PHYSICAL ASSESSMENT Date of Admission: Date of Assessment: Time: VITAL SIGNS: Blood Pressure: Pulse Rate: Respiratory Rate:

Temperature: Height: 52 GENERAL APPEARANCE: Patient AD was seen lying supine with intravenous fluid of Plain Lactated Ringers Solution at 900 cc level regulated at 8-10 drops per minute (KVO) with side drip of Plain Normal Saline Solution at 1liter level incorporated with 40 mEq of potassium chloride regulated at 10 gtts/min. She is oriented to person, place and time, and responds well to the questions. Client establishes good eye contact when conversing with others, and is well groomed. Pallor is noticeable, especially on nail beds and lips. With regards to the movement, the client has limited range of motion. BODY PARTS SKIN Color Edema METHODS Inspection Palpation FINDINGS Light brown complexion Upper extremities has edema with an indentation of 4 mm (2+) and return to normal state in 10 seconds Bipedal edema with an indentation of NORMAL ABNORMAL; The oncotic pressure which holds the fluid inside the blood vessel was reduced due to the leakage of blood protein in the urine. Furthermore, hydrostatic pressure then increases due to the venous congestion on the peripheral vascular beds causing accumulation of fluid in the underlying tissues between the skin pigmented and vascular layer which is called edema. ANALYSIS 120/70 mmHg 88 beats per minute 35 breaths per minute 37.2 degree Celsius Weight: 90 kg September 6, 2010 September 7, 2010 1:00 PM

6 mm (3+) and return to normal state for 17 seconds

Reference: Porth, Carol M. Pathophysiology: Concepts of Altered Health States. pp 611. Medical- Surgical Nursing 5th edition (2006) By: Ignatavicius and Workman p. 1799 ABNORMAL: Generalized itching is one of the late signs and symptoms of Diabetes Nephropathy. It is due to accumulation or increase level of nitrogenous waste product particularly blood urea nitrogen in the bloodstream also known as Azotemia. Reference: http://en.wikipedia.org/wiki/Diab etic_nephropathy ABNORMAL: Anhydrosis or dry skin is often observed in diabetic clients. This is usually due to poor circulation. This can cause reduced sweating in the foot which subsequently leads to dry skin and increases the likelihood of skin fissures. As diabetic's blood glucose level increases, nerve sensitivity decreases, and the body loses fluids. The person also fails to sweat sufficiently when needed. This results to a drying effect on the skin, particularly in the legs, feet, and elbows. RBS: 335 mg/dl References: http://ezinearticles.com http://pdfcast.org

Lesions

Inspection Presence of excoriation in the lower extremities

Moisture

Inspection Dry skin

Palpation Moisture in skin folds especially on the axilla Cold clammy skin on both extremities.

NORMAL

Temperature

Palpation

ABNORMAL; A cool extremity is one of the commonly encountered effects related to poor perfusion to the extremities. Reference: Medical- Surgical Nursing 9th edition (2006) By: Smeltzer, Suzanne and Barell, Brenda G. p. 58

Turgor

Palpation Skin returns to its previous state in 5 seconds (sternum)

NORMAL; Turgor, a reflection of the skins elasticity and hydration status, is measured by the time needed for the skin and underlying tissue to return to their original contour after being tented between the thumb and finger. Turgor decreases with age as the skin loses elasticity. Reference: Medical- Surgical Nursing 7th edition (2005) By: Black and Hawks p. 1384

HAIR Distribution Color and Texture Infection or Infestation

Inspection Inspection Inspection

Evenly distributed Gray resilient hair No infestation and infection

NORMAL NORMAL NORMAL

NAILS Curvature

Inspection

Convex curvature with an angle of 160 Smooth texture

NORMAL.

