Physical Assessment (Abnormal Findings)

Body Part Findings Analysis

Face Grimace Pain indication due to the

Lips Pale and slightly dry Chapped, or cracked, lips is the term commonly
used to describe dry lips. Chapped lips can be
caused by several factors, that include:weather
excessive licking of the lips and certain
medications
Reference: Moore, K. (n.d.). What Causes
Chapped Lips?. Retrieved from
https://www.healthline.com/health/chapped-
lips
Thorax and Lung (anterior Chest slightly elevated, There is labored breathing were there is a
and posterior) deep breathing much greater increase in thoracic cavity
volume. All the inspiratory muscles are
active and they contract more forcefully.
There is increased rate of breathing that
make the PCO2 lower in the alveoli than it
is during normal, quiet breathing.
Increased in inspiration were there are
more neurons activated resulting in
progressively stronger stimulation of the
respiratory muscles, which last for 2
seconds.

Reference: Seeley’s Essential of Anatomy

and Physiology Chapter 15
Discharge Plan

Medication Encourage the patient to continue the medication as prescribed by the

physician.
Exercise Advise the patient’s parent to not let the patient move around and that the
patient should rest as much as needed.
Treatment Instruct the patient’s parent to follow the advice and order of the attending
physician.
Health Teaching Teach the patient’s parent how to properly clean the wound
Inform patient’s parent to seek medical help if any unusual signs and
symptoms occur.
Out-Patient Remind the patient’s parent about the patient’s follow up check-up
appointments as ordered by the physician.
Instruct the patient’s parent to seek immediate help for the patient drom the
medical team if any signs, symptoms and complications occur
Diet Instruct the patient’s parent to follow the prescribed diet for the patient
Spiritual Encourage the patient to continue attending the mass