PHYSICAL ASSESSMENT (HEAD TO TOE APPRAISAL) INTEGUMENTARY Assessment (August 20, 2013) Skin color appears pinkish with smooth

texture, cool and clammy to touch. She has chest scar at left and right with a measurement of 3 cm because she had undergone chest tube thoracostomy last June 24 at left chest, followed by July 5 at right chest. She is afebrile. Presence of bruises was noted at the right arm due to Intravenous fluid Infiltration. Changes Duty day (August 21, 2013) Same data was gathered with no significant changes Duty day (August 27, 2013) Same data was gathered with no significant changes

HEAD Assessment (August 20, 2013) Head is symmetrical, normocephalic, with symmetrical facial movements; closed fontanels, fine hair and clean scalp. Changes Duty day (August 21, 2013) Same data was gathered with no significant change. Duty day (August 27, 2013) Same data was gathered with no significant change.

EYES Assessment (August 20, 2013) Lids are symmetrical, Pinkish conjunctiva, with anicteric sclera; pupil size on the right is 2mm while on the left side is 3mm; with sluggish reaction to light on the right eye while brisk reaction to light on the left eye; and with unequal constriction/convergence; visual acuity is grossly normal, peripheral vision is intact/full.

Changes Duty day (August 21, 2013) Same data was gathered with no significant changes

EARS Assessment (August 20. 2013) Same data was gathered with no significant changes Duty day (August 27. 2013) Same data was gathered with no significant change. Changes Duty day (August 21. gums and mucosa are pinkish with no lesions or ulcerations noted. Alar flaring still noted MOUTH Assessment (August 20.Duty day (August 27. Septum is midline. Alar flaring still noted Duty day (August 27. 2013) Same data was gathered with no significant change. Changes Duty day (August 21. NOSE Assessment (August 20. The patient was able to hear normal voice tones in both ears. 2013) . Changes Duty day (August 21. 2013) Still with oxygen inhalation @ 6 lpm via nasal cannula. Both patent. with pinkish mucosa without discharges. 2013) Alar flaring noted. With oxygen inhalation @ 6 lpm via nasal cannula. 2013) Still with oxygen inhalation @ 6 lpm via nasal cannula. 2013) Lips appear pinkish. Her tongue is midline and missing teeth was noted. 2013) The left and right pinnae were symmetrical and aligned with the outer canthus of the eye with no discharges noted.

Same data was gathered with no significant changes Duty day (August 27. Mucosa was pinkish in color. 2013) Trachea is located centrally midline of the neck. 2013) Uvula is midline. 2013) Same data was gathered with no significant changes PHARYNX Assessment (August 20. 2013) Patient X has irregular breathing pattern with respiratory rate of 61 cycles per minute and apical rate of 106 beats per minutes. 2013) Same data was gathered with no significant changes Duty day (August 27. No palpable lymph nodes noted on any areas of the neck and non-palpable thyroids and neck is in normal range of motion. tonsils and posterior pharynx are not inflamed. 2013) Same data was gathered with no significant changes Duty day (August 27. 2013) Same data was gathered with no significant changes NECK Assessment (August 20. Used of accessory muscle noted due to difficulty of breathing. Changes Duty day (August 21. Changes Duty day (August 21. 2013) Same data was gathered with no significant changes CHEST AND LUNGS Assessment (August 20. . She has scar on the left and right anterior axillary line due to insertion of Chest tube thoracostomy.

Duty day (August 27. crackles noted at left and right side of the lungs. 2013) Same data was gathered with no significant changes GENITOURINARY . Deep breathing exercise was encouraged. and has no scars at the particular area of the abdomen. Her radial rate is 109 beats per minute and a capillary refill of less than 2 seconds. 2013) Non-productive cough still noted and wheezes still present at left and right side of the lungs. 2013) Patient X has symmetrical configuration of the abdomen. wheezes noted at left and right side of the lungs. 2013) The patient’s precordial area is flat. Peripheral pulses are symmetrical. The point of maximal impulse was located at left fifth intercostal space. 2013) Same data was gathered with radial pulse of 124 beats per minute. Changes Duty day (August 21.She has non-productive cough. 2013) Same data was gathered with no significant changes Duty day (August 27. Normoactive Bowel Sounds and tympanic during percussion. GASTROINTESTINAL Assessment (August 20. there was no thrill or heaves has been palpated. 2013) She has productive cough and upon auscultation. 2013) Same data was gathered with radial pulse of 100 beats per minute. CARDIOVASCULAR Assessment (August 20. Changes Duty day (August 21. Changes Duty day (August 21. Upon auscultation. Duty day (August 27.

With a side drip of PNSS 1L attached to soluset for PIPTAZ medication regulated at 30gtts/min. oriented and calm. She has ongoing Intravenous fluid of D5 Water regulated @ KVO rate. her urine is now yellowish in color. Duty day (August 27. with oxygen inhalation @ 6 lpm via nasal cannula. And according to patient. Muscle strength on upper extremities is 5/5 while on the lower Extremities is 3/5. . infusing well @ left arm. 2013) Same data was gathered with no significant changes Duty day (August 27. 2013) Presence of foley catheter attached to urobag draining to color orange urine. 2013) Same data was gathered with no significant changes GENERAL APPEARANCE During the assessment. the patient was conscious. Her spine is in midline. 2013 The foley catheter was removed. Changes Duty day (August 21. the color of her urine was light yellow. Muscle strength not equal. on her bed in a semi-fowler’s position. Duty day (August 21. 2013) Same data was gathered with no significant changes On August 23. She appeared weak and uses accessory muscles due to difficulty of breathing. 2013) According to the patient. MUSCULOSKELETAL Functional level classification: Patient’s range of motion is normal.Assessment (August 20.

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