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PHYSICAL ASSESSMENT
BODY PARTS TECH-NIQUE NORMAL
FINDINGS
ACTUAL FINDINGS ANALYSIS
Skin
Hair and
Scalp
Nails
Inspection,
Palpation
Inspection,
Inspection
-light to dark
brown & feels
warm
-no swelling,
-smooth and
soft
-color black-properly
distributed
-no presence
of parasites
(lice)
-fine texture
-light to dark brown &
feels warm
-mild skin rashes
-smooth and soft
- smooth and soft
-round nail with
160degrees nail base
-pink nail bed
-abnormal
-normal
-normal
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-no masses
-round nail
with
160degrees
nail base
-pink nail bed
Head
Neck
Inspection
Inspection
-face is
symmetrical,
centered-
head position
-smooth andcontrolled
movements
-face is symmetrical,
centered-head position
-smooth and controlled
movements
-normal
-normal
Eyes
Eye brows
Eye lashes
Eye lids
Inspection -blinking
symmetrical,
involuntary &
approximately
15 blinks/min-evenly
distributed
-eye lashes
are short
-eye lid
margins moist
-blinking symmetrical,
involuntary &
approximately 15
blinks/min
-evenly distributed
-eye lashes are short
-eye lid margins moist &
pink
-pupil is equally round
and reactivated to light
-normal
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Pupil
Iris
& pink
-pupil is
equally round
and
reactivated to
light
accommodati
on
-uniform in
color
-transparent,
smooth, moist
accommodation
-uniform in color
-transparent, smooth,
moist
Ears Palpation ,
Inspection
-Ears of equal
size & similar
appearance
-Skin in the
external ear is
-Ears of equal size &
similar appearance
-Skin in the external ear
is smooth and color pink
-normal
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smooth and
color pink
Nose
Mouth
Lips
Buccal
mucosa
Tongue
Gums
Inspection
Inspection
Palpation
Inspection
-color is same
as face
-symmetricalappearance
-no redness in
the nasal
mucosa
-pink in color
-dry
-smooth,
moist with no
lesions
-moist with no
lesions
-pink and
moist
-no dental
carries
-color is same as face
-symmetrical appearance
-no redness in the nasal
mucosa
-pink in color
-moist
-smooth, moist with no
lesions
-moist with no lesions
-pink and moist
-no dental carries
-32 total no. of teeth
-normal
-normal
-normal
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Teeth
-32 complete
no. of teeth
-normal
Thoracic &
Lungs
Inspection
Palpation,
Auscultation
-position of
sternum is
level with ribs
-no masses
-lungs clear
uponauscultation
-position of sternum is
level with ribs
-no masses
- lungs clear upon
auscultation
-normal
-normal
Breast Inspection
Palpation
-smooth skin
surface
-flat areola
-no masses
-smooth skin surface
-flat areola
-no masses
-normal
Heart Palpation,Inspection
-PMI is feltupon
pulsation
-Rhythm:
regular
-PMI is felt uponpulsation
-Rhythm: regular
-normal
Upper
Extremities
Palpation,
Inspection
-bilateral
pulses strong
-bilateral pulses strong &
equal (radial pulse)
-normal
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(right and
left)
& equal
(radial pulse)
-mobile
-intact
condition ofthe skin in
arms
-no lesions, no
swelling
-mobile
- intact condition of the
skin in arms
-no lesions, no swelling
-normal
-normal
Abdomen Inspection,
Auscultation
Percussion
Palpation
-no rashes or
lesions
-umbilicus is
centrally
located
-rounded
abdomen
-symmetrical
-high pitched,
irregular
gurgles 5-
35times/min
-abdomen
rises with
inspiration in
-no rashes or lesions
-umbilicus is centrallylocated
-rounded abdomen
-symmetrical
-high pitched, irregulargurgles 5-35times/min
-abdomen rises with
inspiration in synchrony
with chest
-normal
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synchrony
with chest
Genitourinary (The patient
refused to
assess hisgenitourinary
organs.)
(The patient refused to
assess his genitourinary
organs.)
Lower
Extremities
(right and
left)
Inspection -bilaterally
symmetrical
and equal
-right foot hasno lesions, no
swelling
-left foot has no
lesions, no
swelling
-skin color isthe same as
the other part
of the body
-bilaterally symmetrical
and equal
-right foot has no lesions,
no swelling
-left foot has no
abrasions
- skin color is the same
as the other part of the
body
-normal
- normal
-normal
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A. Biographical Data
Name: J.E Reyes
Age : 17yrs old
Gender: Female
Birth Date: June 7, 1992
Birth place: Manila
Residence: 844-4 Hamabar St. Dagupan Tondo Mla.
Religion: Catholic
Civil Status: Child
Nationality: Filipino
Date of Admission: November 15, 2009
Admission Number: 96879
Room Number: 102 B
Discharge Date: Still in the hospital
Admitting Diagnosis: DHF
Attending Medical Doctor: Dr. GAN
II.Chief Complaint
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Fever (39-40 C) w/ cough and whitish phlegm.
III.History
Present health history
5 days prior to admission patient had a high grade fever intermittent 39-40 c
associated with cough and whitish phlegm, took paracetamol 500 mg. tablet which afforded
some relief. No consult done, no associated signs and symptoms of diffuculty of
breathing,Dysuria abdominal pain and bleeding episode.
Past health history
J.E was born June 7, 1992 , the first daughter of Mr. and Mrs. Reyes. She was well
taken care of her parents starting her intrauterine life. J.E had already illness like Measles,
Chicken Pox, Mumps, Diarrhea.This was J.E. first confinment to the hospital As Sheverbalized First time ko pong na confined sa hospital ngayon lang po talaga.
IV. Hospitalization
Complete immunizations were given to her accordingly. Mild illnesses includehaving cold, cough and flu are treated by medication over the counter. Present
hospitalization at MHMC because of DHF. She havent undergone any surgery. As the
mother explained to us.. Oo, kumpleto naman ang bakuna. Kapag may lagnat, ubo at
sipon ang gamot na binibili naming over the counter.
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V. Family History
J.E came from a nuclear type of family. Both of his parents are healthy. She is the first
daughter of Mr. and Mrs. R. She has her younger sister that is not yet admitted at the
hospital. As the mother verbalized Wala namang sakit ang pamilya namin. Yung kapatid
niya malakas din kita mo naman sa katawan nila
VI. Lifestyle
The patient usually have regular hours of sleep. Allergies from any kinds of foods or
medicines are not common to her. but due to her illness she has no appetite of eating well.
VII. Social Data
She have many friends around her and she is always with her friends as she
verbalized marami akong friends samin mahilig kasi ako lumabas pag hapon
VIII.Psychological Data
Patient is resting well and improving as she verbalized mejo ok n pakiramdam ko
hindi tulad nung unang araw na confined ako dito
IX. Patterns of Health Care
J.E was supported by her parents emotionally, physically and financially. She is under Dr.
Gan As she verbalized lagging andito sila mama at kapatid ko pati lola ko di nila ako
pinapabayaan pati narin si Dr. Gan
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X. Review of System
Integumentary System
As she verbalized Ok naman ako wala rashes.
Excretory System
As she verbalized Hindi naman ako pinagpapawisan
Respiratory System
As she verbalized Hindi naman ako nahihiraang huminga.
Cardiovascular System
As she verbalized Wala naman kaming sakit sa puso
Gastrointestinal System
As she verbalized Hindi naman ako nahihirapang dumumi, regular naman
Genitourinary System
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As she verbalized Hindi naman ako nahihirapang umihi.
Musculoskeletal System
As she verbalized Naigagalaw ko naman ng maayos ang mga kamay at paa ko
Neurologic System
As she verbalized Nakaka-sunod naman ako sa mga bagay na pamilyar sakin
Endocrine System
As she verbalized Wala naman akong sakit na nahawa lang.
5 PRIORITIZE PROBLEMS;
1.) Bleeding
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2.) Hyperthermia
3.) Activity intolerance related to body weakness secondary to DHF
4.) Alteration in comfort
5.) Skin impairment
NURSING CARE PLAN(BLEEDING)
ASSESSME DIAGNOSIS INFERENCE PLANNING INTERVENTI RATIONALE EVALUATIO
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NT ON N
Subjective:
Dumudug
o ang ilongko
as
verbalized
by the
client
Objective:
Weakness
and
irritability.
Restlessn
ess.V/S taken
as follows:
T: 38.1
P:70
R:19
Injury, risk
for
hemorrhage related to
altered
clotting
factor.
