PHYSICAL ASSESSMENT

BODY PARTS TECH-NIQUE Skin Inspection, Palpation NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS

-light to dark -light to dark brown & brown & feels feels warm warm -mild skin rashes -no swelling, -smooth and soft

-abnormal

Hair and Scalp

Inspection,

-smooth and soft -color black

- smooth and soft

-normal

Inspection Nails

-properly distributed -no presence of parasites (lice) -fine texture

-round nail with 160degrees nail base -pink nail bed

-normal

-no masses -round nail with 160degrees nail base -pink nail bed Head Inspection -face is -face is symmetrical, -normal symmetrical, centered-head position centered-smooth and controlled head position movements -smooth and controlled -normal movements -blinking symmetrical, involuntary & approximately 15 blinks/min -evenly distributed -eye lashes are short -blinking symmetrical, involuntary & approximately 15 blinks/min -evenly distributed -eye lashes are short -eye lid margins moist & pink -normal

Neck Eyes

Inspection Inspection

Eye brows

• Eye lashes

-pupil is equally round -eye lid and reactivated to light margins moist

Eye lids

& pink

accommodation

Pupil •

-pupil is equally round -uniform in color and reactivated to light accommodati on -transparent, smooth, moist -uniform in color

Iris •

-transparent, smooth, moist

Ears

Palpation , Inspection

-Ears of equal -Ears of equal size & -normal size & similar similar appearance appearance -Skin in the external ear

-Skin in the is smooth and color pink external ear is smooth and color pink Nose Inspection -color is same -color is same as face -normal as face -symmetrical appearance -symmetrical -no redness in the nasal appearance mucosa -no redness in the nasal mucosa -pink in color -moist -pink in color -dry -smooth, moist with no lesions -normal

Mouth

Inspection Palpation

Lips •

• Buccal mucosa Tongue •

-moist with no lesions -smooth, moist with no -pink and moist lesions -no dental carries -moist with no -32 total no. of teeth lesions -pink and moist -no dental

Gums •

Inspection Teeth

carries -32 complete no. of teeth

-normal

-normal

Thoracic & Lungs

Inspection Palpation, Auscultation

-position of -position of sternum is sternum is level with ribs level with ribs -no masses -no masses - lungs clear upon -lungs clear auscultation upon auscultation -smooth skin surface -flat areola -no masses -smooth skin surface -flat areola -no masses -PMI is felt upon pulsation -Rhythm: regular

-normal

-normal -normal

Breast

Inspection Palpation

Heart

Palpation, Inspection

-PMI is felt upon pulsation -Rhythm: regular

-normal

Upper

Palpation,

-bilateral

-bilateral pulses strong & -normal

Extremities (right and left)

Inspection

pulses strong equal (radial pulse) & equal -mobile (radial pulse) - intact condition of the -mobile skin in arms -intact -no lesions, no swelling 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

-no rashes or lesions -umbilicus is centrally located -rounded abdomen

-normal

-symmetrical -high pitched, irregular gurgles 5-35times/min

-high pitched, irregular -abdomen rises with gurgles 5inspiration in synchrony 35times/min with chest -abdomen rises with

inspiration in synchrony with chest Genitourinary (The patient refused to assess his genitourinary organs.) Inspection -bilaterally symmetrical and equal (The patient refused to assess his genitourinary organs.)

Lower Extremities (right and left)

-bilaterally symmetrical -normal and equal

-right foot has no lesions, -right foot has no swelling no lesions, no -left foot has no swelling abrasions - normal -left foot has no lesions, no swelling - skin color is the same as the other part of the -skin color is -normal body the same as the other part of the body

A. Biographical Data
Name: Age : Gender: Birth Date: Birth place: Residence: Religion: J.E Reyes 17yrs old Female June 7, 1992 Manila 844-4 Hamabar St. Dagupan Tondo Mla. 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 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 She verbalized “First time ko pong na confined sa hospital ngayon lang po talaga.”

