PHYSICAL ASSESSMENT Measurements Measurement Normal Value Blood Pressure 120/80mmHg

Actual Findings 90/60mmHg

Interpretation/ Analysis The clients blood pressure is below the normal range. ANALYSIS: A decrease in blood pressure can be a sign of underlying problems where it may cause inadequate blood flow to the heart. (Kozier and Erbs Fundamentals of Nursing Eight edition, Vol. 1 pg. 538) Normal The respiration of the client is above the normal range of 12-20cpm due to increased mucous production. ANALYSIS: Patients with these disorders develop a tolerance to the gradually worsening hypoxemia and hypercapnia. (Brunner and suddarth medicalsurgical nursing 11th edition, pp. 655) Normal Underweight Clients weight is 97 lbs while it should be 148 lbs based from the

Pulse Rate Respiration Rate

60-100bpm 12-20cpm

62bpm 24cpm

Temperature Weight

36-37 C 44 kg (97 lbs)

36.4 C 106 lb for 5 ft of height +6 lb for each inch over 5 ft

Height BMI

170.18 cm (5'7") 44kg/(1.7018)2= 15.19

approximating ideal body weight rule of 6 for males. 5'4"-5'7" Normal <18.5 Underweight Underweight 18.5-24.9 Normal 25.0-29.9Overweight 30.0-34.9- Obesity 40.0+-Extreme Obesity

Cephalocaudal Body Parts Normal SKIN -Varies from light brown to deep brown; from ruddy pink to light pink; from yellow overtone to olive -Generally uniform except in areas exposed to the sun -Some birthmarks; no abrasions and lesions -Moisture in skin folds; normal temperature; no edema -Good skin turgor

Actual Findings -Pallor - Skin is dry and wrinkled -

NAILS

-Convex curvature; angle of nail plate is about 160 -Smooth texture -Highly vascular and pink in light-skinned clients; dark-skinned clients may have brown

-Capillary refill test: delayed return of color for more than 3 seconds. -His nails are long and have a smooth texture and normal

Interpretation/ Analysis Wrinkled skin is due to the decrease of elasticity of the skin of older adults Incision is due to the insertion of CTT. ANALYSIS: Skin becomes drier. Less elastic and more fragile making the older person more susceptible to skin tears and shearing injuries. Incision involves cutting the skin with sharp instrument. (Kozier and Erbs Fundamentals of Nursing Eight edition, Vol. 1 pg. 411) - Delayed return of color may indicate arterial insufficiency -The client has risk in fluid volume deficit. ANALYSIS: A bluish or purplish tint to the nail bed may

or black pigmentation in nail angle. Unclean longitudinal streaks fingernails. -Intact epidermis -Good capillary refill

HEAD

-Normal head size, shape and symmetry (normocephalic) -Has symmetry in facial expressions

-The client has rounded head and smooth in contour. -Sutures on face

reflect cyanosis, and pallor may reflect poor arterial circulation. (Kozier and Erbs Fundamentals of Nursing Eight edition, Vol. 1 pg. 576) The client has suture on face. ANALYSIS: Sutures is the joining of the skin after and injury or surgery. -Hair loses colors to people who reached adulthood. ANALYSIS: Graywhite hair is a sign of losing ones youth. (Kozier and Erbs Fundamentals of Nursing Eight edition, Vol. 1 pg. 411) - Red color surrounding the edge of the pupil. ANALYSIS:Eye that appears re is due to illness, injury and some other conditions. Blood vessels in the eye enlarge and dilate bring cells to heal and repair.(Kozier and Erbs Fundamentals of Nursing Eight edition, Vol. 1 pg. 588)

HAIR

-Evenly distributed hair -Thick hair; silky, resilient hair -No infection or infestation

-The client is

EYES

- Eyebrows symmetrically aligned; equal movement -equally distributed; curled slightly outward. -eyelids should be intact -no discharge and discoloration, involuntary blinks should be 15 to 20 per minute - sclera should white in color, no edema or tenderness over lacrimal gland -no tearing, trigeminal nerve is intact

