A. GENERAL SURVEY February 14, 2013 1. Physical Appearance o She has an enlarged abdomen and bipedal edema. 2.

Level of Consciousness o Conscious, coherent and oriented. 3. Appearance in relation to chronological age o Her appearance is coordinated with her age 4. Signs of distress o Orthopnic position due to DOB 5. Nutritional status o Height: 411 Weight: 54 kg BMI:24 Normal:18.524.9 6. Body structure o Symmetric body structure 7. Obvious physical deformities o An enlarged abdomen and bipedal edema 8. Mobility o She can ambulate with support 9. Behavior o She is cooperative and able to follow instruction 10.Odors of body and breath o She has minor odor and foul breath 11.Facial Expression o There is facial symmetry. 12. Mood & affect o Appropriate with situation. 13.Speech o No problems in speech 14.Posture and Gait o On orthopneic position. Slouched and bent posture 15.Hygiene and Grooming o Clean and neat B. PHYSICAL ASSESSMENTS PREOPERATIVE PHASE Date: February 14, 2013 Time: 8:00 am Vital Signs T: 36.7OC PR: 89 bpm RR: 26 cpm BP: 120/90 mmHg

BODY PARTS

METHOD

FINDINGS

INTERPRETATION

INTEGUMENT ARY SYSTEM Skin

Inspection

Jaundice with uniform skin color.

D/t presence of bilirubin in the blood

 Senile skin noted HEAD: Head Inspection Rounded; smooth skull contour with palpable temporal pulse (-) dandruff, Oily Thin evenly distributed white colored hair, slightly oily No infestation symmetric Facial Features and movement

Normal d/t aging process

Normal

Palpation

Normal

Scalp Hair

Inspection Inspection

Normal Normal Normal d/t aging process

Normal Normal

Face

Inspection

EYES: Eyebrows Inspection symmetrical Hair evenly distributed and intact skin Equally distributed, slightly curled outward Skin intact Lids close symmetricall y Close and opens spontaneous Normal Normal

Eyelashes

Inspection

Normal

Eyelids

Inspection

Normal Normal Normal

Palpebral Conjunctiva Sclera

Inspection Inspection

Pinkish Icteric

Normal D/t presence of bilirubin Normal

Pupils

Inspection

PERRLA 2-3mm L and R Color same with facial skin Symmetrical Aligned auricle and outer canthus about 100 from vertical Able to identify sound Mobile, firm, and not tender; pinna recoils Symmetrical and Straight No tenderness; no lesions

Ears

Inspection

d/t presence of bilirubin Normal Normal

Normal Normal

Palpation

Nose

Inspection Palpation

Normal Normal

MOUTH: Lips Inspection Palpation Teeth Inspection Brownish pink Soft, smooth moist No teeth without dentures Normal d/t aging process d/t smoking Normal

Gums

Inspection

Moist No lesion, no ulceration Blackish in color

Normal Normal d/t smoking

Tongue

Inspection

Reddish in color, moist Moves freely Muscle equal in size; head centered Thyroid not visible Palpable carotid pulse No palpable lymph nodes No nodules Thyroid lobes not palpated Full and symmetric Chest expansion (+) Crackles in the left side No lifts or heaves in the precordium Jugular veins not visible Full pulsation of carotid artery Palpable apical pulse S1 and S2 heard (+) distention with abdominal

Normal Normal Normal

NECK

Inspection

Normal Normal Normal Normal Normal

Palpation

THORAX

Inspection Palpation Auscultation

Normal

d/t presence of fluids pleural cavity Normal

HEART

Inspection

Palpation

Normal

Normal Normal Normal Due to accumulation of fluid in the peritoneal

Auscultation ABDOMEN Inspection

Palpation

girth of 41in Skin is shiny, dry and scaly Symmetric Contour Supple and dull

cavity Due to stretching of the abdomen Normal D/t presence of fluid in the peritoneal cavity Normal

No nodules UPPER EXTREMITIES: Arms Nails Inspection Inspection Palpation Symmetrical Muehrcke's nails Capillary refill 23secs. Intact epidermis Capillary refill 23secs. (+) bipedal edema grade 2

Normal d/t decrease albumin level Normal

LOWER EXTREMITIES

Inspection Palpation

Normal Normal Due to the accumulation of fluid in the

INTRA OPERATIVE PHASE Date: February 14, 2013 Time: 8:30 am BODY PARTS METHOD FINDINGS INTERPRETATION

THORAX

Inspection Palpation

Auscultation

Full and symmetric Chest expansion Bloody fluid in the collecting bottle with 1000 ml output.

