Far Eastern University Institute of Nursing Nicanor Reyes St.

, Manila

Family Nursing Care Process: Picache Family

Submitted by:
Samonte, Jam Kaisse L. BSN401; Group 4

Submitted to:
Emy Delgado, N, !"SD #lini$al %nstru$tor

PHYSICAL ASSESSMENT
Carlos Picache Area Assessed A. ital Signs Pulse !ate A toddler's heart will beat 92 beats per about 100-120 times per minute. minute, an older child's heartbeat is around 90-110 beats per minute, adolescents around 80-100 beats per minute, and adults pulse rate is anywhere between 50 and 80 beats per minute. The normal re erence ran!e or an adult is 12"20 breaths#minute. A core body temperature between $%.5&' and $(.(&' )9%.0&* and 99.9&* orally+ must be maintained. ),ealth Assessment in -ursin! Third .dition by /anet 0eber and /ane 1elley2 p!. 8%+ 4ound )normocephalic and symmetric, with rontal, parietal and occipital prominences+5 smooth s6ull contour.7mooth, uni orm consistency5 absence o nodules and masses )*undamentals o -ursin! 'oncepts, 8rocess and 8ractice 8th .dition 2( breaths per minute. -ormal Tem"erature $%.5 &', a3illary. -ormal Normal Findings Actual Findings Analysis

!es"iratory !ate

-ormal

#. S$ull

The s6ull is round, normocephalic with a smooth contour. -o tenderness, masses and nodules are elt upon palpation.

-ormal

9olume 1 by 1o:ier, .rb, ;erman and 7nyder2 p!. 585+ C. Hair and Scal" Scal" 7calp is clean and dry. 7parse dandru may be <isible. The color o the scalp is li!hter than the acial s6in5 there is no odor but with presence o lice ,air is lon!, thic6 smooth, so t and is e<enly distributed. =t is not oily, the hair color is blac6 but some parts are brown. There is no presence o lice, nits and split ends. >e<iation rom normal

Hair

-atural hair color, as opposed to chemically colored hair, <aries amon! clients rom pale blond to blac6 to !ray or white. The color is determined by the amount o melanin present.

-ormal

%. Face

(Health Assessment in Nursing Third Edition by Janet Weber and Jane Kelley: pg. 17 ! There is symmetric with a round, o<al, elon!ated or s?uare appearance. -o abnormal mo<ements noted. )Health Assessment in Nursing Third Edition by Janet Weber and Jane Kelley: p!. 200+

*ace is symmetrical and has a smooth, controlled acial mo<ement. 'olor o the acial s6in is air with a ew pimples on the orehead. .yebrows are symmetrical with e?ual mo<ement and hair e<enly distributed.

-ormal

E. Eyes Eye&ro' ,air e<enly distributed5 s6in intact .yebrows symmetrically ali!ned, e?ual mo<ement -ormal

Eyelashes

.?ually distributed5 curled sli!htly outward )"undamentals o# Nursing $on%epts& 'ro%ess and 'ra%ti%e (th Edition )olume 1 by Ko*ier& Erb& +erman and ,nyder2 p!. 588+

-ormal .yelashes on both eyes are distributed e?ually and are sli!htly curled outward. -ormal

Eyelids

The upper lid mar!in should be between the upper mar!in o the iris and the upper mar!in o the pupil. The lower lid mar!in rests on the lower boarder o the iris. -o white sclera is seen abo<e or below the iris. 8alpebral issures may be hori:ontal. The upper and lower lids close easily and meet completely when closed. )Health Assessment in Nursing Third Edition by Janet Weber and Jane Kelley: p!. 22%+ ;ulbar 'on@uncti<a2 Transparent5 capillaries sometimes e<ident5 sclera appears white )dar6er or yellowish and with small brown macules in dar6s6inned clients+ 8alpebral 'on@uncti<a2 7hiny, smooth and pin6 or red

Con(ucti)a

There are about 1( in<oluntary blin6s with no discoloration and dischar!e o the eyelids. Aids close e ortlessly and symmetrically. 0hen lids open, no <isible sclera abo<e cornea, upper and lower boarders o cornea are sli!htly co<ered.

