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PHYSICAL ASSESSMENT

The assessment to Ms. Haji Maymona Jaire was conducted last


February 21, 2009, Saturday at 1:00 pm in Intensive Care Unit, cubicle 14 of
San Pedro Hospital, Davao City.

I- General Surveys
Received lying on bed, asleep; responsive to speech stimulation; not in
respiratory distress. With symmetrical lung expansion. With IVF of PNSS 1
liter + 60 meqs KCl @ 80cc/ hour, infusing well at left cephalic vein at 800 cc
level. With side drip in soluset of PNSS 90cc + 10cc of dopamine @ 20cc/
hour at 70 cc level. With NGT @ right nostril for feeding and medication
purposes, closed distal end. Attached to mechanical ventilator with the set
up of RR= 14, Tidal Volume= 475, Mode= assist control, FiO2= 60%. With
endotrachel tube at right side at 22 level. Attached to cardiac monitor with
sinus rhythm. With foley catheter fr. 14 draining to urobag with yellowish
urine at 380 cc urine output. Her body built is endomorphic and looked
according to her age. Hygiene was well maintained and grooming was good.
No body odor was noted. Distress noted on her facial expression.

II- Vital Signs


Upon taking his vital signs, Ms. Jaire has an axillary temperature of
37oC (35.6-37.4oC), a pulse rate of 84 bpm, a cardiac rate of 90 bpm (70-90
bpm), a respiratory rate of 15 cpm (20-25 cpm), and a blood pressure of
140/90 mmHg (110/70-130/90).

III- Skin
He has a light brown-toned skin and uniformed skin color to those
exposed to the sun and there are no signs of edema and/or lesions noted.
Skin was warm to touch and has good skin turgor with a good capillary
circulation of 3-4 seconds. Dry skin not noted. Scars were noted on the lower
extremities.

IV- Head
Head is rounded and normocephalic and symmetrical to the body
parts. Has a smooth skull contour. He has evenly distributed hair. With
dressing on left frontal side, dry and intact. No presence of infection or
lesions noted upon palpation. No nodules or masses noted. His facial
movements a symmetric as evidenced by elevating and lowering the
eyebrows, closing of the eyes tightly. No dandruffs noted on his scalp.

VI. Eyes
Eyebrows symmetrically aligned; equal in movement. Hair is evenly
distributed and skin intact. Have equally distributed and normal curl of
eyelashes. Eyelids close symmetrically, with normal blinking. When lids open,
no visible sclera above cornea and upper and lower borders of cornea are
slightly covered.
Has normal symmetry of the eye. Pupils are black in color, equal in
size, with 3 mm in diameter and reacts to any stimuli. Pupils equally round
and briskly reacting to light. Iris is flat and round. No tenderness or edema on
the lacrimal duct upon palpation. Both eyes move coordinate and in unison
with parallel alignment.

VII. Ears
Both pinna are same in color as facial skin and aligned with outer
canthus of eye upon inspection. Pinna are mobile, firm and non tender upon
palpation. Pinna recoils after it is folded. Presence of discharges was not
observed on external canal. Pinna is also free from lesions, swelling, and
masses. Hearing acuity is well. He was able to hear normal voice tones and
whispering on both ears.
VIII. Nose
Nose is symmetric and straight with no presence of discharges,
swelling, and flaring upon inspection and with uniform color. It is also non
tender and with no lesions upon palpation. Air moves freely as the client
breathes through the nares. Mucosa is pink, with clear watery discharge and
no lesions. Nasal septum is intact and in midline upon inspection. Maxillary
and frontal sinuses are not tender upon palpation.

IX. Mouth
Lips and buccal mucosa are uniformly pink in color. It was also soft,
moist and smooth in texture. The tongue is midline and pink in color. It is
also moist with thin whitish coating upon inspection. The base of the tongue
is smooth with prominent veins. Palate is soft, smooth and lighter pink in
color. Hard palate is lighter pink and has a regular texture than the soft
palate. Gag reflex is present.

