INITIAL ASSESSMENT:

General survey/appearance

- Received the patient lying on bed with a body positioning semi-dorsal recumbent with
elevated knee flex. The patient has an irritable behavior and distressed due to pain. Pain
is observe during inspection and it is expressed during breathing pattern at the same time
with vocal sound and facial grimace. Speaks in sentences when asked but in
incomprehensible speech or sounds. Chief complaint is abdominal pain and back pain.
Vitals signs are- BP 120/70 mmhg. PR is 82 bpm and oxygen saturation is 99% with the
use of pulse oximeter. RR is 23bpm. Temp. is 36.2 C.

Glascow Coma Scale

To eye opening response: Open’s eye’s to verbal command, speech, sound or shout (3).
To verbal response: Has an incomprehensible sounds or speech (2).
To motor response: Has a purposeful movement to painful stimulus (5).

Skin

-Patients skin is dark yellow brownish skin, dry, thin and elastic. No skin lesions are detected.
Skin on the left and right arm is punctured due to intravenous fluid infusion with noted edema
and pain. Skin on the right upper quadrant of the abdomen is incised due to biliary drainage
procedure. Poor skin turgor.

Hair

-Patients hair color is black and white with a 4-5 inch length and it is clean and dry. Hair is
unevenly distributed. No signs of infections and infestations observed.

Nails

-Patients nails on hands are pale lightened pink long nails and on foot is dark pink long nails. No
clubbing and has a complete and intact nail plate with the epidermis on both hand and foot.
Capillary refill is 2 seconds.
Head

-The patients head is symmetrically round, hard and smooth without any lesions or bumps are
detected. Has a sagged face. Dark yellow brownish in color

Neck

-The patients neck has no signs of complication nor irritation and motion while swallowing. No
deformities, asymmetry, masses is detected. Lymph nodes is not visible upon palpation. Her
thyroid gland is not visible.

Eye

-The patients eye movements are slow and symmetry. Eyebrows are symmetrically aligned.
Involuntary blinks is 15-20 times per minute. Eyelids and palpebromolar groove shrinked on
both sides. Eye appears moist and smooth. Has a yellow sclera and conjunctiva. No swelling or
redness over lacrimal gland. Cornea is black.

Ear

Ears are symmetrically equal in size and shape and it is aligned with the outer canthus of the eye.
No complaints of ear pain. No presence of discharge, redness, and swelling detected. Color of
ear is the same with the color of the face. The patient can loudly and clearly hear the verbal
sounds, or voice sound is audible.

Mouth

-Patients lips are dark pink and dry without any lesions suspected. Sides of tongue are yellow
color and on the lower right side of the tongue has a blacking. The tongue is centrally positioned.
Patient still can taste accurately from different kinds of food she ingested. Her teeth is damage
and decreased or lessen.

Nose

-Patients nose is asymmetric, long, flat, and dry. Able to smell foods accurately. No presence of
feces on both nostril . No purulent drainage noted.
Chest/Lung

-Respirations 23 breaths per minute. The patient has dyspnea. Symmetric chest wall expansion
and positive clear breath sound.

Abdomen

-Abdomen is palpated with positive abdominal distension, firm, with pain and with an incised
skin and muscle through the right upper abdominal quadrant and the minor surgical procedure is
called biliary drainage. Has a passive abdominal movement caused by respirations.

Extremities

UPPER

-Patient’s hand is symmetrical in length and has no bruise, no deformity, and tremors are
detected and observed. Dark brown skin color, dry and mild temperature to touch. Right hand
has a positive pressure, bulging, and pain where the IV is attached. Capillary refill are 2 seconds.
Hand’s movement is smooth and flexible. Has full equal pulses.

LOWER

-Patient’s feet is symmetrical in length and has no bruise, no deformity nor tremors are detected
and observed. Both thigh and leg muscles are skinny. Has a positive edema on both foot/pedal.
No capillary refill.