GENERAL SURVEY Received patient lying on bed, awake, conscious and coherent with an ongoing IVF of D5LRS regulated

at 20gtts/min, to run for 12 hours, hooked at the right arm, patent and infusing well. The patients appearance is appropriate to her stated age, sex and race. The patient appears neat. Body odor was pleasant. The patient was conscious and moody but she answers accurately to the questions being asked. Her affect and mood was appropriate with the situation while her speech is clear and moderate.) INITIAL VITAL SIGNS: BP= 110/80 mmhg T= 36.5 C PR= 78 bpm RR= 21 cpm AREA ASSESSED I. SKIN Color Moisture

wt: ht: BMI:

62 kg 51

METHOD USED Inspection Palpation

NORMAL FINDINGS Light to dark brown Moisture in the skin folds and axilla (varies with environmental temperature and humidity, body temperature and activity Feels smooth & firm with even surface Pinched-up skin returns immediately to original position. (1-2 secs) No edema No lesions Skin is normally warm in temperature

ACTUAL FINDINGS Light brown (+) Moisture in the skin folds and axilla Smooth and firm Skin returns immediately to original position when pinched. No edema No lesions Very warm skin and flushed skin T=38.1C

CLINICAL ANALYSIS Normal Normal

Texture Mobility & turgor

Inspection and Palpation Palpation Inspection and Palpation Inspection and Palpation Inspection and Palpation

Normal Normal

Edema Lesions Temperature

Normal Normal Due to increased pyrogens in the body

*NAIL
Inspection clean

Due to poor hygiene Dirty nails

II. HAIR Color Amount and distribution Presence of parasites

Inspection Inspection and Palpation

Filipino:Black Equally distributed ,thick silky and resilient

Black Equally distributed ,thick silky and resilient None

Normal Normal

Inspection and Palpation III. SCALP Shape Texture Lesions *HEAD CONTROL IV. NECK Position

None

Normal

Inspection Inspection and Palpation Inspection and Palpation Inspection

Symmetrical and round Smooth, firm None Head moves up and down;side to side

Symmetrical and round Smooth and firm None No resistance in moving

Normal Normal Normal Normal

Inspection

Centrally located between the shoulders

Located centrally between shoulders Can move spontaneously in all directions

Normal

Mobility

Inspection

Can move spontaneously in all directions

Normal

V. EYES Eyebrows

Inspection

Hair evenly distributed, skin intact, move symmetrically, equal movement Skin intact without redness, no discharge, or

Evenly distributed and move symmetrically Slightly pale,no discharge and

Normal

Eyelids

Inspection

Due to decrease tissue

lesions. Eyelashes Conjunctiva (bulbar and palpebral) Sclera IRIS Shape Color Inspection Inspection Equally distributed Pink palpebral conjunctiva

no lesions Evenly distributed Pale pink

perfusion Normal Due to decrease tissue perfusion Normal

Inspection

Sclera appears porcelain white

Appears White

Inspection Inspection

Round Color according to race:Filipino(brown to black) Equal in size

Round Black

Normal Normal

Symmetry PUPIL Reaction to light

Inspection

Equal in size

Normal

Inspection

PERRLA

Round, regular and equal size in both eyes

Normal

VI. EARS Skin Condition

Inspection

Color same as facial skin, skin intact with no lumps or lesions Mobile, firm, not tender, pinna recoils after it is folded Symmetrical Lateral to the eyebrows and auricles in line with cantus of the eye

Light brown in color, skin intact with no lumps or lesions Pinna recoils after it is folded, firm and not tender Symmetrical Lateral to the eyebrows and auricles in line with cantus of the eye

Normal Normal Normal Normal

Texture, elasticity & areas of tenderness Symmetry Position

Inspection and Palpation

Inspection Inspection

Due to poor hygiene

Discharge VII. NOSE Skin appearance Symmetry VIII. Lips MOUTH AND OROPHARYNX

Inspection Inspection and Palpation Inspection

Absence of cerumen Color: Same asface;Consistency: Smooth Symmetrical

(+)cerumen Light brown color, smooth Symmetrical Normal Normal

Inspection and Palpation

Pink color, soft, moist

Pale Pink, dry

Due to decrease tissue perfusion Due to poor hygiene Normal

Teeth Tongue

Inspection Inspection

White, shiny, tooth enamel Freely moving; centered roughened from papillae , no lesions

