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Physical Assessment NAME: patient 2b Age: 35 years old Weight: 75 kgs.

Height: 61 Date of assessment: September 5, 2011 c/c: Lacerated wound and swelling of lower extremities AP: Dr. Castillo and Dr.Yap Dr. Rafael Dr. Sulit General assessment/ survey: Patient E is a 34 years old who is conscious, coherent and responsive to verbal communication and stimuli; supine position. Appearance was appropriate to developmental age. He was not able to take a bath for 1 week and fairly not well groomed. Skin is febrile, dry lips. Vital signs as follows: Time Date Temperature Pulse rate Respiratory rate Blood pressure 8 am 9-5-11 37.9C 82bpm 25cpm 90/70mmHg 37.8C 88bpm 22cpm 110/80mmHg 12nn room #: 2B 214 case #: 103211

Review of systems: Integumentary: Patient has no history of any ski allergies. Presence of sutures at right frontal and lower area. Presence of fine hair noted. With skin turgors back normally less than 2 seconds. Skin is warm to touch and brown and color. I. Skull Patient has no history any surgery in head . Patient skull is round with head circumstance of 21 inches. The fontanels are intact and closed upon inspection, no alopecia observed. Complains of mild pain upon palpation. Hair Patient E does not have any hair abnormalities. The patient hair is black in color, short and not well combed; dry in appearance. Hair is evenly distributed to the whole scalp. No excess of hair growth on the other body parts. Dandruff is noted and no lice. Scalp is free from lice at all area; dandruff are present. II. Face The patient E face is symmetrical with no involuntary facial muscle observed. Facial scars noted at lower chin. Sutures 2-3 cm at the right frontal area. Eyes Patient E has no history of any eye surgery and infections. The globes, palpebral fissure and lid margin has no masses and swelling. Eyebrows and eyelashes are symmetrical and evenly well distributed and no lice. The sclera is clear and the pupil are equally round and reactive to light and accommodation. Positive in blinking reflex. Patient conjunctiva is moist and pink in color, with no ulceration noted. No foreign objects noted and (-) for any discharges. Ears Patient E doesnt have any ear problem recurrent infection. Patient ears are symmetrical and equal in size aligned with the outer cantus of the eye. Patient E ears are intact with no lesions noted (-) ear canal discharges. Mobile, firm and non tender noted. Patient hearing test is good using whisper test. Nose Patient x doesnt have any history of nasal bleeding. Patient nose is not deviated. Nasal septum is intact or not deviated to the right and left; (-) nasal discharges. Patient is able to smell.

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Mouth and lips Symmetrical in structure. The patient mouth is intact, with no lips discoloration, ulceration, (-) of foreign objects. Teeth are yellowish to brown in yellow in color. Tongue Patient tongue is pink in color, and it can move freely to any direction with pain. Intact (-) ulcerations noted. (+) gag reflex. Patient has good appetite; and able to differentiate taste. Uvula and tonsils Patient x uvula is in the midline. Pink in color and moistened. It vibrates upon saying the word AH (+) gag reflex with (-) of swelling and inflammation.Patient tonsils are g-1, no pain in swallowing. No lesions and extra muscle noted. Neck Patient E trachea is in the midline. No difficulty movement upward and downward.Able to rotate 180 degree range of motion. Lymph node is on palpable. No difficulty of swallowing and it can move freely with pain. Anterior thoracic cavity Patient E ribs not visible with (-) of chest drawing. Chest is symmetrical. No extra hair growth noted.Skin is brown in color and intact. No crackles heard at left and right lobes. Apical pulse of 93 bpm, with chest circumference of 38 inches. Posterior thoracic cavity Patient E spine is vertically aligned, with no bone deformities. The right and left shoulders are same in height. Skin is intact with no excess hair growth and no lesions noted. Breast Patient x breast is intact and no extra hair growth the is round with same color; (-) retraction and discharges Abdomen The patient x abdomens skin is intact with no lesions and masses noted. Is flat. Umbilical is inverted and give free from discoloration. No abdominal distension present. Abdomen circumference is 36 inches. 17 auscultated bowel sound in right lower quadrant in one full minute.

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Musculoskeletal Uppers -Patient E can move his extremities freely with any joint / muscle pains. Symmetrical in size with coordinated movements. Fingers are short and cut and all present Lower -Patient E lower extremities have splint and bandages in right and left leg. Pain observed upon abduction of leg needs an support when moving up his legs.

Respiratory system: -no difficulty of breathing nor respiratory distress noted. Negative for any lungs sound upon auscultation. Negative for nasal discharges. Respiratory rate of 22 cpm

Neurologic system Patient is responsive to verbal communication. No difficulty of speech. Can talk freely. Able to answer simple questions. Able to recall the recent and remote memory, and able to do the cerebellar function both the upper and lower extremities.

Gordons 11 Functional Health Pattern


Functional health pattern Health management/ health perception cues Patient has good compliance to the therapeutic regimen. oo nurse ginapalit man namu ang gina order sa doctor as verbalized by the patient.
The patients usual food intake before the hospitalization includes fish, meat, vegetables, fruits, chicken. Upon

Nursing problem Effective therapeutic regimen management

Ranking 9

Nutritional metabolic pattern

Hyperthermia r/t increase metabolic secondary to tissue injury . Impaired skin integrity r/t injury secondary to bone structure.

Elimination

confinement patient has fever with temperature of 37.9 degrees celsius; Skin is febrile; dry lips noted. Upon confinement, patient E has no difficulty of urination. In our shift patient E urinate 4 times within our shift, with the urine output 80-100 ml urine is yellow in color, no other particles not yet defecated.
The patient before hospitalized wakes up early in the morning for his to have fine walking around their house as his exercise. Patient E needs on assistances from the family, appears to be weak and unable to walk due to splint/ bandages applied to his legs due to surgical position.

No problem identified

Activity-exercise pattern

Impaired physical mobility r/t decrease muscle strength secondary to damage of the bone structure

Cognitive perceptual

She easily

Acute pain r/t muscle

pattern

communicates, spasm secondary to understands injury of the soft questions, instructions tissue and be able to follow and answer them correctly. Patient complains pain at injured site. He wants the family to be with his side. Patient sleep and rest was change due to his present medical condition. He complains of difficulty of sleeping due to utilization due to environment. He usually 4-5 hours sleep and he think to time to rest because the nurses awake him for medication at irregular interval. Upon admission patient E could not do his regular ADL due to present medical condition. He could perform ADL with assistance with the family. He dont have an idea what will happen to the next operation. He is hoping that the operation will be successful. As of now he dont like his present condition because it may altered the function in the family, company, and others. Patient E is 34 years old, active and married and blessed four children. He conceive his role as a father to his children Sleep deprivation r/t environmental stimuli 5

Sleep rest pattern

Self perception

Anxiety r/t suture surgical procedure of the affected tissue and bone Disturbed body image r/t tissue injury of leg secondary to loss of bone structure

Role and relationship pattern

No problem identified

Coping/stress tolerance pattern

Value-belief pattern

Sexuality and reproductive

and provide necessary needs and wants of the family. Patient support system is immediate family follow his therapeutic regimen and strong faith in God count his fast progress. Patient is a roman catholic. Believing in God as only God. He is active and the one who makes decision in the family. Patient is sexual active having 4 children.

No problem identified

No problem identified

Risk for impaired parenting r/t medical condition