PHYSICAL EXAMINATION

NORMAL FINDINGS ABNORMAL PATIENT FINDINGS

SYSTEM FINDINGS

SKIN, HAIR, AND NAILS

Head Skull is generally round. (+) tenderness - Head is round in

No tenderness upon (+) lesions shape, no
palpation. tenderness noted
upon palpation

Hair Evenly distributed. Unevenly distributed, - Hair is short, thick

signs of alopecia and coarse and is
evenly distributed

Moist or oily. No Dry - Scalp is smooth

Scalp presence of scars. Free (+) lesions and oily and there
from lice and dandruff. (+) dandruffs, lice were no lesions
No tenderness or (+) tenderness, noted. No dandruffs
masses upon palpation. palpable mass and lice noted. Has
no experienced hair
loss.

NAILS Nails are clean, Pink Dirty, broken, Spoon - Nails are clean
tones, 160-degree angle nails, Thickened nails and pink tones
between the nail base with a 160-degree
and the skin, Nails are angle between
 hard and immobile, the nail base and
Nails are smooth and skin. Nails are
firm hard and
immobile. Nails
are smooth and
firm
Face Symmetrical. No Asymmetrical, - Face is
involuntary movements. presence of symmetrical
involuntary
movements
Eyes

a. Iris Both have even colors Greyish, uneven a. Iris are black
colors in color.

b. Sclera is
yellow in color
b. Sclera and after the
Cloudy white Yellowish, red surgery it
appears less
yellowish.

c. Cornea Moist Dry c. Cornea is

moist.

Equally round and Unequal, non d. Both pupils

d. Pupils reactive to light reactive to light are equally
accommodation round,
reactive to
light.
e. Eyelashes Evenly distributed, curls Unevenly distributed, e. Eyelashes are
outward curls inward (+) evenly
distributed
and curls
outward.
f. Eyelids No lesions, non tender Lesions, tenderness
f. No lesions
noted and the
skin is intact.
(+) earwax, aligned, no Presence of palpable - Ears are
Ears palpable mass, non mass aligned and
tender (+) tenderness clean, earwax
was noted. No
palpable
masses noted
and non
tender.
Nose Absence of lesions, no (+)lesions, swelling - No lesions
swelling and tenderness and tenderness noted upon
noted. inspection. No
swelling of the
mucous
membrane.

Mouth
a. Teeth No plaque and caries Presence of plaque a. Client has
noted and dental caries, loss one teeth
tooth loss in right
wisdom/ 3rd
molar.
b. Oral mucosa Pink and moist, no (+) lesions, dry
lesions noted b. Oral mucosa
is pink and
moist. No
lesions were
c. Gingiva Pink and moist, no (+)lesions, bleeding, noted.
bleeding, swelling and swelling
lesions noted. c. Gingiva is
pink and
moist. No
lesions and
bleeding
noted. No
d. Lips Hydrated, not dry, inflammation
symmetrical noted.

d. Lips are
e. Tongue Pinkish, no lesions symmetrical.
noted

e. Tongue is
pinkish with
no visible
f. Uvula Positioned in the lesions noted.
midline, no swelling and
lesions noted. f. Positioned in
the midline.
Pinkish in
color. No
swelling and
 lesions noted.
Neck No lesions, masses (+) lesions - No lesions
present. Able to move (+) masses and swelling
neck freely Unable to move neck noted. Client
freely is able to
freely move
her neck.

Cervical Lymph Nodes Unable to palpate or Enlarged nodes, able No enlarged

see nodes to palpate or see or hard nodes
nodes, tenderness, noted, nodes
firm, hard nodes are unable to
palpate

Lungs and thoracic region Symmetrical chest (+) adventitious - Respiratory

expansion, scapula are sounds rate is within
symmetrical and (+) Labored normal limits.
prominent. Produces a breathing No reports of
resonant sound when Respiratory rate is pain during
percussed. not within normal inhalation and
No adventitious sound. limits exhalation. No
adventitious
sounds noted
upon
auscultation.
Breast and Lymphatic

Breast Symmetrical Asymmetrical, peau Breast are

d'orange
 Round and pendulous symmetrical.

