HEALTH AND NURSING ASSESMENT

MR. J WITH CLOSE FRACTURE IN LEFT SHOULDER

Head-to-Toe Assesment
Assesment conducted by : ENI SUNDARI Date :_ September 2th 2020
Time : 21.00 p.m.
LOC o RLQ (active / hyper / absent)
 Alert □Drowsy □Lethargie □Stuporous □ Palpation : no lumps
□Coma Upper Extremities
Orientation □ Radial pulse equal, +2 : (+)
□ Person good o Other : (-)
□ Place good □ Temp vs trunk (warm / cool)
□ Time good □ Grip equal and strong : normal
□ Situation good □ Capillary refill <3 sec : yes
Vitals □ Vein filling rapid ; yes
□ Temp37,2C □ R____20x/minuts__ In left shoulder looks bruised, and in
□ BP : 110/80mmHg □ Pulse Ox_: 98% palpation there is a changes in shapes.
Head Lower Extremities
□ Hair : black colour, clean and tidy, no □ Hair present : yes
lesions □ Edema : no oedema
□ PERLA : 2 mm □ Foot strength : normal = 5
□ Nose : clean, symmetrical, no breathing □ Homain’s (-) Claudication (-)
nostrils, no flu, no lesions □ Temp vs Trunk (warm / cool)
□ Ears : clean, symmetrical, no swelling □ Nails : normal
behind the ear □Yellowed □Thickened □Ingrown
□ Mouth _________________________________
_______________________________ ___
o Midline tongue : symmetrical □ Pedal pulse R(palp) L(palp)
o Moist : yes ROM / Strength
o Lesions : no inflammation and □ Upper R : full □ Upper R : 5
lesions □ Upper L : - □ Upper L : 0
o Dentition : normal, complete □ Lower R : full □ Lower R : 5
Neck □ Lower L : full □ Lower L : 5
□ Carotis pulse (+) □ JVD (-) □ Trachea □ Sensation : normal (+), warm
Midline General Assesment
Chest : symmetic □ Weight/Height : 65 kg / 165 cm
□ Apical Pulse_(+)_□ Muffles (-) □ □ BM : normal is 21,25
Arrhythmia (-) Pain Assesment
□ Breath Sounds – Anterior : Vesicular □ Acute/Chronic □Intensity (0-10) : 7
Posterior : _ Vesicular , Lateral : Vesicular □ Location : left shoulder
□ Chest Symmetry : normal □ Duration : 3-4 minutes
□ Skin Turgor (clavicle) : normal, < 2 □ Characteristic : pricked
second □ Precipitation : Close fracture left
Abdomen shoulder
□ Inspection : normal, no lessions, no □Frequenc : disappear and arise
acites □ Non-verbals : face grimacing and
□ Ausculation holding the left shoulder
o LUQ (active / hyper / absent) □ Sleep : can’t sleep because pain
o RUQ (active / hyper / absent)
o LLQ (active / hyper / absent) Skin Assesment
 □ Description: skin
is tan, not
cyanosis, skin
feels moist, the
skin area looks
clean on the
patient's body, the
face looks reddish
due to fever, hot
acral, no edema,
skin turgor <2 seconds