Texture

Palpation Inspection

NORMAL

Nail bed color

Pallor both ABNORMAL: Pallor (loss of color) is seen when there is finger and decreased blood supply such toe nails. as in diabetes. Diabetes leads to hypoperfusion (decreased circulation) of tissues, and poor tissue oxygenation (hypoxia). Continuous elevation of glucose levels cause blood to become viscous thus causing impaired tissue perfusion. Also, due to the decreased number of erythropoietin hormone that stimulates the bone marrow, there is impaired production of functional red blood cells within the circulation causing drop in hematocrit and haemoglobin level which leads to paleness or pallor. Hematocrit: 27.1% Haemoglobin: 8.9 mg/dl Reference: medical-dictionary. thefreedictionary.com/ Health Assessment in Nursing, 3rd edition By: Jjanet Weber&Jane Kelle, p. 166 Medical- Surgical Nursing 11th edition Volume 2 By: Brunner and Suddarth p. 1045, 1047, 1524

Inspection Tissues surrounding nails Capillary Refill

Intact epidermis Return to usual color in 4 seconds (finger nail)

NORMAL

Blanch Test (Normal findings: pink color should return in less than 2 seconds after pressure is removed)

ABNORMAL; A blanch test can be carried out to determine the capillary refill, that is, the peripheral circulation. Normal nail bed No change capillaries blanch when pressed but quickly return to in pale color pink or usual color when (toe nail) pressure is released. Diabetes leads to hypoperfusion (decreased circulation) of tissues, and poor tissue oxygenation (hypoxia). Continuous elevation of glucose levels cause blood to become viscous thus causing impaired tissue perfusion. Reference: medical-dictionary. thefreedictionary.com/ blanch+test

HEAD and FACE Size, shape and symmetry Nodules and Masses Facial Features

Inspection

Rounded and smooth contour Absence of nodules and masses Symmetric al facial features Palpebral fissures and nasolabial folds are

NORMAL

Palpation

NORMAL

Inspection

NORMAL

NORMAL

equal in size Inspection Facial Nerve EYES (Structure and Visual Acuity) Inspection Skin surrounding the eyes Eyebrows Inspection Symmetric facial movements NORMAL

Light brown color Evenly distributed Intact skin with symmetrical movement

NORMAL

NORMAL NORMAL

Eyelashes Eyelids

Inspection Inspection

Curled slightly outward Intact skin with no discharged or discoloration Close symmetricall y and bilaterally No visible sclera when closed

NORMAL NORMAL

NORMAL

NORMAL

NORMAL

Bulbar Conjunctiva

Inspection

Transpare nt with evident capillaries

NORMAL

 Sclera appears white Palpebral Conjunctiva Inspection Shiny and smooth Pale in color

NORMAL ABNORMAL; Due to the decreased number of erythropoietin hormone that stimulates the bone marrow, there is impaired production of functional red blood cells within the circulation causing drop in hematocrit and haemoglobin level which leads to paleness or pallor. Hematocrit: 27.1% Haemoglobin: 8.9 mg/dl Reference: Medical- Surgical Nursing 11th edition Volume 2 By: Brunner and Suddarth p. 1045, 1047, 1524

Lacrimal Gland

Inspection

NORMAL

Inspection Lacrimal Sac and Nasolacrimal duct Cornea

No edema and tenderness No edema or tearing

NORMAL

Inspection

NORMAL NORMAL; Arcus senilis, a normal condition in older clients ages 40 years old above, appears as a white arc around the limbus. The condition has no effect on vision. Reference: Health Assessment in Nursing

Transpare nt, shiny Presence of a thin grayish white ring

3rd edition By: Weber and Kelley p. 229 NORMAL Pupils Corneal Sensitivity test NORMAL Inspection Blinks when the cornea is touch Black in color; equal in size with 4mm in diameter Illuminated pupil constricts (direct response) Nonilluminated pupil constricts (consensual response) Pupils constricts when looking at near object, pupils dilate when looking at far object and pupils converge when near object is NORMAL

NORMAL

Direct and consensual reaction

NORMAL

Inspection Lens

ABNORMAL; high blood sugar in diabetes causes the lens of the eye to swell. This swelling of the lens causes change in

Cover test Visual Fields Inspection Visual Acuity

the individuals ability to see. Blurred vision can be a symptom of serious eye problem with diabetes. Milky-white Clouding or fogging of the appearance on the left eye normally clear lens result in immobility to focus light and Diminishe impaired vision. d temporal Reference: field of the http://www.webmd.com left eye Difficulty in NORMAL reading news paper

moved toward nose.

