PHYSICAL ASSESSMENT ACTUAL VITAL SIGNS RR - 20 PR - 86 BP - 160/90 Height " #$%& 't. Weight " %( )g.

Body Parts Ge!era% Te h!i"#e Used *ns!e+tion ,-ttitude. Nor$a% &i!di!gs 3oo!erati1e4 able to 'ollo5 instru+tions A t#a% &i!di!gs *rritable et able to 'ollo5 instru+tions Sig!i'i a! e NORMAL VALUES 12-20 beats/min. 60-100 beats/min. 90/60- 130/90 mmHg INTERPRETATION Normal Normal Not normal due to h !ertension

Normal

,/uantit and 0ualit o' s!ee+h. ,Rele1an+e and organi2ation o' thoughts.

6nderstandable4 6nderstandable4 Normal moderate !a+e moderate !a+e 7ogi+al se0uen+e4 moderate !a+e8 +lear in'le+tion8 e9hibits thought asso+iation 3on'used 'or some times Presen+e o' hallu+ination Not normal. :or !atients 5ith ;idne 'ailure4 be+ause o' high to9ins in blood4 their +entral ner1ous s stem is a''e+ted easil . Normal Normal Normal

Head

*ns!e+tion Pal!ation *ns!e+tion

Normo+e!hali+ No abnormal mass <1enl distributed4 thi+; hair4 no in'e+tion and in'estation = mmetri+ to the 'a+e4 both e es +oordinated

Normo+e!hali+ No abnormal mass <1en distribution o' hair4 no in'e+tion and in'estation = mmetri+ to the 'a+e4 both e es +oordinated

Hair a!d s a%(

Eyes

*ns!e+tion

Normal

5ith !arallel alignment. Bilateral and +lear 1ision

5ith !arallel alignment. >e+reased and blurred 1ision on le't e e Blood s!ots 1ision on right e e

Not normal ma be due to diabeti+ retino!ath Not normal due to lea;age o' 'luid and s5elling o' blood 1essel in the e es

E)ter!a% eye Str# t#re Eye*ro+s *ns!e+tion Hair e1enl distributed4 =;in inta+t <0uall distributed4 3urled slightl out5ard =;in inta+t4 No dis+harge4 No dis+oloration4 7ids +lose s mmetri+all No edema or tearing Bla+; in +olor4 e0ual in si2e normall 3-% mm in diameter4 Round4 smooth border4 iris 'lat and round <1enl distributed 5ith s;in inta+t <0uall distributed4 3urled slightl out5ard =;in inta+t4 no dis+harge4 no dis+oloration4 lids are s mmetri+al. No edema and tearing Bla+; in +olor4 e0ual in si2e (mm in diameter Normal

Eye%ashes

*ns!e+tion

Normal

Eye%ids

*ns!e+tion

Normal

La ri$a% g%a!d P#(i%s

*ns!e+tion *ns!e+tion

Normal Normal

6ne0ual !u!il res!onse8 le't e e slo5l

Not normal due to blood 'lo5 interru!tion in

+onstri+t

the o!ti+ ner1e that ma be related to the de1elo!ing neuro!ath Not normal due to !resen+e o' 5ound

Ears

*ns!e+tion

= mmetri+all aligned to the 'a+e4 'irm and not tender 5ith no dis+harged noted. = mmetri+ and straight4 no dis+harges or 'laring

Positioned s mmetri+all to the 'a+e4 blood dis+harge !resent in le't ear = mmetri+ and straight4 5ith blood dis+harge

Nose

*ns!e+tion

Not normal due to nasal se!tum !er'oration +aused b !rolonged o9 gen administration 1ia nasal +annula

Mo#th Li(s *ns!e+tion 6ni'orm !in; in Pale in +olor4 +olor4 so't and dr moist and smooth Not normal due to de+reased blood su!!l related to !rolonged bed rest8 limited 'luid inta;e Normal

To!g#e

*ns!e+tion

?ongue at midline 5ithout lesion 3om!lete4 5hite4 shin tooth enamel4 'ree o' debris

>r and 'ree o' lesion *n+om!lete teeth4 dar; enamel

Teeth

*ns!e+tion

>ue to smo;ing and drin;ing dar;-+olored be1erages

Ne ,

*ns!e+tion

Pal!ation

3oordinated 4 smooth mo1ement 5ith no dis+om'ort No masses4 tenderness

3oordinated mo1ement 5ith no dis+om'ort No masses4 tenderness

Normal

Normal

U((er E)tre$ities S,i! *ns!e+tion Pin;ish in +olor Pallor Not normal. *t is a mani'estation o' inade0uate +ir+ulating blood or hemoglobin. Not normal due to the damaged ;idne s$ inabilit to balan+e the le1els o' the minerals +al+ium and !hos!horus in the blood Not normal. *t is the !o5der de!osits o' urea and uri+ a+id salts on the s;in +aused b se1ere uremia.