Normal

d/t to procedure done (thoracentesis)

ABDOMEN

Inspection

Palpation

(+) distention with abdominal girth of 41in. Skin is shiny, dry and scaly Present of tube and dressing with a yellowish fluid in the collecting bottle at 300ml Symmetric Contour Supple and dull

Due to accumulation of fluid in the peritoneal cavity d/t stretching of the skin d/t to procedure done (paracentesis)

Normal D/t presence of fluid in the peritoneal cavity Normal

No nodules

POST OPERATIVE PHASE Date: February 14, 2013 Time: 9:30 am Vital Signs T: 36.2OC PR: 92 bpm RR: 24 cpm BP: 110/90 mmHg BODY PARTS METHOD FINDINGS INTERPRETATION

THORAX

Inspection Palpation

Auscultation

Full and symmetric Chest expansion Presence of dressing below the tip of scapula (+) Crackles in the left side

Normal

d/t to site of thoracentesis d/t presence of fluids pleural cavity

ABDOMEN

Inspection

Palpation

(+) distention with abdominal girth of 41in. Skin is shiny, dry and scaly Present of tube and dressing with a serosanguin ous in the collecting bottle at 300ml Symmetric Contour Supple and dull

Due to accumulation of fluid in the peritoneal cavity d/t stretching of the skin in the abdomen d/t to site of paracentesis

Normal D/t presence of fluid in the peritoneal cavity Normal

No nodules

Date: February 15, 2013 Time: 7:00 am Vital Signs T: 36.9OC PR: 94 bpm RR: 26 cpm BP: 110/70 mmHg BODY PARTS METHOD FINDINGS INTERPRETATION

INTEGUMENT ARY SYSTEM Skin

Inspection

Jaundice with uniform skin color. Senile skin noted HEAD:

D/t presence of bilirubin in the blood Normal d/t aging process

Head

Inspection

Rounded; smooth skull contour

Normal

Palpation

with palpable temporal pulse (-) dandruff, Oily Thin evenly distributed white colored hair, slightly oily No infestation symmetric Facial Features and movement

Normal

Scalp Hair

Inspection Inspection

Normal Normal Normal d/t aging process

Normal Normal

Face

Inspection

EYES: Eyebrows Inspection symmetrical Hair evenly distributed and intact skin Equally distributed, slightly curled outward Skin intact Lids close symmetricall y Close and opens spontaneous Pinkish Icteric Normal Normal

Eyelashes

Inspection

Normal

Eyelids

Inspection

Normal Normal Normal

Palpebral Conjunctiva Sclera

Inspection Inspection

Normal D/t presence of bilirubin Normal

Pupils

Inspection

PERRLA 2-3mm L and R

Ears

Inspection

Palpation

Color same with facial skin Symmetrical Aligned auricle and outer canthus about 100 from vertical Able to identify sound Mobile, firm, and not tender; pinna recoils Symmetrical and Straight No tenderness; no lesions

d/t presence of bilirubin Normal Normal

Normal Normal

Nose

Inspection Palpation

Normal Normal

MOUTH: Lips Inspection Palpation Brownish pink Soft, smooth moist No teeth without dentures Moist No lesion, no ulceration Blackish in color Normal d/t aging process d/t smoking Normal

Teeth

Inspection

Gums

Inspection

Normal Normal d/t smoking

Tongue

Inspection

Reddish in color, moist Moves freely

Normal Normal

NECK

Inspection

Palpation

Muscle equal in size; head centered Thyroid not visible Palpable carotid pulse No palpable lymph nodes No nodules Thyroid lobes not palpated Full and symmetric Chest expansion (+) Crackles in the left side No lifts or heaves in the precordium Jugular veins not visible Full pulsation of carotid artery Palpable apical pulse S1 and S2 heard (+) distention with abdominal girth of 41in. Skin is shiny

Normal

Normal Normal Normal Normal Normal

THORAX

Inspection Palpation Auscultation

Normal

d/t presence of fluids pleural cavity Normal

HEART

Inspection

Normal Normal

Palpation

Normal Normal Due to accumulation of fluid in the peritoneal cavity Due to accumulation of fluid in the peritoneal cavity d/t to site of paracentesis

Auscultation ABDOMEN Inspection

Present of tube and dressing with a serosanguin ous in the collecting

Palpation

bottle at ml Symmetric Contour Supple and dull 500ml

Normal D/t presence of fluid in the peritoneal cavity Normal

No nodules UPPER EXTREMITIES: Arms Nails Inspection Inspection Palpation Symmetrical Muehrcke's nails Capillary refill 23secs. Intact epidermis Capillary refill 23secs. (+) bipedal edema grade 2

Normal d/t decrease albumin level Normal

LOWER EXTREMITIES

Inspection Palpation

Normal Normal Due to the accumulation of fluid in the

Date: February 21, 2013 Time: 7:30 am Vital Signs T: 36.6OC PR: 98 bpm RR: 26 cpm BP: 80/60 mmHg Weight: 51kg

BODY PARTS

METHOD

FINDINGS

INTERPRETATION

ABDOMEN

Inspection

(+) distention with abdominal girth of 37in. Skin is shiny, dry

Due to accumulation of fluid in the peritoneal cavity Due to stretching of

and scaly Palpation Symmetric Contour Supple and dull

the skin n the abdomen Normal D/t presence of fluid in the peritoneal cavity Normal d/t urine retention

No nodules GUT Inspection Presence of IFC connected to a urobag with a100cc yellow urine.