Date of Physical Assessment: July 06, 2011 / 6:55pm 6days Post op
BMI: 30.18 obese class 1 Height:56 Weight: 85kg. 187lbs. Vital Signs: BP: 120/90mmhg Temperature: 37.3C Pulse rate: 89bpm Respiratory rate: 29cpm Pain Scale: 3 General Observations: The patient was restless, conscious, coherent, oriented to time, person, and place. He has thrombo embolic stockings on both lower extremities and had undergo laminectomy (June 30, 2011) on the thoracic (T9) and therefore completely limited in mobilization. Hemovac at the back was noted and complain for back pain.
BODY PARTS METHODS OF ASSESSMENT NORMAL ACTUAL FINDINGS INTERPRETATION Skin Inspection
Color: skin is uniform whitish pink or brown in color.
No bleeding and ecchymosis and vascularity
Lesions: no skin lesions are present except for birthmarks or moles which may be flat or elevated. No edema present The overall appearance of the skin is light brown
Some elevated circumscribed fluid- filled less than 1cm in diameter was noted at the upper back. The blood supply particularly at the back area decreased (due to prolong lying in bed). Thus insufficient amount of oxygen cause skin lesions (vesicle) and dry skin is an indication of decrease fluids in the body and frequent turning on the bed.
(Fundamentals of nursing, 6 th ed page 687).
Palpation Moisture in skin folds varies with the environment
Skin turgor: when released should return to original contour rapidly and no edema is present. Generally dry and warm
Dry skin probably due to environment
(Kozier, Skill 30-2 p.579)
Head
a. Skull Inspection
Rounded (normo- cephalic) and asymmetric with frontal, parietal, temporal, occipital and prominences:
Normocephalic, with prominences in the frontal and occipital area
The shape of the head is normocephalic.
The shape is gently curve with prominence at the frontal and parietal bones.
(Fundamentals of nursing taylor 6 th ed. vol.1 page616 ) b. Scalp Palpation Smooth skull contour absence of nodules or masses The scalp is moist, symmetrical and firm.
No lesions and mass noted The scalp is moisten showing normal for a scalp
(Fundamentals of nursing taylor 6 th ed. vol.1 page614) c. Hair Inspection Color: dark black to blonde; may turn gray or white; may be chemically distributed The hair is dark brown in color. The texture was fine, smooth and thin slightly curly hair. Equally distributed and no signs of alopecia and lice. Client manifests normal findings Face Inspection Face is symmetrical
Shape is gently curved with prominences at the frontal and parietal bones Symmetrical. No involuntary muscle movement Client manifests normal findings Palpation Smooth uniform consistency; absence of nodules or masses Smooth uniform consistency; absence of nodules or masses Client manifests normal findings
Eyes
Inspection
Should be symmetrical with no dropping infection, tumors or other abnormalities with the visual acuity of 20/20
Sclera: white without exudates, lesions foreign bodies in dark skinned may have brown patches
Pupils: deep black, round and equal diameter of 2-6mm PERRLA
No tearing, swelling or discharge in conjunctiva Eyebrows equally distributed and dark brown in color
Eyelashes slightly curved upward evenly distributed and color is same with eyebrows
Eyelids function normally
Conjunctiva is moist and pinkish
Cornea is smooth and transparent
Sclera: white without exudates
Pupil size: 4mm; equal reaction to light; right and left briskly reactive to light
Reaction to accommodation; uniform constriction grossly normal vision 20/20 intact peripheral vision No significant findings Ears Inspection
External ear gently no pain, edema, and lesions
Earlobes are bean shaped, parallel, and symmetrical. Skin is same color as complexion
Ear canal and the tympanic membrane External pinnae: normoset
External canal has no unusual discharges
Tympanic membrane is intact and pearly gray in color Gross hearing are No significant findings should be intact, translucent, shiny, and pearly gray in color
No redness and discharge
Assessing hearing sounds one ear at a time can hear whispered voice and ticking watch from distance of 1-2 feet
symmetrically normal Nose
Inspection
Palpation
Nose is in the midline and is symmetrical, No unusual discharges, No nasal flaring, Both nares are patent, No bones and cartilage deviation, Nasal septum is in the midline, and Nasal mucosa is pink in color
No pain, tenderness and discomfort during palpation
Septum is in the midline, Mucosa is pinkish, Both nares are patent, Gross smell are symmetrical and No unusual discharge
There is no pain upon palpation and no swelling and tenderness of the paranasal sinuses
No significant findings
No significant findings Mouth Inspection
Lips are pink and moist with no Lips are dry and no edema noted. No significant findings
lesions or inflammation. Tongue is in the midline, pink, moist, rough without lesions. taste buds are white in color
Symmetrical: moves freely. Gums are paled red stripped surface
No swelling or bleeding
Gums are pink, no gum bleeding and no lesions noted. Tongue is in midline that moves freely and no dentures.
