V.

Physical assessment

FINDINGS NORMS INTERPRETATION

Vital signs

o Temperature 38.8°C 35.9 – 37.0 °C Increased temp. Patient’s

skin is warm to touch

o PR 140bpm 60-100 bpm Increase cardiac rate

because the patient is
experiencing pain

o RR 24bpm 12-20 breaths/min Increased respiratory

rate, the patient is
experiencing labored
breathing.

o Blood Pressure 170/1000mmHg Systolic: 100-120 mmHg Elevated blood pressure

Diastolic: 60-80 mmHg

General Survey

a. Body built, height Body is proportionate. Proportionate, varies with No deviation from
and weight lifestyle. Normal

b. Overall hygiene Clean and neat Clean and neat. No deviation from
and grooming Normal

d. Body and breath Body and breath odor is No body and breath odor. No deviation from
odor absent. Normal

e. Signs of distress STRESS No distress noted. It is quite normal to have

emotional reactions.
These reactions can
include fear, anxiety and
worry about what the
pain means, how long it
will last and how much it
will interfere with
activities of daily living.

f. Obvious signs of The client is not healthy Healthy appearance. The client experiences
health or illness in appearance. body weakness on is left
side.

g. Client’s attitude Cooperative Cooperative. No deviation from

 Normal

h. Clients mood and Response is not Appropriate to situation. Appropriateness of the

appropriateness of appropriate to situation. response is affected due
response to altered mental status.

i. Quantity and quality Speech is quite Understandable, moderate No deviation from

of speech and understandable, has pace and exhibits thought Normal
organization moderate pace. association.

j. Relevance and The client is not oriented Logical sequence makes The client’s cerebral
organization of to time, place and sense and has sense of function is damaged.
thoughts person. reality.

HEAD TO TOE EXAMINATION

INTEGUMENTARY

Skin

a. Skin color Has fair skin tone. Varies from light to deep No deviation from
brown, from ruddy pink to light Normal
pink, from yellow overtones to
white.

b. Uniformity of skin Skin color is uniform The skin color is generally No deviation from
color uniform except in areas Normal
expose to the sun. Areas of
lighter pigmentation in dark-
skinned people.

c. Assess edema No presence of skin No skin edema. No deviation from

edema. Normal

d. Lesions No visible mole. Freckles, birth marks, some No deviation from

flat and raised mole. Normal

e. Skin temperature Skin temperature is Skin temperature is uniform in No deviation from

uniform. all areas, and is within normal Normal
range.

Nails

a. Fingernail plate Convex curvature Convex curvature, angle of No deviation from

nail plate is about 160º. Normal

b. Fingernail bed Nails are pink, highly The nails are pink in light- No deviation from
color vascular and pink. skinned clients, brown or black Normal
in dark-skinned clients. The
nails are highly vascular and
 pink.

c. Fingernail bed Texture is smooth Smooth texture. No deviation from

texture Normal

HEAD

Skull

a. Skull size, shape Normocephalic, The skull is rounded No deviation from

or symmetry symmetrical, with no (normocephalic and Normal
deformities. symmetrical, with frontal,
parietal and occipital
prominences), smooth skull
contour.

Hair

d. Hair growth Black, evenly distributed Evenly distributed hair, thick, No deviation from
hair, thick silky resilient hair. Normal

Face

f. Facial features It is oval, Facial features Facial features are symmetric No deviation from
are symmetric, or slightly asymmetric. Normal

g. Symmetry of facial Symmetric facial Symmetric facial movements. No deviation from

movements movements. Normal

Inspect for the skin. Brown in complexion Same color of the face.
withdry skin.

EYES

Eyebrows

Inspect for hair Thick, black, coarse Evenly distributed NORMAL

distribution, which are evenly
alignment, skin, and distributed, Symmetrically aligned
quality and
Symmetrically aligned Equal movement
movement.
Equal movement

Eyelashes

Inspect for hair Thin, outward direction of Equally distributed NORMAL

distribution and growth, no matting.
direction of curl. Curl slightly outward

Eyelids
Inspect for the No edema or Skin intact; no discharged and NORMAL
surface abnormalities of the lids. discoloration; lids close
characteristics, symmetrically; bilateral
position in relation to blinking; approximately 15- 20
the cornea, ability to blinks per minute; when lids
blink and frequency open, no visible sclera above
of blinking. corneas and upper and lower
borders of cornea are slightly
covered.

Conjunctiva

Inspect the palpebral no lesions, nodules or pink and shiny NORMAL

conjunctiva (lining the swelling.
eyelids) for color, smooth
texture and presence no lesions
of lesions.

