BODY PARTS TECH-NIQUE Skin Inspection, Palpation NORMAL FINDINGS ACTUAL FINDINGS
ANALYSIS
-light to dark -light to dark brown & brown & feels feels warm warm -mild skin r
ashes -no swelling, -smooth and soft
-abnormal
Hair and Scalp
Inspection,
-smooth and soft -color black
- smooth and soft
-normal
Inspection Nails
-properly distributed -no presence of parasites (lice) -fine texture
-round nail with 160degrees nail base -pink nail bed
-normal
-no masses -round nail with 160degrees nail base -pink nail bed Head Inspection
-face is -face is symmetrical, -normal symmetrical, centered-head position cente
red-smooth and controlled head position movements -smooth and controlled -normal
movements -blinking symmetrical, involuntary & approximately 15 blinks/min -eve
nly distributed -eye lashes are short -blinking symmetrical, involuntary & appro
ximately 15 blinks/min -evenly distributed -eye lashes are short -eye lid margin
s moist & pink -normal
Neck Eyes
Inspection Inspection
•
Eye brows
• Eye lashes
-pupil is equally round -eye lid and reactivated to light margins moist
•
Eye lids
& pink
accommodation
Pupil •
-pupil is equally round -uniform in color and reactivated to light accommodati o
n -transparent, smooth, moist -uniform in color
Iris •
-transparent, smooth, moist
Ears
Palpation , Inspection
-Ears of equal -Ears of equal size & -normal size & similar similar appearance a
ppearance -Skin in the external ear
-Skin in the is smooth and color pink external ear is smooth and color pink Nose
Inspection -color is same -color is same as face -normal as face -symmetrical a
ppearance -symmetrical -no redness in the nasal appearance mucosa -no redness in
the nasal mucosa -pink in color -moist -pink in color -dry -smooth, moist with
no lesions -normal
Mouth
Inspection Palpation
Lips •
• Buccal mucosa Tongue •
-moist with no lesions -smooth, moist with no -pink and moist lesions -no dental
carries -moist with no -32 total no. of teeth lesions -pink and moist -no denta
l
Gums •
Inspection Teeth
carries -32 complete no. of teeth
-normal
-normal
Thoracic & Lungs
Inspection Palpation, Auscultation
-position of -position of sternum is sternum is level with ribs level with ribs
-no masses -no masses - lungs clear upon -lungs clear auscultation upon ausculta
tion -smooth skin surface -flat areola -no masses -smooth skin surface -flat are
ola -no masses -PMI is felt upon pulsation -Rhythm: regular
-normal
-normal -normal
Breast
Inspection Palpation
Heart
Palpation, Inspection
-PMI is felt upon pulsation -Rhythm: regular
-normal
Upper
Palpation,
-bilateral
-bilateral pulses strong & -normal
Extremities (right and left)
Inspection
pulses strong equal (radial pulse) & equal -mobile (radial pulse) - intact condi
tion of the -mobile skin in arms -intact -no lesions, no swelling condition of t
he skin in arms -no lesions, no swelling
-normal -normal
Abdomen
Inspection, Auscultation Percussion Palpation
-no rashes or lesions -umbilicus is centrally located -rounded abdomen -symmetri
cal
-no rashes or lesions -umbilicus is centrally located -rounded abdomen
-normal
-symmetrical -high pitched, irregular gurgles 5-35times/min
-high pitched, irregular -abdomen rises with gurgles 5inspiration in synchrony 3
5times/min with chest -abdomen rises with
inspiration in synchrony with chest Genitourinary (The patient refused to assess
his genitourinary organs.) Inspection -bilaterally symmetrical and equal (The p
atient refused to assess his genitourinary organs.)