- reddish right conjuctiva - (+) PERRLA - eyebrow symmetrical - White color surrounding the edge of the pupil. - Equal eyebrow distribution. - Eyelashes are even, direction of curl is upward. - can perform 6 ocular movement

EARS

Color same as facial skin, symmetrical -auricle aligned with outer canthus of eye about 10 degree from vertical, mobile, firm, and not tender -can hear normal voice tones audible

MOUTH AND THROAT

-Uniform pink color, soft, moist, smooth texture, symmetry of contour -ability to purse -32 teeth in adult, pink gums, firm texture of gums and no retraction -the tongue should be in the central position, pink in color, no lesions, raised papillae -moves freely

- The level of auricles ABNORMAL: is normal in relation -The client has to the eyes. earwax due to poor hygiene practices. - Pinna recoils ANALYSIS: - Positive response to Hygiene is the normal voice tones. science of health and -(+) dry cerumen its maintenance. -earwax discerned on Personal hygiene is Left and Right ears. the self-care by which people attend to such functions as bathing, toileting, general body hygiene and grooming. It involves care of the skin, hair, nails, teeth, oral and nasal cavities, eyes, ears, and perineal-genital areas. (Kozier and Erbs Fundamentals of Nursing Eight edition, Vol. 1 pg. 742) - Lips are symmetry -Loss of several teeth in contour. and plaques are related to deficient - Lips are pale. calcium stores. - Tounge is pink in color. -lower portion 4 remaining teeth. -yellowish teeth -(+) plaques - tongue is in central position and moves freely. ANALYSIS: Healthy teeth must be conscientiously and effectively cleaned on a daily basis. Brushing and flossing are particularly effective in a mechanically breaking up the bacterial plaque that collects around teeth. (Brunner and suddarth medicalsurgical nursing 11th

NOSE AND SINUSES

-Symmetric and straight, no discharge of flaring -uniform color, not tender and no lesions -air moves freely as the client breathes through the nares -mucosa pink -clear watery discharge -nasal septum intact and in midline

- Uniform in color, size, shape or size. - No discharges from the nares. - Firm nasal bone and cartilage. - No tenderness -air moves freely - nasal septum intact and in midline `- No swellings or masses

edition, pp.11451146) Normal

NECK

Muscles equal in size head centered, head can be flex 45, 60,70 - Client is able to lymph nodes is not perform all head palpable thyroid gland not visible on inspection movement.

Normal

- Thyroid gland is smooth and no obvious lumps. - No enlargement of lymph nodes.

Body Parts Breasts

Normal Findings -Rounded in shape -skin uniform in color, areola is round or oval -color varies from light pink to dark brown -nipples should be everteda -no discharge, no tenderness, masses or nodules,

Actual Findings - Areola is equal in size and is brown in color. - Nipples are everted. - No discharge from the nipple.

Interpretation/Analysis Normal

Respiratory

-Chest symmetric, - Chest is spine vertically asymmetrical. aligned, skin intact -eupnea which is a normal breathing. -no abnormal sound. - rapid shallow breathing - wheezing sound heard on the left lower portion of the lung fields

ABNORMAL: Rapid shallow breathing due to mucous production Wheezing due to different lung disorders ANALYSIS: Wheezing is due to air passing through a constricted bronchus as a result of secretions, swelling, tumors Normal

Cardiac

-S1 and S2 sound should be heard at all sites. 60-90 beats per minute

- Normal heartbeat. - Apical pulse is heard in the PMI

Abdomen develop

-Uniform in color, no evidence of enlargement of liver or spleen -symmetric contour, movements caused by respiration - audible bowel sound, absence of arterial bruits and friction rub, tympany sound over the stomach and gas filled bowels; dullness, especially over the liver and spleen or a full bladder -no tenderness, relaxed abdomen with smooth, consistent tension, bladder and liver should not be palpable

-uniform in color -symmetric contour -no tenderness -audible bowel sound

Normal

URINARY

Smooth urine movement during urination. Not painful during urination

- no pain experienced during urination -UO: 100 cc/hr -with IFC

The client is excreting urine lower than normal due to limited intake of fluid. Normal urine output for an adult is 1,400 to 1,500 mL per 24 hours (Kozier & Erbs Fundamentals of Nursing, 8th ed., by: Kozier & Erb, page 1328) The patient refused to perform assessment.

