Nursing Systems Physical Assessment

Area Assessed Head: Hair distribution color texture Scalp Size and shape Motor portion of cranial nerves VII(facial nerve) Neck: Position,Symmetrical Range of motion Lymph nodes

Actual Findings Long and evenly distributed Black Smooth Clean and dry Symmetrical,rounded,head positioned at midline with no lumps,lesions and parasites Symmetrical smile,frown, and forehead wrinkles; Equal puffing out of cheeks Head centered symmetrical Smooth movements without discomfort Small,round,soft,mobile,non-tender lymph nodes

Area Assessed Eyes: Visual acuity

eyelids

eyelashes eyebrows Cornea Ears Ear canal opening Hearing acuity

Actual Findings Presence of eyebags Parallel to each other PERRLA-Pupils Equally Round React to light Accommodation Same color as the skin Eyelids close completely No lesions,scaling of inflammation Distributed evenly and curved outward Symmetrical in size,extension,hair texture and movement Clear transparent cornea Free of lesions, discharge or inflammation Canal walls pink Patient normally hears word when whispered

Area Assessed Nose Size,shape and skin color Nares Mouth and Pharynx

Actual Findings No bumps,lesions,edema or tenderness Smooth,symmetric with same color as face Oval,symmetric and without discharge. Flaring of nostrils. light pink,dry,symmetric

Freely movable joints without edema Pink nail beds with smooth rounded nails Bilaterally equal hands strength .lips Buccal mucosa Gums tongue teeth Pink. wrist and elbow joints Color. no lesions Even skin tone Bilaterally equal shoulder height firm. shape of finger nails Place two fingers in each of the patient’s palms while the patient squeezes your fingers Actual Findings Uniform color. Client sits up with arms in lap dull over the area Symmetrical axillae without hair.slightly rough tongue with a midline depression Firmly set.moist Slightly pink color. no lesions and lumps symmetrical Equal chest expansion Accessory muscle(shoulder) used during respiration Area Assessed Upper Extremities: Skin tone Ask patient to extend the arms forward and then rapidly turn the palms up and down Fingers. smooth surface.texture without lesions.moist and tightly fit against each other Moist.shiny with tooth decay Area Assessed Anterior Thorax: Skin tone symmetry Client’s position Percuss over the anterior thorax axillae Posterior Thorax: Skin tone Shoulder blades Palpate over the posterior thorax scapulae Symmetry of chest expansion Accessory muscle used during respiration Actual Findings Even brown skin tone. only a yellowish bruise on her right arm Steady arms without tremors or pronator drift Smooth.no lesions and lumps Symmetrical placement of all structures. Smooth surface.

or solid firm Non-palpable liver.Area Assessed Abdomen: Abdominal contour Skin characteristics Bowel sounds Palpate kidneys on each side of the abdomen Palpate the liver at the right intercostals border Palpate for spleen at the left costal border Actual Findings rounded contour Symmetrical contour without lesions. rash. no bruits Non-palpable kidneys.or smooth firm Non-palpable spleen Area Assessed Lower extremities: Skin tone Hair and nail growth edema Lesion and lumps Actual Findings Pallor Symmetrical hair and nail growth Bilaterally pitting edema No lesions or lumps . presence of stretch mark Normal bowel sounds in four quadrants.

Color of urine is yellow. The patient denies the presence of coughing. Subjective: Skin Integrity: “wala man ko’y samad samad” as verbalized by the patient. Objective: Patient has less fluid intake. HR= 90 bpm Objective: The patient only takes 4-5 spoons of rice and drinks half water of the glass. Subjective: Nutrition: “daghan man ko makaun pero dili lang naho hutdon and sud. Objective: Patient has moist skin with brown pigmented skin tone. Subjective: Elimination: “ok ra ako pagpangihi” as stated by the patient. The patient scores the pain with 6 and we scores 3 as moderate pain. and color yellow.ot ako dughan” as verbalized by the patient. PR=90 bpm. Objective: Describe: The patient has irregular respiration. Subjective: Activity/Safety: “malipong ko osahay” as verbalized by the patient. She has a bruise on her right arm of a yellowish color. Objective: Pupil size : Right: 3cm Left: 3cm Reaction: Bilateral eyes are equally round black reactive to light accommodation. . Objective: Patient’s activity was limited sitting on bed. urinates 3x a day and defecates only when she needs to. The patient has complete upper teeth while she lost 1 bicuspid and 1 molar of her lower teeth. Consistency of stool is soft. Objective: Heart Rhythm: The patient’s heart rhythm is regular with the presence of discomfort and pain.an sa plato”as verbalized by the patient. Guarded movement of the heart BP= 100/70 mmHg.Subjective: Communication: “Okay ra ako panan-aw og klaru ako pagdungog” as verbalized by the patient Subjective: Oxygenation: “Kailangan pa ko mugamit sa oxygen support” as verbalized by the patient Subjective: Circulation: “osahay muhu. Having a normal breathing sound of bronchial. Patient was able to answer the questions well when interviewed. Patient claims for dizziness and can take only to 2-3 steps without the oxygen support. RR= 35 cpm.

Objective: She shares her problems to her father. Patient is taking her medications religiously. She verbalizes her feelings. Subjective: Coping: “nakasabot man ko sa aho sitwasyon ” as verbalized by the patient Objective: Patient claims to sleep for 4-5 hours at night and has a difficulty in breathing when lying on bed. . Seen patient always smiling during nursing rounds.mas ok maglingkod og porma ” As verbalized by the patient.Sujective: Comfort/Sleep/Awake: “maglisod ko matulog kung muhigda sa kama.

37.0 fl 27.0-100.0-16.LABORATORYEXAMINATIONS HEMATOLOGY REPORT EXAMINATION HEMOGLOBIN RESULT REFERENCE VALUE (M) 13. 2012 HEMATOCRIT 10.0.0-18.0gm/L (F) 12.0-5.54 (F) 0.0 (F) 4.06 Examination Mean Cell Vol.02-0.99 3.51-0.01-0.73 31.43 Thrombocytes (platelets) Differential Count Neutrophil 537 Above the normal range.5-6. Conc.0 pg 330-350 g/l SIGNIFICANT Within the normal range Within the normal range Above the normal range .06 0.0gm/L DATE: July 28.46 0.31 WBC RBC 15.25-0.51 REFERENCE VALUE 80.0-34.45 0.40 0. (MCH) Mean Cell Hgb.67 Lymphocyte Monocyte Eosinophils 0. Results 83.08 0. less than the normal range Above the normal range Within the normal range Within the normal range 0.19 372.7 less than the normal range (M)0.40-0.47 5-10x10g/L (M) 4.5x 10^/L 140-440x10/L less than the normal range Above the normal range less than the normal range SIGNIFICANT 0.03 0. (MCV) Mean Cell Hgb.

5-8.0 1.015-1.Urinalysis Examination Macroscopic Color Transparency Reaction Specific gravity Glucose Protein Result yellow cloudy 6.020 Negative 2+ Reference Value Pale yellow to amber Clear to slightly hazy 4.025 Negative negative Significant Normal Abnormal Normal Normal Normal Abnormal .0 1.