Physical Assessment

Physical Assessment was taken last July 29, 2010 at around 1130H.

General Survey:

Patient was awake on sitting position; with IVF of PNSS 1L x 12hours at 980cc level.

Baseline V/S: Final V/S:

T= 36.5°C T= 36.5

P= 60-100 bpm P= 65

R= 16-20 R= 17

BP= 120/80 BP= 110/70

CR= 60-90 CR= 69

BODY ASSESSMENT NORMAL ACTUAL ANALYSIS

PART TECHNIQUE FINDINGS FINDINGS

1. Skin Inspection Fair Fair complexion, NORMAL

complexion, absence of scars
absence of & lesions. Good
Palpation scars & lesions. skin turgor.
Good skin
turgor.

2. Scalp Inspection No lice & nits. No lice & nits. NORMAL

Palpation No lumps and No lumps and

lesions. lesions.

3. Hair Inspection Evenly Evenly distributed NORMAL

distributed black hair,
hair, color Smooth in texture
varies mostly in & Shiny.
 black.

Palpation Smooth in
texture &
Shiny.

4. Face Inspection Symmetrical Symmetrical face NORMAL

face movement,
movement, symmetrical
symmetrical nasolabial folds
nasolabial folds

5. Eyes Inspection 20/20 vision, 20/20 vision, NORMAL

round cornea, round cornea,
black color ; black color ; white
white sclera. sclera. Reacts to
Reacts to light light &
& accommodation
accommodatio
n.

6.Eyebrow Inspection Hair evenly Hair evenly NORMAL

s distributed distributed with
with skin intact skin intact
,symmetrically ,symmetrically
aligned with aligned with equal
equal movement.
movement.

7. Eyelids Inspection Skin intact, no Skin intact, no NORMAL

discharge, no discharge, no
discoloration. discoloration. Lids
Lids able to able to close
close symmetrically.
symmetrically.

8. Ears Inspection Same color as Same color as NORMAL

facial skin, facial skin,
symmetrical. symmetrical.

Auricle with Auricle with outer

 Palpation outer canthus canthus of eyes
of eyes about about 10 degree
10 degree of of vertical, mobile
vertical, mobile firm and not
firm and not tender, free from
tender, free lesions.
from lesions.

9. Hearing Inspection No voice tone No voice tone NORMAL

Acuity audible & able audible & able to
to understand understand
spoken words. spoken words.

10. Nose Inspection Midline & With nasal ABNORMAL

Symmetrical to package
face, no (Merocel)
lesions, no
nasal
discharges or
flaring uniform
in color, air
moves freely.

11. Mouth Inspection Proportional Proportional and NORMAL

and symmetrical with
symmetrical face.
with face.

12. Lips Inspection Pink in color, Pink in color, NORMAL

smooth, no smooth, no
lesions. lesions.

13. Teeth Inspection Complete Complete without NORMAL

without dentures.
dentures.

14. Inspection Tongue floor is Tongue floor is in NORMAL

Tongue in central central position,
position, pink pink in color,
in color, moist, moist, no lesions
no lesions or
 swelling. or swelling.

15. Chest Inspection Symmetrical Symmetrical NORMAL

during lung during lung
expansion & expansion &
Palpation recoil. recoil.

No lesions and No lesions and

abnormal abnormal grating
Percussion grating sound. sound.

Resonance. Resonance.
Auscultation No abnormal No abnormal
breath sounds. breath sounds.

16.Heart Auscultation Normal rate, Normal rate, NORMAL

rhythm, no rhythm, no
murmur. murmur.

17. Inspection No lesions, No lesions, NORMAL

Abdomen masses & masses &
tenderness. tenderness.
Auscultation
No abnormal No abnormal
bowel sounds. bowel sounds.

Percussion Tympany. Tympany.

Palpation No lesions, No lesions,

masses or masses or
tenderness tenderness

18.Upper Inspection Symmetrical to Symmetrical to NORMAL

Extremitie the body & no the body & no
Palpation
s lesions. lesions.

No No tenderness,
tenderness, no no palpable mass
palpable mass noted. Palpable
noted. Palpable Brachial & Radial
Brachial & Pulse. Able to
 Inspection on Radial Pulse. move freely
abduction, Able to move without
adduction, freely without discomfort; able
flexion, discomfort; to adduct, abduct,
extension. able to adduct, flex, and extend.
abduct, flex,
and extend.

19. Palms Inspection Pink in color Pink in color NORMAL

hand, no hand, no lesions.
lesions.

20. Inspection Nails are clean. Nails are clean. NORMAL

Fingernails
Pink nail beds. Pink nail beds.

21. Lower Inspection Symmetrical to Symmetrical to NORMAL

Extremitie the body, no the body, no
s lesions noted, lesions noted,
muscle appear muscle appear
equal with equal with good
good muscle muscle tone.
tone.
Palpation

22. Inspection Pink nail beds Pink nail beds NORMAL

Toenails with capillary with capillary refill
refill of 1-3 of 2 seconds.
seconds.

Identified Problem
1. Ineffective airway clearance related to nasal obstruction
2. Acute pain related to post functional endoscopic sinus surgery
3. Anxiety related to impending surgery
4. Risk for bleeding related to traumatize tissue
5. Difficulty of sleeping related to change of environment