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Initial Vital Signs Temperature: Heart Rate: Respiratory Rate: Blood Pressure:
Inspection
The patient can still maintain proper hygiene by the help of significant others. Good Hygiene promotes comfort.
Inspection
Cooperative; mood is appropriate to situation; speech is understandable, demonstrates normal thought association and logical sequence.
The patient has a good level of consciousness; she can be able to speak and response to questions.
Skin
Body Part Skin Color, Uniformity Techniques Used Inspection Actual Findings Brown and no discolorations Interpretation There are no discolorations that may indicate hyper or hypo pigmentation, pallor, cyanosis, jaundice or erythema.
Inspection Palpation
Theres no sign of
excess fluid accumulation in the body. Dry skin indicates dehydration and fluid deficiency. Pallor skin indicates inadequate circulation of blood or hemoglobin and subsequent reduction in tissue oxygenation.
Palpation
Poor skin turgor may indicates poor circulation of blood, dehydration as well extreme weight loss. It may be due to the patients age that the elasticity of the skin is not normal and has inability to return to its place promptly Normally, geriatric patients has wrinkled and sagging skin. No signs of Hyperthermia or hypothermia.
Hair
Body Part Scalp Techniques Used Inspection Actual Findings Well distributed throughout the scalp Interpretation Theres no indication of flakes.
Inspection
There are no signs of dryness and alopecia. In geriatric patients, The hair thins a little, starts to loose pigment and turns gray.
Body Hair
Inspection
No indications of Hirsutism.
Nails
Body Part Fingernail shape, texture, and color Techniques Used Inspection Actual Findings Convex curvature; smooth texture; dirty nails; pale Interpretation Normal in shape and texture; dirty nails suggest poor selfcare; paleness of the nails is one of teh effects of anemia
Inspection
Prompt return and intact skin near the nails indicate an adequate circulation. No signs of cyanosis.
Inspection
The clients face has no abnormalities; there are no signs of exopthalmus, myxedema, periorbital edema, sunken eyes. There are no involuntary facial movements that may indicate tremors.
eyebrows are equal in movement; symmetric eyebrow shows no problem in the neural functions. Eyelashes and Eyelids Inspection Palpation Lids close symmetrically, no masses or lumps, no discharge or discoloration
No signs of swelling or redness that may indicate infections. Lids close bilaterally; negative discharge indicates absence of infection
Inspection
Pallor conjuntiva Pale conjuntiva indicate inadequate circulation of blood or decreased hemoglobin and subsequent reduction in tissue oxygenation. It also indicates anemia.
Inspection
Pupils are black, symmetric, round; Pupils illuminated; Constricted when lighted and dilated when light passed
No signs of cloudiness, miosis or aniscoria. There a no abnormal reactions; pupils are able to function well; indicates proper functioning of the cranial nerves III
Inspection
Indicates that there are no nueral impairment particularly caranial nerves II, IV and VI; wearing eyeglasses is normal to geriatric patient has visual changes like decreased accomodation for near vision or presbyopia.
Inspection Palpation
No indications of infection and inflammation. Elderlys lacrimal glands involute, causing decreased tear production.
Inspection
No indication of infections or inflammation. No redness and swelling that indicates otitis externa.
Hearing
Inspection
Nasal Cavity
Inspection
There is obstruction that could affect respiration and gas exchange (presence of secretions); patient has experiencing difficulty of breating
when theres presence of secretions. There is an alteration in her breathing pattern. Bone and Cartilage Inspection Palpation No displacement of bone and cartilage,no tenderness or masses
No manifestation of septal defect, trauma, may also indicate the absence of inflammation or tumor
Palpation
Inspection
Some tooth loss may occur owing to bone resorption ( Osteoporosis), which decreases the inner tooth structure and its outer support.
Tongue
Inspection
Uvula
Inspection
Centered No manifestationof
nerve damage (vagus nerve or X) or presence of tumors or trauma that culod deviate the uvula to one side Tonsils Inspection No discharge, not enlarged
Neck
Body Part Neck Muscles Techniques Used Inspection Palpation Actual Findings Equal in size, centered and coordinated movements, equal strength, wide range of movements,no masses or lumps Not felt or palpable Interpretation No indications of muscle weakness or shortening of sternocleidomastoid
Lymph Nodes
Palpation
No signs of infections or tumors which would indicates absence of autoimmune disorder or metastatic disease Thyroid Gland Inspection Palpation Not visible and palpable
Lung sounds
Auscultation
Crackles are short explosive breath sounds, usually associated with pulmonary disorders. This sounds produce when there is air passing through fluids or mucus in any air passage. (+) crackles indicates presence of secretions.
Carotid Artery
Palpation
Full pulsations would mean no possible stenosis or thrombosis, impaired cardiac output or arteriosclerosis
Jugular Vein
Inspection
Vein not visible The absence of distention could mean that the patient is absent of CHF, liver failure that could impede the circulation to resulting to hypervolemia
Peripheral Vein
Palpation
Abdomen
Body Part Liver Techniques Used Palpation Actual Findings Symmetric contour Interpretation Liver is not enlarged or inflamed Bladder Palpation Not palpable Ultrasound: Smooth, contour; wall is not thickened Can indicate the absence of urinary retention; theres no prensence of bladder distention
Inspection Palpation
No signs of muscle hypertrophy, malpositioning, flaccidity or spasicity; poor or less strength is due to her current condition, she is weak and powerless.
Inspection Palpation
Presence of osteoporosis
With aging, loss of bone matrix (resorption) occurs more rapidly than new bone growth (deposition), the net effect is a loss of bone density (osteoporosis).
Inspection Palpation
It would indicate that there are no swollen joints; patient has no rheumatoid arthritis.