normal,which may be a familial trait. Transient mayopiaoccurs due to influenza, steroids, sever dehydrationand large intake of antacids. (Black, Medical SurgicalNursing7th edition, page 1963).Normal
Normal
Normal
Normal
Normal
http://en.wikipedia.org/wiki/Refractive_errorhttp://en.wikipedia.org/wiki/Eyehttp://en.wikipedia.org/wiki/Collimated_lighthttp://en.wikipedia.org/wiki/Focus_(optics)http://en.wikipedia.org/wiki/Retinahttp://en.wikipedia.org/wiki/Accommodation_(eye)http://en.wikipedia.org/wiki/Refractive_errorhttp://en.wikipedia.org/wiki/Eyehttp://en.wikipedia.org/wiki/Collimated_lighthttp://en.wikipedia.org/wiki/Focus_(optics)http://en.wikipedia.org/wiki/Retinahttp://en.wikipedia.org/wiki/Accommodation_(eye)8/7/2019 dona mae rosalit
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CN XIAccessory (Spinal)
CN XIIHypoglossal
at the center, softpalate rises
Able to shrug
shoulders againstresistance and ableto turn the head sideand againstresistance.
Able to move tonguefrom side to side
swallow and able toidebtify the taste of thefood.
Can shrug shouldersagainst resistance and canturn the head fro right toright.
Able to protrude thetongue and move it side toside.
Normal
Normal
Muscle Strength
Left Arm
Right Arm
Left Leg
Right Leg
MNT Grading System:
(+5) Active motionagainst fullresistance
(+5) Active motionagainst fullresistance
(+5) Active motion
against fullresistance(+5) Active motionagainst fullresistance
+4 active motion againstsome resistance.
+4 active motion againstsome resistance.
+4 active motion againstsome resistance.+4 active motion against
some resistance.
Abnormal, possibly related to the amount of foodthat patient is eating. Possible exhaustionexperienced by the patient when she coughs.(http://en.wikipedia.org/wiki/Muscle_weakness)Abnormal
Abnormal
Abnormal