RMC Pa

Fernando, Patricia S.A.
BSN 205-Group 18
Patient: Gamboa, Tomas Dx: Pleural EIIusion secondary to PTB
Vital signs
Temperature 35.9- 36.9 36.8 NORMAL
Cardiac rate 60-100 bpm 98bpm NORMAL
Respiratory rate 16-20 bpm 27bpm NORMAL
Blood pressure 120/80 mmHg 120/80 mmHg NORMAL
PHYSICAL ASSESSMENT
Area of Assessment /
Body Part
Normal Findings
(ReI. Fundamentals oI
Nursing by Kozier and
Erb)
Actual Findings

Analysis
General Survey
Posture, Gait,
Standing, Sitting,
Walking
Relaxed, erect posture,
coordinated movement
The client is relaxed and
has coordinated body
movement when sitting,
NORMAL

Overall Hygiene and
Grooming

Clean and neat

The client has poor
hygiene and grooming

Due to hospitalization

Body and Breath Odor

No body odor or minor
body relative to work or
exercise; no breath
odor.

The patient has body and
breath odor

NORMAL

Obvious signs oI
Health or Illness

Healthy appearance

The patient is lying on
bed with CTT and IVF. He
has diIIiculty oI breathing

Due to hospitalization

SkIN

lnspecL skln color varles from llghL Lo deep
brown from ruddy plnk Lo
llghL plnk from yellow
overLones Lo ollve
8rown normal
lnspecL unlformlLy of skln
color
Cenerally unlform excepL
ln areas exposed Lo Lhe
sun
sun
normal
lnspecL presence of edema no edema no edema normal
Cbserve and palpaLe skln
molsLure
MolsLure ln skln folds and
Lhe axlllae (varles wlLh
envlronmenLal
LemperaLure and humldlLy
body LemperaLure and
acLlvlLy)
MolsL ln skln folds normal
alpaLe skln LemperaLure unlform wlLhln normal
range
unlform normal
noLe skln Lurgor (fullness
or elasLlclLy) by llfLlng and
plnchlng Lhe skln on an
exLremlLy
When plnched skln sprlngs
back Lo prevlous sLaLe
2 seconds normal
NAILS

lnspecL flngernall plaLe
shape Lo deLermlne lLs
curvaLure and angle
Convex curvaLure angle of
nall abouL 160
o

Convex curvaLure angle
approxlmaLely 160
normal
lnspecL flngernall LexLure SmooLh LexLure SmooLh normal
lnspecL flngernall bed
color
Plghly vascular and plnk ln
llghLsklnned cllenLs dark
sklnned cllenLs may have
brown or black
plgmenLaLlon ln
longlLudlnal sLreaks

lnklshbrown ln color

normal
lnspecL Llssues surroundlng
nalls
lnLacL epldermls lnLacL epldermls normal
erform blanch LesL of
caplllary reflll

rompL reLurn of plnk or
usual color (generally less
Lhan 4 seconds)
8eLurn Lo plnk color ln 2
seconds

normal
nLAD
lnspecL Lhe skull for slze
shape and symmeLry
8ounded (normocephallc
and symmeLrlc wlLh
fronLal parleLal and
occlplLal promlnences)
smooLh skull conLour
normocephallc smooLh
skull conLour
normal
alpaLe Lhe skull for
nodules masses and
depresslons
SmooLh unlform
conslsLency absence of
nodules or masses
SmooLh unlform
conslsLency no nodules or
masses
normal
Color and appearance of
scalp
Scalp llghLer Lhan Lhe color
of Lhe faclal skln
of Lhe faclal skln
normal
reas of Lenderness no Lenderness no Lenderness normal
Palr evenness of growLh Lvenly dlsLrlbuLed Lvenly dlsLrlbuLed normal
Palr Lhlckness or Lhlnness
1exLure and olllness
1hlck halr
Sllky reslllenL halr
1hlck halr
normal
lnspecL Lhe faclal feaLures SymmeLrlc or sllghLly
asymmeLrlc faclal feaLures
palpebral flssures equal ln
slze symmeLrlc nasolablal
folds
SymmeLrlc faclal feaLures normal
noLe symmeLry of faclal
movemenLs

