Beruflich Dokumente
Kultur Dokumente
with maculo-papular rash HEART: Normal rate regular rhythm, (-) murmur, Normal PR () EXTREMETIES:Full and equal pulses Vital Signs: Blood Pressure 120/70 mmHg Pulse Rate 84 bpm Respiratory Rate 19 cpm Temperature 38.2 C
Cephalo-caudal Assessment
Rounded (normocephalic) *symmetric with frontal, parietal and occipital prominences Smooth, uniform in consistency, absence of nodules and mass Inspection & Palpation Rounded (normocephalic) *symmetric with frontal, parietal and occipital prominences Smooth, uniform in consistency, absence of nodules and mass
NORMAL FINDINGS
METHOD OF ASSESSMENT
ACTUAL FINDINGS
INTERPRETATION
Normal Normal
Black - brown Silky; smooth presence of hair Thin straight; evenly distributed
Brown- black Silky; smooth presence of hair Thin straight; evenly distributed
Scalp
Normal
INTERPRETATION
Normal
Eyes Eyebrows *Hair distribution and alignment Eyelashes *Evenness, distribution and direction of curl
Hair evenly distributed, skin intact, eyebrows symmetrically aligned Equally distributed, Curled slightly outward
Inspection Inspection
Hair evenly distributed, skin intact, eyebrows symmetrically aligned Equally distributed, Curled slightly outward
Normal Normal
AREA OF ASSESSMENT
NORMAL FINDINGS
METHOD OF ASSESSMENT
ACTUAL FINDINGS
INTERPRETATION
(-) Sunken eyeballs Skin intact, No discharge; no discoloration Pupil equally round and of the same size and black in color Pupil constricted when accommodated with light Bulbar Conjunctiva is clear with tiny capillaries visible, Palpebral conjunctiva is pink; no discharge
Inspection Inspection
(-) Sunken eyeballs Skin intact, No discharge; no discoloration Pupil equally round and of the same size and black in color Pupil constricted when accommodated with light Bulbar Conjunctiva is clear with tiny capillaries visible, Palpebral conjunctiva is pink; no discharge
Normal Normal
Inspection
Normal Normal
Conjunctiva
Normal
AREA OF ASSESSMENT
Sclera Lacrimal gland, Nasolacrimal duct.
NORMAL FINDINGS
Anicteric sclera No edema, No Tenderness and tearing.
METHOD OF ASSESSMENT
Inspection Inspection & palpation
ACTUAL FINDINGS
Red sclera No edema, No Tenderness and tearing.
INTERPRETATION
Abnormal Normal
Color same as facial skin; symmetrical; Auricle aligned with outer about 10 above ventricle
Color same as facial skin; symmetrical; Auricle aligned with outer about 10 above ventricle
Normal
No discharge; No lesion; Tympanic membrane intact and pearly grey in color Mobile, firm, no tenderness, pinna recoils after it is folded
Normal No discharge; No lesion; Tympanic membrane intact and pearly grey in color Mobile, firm, no tenderness, pinna recoils after it is folded
AREA OF ASSESSMENT
Nose Septum Turbinates
NORMAL FINDINGS
METHOD OF ASSESSMENT
ACTUAL FINDINGS
INTERPRETATION
(-) nasal discharge/mucus secretion; Patent nostrils Intact and in midline Pinkish, moist and intact (-) nasal flaring
Inspection
(-) nasal discharge/mucus secretion; Patent nostrils Intact and in midline Pinkish, moist and intact (-) nasal flaring
Nares
Inspection
Symmetry of contour; Uniform pink color, moist White teeth and pinkish gums Pinkish in color; Moves freely; (-) presence of sore
Inspection
Symmetry of contour; Uniform pink color, moist White teeth and pinkish gums Pinkish in color; Moves freely; (-)presence of sores Inflamed
Normal
Normal
Inspection
Normal
Tonsils
Not inflamed
Abnormal
Thyroid gland
NORMAL FINDINGS Symmetrical, flexible, full range of motion, with out lumps, tenderness or pain (-) jugular vein distention
Inspection/ palpation
ACTUAL FINDINGS Symmetrical, flexible, full range of motion, with out lumps, tenderness or pain (-) jugular vein distention
INTERPRETATIO N normal
Normal
Skin Color
Inspection
Fair but with red spots With confluent bumps because of macula papular rash
Abnormal
Texture
Abnormal
NORMAL FINDINGS Elastic and full; skin springs back immediately when pinched
ACTUAL FINDINGS Elastic and full; skin springs back immediately when pinched
INTERPRETATIO N Normal
Nail Color
Shape and texture
Pinkish Smooth, convex in curvature, long Prompt return of pink or usual colour
Pinkish Smooth, convex in curvature, long Prompt return of pink or usual colour
Normal Normal
Capillary refill
Normal
NORMAL FINDINGS Light to deep brown symmetrical chest wall with no wounds/lesions
INTERPRETATION abnormal
Breath sound
Auscultation
Normal
Chest expansion
Normal
AREA OF ASSESSMENT
Heart
NORMAL FINDINGS
NRRR (normal rate regular rhythm) (-) murmur Symmetrical/ Flat abdominal contour Audible bowel sounds Over the stomach and gas filled
METHOD OF ASSESSMENT
Auscultation
ACTUAL FINDINGS
NRRR (normal rate regular rhythm) (-) murmur Symmetrical/ Flat abdominal contour Audible bowel sounds Over the stomach and gas filled
INTERPRETATION
Normal
Abdomen contour
Normal
Normal
Upper Extremities
Abnormal
lower Extremities
Normal
Before Hospitalization
Hospitalization
The relative stated that our patient used to eat Poor health status and foods that are high in fats. shows signs of weakness. But he knows that to maintain his health status he always eat right. The client eatwith her family thrice a day. He On a Hypoallergenic diet. eats all the foods that was serve to him. Patient experienced Loose He usually urinates 3-4 Bowel Movements (7-12x times a day and defecates per day) for a period of 3 once a day. days. Further decrease in He doesnt have time to physical activity due to exercise every day.
Nutritional-Metabolic
Elimination
Activity &Exercise
Cognitive-Perceptual
Patient is Lethargic and He has good eyesight and having difficulty no other sensory defects. communicating.
Sleep-Rest
He sleeps 6-7 hours a day, but sometimes hes Intermittent sleep and having a hard time been very lethargic. sleeping when hes thinking about problems in his life.
His wife stated that the patient is comfortable with He looks weak. his self.
He seldom goes to church Still unable to go to because of his work church. everyday
Value-Belief