Lower Extremities (right and left)
-bilaterally symmetrical -normal and equal
-right foot has no lesions, -right foot has no swelling no lesions, no -left foo
t has no swelling abrasions - normal -left foot has no lesions, no swelling - sk
in color is the same as the other part of the -skin color is -normal body the sa
me as the other part of the body
A. Biographical Data
Name: Age : Gender: Birth Date: Birth place: Residence: Religion: J.E Reyes 17yr
s old Female June 7, 1992 Manila 844-4 Hamabar St. Dagupan Tondo Mla. Catholic
Civil Status: Child Nationality: Filipino
Date of Admission: November 15, 2009 Admission Number: 96879 Room Number: 102 B
Discharge Date: Still in the hospital Admitting Diagnosis: DHF Attending Medical
Doctor: Dr. GAN
II.Chief Complaint Fever (39-40 C) w/ cough and whitish phlegm. III.History Pres
ent health history 5 days prior to admission patient had a high grade fever inte
rmittent 39-40 c associated with cough and whitish phlegm, took paracetamol 500
mg. tablet which afforded some relief. No consult done, no associated signs and
symptoms of diffuculty of breathing,Dysuria abdominal pain and bleeding episode.
Past health history J.E was born June 7, 1992 , the first daughter of Mr. and M
rs. Reyes. She was well taken care of her parents starting her intrauterine life
. J.E had already illness like Measles, Chicken Pox, Mumps, Diarrhea.This was J.
E. first confinment to the hospital As She verbalized “First time ko pong na con
fined sa hospital ngayon lang po talaga.”
IV. Hospitalization Complete immunizations were given to her accordingly. Mild i
llnesses include having cold, cough and flu are treated by medication over the c
ounter. Present hospitalization at MHMC because of DHF. She haven’t undergone an
y surgery. As the mother explained to us.. “Oo, kumpleto naman ang bakuna. Kapag
may lagnat, ubo at sipon ang gamot na binibili naming over the counter.
V. Family History J.E came from a nuclear type of family. Both of his parents ar
e healthy. She is the first daughter of Mr. and Mrs. R. She has her younger sist
er that is not yet admitted at the hospital. As the mother verbalized “ Wala nam
ang sakit ang pamilya namin. Yung kapatid niya malakas din kita mo naman sa kata
wan nila”
VI. Lifestyle The patient usually have regular hours of sleep. Allergies from an
y kinds of foods or medicines are not common to her. but due to her illness she
has no appetite of eating well.
VII. Social Data She have many friends around her and she is always with her fri
ends as she verbalized “marami akong friends samin mahilig kasi ako lumabas pag
hapon”
VIII.Psychological Data Patient is resting well and improving as she verbalized
“mejo ok n pakiramdam ko hindi tulad nung unang araw na confined ako dito”
IX. Patterns of Health Care
J.E was supported by her parents emotionally, physically and financially. She is
under Dr. Gan As she verbalized “lagging andito sila mama at kapatid ko pati lo
la ko di nila ako pinapabayaan pati narin si Dr. Gan”
X. Review of System
Integumentary System As she verbalized “Ok naman ako wala rashes.”
Excretory System As she verbalized “Hindi naman ako pinagpapawisan”
Respiratory System As she verbalized “Hindi naman ako nahihiraang huminga.”
Cardiovascular System As she verbalized “Wala naman kaming sakit sa puso”
Gastrointestinal System
As she verbalized “Hindi naman ako nahihirapang dumumi, regular naman”
Genitourinary System As she verbalized “Hindi naman ako nahihirapang umihi.”
Musculoskeletal System As she verbalized “Naigagalaw ko naman ng maayos ang mga
kamay at paa ko”
Neurologic System As she verbalized “Nakaka-sunod naman ako sa mga bagay na pami
lyar sakin” Endocrine System As she verbalized “Wala naman akong sakit na nahawa
lang.”
5 PRIORITIZE PROBLEMS; 1.) Bleeding 2.) Hyperthermia 3.) Activity intolerance re
lated to body weakness secondary to DHF 4.) Alteration in comfort 5.) Skin impai
rment
NURSING CARE PLAN(BLEEDING)
ASSESSME NT
DIAGNOSIS
INFERENCE PLANNING
INTERVENTI RATIONALE ON
EVALUATIO N
Subjective: “Dumudug o ang ilong ko” as verbalized by the client
Injury, risk for hemorrhag e related to altered clotting factor.
