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PHYSICAL ASSESSMENT
BODY PARTS TECH-NIQUE NORMAL FINDINGS
ACTUAL FINDINGS ANALYSIS
Skin
Hair and Scalp
Nails
Inspection, Palpation
Inspection,
Inspection
-light to dark brown & feels warm
-no swelling,
-smooth and soft
-color black
-properly distributed
-no presence of parasites (lice)
-fine texture
-light to dark brown & feels warm
-mild skin rashes
-smooth and soft
- smooth and soft
-round nail with 160degrees nail base
-pink nail bed
-abnormal
-normal
-normal
-no masses
-round nail with 160degrees nail base
-pink nail bed
Head
Neck
Inspection
Inspection
-face is symmetrical, centered-head position
-smooth and controlled movements
-face is symmetrical, centered-head position
-smooth and controlled movements
-normal
-normal
Eyes
Eye brows
Eye lashes
Eye lids
Inspection -blinking symmetrical, involuntary & approximately 15 blinks/min
-evenly distributed
-eye lashes are short
-eye lid margins
-blinking symmetrical, involuntary & approximately 15 blinks/min
-evenly distributed
-eye lashes are short
-eye lid margins moist & pink
-pupil is equally round and reactivated to light accommodation
-normal
Pupil
Iris
moist & pink
-pupil is equally round and reactivated to light accommodation
-uniform in color
-transparent, smooth, moist
-uniform in color
-transparent, smooth, moist
Ears Palpation , Inspection
-Ears of equal size & similar appearance
-Ears of equal size & similar appearance
-Skin in the external ear is smooth and color pink
-normal
-Skin in the external ear is smooth and color pink
Nose
Mouth
Lips
Buccal mucosa
Tongue
Gums
Inspection
Inspection Palpation
-color is same as face
-symmetrical appearance
-no redness in the nasal mucosa
-pink in color
-dry
-smooth, moist with no lesions
-moist with no lesions
-pink and moist
-no dental carries
-color is same as face
-symmetrical appearance
-no redness in the nasal mucosa
-pink in color
-moist
-smooth, moist with no lesions
-moist with no lesions
-pink and moist
-no dental carries
-32 total no. of teeth
-normal
-normal
Teeth
Inspection
-32 complete no. of teeth
-normal
-normal
Thoracic & Lungs Inspection
Palpation,
Auscultation
-position of sternum is level with ribs
-no masses
-lungs clear upon auscultation
-position of sternum is level with ribs
-no masses
- lungs clear upon auscultation
-normal
-normal
Breast Inspection
Palpation
-smooth skin surface
-flat areola
-no masses
-smooth skin surface
-flat areola
-no masses
-normal
Heart Palpation, Inspection
-PMI is felt upon pulsation
-Rhythm: regular
-PMI is felt upon pulsation
-Rhythm: regular
-normal
Upper Palpation, -bilateral pulses -bilateral pulses strong & -normal
Extremities (right and left)
Inspection strong & equal (radial pulse)
-mobile
-intact condition of the skin in arms
-no lesions, no swelling
equal (radial pulse)
-mobile
- intact condition of the skin in arms
-no lesions, no swelling
-normal
-normal
Abdomen Inspection,
Auscultation
Percussion
Palpation
-no rashes or lesions
-umbilicus is centrally located
-rounded abdomen
-symmetrical
-high pitched, irregular gurgles 5-35times/min
-abdomen rises with inspiration in synchrony with chest
-no rashes or lesions
-umbilicus is centrally located
-rounded abdomen
-symmetrical
-high pitched, irregular gurgles 5-35times/min
-abdomen rises with inspiration in synchrony with chest
-normal
Genitourinary (The patient refused to assess his genitourinary organs.)
(The patient refused to assess his genitourinary organs.)
Lower Extremities
(right and left)
Inspection -bilaterally symmetrical and equal
-right foot has no lesions, no swelling
-left foot has no lesions, no swelling
-skin color is the same as the other part of the body
-bilaterally symmetrical and equal
-right foot has no lesions, no swelling
-left foot has no abrasions
- skin color is the same as the other part of the body
-normal
- normal
-normal
A. Biographical Data
Name: J.E Reyes
Age : 17yrs old
Gender: Female
Birth Date: June 7, 1992
Birth place: Manila
Residence: 844-4 Hamabar St. Dagupan Tondo Mla.
