MEDICAL MANAGEMENT I.

Laboratory Test Urinalysis(urine cns) CBC X-RAY All laboratory tests were ordered by the physician to identify any abnormal values that may indicate that a certain illness or infection is present.

08/5/11

II. Medications Rifampicin Isoniazid Pyrazinamide Multivitamins The drug was administered to the patient prior to the infection seen on the results from her laboratory exam Vitamins was administer to the patient prior to malnutrition

8/8/11- until present

Nursing Assessment: Area Assessed Technique Normal Findings Actual Findings Evaluation

Skin Color Inspection Vary According to race Theres no skin lesion or any abnormal discolorations to be found Light colors to be seen on palms, soles, nail beds and lips Normally dry Warm to touch Smooth, soft to touch (palm and soles are thick) Skin immediately going back to normal Normal

Lips, Nails Beds, Soles and palm

Inspection

Moisture Temperature Texture

Inspection/ palpation Palpation Palpation

Light colors to be seen on palms, soles, nail beds and lips Normally dry Warm to touch Smooth, soft to touch (palm and soles are thick) Skin immediately going back to normal

Normal

Normal Normal Normal

Tugor

Palpation

Normal

Nails Nails Inspection Transparent , smooth and convex cut and clean Light pink in color Firm White color of nail bed under pressure should return to pink within 2-3 seconds Transparent , smooth and convex cut and clean Light pink in color Firm Returns immediately Normal

Nail beds Nail Base Capillary Refill

Inspection Inspection Inspection/ Palpation

Normal Normal Normal

Hair Distribution Color Texture Inspection Inspection Inspect/ Palpate Evenly distributed Vary according to race Smooth Evenly distributed Normal Black Smooth Normal Normal Normal

Eyes Eyes Visual activity Inspection Inspection (penlight) Parallel to each other Pupils equally round, react to light and accommodate Symmetrical in size, extension, hair texture and even movement Distribute evenly and curved outward Same color as the skin Transparent with light pink color Color White Transparent, shiny Black, Constrict briskly Clearly Visible Crossed eye Pupils equally round, react to light and accommodate Symmetrical in size, extension, hair texture and even movement Distribute evenly and curved outward Same color as the skin Transparent with light pink color Color White Transparent, shiny Black, Constrict briskly Slightly blurred vision Abnormal Normal

Eyebrows

Inspection

Normal

Eyelashes

Inspection

Normal

Eyelids Conjunctiva Sclera Cornea Pupils Iris

Inspection Inspection Inspection Inspection Inspection(penlight) Inspection

Normal Normal Normal Normal Normal Abnormal

Ears Ear canal opening Inspection Free from lesions, discharge of inflammation Canal walls pink Free from lesions, discharge of inflammation Canal walls pink Normal

Nose Shape, Size and skin color Inspection Smooth, symmetric with same color as the face Oval, symmetric and without discharge Smooth, symmetric with same color as the face Oval, symmetric and without discharge Normal

Nares

Inspection

Normal

Mouth and Pharynx Lips Buccal mucosa Gums Inspection Inspection Inspection Pink, moist symmetric Glistening pink soft moist Slightly pink color, moist and tightly fit against each tooth Moist, Slightly rough on dorsal surface medium or dull red Firmly set shiny Hard palatedome- shaped soft palate- light pink Neck is slightly hyper extended, without masses or asymmetry Neck moves freely without discomfort Rises freely with swallowing Midline Clear breath sounds Skin same color with the whole body; asymmetrical Pink, moist symmetric Glistening pink soft moist Slightly pink color, moist and tightly fit against each tooth Moist, Slightly rough on dorsal surface medium or dull red Normal teeth for a 2 year child Hard palatedome- shaped soft palate- light pink Neck is slightly hyper extended, without masses or asymmetry Neck moves freely without discomfort Rises freely with swallowing Midline Crackling sounds Same color skin Normal Normal Normal

Tongue

Inspection

Normal

Teeth Hard and Soft palate Symmetry of neck muscles, alignment of trachea Neck Rom

Inspection Inspection

Normal Normal

Inspection

Normal

Inspection

Normal

Thyroid gland Trachea Thorax and Lungs Abdomen

Palpation Inspection Auscultation Inspection/ Palpation

Normal Normal abnormal Normal

Asymmetrical

Neurology System Level of consciousness Behavior and appearance Inspection Inspection Fully conscious, response quickly Makes eye contact with examiner, hyper active expresses feelings with response to the situation. Fully conscious, response quickly Mild weakness Normal Abnormal