HEALTH AND NURSING ASSESMENT

Mr. S With Appendicitis

Head-to-Toe Assesment Date : September 1st 2020

Assesment conducted by Vivian Yessica Time : 10.00 AM

LOC □ Grip equal and strong : Normal

□Alert □Drowsy □Lethargie □Stuporous □Coma □ Capillary refill <3 sec : yes
Orientation □ Vein filling rapid : yes
□ Person good Lower Extremities
□ Place good □ Hair present : yes
□ Time good □ Edema : no oedema
□ Situation good □ Foot strength : Normal = 5
Vitals □ Homain’s (-) Claudication (-)
□ Temp : 39oC □ R : 20x/minute □ Temp vs Trunk (warm / cool)
□ BP : 120/84 mmHg □ Pulse Ox : 98% □ Nails □Yellowed □Thickened □Ingrown
Head Normal
□ Hair : Good condition, black colour, clean □ Pedal pulse R(palp / doppler) L(palp / doppler)
and tidy ROM / Strength
□ PERLA : 3 mm □ Upper R full □ Upper R 5
□ Nose : symmetrical, no pain, no breathing □ Upper L full □ Upper L 5
nostril □ Lower R full □ Lower R 5
□ Ears : normal □ Lower L full □ Lower L 5
□ Mouth _______________________________ □ Sensation : Normal, warm
o Midline : tongue normal, symmetrical
o Moist : yes General Assesment
o Lesions : No □ Weight/Height : 58 kg / 160 cm
o Dentition : normal □ BM Normal : 22,7
Neck Pain Assesment
□ Carotis pulse (+) □ JVD (-) □ Trachea Midline □ Acute/Chronic : Acute □Intensity (0-10) : 5
Chest □ Location : Lower right region
□ Apical Pulse (+) □Muffles (-) □Arrhythmia (-) (Appendix)
□ Breath Sounds – Anterior : Vesicular – □ Duration : 2-4 minute
Posterior : Vesicular – Lateral : Vesicular □ Characteristic : pricked
□ Chest Symmetry : Normal □ Precipitation : Appendicitis
□ Skin Turgor (clavicle) : < 2 second □ Frequency : disappear and arise
Abdomen □ Non-verbals : face grimace
□ Inspection : No distention, no lesions, □ Relief factors : when moving
□ Ausculation □ Sleep : cant sleep because pain
o LUQ (active / hyper / absent) Skin Assesment
o RUQ (active / hyper / absent) □ Description: skin is
o LLQ (active / hyper / absent) tan, not siaonis, skin
feels moist, the skin
o RLQ (active / hyper / absent)
area looks clean on
□ Palpation : tenderness in lower right region the patient's body,
(+) lump (-) the face looks
Upper Extremities reddish due to fever,
□ Radial pulse equal, +2 (+) hot acral, no edema,
o Other (-) skin turgor <3
□ Temp vs trunk (warm / cool) seconds