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Areas of Assessment

Methods Used Inspection

Normal Findings

Actual Findings The patient looks weak and in pain.

Analysis

General Appearance

Auscultation Palpation Vital Signs Use of thermometer

Temp: 36.5-37.5 oC Pulse: 60-100 bpm Respiration: 12-20 bpm BP: 90-100/60 mm Hg

Inspection Palpation

Skin, Hair and Nail

Skin color ranges from pale white with pink, yellow, brown, or olive tones to dark brown or black. No strong odor should be evident. Skin should be soft, warm, slightly moist with good turgor and without edema. Hair is normally lustrous, silky, strong and elastic. Fine, downy hair covers the body. Nails should be cleaned and groomed and pink undertones should be seen.

Skin color of brown. No strong odors observed. Skin is brown in color. No strong odor. Skin is soft to touch and warm. Slightly soft with good turgor, no edema. Hair is well distributed, lustrous, silky, strong and elastic. Fine downy hair covers the body. Nails are clean and with good capillary refill.

All findings are normal. There is no deviation observed to the patient.

Capillary refill is good.

Inspection Palpation Head

Head is normocephalic and symmetric. Full range of motion of the head is normal. Face is normally proportionate and symmetric. Movements are equal bilaterally. Lips, tongue and buccal mucosa appear pink and moist. No lesions are present. Nose is midline in face, septum is straight, and nares are patent. No discharge or tenderness is present. No tenderness should be felt over sinuses.

Head is normocephalic and symmetric. Face is proportionate and symmetric. Full range of motion of the head is normal.

All findings are normal. There is no deviation observed to the patient.

Inspection Mouth

Lips appear pale and it is also slightly dry.

The patient was instructed NPO before and after the operation. All findings are normal. There is no flaring of the nares so it can indicate that difficulty of breathing is not felt by the patient.

Inspection Palpation Nose

Nose is midline in face, septum is straight and nares are patent. Nares is also not flaring and no discharge or tenderness is observed. And no tenderness is palpated over sinuses.

Inspection

Eyes

No swelling, discharge or lesions of eyelids. Sclera and conjunctiva are clear and free of discharge, lesions, redness or lacerations. Pupils are equal, round and reactive to light. Eyebrows should be symmetric in shape and movement and not meeting midline. Eyelashes should be evenly distributed and curled outward. No excessive cerumen, discharge, lesions in the ears. There will be good hearing acuity. No adventitious sounds should be heard.

Eyes are dark brown in color. No swelling, discharge or lesions of eyelids are observed. Pupils are equal round and reactive to light. Eyebrows and eyelashes are also normal.

All findings are normal.

Inspection Ears

No cerumen, discharge and lesions are observed. Patient had good hearing acuity. No adventitious breath sounds are heard.

The patient doesn t have any problem regarding to her ears after inspection.

Auscultation Thorax and Lungs

Since patient doesn t have any difficulty of breathing, no adventitious breath sounds are heard. There is no observed heart problem. There are no innocent murmurs heard upon auscultation.

Auscultation Heart

Heart sound is lub dub. Innocent murmur may be heard.

Heart sound is lub dub. And there are no innocent murmurs heard.

Inspection Auscultation Percussion Palpation Abdomen

Abdomen is soft to palpation and without masses or tenderness. Liver is usually palpable 1 to 2 cm below the right costal margin.

Abdomen is soft; some skin tag is present in the right upper part of the patient s abdomen. Upon auscultation, peristaltic movement decreases. Upon percussion, there is a tenderness and swelling of the middle portion of the abdomen. Upon palpation, liver is not palpable.

The tenderness and swelling is an indicative of the patient s wound brought about by the operation. Peristaltic movement decreases because of the immobility of the GI tract due to the anesthesia given to the patient. Liver was not able to palpate because the patient still experience pain to her abdomen. Patient s extremities are normal but she cannot move too much because of her wound and she s still in the recovery stage.

Inspection Arms and Legs

It is symmetric in size, shape, movement, and positioning. Extremities are mobile.

Extremities are mobile although patient was not moving too much.

METHODS y Medication o Describe the importance of regularly taking of prescribed medications including the potential unpleasant effects of non compliance o Instruct the client to continue with follow up medical care o Advise the client not to miss the intake of medications given by her physician upon discharge. Exercise o Maintain a quiet, pleasant, environment to promote relaxation. Provide clean and comfortable environment. o Encourage client to continue deep breathing exercises, also instruct the family for the exercise needed. This is to promote circulation of blood,relaxation also. Treatment o Continue home medications. o For the follow-up check-up repeat. o Encourage patient to take multivitamins for immunity Health Teachings o Explain the underlying disorder and treatment plan. o Lifestyle change (proper food preference) o General health measures (adequate sleep, proper diet, and maintaining a clean surrounding). o Instruct patient to limit his activity for 24 to 48 hrs after discharge. o Provide written and oral instructions about activity, diet recommendations, o Medications, and follow-up visits. Out Patient o Patient will be advised to go back in the hospital in a specific date to have a follow-up check up after discharge. o Consult doctor for are any problems or complications encountered. Diet Spiritual o Nursing actions to help clients meet their spiritual needs include: o providing presence o supporting religious practices o assisting clients with prayer o referring client for spiritual counseling

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