-ormal

;ulbar 'on@uncti<a2 Bnderlyin! structures are <isible and with white sclera. =t is moist, smooth and transparent. 8alpebral 'on@uncti<a2 8in6, shiny, smooth and are ree o swellin! or orei!n bodies.

-ormal

Cornea

-ormal

Transparent, shiny and

smooth5 details o the iris are <isible

Lacrimal gland* lacrimal sac and nasolacrimal duct Pu"il -o edema or tenderness o<er lacrimal !land5 -o edema or tearin! o<er lacrimal sac and nasolacrimal duct

>etails o the iris in the cornea are <isible. =t is transparent, shiny and smooth with no opacities. )'orneal sensiti<ity was not per ormed as cited by the 'linical =nstructors+

-ormal

-ormal

-o edema, ;lac6 in color5 e?ual in tenderness or si:e5 normally $ or ( mm tearin! present in diameter5 round, smooth upon palpation. border, iris lat and round The iris is blac6, >irect and 'onsensual typically round, 4eaction to li!ht2 lat and is about =lluminated pupil D mm in constricts )direct diameter. response+5 -onilluminated pupil The pupilCs constricts )consensual which are response+ illuminated and not illuminated 8upilCs 4eaction to by the li!ht Accommodation2 8upilCs constricts. constricts when loo6in! at near ob@ect5 pupilCs dilate when loo6in! at ar ob@ect5 pupilCs con<er!e when 8upilCs are near ob@ect is mo<ed e?ually round toward nose and is reacti<e to li!ht and accommodation. The pupilCs constrict when loo6in! at the tip o the penli!ht 8eripheral 9ision *ield2 and dilate when 0hen loo6in! strai!ht loo6in! at the

-ormal

-ormal

-ormal

-ormal

ahead, client can see ob@ects in the periphery .3traocular Euscle Tests2 ;oth eyes coordinated, mo<e in unison with parallel ali!nment )"undamentals o# Nursing $on%epts& 'ro%ess and 'ra%ti%e (th Edition )olume 1 by Ko*ier& Erb& +erman and ,nyder2 p!s. 588-592+

wall5 it con<er!es when penli!ht is mo<ed toward the nose. 'lient sees penli!ht within oneCs periphery

.yes e ortlessly mo<e in unison, coordinated and ha<e parallel ali!nment.

F. Ears

.ars are e?ual in si:e bilaterally )normally D to 10 cm+. The auricle ali!ns with the corner o each eye and within a 10-de!ree an!le o the <ertical position. .arlobes may be ree attached or soldered )ti!htly attached to ad@acent s6in with no apparent lobe+. The s6in is smooth with no lesions, lumps or nodules. 'olor is consistent with acial color. -o dischar!e should be present. -ormally the auricle, tra!us, and mastoid process are not tender.

'olor or the auricle is the same as the acial s6in, symmetrical with a 10-de!ree <ertical an!le rom the outer canthus o the eye. 76in is smooth and no dischar!e present.

-ormal

-ormal -o tenderness elt upon palpation o the auricle, tra!us and mastoid process. 7mall amount o

-ormal

.3ternal canal2 A small amount o odorless cerumen )ear wa3+ is the

only dischar!e normally present. )Health Assessment in Nursing Third Edition by Janet Weber and Jane Kelley: p!s. 2%0-2%1+ +. Nose and Sinuses 'olor is the same as the rest o the ace5 the nasal structure is smooth and symmetric. The nasal mucosa is dar6 pin6, moist, ree o e3udates. 'lient is able to sni throu!h each nostril while other is occluded.

cerumen is present and there is an absence o s6in lesion, pus and blood.

.3ternal nose is strai!ht, symmetric and is uni orm in color as the rest o the ace. There is no dischar!e or larin!. Air mo<es reely )e<en when one nostril occluded+ while breathin! throu!h each nostril. Turbinate is dar6 pin6. There is a small amount o clear watery dischar!e but no lesions are present. -o tenderness and masses elt upon palpation. *rontal and ma3illary sinuses are not tender.

