Date and Time of Assessment: August 24, 2012 I.
General Survey:
Received client lying down on bed, with on going IVF of PNSS 600 cc infusing well at right metacarpal vein at 80 gtts/min or 80 cc/hr. With nasal cannula, hooked NGT and neck collar or brace. Her level of consciousness was alert, coherent and oriented to time, place and person. She was in a supine position, with elevated both legs through pillow. Client did not want to talk because according to her, her NGT was so painful whenever she talked, moved or swallowed. She was able to follow instructions. Patient was wearing hospital gown. She was well kempt. No body odor noted that has any relation to physical activity such as exercise, however foul body odor was noted that was seemingly prominent in the auxiliary area. Foul breath was also noted. which results to speech impediment
II. Vital Signs and Anthropometric Measurement
Temp. - 35.6 C RR PR - 28 cpm
- 83bpm (radial) 90 bpm (apical)
BP
- 150/100
Wt Ht BMI
- 118 lbs - 51 ft - 22.29 normal
BMI = (weight in pounds x 703/ height in inches 2) = (118 x 703 / 3721)
III. Skin The skin color varies from medium brown to dark brown. Generally uniform, except in areas exposed to the sun, no lesions was noted. There were various interruptions in the lower extremities; such as scars and scaling, especially in the bipedal part. When pinched, the skin springs back to previews state slowly. No edema noted.
IV. Head Hair The dominant color of the hair was black. Hair was evenly distributed and it thick. However, hair was oily. Upon inspection, there were no lice, nits, sores or ringworm seen. However, dandruff was seen and it was more evident in the parietal area. In general, the amount of body hair was somehow variable. The head was normocephalic and symmetric, with frontal, parietal, and occipital prominences; smooth skull contour.
V. Eyes The eyebrows are evenly distributed, skin was intact, symmetrically aligned, equal movement. The eyelashes was equally distributed; straight. The eyelids was intact, no discharges or discoloration. However, conjunctiva were pale. She has thick black eyebrows. Lids close symmetrically and moves in unison.
Pupils are brown, equally round and reactive to light and accommodation at 2 mm diameter. Upon palpation of the lacrimal gland, no edema or tenderness. Cornea was opaque and the surface is not smooth. Pupils constrict whenever looking at near objects such as ball pen. When asked to look straight ahead, patient can his in his peripheral vision.
VI. Ears
The auricles has same color with the face and was aligned with the outer canthus of the eyes. Upon palpation, the auricles was firm and not tender; pinna recoils after it was folded. No infestation, lesions, and discharges was seen. Was able to response in normal voice tones. Able to hear ticking in both ears.
VIII. Nose
The nose was symmetric and straight. No discharge or flaring was noted. Nose was uniform in color, not tender and no lesions was seen upon inspection. Air moves freely as the client breath through the nares. Has watery discharge. Nasal septum was intact and in the midline. Upon palpation of the maxillary and frontal sinuses no tenderness was present. However, booger was seen in both nares.
IX. Mouth Mouth was not asses per the client refused to open her mouth due to pain of NGT insertion.
X. Neck and Throat Patient was wearing a neck brace and it was bigger than the supposed size of the client.
XI. Breasts The breast was even but with birthmark in the right pectoralis. Almost the same color with the abdomen. The skin was smooth and intact. No striae seen. The areola were oval and bilateral the same. The nipples were everted and equal in size; both nipples point in the same direction. No discharge. Lymph nodes were not visible upon inspection and palpation. No tenderness or masses.
XII.Chest and Lungs
Since the client cannot stand up, this area was not properly assessed. The skin was intact and has uniform in color. Upon palpation, no tenderness or masses noted. Adventitious breath sound was present, cackles. The breathing pattern was normal.
XIII. Heart
Patients apical pulse was at the rate of 90, which is within the normal range.
XIX. Abdomen
Upon inspection, presence of scars was seen the left illium due to mosquito bites. The abdominal contour was flat. No evidence of enlargement of liver and spleen, when the client hold his breath. Burburigmos sound was present upon auscaltation, 21 per minute. No tenderness upon percussion.
XX. Genito-urinary
The husband did not allow us to assess the genitals. Client was wearing diaper.
XXI. Extremities
Upper Limbs
Both upper extremities are weak. Clean and well trimmed nails.
Lower Limbs Both feet can be move. No lesion was seen. Clean and well trimmed nails.
