IV.

Nursing Assessment

1. General Survey: Patient is conscious and alert. Patient is afebrile (36.4) and shows
generalized weakness. The patient is in supine position with complete bed rest and no
bathroom privilege. Patient is not in distress. Facial grimace is seen.
2. Skin: Nails are smooth and slightly rounded. Skin is warm and slightly moist. The
hair is finely distributed.
3. Head: The head is normocephalic. The hair is finely distributed and smooth. No signs
of alopecia or foreign bodies.
4. Eye: Patient's eyes shows negative sign of visual dysfunction, redness, pain or
lacrimation in the eyes. With pink palpebral conjunctiva. Pupils are equal, round and
reactive to light and accommodate.
5. Ears: Patient’s appearance of external ear is normal. Canals are clear without
discharges.
6. Mouth: no mouth lesions
7. Nose and Sinuses: Nose is symmetrically placed on face. Mucous membranes are
moist and dark pink without perforation and bleeding. With minimal nasal discharges.
8. Neck and Lymph Nodes: Neck is symmetric without tenderness or limitation of
movement. Nodes are neither palpable nor tender Trachea is centrally placed in the
middle.
9. Chest: normal chest expansion.
10. Upper and Lower Extremities: Normal range of motion, with no skin lesions and
markings. With bipedal edema.
11. Genitals: not assessed.