-ormal

-ormal

-ormal

The nasal septum is intact and ree o ulcers or per orations. Turbinates are dar6 pin6 )redder than oral mucosa+, moist and ree o lesions. The superior turbinate will not be <isible rom this point o <iew. *rontal and ma3illary sinuses are non-tender to palpation, and no crepitus is e<ident. )Health Assessment in Nursing Third Edition by Janet Weber and Jane Kelley: p!s. 28%-28(+ H. Mouth and ,ro"haryn Li"s and #uccal Futer Aips2 Bni orm pin6

-ormal

Futer lips and

-ormal

Mucosa

color5 so t, moist, smooth te3ture5 symmetry o contour5 ability to purse lips =nner Aips2 Bni orm pin6 color, moist, smooth, so t, !listenin! and elastic te3ture $2 adult teeth5 smooth, white, shiny tooth enamel5 pin6 !ums5 moist irm te3ture to !ums5 no retraction o !ums 'entral position5 pin6 color5 moist5 sli!htly rou!h5 thin whitish coatin!5 smooth, lateral mar!ins5 no lesions5 raised papillae Eo<es reely5 no tenderness

inner lips are uni orm in color and ha<e a smooth, moist and so t te3ture. -o tenderness is elt upon palpation. >e<iation rom normal 20 child teeth with presence o dental carries. -ormal The ton!ue is in central position, pin6 in color and has a moist te3ture and smooth ton!ue base. Eouth loor and roo smooth and pin6 in color. -o lesions and tenderness elt and can mo<e reely. There are no nodules, lumps or e3coriated areas elt upon palpation 'olor is pin6 uni orm as the loor o the mouth B<ula is in midline o the so t palate. 7o t palate is li!ht pin6 with a -ormal Abnormal

Teeth and gums

Tongue or Floor o. the Mouth

Sali)ary +land

7mooth ton!ue base with prominent <eins 7mooth with no palpable nodules

-ormal

Palates and /)ula

-ormal

,ro"harynand Tonsils

7ame as color o buccal mucosa and loor o mouth. Ai!ht pin6, smooth so t palate Ai!hter pin6 hard palate, more irre!ular te3ture B<ula positioned in midline o so t palate

-ormal

Fropharyn32 8in6 and smooth posterior wall Tonsils2 8in6 and smooth5 no dischar!e5 o normal si:e or not <isible )"undamentals o# Nursing $on%epts& 'ro%ess and 'ra%ti%e (th Edition )olume 1 by Ko*ier& Erb& +erman and ,nyder2 p!s. %02-%0D+ I. Nec$ Nec$ Muscles Euscles e?ual in si:e5 head is centered

smooth te3ture while hard palate is in a li!hter pin6 color and more irre!ular in te3ture. Ga! re le3 is present. The oropharyn3 has a pin6 and smooth posterior wall5 tonsils are sli!htly in lamed ,ead is at the center and muscles are same in si:e and stren!th with a coordinated and smooth mo<ement )no discom ort elt+ -ormal

Lym"h Nodes

-ot palpable

>e<iation rom normal

Trachea

Thyroid +land

Aymph nodules are palpable5 'entral placement in possibly midline o the nec65 spaces in lamed. are e?ual on both sides Trachea is in midline o the nec6 and has -ot <isible on inspection e?ual spaces on both sides. Aobes may not be palpated = palpated lobes are small, smooth, centrally located, painless and rise reely with swallowin! )"undamentals o# Nursing $on%epts& 'ro%ess and 'ra%ti%e (th Edition Thyroid !land is not <isible. -o masses or nodules present upon palpation.

-ormal

-ormal -ormal

0. Posterior Thora-

)olume 1 by Ko*ier& Erb& +erman and ,nyder2 p!s. %0(-%08+ Anteroposterior to trans<erse diameter in ratio o 122 5 chest symmetric5 spine <ertically ali!ned5 spinal column is strai!ht, ri!ht and le t shoulders and hips are at the same hei!ht

76in intact5 uni orm temperature 'hest wall intact5 no tenderness no masses

7pine is <ertically ali!ned and spinal column is strai!ht and ri!ht and le t shoulders, hips are at the same hei!ht. 'hest is symmetric and anteroposterior diameter to trans<erse diameter is o 122 ratios5 s6in is intact.