Sclera

Inspect of color and White sclera and no White in color and clear. NORMAL
clarity. evidence of nerves.

Cornea

Inspect for clarity and Transparent with no Transparent, NORMAL

texture. scars, abrasions, and
ulcers. Smooth and shiny, details of
iris are visible; in older people;
a thin grayish white ring
around the margin may be
evident.

Iris

Inspect for shape and Round and brown in Round and brown in color. NORMAL
color. color, flat, and regular
contour.

Pupils

Inspect for color, Black in color, equal in brown or black NORMAL

shape, and symmetry size, round. 2-3 mm in
of size. diameter. round

EARS

Auricles
Inspect for color, Color same as the face. Color same as the face. NORMAL
symmetry and
position. Auricle is aligned with Auricle is aligned with outer
outer cantus of the eye. canthus of the eye, about 10
degrees from vertical.

External Ear

Inspect ear canal for No lesions Contains hair follicles and NORMAL
cerumen, skin lesions glands, dry cerumen, grayish-
and areas for tan color; sticky wet cerumen
tenderness. in various shades of brown. No
lesions and tenderness.

NOSE

Inspect for any Symmetric and straight, Symmetric NORMAL

deviations in shape, with no discharged of
size, or color and flaring, uniform in color. Uniform as the face color
flaring or discharge
Bony projection found. No discharge
from nares.
No tenderness

No mass or bony projections

Inspect the nasal Intact nasal septum. Intact and in midline NORMAL
septum between
nasal chambers.

MOUTH

Lips

Inspect for symmetry Symmetrical, dark in Symmetrical, Pinkish, Smooth.

of contour, color and color and with dry
texture. texture.

Musculoskeletal

Inspect the muscle The body is symmetric. The muscles on the body NORMAL
size. Compare the should be symmetrical.
muscles on one side
of the body to the
same muscle on the
other arm.

Inspect the muscles No fasciculation or There should be no tremors. NORMAL

for fasciculation and
tremors. Inspect any tremors.
tremors of the hands
and arms out in front
of the body.

Bones

Inspect skeleton for No deformities There should be no NORMAL

normal structure and deformities.
deformities.

Joints

Inspect the joint for No swelling There should be no swellings NORMAL

swelling. of the joints.

VI. Laboratory and Diagnostic Examination results

INTERPRETATION
DATE PROCEDURE NORMS RESULT
AND ANALYSIS

July 10, 2010 Ph 8.0

WBC 4.00-10.00 14.01 High white blood cell

count. It may indicate
Neutrophil 50.0-70.0 % 81.8 % that the patient is
experiencing an
Lymphocytes 20.0-40.0 % 11.5 %
infection.
Basophils 0.1-1.0 % 0.2 %

Monocytes 3.0-8.0 % 5.6 %

Eosinophils 0.5-5.0 % 0.9 %

VII. Medications
 DOSAGE
GENERIC/
/ CLASSIFI- CONTRA- SIDE NURSING
TRADE INDICATION
FREQUE CATION INDICATION EFFECTS RESPONSIBILITY
NAME
NCY
Metformin 50mg 1 Anti Management hypersensitivity, diarrhea, Assess for
tab OD diabetic of type 2 metabolic nausea, patient's history of
diabetes acidosis, unpleasant diabetes
mellitus; may dehydration, metallic
be used with sepsis, renal taste. Monitor for
diet, insulin, dysfunction, patient's blood
or hepatic glucose before
sulfonylurea impairment. and after giving
hypoglycemi medications
a. Assess for
hypersensitivity to
Metformin

Assess for
patient's renal
function

Monitor for signs

and symptoms of
hypoglycemic
reactions (e.g. cold
and clammy skin)

Discontinue if
renal impairment
occurs

Instruct patient to
do proper foot care

instruct patient for

unpleasant
metallic taste of
the drug

Lanoxin 0.5mg Inotropics Inhibits Contraindicated Fatigue, Drug-induced

1tab OD sodium in patients muscle arrhythmias may
potassium hypersensitive weakness, increase the
to the drug.
activated dizziness, severity of heart
ATP, Intermittent hallucination failure and
promoting complete heart s, vertigo, hypotension.
movement of block or 2nd- malaise
calcium from degree Before giving
extracellular atrioventricular loading dose,
to block, obtain baseline
especially if data (heart rate
intracellular
there is a and rhythm, BP,
cytoplasm history of
and and electrolytes)
Stokes-Adams
strengthenin attack. Before giving drug,
g myocardial Arrhythmias
take apical-radial
contraction caused by