PHYSICAL ASSESSMENT: 13 FUNCTIONAL AREAS

GENERAL SURVEY:

Received this 18 year- Old, male, Filipino, single, Roman Catholic per wheelchair with
husband, awake, conscious, coherent, oriented to time, place and person, attached to foley
catheter and IV in her left metacarpal vein, cooperative to instructions given by the physician.
Approximate height of 56 and weight of 55kilos, medium built, fair skin, clean clothes
and body, with signs of distress, no signs of deformity, with normal speech and voice tone, bed
rest.

FUNCTIONAL AREAS FINDINGS
1. RESPIRATORY FUNCTION -RR=21, 32, 22,20, regular in rate and rhythm,
no pulmonary distress, chest expansion was
symmetrical with ease during respiration, no
adventitious sound were heard when
auscultated.
2. CIRCULATORY FUNCTION -CR=85, 92, 80, 79 bpm, BP taken at left upper
arm with patient in supine position, nail beds
and palms are pinkish in color, no presence of
edema, heart sounds are regular and normal
in rhythm.
3. SPECIAL SENSES FUNCTIONS
A. EYES -almond shape, black in color, scleras are
white, eyebrows and eyelashes are equally
distributed.
- conjunctiva are pale and moist, normal eye
movement, pupils are equally round and
reactive to light accommodation.
- no masses or tenderness palpated.
B. EARS -parallel, symmetric proportional, no presence
of discharges, there are presence of cerumen,
can hear the beep of thermometer.
-no presence of tenderness, masses or
swelling on the ears and mastoid.
C. NOSE -no deviation in terms of shape, size, nose
slightly pointed and no discharges, no evident
of bleeding or perforation.
-no masses or tenderness and swelling on the
nose and sinuses.
D. MOUTH -is moist and symmetrical in shape, tongue in
pinkish color, no lesions or abrasions and cysts
present.
-no bleeding and lesions on gums, teeth are
complete, no tooth decay but there are
presence of tooth cavities.
4. REST AND COMFORT FUNCTIONS -pain present in her surgical wound while
moving but pain is tolerable as verbalized.
-could not sleep well due to pain.
5. ELIMINATION FUNCTIONS -Foley catheter connected to urine bag with
urine amber in color, recorded output of
550cc.
-have not yet defecated after post operation.
6. NUTRITION FUNCTION -NPO with zip of water, no scars or lesions in
abdomen except for the post operative
wound, no stretch marks, no masses or
distention and tenderness palpated.
7. NEUROLOGIC FUNCTION -conscious and coherent and oriented to time,
in bedrest and was not able to perform
rumbergs test but reflexes are all ok.
8. MOTOR FUNCTIONS -can bend her legs and arms with pain in her
wound, no presence of deformity, no swelling
or inflammation on the joints.
9. REPRODUCTIVE FUNCTIONS -areola are dark brown, no presence of masses
on breast, skin color are brown, no tenderness
present on lymph nodes.
-menarch is 13 yrs old, regular cycle, 5-6 pads
per day.
10. THERMOREGULATORY FUNCTIONS -temperature taken at right axilla with 36.6,
36.9, 37.1, 35.6 degree celcius, no chills and
diaphoresis present, skin are cool to touch.
11. SKIN INTEGRITY OR INTEGUMENTARY
FUNCTION
-with fair skin color, good hydration, no
presence of lesions or scars, slightly dry and
rough but no skin turgor present.
- hair equally distributed, with thick wavy hair,
black and dry, no presence of lice or dandruff.
Nails are pinkish in color, no presence of
clubbing.
12. SOCIAL FUNCTIONS -able to converse well and approachable, low
tone of voice and very cooperative.
-lives with her husbands family, with close
family ties.
13. MENTAL AND EMOTIONAL
FUNCTIONS
-able to recall and has remote memory, able
to know reasons of hospitalization, able to
respond all directions given to her, able to
maintain eye to eye contact.