Pruritus

Presen+e o' uremi+ 'rost

Pal!ation

=lightl moist

Poor s;in turgor Not normal due to de+reased 'luid inta;e Not 5arm4 not +old to tou+h4 ?"36.# Normal

Pal!ation

Normothermia

Ar$s

*ns!e+tion

Normall 'irm4 no +ontra+ture4 no s5elling4 e0ual si2e on both sides o' bod

Normall 'irm4 no +ontra+ture4 e0ual si2e on both sides o' bod Pain and s5elling on the lo5er right arm =lo5 5ound healing on right ;nu+;les

Normal

Not normal due to in'lammation o' the 1ein +aused b *A insertion Not normal due to ele1ated blood sugar le1el that sti''ens the arteries and +auses narro5ing o' the blood 1essels

Pal!ation

Pulse Rate@ 60100

-us+ultation Nai%s *ns!e+tion =mooth4 highl 1as+ular and inta+t e!idermis 3a!illar Re'ill o' 1-2 se+onds

Pulse rate@ 86 Presen+e o' thrill on le't Normal due to arm !resen+e o' -A Presen+e o' 'istula bruit on le't arm Pale4 smooth te9ture4 +lubbing 3a!illar re'ill@ ( se+onds Not normal due to de+reased o9 gen rea+hing the !eri!her Not normal due to de+rease blood +ir+ulation Normal

Pal!ation

Chest a!d L#!gs

*ns!e+tion

= mmetri+ +hest e9!ansion4 0uiet4 rh thmi+ and e''ortless res!iration

= mmetri+ +hest e9!ansion4 0uiet4 rh thmi+ and e''ortless res!iration

Pal!ation

No retra+tion4 no tenderness4 no masses /uiet4 rh thmi+ Normal heart rate 60-100b!m 6nblemished s;in4 uni'orm in +olor

No retra+tion4 no tenderness4 no masses /uiet4 rh thmi+ 3ardia+ rate o' 86

Normal

-us+ultation Heart -us+ultation

Normal Normal

A*do$i!a%

*ns!e+tion

-us+ultation

6nblemished s;in4 uni'orm in +olor Protruded umbili+us Pain on le't u!!er 0uadrant -1erage normal *naudible bo5el bo5el sounds sounds #-2# !er minute No lesions4 No >is+harge4 No =megma Reddish to bro5n dis+oloration o' glans !enis <s+har on !enile head Pain on !enile sha't

Normal

Not normal due to !resen+e o' 'luid in the abdomen

Ma%e ge!ita%ia

*ns!e+tion

Not normal due to s+arred tissue and +al+ium de!osits

Lo+er e)tre$ities S,i! *ns!e+tion No lesion4 +an mo1e 'reel >ar; and not uni'orm in +olor Not normal due to insulin le1el that is too high4 the e9tra insulin ma trigger a+ti1it in s;in +ells Not normal due to narro5ed blood 1essels that lead to de+reased blood

=lo5 5ound healing on (th digit o' le't 'oot and on #th digit o' right 'oot

>e+reased sensation Pal!ation 3a!illar re'ill@ 1-2 se+onds 3a!illar re'ill@ 3 se+onds

'lo5 and o9 gen to a 5ound Not normal. *t +aused b damage to the blood 1essels. Not normal due to de+rease blood +ir+ulation Normal

M#s %es

<0ual si2e on both sides o' the bod 4 no +ontra+tures4 no tremors Normall 'irm4 smooth4 +oordinated mo1ements <0ual strength on ea+h bod side

<0ual si2e on both sides o' the bod 4 no +ontra+tures4 no tremors Normall 'irm4 smooth4 +oordinated mo1ements Beneral 5ea;ness

Normal

Not normal due to !rolonged bed rest and de+reased a+ti1it Not normal due to bone in'lammation Not normal due to a +ondition +alled +hroni+ ;idne diseasemineral and bone disorder

Bo!es

No de'ormities4 no tenderness or s5elling

Pain4 s5elling4 5armth and redness on le't (th distal !halan9 Cea;ness

-oi!ts

No s5elling4 no tenderness4 +re!itation or nodules Doints mo1e smoothl

Pain

=ti''ness

Not normal. ?hese s m!toms result 'rom am loidosis4 a +ondition in 5hi+h an abnormal !rotein in the blood +alled am loid is de!osited in tissues and organs4 in+luding the Eoints and tendons.