PHYSICAL ASSESSMENT General Survey: Received this male patient at Pediatric Intensive Care Unit Bed No.

1, Filipino, Roman Catholic, inside a crib in supine position in a nest with one small pillow supporting the head and the upper part of the body; asleep; kempt and wears a diaper; with presence of heplock at the left metacarpal vein attached to intravenous fluid therapy of D 5IMB 500cc X 3 cc per hour; with oral-gastric tube inserted per right nare secured by leucoplast in place (French 5) for feeding;

Date

Functional Area

Assessment

03/23/10 8:00am

Respiratory Function

With use of accessory muscles; with chest in-drawing; with slight sternal retraction; with O2 attached to client via nasal cannula, running at 0.5 liters per minute; with wheezing upon auscultation of the anterior and posterior thorax. Respiratory rate of 55 breaths per minute, non- labored, spontaneous; nasal septum located at the center; trachea located at midline of the neck, with equal spaces; both nares are patent, tenderness and masses not noted upon palpation of the sinuses, with cylindrical chest shape; with equal chest expansion in anterior and posterior thorax; with full, symmetrical tactile fremitus felt clearly at the upper portion of the anterior and posterior thorax and decreases upon reaching the lower portion, resonance heard upon percussion of the posterior and anterior lung fields.

03/23/10 8:00am

Rest and Comfort

Objective cues: Patient is irritable; he cries frequently especially when he is touched or when his vital signs are being taken; irritability is aggravated when he sees people around him or when the environment is noisy; extremities are restrained; Client sleeps in a supine position in a nest with one small pillow supporting the head and the upper part of the body; with an average of 12-15 hours of sleep during the night including naps during the day.

03/23/10 8:00am

Nutrition

On Nutrimugen Milk formula Nutrimugen about 45 cc in amount every 3 hours and consumes 20 cc per feeding with added multivitamins once a day; with orogastric tube(OGT) on right nare secured by leukoplast in place; dry, rough, not well-hydrated lips; with weight of 2.2 kgs small for gestational age; emaciation noted; has intact gag reflex; nasogastric tube feeding tolerated; lesions not noted; mouth is dry and light pink in color; nausea and vomiting not noted.

03/23/10 8:00am

Integumentary Function

With sagging skin; with warm, red spots located at the lumbo-sacral region, patient cries when they are touched; with presence of red, lesions located at the right scrotal area, linear and about of an inch in length; With warm, dry to touch, skin; with presence of a 1mm lesion on right cheek; with single palmar crease; presence of dandruff not noted; with good skin turgor: skin goes back immediately after pinching; with thin black

hair distributed evenly over the scalp; infestation of lice not noted; nails well-trimmed; light brown skin complexion; no presence of sutures, staples or drams noted.

03/23/10 8:00am

Motor Function

Client has weak spontaneous movements. Extremities in some degree of flexion when restraints are removed; extension of extremities followed by previous position of flexion; with poor muscle tone, loose ligaments; Extremities are symmetrical in size and length; Joints are smooth when passive exercise was done. Deformities and dislocations not noted.

03/23/10 8:00am

Circulatory Function

Blood Pressure with systole of 90mmHg taken at right leg on supine position, Cardiac rate of 140 beats per minute synchronous with pulse rate, with venoclysis D5IMB 500cc X 3 cc per hour attached to heplock at right metacarpal vein, patent and infusing well; capillary refill of less than 2 seconds on upper and lower extremities; misbeats and heart murmurs not noted upon auscultation.

03/23/10 8:00am

Special Senses a. Eyes With sunsetting eyes; hair evenly distributed in both eyebrows and lashes. Eyebrows are symmetrically aligned with equal movements. Facial nerve is intact (Cranial nerve 7). Eyelashes are slightly curled outward as noted bilaterally. Globes of the eyes are not protruding. Bulbar conjunctiva is transparent. Sclera appears white. Palpebral conjunctiva is shiny, smooth and pink. Edema or tearing over lacrimal gland and sac not noted. Masses not noted upon palpation of the eyelids and globes of both eyes. Elicits blinking reflex on both eyes. Trigeminal nerve is intact (Cranial nerve 5). Pupils are approximately 1 mm in diameter and are equally round and reactive to light and accommodation. Movement of the eyes are slightly uncoordinated and with slight misalignment. Nose is smooth and symmetrical; color is the same with the face; nostrils are patent; nasal mucosa is pinkish in color, lesions not noted, masses and tenderness not noted upon palpation of the nose, with good smelling acuity, cranial nerve no. 1 olfactory is intact. Ears are short and low set; equal in size and level with each other; lesions not noted, color is same with the face, ear canal has a small amount of cerumen; ears are smooth, firm and mobile, tenderness not note; lesions, nodules, and tenderness not noted.

b.

Nose

c.

Ears

d.

Mouth

Lips slightly pale, symmetrical and dry with surface free of lesions, buccal mucosa is moist and slightly pale, gums are pinkish in color and moist; tongue appears dull red in color with thin white coating, at midline; smooth, with full mobility and strength, CN#9 and CN#12, Glossopharyngeal and Hypoglossal are intact; with good strength of mastication, CN#5, trigeminal nerve is intact; palates are intact and uvula rises upon saying ah, gag reflex is present, CN#7 and 9, glossopharyngeal and vagus nerves are intact; with good tactile perception.

03/23/10 8:00am

Elmination Function

Patient has a rounded abdominal contour in supine position; umbilicus is dark brown in color no signs of inflammation noted; 6 7 bowel sounds audible on each four quadrants of the abdomen, normoactive, masses and tenderness not noted upon palpation of the four quadrants of the abdomen, tympany heard upon percussion at the LUQ of the abdomen and dull sound heard at the RUQ of the abdomen; defecates to a soft, aromatic, yellowish stool and voids to a yellow-colored urine, approximately 40cc/voiding; uses two diapers per day; With GCS of 14, opens eyes spontaneously, with irritable cry, normal spontaneous movement when restraints are removed;

03/23/10 8:00am

Neurologic function

03/23/10 8:00am

Thermoregulatory function

Client has a temperature of 36.8 C taken via tympanic route; skin is warm to touch; chills and diaphoresis not noted.

03/23/10 8:00am

Reproductive Function

With intact perineal skin and is slightly more pigmented than the skin of buttocks. Lesions, swelling and discharges not noted; urinary meatus noted at the end of the shaft; with rugated scrotum; testicles have descended as noted bilaterally; with symmetrical nipples; areola is dark brown;

03/23/10 8:00am 03/23/10 8:00am

Social Function

NA

Mental and Emotional

NA