SymmeLrlc faclal
movemenLs
SymmeLrlc faclal
movemenLs
normal
LLS

lnspecL Lhe eyebrows for
halr dlsLrlbuLlon and
allgnmenL and skln quallLy
and movemenL
Palr evenly dlsLrlbuLed
skln lnLacL eyebrows
symmeLrlcally allgned
equal movemenL
equal movemenL
normal
lnspecL Lhe eyelashes for
evenness of dlsLrlbuLlon
and dlrecLlon of curl
Lqually dlsLrlbuLed curled
sllghLly ouLward
sllghLly ouLward
normal
lnspecL Lhe eyellds for
surface characLerlsLlcs
ablllLy Lo bllnk and
frequency of bllnklng
Skln lnLacL no dlscharge
no dlscoloraLlon llds close
symmeLrlcally
symmeLrlcally
normal
Color LexLure and
presence of leslon ln bulbar
con[uncLlva
1ransparenL 1ransparenL normal
Color LexLure and
presence of leslon ln
palpebral con[uncLlva
Shlny smooLh plnk or red Shlnny and smooLh normal

Color and clarlLy of sclera WhlLe ?ellowlsh ln color normal
lnspecL Lhe cornea for
clarlLy and LexLure
1ransparenL shlny and
smooLh deLalls of Lhe lrls
are vlslble
are vlslble
normal
lnspecL Lhe puplls for color
shape and symmeLry of
slze
8lack ln color equal ln slze
normally 3 Lo 7 mm ln
dlameLer round smooLh
border
8lack ln color equal ln slze normal
LlghL reacLlon and
accommodaLlon
lllumlnaLed pupll consLrlcLs
and nonlllumlnaLed pupll
consLrlcLs pupll consLrlcLs
when looklng aL near
ob[ecL and dllaLe when
looklng aL far ob[ecL pupll
converge when near ob[ecL
ls moved Loward Lhe nose
normal
Lye allgnmenL and
coordlnaLlon
8oLh eyes move ln
coordlnaLlon and unlson
wlLh parallel allgnmenL
8oLh eyes move ln

normal
LAkS

lnspecL Lhe aurlcles for
color symmeLry of slze and
poslLlon
Color same as faclal skln
symmeLrlcal aurlcle
allgned wlLh ouLer canLhus
of eye abouL 10
o
from
verLlcal
symmeLrlcal aurlcle
of eye abouL 10
o
from
verLlcal
normal
alpaLe Lhe aurlcles for
LexLure elasLlclLy and
areas of Lenderness
Moblle flrm and noL
Lender plnna recolls afLer
lL ls folded
Moblle flrm and noL
lL ls folded
normal
lnspecL ear canal for
cerumen skln leslons pus
and blood
ury cerumen graylshLan
color or sLlcky
color
normal
ssess cllenL's response Lo
normal volce Lones
normal volce Lones
audlble
normal volce Lones
audlble
normal
erform waLch Llck LesL ble Lo hear Llcklng ln boLh
ears
ble Lo hear Llcklng ln boLh
ears
normal
NCSL

lnspecL Lhe exLernal nose
for any devlaLlons ln shape
slze or color and flarlng or
dlscharge from Lhe nares
SymmeLrlc and sLralghL no
dlscharge or flarlng
unlform color
unlform color
normal
resence of redness
swelllng growLh and
dlscharge ln nasal cavlLy
Mucosa ls plnk clear
waLery dlscharge no leslon
Mucosa ls plnk and no
leslon
normal
LlghLly palpaLe Lhe exLernal
nose Lo deLermlne any
areas of Lenderness
masses and dlsplacemenLs
of bone and carLllage
noL Lender no leslons noL Lender no leslons normal
1esL paLency of boLh nasal
cavlLles
lr moves freely as Lhe
cllenL breaLhes Lhrough
nares
nares
normal
lnspecL nasal sepLum
beLween Lhe nasal
chambers
nasal sepLum lnLacL and ln
mldllne
mldllne
normal
alpaLe for Lenderness of
slnuses
noL Lender no Lenderness normal
MCU1n