Yellowish teeth Freely moving; centered roughened from papillae , no lesions Uvula is positioned in the midline Centrally located between the shoulders Can move spontaneously in all directions

Uvula IX. NECK Position

Inspection

Uvula is positioned in the midline

Normal

Inspection

Centrally located between the shoulders

Normal Normal

Mobility

Inspection

Can move spontaneously in all directions

X.

THORAX AND LUNGS Chest expansion

Inspection

Full and symmetric chest expansion

Assymetric AP: 2:1

Due to the compression of left lung and the protrusion of the Left diaphragm

Breathing pattern

Inspection and Auscultation

Quiet, and effortless

shallow and labored

Due to hypoventilation caused by increased PCO2and decreased O2 Due to restriction of air movement cause by obtruction Normal

Breath sounds

Auscultation

Lungs clear to auscultation on inspiration and Wheezes expiration Rate:60-100bpm PR:85 bpm

Rate and Rhythm

Auscultation

XI. BREAST Size, shape & contour

Inspection and Palpation

No tenderness, nodules, swelling and edema

No tenderness, nodules, swelling and edema

Normal

XII.

ABDOMEN Inspection Flator round Distention in the diaphragmatic area particularly left No rashes and no integrity Positioned at the midline Light brown Bowel sounds of 25 times/min in all quadrants Due to the protrusion of the left diaphragm Normal Normal Normal Normal

Abdominal contour

Abdominal girth Abdominal Integrity Umbilic11us Color of umbilicus Bowel sounds Quadrants Tenderness

Inspection Inspection Inspection Inspection Auscultation

No rashes and no integrity Center Lighter than the outer part of the body High pitch,irregular gurgles 535times/min;present equally in four quadrants

Palpation

No tenderness

(+) of tenderness in the diaphragmatic area (left and right upper quadrant)

Due to inflammation

 Masses

Palpation

No masses

(+) of mass in the diaphragmatic area (left and right upper quadrant) (+) of tenderness in the diaphragmatic area (+) of mass in the diaphragmatic area

Due to the protrusion of the diaphragm in the left area

Regions Tenderness masses

Palpation

No tenderness in all regions

Due to inflammation

Palpation

No masses in all region

Due to the protrusion of the diaphragm in the left area

XIII.

UPPER EXTREMETIES Inspection and palpation Normal racial skin tone; warm and equal temperature; no edema, lesions and tenderness Equal Symmetrical Warm to touch Light brown color Due to increased pyrogens in the body

Skin Characteristics

Size(arms) Inspection Symmetry Inspection MUSCLE Size Inspection ROM Inspection Full ROM 0/5-no detection of muscular contraction 1/5- barely detectable flicker or trace of contraction 2/5-active movements of body was with elimination of gravity 3/5-active movement against gravity only Full ROM in the left arm; and Due to inflammatory process (3/5) or limited ROM in the right arm Equal size on both sides of body Equal size on both sides of body Normal Symmetrical Normal Symmetrical Normal

and not against resistance 4/5-active movement against gravity only and some resistance 5/5-active XIV. LOWER EXTREMETIES Skin Characteristics Inspection and palpation Normal racial skin tone; warm and equal temperature; no edema, lesions and tenderness Uniformity in color Equal Symmetrical FULL ROM 0/5-no detection of muscular contraction 1/5- barely detectable flicker or trace of contraction 2/5-active movements of body was with elimination of gravity 3/5-active movement against gravity only and not against resistance 4/5-active movement against gravity only and some resistance 5/5-active Warm to touch Light brown color Due to increased pyrogens in the body

Skin color Size(legs) Symmetry ROM

Inspection Inspection Inspection Inspection

Uniform color Equal Symmetrical Full ROM in the same leg

Normal Normal Normal Normal