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    Physical Assessment Dara

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    Michael Bon Margaja
    Patient was assessed on November 12, 2019. Initial vital signs showed a temperature of 36.6 degrees C, pulse of 60 bpm, respiration of 22 cpm, and blood pressure of 100/70. Physical examination found pale skin, thin hair, difficulty moving the neck, distended abdomen with a palpable 17x19 cm mass, and edema in the lower extremities. Bed sores were also present.

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    Physical Assessment Dara

    Uploaded by

    Michael Bon Margaja
    77 views3 pages
    Patient was assessed on November 12, 2019. Initial vital signs showed a temperature of 36.6 degrees C, pulse of 60 bpm, respiration of 22 cpm, and blood pressure of 100/70. Physical examination found pale skin, thin hair, difficulty moving the neck, distended abdomen with a palpable 17x19 cm mass, and edema in the lower extremities. Bed sores were also present.

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    Patient was assessed on November 12, 2019. Initial vital signs showed a temperature of 36.6 degrees C, pulse of 60 bpm, respiration of 22 cpm, and blood pressure of 100/70. Physical examination found pale skin, thin hair, difficulty moving the neck, distended abdomen with a palpable 17x19 cm mass, and edema in the lower extremities. Bed sores were also present.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    77 views3 pages

    Physical Assessment Dara

    Uploaded by

    Michael Bon Margaja
    Patient was assessed on November 12, 2019. Initial vital signs showed a temperature of 36.6 degrees C, pulse of 60 bpm, respiration of 22 cpm, and blood pressure of 100/70. Physical examination found pale skin, thin hair, difficulty moving the neck, distended abdomen with a palpable 17x19 cm mass, and edema in the lower extremities. Bed sores were also present.

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    Physical Assessment

    Patient was assessed on November 12, 2019 where she was on a supine position. She elicited a
    grimace on her face, showed exhaustion and impaired comfort. Patient was conscious about her being
    admitted to the hospital, she was responsive to the queries and cooperative to the nursing students by
    allowing them to do a physical exam. Initial vital signs were 36.6 ˚ C , pulse rate 60 bpm, respiration 22
    cpm, and blood pressure 100/70.

    Body Part Results Review of Systems


    Skin Inspection: Pale skin generally results from a
    No jaundice and cyanosis were decrease in blood flow. It may
    seen but slight pallor was noted. also result from a reduction in
    Palpation: the number of RBCs.
    Patient has cold and clammy skin
    with good skin turgor.
    Hair Inspection:
    Patient’s hair is slightly brown in
    color with strands of white hair.
    Palpation:
    Patient’s hair strands are thin.
    Head Inspection:
    Patient’s head is rounded;
    normocephalic and symmetrical
    in shape.
    Palpation:
    There are no nodules or masses
    and depressions when palpated.
    Face Inspection:
    No lesions and bruises were
    noted on the patient’s face.
    Patient’s face was symmetrical
    but extremely thin.
    Palpation:
    No tenderness and masses
    noted.
    Eyes Inspection: Pale papebral conjunctivae may
    Anicteric sclerae, pale papebral indicate anemia.
    conjunctivae.
    Nose Inspection:
    The nose appeared symmetrical,
    straight and uniform in color.
    There was no presence of
    discharge or flaring.
    Palpation:
    When lightly palpated, there
    were no tenderness and lesions.
    Mouth Inspection: Pale lips are usually caused by
    anemia
    Patient’s lips are pale, cracked
    and dry. Absence of lesions on
    the patient’s gum and inner
    cheeks and tongue. Patient’s
    teeth is slightly yellow in color.
    Neck Inspection: Difficulty moving the head due
    Patient’s neck muscles are equal to dizziness or lightheadedness
    in size. The client showed is a possible side effect of cancer
    difficulty moving her head. and its treatment.
    Palpation:
    Lymph nodes of the patient are
    not palpable.
    Chest/Lungs Inspection:
    Patient’s chest wall is intact and
    symmetrical to the body.
    Patient’s breasts are nontender
    with enlarged dark areola and
    nipples protruding.
    Palpation:
    No tenderness and masses felt
    upon palpation with no
    indentation on the chest wall.
    Auscultation:
    Presence of symmetrical, clear
    breath sounds on both lobes,
    with no wheezing heard.
    Upper Extremities Inspection:
    Extremities are symmetrical in
    size and length. No deformities
    and swelling on both arms.
    Palpation:
    No tenderness and masses
    detected during palpation nor
    signs of edema.
    Nails Inspection: Pail fingernails can indicate
    Patient’s nails are pale or white problems with anemia, liver
    in color. disease, or even heart disease.
    Palpation:
    Poor capillary refill.
    Abdomen Inspection: Abdominal distention occurs
    Patient’s abdomen is distended. when substances, such as air or
    Palpation: fluid, accumulate in the
    Patient’s abdomen is tender on abdomen causing its expansion.
    all quadrants. Palpable mass
    17x19 cm in size is present. Cancer begins when a cell
    develops errors in its DNA. The
    mutations tell the cell to grow
    and multiply quickly, creating a
    mass of abnormal cells.
    Back Inspection: Bedsores are caused by pressure
    Bed sores were found present. against the skin that limits blood
    flow to the skin. Other factors
    related to limited mobility can
    make the skin vulnerable to
    damage and contribute to the
    development of pressure sores.
    Lower Extremities Inspection: Swelling in the legs is caused by
    No lesions or bruises are noted. a build-up of fluid called edema.
    Palpation: It happens when the tissues or
    Edematous noted. blood vessels in the legs hold
    more fluid than they should.

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