lnspecL Lhe ouLer llps for
symmeLry of conLour color
and LexLure
unlform plnk color sofL
molsL and smooLh LexLure
symmeLry of conLour
symmeLry of conLour
normal
lnspecL and palpaLe Lhe
lnner llps and buccal
mucosa for color molsLure
LexLure and Lhe presence
of leslons
unlform plnk color molsL
smooLh sofL gllsLenlng
and elasLlc LexLure
and elasLlc LexLure
normal
lnspecL Lhe LeeLh for color
and number
28 LeeLh smooLh whlLe
shlny LooLh enamel
1here are mlsslng LeeLh
yellowlsh ln color
presence of denLal carles
uevlaLed from normal
lnspecL gums for Lhe color
and condlLlon
lnk gums molsL flrm
LexLure Lo gums
lnk gums molsL flrm
LexLure Lo gums
normal
lnspecL Lhe Longue for
poslLlon color and
LexLure
CenLral poslLlon plnk
color molsL sllghLly rough
Lhln whlLlsh coaLlng
normal

NLCk AND LMn NCDLS

alpaLe lymph nodes and
noLe for Lenderness
noL palpable noL palpable normal
lnspecL and palpaLe
Lrachea for placemenL
CenLral placemenL ln
mldllne of Lhe neck spaces
are equal on boLh sldes
normal
CAkDICVASCULAk

usculLaLe Lhe hearL ln all
four anaLomlc slLes aorLlc
pulmonlc Lrlcuspld and
aplcal (mlLral)
S1 and S2 are usually heard
aL all slLes
S1 and S2 heard in all
site.
normal

LUNGS
lnspecL symmeLry of lung
expanslon
SymmeLrlc lung expanslon symmeLrlc lung
expanslon
uue Lo pleural effuslon
usculLaLe lung sound no reLracLlon asymmeLrlc
breaLh sounds on boLh
lungs
Decrease breath sound
on the right lung
A8DCMLN
lnspecLlon ausculaLaLlon
and palpaLlon of four
quadranLs
no Lenderness Normal
bowel sounds can be
characterized as
murmuring, gurgling, or
tinkling.

No tenderness

normal
MUSCULCSkLLL1AL SS1LM
lnspecL muscles for slze Lqual slze on boLh sldes of
Lhe body
Lqual slze on boLh sldes of
Lhe body
normal
lnspecL Lhe muscles and
Lendons for conLracLures
(shorLenlng) and Lremors
no conLracLures no
Lremors

no conLracLures no
Lremors

normal
alpaLe muscles aL resL Lo
deLermlne muscle LonlclLy
normally flrm flrm normal
1esL for sLrengLh (neck
upper and lower
exLremlLles)
Lqual sLrengLh on each
body slde
body slde
normal
lnspecL Lhe skeleLon for
sLrucLure
no deformlLles no deformlLles normal
alpaLe Lhe bones Lo
locaLe any areas of edema
or Lenderness
no Lenderness or swelllng no Lenderness or swelllng normal
lnspecL Lhe [olnL for
swelllng Lenderness
smooLhness and presence
of nodules
no swelllng Lenderness or
nodules [olnLs move
smooLhly
nodules [olnLs move
smooLhly
normal

Fernando, Patricia S.A. BSN 205-Group 18
Patient: Panuncio, Georgie Dx: Pleural EIIusion secondary to PTB
Vital signs
Temperature 35.9- 36.9 36.8 aIebrile
Cardiac rate 60-100 bpm 111bpm tachycardia
Respiratory rate 16-20 bpm 23bpm tachyarrhythmia
Blood pressure 120/80 mmHg 100/70 mmHg Low blood pressure
PHYSICAL ASSESSMENT
Area of Assessment /
Body Part
Normal Findings
(ReI. Fundamentals oI
Nursing by Kozier and
Erb)
Actual Findings

Analysis
General Survey
Posture, Gait,
Standing, Sitting,
Walking
Relaxed, erect posture,
coordinated movement
The client is relaxed and
has coordinated body
movement when sitting,
standing and walking
NORMAL

Overall Hygiene and
Grooming

Clean and neat

The client appears clean
and neat

NORMAL

Body and Breath Odor

No body odor or minor
body relative to work or
exercise; no breath
odor.

