1 General appearance/survey: Patient appeared weak looking but was somehow coherent in a semi-fowlers position due to DOB.

The client is willing to cooperate when it comes in taking vital signs ph!sical assessment. The patient"s skin was uniform in color and slightl! dr! especiall! on the lower e#tremities nails were slightl! long and dirt!.

Physiologic Cues Temperature Pulse

Normal $%.&' ( $).&' %* ( 1** beats+min

Actual Findings
o 36.7 C 86 beats/min

Analysis
Normal Normal

,espiration

1& ( -* breaths+min

30 breaths/min

./ 0ormall! breathing is carried out automaticall! and effortlessl!. 1ith a normal rate of 1---* 23undamental s of 0ursing th 4 edition 5o6ier 7 8rb p. &94: ;/ The patient has tach!pnea <uick and shallow breaths

Blood Pressure PARTS

s!stolic pressure ( =* to 19* mm>g diastolic pressure - %* to =* mm>g NOR A! F"N#"NGS

110/70 mmHg

Normal

ACT$A! F"N#"NGS

ANA!%S"S & "NT'RPR'TAT"O

N 1. >8;D a.?kull ,ounded 2normocephalic with frontal parietal and occipital prominences: 8venl! distributedC thick hairC silk! resilient hairC no infestation or infection Cvariable amount of bod! hair ?!mmetric facial features palpebral fissures e<ual in si6e 0ormocephalic 0ormal

b.>air

>air is not evenl! distributed within the frontal bone and its thin e#periencing hair loss Dns!mmetric facial features

0ormal

c.3ace

0ormal

1.1 8!eball ?hape is roundC si6e e<ual 1.-. @id Aargin Protects e!es anteriorl! meet at the medial and lateral corners of e!e. ?mooth and ?hin!

,ound uniform in color ?!mmetrical

0ormal 0ormal

1.$. 'onBunctiva

?lightl! Pale Palpebral 'onBunctiva

./ Patient has pale conBunctiva due to decreased count

1.9.?clera ;ppears white Delicate membraneC covers part of the outer surface of the e!eball Outer most tunic thick white connective tissue. Pupils constrict when looking at near obBects pupils converge when obBect is moved towards the nose >air evenl! distributed intact skin 8<ual movement 0ormal pupil constriction

in red blood cells ;/ Paleness also known as pale comple#ion or pallor is an unusual lightness of skin color when compared with !our normal hue. Paleness is caused b! reduced blood flow or a decreased number of red blood cells. 23undamentals of th 0ursing 4 edition 5o6ier 7 8rb p. &&4: 0ormal

1.&. Pupils

0ormal

>air evenl! distributed intact skin 8<ual movement

0ormal

1.% 8!ebrows and e!e movement

0ormal

Fision Testing - Fisual 3ield

1hen looking straight ahead clients can see obBects in peripher! ;ble to read newspaper

'lient can see from her peripher!

0ormal

$ Fisual ;cuit!

;ble to newspaper

read 0ormal

'. 8;,? a.Pinna

?ame color as facial ?ame color as facial skin pinna recoils skin pinna recoils after it is folded after it is folded Dr! ear wa# gra!ish-tan color or stick! wet cerumen in various shades of brown+ pearl! gra! colorC semitransparent ,esponds to moderatel! loud voice tone ?!mmetric normal breathing able to identif! familiar smell 1et and sticking cerumen with transparent color

0ormal

b.8#ternal canal

0ormal

c.>earing acuit!

,esponds to moderatel! loud voice tone

0ormal

D. 0ose

?!mmetrical patent 0ormal vestibules mucosa is pink septum midline and intact turbinates are flat no nasal discharge no tenderness over the frontal and ma#illar! sinuses

8. AODT>+@.P? a.Gums b.Teeth

Pink gumsC moist firm te#ture $- adult teeth smooth white shin! tooth enamel

@ips are moist 0ormal buccal mucosa and gums are pink and moist smooth no signs of swelling.

few cavities and missing central and lateral incisors !ellowish shin! tooth enamel

./ 'lient is prone to oral problems due to inabilit! to maintain oral h!giene: and has a smoking histor! ;/@oss of teeth occurs mainl! of periodontal disease rather than dental carries 23undamentals of th 0ursing 4 edition 5o6ier 7 8rb p. )%9:

c.Tongue d.Palatehard+softe.Orophar!n #+ Tonsil

'entral position pink in color Tongue is at midline Pink and smoothC freel! movable Pink and smooth posterior wall