This
infectious
disease ismanifested
by a
sudden
onset of
fever, with
severe
headache,
muscle and
joint pains
(myalgias
and
arthralgias
severe
pain givesit the name
break-bone
fever or
bonecrushe
r disease)
and rashes
and usually
After 1 hr.
Of nursing
interventions, the
client will
be able to
demonstrat
e behaviors
that reduce
the risk for
bleeding.
Independen
t:
Assess for
signs and
symptoms
of G.I
bleeding.
Check for
secretions.
Observe
color and
consistency
of stools or
vomitus.
Observe
for
presence of
petechiae,
ecchymosis
, bleeding
from one
The G.I
tract
(esophagus
and
rectum) is
the most
usual
source of
bleeding of
its mucosal
fragility.
Sub-acute
disseminat
ed
intravascul
ar
coagulation
After 1 hr.
Of nursing
interventions, the
client was
able to
demonstrat
e behaviors
that reduce
the risk for
bleeding.
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CR:73
BP:110/80
appears
first on the
lower limbs
and the
chest.
There mayalso be
gastritis
and some
times
bleeding.
more sites.
Monitor
pulse, Blood
pressure.
Note
changes inmentation
and level of
consciousne
ss.
(DIC) may
develop
secondary
to altered
clotting
factors.
An
increase in
pulse with
decreased
Blood
pressure
can
indicate
loss of
circulating
blood
volume.
Changes
may
indicate
cerebral
perfusion
secondary
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Avoid
rectal
temperatur
e, be gentle
with GI tube
insertions.
Encourage
use of soft
toothbrush,
avoiding
straining for
stool, and
forceful
nose
blowing.
Use small
needles for
injections.
Apply
pressure to
venipunctur
to
hypovolemi
a,
hypoxemia.
Rectal and
esophageal
vessels are
most
vulnerable
to rupture.
In the
presence of
clotting
factor
disturbance
s, minimal
trauma cancause
mucosal
bleeding.
Minimizes
damage to
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e sites for
longer than
usual.
Recommend
avoidance
of aspirin
containing
products.
Collaborativ
e:
Monitor Hb
and Hct andclotting
factors.
tissues,
reducing
risk for
bleeding
and
hematoma.
Prolongs
coagulation
,
potentiatin
g risk of
hemorrhag
e.
Indicators
of anemia,
active
bleeding,
or
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impending
complicatio
ns.
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NURSING CARE PLAN(HYPERTHERMIA)
Cues Nursing Rationale Nursing Intervention Rationale Evaluation
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Cues Nursing
diagnosis
Rationale Nursing
objectives
Intervention
s
Rationale Evaluation
Objective
cues:
>skin is
warm to
touch
>flushed
skin
>increased body
temp.
Above
normal
range
(36.5C-
37.5C)
Temp
taken.
38.1
P:
alteration
in
thermoregu
lation
(hyperther
mia)
E:related to
infection s/t
DFS
S/Sx:
>skin is
warm to
touch
>flushed
skin
>increased
body temp.Above
normal
Body
temperatu
re
increases
(fever)as a
protective
response
to
infection
and injury.
Theelevated
body
temperatu
re
enhances
the bodys
defense
mechanis
m
although it
can cause
discomfort
for the
person. A
true feverresults
from an
Short term
goal:
After 10-
15mins of
nursing
interventio
n the body
temperatu
re willdecrease
from
38.1C to
a range of
37.8C-
37.6C
As will besupported
by skin
slightly
warm to
touch,
lessen
flushedskin.
Independent
:
1. Monitor
temperature
especially
during
episodes of
chills. Note
heart rateand rhythm.
2. If the
client is not
in chillingstage render
continuous
tepid sponge
bath.
1. Chills is
an
indication of
a rising
temperatur
e.
Hypertherm
ia can causedysrhythmia
s.
2. To
replaceartificially
the bodys
sweating
mechanism
by cooling
the skins
surface
Short term
goal:
After 10-
15mins of
nursing
intervention
the body
temperature
wasdecreased
from 38.1C
to a range
of 37.8C
As will be
supported
by skinslightly
warm to
touch,
lessen
flushed skin.
Goal met
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Health History
Physical
assessment
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NursingCare PlanRon Chan III- I4
Mam. Correa