Nursing Physical Assessment

She was appears to be restless, and appears to be dark brown in color. the patient’s vital signs at a
temperature of 36°C, Pulse rate was 74, respirations were 27, blood pressure was 110/70, has NGT but
she keeps on pulling it out when inserted. Blood secretion has been founded along with mucus.
Aspiration of secretion has happened and already suctioned by nurses to promote patent airway. Side
railings were raised to promote safety. Common laboratory findings are: Creatinine at 46.1, BUN 24.3,
SGPT 23.9, sodium 158, potassium 5.6, Calcium at 1.25 and Chloride at 117. And she seems to have
some behavioral changes. Cannot receive food in mouth. The patient’s bowel sound were hypoactive
and stated no bowel movement today. On foley catheter. Urine output was 600-800cc. appeared frail
and thin with some general weakness. The patient’s height was 4’1” and her weight was 30 kgs. The
patient wasn’t able to perform independent activities.