PEROS (Physical Assessment and Review of Systems)

Areas Subjective Findings Objective Findings Problem Identified

Assessed

General “Dako jud ni siya Inspection Imbalanced Nutrition: less

Health pag anak, 2.7kg”, than body requirements
 The patient's body size is small for a 3-
Survey as verbalized by related to associated
the mother. month-old girl's desired body size (60 cm). conditions of inability to ingest,
 Height: 48.5 cm or absorb nutrients (defects in
“Sauna maka
organ function or metabolism,
tolerate pa siyag  Weight: 2.3 kg as evidenced by lack of
60cc nga fluid,
 Clean and appropriate grooming. appropriate weight gain,
karon 30cc
insufficient muscle tone, pale
nalang”, as  How does the pt. smell? – Odorless.
conjunctiva or mucous
verbalized by the  No signs of distress, is awake, irritable, and membranes, and laboratory
mother.
crying. tests reflecting nutritional
“sige lang siyag deficiency.
 GCS 14 (E4V4M6)
hilak”, as
Impaired Skin Integrity related
verbalized by the  A sepsis t/c malrotation enterocolitis
to alteration in fluid volume,
mother.
inadequate nutrition and
“pag uli namo malnutrition, possibly
gikan og Polymedic evidenced by [poor or delayed
ning taas napud wound healing and disruption
iyang hilanat mga of skin surface or wound
40 to”, as closure].
verbalized by the
Risk for imbalanced Fluid
mother
Volume possibly evidenced by
“Gasuka, kalibang risk factors of excessive losses
siya sa balay”, as from vomiting or diarrhea,
verbalized by the decreased intake, nausea,
mother. decreased plasma proteins,
“Balik-balik iyang malnutrition, continued use of
kaso ba, ma diuretics; excess sodium and
question jud fluid retention.
nganong dili jud
Risk for Infection as evidenced
siya maulian”, as
by risk factors of tissue trauma,
verbalized by the
malnutrition, and associated
mother.
conditions of decreased Hb,
“mas ning grabi increased environmental
siya, dehydrated exposure, and malnutrition.
najud kayo siya, dili
Risk for Electrolyte Imbalance
napud siya mo
possibly evidenced by risk
totoy, sige napud
factors of vomiting,
siyag suka og
dehydration.
kalibang”, as
verbalized by the Risk for impaired Attachment
mother. related to risk factors of
interruption in bonding
process, physical illness,
perceived threat to own
survival as evidenced by not
being breast feed, anxiety
associated with the parental
role and demands of infant.

Deficient Knowledge regarding

pathophysiology of condition,
nutritional needs, growth and
development expectations,
and parenting skills may be
related to lack of information,
misinformation or
misinterpretation, possibly
evidenced by verbalization of
concerns, questions, and
 misconceptions, or
development of preventable
complications.

Integumenta “Naunsa na iyang Inspection Impaired Comfort may be

ry System kamot? Nalata na related to body response to
 The skin color is pale.
iyang kamot?” as infective agent, properties of
 No unevenness of hair distribution.
verbalized by the infection (e.g., skin irritation,
mother.  No presence of lice, nits, dandruff, and development hematoma)
condition of the scalp. evidenced by irritability, and
Nails on both the upper and lower crying.
extremities were oval in shape, pinkish in
color, with some drying but no
discoloration. Hyperthermia may be related
 Hematoma/ skin irritation on the left arm. to increased metabolic rate,
 No presence of edema. illness, and dehydration, as
evidenced by increased body
temperature, flushed, warm
Palpation skin; and increased pulse and
respiratory rates.
 Dry and poor skin turgor in general
Impaired Skin Integrity related
 Warm to touch
to associated condition of
 Febrile twice, 5 AM – 38.5, 3 PM- 38.2
vascular trauma,
immunodeficiency; or related
factors of alteration in fluid
volume, inadequate nutrition,
[infection], as evidenced by
acute pain, alteration in skin
integrity, hematoma and
redness on the left arm,

Risk for Infection possibly

evidenced by risk factors
 alteration in skin integrity,
several attempt to attach iv
mainline (traumatized tissues).