Buccal mucosa is pink and moist.
Uvula is in midline. Pink and not swelling same as with the tonsils
Nails Inspection
Palpation
Color: have a pink cast in light-skinned brown in dark skinned
Shaped and configuration is surface is smooth and slightly rounded or flat. Curved nails are normal. Uniform nails thickness throughout; no splintering or brittle edges
Capillary refill present should return to 2-3 seconds
Light pink in color, convex in shape
Has a capillary refill of 2-3 seconds No significant findings
No significant findings Neck Inspection
Symmetrical with head in central position able to move freely without discomfort or noticeable limits
Muscles should be Trachea is in the midline No jugular vein engorgement Normal range of motion And has a muscle grading of 4
Cervical lymph No significant findings
Palpation
symmetrical without palpable masses or lumps
nodes are not palpable and non- tender
No significant findings
Chest Inspection
Palpation
Percussion
Auscultation
Skin is intact without lesions, same as skin color, Spine vertically aligned, No kyphosis, scoliosis and lordosis, Full and symmetric chest expansion
Without nodules
Resonant
Quiet, rhythmic and effortless breathing Without lesions; with skin intact
Rapid shallow breathing
Partial chest expansion upon respiration
Without nodules, no masses upon palpation
Resonant located at 4 th intercostals space right anterior axillary
Crackles (rales) at the right lower lobes of the lung during Tachypnea is rate of breathing regular but abnormally rapid greater than 20 breaths per minute.
The patient has respiratory rate of 29 beats per minute.
It result from pulmonary irritation and heightened oxygen demand result from pain and anxiety
(kozier, skills 30- 31 p.614)
No significant findings
No significant findings
Rales heard upon auscultation indicates pulmonary tuberculosis
(kozier, skill 30-31 p. 616)
inspiration Thorax a. Ante rior Inspection
Palpation
Auscultation
Skin intact
No tenderness and no masses
Bronchovesicular and vesicular sounds are heard above and below the clavicles and along the lung periphery
Bronchial sound can be heard over the trachea Skin intact
No tenderness and no masses upon palpation
Respiratory rate of 29 beats per minute was noted
Bronchial sound heard over the trachea loud, high pitch and hollow sounding, with expiration lasting longer than inspiration No significant findings
No significant findings
No significant findings
b. Post erior Inspection
Palpation
Auscultation
Anteroposterior to transverse diameter in ratio 1:2; chest symmetric; Spine vertically aligned; Skin intact; Chest wall intact
Uniform temperature; no tenderness; no masses; no lumps symmetrical chest excursion of at least 5 cm; presence of pulsation and no unusual movement
Normal breath sounds Lateral deviation of spine noted
Chest excursion symmetrical about 5 cm apart, no masses and tenderness upon palpation Pulsation is present, no lumps and unusual movements
Fine crackles noted on the right and left The disease (Potts) is characterized by bone destruction and abscess formation
(Pathophysiology 6 th edition by Carol Mattson Porth p. 133)
No significant findings
Fine crackles signifies
heard over the posterior thorax includes bronchovesicular and vesicular sounds heard above and below the clavicles and along the lung periphery and the abnormal sounds or adventitious sounds
lung bases pulmonary tuberculosis
(Fundamentals of Nursing, 6 th
edition, potter- perry, p.721) Heart Auscultation
There is no lifts and heaves and there is no presence of heart murmurs Heart murmurs noted upon auscultation at the end of the systolic and diastolic phase. Increased blood flow through a normal valve, forward flow through a stenotic valve or into a dilated vessel or heart chamber, or backward flow through a valve that fails to close
(Fundamental of Nursing, 6 th
edition, potter- perry, p.726)
Abdomen Inspection
Auscultation
Abdominal contour is flat or rounded, symmetrical and uniform in color
Normally air and fluid move through intestine, creating soft gurgling or clicking sounds that occur 5-35 times per minute
Sounds are generally described as normal, audible, absent, The clients abdomen is rounded, uniform in color, and no scars noted
Tympany over the stomach and gas filled bowels; dullness specially over the liver and spleen, or a full bladder
No tenderness, relaxed abdomen with smooth, consistent tension bladder and liver is not palpable
Dull percussion noted over the liver
Abdominal tenderness and distension noted on the lower left quadrant of the abdomen
No significant findings
Tenderness and distension signifies decreased bowel movement
(Fundamental of Nursing, 6 th
edition, potter- perry, p.744)
Musculoske letal Inspection
Palpation
Muscles has equal size on both sides of the body, no contractures, no fasciculation, or tremors
Bones has no deformities
Joints has no swelling
Muscles are firm, has smooth coordinated movements
Bones has no Muscle weakness noted at lower extremities with the grade of 4+ hyperactive and very brisk
Acute pain noted upon palpation of lower extremities Hyperactive and very brisk muscle grading often associated with spinal cord disorders
(Fundamental of Nursing, 6 th
edition, potter- perry, p.767)
Spinal cord disorders can cause spinal nerve compression causing pressure damage includes pain
(Fundamental of Nursing, 6 th
edition, potter- perry, p.764)
Extremities Inspection Bilateral symmetry without any presence of deformities, edema and discoloration. Intact. Hands are steady and no tremor noted.
