Lyceum of the Philippines University

Batangas
Capitol Site Batangas City
College of Nursing

Case Presentation
Perforated Peptic Ulcer Disease

Prepared by
Group A
Aala, Caren Dianne
Abanador, Arlan Benn
Abaya, Ria Jhane
Acosta, Princess
Adame, Dianne Venus
Adaya, Leizel D.
Aguila, Ivanah
Alcayde, Van James
Aleroza, April Rose P.
Alog, Andrea
Alvarez, Leny

Prepared For:
Mrs. Sheila A. Clanor
R.N MAN
 Date: February 02, 2010

Admitting Diagnosis: Pleural Effusion

Day and Time: Tuesday at 10:00 am

Posture: Client is alert and cooperative. Sitting

comfortably on chair with arm and shoulders
slouched forward smiling with mild anxiety. Dress is
neat and clean

Vital signs: BP: 130/80 mmHg

T: 36.5 ° C
P: 124 bpm
R: 30 bpm

Methods used: Inspection, Palpation,

Percussion,Auscultation
 BODY PART METHOD FINDINGS ANALYSIS

Skin Inspection Color: Brown complexion (Normal) Balance amount of melanin

distribution in the skin

(Normal) Light color of the skin are those that

are not always expose to the sun

Presence of scars (Abnormal) there is a scars both on the upper

and lower extremities and tattoo on his right
arm

Palpation No presence of edema and lesions

(Normal) No fluid detention and there’s no
damage in skin appearance
Palpation
Texture: Smooth
(Normal) Good and smooth to touch
Palpation Moisture: Present in skin folds
(Normal) Due to room temperature and humidity

(Normal) A balance between heat produced and

Palpation Temperature: Warm to touch heat loss from the body

(Normal) Indicating sufficient fluid intake of the

body
Skin pinches easily and immediately
Palpation returns to its original position
(Normal) Indicating sufficient fluid intake of the
Palpation body
Skin pinches easily and immediately
returns to its original position
Hair Inspection Color: Black (Normal) Determined
by the amount of
melanin present

Inspection Evenly distributed hair (Normal) No signs of

hair loss

Palpation Thin, silky, resilient

(Normal) Indicates
hormonal balance
and balanced
distribution of
natural oil

No presence of
Inspection infestation (Abnormal) Improper
hair hygiene
Nails Inspection Nails are clean and have a pink nail bed (Normal) Good nail hygiene
and cleaning

Inspection Convex curvature shape, 160 degree (Normal) Indicates sufficient

angle between the nail base and the intake of iron and
skin adequate supply of water

(Normal) Normal circulation,

Palpation Smooth, nail plate is firmly attached to nail absence of chronic fungal
bed

(Normal) No signs of
inflammation or any breaks in
Inspection Intact epidermis he skin

(Normal) Normal blood and

Inspection oxygen circulation in the
Pink and highly vascular body

(Normal) Proper peripheral

blood circulation
Inspection Blanch test: prompt return to pink in 2-3
seconds
Head Inspection Symmetric, round, (Normal) Adequate
erect and in amount of growth
midline hormone output

(Normal) Absence of
Palpation No nodules noted local deformities

(Normal) Indicate
proper functioning
Inspection Facial features: of facial muscles
symmetrical, and bones and
centered head nerves
position
Eyes Hair evenly distributed (Normal) No signs of loss
Eyebrows Inspection symmetrical, with equal eyebrows, proper
movement functioning of the muscle
of eyebrow

Eyelids Inspection Skin intact without discharge (Normal) Normal, indicating

lids close symmetrically presence of blink reflex
during assessment, for
about 15-20 involuntary
blinks per minute
Transparent and white sclera
Bulbar Inspection (Normal) Adequate body input
conjunctiva of iron and clear with tiny
vessels visible
Shiny and pinkish
(Normal) pink with no
Palpebral Inspection discharged
conjunctiva Black to brown

Sclera Inspection (Normal) no petechiae

Black, equal size, round

Pupils Inspection (Normal) Does not show any

signs if cataracts
Ears Inspection Color: same as the facial (Normal) Absence of
skin cyanosis or pallor

Inspection Symmetrical aligned with (Normal) Good circulation of

outer cantus of eye blood and oxygen in the
body

Auricles Inspection Aligns with the corner of (Normal) Within 10-degree

each eye angle of the vertical
position
Palpation Mobile, no firm areas of
tenderness (Normal) No inflammation,
no lesions and
tenderness when
Pinna Inspection Elasticity: Recoils when moved or touched
folded
(Normal) Does not indicate
Inspection inflammation of external
Voice tone is audible ear

(Normal) Air or bone

conduction transmits
sounds to the auditory
nerve enabling the
sounds to be heard and
distinguished
Nose and sinuses
External nose Inspection Symmetry and there’s no (Normal) Indicates proper
flaring alignment of muscles of
the nose and the nasal
septum in the midline

Palpation No areas of tenderness and (Normal) No damage of the

no lesions tissue structure and skin
appearance

Inspection Nasal patency: air moves (Normal) Indicate normal

freely functioning of both nasal
cavities enabling to move
freely

Nasal cavities Inspection Mucosa pink, clear, watery (Normal) Absence of

discharge, no lesions inflammation of inspection
in the nose

Nasal septum Inspection Intact in midline (Normal) Divides nose

symmetrically

Facial sinuses Palpation Absence of tenderness and (Normal) Proper function of

inflammation when areas sinuses
are pressed
Mouth
Outer Lips Palpation Symmetry of contour (Normal) Uniform color
indicates good circulation of
Inspection Uniform pink blood and oxygen