Smooth (+) edema Smooth

(-) Edema (+) masses (-) Edema

(-) masses (+)redness, swelling, (-) masses

and lesions
(-) redness, swelling, (-)redness, swelling,
and lesions and lesions

Retracted nipple and

dimpling Nipples are equal in
Nipples are equal in
Nipples size.
size

Heart and Neck vessel

-Neck vessels

a. Jugular veins Pulse is not visible Bounding, visible Pulse is not visible
pulse
(-) distention (-) distention
(+) distention
(-) protrusion at > 45 (-) protrusion at > 45
degrees (+) protrusion at >45 degrees
degree

b. Carotid arteries (+) Blowing and

No blowing and No blowing and
swishing sounds
swishing sounds swishing sounds
Pulse strength at 0,
2+ pulse 2+ pulse strength
1+, 3+, and 4+
 -Heart Audible heart sound Inaudible heart Audible heart sound
sound. Heart rate is
Absence of extra heart Absence of extra
not within normal
sounds heart sound
limits
(-) lifts (-) lifts
(+) lifts
(-) heaves (-) heaves
(+) heaves
(-) murmurs (-) murmurs
(+) murmurs

Peripheral Vascular - Extremities are - Extremities - Extremities

bilaterally are are bilaterally
symmetrical asymmetrical symmetrical

- Extremities are - Extremities

- Extremities
equally warm to are equally
have unequal
touch warm to touch
temperature/
cold to touch
- Extremities have - Extremities
equal bilateral have equal
- Extremities
pulse strength bilateral pulse
have unequal
strength
bilateral pulse
strength

- Pulse
- Pulse strength=
- Pulse strength strength= 2+
2+
is diminishing
(1+) or
bounding (4+)
- Capillary refill
- Capillary refill time= 2s
 Capillary refill time= time= 2s
>2s

(-) edema (-) edema

(+) edema
(-) prominent venous (-) prominent venous
patterns (+) prominent venous patterns
pattern

Abdomen Pale coloration Purple, jaundice Abdomen are pale

coloration
Redness

Umbilicus is Umbilicus is located

Deviated umbilicus
located midline midline

Hairs in abdomen
was been shaved
and incision was
present.

Male Genitalia

Internal and External

Genitalia

Pubic hair is Pubic hair is

a. Testicles/Scrotum distributed distributed

(+) lice and nits
(-) lice and nits (-) lice and
(-) lesions (+) lesions nits
(-) swelling and (-) lesions
(+) swelling and
excoriation (-) swelling
excoriation
and
excoriation
 (-) lesions
Penis (+) lesions
(-) swelling and
excoriation (+) swelling and (-) lesions
excoriation (-) swelling and
excoriation
Appears loose and
wrinkled without
erection.

Anus and rectum (-) Lesions and (+) lesions (-) Lesions
rashes and rashes
(+) ulcers
(-) fissures (-) fissures
(-) redness (+) fissures (-) redness

(+) redness

Musculoskeletal Both upper Extremities are Both upper

extremities are unequal in size extremities
equal in size. are equal in
size.

Swollen and
(-) tenderness enlarged joints
(-) muscle (-) tenderness
(+) tenderness
spasms (-) muscle
(+) muscle spasms spasms

Neurologic Alertness, Presence of Client is alert and

responds to vocal fasciculations, tics responsive during
stimuli and tremors the interview. No
No fasciculations, fasciculations, tics,
tics, or tremors or tremors are
are noted. noted.
 NURSING CARE PLAN #1

Nursing Diagnosis: Risk for infection related to bacterial invasion of the neural tube sac secondary to spina bifida as evidenced by open spinal canal.