The patient has no body
and breath odor

NORMAL

Obvious signs oI
Health or Illness

Healthy appearance

The patient looks skinny
and looks restless

Due to Hospitalization

SkIN

lnspecL skln color varles from llghL Lo deep
brown from ruddy plnk Lo
llghL plnk from yellow
overLones Lo ollve
8rown normal
lnspecL unlformlLy of skln
color
sun
sun
normal
lnspecL presence of edema no edema no edema normal
Cbserve and palpaLe skln
molsLure
MolsLure ln skln folds and
Lhe axlllae (varles wlLh
envlronmenLal
LemperaLure and humldlLy
body LemperaLure and
acLlvlLy)
MolsL ln skln folds normal
alpaLe skln LemperaLure unlform wlLhln normal
range
unlform normal
noLe skln Lurgor (fullness
or elasLlclLy) by llfLlng and
plnchlng Lhe skln on an
exLremlLy
When plnched skln sprlngs
back Lo prevlous sLaLe
2 seconds normal
NAILS

lnspecL flngernall plaLe
shape Lo deLermlne lLs
curvaLure and angle
Convex curvaLure angle of
nall abouL 160
o

Convex curvaLure angle
approxlmaLely 160
normal
lnspecL flngernall LexLure SmooLh LexLure SmooLh normal
lnspecL flngernall bed
color
Plghly vascular and plnk ln
llghLsklnned cllenLs dark
sklnned cllenLs may have
brown or black
plgmenLaLlon ln
longlLudlnal sLreaks

lnklshbrown ln color

normal
lnspecL Llssues surroundlng
nalls
lnLacL epldermls lnLacL epldermls normal
erform blanch LesL of
caplllary reflll

rompL reLurn of plnk or
usual color (generally less
Lhan 4 seconds)
8eLurn Lo plnk color ln 2
seconds

normal
nLAD
lnspecL Lhe skull for slze
shape and symmeLry
8ounded (normocephallc
and symmeLrlc wlLh
fronLal parleLal and
occlplLal promlnences)
smooLh skull conLour
normocephallc smooLh
skull conLour
normal
alpaLe Lhe skull for
nodules masses and
depresslons
SmooLh unlform
conslsLency absence of
nodules or masses
SmooLh unlform
conslsLency no nodules or
masses
normal
Color and appearance of
scalp
of Lhe faclal skln
of Lhe faclal skln
normal
reas of Lenderness no Lenderness no Lenderness normal
Palr evenness of growLh Lvenly dlsLrlbuLed Lvenly dlsLrlbuLed normal
Palr Lhlckness or Lhlnness
1exLure and olllness
1hlck halr
1hlck halr
normal
lnspecL Lhe faclal feaLures SymmeLrlc or sllghLly
asymmeLrlc faclal feaLures
palpebral flssures equal ln
slze symmeLrlc nasolablal
folds
SymmeLrlc faclal feaLures normal
noLe symmeLry of faclal
movemenLs

SymmeLrlc faclal
movemenLs
SymmeLrlc faclal
movemenLs
normal
LLS

lnspecL Lhe eyebrows for
halr dlsLrlbuLlon and
allgnmenL and skln quallLy
and movemenL
equal movemenL
equal movemenL
normal
lnspecL Lhe eyelashes for
evenness of dlsLrlbuLlon
and dlrecLlon of curl
sllghLly ouLward
sllghLly ouLward
normal
lnspecL Lhe eyellds for
surface characLerlsLlcs
ablllLy Lo bllnk and
frequency of bllnklng
symmeLrlcally
symmeLrlcally
normal
Color LexLure and
presence of leslon ln bulbar
con[uncLlva
1ransparenL 1ransparenL normal
Color LexLure and
presence of leslon ln
palpebral con[uncLlva
Shlny smooLh plnk or red Shlnny and smooLh normal

Color and clarlLy of sclera WhlLe ?ellowlsh ln color normal
lnspecL Lhe cornea for
clarlLy and LexLure
are vlslble
are vlslble
normal
lnspecL Lhe puplls for color
shape and symmeLry of
slze
8lack ln color equal ln slze
normally 3 Lo 7 mm ln
dlameLer round smooLh
border
8lack ln color equal ln slze normal
LlghL reacLlon and
accommodaLlon
normal
Lye allgnmenL and
coordlnaLlon
8oLh eyes move ln
8oLh eyes move ln
normal
LAkS