Palpation Soft, moist, smooth

Teeth and gums, Inspection 26 adult teeth (others are (Abnormal) Indicates poor
inner lips and decay) brushing and cleaning of the
buccal mucosa teeth
Inspection
Pink gums, no retraction of (Normal) Normal functioning of
gums hypoglossal, adequate iron and
fluid intake
Inspection
Tounge
In central position, pink, moist
with thin whitish coating.
Inspection
(Normal) Absence of oral yeast
Moves freely infection, mobility of tongue is
Palpation not restricted

No areas of tenderness
exhibited
Palpation
(Normal) No swelling and
ulceration present
Smooth tongue base with
prominent veins.
Hard palate Inspection Lighter pink more (Normal) No
irregular discoloration present
texture due to inadequate blood
and circulation
(Normal) Intact
Soft palate Palpation
Smooth, lighter pink

(Normal) Normal
Uvula Inspection function
Position in the midline of
soft palate
Oropharynx Inspection
Pink and smoother wall (Normal) No fluid
retention

Tonsils Inspection Pink and smooth,

(Normal) Behind
absence of discharge,
tonsillar pillar, normal
presence of gag reflex
functioning of
glossopharyngeal and
vagus nerve
Neck Inspection Symmetric with head (Normal) No signs in
centered and the enlargement of
without bulging the thyroid gland
masses
(Normal) Absence of
Cervical Palpation Visible and palpable prominence or
vertebrae swellings in C7
vertebrae

(Normal) No cases that

Trachea Palpation Place in the midline the trachea may be
pulled to one side

(Normal) There’s no
Lymph nodes Palpation No swelling, acute infections
enlargement or
tenderness
Thorax Inspection Chest symmetric (Normal) Symmetrical
anteroposterior to curvature of thoracic
transverse diameter spine

Inspection Spine vertically aligned (Normal) Aligned spinal

curvatures absence of
abnormal vertebral
curvatures like kyphosis
or lordosis.

Posterior thorax Palpation Skin intact uniform (Normal) No alteration in skin

temperature appearance.

(Normal) No areas of thorax

by which body
temperature is above or
below normal range.

Palpation Bilateral symmetry of vocal (Normal) Does not exhibit

fremitus increased fremitus related
to consolidated lung
tissue.
 Auscultation Fremitus is heard clearly (Normal) Does not exhibit
at apex of lungs decreased fremitus
related to pneumothorax

Moderated vesicular and (Abnormal) Presence of

Auscultation bronchovesicular sounds adventitious breath
sounds caused by rubbing
pleura or air passing
through
Quiet rhythmic, effortless
respiration
(Normal) Does not exhibit
Inspection respiratory problems such
as abnormal breathing like
dyspnea and orthopnea

(Abnormal) Caused by the

mucous secretions in the
Presence of crackles,
respiratory tract
wheezing sound
Auscultation
Chest
Heart and central Inspection No lift or heaves (Normal) No enlargement
vessel of either the two
ventricles

(Normal) No pulsation can

Auscultation No pulsations be seen on healthy
client.

(Normal) S1 occurs when

Auscultation S1 and S2 heard at all the atrioventricular
sites valves close when
S1 louder at apical area ventricles are filled

(Normal) S2 occurs when

Auscultaion SV close after
S2 louder at base of heart ventricles are empty
(no murmurs sound heard)

Symmetric pulse volume (Normal) No problem in

the elasticity of the
Carotid artery Palpation artery
Full pulsation
(Normal) Indicates paired
cardiac output
Peripheral Palpation Symmetric Pulse (Normal) Indicates
Vascular paired circulation
System

(Normal) No arterial
Palpation Volume occlusion

(Normal) Does not

Palpation Full pulsation exhibit signs of
high cardiac
output and
hypertension
Abdomen Inspection Presence of 3 small incision of (Abnormal) Tissues are
the right lower quadrant damaged due to medical
reasons (surgery)

Uniform color (Normal) Indicates balance of

melanin production
Inspection
Symmetric contour (Normal) No protrusion around
umbilicus indicating
hernia or two more or
enlargement of organ,
swelling or discoloration

(Normal) No pain in
Abdominal Movement: abdominal area, no bowel
Auscultation Symmetric movement obstruction
caused by respiration
(Normal) Normal movement of
Audible bowel sounds, (5 intestines and proper
times per minute) gastrointestinal track
absence of friction rub functions, normal
intestinal motility
Musculoskeletal Inspection Smooth coordinated (Normal) Client was
System Joint movement able to perform
with range of normal movement,
motion active ROM

Upper and lower Inspection No presence of scars in (Normal) There’s no

extremities the skin damage in skin
appearance

Presence of D5w IV in (Abnormal) For the

the left hand patient not to be
dehydrated
 Discussion of Abnormal Findings

During physical assessment there are abnormal

findings that had been assessed such as the hair of
the patient that has dandruffs, his teeth is only 26 and
most of them can be called as tooth decay maybe
because of old age and poor brushing and cleaning of
the teeth. There is also presence of wheezing sound
and crackles during auscultation because of the
mucous secretions in his respiratory tract, there is
also presence of moderated vesicular and
bronchovesicular sounds because of the presence of
adventitious breath sounds caused by rubbing pleura
or air passing through. Presence of D5w IV in the right
hand abnormal because for the patient not to be
dehydrated.