X. Neck
No lymph nodes upon palpation. There is symmetry of posterior and
anterior portions of neck. Lesions were not noted. Thyroid gland is not
palpable. Neck muscles are equal in size and head is centered. Head
movement is coordinated and smooth movements were done with no
discomfort. Can flex head 45 degrees and can move chin to the chest. The
head can hyperextend up to 60 degrees and can move it backwards. Head
flexes laterally 40 degrees, and can rotate 70 degrees. Head has equal
strength. Shoulders have no equal strength; in the right side is weak while
in the left side is strong. The trachea is in central placement in midline of
the neck upon palpation.
XI. Breast and Axilla
His breasts are both symmetrical in shape and size and even with the
chest wall. Skin smooth and intact and in uniform color. His areola is round
and light brown in color with irregular replacement of sebaceous glands on
the surface upon inspection with no discharges noted and no masses were
noted upon palpation. The nipples are round, everted and equal in size,
similar in color, soft, smooth and both points in the same direction. No
discharges were noted. No tenderness or masses noted upon palpation.

XII. Chest and Lungs


Chest is symmetric and spine was vertically aligned with straight spinal
column. Skin is intact with uniform temperature upon palpation. The
posterior chest has a full and symmetric chest expansion. He has a bilateral
symmetry of vocal fremitus. Fremitus is heard most clearly at the apex of the
heart. Vesicular and bronchovesicular breath sound were heard upon
auscultation. Anterior thorax is quiet and rhythmic and effortless to
respirations. Has a full symmetric lung excursion upon palpation. With
nitroglycewrin patch noted at left side of the chest.

XIII. Heart
He has a regular cardiac rhythm. Point of maximal impulse was
auscultated at the left intercostal space, left midclavicular line. His apical,
aortic, pulmonic and tricuspid pulses are clearly audible. Carotid arteries has
symmetric pulse volume and no bruit was heard upon auscultation. Jugular
veins were not visible upon inspection.

XIV. Abdomen

Abdomen is unblemish and has a uniform skin color. No striae noted.


No dilated veins visible. Abdomen is soft, round and not distended. Bowel
sounds is normal.
XV. Genito-Urinary
Genitals are free from lesions and warts. She is with clean diaper. Pubic
hair is free from dandruff and lice. No abnormalities were noted.

XVI. Extremities

There is symmetry on both arms and legs in size and are appropriate
for body proportion. Also have symmetrical and strong pulses. Muscle
strength is not equal on both hands. The right hand and foot is weak while in
the left hand and foot is strong. Fingers and toes are complete. Fingernails
and toenails are properly trimmed.

XVII. Neurological Assessment


The client’s neurological function is RLS score of 1-2 and GCS score of
11.

Cranial Nerve Assessment:

Cranial Nerve I: Olfactory


Not applicable. Patient cannot talk because she is intubated.
Cranial Nerve II: Optic
She can see us even in the distance of 5 meters.
Cranial Nerve III: Oculomotor
Extraocular eye movement was good because when we ask her to
follow the procedure, she has a good result. The pupil constricts upon the
introduction of light and has a diameter of 3 mm.
Cranial Nerve IV: Trochlear
She can move the eyeball downward and laterally.

Cranial Nerve V: Trigeminal


She elicit blink reflex upon light touch to the lateral sclera. She can feel
sensation on the skin of face while she closes his eyes.
Cranial NerveVI: Abducens
She can move his eyeball laterally and be able to see his periphery.
Cranial Nerve VII: Facial
Facial expression like smiling, raising eyebrows, frowning and closing
the eyes tightly were well done. Where not able to assess identifying various
tastes because she is intubated.
Cranial Nerve VIII: Auditory
She was able to hear spoken words and whispers while her eyes were
closed.
Cranial Nerve IX: Glossophayngeal
She cannot move tongue side to side and up and down.
Cranial Nerve X: Vagus
We cannot assess the swallowing capacity of the patient because she
is intubated.
Cranial Nerve XI: Accessory
He can do head movement and can shrug his shoulders against
resistance of hands in the left side only.
Cranial Nerve XII: Hypoglossal
Not applicable. Patient cannot talk because she is intubated.

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