PHYSICAL ASSESSMENT AND REVIEW OF SYSTEMS

AREAS NIGHT 1 NIGHT 2 PROBLEM

ASSESSE IDENTIFIED
D

General o Subjective findings: Subjective findings: (Not

health (Not Applicable) applicable)
survey

Objective findings:
-Vital signs: Objective findings:
T: 35.6- 36.2 C -Vital signs
BP: 90/70-100/60 mmHg T: 35.8-36 C
PR: 87-114 bpm BP: 85/60- 100/60 mmHg
RR: 21-23 bpm PR: 98-100 bpm
O2sat: 95-- 96% RR: 21-22 bpm
GCS:7/15 O2sat: 92-98%
GCS: 7/15
o Venoclysis mainline on left
metacarpal vein PNSS 1 L
@10cc/hour via infusion o Venoclysis mainline on
pump left metacarpal vein PNSS
o With solution set Ceftriaxone 1 L @10cc/hour via
2mg IVTT infusion pump
o Side drip with Human albumin o With solution set
20% vial +20 mg Furosemide Ceftriaxone 2mg IVTT
o Side drip with Human
per vial to run for 2hrs q12hr
albumin 20% vial +20 mg
o
Furosemide per vial to run
Activity intolerance
for 2hrs q12hr
(+) Body weakness o Fatigue
(+) Weak appearance Impaired skin integrity
(+)Pale skin Fluid volume excess
(+) Body weakness
(+) Ascites
 (+) Jaundice
(+) Wt. loss
(+) Loss of appetite
(+) Blood in stool
Integument Subjective findings:
ary system
(Not Applicable)
Objective findings:
(+) Pale skin
(+) Pale nailbed
(+) Ascites
(+) Bruising on abdomen
Lab test:
Ultrasound-whole abdomen
Impression: Moderate ascites,
Liver cirrhosis
(+) Weak appearance Imbalanced Nutrition
(+) Ascites Disturbed body image
(+) Jaundice
(+) Wt loss
(+) Loss of appetite
(+)Blood in stool
Subjective findings:
(Not applicable)
Fatigue
Objective findings: Fluid volume excess
(+) Pale skin
(+) Pale nailbed
(+) Ascites
(+) Bruising on abdomen
Lab test:
Ultrasound-whole abdomen
Impression: Moderate ascites,
Liver cirrhosis
HEENT Subjective findings: Subjective findings:
a) Hea (Not Applicable) (Not applicable)
d
and Fatigue
face Objective findings:
Objective findings:
b) Eye (+) Weak in appearance
s (+) Weak in appearance Disturbed body image
c) Ear (+)Jaundice
s (+)Jaundice
d) Nos (+)Dry oral mucosa and lips
(+)Dry oral mucosa and lips
e
e) Ora
l Lab result:
Cav Lab result:
ity Total Bilirubin: 150.36 (1.7-
Total Bilirubin: 150.36 (1.7-2ul/L) 2ul/L)
B1 or Indirect: 95.40 (1.7-17.1) B1 or Indirect: 95.40 (1.7-17.1)
B2or direct: 54.96(0-3.4) B2or direct: 54.96(0-3.4)
Neck Subjective findings: Subjective findings: No problem Identified
(Not Applicable) (Not applicable)

Objective findings:
Objective findings:
(-) stillness (-)stillness
(-) lumps (-) lumps
(-) vein engorgement (-) vein engorgement

Respirator Subjective findings: Subjective findings:

y system
o Not applicable (Not applicable)
Ineffective airway
Objective findings: Objective findings: clearance
o RR: 21-23

o RR: 21-22 bpm Ineffective breathing

(+)fine crackles pattern
(+)fine crackles

Lab result:
Lab result:

