Name: Patient TL Age: years old

Diagnosis: PHYSICAL ASSESSMENT

Date Performed: November 4, 2013 General Appearance

The client is conscious with GCS of 15. Upon assessment the client was on semifowlers position on bed and wearing comfortable clothing. He is cooperative and responsive to questions. The vital signs are as follows: Blood Pressure: ; Respiratory Rate: ; Pulse Rate: ; Temperature: 36.8C.

System

Deviation

HEENT Integumentary

Presence of Nasal Cannula subclavian catheter on the right side Presence of Heplock on the Right metacarpal

Edema on left foot

BODY PARTS

NORMAL FINDINGS

ACTUAL FINDINGS

INTERPRETATION and ANALYSIS

Physical Assessment I Skull Proportional to the body size of the The skull of the patient is Normal findings

body, round, with

proportion to his

prominences in the body and frontal area interiorly and the occipital area posteriorly symmetrical in all planes gently curved. Scalp White, clean, free from masses, lumps, scars, nits, dandruff, and lesions Hair Black, evenly distributed hair and covers the whole scalp, thick, shiny free from split ends. Eyes Parallel and evenly The eyes are both placed, symmetrical, nonprotruding, with scant amount of secretions, both eyes black and clear. Eye Movement Able to move eyes in full range of The patient can able to move her Normal findings black and clear. And also it is symmetrical and evenly placed. Normal findings. The scalp is free from lumps, masses, nits, lesion and dandruff. Hair is black, evenly distributed, shiny, silky and fine. Normal findings Normal findings symmetrical in shape.

motion or able to move in all direction. Lower palpebral Conjunctiva Conjunctivaeare clear and free of swelling and lesion Pupils Pupils are equally round and reacting to light and accommodation Field of vision When looking straight ahead, clients can see objects in periphery Visual Acuity Normal distant visual acuity is 20/20 with or without corrective lenses. The client can distinguish what the person with normal vision can distinguish from 20 feet away The lower

eyes in all direction with full range of motion. The patients conjunctivae are clear and free from lesions Normal findings

Pupils are equally round and reacting to light and accommodation Patient is able to see objects at periphery

Normal findings

Normal findings

Unable to read newsprint without the use of reading glasses.

Interpretation As people get older, the vision diminished because of loss of elasticity of the lens of the eyes. Analysis Nearly, all elders have some lens opacity that reduces visual acuity and causes blurred vision. (Fundamentals of Nursing, Kozier and Erb,8th Edition , Volume 1

page 414.) Ears Parallel, symmetrical, proportional to the size of the head, His ears are both parallel and symmetrical. And also it is proportion Normal findings

bean-shaped, helix with his body. is the line with outer canthus of the eye; skin is the same color as the surrounding area, clean. Nose Midline, symmetrical, and patent. Mouth Uniform pink color, His nose is intact, symmetrical and patent. Uniform pink color, Normal findings Normal findings

soft, moist, smooth soft, moist, smooth texture Neck Proportional to the size of the body and head, symmetrical and straight. texture Proportional to the size of the body and head, symmetrical and straight.. Normal Fndings

Physical Assessment II Thorax The chest contour is symmetrical and The patient has straight contour Subclavian cathether are used for Interpretation:

the chest is twice as wide as deep (antero-posterior diameter in a 1:2 ratio). The spine is straight. The chest wall moves symmetrically during respiration

chest and it moves symmetrically during respiration. Presence of subclavian catheter

patients undergoing hemodialysis Analysis: Immediate access to the patients circulation for acute hemodialysis is achieved by inserting a doublelumen or multilumen catheter into the subclavian, internal jugular, or femoral vein Double-lumen, cuffed catheters may also be surgically inserted into the subclavian vein of patients requiring a central venous catheter for dialysis (Medical Surgical Nursing by Brunner and Suddhart 8th edition vol. 2 p. 1287) INTERPRETATION

BODY PARTS

NORMAL FINDINGS

ACTUAL FINDINGS The patient has a tan color of the skin. Symmetrical and well distributed hair. Warm dry and elastic, no appears of tenderness.

Physical Assessment III Upper Extremities Arms

Skin color varies (pinkish, tan, dark brown) symmetrical, fine hair evenly distributed, presence/ absence of visible veins. Warm dry and elastic, no appears of tenderness.