-ormal

-ormal

-o masses and tenderness elt upon palpation. The s6in is intact 'hest e3cursion2 *ull and with a uni orm symmetric chest e3pansion temperature. Thumbs separates )$ cm+ on e?ual distance and time when client is as6ed to ta6e a deep breath. 'hest is symmetric. *remitus is heard and has a bilateral symmetry. 0hen percussed, resonance )e3cept o<er the

-ormal

-ormal

9ocal *remitus2 ;ilateral symmetry o <ocal remitus5 remitus is heard most clearly at the ape3 o the lun!s 8ercussion notes resonate, e3cept o<er scapula5 lowest point o resonance is at the diaphra!m

-ormal

-ormal

9esicular and broncho<esicular breath sounds

scapula+ and dullness )o<er the ribs+ are heard. *latness and tympany are not present. 9esicular breath sounds are heard o<er the lun! periphery )particularly at lun! base+ while broncho<esicular breath sounds are heard between scapula and 1 to 2 ='7 lateral to sternum. 4espirations are e ortless, ?uiet and rhythmic. 'ostal an!le is less then 90de!rees and ribs insert into spine at a D5-de!ree an!le. Thumbs e3pand on a $ cm distance when client is as6ed to ta6e a deep breath. There is bilateral symmetry o <ocal remitus. 0hen the trachea is auscultated, bronchial sounds are heard. 0hen the

)"undamentals o# Nursing $on%epts& 'ro%ess and 'ra%ti%e (th Edition )olume 1 by Ko*ier& Erb& +erman and ,nyder2 p!s. %1D-%1%+

1. Anterior Thora- Huiet, rhythmic, and e ortless respirations5 costal an!le is less than 90-de!rees, and the ribs insert into the spine at appro3imately a D5-de!ree an!le *ull symmetric e3cursion5 thumbs normally separate $ to 5 cm5 same as posterior <ocal remitus5 remitus is normally decreased o<er heart and breast tissue

-ormal

-ormal

Trachea2 ;ronchial and tubular breath sounds

-ormal

Anterior 'hest2 ;roncho<esicular and

-ormal

<esicular breath sounds )"undamentals o# Nursing $on%epts& 'ro%ess and 'ra%ti%e (th Edition )olume 1 by Ko*ier& Erb& +erman and ,nyder2 p!s. %1(-%18+ L. Carotid and 0ugular Arteries Carotid Arteries 7ymmetric pulse <olumes5 ull palpations, thrustin! ?uality5 ?uality remains same when client breathes, turns head, and chan!es rom sittin! to supine position5 elastic arterial wall -o sound heard on auscultation 0ugular eins 9eins not <isible )indicatin! ri!ht o heart is unctionin! normally+ )"undamentals o# Nursing $on%epts& 'ro%ess and 'ra%ti%e (th Edition )olume 1 by Ko*ier& Erb& +erman and ,nyder2 p!s. %21-%2$+ 7houlders2 7houlders are symmetrically round, no redness, swellin!, or de ormity or heat. Euscles are ully de<eloped. 'la<icles and scapulae are e<en and symmetric. .3tent o orward le3ion should be 180I5 hypere3tension, 50I5

anterior chest is ausculated, broncho<esicular and <esicular breath sounds are heard.

*ull palpations, thrustin! ?uality with symmetric pulse <olumes are elt upon palpation.

-ormal

-ormal There are no sounds heard upon auscultation. /u!ular <eins are not <isible upon inspection.

-ormal

M. /""er E-tremities

Euscles in shoulders are ully de<eloped5 it is symmetrically round without any redness, de ormity or swellin!.