GENETALS

>(-) swelling or >tenderness specificall in mons pubis an inguinal area >skin intact,no lesions >no lice,lesions,scars

The patient refused to perform assessment. -with IFC

Body Parts Musculoskeletal

Normal Findings -Muscles should be equal size on both sides of body -no contractures and tremors, normally firm, smooth coordinated movements, and equal strength on each body side -bones and joints shouldnt have deformities, tenderness or swelling, joints move smoothly

Actual Findings -increase muscle tone -muscle spaticity -weakness -both legs are unable to feel sensation

Interpretation/ Analysis The clients mu

Neurologic 1. Mental Status Immediate recall Should not have - No memory Normal

any problem with memory

lapses - Able to restate a series of numbers. - Client is able to recall events.

Recent memory

Should be able to recall any recent events Should be able to describe any previous events when asked

Normal

Remote memory

- No memory lapses

Normal

2. Level of Consciousness -using GCS

Body Parts 3. 12 Cranial Nerves Olfactory

Conscious person should score 15. A comatose person should scores 7 or less. Normal Findings Sensory of smell should function well Vision and visual field should be 20/20

- Client is alert and Normal completely oriented.

Actual Findings

Interpretation/ Analysis Normal

- Has efficient smelling ability

Optic

- Client has normal Normal and perfect vision.

Oculomotor

Trochlear

Can do 6 ocular movements and pupil is responding Can do the 6 ocular movements Can feel any sensation Can do different moods and can move face symmetrically

- Has efficient EOM

Normal

- Able to perform six ocular movements - Efficient sensation reflex - Clients facial expression are symmetric

Normal

Trigeminal

Normal

Facial

Normal

Abducens

Can move eyeballs

- Client is able to move the eyeball laterally.

Normal

Glossopharyngeal

Can swallow and can determine taste Can maintain balance and can hear normal sound of the voice Assess for clients speech for hoarseness - Client has efficient hearing capacity

Normal

Auditory

Normal

Vagus

- slurred voice

The client cannot speak audibly.

ANALYSIS: Accessories Can shrug against the force of the hand - Client is able to move head and shrug shoulders against the resistance of hands. Normal

Hypoglossal

Can protrude tongue and moves it freely - Able to touch nose symmetrically Performs with coordination and rapidly Rapidly touches each finger thumb with each hand Can alternately supinate and pronate hand

Normal

5. Fine Motor Function Finger to nose test Finger to nose Nurses finger Finger to thumb

Repeatedly and rhythmically touches the nose - Able to perform with coordination - Can touch finger to thumb with accuracy - Able to supinate and pronate hands

Normal

Normal

Normal

Alternate supination and pronation

Normal

6. Sensation Pain

Can identify

- loss of sensation

Normal

sharp and dull sensation Light touch Can feel light tickling/light sensation

to feel the pain in lower extremities - unable to distinguish light and tickling sensation on both legs - Able to distinguish or feel hot and cold temperature Normal

Temperature

Can identify hot and cold sensation

Normal

7. Tactile Discrimination One to two point discrimination

Can distinguish between one and two point stimulus

Stereognosis

Recognize common objects Both point of stimulus are felt

Extinction phenomenon

- Client is able to distinguish and determine whether the pin is two pricks or one prick. - Can recognize usual object by touching it - Able to feel both stimulus

Normal

Normal

Normal