HEENT Head and face – (Inspection) Risk for impaired oral Mucous
Membrane possibly evidenced
a. Head  Head circumference: 32.5 cm
by risk factors of dehydration,
and face  Normal head symmetry
malnutrition, vitamin
b. Eyes  Both lateral sides of a face move deficiency.
c. Ears simultaneously
d. Nose Risk for Dry Mouth related to
e. Oral (Palpation) dehydration or absence of oral
Cavity intake, decreased saliva
 No presence of any masses.
production, poor or
Eyes – (inspection) inadequate oral hygiene, and
nutritional deficits, as
 Opens eye spontaneously. evidenced by xerostomia (dry
 Presence of pinkish tone within eyelids, not mouth), oral discomfort, dry
swelling and no discharges. lips.

Risk for Aspiration related to

(presence of open to drain
Ears –(Inspection) tube, increase in intragastric
 No presence of discharges and no odor and pressure, delayed gastric
pale in color. emptying, treatment regimen).

Risk for ineffective Breathing

Nose – (Inspection)
Pattern possibly evidenced by
 Normal symmetry, pointed nose. risk factors of response to
 No presence of discharges. infectious process, decreased
 Nasal cannula securely attached. energy, fatigue.
 No presence of masses and displacement Imbalanced Nutrition: Less
of bone and cartilage.
 Oral cavity–(inspection). than Body Requirements
related to GI tract function
 OGT securely attached.
alterations, Lengthy NPO status
 Dry mouth and dry lips, lip smacking. as evidenced by reduced
 Pinkish gums, presence of tiny mouth muscle mass, electrolyte
sores. imbalances, and poor skin
 Tongue pinkish in color, normal symmetry. turgor and weight loss.

Neck Inspection Deficient Fluid Volume may be

related to decreased ability or
 Poor skin turgor observe in the neck area.
aversion to swallowing, OGT
 -Head moves spontaneously and purposely.
attached for open to drain,
 The bony thorax is normal. presence of fever, as
evidenced by dry mucous
Palpation
membranes, poor skin turgor.
 No enlargement of cervical nodes and
Disturbed Body Image related
enlargement of thyroid gland of the neck.
to visible presence of neck as
 Decrease muscle for tone and strength, no
evidenced by poor skin turgor.
presence of lumps or masses.

Respiratory “Napositive siya sa Inspection Ineffective Airway Clearance

System COVID atong 3 may be related to decreased
 No spinal deformities.
weeks pa siya”, as energy, fatigue, as evidenced
 Equal chest expansion, visible ribcage,
verbalized by the by changes in depth and rate
mother. supraclavicular retractions, normal rate of of respirations, cough without
respirations. sputum production.
“giubo og  Presence of coughing when crying.
gidanggas akong Ineffective Breathing Pattern
manghod pero dili Auscultation may be related to pain,
man kayo siya mag muscular impairment,
 duol-duol ni baby”,  Minimal haziness at the right lower lung. decreased energy, and fatigue,
as verbalized by possibly evidenced by
the mother. coughing.

Impaired Comfort may be

related to muscle contractions,
physical or psychological
exhaustion, possibly evidenced
by couching, alteration in
muscle tone, irritability and
crying.

Cardio- “Pero sa balay Inspection Decreased Cardiac Output

vascular naman gi monitor related to alteration in heart
 Normal chamber sizes
System namo iyang 02 rate, rhythm, and conduction
 Heart not enlarged
saturation pero as evidenced by tachycardia,
okay man”, as  Very minimal pericardial fluid seen at the bradycardia, decreased
verbalized by the apical area. peripheral pulses; cold,
 mother.  Pericardial effusion noted on LV side A4C clammy skin/poor capillary
(0.1cm), not appreciated on subcostal view refill.
“Ning baba napud
iyang O2 saturation Palpation Ineffective Tissue Perfusion
after 2 days related to stasis, inflammatory
namong na  Anterior chest wall had no abnormal lifts, response, atrioventricular
discharged sa heaves or vibrations. shunts in pulmonary and
Polymedic”, as peripheral circulation, possibly
verbalized by the evidenced by signs and
mother. Auscultation symptoms dependent on
system involved, such as renal
 Aorta obscured by gas (decreased specific gravity and
 Mild mitral regurgitation pale urine in face of
 Bradycardia dehydration), peripheral (poor
 Tachycardia skin turgor), or cardiac
(arrhythima).