Inspection

Ocular muscles Coordinat ed movement with parallel alignment Ears and Hearing Auricles

Inspection

Color is light brown, which is same with facial skin Align with outer canthus of the eye about 10 degrees from vertical Mobile , firm and nontender and

NORMAL

NORMAL

Palpation

NORMAL

pinna recoils after it is folded Gross Hearing Acuity Inspection Normal voice tones audible NORMAL

Nose and sinuses External nose

Inspection

Symmetric and straight with uniform color No discharge Air moves freely as the client breaths through the nares Not tender and no lesions Mucosa pink in color having no lesions Intact and in midline Maxillary and frontal sinuses are not tender

NORMAL

NORMAL NORMAL

Nasal Cavities

Check for patency

Inspection and Palpation Inspection

NORMAL

NORMAL

Inspection Nasal Septum Facial Sinuses Palpation

NORMAL NORMAL

Mouth and Oropharynx Lips and

Inspection

Pale

ABNORMAL; Due to the

oral Mucosa

decreased number of erythropoietin hormone that stimulates the bone marrow, there is impaired production of functional red blood cells within the circulation causing drop in hematocrit and haemoglobin level which leads to paleness or pallor. Haemoglobin: 8.9 mg/dl Hematocrit: 27.1% Reference: Medical- Surgical Nursing 11th edition Volume 2 By: Brunner and Suddarth p. 1045 and 1047 Inspection Dry appearance ABNORMAL; Xerostomia (dry mouth) occurs when there is not enough saliva to keep the mouth moist. Dry mouth is a usual side effect of diuretics and antiinflammatory medications. Reference: http://www.diabeteshealth.com/ read/2006/12/01/4933/drymouth-and-diabetes/

Teeth and Gums

Inspection

28 Adult teeth

ABNORMAL. This is due to tooth decay because of poor oral hygiene which the patient to undergo tooth extraction as management. ABNORMAL; with age, it is common place that the thickness of a tooths enamel becomes thinner, thus revealing more of the (darker) dentin that lies underneath. The color of a tooths dentin itself also tends to change with

Inspection Yellowish discoloration

time. Its color typically becomes darker as a tooths normal physiologic and reparative processes create more of it (secondary dentin). Reference: http://www.animated-teeth.com Tongue and floor of the mouth Inspection Centrally located with pink color and visible raised papillae (taste buds) Freely moves with no signs of tenderness Light pink and uvula positioned in midline of soft palate Pinkish Pink in color an having no discharge Grade 1 normal in size (behind tonsillar pillars) Presence of Gag Reflex NORMAL

Inspection

NORMAL

Palates and Uvula

Inspection

NORMAL

Oropharynx Tonsils

Inspection Inspection

NORMAL NORMAL

NORMAL

Gag Reflex

Inspection

NORMAL

Neck Neck Muscles

Inspection

Palpation Lymph nodes Trachea Palpation

Muscles are equal in size and head centrally located Not palpable Central placement along neckline with equal spaces on both sides Gland ascends during swallowing but not visible Lobes are not palpable

NORMAL

NORMAL NORMAL

Inspection Thyroid gland

NORMAL

Palpation

NORMAL

Thorax and Lungs Posterior Thorax Anterior Thorax Inspection

The client refused Increased respiratory rate of 35 breaths per minute ABNORMAL; The excess acids caused by absence of insulin increase hydrogen ion and carbon dioxide levels in the blood. These products trigger the respiratory control areas of the brain to increase the rate and depth of respirations in attempt to excrete more carbon dioxide and acid. Reference: Medical- Surgical Nursing 5th edition (2006) By: Ignatavicius and Workman p. 1658

Palpation

Full symmetric excursion: thumbs normally separate 3 to 5 cm

NORMAL

Auscultation

Bronchovesic NORMAL ular and vesicular breath sounds Apical pulsations are not visible S1 heard at all sites but usually louder at apical area S2 heard at all sites but prominently on the base NORMAL