-ormal

adduction, 50I and abduction 180I. -ormal .lbows2 .lbows are symmetric without de ormities, redness or swellin!. -ormal 4FE are 1%0I o le3ion5 180I o e3tension. 90I pronation. 90I supination. 7ome clients may lac6 5I-10I or ha<e hypere3tension. 0rists2 0rists are symmetric without redness or swellin!. They are nontender and ree o nodules. -ormal 4FE are 90I, le3ion5 (0I, hypere3tension5 55I, ulnar de<iation5 and 20I, racial de<iation. 'lient should ha<e ull 4FE a!ainst resistance. ,ands and in!ers2 ,ands and in!ers are symmetric, nontender and without nodules. *in!ers lie in strai!ht line. -o swellin! or de ormities. 4ounded protuberance noted ne3t to the thumb o<er the thenar prominence. 7maller protuberance seen ad@acent to the small in!er. -ormal 4FE are 20I o abduction, ull adduction o in!ers )touchin!+, 90I o le3ion and $0I o hypere3tension. -o de ormities, redness or swellin! present upon inspection. .lbows are symmetric. -ormal -o de ormities, redness or swellin! present upon inspection. 0rists are symmetric. -ormal

-o nodules present upon inspection. *in!ers lie in strai!ht line are symmetric *le3ion, e3tension, abduction, adduction and rotation o shoulders, elbows, wrists, hands and in!ers at di erent an!les or with resistance can be per ormed e ortlessly and

-ormal

-ormal

The client reports no tenderness. -ontender, without nodules. )Health Assessment in Nursing Third Edition by Janet Weber and Jane Kelley: p!s.5(0 -5(%+

without any di iculty. -o tenderness and nodules elt upon palpation. Euscles are irm with smooth coordinated mo<ements. There is e?ual stren!th and temperature on both sides o arms and hands. ,ips are stable, nontender with no crepitus present. ;uttoc6 is e?ual in si:e.

N. Lo'er E-tremities

,ips2 ;uttoc6s are e?ually si:ed5 iliac crests are symmetric in hei!ht. ,ips are stable, nontender and without crepitus -ormal 4FE2 90I o hip le3ion with 6nee strai!ht and 120I o hip le3ion with the 6nee bent and the other le! remainin! strai!ht. D5I-50I o abduction5 20I-$0I o adduction. D0I internal hip rotation, D5I e3ternal hip rotation. 15I hip hypere3tension. *ull 4FE a!ainst resistance. 1nees2 1nees symmetric, hollows present on both sides o the patella, no swellin! or de ormities. Aower le! with ali!nment with upper le!. -ormal 4FE2 120I-1$0I o le3ion5 0I o e3tension to 15I o hypertension. An6les and *eet2 Toes usually point orward and lie loat5 howe<er, they may point in )pes <arus+ or

-ormal

Aower le! is ali!ned with upper le!. 1nees are symmetric with no swellin! or de ormities present.

-ormal

-ormal 76in in an6les and eet is smooth and ree o calluses and corns. Toes and

point out )pes <al!us+. Toes and eet are in ali!nment with the lower le!. 7mooth, rounded medial malleolar prominences with prominent heels and metatarsopha!eal @oints. 76in is smooth and ree o corns and calluses. Aon!itudunal arch5 most o wei!ht bearin! is on oot midline. 20I dorsi le3ion o an6le5 D5I plantar le3ion o an6le and oot5 20I o e<ersion5 $0I o in<ersion. 10I o abduction5 20I o adduction. D0I o le3ion5 D0I o e3tension. 'lient has ull 4FE a!ainst resistance. -ontender and cool. Euscles irm. -o nodules. -o bul!e o luid appears on medial side o 6nee. -o pain or clic6in! noted. -o pain, heat, swellin! or nodules are noted. )Health Assessment in Nursing Third Edition by Janet Weber and Jane Kelley: p!s.5(( -58$+

eet are ali!ned with lower le!5 prominences are smooth. *le3ion, e3tension, abduction, adduction and rotation o hips, 6nees, an6les and eet at di erent an!les or with resistance can be per ormed e ortlessly and without any di iculty. Euscles are irm and no tenderness, pain, swellin! or nodules elt upon palpation.

-ormal

-ormal