PHYSICAL ASSESSMENT

Parameters Normal Findings Conscious and coherent General Appearance Actual Findings o Conscious and Coherent Slightly thin -The patient loss weight due to decrease appetite & environmental stimuli -Due to body trauma experienced -due to vehicular accident Interpretation

weak in appearance un ambulatory with limited range of motion With good skin turgor Skin warm to touch With thick and straight black hair evenly distributed

Skin

With good skin turgor Skin warm to touch Evenly distributed hair

Normal Findings

o o

Normal Findings

Hair

With good capillary refill of 1-3 seconds With pinkish nail beds

With capillary refill of 1-3 second With pinkish nail beds

Nails

 With clean and short nails With round symmetrical skull

o o

With long Dirty nails With round symmetrical skull

-with improper hygiene care

Skull, head and Face

Normal Findings

With hematoma on left parietal area Symmetrical facial movement

Due to vehicular trauma

Symmetrical facial movement

No eye discharge With whitish sclera Eyebrows hair evenly distributed/ski n intact

No eye discharge With whitish sclera Eyebrows hair evenly distributed/sk in intact (+) blink reflex With pinkish Normal Findings

Eyes

o (+) blink reflex With pinkish conjunctiva

conjunctiva

Able to hear on both ears Ears symmetrical in appearance

Able to hear on both ears symmetrical in Normal Findings

 no ear discharges

appearance o no ear discharges

Pinkish lips without missing teeth Mouth With pink gums No foul odor With symmetrical contour Muscoloskeletal (Upper and lower extremities) Symmetrical Can move freely

With dry pale lips

decrease intake of fluid

With pink gums No foul odor

With pain scale of 6/10 at pelvic area Cant move right leg With abrasion on right elbow Due to vehicular trauma

 Not in respiratory distress Respiratory With symmetrical chest expansion With clear breath sounds upon auscultation No abdominal distention Abdomen Flat rounded abdomen

With respiratory rate 23bpm With equal chest expansion upon respiration With heart rate of 96 bpm

Normal Findings

No abdominal distention Flat and round abdomen Normal Findings

Anatomy and Pathophysiology

The pelvic bone In human anatomy, the pelvis (plural pelves or pelvises) is the part of the trunk inferiorposterior (below-behind) to the abdomen in the transition area between the trunk (torso) and the lower limbs (legs). The term is used to denote several structures. the structure connecting the spine to the femurs (thigh bones), the pelvic cavity, the space enclosed by the pelvic girdle, subdivided into the greater or false pelvis (inferior part of the abdominal

cavity) and
o

the lesser or true pelvis which provides the skeleton for the perineum and the pelvic cavity (which are separated by the pelvic diaphragm),

The pelvis is the section between the legs and the torso that connects the spine (backbone) to the thigh bones. In adults, it is mainly constructed of two hip bones, one on the right and one on the left of the body. The two hip bones are made up of 3 sections, the Ilium, Ischium and Pubis. These sections are fused together during puberty, meaning in childhood they are separate bones. Along with the hip bones is the Sacrum, the upper-middle part of the pelvis, which connects the spine (backbone) to the pelvis. To make this possible, the hip bones are attached to the Sacrum. The gap enclosed by the pelvis is the section of the body underneath the abdomen (stomach) and mainly consists of the reproductive organs (sex organs) and the rectum. Functions The pelvic girdle is a basin-shaped ring of bones connecting the vertebral column to the femurs. Its primary functions are to bear the weight of the upper body when sitting and standing; transfer that weight from the axial skeleton to the lower appendicular skeleton when standing and walking; and provide attachments for and withstand the forces of the powerful muscles of locomotion and posture. Compared to the shoulder girdle, the pelvic girdle is thus strong and rigid.Its secondary functions are to contain and protect the pelvic and abdominopelvic viscera (inferior parts of the urinary tracts, internal reproductive organs); provide attachment for external reproductive organs and associated muscles and membranes. Ilium (bone) The ilium is the uppermost and largest bone of the pelvis. The Ilium is a bone in the hip it is connected to two other bones called the pubis and ischium. Functions The ilium serves as the attachment site for the lateral muscles of the abdominal wall and the back of the pelvis,giving form to the interior part of the torso,and protecting its contents

Pathophysiology The right ilium was being fractured (via 3d x-ray) due to bone and tissue trauma that causes decrease of muscle strength causing her to feel pain on the affected part.