Heart and Central Vessels Precordium and Heart

Inspection

Auscultation

NORMAL

NORMAL

Carotid Arteries

Palpation

NORMAL

Inspection Jugular Veins Peripheral Vascular system

Symmetric pulse volumes, full pulsations with thrusting quality (85 beats per minute) Veins not visible

NORMAL

 Peripheral pulses

Palpation

Scale 2: diminished pulse; cannot be obliterated for the radial pulse Scale 1 weak, thready and difficult to feel Posterior tibialis Popliteal

ABNORMAL: Peripheral circulatory disorders are frequent complications of diabetes. It is is characterized by significant impairment of blood circulation to the legs and feet, causing symptoms such as pain in the legs and feet during walking that is relieved with rest (intermittent claudication). Acute symptoms may include obstruction of blood vessels by pieces of atherosclerotic plaque (emboli) or by blood clots (thrombi), resulting in lack of blood flow to a limb and insufficient perfusion of tissue in the affected area. Reference: http://www.mdguidelines.com/d iabetes-with-peripheralcirculatory-disorders

Abdomen Skin and Contour

Inspection

Bowel Sounds

Auscultation

Unblemish ed skin; uniform in color and contour; rounded Bowel sounds is 10 per minute

NORMAL

NORMAL.

Musculoskeletal System Muscles

Inspection and Palpation

Muscle pain and tenderness

ABNORMAL; Hypoxic cells do not metabolize glucose efficiently, the Krebs cycle is blocked, and lactic acid increases, causing more acidosis. Muscle fatigue is thought to be cause by

depletion of glycogen and accumulation of lactic acid. Reference: Medical- Surgical Nursing 5th edition By: Ignatavicius and Workman p. 1501 Medical- Surgical Nursing 11th edition By: Brunner and Suddarths p. 2341 Bones Joints Inspection Inspection and Palpation No deformities Slight inflammation of kneecap with tenderness resulting to limited range of motion. Normal ABNORMAL: The concentration of blood glucose levels exceeds renal threshold which resulted to retention of waste products in the blood specifically blood uric acid. This causes irritation to the tissues of the joint thus producing pain. Blood uric acid= 716 umol/ L Reference: http://www.medicinenet.com

Lower Extremities

Palpation

Bipedal edema with an indentation of 6 mm (3+) and return to normal state for 17 seconds.

ABNORMAL; Pitting edema is a condition in which indentation in the skin remains after even slight compression with the fingertips. The oncotic pressure which holds the fluid inside the blood vessel was reduced due to the leakage of blood protein in the urine. Furthermore, hydrostatic pressure then increases due to the venous congestion on the peripheral vascular beds causing accumulation of fluid in

the underlying tissues between the skin pigmented and vascular layer which is called edema. Reference: Black, Joyce M. and Hawks, Jane H. Medical-Surgical Nursing: Clinical Management for Positive Outcomes. 7th ed. pp 1656. Neurologic System Inspection Level of Consciousness

Client is awake and eyes open upon assessment Client is oriented as time and place Patient can recall and convey short, immediate and long term memory events Client has no difficulty speaking and identifying objects Client has good eye contact

NORMAL

Orientation

Inspection

NORMAL

Memory

Inspection

NORMAL

Inspection Language Communication

NORMAL

NORMAL

Light- touch sensation

Palpation Client was

ABNORMAL: The elevation of blood glucose level causes

unable to feel light- touch sensation on the lower extremities

increased blood viscosity which leads to a sluggish blood flow. This resulted to poor tissue perfusion which alters the oxygen delivery and nourishment of cells leading to nerve damage then causing decreased sensation. Reference: http://www.medicinenet.com

Pain sensation

ABNORMAL: Client can feel Peripheral circulatory disorders are frequent complications of deep diabetes. It is is characterized sensations by significant impairment of only on the blood circulation to the legs lower and feet, causing symptoms extremities such as pain in the legs and feet during walking that is relieved with rest (intermittent claudication). Acute symptoms may include obstruction of blood vessels by pieces of atherosclerotic plaque (emboli) or by blood clots (thrombi), resulting in lack of blood flow to a limb and insufficient perfusion of tissue in the affected area. Reference: http://www.mdguidelines.com/d iabetes-with-peripheralcirculatory-disorders

