PHYSICAL ASSESSMENT
Date of Assessment: The physical assessment was performed on September 15, 2011 at 4:00 PM. Vital Signs:
Blood pressure 80 / 50 mmHg Pulse Rate 87 beats / minute via radial pulse Temperature 35.7 oC per axilla Respiratory Rate 22 breaths / minute
General Appearance: The client was seen lying on bed with his father on the bedside chair during the assessment day. He was weak and pale in appearance and incoherent as he cant manage to answer courteously the different questions and inquiries being asked so we interviewed his father, Jose Llapitan. He is currently experiencing intermittent fever. He was wearing a blue sando shirt and a black cotton shorts. He was hooked with an intravenous fluid of D5IMB inserted at his right metacarpal vein. The clients body built is ectomorphic (Lean, bony and skinny built). He remained lying on bed until the end of assessment. His over-all complexion is brown.
Head to Toe Assessment: Head Head is elongated, found to be symmetrical with the body size No head lice (pediculi) No dandruff noted Facial features found to be symmetric Hair color is black, evenly distributed Scalp lighter in color than over-all complexion, no discolorations noted No masses, lesions and tenderness palpated
Eyes Symmetrically aligned and with coordinated movements Eyebrow hairs evenly distributed, symmetrical Eyelashes slightly curved directing downward and evenly distributed Eyelids close symmetrically, no discolorations seen Pale conjunctiva and some capillaries appear evidently White sclera Iris found to be round and black in color Cornea transparent, shiny and moist Pupils black in color, equally round and reactive to light and accommodation With a good peripheral vision able to see objects for 180 o Has good ocular movement able to move eyeballs from left to right, up and down No swelling of the lacrimal gland No discharges, cloudiness, opacities or irregularities noted Ears Earlobes attached, bean-shaped Ear auricles color same with the complexion which is brown Upper border of auricles in line with the outer canthus of eyes With good hearing acuity able to hear voice tone well because (about 2 3 feet) Ear canal with minimal cerumen No mass, lesions or tenderness upon palpation Nose Nose symmetrical and uniform in color as with the complexion which is brown No nasal discharges seen Nasal septum intact in the midline Patency of the nose tested and found that air moves freely as the child breathes through the nares No nasal flaring No swelling, tenderness and masses upon palpation Mouth Lips symmetrical in contour Lips pale pinkish in color Buccal mucosa is pinkish, smooth and moist in appearance, with no lesions noted Dorsal surface of tongue rough with a midline groove and with small fissures Ventral surface smooth, pinkish and with visible veins Gums pinkish, moist and with firm texture
A total of 23 teeth found, 11 at the upper portion while 12 in the lower portion Hard palate appears bony and whitish Soft palate appears muscular and whitish Uvula positioned in the midline of the soft palate Tonsils pinkish in color and smooth, with no swelling noted Tongue has good movement able to move from left to right, up and down Neck Trachea found in the midline Neck symmetrical Thyroid gland centrally located and found without masses upon palpation Skin color same with the over-all complexion which is brown No swelling, tenderness and masses noted No palpable lymph nodes Has normal range of motion able to move from left to right, up and down Chest Lungs clear to auscultation Symmetrical chest movement Skin is uniform in color which is brown, smooth, intact with no major discoloration With a respiratory rate of 22 breaths/minute Regular and even rhythm No difficulty of breathing noted Pinkish areola (assessment with the help of the father) Nipples rounded with the same color with areola (assessment with the help of the father) No masses or tenderness palpated Abdomen Abdomen flat Skin uniform in color, smooth Symmetrical Umbilicus found in the midline and slightly protruding No masses or tenderness palpated No skin lesions, masses, tenderness or scars noted Upper Extremities Pulse rate 87 beats/minute taken via radial pulse Right and left arms symmetrically aligned Has uniform color as with the over-all complexion which is brown
Vaccination scars seen at his right and left deltoids Pinkish nail beds Poor capillary refill (4 seconds) With an intravenous fluid of D5IMB inserted at his right metacarpal vein No edema, masses, tenderness noted upon palpation Lower extremities Right and left feet symmetrically aligned Has uniform color as with the over-all complexion which is brown Pinkish nail beds Good capillary refill (1-2 second/s) No edema, masses, tenderness noted upon palpation
NURSING CARE PLAN
Nursing Diagnosis Altered Peripheral Tissue Perfusion related to decreased Hgb concentration in the blood as manifested by body weakness, pale conjunctiva and and decreased capillary refill (4 seconds). Nursing Goal After 1-2 days of efficient and effective nursing intervention, the clients tissue perfusion will be improved as would be manifested by verbalization of absence in body weakness, nonexistence of pale conjunctiva and will have an increased capillary refill less than 2 seconds. Nursing Interventions 1. Provide food rich in iron and administer Vitamin C 500mg OD, PO as ordered.
Rationale: Iron helps in RBC production and Vitamin C helps in the immediate absorption of Iron.
2. Provide enough rest and sleep.
Rationale: To decrease oxygen consumption.
3. Elevate the head of the bed.
Rationale: To increase gravitational blood flow.
4. Position the client in semi-fowlers position.
Rationale: To increase expansion of the lungs.
5. Recommend avoidance of aspirin containing products.
Rationale: Prolongs coagulation, potentiating risk of hemorrhage.
Nursing Evaluation After 1-2 days of efficient and effective nursing intervention, the clients tissue perfusion was improved as would be manifested by verbalization of absence in body weakness, nonexistence of pale conjunctiva and has an increased capillary refill less than 2 seconds.
NURSING CARE PLAN
Nursing Diagnosis Risk for fluid volume deficit related to platelet destruction and compromised platelet production secondary to bleeding/hemorrhage. Nursing Goal After 3 hours of efficient health teachings and effective nursing intervention, the client will no longer be at risk for fluid volume deficit secondary to bleeding. Nursing Interventions 1. Advise the client and his significant others to prevent injury.
Rationale: Injury and compromised platelet production and decreased platelet concentration, predisposes the client to bleeding.
2. Provide padding on bed edges and raise the side rails.
Rationale: To decrease the risk for injury, hence decreasing the risk for bleeding.
3. Advise the client and his significant others to avoid as much as possible foods that may injure the oral mucosa (e.g. fish bones, food with bony fragments).
Rationale: To decrease the risk of injury, hence decreasing the risk for bleeding.
4. Administer platelet transfusion as ordered.
Rationale: This is an immediate treatment for sever thrombocytopenia.
Nursing Evaluation After 3 hours of efficient health teachings and effective nursing intervention, the client is no longer at risk for fluid volume deficit secondary to bleeding.
