REVIEW OF SYSTEM

Date Performed: January 8, 2015

System

Review of
System (ROS)

Ideal

A. Gener
al/
Overall
health

Masakit,
hindi ako
kumportable.
as verbalized
by the
patient.

- awake

B. Integu
mentar

Sobra
maglagas

- Varies from light

to deep brown,

Observed

- unable to stand
- weakness
- no body
- dry and scaly
weakness
skin.
- irritable
- client is alert
- discomfort
and oriented to
- slurred speech
what is happening - limited ROM
at the time of the
- pain scale of
interview and
8/10
physical
- anxiety
assessment.
- immobility
- facial grimace
- facial features
- yellowish, semi
are symmetric
scanty, foul
with movement.
smelling liquid
Client establishes coming out from
good eye contact the external fixator
when conversing
site
with others.
T 36.5 `C
- speech is clear, P 96bpm
moderately paced R 18 cpm
and culturally
BP 110/90
appropriate.

- dry and scaly

skin

Significance
Patient is unable
to stand
because of the
pain in her
fractured leg
with external
fixator. An
external fixator
acts as a
stabilizing frame
to hold the
broken bones in
proper position.
It is used as a
temporary
treatment for
fractures. There
may be some
inflammation or
less commonly,
infection
associated with
external fixators.
This is typically
managed with
wound care
and/or oral
antibiotics. The
patient has
slurred speech
because of the
Intermaxillary
Fixation (IMF)
on her jaw.
Hair loss due to
medications is

y
(Skin,
hair,
nails)

ang buhok
ko.,as
verbalized by
the patient.

from pink to light

pink

- pale

- No IVT

- no edema

- No rash

- slightly thick
colored hair

- skin is intact and

there are no
reddened areas.
- skin rebounds
and does not
remain indented
when pressure is
released.

- a scar or mark of
the previous
bedsore in the
clients back was
observed.

- scalp is clean
and dry. Hair is
smooth and firm.
- nails are clean
and manicured

C. Head

D. Eyes

Walang
masakit.
Okay
naman.as
verbalized by
the patient.
Malabo lang
ang mata ko.
370 ang right,
400 ang left.

- Normal in size

usually diffuse
and
nonscarring.
There are side
effects of some
medicines that
cause hair loss
by interfering
with the normal
cycle of hair
growth.
A pressure sore
is any redness
or break in the
skin caused by
too much
pressure on the
skin for too long
period of time. It
prevents blood
from getting to
the skin. A
bedsore is
usually caused
by lack of
ambulation or
not changing
position for a
long time
causing the skin
to get heated.

- Normocephalic

-No tenderness
upon palpation

-Evenly placed &

in line

-Cornea and iris

are intact

- White sclera

-Sclera is white

Myopia is a
vision condition
which close
objects are seen

Malabo ang
paningin ko
kapag
malayo as
verbalized by
patient.

E. Ears

Okay
naman. as
verbalized by
patient.

- Conjunctiva is
pink

-Conjunctiva is
pink

- 20/20 vision on
both eyes

-400/370 vision on
both eyes

- no presence of
discharges
- normal hearing
sounds
- Normal skin
color
- no pain or
tenderness

F. Nose
&
Sinuse
s

Okay lang.
Hindi naman
ako sinipon
kahit malamig
dito. as
verbalized by
patient.

- Client is able to
sniff through each
nostril while other
is occluded.
- colour is the
same as the rest
of the face
- nasal structure
is smooth and
symmetric
- no tenderness
- Nasal septum is

- pupils
responsive to light
(PERRLA)
- no discharges
- auricled are
smooth and
symmetrical
-skin color is the
same as the
complexion
- normal hearing
sounds
- no pain or
tenderness
-no discharge

clearly but
objects farther
away appears
blurred. Can be
corrected
through gradedeyeglasses.

G. Mouth
&
Throat

H. Neck

I. Respir
atory

Hindi
kumportable
kasi may
bakal sa
ngipin ko.
Masakit
kapag
nginanganga.
as
verbalized by
the patient.