Genitals and Inguinal Area Pubic hair and skin

Inspection

Thinner and straight; distributed in the shape of an inverse triangle Pubic skin

NORMAL

Vulva

Inspection

NORMAL

is intact and no lesions Labia Majora and Minora Inspection Skin of vulva area slightly darker Labia atrophied and flatter NORMAL

NORMAL

Palpation Inguinal Lymph nodes

ABNORMAL; Swelling of lymph Enlargeme nodes generally results from localized or systemic infection. nt and The lymph nodes in the groin tenderness (femoral or inguinal lymph nodes) may swell from an injury or infection in the foot, leg, groin, or genitals. Reference: http://www.buzzle.com

Rectum and Anus Anus

Inspection

Intact perineal skin; slightly more pigmented than the skin of buttocks

NORMAL

NARRATIVE SUMMARY: A complete and accurate physical examination requires a systematic approach utilizing the techniques of inspection, palpation, percussion, and auscultation. The entire procedure also necessitates a reliable environment conducive to an interview and assessment, as well as a trusting relationship between the patient and the examiner. These factors helps decrease the anxiety that the patient may be experiencing from being physically incompetent and ill. The examination is performed in a head to toe approach or cephalocaudal examination. A head to toe assessment was conducted to Mrs. AD last September 7, 2010 at 1 oclock in the afternoon. Upon inspection of the skin, excoriation on lower extremities were noted which could be associated with the itchiness felt by the patient due to increase accumulation of BUN in the blood. Dry skin is also manifested by the client due to increase blood

glucose level. Edema on both upper and lower extremities was present due to the collection of fluid in the tissue spaces as a further consequence of her decreased tissue perfusion related to renal failure. Meanwhile, upon palpation for skin turgor on patients clavicle, it was found out that the skin returns to previous state in 5 seconds which is a normal consequence of aging. On the other hand, there was paleness in the nailbeds of the fingers and the toes which is attributed to the decrease hemoglobin and hematocrit circulating in the extremities. For the capillary refill, the color of the nailbeds of the fingers returns in 4 seconds while no change in the pale color of the nailbeds of the toes were noted. When it comes to the patients eyes, milky-appearance on the left eye was noted while the palpebral conjunctiva was pale in color because of decrease hemoglobin concentration. In addition, the same findings were found in the lips and oral mucous membrane. There was also dryness in the patients lips. There was also presence of yellowish teeth and extraction of his 4 teeth can be related to the patients poor dental hygiene. However, in the assessment of her thorax, there was increased respiratory rate as a compensatory mechanism for the excessive accumulation of carbon dioxide levels within the blood. It was also noted that the patient has a somewhat diminished radial pulse which cannot be obliterated. While the posterior tibialis and popliteal pulses are weak, thready and difficult to feel. Diabetes leads to hypoperfusion (decreased circulation) of tissues, and poor tissue oxygenation (hypoxia). Continuous elevation of glucose levels causes blood to become viscous thus causing impaired tissue perfusion thus reflected on the pulses. Moreover, pulses are difficult to feel in the presence of edema. For the patients musculoskeletal system, there was muscle pain and tenderness which is caused by depletion of glycogen and accumulation of lactic acid. There was also limited range of motion in the joints because of pain in the affected joints. The concentration of blood glucose levels exceeds renal threshold which resulted to retention of waste products in the blood specifically blood uric acid. This causes irritation to the tissues of the joint thus producing pain. Furthermore, upon assessing light- touch sensation on the lower extremities it was noted that the patient was unable to feel it. The elevation of blood glucose level causes increased blood viscosity which leads to a sluggish blood flow. This resulted to poor tissue perfusion which alters the oxygen delivery and nourishment of cells leading
to nerve damage then causing decreased sensation. This same reason was associated to the assessment that the client can only feel deep sensations specifically pain.

Regarding assessment of the patients inguinal lymph nodes, there were presence of enlargement and tenderness from injury and infection.

Other findings apart from those mentioned above are within their normal range and conditions.