Normal findings

Hands

Uniform color, no discoloration

Uniform in color, no discoloration, has 10 fingers and

Normal findings

nails are convex The heplock is located on the right metacarpal Palms Lighter than the dorsal aspect Nails Nails are transparent, smooth, and convex with pink nail beds and white translucent tips. Five fingers in each hand. As Lighter than the dorsal aspect The patient has 5 fingers on each hand. His nails are smooth and with pink nail beds. In capillary refill test, his nail bed turned to pink for less Normal findings Normal findings

pressure is applied than 2 seconds to the nail bed appears white or bleach and pink color returns immediately as pressure is released. Range of Motion Shoulder Perform with relative ease. He is able to raise her both arms vertical and place his hand behind his neck, without any pain. Arms Perform with The patient is able Normal findings Normal findings when the pressure is released.

relative ease.

to abduct, adduct and rotate (internal and external) his arm without any pain.

Elbows

Perform with relative ease

He is able to bend and straighten his elbows without any pain.

Normal findings

Hand &Wrist

Perform with relative ease

He is able to extend, spread and make a fist, thumb across the knuckles without any pain.

Normal findings

Lower Extremities Legs

Skin varies (pinkish, tan, dark, brown), skin is smooth, fine hair evenly distributed, absence of varicose vein, muscles symmetrical, length symmetrical. Muscle appear equal, warm &with good muscle tone.

The patient has a tan color skin. He has fairly distributed hair.

Normal findings

Toes

Five in toes in

The patient has

Interpretation Edema of the foot may ba caused by. Analysis Patient with renal diseases may have increased extracellular fluid volume that can lead to edema and heart failure. The kidneys cannot excrete adequate urine to maintain a normal extracellular fluid balance leading to pheripheral edema, heart failure and pulomonary edema (Medical Surgical Nursing by Lemone and Burke 3rd edition vol. 1 p. 778)

each foot: sole and five toes in each dorsal surface is smooth: With pink nail beds and translucent tips. foot. When capillary refill test is performed, nail bed turned pink for less than 2 seconds when the pressure is released Patient has edema on the right foot

Range of Motion (Lower extremeties) Mental and emotional status

Perform with relative ease

The patient can perform range of motion without pain.

Normal findings

Orientation

The patient is aware of self,

The patient has reduced

Normal findings

others, time, home awareness of self, address and current location. others. He has no awareness of time, home address and location Motor and Cerebellar system Stands erect with minimal swaying, a. Romberg test with eyes both open and closed Reflexes Deep tendon reflex Normal reflex scores range from 1+ (Present but decreased) to 2+(normal) to 3+(increased or brisk, but not pathologic) Cranial Nerve Assessment The patient has an Not performed ability to I. Olfactory differentiate the different aromas. Not performed Not performed Not performed Not performed Not performed

The patient has 20/20 vision in the II. Optic Snellen chart

Unable to read newsprint without the use of reading glasses.

Interpretation As people get older, the vision diminished because of loss of elasticity of the lens of the eyes. Analysis Nearly, all elders have some lens opacity that reduces visual acuity and causes blurred vision. (Fundamentals of Nursing, Kozier and Erb,8th Edition , Volume 1 p.414

The pupils are round with a III. Oculomotor regular border, is

The pupils are round with a regular border, is

Normal findings

centered in the iris. centered in the iris. Equally round and reacting to light and accommodation Ability to move eyes in full range IV. Trochlear of motion Elicit blink reflex; feels the dull and V. Trigeminal sharp Ability to move eyes in full range Equally round and reacting to light and accommodation The eyes are able to move in all direction. Elicit blink reflex; feels the dull and sharp The patient is able to move eyes in full Normal findings Normal Findings Normal findings

of motion VI. Abducens

range of motion or can able to move in all direction.

The patient has an ability to identify VII. Facial the taste of different aromas VIII. Auditory The patient is able to repeat a word. IX. Glossopharynge al The patient has the ability to swallow without any difficulty. No hoarseness and wellIX. Vagus modulated The patient is able to resist the force X. Accessory applied. The tongue should be pink and moist XII. Hypoglossal

Not performed

Not performed

The patient is able to repeat a word. Not performed

Normal findings

Not performed

No hoarseness and wellmodulated The patient can able to resist the force. The tongue is moist and pinkish

Normal findings

Normal findings

Normal findings

and able to move it in color. side to side. He can protrude his tongue and move it side to side.