Religion: Catholic
Civil Status: Child
Nationality: Filipino
Date of Admission: November 15, 2009
Admission Number: 96879
Room Number: 102 B
Discharge Date: Still in the hospital
Admitting Diagnosis: DHF
Attending Medical Doctor: Dr. GAN
II.Chief Complaint
Fever (39-40 C) w/ cough and whitish phlegm.
III.History
Present health history
5 days prior to admission patient had a high grade fever intermittent 39-40 c associated with cough and whitish phlegm, took paracetamol 500 mg. tablet which afforded some relief. No consult done, no associated signs and symptoms of diffuculty of breathing,Dysuria abdominal pain and bleeding episode.
Past health history
J.E was born June 7, 1992 , the first daughter of Mr. and Mrs. Reyes. She was well taken care of her parents starting her intrauterine life. J.E had already illness like Measles, Chicken Pox, Mumps, Diarrhea.This was J.E. first confinment to the hospital As She verbalized “First time ko pong na confined sa hospital ngayon lang po talaga.”
IV. Hospitalization
Complete immunizations were given to her accordingly. Mild illnesses include having cold, cough and flu are treated by medication over the counter. Present hospitalization at MHMC because of DHF. She haven’t undergone any surgery. As the mother explained to us.. “Oo, kumpleto naman ang bakuna. Kapag may lagnat, ubo at sipon ang gamot na binibili naming over the counter.
V. Family History
J.E came from a nuclear type of family. Both of his parents are healthy. She is the first daughter of Mr. and Mrs. R. She has her younger sister that is not yet admitted at the hospital. As the mother verbalized “ Wala namang sakit ang pamilya namin. Yung kapatid niya malakas din kita mo naman sa katawan nila”
VI. Lifestyle
The patient usually have regular hours of sleep. Allergies from any kinds of foods or medicines are not common to her. but due to her illness she has no appetite of eating well.
VII. Social Data
She have many friends around her and she is always with her friends as she verbalized “marami akong friends samin mahilig kasi ako lumabas pag hapon”
VIII.Psychological Data
Patient is resting well and improving as she verbalized “mejo ok n pakiramdam ko hindi tulad nung unang araw na confined ako dito”
IX. Patterns of Health Care
J.E was supported by her parents emotionally, physically and financially. She is under Dr. Gan As she verbalized “lagging andito sila mama at kapatid ko pati lola ko di nila ako pinapabayaan pati narin si Dr. Gan”
X. Review of System
Integumentary System
As she verbalized “Ok naman ako wala rashes.”
Excretory System
As she verbalized “Hindi naman ako pinagpapawisan”
Respiratory System
As she verbalized “Hindi naman ako nahihiraang huminga.”
Cardiovascular System
As she verbalized “Wala naman kaming sakit sa puso”
Gastrointestinal System
As she verbalized “Hindi naman ako nahihirapang dumumi, regular naman”
Genitourinary System
As she verbalized “Hindi naman ako nahihirapang umihi.”
Musculoskeletal System
As she verbalized “Naigagalaw ko naman ng maayos ang mga kamay at paa ko”
Neurologic System
As she verbalized “Nakaka-sunod naman ako sa mga bagay na pamilyar sakin”
Endocrine System
As she verbalized “Wala naman akong sakit na nahawa lang.”
5 PRIORITIZE PROBLEMS;
1.) Bleeding
2.) Hyperthermia
3.) Activity intolerance related to body weakness secondary to DHF
4.) Alteration in comfort
5.) Skin impairment
NURSING CARE PLAN(BLEEDING)
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: “Dumudugo ang ilong ko”
as verbalized by the client
Objective:
•Weakness and irritability.
•Restlessness.
•V/S taken as follows:
T: 38.1
Injury, risk for hemorrhage related to altered clotting factor.
This infectious disease is manifested by a sudden onset of fever, with severe headache, muscle and joint pains (myalgias
and arthralgias
—severe pain gives it the name break-bone fever or bonecrusher
After 1 hr. Of nursing interventions, the client will be able to demonstrate behaviors that reduce the risk for bleeding.
Independent:
•Assess for signs and symptoms of G.I bleeding. Check for secretions. Observe color and consistency of stools or vomitus.
•Observe for presence of petechiae,
•The G.I tract (esophagus and rectum) is the most usual source of bleeding of its mucosal fragility.