Breast and Inspection No problems identified.

axilla
 Chest circumference: 32 cm
 Normal symmetry, No presence of lesions
and discharges.

Gastro- “Gasuka, kalibang Inspection: Risk for Dysfunctional

intestinal siya sa balay”, as Gastrointestinal Motility
 Abdominal circumference: 34 cm
System and verbalized by the related to limited fluid intake,
 Pale and distended abdominal area.
the abdomen mother. fluid and gas distended small
 Normal umbilicus position and no and large intestine, suggestive
“Ning dako iyang discharge. ileus as evidenced by
tiyan maski  No signs of bulges or hernias. acceleration of gastric
makalibang og  Yellow, soft stool. emptying; diarrhea, distended
makaihi ra sya”, as
abdomen, and vomiting.
verbalized by a Percussion
family member. Deficient [hypotonic] Fluid
 Fluid and gas-distended small and large Volume related to vomiting,
 intestine, the liver is normal in size (6.33
cm) and the spleen (4.5 cm) are normal in
size and configuration.
 The colon was likewise filled with fluid and
gas, still within normal in caliber.
Palpation
 No demonstrable abdominal masses.
diarrhea as evidenced by
delayed capillary refill, poor
skin turgor, dry mucous
membranes, report of thirst
Acute Pain may be related to
abdominal fullness or pressure,
possibly evidenced by
irritability and crying.

Impaired Comfort may be

related to body response to
infective agent of infection
(e.g., distended abdomen),
evidenced by irritability, and
crying.

Genito- Inspection No problem identified.

urinary /
 Urinary bag attached.
Reproductive
 Urinary bladder partially filled, 13cc.
system
 Bladder wall is not abnormally thickened.
 Para-renal spaces are normal.
 Palpation

(Female)

 No presence of masses.

M Inspection Risk for disproportionate

Growth related to possibly
U  Height: 48.5 cm
evidenced by risk factors of
S  Fists clenched, elbows bent, hips and knees maladaptive feeding
flexed. behaviour.
C
 Lethargic/ Floppy
Ineffective infant Feeding
U  Small body size for a 3- month old baby girl.
Pattern may be related to
 No deformities. immaturity of the respiratory
L
center, metabolic imbalances,
O fatigue, as evidenced by
Palpation
S absolute NPO, abnormal heart
 No abnormal growth/protrusion of bone, rhythm, decreased energy.
K crepitus in the whole system.
Ineffective breastfeeding
E  No presence of any masses.
related to inadequate milk
supply of the mother as
L
evidenced by poor
E development of the
musculoskeletal system,
T
insufficient infant weight gain;
A sustained infant weight loss
and prone to infection.
L

System
Neurologic “sige lang siyag Cerebellar, motor Impaired Comfort may be
System hilak”, as related to body response to
Mental status
verbalized by the infective agent of infection as
mother.  Irritable, cries with minimal stimulation, evidenced by irritability, and
limiting her periods of sleep, observed crying.
spontaneous eye opening, movements of Disturbed Sleep Pattern
the face and extremities, and response to related to environmental
stimulation. barrier [e.g., ambient
temperature, ambient noise,
Motor skills
unfamiliar setting] and possible
 Able to move arms. pain as evidence by difficulty
 Able to move legs. falling and remaining asleep,
 Able to move fingers up and down. crying, and mood alterations.
 Palmar grasp reflex

Lymphatic / Inspection Risk for Infection possibly

Hemato-logic evidenced by risk factors of
 Skin is pale in appearance.
System alteration in skin integrity,
 Hematoma circular in shape is observed in
malnutrition and associated
the left arm. condition of present illness,
immunosuppression, as
Palpation
evidenced by presence of
No enlargement of the lymph nodes. hematoma in the left arm.

Acute Pain may be related to

localized inflammation and
tissue trauma, as evidenced by
presence of hematoma with
redness in the left arm,
irritable and crying.