A PHYSICAL EXAMNINATION

ON
CHRONIC KIDNEY DISEASE

SUBMITTED TO, SUBMITTED BY,

Mr.Binu Xavier Sanhati Banerjee

Associate professor M.Sc Nursing 1st Year

IQ City Institute Of Nursing Sciences IQ City Institute Of

Durgapur Nursing Sciences,

Durgapur

SUBMITTED ON,
 PHYSICAL EXAMINATION OF CLIENT

Identification data

Name: Mr. Monoranjan Sarkar

Age: 52 years

Gender: Male

Religion: Hindu

Address: Jamuria, kabi para, Paschim Barddhaman, West Bengal , Pin-713340, India

Ward: Surgical Intensive Care Unit

Bed no: 04

Registration number:17665893023

Under treatment of (doctor): Dr. Partha Pratim Mondal

Date of admission: 22/ 04/2022

Diagnosis: Chronic Kidney Disease

Provisional : Not applicable

Final : Chronic kidney disease

Name of surgery (if done) : No

Date of surgery (if done):No

General appearances

Level of consciousness :conscious, alert

Look : depressed
Nourishment: Malnourished

Body build (ectomorphic, mesomorphic, endomorphic): Ectomorphic

Health : weak, ill health

Anatomy posture

Gait : normal

Body curvature : Normal

Movement: Normal

Activity exercise pattern: Slightly Limited

Emotional state :calm, cooperative

Orientation: Oriented to time, place, person

Anthrometric data

Height: 156 cm

Weight : 45 kg

Physical and physiological parameters

Basic physiological data
Vital sign
Temperature(° F) 98.6 degree F
Pulse (Beats/ Min) 82 beats/min
Respiration(Breath/ min) 24 breaths/min
BP (mmof Hg) 110/80 mmofhg

CENTAL NERVIUS SYSTEM

Level of consciousness 15
Orientation to time place, person yes
 Speech Normal

Skin
Colour Brown
Turgor Normal
Temperature Normal
Texture Normal
Integrity if loss specify Nil
Lesions: Absent
Sensation Touch

Head
Shape of the head symmetrical
Others: Absent of Lesions
Scalp
Cleanness Clean
Dandruff Absent
Hair (colour texture, distribution) Black and symmetrical

Neck
Range of movement Normal
Swelling around the neck Absent

Throat
Voice Normal
Face
Colour Normal
Look Flushed

Eyes
 Eye brows(normal, absent)
Right:
Left:
Eye lids
Right:
Left:
Eye lashes (present, absent)
Right:
Left:

Conjunctiva (pale, red, icterus)

Right:
Left:
Sclera
Right:
Left:
Pupil(Size shape, symmetry Reaction to light)
Right:
Left:
Lens(Opacity)
Right:
Left:
Vision
Right:
Left:
Ear
External ear ( size shape, symmetry , discharge

Hearing
 Right:
Left:

Nose
Shape:
Nares:
Right:
Left:

Septum (normal/ deviated /

Discharge
Smell
Mouth
Lips:
Odour of the mouth:

Teeth:
Mucus membrane:
Gums:
Taste:

Chest
Respiratory rate/Rhythm:/Depth
Heart rate/ rhythm/ volume
Breast (size/ shape/ symmetry/ discharge)
Others
Thorax (inspection)
Shape & size:
Symmetry:
Expansion:
Thorax (Palpation):
 Axiallary lymph nodes:
Breast :
Thorax (Auscultation):
Breath sound:
Heart sound:
S 1, S 2:

Abdomen
Inspection (size, shape. Skin rash)
Abdominal girth
Palpation (liver margin, spleen, tenderness,
Hernia, Lump)
Auscultation (peristalsis/ bowel sound)
Percussion – gas, fluid, mass, abdominal
reflex

Upper extremities
Right (size, shape, symmetry)
Joints
Pulse
Finger/ nail (clubbing)
Muscle tone
Left(size, shape, symmetry)
Joints
Pulse
Finger/ nail (clubbing)
Muscle bulk
Muscle tone
Lower extremities
Right(size, shape, symmetry)
Joints
Pulse (Dorsalis /pedis/tibialsis, etc)
Edema/ varicose vein/
Muscle tone
Left:(size, shape, symmetry)
Joints
Pulse (Dorsalis /pedis/tibialsis, etc)
Edema/ varicose vein/
Muscle tone

Back
Spine – pain, stiffiness, symmetry
Genitalia and rectum
Void(free/ through catheter)
Stool
Invasive line
Site
Condition
Incisional wound
Site
Condition
Other wound
Site
Condition
Pain (score if pain present)
Site
Others
Investigation