IV. Hospitalization Complete immunizations were given to her accordingly. Mild illnesses include having cold, cough and flu are treated by medication over the counter. Present hospitalization at MHMC because of DHF. She haven’t 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.

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”

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 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 2.) Hyperthermia 3.) Activity intolerance related to body weakness secondary to DHF 4.) Alteration in comfort 5.) Skin impairment

NURSING CARE PLAN(BLEEDING)

ASSESSME NT

DIAGNOSIS

INFERENCE PLANNING

INTERVENTI RATIONALE ON

EVALUATIO N

Subjective: “Dumudug o ang ilong ko” as verbalized by the client

Injury, risk for hemorrhag e related to altered clotting factor.

Objective: •Weakness and irritability. •Restlessn ess. •V/S taken as follows:

This infectious disease is manifested by a sudden onset of fever, with severe headache, muscle and joint pains (myalgias and arthralgias —severe pain gives it the name break-bone fever or

After 1 hr. Of nursing interventio ns, 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.

After 1 hr. Of nursing interventio ns, the •The G.I client was tract (esophagus able to demonstrat and e behaviors rectum) is that reduce the most the risk for usual bleeding. source of bleeding of its mucosal fragility.

•Observe for presence of

•Sub-acute disseminat

T: 38.1 P:70 R:19 CR:73 BP:110/80

bonecrushe r disease) and rashes and usually appears first on the lower limbs and the chest. There may also be gastritis and some times bleeding.

petechiae, ecchymosis , bleeding from one more sites.

ed intravascul ar coagulation (DIC) may develop secondary to altered clotting factors.

•Monitor pulse, Blood •An pressure. increase in pulse with decreased Blood pressure can indicate loss of circulating blood •Note volume. changes in mentation and level of •Changes consciousne may ss.

•Avoid rectal temperatur e, be gentle with GI tube insertions.

indicate cerebral perfusion secondary to hypovolemi a, hypoxemia.

•Encourage use of soft toothbrush, avoiding straining for stool, and forceful nose blowing.

●Rectal and esophageal vessels are most vulnerable to rupture.

•Use small needles for injections.

•In the presence of clotting factor disturbance s, minimal trauma can cause mucosal bleeding.

Apply pressure to venipunctur e sites for longer than usual.

•Recomme nd avoidance of aspirin containing products.

•Minimizes damage to tissues, reducing risk for bleeding and hematoma.

•Prolongs coagulation , Collaborativ potentiatin e: g risk of hemorrhag • e. Monitor Hb and Hct and clotting factors. •Indicators of anemia,

active bleeding, or impending complicatio ns.

NURSING CARE PLAN(HYPERTHERMIA)

Cues

Nursing diagnosis

Rationale

Nursing objectives

Intervention s

Rationale

Evaluation

Objective cues:

>skin is warm to touch >flushed skin >increase d body temp. Above normal range (36.5°C37.5°C)

P: alteration in thermoregu lation

Temp taken. 38.1

Body temperatu re increases (fever)as a protective (hyperther response mia) to infection and injury. E:related to The infection s/t elevated DFS body temperatu re S/Sx: enhances the body’s defense >skin is mechanis warm to m touch although it can cause >flushed discomfort skin for the >increased person. A body temp. true fever Above results normal from an

Short term goal:

Independent : 1. Chills is an indication of a rising temperatur e. Hypertherm ia can cause dysrhythmia s.

Short term goal:

After 1015mins of nursing interventio n the body temperatu re will decrease from 38.1°C to a range of 37.8°C37.6°C As will be supported by skin slightly warm to touch, lessen flushed skin.

1. Monitor temperature especially during episodes of chills. Note heart rate and rhythm.

After 1015mins of nursing intervention the body temperature was decreased from 38.1°C to a range of 37.8°C As will be supported by skin slightly warm to touch, lessen flushed skin.

2. If the client is not in chilling stage render continuous tepid sponge bath.

2. To replace artificially the body’s sweating mechanism by cooling the skin’s surface

Goal met

Health History Physical assessment

Nursing Care Plan
Ron Chan III- I4 Mam. Correa

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