However muscle weakness and numbness when hyperflexion, and positive from joint pain with pain scale of 5/10 were noted on the lower extremeties. The most common sensory deficit from spinal nerve root compression are paresthesias and numbness particularly of the leg and foot
(Pathophysiology by Carol Matson Porth 7 th edition page 1205) Palpation Glasgow coma scale is 15
Positive reflexes such as biceps reflex, triceps reflex, brachioradialis reflex, patellar reflex and Achilles reflex Glasgow coma scale is 15
Positive reflexes such as Brachioradialis reflex, patellar reflex and Achilles reflex Client manifests normal findings
Cranial Nerves I Olfactory
By asking patient to close his eyes and identify different mild aromas.
Identify different mild aromas such as coffee, vanilla, peanut butter, orange, lime, chocolate
Able to identify mild aromas such as coffee, vanilla, peanut butter, orange, lime, chocolate
Client manifests normal findings
II Optic
The nurse will ask the patient to Ability to clearly visualize the snellen chart; check visual Able to clearly visualize the snellen chart; check visual Client manifests normal findings read snellen chart; check visual fields by confrontatio n fields by confrontation
fields by confrontation
III Oculomotor
The nurse will be assessing the six ocular movements and pupil reaction of a patient Ablility to perform extraocular eye movement (EOM); movement of sphincter of pupil; movement of ciliary muscles of lens
Able to perform extraocular eye movement (EOM); movement of sphincter of pupil; movement of ciliary muscles of lens Client manifests normal findings IV Trochlear The nurse will be assessing the six ocular movements of a patient. Ablity to perform extraocular eye movements specifically movements of eyeballs downward laterally Able to perform extraocular eye movements specifically movements of eyeballs downward laterally
Client manifests normal findings VTrigeminal
Thenurse lightly touches the lateral sclera of the eye while the patient is looking upward. To test light sensation, have the client close eyes, wipe a wisp of cotton over patients forehead and paranasal sinuses. Ask client to clench teeth. Pesence of blink reflex; can feel the sensation of skin of face and nasal mucosa; able to feel the sensation of anterior oral cavity; mastication of muscles
Patient has presence of blink reflex; can feel the sensation of skin of face and nasal mucosa; able to feel the sensation of anterior oral cavity; mastication of muscles
Client manifests normal findings VI Abducens
The nurse will be Ability to move eye balls laterally Able to move eye balls laterally Client manifests normal findings assessing the directions of gaze.
VII Facial
The nurse will ask the patient to smile, raise eyebrows, frown, and puff out cheeks, close eyes tightly. Identifying various tastes placed on tip and sides of tongue.
Ability to perform different facial expressions; able to identify different tastes
Able to perform different facial expressions; able to identify different tastes in tongue (sweet, bitter, sour, salty).
Client manifests normal findings
VIII Auditory
The nurse will be assessing the patients ability to hear spoken word and vibrations of tuning fork. Ability to clearly hear spoken words and vibrations of tuning fork Able to clearly hear spoken words and vibrations of tuning fork. Rombergs test performed, the patient stood up and asked to close his eyes a loss of balance is interpreted. Client manifests normal findings IX Glossophary ngeal
The nurse will be applying tastes on posterior tongue for identification . Asking the patient to move tongue from side to side and up and down.
Ablity to move the tongue from side to side and up and down; no difficulty in swallowing;; able to identify different taste on posterior tongue
Able to move the tongue from side to side and up and down; no difficulty in swallowing;; able to identify different taste on posterior tongue
Client manifests normal findings X Vagus
The nurse will do palpation on the pharynx Palpable pharynx and larynx by stimulating; presence of gag reflex; no Pharynx and larynx are palpable; patient swallows and says Ah presence of gag Patient has normal findings and larynx, assessing the gag reflex with the use of tongue depressor and assess the presence of hoarseness.
presence of hoarseness of clients speech
reflex; there was no presence of hoarseness of clients speech
XI Accessory
The nurse will apply pressure on patients shoulders and ask patient to shrug shoulders against resistance and turn head to side against resistance from the nurse hand.
Ablity to shrug shoulders against resistance and able to turn to side against resistance without any difficulty
Able to shrug shoulders against resistance and able to turn to side against resistance without any difficulty
Patient has normal findings XII Hypoglossal By asking patient to protrude tongue at midline and move it side to side and up and down Ability to protrude tongue at midline and move up and down and side to side
Able to protrude tongue at midline and move up and down and side to side