•Sub-acute disseminated intravascular
After 1 hr. Of nursing interventions, the client was able to demonstrate behaviors that reduce the risk for bleeding.
P:70
R:19
CR:73
BP:110/80
disease) and rashes and usually appears first on the lower limbs and the chest. There may also be gastritis and some times bleeding.
ecchymosis, bleeding from one more sites.
•Monitor pulse, Blood pressure.
•Note changes in mentation and level of consciousness.
coagulation (DIC) may develop secondary to altered clotting factors.
•An increase in pulse with decreased Blood pressure can indicate loss of circulating blood volume.
•Changes may indicate cerebral perfusion secondary to hypovolemia, hypoxemia.
•Avoid rectal temperature, be gentle with GI tube insertions.
•Encourage use of soft toothbrush, avoiding straining for stool, and forceful nose blowing.
•Use small needles for injections. Apply pressure
●Rectal and esophageal vessels are most vulnerable to rupture.
•In the presence of clotting factor disturbances, minimal trauma can cause mucosal bleeding.
•Minimizes damage to tissues, reducing risk for bleeding and hematoma.
to venipuncture sites for longer than usual.
•Recommend avoidance of aspirin containing products.
Collaborative:
•
Monitor Hb and Hct and clotting factors.
•Prolongs coagulation, potentiating risk of hemorrhage.
•Indicators of anemia, active bleeding, or impending complications.
NURSING CARE PLAN(HYPERTHERMIA)
Cues Nursing diagnosis
Rationale Nursing objectives
Interventions Rationale Evaluation
Objective cues:
>skin is warm to touch
>flushed skin
>increased body temp. Above normal range
(36.5°C-37.5°C)
P: alteration in thermoregulation
(hyperthermia)
E:related to infection s/t DFS
S/Sx:
>skin is warm to touch
>flushed skin
Body temperature increases (fever)as a protective response to infection and injury. The elevated body temperature enhances the body’s defense mechanism although it can cause discomfort for the
Short term goal:
After 10-15mins of nursing intervention the body temperature will decrease from 38.1°C to a range of 37.8°C-37.6°C
As will be supported by skin slightly warm to touch, lessen
Independent:
1. Monitor temperature especially during episodes of chills. Note heart rate and rhythm.
2. If the client is not in chilling stage render continuous tepid sponge
1. Chills is an indication of a rising temperature. Hyperthermia can cause dysrhythmias.
2. To replace artificially the body’s sweating mechanism by cooling the
Short term goal:
After 10-15mins of nursing intervention the body temperature was decreased from 38.1°C to a range of 37.8°C
As will be supported by skin slightly warm to touch, lessen flushed
Temp taken.
38.1
Subjective cues:
-“medyo mainit ang pakiramdam ko”
>increased body temp. Above normal range
(36.5°C-37.5°C)
Temp taken.
38.1
person. A true fever results from an alteration in the hypothalamic set point. Pyrogens such as bacteria and viruses causes arise in the body temperature. An elevated body temperature related to the body’s inability to promote heat loss or reduce heat production in hyperthermia. Whereas fever is an
flushed skin.
Long term:
After 3-5 hours of nursing intervention the patient will be able to maintain a core temperature within normal range of 36.5°C-37.5°C.; skin not warm to touch, no flushed skin.
bath.
3. Encourage the client to increase fluid intake.
4. Provide warm liquids to drink as tolerated.
5. Monitor client for degrees and patterns of chills and fever.
skin’s surface
3. To maintain fluid volume at a functional level.
4. To provide warmth and comfort.
5. Fever patterns aid in diagnosis.
skin.
Goal met
Long term:
After 3-5 hours of nursing intervention the patient was be able to maintain a core temperature within normal range of 37.4°C.; skin not warm to touch, no flushed skin.
Goal met
upward shift in the set point, hyperthermia results from an overload of the body’s thermoregulatory mechanisms. When the pyrogens enter the body; it acts as an antigen, triggering the immune system. More white cells are produce to help promote the body’s defense against the infection this substances
6. Provide extra blanket and clothing as needed.
7. Maintain a room temperature that is comfortable for the client.
6. To provide warmth and comfort.
7. To provide warmth and comfort.
also trigger the hypothalamus to the set point. To meet the new higher set point, the body produces and conserves heat. Several hours may pass before the body temperature reaches the new set point
Health History
Physical assessment
Nursing Care Plan
Ron Chan III- I4
Mam. Correa