Okay
naman.
Walang
masakit. as
verbalized by
patient

Okay
naman.
Nakakahinga
ako ng
maayos as
verbalized by
the patient

intact with no
ulcers or
perforations.
- normal colour
- no bleeding
- no retraction of
gums

- Pinkish gums
with no signs of
bleeding
- no bleeding
- with elastic
Intermaxillary
Fixation (IMF)

-no tenderness
when palpation
- firm with soft
rounded surface

- firm with soft

rounded surface

- a small scar in
the middle area
from the
- no mass or lump tracheostomy
procedure.
- no signs of
- RR of 18cpm
respiratory
distress
- no crackles, no
wheezing
- no cough
- no presence of
- no abnormal
nasal discharge
breath sounds
- No fremitus felt
- the client does
on right middle
not use accessory lobe of the lung
(trapezius/should
er) muscles to
assist breathing.

Intermaxillary
fixation is a
technique used
to stabilize a
fractured jaw by
applying an
elastic bands or
stainless steel
wire between
maxillary and
mandibular arch
bars or other
types of splints.
T he teeth are
wired or banded
together.
When the
tracheostomy
tube is removed,
the wound left
should heal over
within 1-2 weeks
leaving a small
minimal scar.
The fall (from
the 4th floor of
the building)
resulted to
segmental
atelectasis on
the right middle
lobe, which
defined as the
decrease in the
volume of the
lung due to the
impediment of
the small or

- Fremitus is
symmetric and
easily identified in
the upper regions
of the lungs.
- Respirations are
relaxed,
effortless, and
quiet.

J. Gastroi Nahihirapan
ntestin ako kumain
al
kapag
matigas.Hindi
naman ako
ganito
kapayat dati.
as verbalized
by the
patient.

- no lesions

- no lesions

- no signs of
gastrointestinal
dysfunction

- no
gastrointestinal
dysfunction

- abdomen is
nontender and
soft. There is no
guarding.

- patient cannot
eat solid food

- bowel sounds 520 per minute

-umbilicus and
surrounding area
are free of
swellings, bulges
or masses.

- low appetite

subsegmental
bronchus. The
condition
appears as
linear opacity in
a chest
radiograph.
People suffering
from respiratory
tract infection,
hypoventilation,
and pulmonary
embolism are
generally
affected with
subsegmental
atelactasis.
The patient has
low appetite due
to the
Intermaxillary
Fixation (IMF)
on her jaw and
teeth. These
fixators are
usually made of
elastic or
stainless steel
wires which
cause difficulty
of chewing solid
foods.
Nutritional
status can be
affected by
disease or injury
states, physical
factors, social
factors and
psychological
factors. During

K. Muscul
oskelet
al

Pag tinataas
yung right leg
ko
masakit.Sobr
ang sakit
niya. as
verbalized by
the patient.

Gait
- Client able to
stand on heels
and toes.
- Toes point
straight ahead.
Equal on both
sides.
- Posture erect,
movements
coordinated and
rhythmic, arms
swing in
opposition,stride
length
appropriate.
TMJ
- jaw moves
laterally 1 to 2
cm. Snapping and
clicking may be
felt and heard.
- mouth open 1 to
2 inches
- jaw protrudes
and retracts
easily. The clients
mouth opens and
closes smoothly.
Shoulders, Arms
and Elbows
- symmetrically
round, no

- client unable to
stand on her heels
and toes because
of her fractured
leg
- external fixators
on right arm and
leg
- presence of
yellowish
discharge
- tenderness on
the area where
external fixators
are inserted. (pin
site)
-decreased ROM
on right leg
Muscle grading:
(Left)
Biceps 1
Triceps 4
Hands 2
Quadriceps 1
Achilles tendons 2
(Right / with
external fixators
on the arm and
leg)

times of illness,
adequate
nutrition plays
an important
role in healing
and recovery.
Severe fractures
are treated with
surgery to
realign and fix
broken bones.
Surgeons can
fix bones with
wires, plates,
screws or rods,
using a
procedure
known as open
reduction and
internal fixation.
In some cases,
an external
frame or fixator
is attached to
the broken
bones with
metal pins to
help keep them
in place. This is
removed once
the fracture has
healed.
The most
common and
even expected
problem with
external fixation
treatment is pin
site infection.
Pin site infection
begins

redness, swelling
or deformity or
heat.
- muscles are fully
developed.
- The client
reports no
tenderness
Hands and
Fingers
-symmetric, non
tender, and
without nodules.
-Fingers lie in
straight line.
- No swelling or
deformities.
- The client
normally has full
ROM against
resistance.
Hips
- Buttocks are
equally sized.
- Hips are stable;
non tender and
without crepitus.
-Full ROM against
resistance
Knees
- Symmetric;
hollows present
on both sides of
the patella, no
swelling or
deformities.
- Non tender and

