Anda di halaman 1dari 7

H.

Physical Assessment

a. General Survey:
Body Built: Ectomorph Grooming/Hygiene: Good grooming and hygiene Posture & Gait: unsteady gait with slight kyphosis Body Odor and Breath Odor: Has fresh scent without halitosis

Signs of Distress: no signs of distress Orientation: Oriented to Time, Place, and Person Quantity & Quality of Speech: Slurred speech

Obvious Signs of Illness(es): disoriented Level of Affect: Consciousness: appropriate Awake - oriented affect Organization of thoughts: Mood:

b. Anthropometric Measurement*
Height 410 Weight 100 lbs IBW/BMI: 20.9 Normal BMI

c. Vital Signs
Temperature 36.0 C Pulse Rate 86 bpm Respiratory Rate 20 cpm Blood Pressure 110/80 mmHg

d. Physical Examination
Body Part Skin Normal Findings Actual Findings Analysis & Interpretation

I:

Skin wrinkles Pale skin skin on hands and forehands are thin, fragile and loose purple patches(actinic purpura) Poor skin turgor P:

P:

Skin wrinkles Pale skin skin on hands and forehands are thin, fragile and loose purple patches(actinic purpura) Poor skin turgor

This is a normal change in the body of the patient due to aging process

Hair

I:

I: gray scalp evidence of hair loss graying of hair I: yellow thicken brittle P: hard

gray scalp evidence of hair loss graying of hair yellow thicken brittle hard

This is a normal change in the body of the patient due to aging process This is a normal change in the body of the patient due to aging process

Nails

I:

P:

Head & Face

I:

I: lower portion of face looks small and sunken (if without teeth) presence of coarse facial hair on chin ad upper lip

Eyes

lower portion of face looks small and sunken (if without teeth) presence of coarse facial hair on chin ad upper lip there is scar in the back of the scalp wrinkled eyelids dry eyes corneas lose shininess smaller pupils sluggish reaction of pupil in light

This is a normal change in the body of the patient due to aging process however the scar in the back of the scalp is due to an accident occurred in the patient last 2011

I:

I: wrinkled eyelids dry eyes corneas lose shininess smaller pupils irregular pupils reactive to light visual acuity remains costant( 20 to 50 years) visual acuity diminishes (approximately 70 years) requires more light for reading and doing fine works(presbyopia) alteration of color perception soft bulges in upper and lower lids I: loss of hearing high pitched sounds drier cerumen deficits in equilibrium and hearing

This is a normal change in the body of the patient due to aging process

P:
Ears

I:

loss of hearing high pitched sounds drier cerumen deficits in equilibrium and hearing

This is a normal change in the body of the patient due to aging process

Nose

I:

decrease smell sensation

I: decrease smell sensation

This is a normal change in the body of the patient due to

aging process
Mouth & Pharynx

I:

I: diminished salivary secretions decrease sense of taste increase sensitivity to bitter and salty taste loss of teeth darkened teeth submandibular gland become easier to feel systolic bruits heard in the middle or upper portions of carotid arteries

diminished salivary secretions decrease sense of taste loss of teeth darkened teeth

This is a normal change in the body of the patient due to aging process

Neck

P:

N/A

N/A

A:

Spine

I:

N/A Dorsal curving of thoracic spine (kyphosis) I: Increased anteroposterior diameter of the chest(barrel chest) Stiffer and harder to move chest wall Weaken respiratory muscles Increased residual volume Cough become less effective Increased work of breathing Slow heart rate Orthostatic hypotension N/A Diminished breast Flaccid breast Pendulous Weaken respiratory muscles Cough become less effective Increased work of breathing

N/A

Thorax/Lungs

I:

This is a normal change in the body of the patient due to aging process


Cardiovascular/Heart

A:

N/A

N/A

Breast & Axilla (Optional)

I:

N/A

P:

appearance of breast Axillary hair diminishes Easily palpable firm and stringy strand of ducts surrounding the nipple N/A Accumulation of fats in lower abdomen and near the hips Soft and protruding abdomen Subtle losing of height Limbs are long in proportion to trunk Diminished range of motion Gait impairment Decreased strength N/A Pubic hair may decrease and become gray Menstrual periods ceased Vaginal dryness Smaller labia and clitoris Narrowed and shortened vagina Thin, pale and dry vaginal mucosa N/A N/A Subtle losing of height Limbs are long in proportion to trunk Diminished range of motion Gait impairment Decreased strength This is a normal change in the body of the patient due to aging process N/A

Abdomen

I:

Musculoskeletal

I:

Genitals (Optional)

I:

N/A

Rectum and Anus (Optional)

N/A

e. Neurologic Status: N/A


Cranial Nerves Reflexes* Sensory Function

Able to identify scent correctly with each nostril

IX Present of Gag reflex

Biceps Reflex Biceps contract +1 left, +2 right

Touch was able to feel the stimuli introduced to her whether it is sharp or dull

II

Both eyes move in a smooth coordinated manner

Triceps Reflex Presence of symmetrical rise of soft palate and uvula Gag reflex is present Elbow extends +1 left +2 right

Pain was able to feel the moderate pain introduced to patient

III,IV,VI V

Brachioradialis Reflex Elbow flexes with pronation of forearm +1 both left and right

Temperature was able to distinguish warm water to cold water even when eyes closed

The pupil is sluggish when exposed to light Unable to see in periphery XI With symmetrical strong contraction of trapezious muscles, Strong contraction of sternocleidomas toid on opposite side that head is turned. XII Presence of symmetrical tongue with smooth outward movement and bilateral strength

Patellar Reflex Presence of extension of knee +1 both right and left

Position was able to determine the position of a certain body even when eyes closed

Eye lids blink bilaterally. Identifies light touch, dull and sharp sensations to cheeks and forehead Muscles contract bilaterally

VII Able to identify taste correctly Able to perform facial movements coordinately

Achilles Reflex Plantar flexion of foot +1 right and left

Tactile Discrimination was able to feel a smooth and soft stimuli when eyes close.

VIII Unable to hear some whispered words With impaired in hearing

Plantar/Babinski Reflex Plantar flexion of foot +1 right and left

* Scoring (+1, +2)

I. Evidence-based Nursing (for NCM & RLE 103 & onwards)

Present Practice The institution especially at the St. Vincent dormitory does bible sharing every morning.

Evidence-based Nursing According to Marche (2006), aging, religion, and health suggests that religious and spiritual care can impact on the well-being of seniors on a number of dimensions of health. Religious involvements may provide an important framework for seniors to explore the meaning and purpose of their lives, develop or maintain support systems. For some, religion can provide a means of coping with the challenges that accompany aging, such as chronic pain, isolation, dependence, and disability. Religious coping methods such as prayer, reading of scripture, ritual, meditation, and talking with caregivers, ministers or clergy can have psychological, physical, spiritual, and emotional benefit. While Krause warns that religion should not be pursued for health benefits alone, recognizing the interrelationships among the various dimensions of health is important for a multi-dimensional understanding of religion, health, and aging.

Recommendations to Present Practice I would recommend for the institution to continue that practice to help the elderly improve their values formation and spirituality and also make them more productive.

Anda mungkin juga menyukai