DEFINING SCIENTIFIC BASIS EXPECTED OUTCOME NURSING RATIONALE

CHARACTERISTICS INTERVENTION

 Assess neural tube  Gives information

Subjective data: Vulnerable to invasion Short Term: sac for breaks or about the potential for
and multiplication of leakage of CSF, infection of the sac
Client’s mother After 2-3 hours of nursing irritation of sac, site, meningitis if the
pathogenic organisms,
verbalized, “Mahadlok intervention client’s mother redness, swelling, sac is ruptured, or is
which my compromise
man ko aning burot sa will identify interventions to purulent drainage at present.
health. Spina bifida is or around sac area;
luyo sakong anak, naa prevent or reduce risk of
part of a group of birth Assess for fever,
man guy tubig basin infection and client will
defects called neural irritability, nuchal
nya magka-impeksyon receive specific intervention rigidity, cloudy foul-
tube defects.Caused by
na nya abli raba ang for protrude spinal cord. smelling urine.  Avoids the
a defect in the neural
burot.”  Do handwashing bef proliferation of
arch generally in the
ore or after microorganisms to the
lumbosacral region, procedures involving site.
spina bifida is a failure Long term: the site and
of the posterior maintain sterile
laminae of the After 1 day of nursing technique when
Objective data: vertebrae to close; this intervention, client will no caring for the client.
leaves an opening longer have protruding
 Protrude spinal through which the spinal cord and client’s  Use sterile saline or
cord noted antibiotic solution as  Avoids the sac
spinal meninges and mother will demonstrate
 Redness around prescribed to make membrane to be dried
the area spinal cord may techniques and lifestyle
sure a moist sterile that could result to sac
 Open spinal protrude. changes to promote healing dressing is applied breakage and
canal in the of the wound due to the over the sac. contamination.
 lower middle spina bifida.  Reinforce moist
back dressing with dry  Prevents
 Exposed tissue sterile dressing and contamination by
and nerves change as needed; capillary action
 Curved spine Remove moist through moisture.
noted dressing after it has
 Swollen seen dried to avoid
around the area damage to sac.
 Fluid around the  Apply shield over
sac the sac dressing and
 Cyanosis around tape a plastic sheet  Protects the sac from
the area below the defect; urine or fecal
following surgical contamination.
closure on the
defect, apply a
transparent
occlusive dressing
over the area below
the sac site.
 Keep anal area
clean and apply a  Prevent fecal
sterile shield contamination caused
between anus and by poor anal sphincter
sac. control which allows
for dribbling and
incontinence of stool.

 Protects sac from

 Teach parents to contaminants and
cleanse the sac
gently with moist maintains cleanliness .
cotton balls if soiled,
avoid diapering the
 infant until after
surgery and healing
has taken place.
 Following surgical
 Indicates wound
repair of the defect,
infection.
observe any
changes in wound
including redness,
swelling, warmth,
drainage, fever.
 Maintain the infant
in a prone position
or side-lying, as  Reduces pressure on
permitted, with the sac to prevent
head lower than possible rupture and
buttocks or hips prevents rolling on
slightly flexed with a side or back.
pad between the
knees; anchor
position with
sandbags.
 Teach parents about
proper positioning
infant and  Prevents damage to
application of the sac and possible
protection around infection.
sac such as foam
rubber doughnut.

 Handle infant
gently, hold and
support back above
the defect, or place
 Prevents pressure on
on a pillow in prone
the sac area.
 position to move
from place to place.

 Teach parents about

signs and symptoms
of infection on the
surgical site, and
notify health care
provider
accordingly.  Promotes early
detection of an
 Tell parents about infectious process for
the importance of early treatment.
handwashing,
dressing change,
use of clean or
sterile linens,
gloves, supplies
 Prevents transmission
when caring for sac
of infectious
area.
organisms; sterile
technique may not be
needed in giving care
after surgery is
performed.