lnspecL Lhe aurlcles for
color symmeLry of slze and
poslLlon
symmeLrlcal aurlcle
of eye abouL 10
o
from
verLlcal
symmeLrlcal aurlcle
of eye abouL 10
o
from
verLlcal
normal
alpaLe Lhe aurlcles for
LexLure elasLlclLy and
areas of Lenderness
Moblle flrm and noL
lL ls folded
Moblle flrm and noL
lL ls folded
normal
lnspecL ear canal for
cerumen skln leslons pus
and blood
color or sLlcky
color
normal
ssess cllenL's response Lo
normal volce Lones
normal volce Lones
audlble
normal volce Lones
audlble
normal
erform waLch Llck LesL ble Lo hear Llcklng ln boLh
ears
ble Lo hear Llcklng ln boLh
ears
normal
NCSL

lnspecL Lhe exLernal nose
for any devlaLlons ln shape
slze or color and flarlng or
dlscharge from Lhe nares
unlform color
unlform color
normal
resence of redness
swelllng growLh and
dlscharge ln nasal cavlLy
Mucosa ls plnk clear
waLery dlscharge no leslon
Mucosa ls plnk and no
leslon
normal
LlghLly palpaLe Lhe exLernal
nose Lo deLermlne any
areas of Lenderness
masses and dlsplacemenLs
of bone and carLllage
noL Lender no leslons noL Lender no leslons normal
1esL paLency of boLh nasal
cavlLles
nares
nares
normal
lnspecL nasal sepLum
beLween Lhe nasal
chambers
mldllne
mldllne
normal
alpaLe for Lenderness of
slnuses
noL Lender no Lenderness normal
MCU1n

lnspecL Lhe ouLer llps for
symmeLry of conLour color
and LexLure
symmeLry of conLour
symmeLry of conLour
normal
lnspecL and palpaLe Lhe
lnner llps and buccal
mucosa for color molsLure
LexLure and Lhe presence
of leslons
and elasLlc LexLure
and elasLlc LexLure
normal
lnspecL Lhe LeeLh for color
and number
28 LeeLh smooLh whlLe
shlny LooLh enamel
1here are mlsslng LeeLh
yellowlsh ln color
presence of denLal carles
uevlaLed from normal
lnspecL gums for Lhe color
and condlLlon
lnk gums molsL flrm
LexLure Lo gums
lnk gums molsL flrm
LexLure Lo gums
normal
lnspecL Lhe Longue for
poslLlon color and
LexLure
normal

NLCk AND LMn NCDLS

alpaLe lymph nodes and
noLe for Lenderness
noL palpable noL palpable normal
lnspecL and palpaLe
Lrachea for placemenL
normal
CAkDICVASCULAk

usculLaLe Lhe hearL ln all
four anaLomlc slLes aorLlc
pulmonlc Lrlcuspld and
aplcal (mlLral)
S1 and S2 are usually heard
aL all slLes
S1 and S2 heard in all
site.
normal

LUNGS
lnspecL symmeLry of lung
expanslon
SymmeLrlc lung expanslon symmeLrlc lung
expanslon
usculLaLe lung sound no reLracLlon asymmeLrlc
breaLh sounds on boLh
lungs
Decrease breath sound
on the left lung
A8DCMLN
lnspecLlon ausculaLaLlon
and palpaLlon of four
quadranLs
no Lenderness Normal
bowel sounds can be
characterized as
murmuring, gurgling, or
tinkling.

No tenderness

normal
MUSCULCSkLLL1AL SS1LM
lnspecL muscles for slze Lqual slze on boLh sldes of
Lhe body
Lqual slze on boLh sldes of
Lhe body
normal
lnspecL Lhe muscles and
Lendons for conLracLures
(shorLenlng) and Lremors
no conLracLures no
Lremors

no conLracLures no
Lremors

normal
alpaLe muscles aL resL Lo
deLermlne muscle LonlclLy
normally flrm flrm normal
1esL for sLrengLh (neck
upper and lower
exLremlLles)
body slde
body slde
normal
lnspecL Lhe skeleLon for
sLrucLure
no deformlLles no deformlLles normal
alpaLe Lhe bones Lo
locaLe any areas of edema
or Lenderness
no Lenderness or swelllng no Lenderness or swelllng normal
lnspecL Lhe [olnL for
swelllng Lenderness
smooLhness and presence
of nodules
nodules [olnLs move
smooLhly
nodules [olnLs move
smooLhly
normal

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