Biceps 1
Triceps 5
Hands 4
Quadriceps 1
Achilles tendons 5
- (+) toe flexion

superficially and
if left untreated
will progress to
the deeper soft
tissues and
eventually to the
bone. The first
sign of pin site
infection is
usually redness
with tenderness
around the pin
in an area that
was previously
not tender. The
other common
sign of infection
is drainage from
the pin site.
Clear yellow
drainage may
be due to
infection or
swelling or both.
Fever and a
sense of not
feeling well are
later signs of
infection and
usually do not
occur.
After a fracture,
the patient is
expected to
have restricted
movement of
the injured area.
This will be
necessary until
healing is

cool. Muscles
firm. No nodules.
- No bulge of fluid
appears on
medial side of
knee.
- No pain or
clicking noted.

L. Neurol
ogic

Malungkot
ako. Ayoko
magtagal dito
sa ospital. as
verbalized by
the patient.

Cranial Nerves
CN I: client
correctly identifies
scent presented
to each nostril
CN II: 20/20
vision on both
eyes. Reads print
at 14 inches
without difficulty.
CN III: Eyes
move in a
smooth,
coordinated
motion in all
directions
CN V: The client
correctly identifies
sharp and dull
stimuli and light
touch to the
forehead, cheeks
and chin.
CN VII: Client
smiles, frowns,
wrinkles
forehead, shows
teeth, puff out

complete. When
fracture is
healed, the
patient may be
able to return to
normal
movement. But
immobilizing a
part of the body
for a long time
can cause a
loss of muscle
strength.
- Cranial nerves
Some patients
are intact.
find comfort
after leaving the
- awake and
operating room.
responsive
Even as they
recover
- Client has
physically, their
400/370 vision
mental health
and is
suffers as they
nearsighted.
experience
sadness, fatigue
- able to identify
or anxiety -all of
sensations felt
which are
symptoms of
- biceps, triceps,
post-op
achilles and
depression, a
brachioradialis 2+ commonly
experienced but
little known
- slight discomfort condition.
Symptoms of
post-op
- (-) eye contact
depression vary
- use of non verbal with each
reply
person but
common ones
- guarding
include changes
in appetite and

cheeks, purses
lips, raises
eyebrows, and
closes eyes
against
resistance.
Movements are
symmetrical.
Client identifies
correct flavour.
CN VIII: Client
hears whispered
words from 1 to 2
feet.
CN IX & X: Uvula
and soft palate
rise bilaterally and
symmetrically on
phonation.
Gag reflex intact.
Client swallows
without difficulty.
No hoarseness
noted.
CN XI:
Symmetric, strong
contraction of the
trapezius
muscles.
CN XII: Tongue
movement is
symmetric and
smooth and
bilateral strength
is apparent.
- coherent
- client names
familiar objects

energy levels,
shifts mood
such as apathy
or irritability,
feelings of
hopelessness
and despair.
Normally this
crisis may last
up to 3 to 6
months only.

without difficulty.
- client expresses
full, free-flowing
thoughts; follows
directions
accurately;
expresses
realistic
perceptions; is
easy to
understand and
makes sense;
does not voice
suicidal thoughts.
- client is aware of
self, others, time,
home address
and current
location.
- recalls recent
events without
difficulty.

M. Gynec
ologic

Dahil sa
nangyari
sakin
syempre
hindi kami
nakakapagsex ng asawa
ko
as verbalized
by the
patient.

- recalls past
events
- No masses
should be
palpated on both
breasts

- LMP is last
December 3, 2015

- Round and
pendulous. One
breast normally
larger than the
other.

- Last sexual
intercourse was a
year ago.

- no rash or
infection noted

- Menarche at 13
years old.

- No mass,
tenderness or
rash on the breast

was noted.
- no tenderness