Lab result:
Ultrasound-whole abdomen
Impression: Moderate ascites,
Liver cirrhosis
X-RAY of the chest
Impression: Crowding of the lower
lung parenchyma due to
diaphragmatic elevation
The included upper abdomen was
Lab result:
Ultrasound-whole abdomen
Impression: Moderate ascites,
Liver cirrhosis
X-RAY of the chest
Impression: Crowding of the
lower lung parenchyma due to
diaphragmatic elevation
The included upper abdomen
was opacified,likely ascites
 opacified,likely ascites
Cardiovasc Subjective findings:
ular system
(not applicable)
Objective findings:
PR: 87-114 bpm
RR: 21-23 bpm
(+)ascites
(+)Fluid retention
Lab result:
Ultrasound-whole abdomen
Impression: Moderate ascites,
Liver cirrhosis
X-RAY of the chest
Impression: Crowding of the lower
lung parenchyma due to
diaphragmatic elevation
The included upper abdomen was
opacified,likely ascites
Breast and Not assessed
Axilla
Gastrointes Subjective findings:
tinal
Not applicable
system and
the
abdomen
Subjective findings: Fluid volume excess
(not applicable)
Objective findings:
PR: 87-114 bpm
RR: 21-23 bpm
(+)ascites
(+)Fluid retention
Lab result:
Ultrasound-whole abdomen -
Impression: Moderate ascites,
Liver cirrhosis
X-RAY of the chest
Impression: Crowding of the
lower lung parenchyma due to
diaphragmatic elevation
The included upper abdomen
was opacified,likely ascites
Not assessed
Subjective findings:
(Not applicable)
Objective findings:
 Objective findings: (+)Anorexia Altered gastric motility
(+)Anorexia (+) Dyspepsia
(+) Dyspepsia (+)Change in bower habits Imbalanced Nutrition
(+)Change in bower habits (+) Dull abdominal pain
(+) Dull abdominal pain (+)Melena Acute pain
(+)Melena (+) Gastritis
(+) Gastritis Risk for bleeding
Lab result:
Lab result: Post endoscopy diagnosis:
Distal esophageal varices and
Post endoscopy diagnosis: Distal
Portal hypertensive
esophageal varices and Portal
gastropathy
hypertensive gastropathy

Genitourin Subjective findings: Subjective findings:

ary/
(Not Applicable)
Reproducti
ve system

Objective findings: Objective findings: Fluid volume excess

(+) tea colored urine
(+) tea colored urine Lab result: Risk for infection
Lab result: Urinalysis:
o Protein: +
Urinalysis: o Mucus:+4
o Protein: + o Bacteria:+2
o Mucus:+4 o Bilirubin: +1
o Bacteria:+2
o Bilirubin: +1

Musculosk Subjective findings: Subjective findings: Activity intolerance

eletal
(Not Applicable) (not applicable0
system
Objective findings: Fatigue
o Venoclysis mainline on
 Objective findings: left metacarpal vein 1L
PNSS @ 10 cc/hour via
o Venoclysis mainline on left infusion pump
metacarpal vein 1L PNSS @ o C solution set of
10 cc/hour via infusion pump ceftriaxone
o C solution set of ceftriaxone o Side drip with Human
 Side drip with Human
albumin 20% vial +20 mg
albumin 20% vial +20 mg
Furosemide per vial to run
Furosemide per vial to run
for 2hrs q12hr
for 2hrs q12hr
o
o (+)Body weakness
(+)Body weakness

Neurologic Subjective findings: Subjective findings:

system
(Not Applicable (Not applicable)

Objective findings:
No problem identified

o Coherent
Objective findings: o Conscious
o Conversant
o Coherent
o Conscious
o Conversant

Lymphatic/ Subjective findings: Subjective findings:

Hematologi
(Not Applicable)
c system

Objective findings:
o Anemia Objective findings: Risk for bleeding
o Thrombocytopenia
o Anemia Anemia
o Thrombocytopenia
 Lab result:
Lab result:
RBC: 3.42(4-6X10 12/L)
Hematocrit: 0.33 (0.37-0.57
Hemoglobin: 112 (110-180g/ RBC: 3.42(4-6X10 12/L)
Hematocrit: 0.33 (0.37-0.57
Hemoglobin: 112 (110-180g
PROTIME:20.2 seconds

Control:14.5 seconds

Activity: 67%

Endocrine Subjective findings: Subjective findings:

system
(Not Applicable)

Objective findings: Objective findings:

o Hypoalbuminemia o Hypoalbuminemia

Lab result: Lab result:

Albumin: 27.1 (35-41ul/L) Albumin: 27.1 (35-41ul/L)

HBA1C: Glycosylated haemoglobin HBA1C: Glycosylated

10.2(<7%)HGT: HEMOGLUCOTEST: haemoglobin 10.2(<7%)HGT:
134(70-110mg% HEMOGLUCOTEST: 134(70-
110mg%