Objective: •Weakness and irritability. •Restlessn ess. •V/S taken as follows:
This infectious disease is manifested by a sudden onset of fever, with severe he
adache, muscle and joint pains (myalgias and arthralgias —severe pain gives it t
he name break-bone fever or
After 1 hr. Of nursing interventio ns, the client will be able to demonstrat e b
ehaviors that reduce the risk for bleeding.
Independen t:
•Assess for signs and symptoms of G.I bleeding. Check for secretions. Observe co
lor and consistency of stools or vomitus.
After 1 hr. Of nursing interventio ns, the •The G.I client was tract (esophagus
able to demonstrat and e behaviors rectum) is that reduce the most the risk for
usual bleeding. source of bleeding of its mucosal fragility.
•Observe for presence of
•Sub-acute disseminat
T: 38.1 P:70 R:19 CR:73 BP:110/80
bonecrushe r disease) and rashes and usually appears first on the lower limbs an
d the chest. There may also be gastritis and some times bleeding.
petechiae, ecchymosis , bleeding from one more sites.
ed intravascul ar coagulation (DIC) may develop secondary to altered clotting fa
ctors.
•Monitor pulse, Blood •An pressure. increase in pulse with decreased Blood press
ure can indicate loss of circulating blood •Note volume. changes in mentation an
d level of •Changes consciousne may ss.
•Avoid rectal temperatur e, be gentle with GI tube insertions.
indicate cerebral perfusion secondary to hypovolemi a, hypoxemia.
•Encourage use of soft toothbrush, avoiding straining for stool, and forceful no
se blowing.
●Rectal and esophageal vessels are most vulnerable to rupture.
•Use small needles for injections.
•In the presence of clotting factor disturbance s, minimal trauma can cause muco
sal bleeding.
Apply pressure to venipunctur e sites for longer than usual.
•Recomme nd avoidance of aspirin containing products.
•Minimizes damage to tissues, reducing risk for bleeding and hematoma.
•Prolongs coagulation , Collaborativ potentiatin e: g risk of hemorrhag • e. Mon
itor Hb and Hct and clotting factors. •Indicators of anemia,
active bleeding, or impending complicatio ns.
NURSING CARE PLAN(HYPERTHERMIA)
Cues
Nursing diagnosis
Rationale
Nursing objectives
Intervention s
Rationale
Evaluation
Objective cues:
>skin is warm to touch >flushed skin >increase d body temp. Above normal range (
36.5°C37.5°C)
P: alteration in thermoregu lation
Temp taken. 38.1
Body temperatu re increases (fever)as a protective (hyperther response mia) to i
nfection and injury. E:related to The infection s/t elevated DFS body temperatu
re S/Sx: enhances the body’s defense >skin is mechanis warm to m touch although
it can cause >flushed discomfort skin for the >increased person. A body temp. tr
ue fever Above results normal from an
Short term goal:
Independent : 1. Chills is an indication of a rising temperatur e. Hypertherm ia
can cause dysrhythmia s.
Short term goal:
After 1015mins of nursing interventio n the body temperatu re will decrease from
38.1°C to a range of 37.8°C37.6°C As will be supported by skin slightly warm to
touch, lessen flushed skin.
1. Monitor temperature especially during episodes of chills. Note heart rate and
rhythm.
After 1015mins of nursing intervention the body temperature was decreased from 3
8.1°C to a range of 37.8°C As will be supported by skin slightly warm to touch,
lessen flushed skin.
2. If the client is not in chilling stage render continuous tepid sponge bath.
2. To replace artificially the body’s sweating mechanism by cooling the skin’s s
urface
Goal met
Health History Physical assessment
Nursing Care Plan
Ron Chan III- I4 Mam. Correa