0ormal >ard and ?oft Palate no lesions uvula is at midline 0ormal in si6e 0ormal supple s!mmetrical no neck vein engorgement no mass normal muscle development and tone trachea in midline soft no palpable l!mph nodes no carotid

3. 0eck

?!mmetrical no mass trachea in midline no palpable l!mph nodes

bruit G. '>8?T a.;nterior b.Posterior ?hape is elliptical no scars and lesions skin is the same of the comple#ion anterior-posterior diameter 2ratio 1/-: Aoves s!mmetricall! no flail chest no chest retractions no bulging at the .'? must be noted the spine should be straight e#piration is longer than the inspiration. ?kin is brown no lesions no dilated superfical blood vessels bon! thora# is barrel shaped s!mmetrical chest e#pansion with intercostal retractions subcostal retractions suprasternal retractions no lagging 2H: whee6ing 2Hcrackles: 2H: tight air entr! heard on both lung fields ./There is presence of crackles caused b! the secretions associated with infection of the alveoli ;/The bod!"s immune s!stem responds to the bacilli b! initiating an inflammator! reaction. Phagoc!tes engulf man! of the bacteria and destro! the bacilli and normal tissue results in accumulation of e#udates in the alveoli2 Aedical?urgical 0ursing th 11 edition Brunner 7 ?uddarth"s p. %99: 0ormal

G. >eart

Pulsation of the apical impulse ma!be visible there should be no heaves and lifts.

;d!namic precordium no palpable thrills. The ape# beat is at the th & .'? left midclavicular line normal heart rate and regular rh!thm.

0ormal

0o heaves nor thrusts. Pulsation on the apical impulse is not visible no heaves and lifts noted. 0o palpable pulsations over the aortic pulmonic and mitral valves apical pulsation can be felt there should be no abnormal heaves and thrills felt over the ape#. ?1 and ?- can be heard at all anatomic site no abnormal heart sounds is heard cardiac rate ranges from %* ( 1** bmp. 0ormal

0o pulsations palpated over the aortic pulmonic and mitral valves apical impulse felt. 0ormal

?1 and ?- is heard at all anatomical site no abnormal heart sound heard cardiac rate is )4 bpm.

.. ;bdomen

?kin is uniform no lesionsC some clients ma! have striae or scarC no venous engorgementC contour ma! be flat round or scapoidC ma! have visible peristalsisC aortic pulsation ma!be visible in thin clients. 0ormal bowel

3lat no superfical blood vessels soft inverted umbilicus no bruits on the epigastric and lumbar areas no masses upon palpation nontender

0ormal

0ormal 0ormal bowel

sounds are high pitched which occurs ever! & ( -* seconds number of bowel sounds is $ ( $* per minute. T!mpan! sounds should be heard predominantl!C dull sounds should be heard over solid masses like the liver and spleen. 0o tendernessC with smooth and consistent tensionC no muscle guardingC liver not palpable in normal adult but palpable in e#tremel! thin person. I. DPP8, 8JT,8A8T.8? 8<ual in si6e on both sides of the bod!C no muscle atroph!C normall! firmC smooth coordinated movements

sounds high pitched & bowel sounds+min 0ormal T!mpan! sounds was heard predominantl! over the abdomen 0ormal 0o tenderness noted has smooth and consistent tension no muscle guarding noted

0o gross deformities with full and e<ual pulses no edema 8<ual in si6e on both sides of the bod!C with a muscle grade $ firm smooth coordinated movements

5. @ower 8#tremeties

8<ual in si6e on both sides of the bod!C no muscle

0o gross deformities with full and e<ual pulses no edema.

./ Decreased muscle strength and tone ;/ integumentar! changes accompan! progressive losses of of subcutaneous fat and muscle tisssue muscle atroph! and loss of elasitc fiber 23undamentals of th 0ursing 4 edition 5o6ier 7 8rb p. 911: ./ Decreased muscle strength and tone

atroph!C normall! firmC smooth coordinated movements

8<ual in si6e on both sides of the bod!C with a muscle grade $C no muscle atroph!C normall! firmC smooth coordinated movements

;/ integumentar! changes occur with age progressive losses of of subcutaneous fat and muscle tisssue muscle atroph! and loss of elastic fiber 23undamentals of th 0ursing 4 edition 5o6ier 7 8rb p. 911: