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    Physical Assessment and Review of Systems Areas Assesse D Night 1 Night 2 Problem Identified

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    Asniah Hadjiadatu Abdullah
    The physical assessment identified several problems. The patient presented with general weakness, pale skin, weight loss, and an infected wound on the right foot. Labwork showed anemia and elevated white blood cell count, likely due to infection. Several systems were affected, including integumentary (skin impairment and infection), cardiovascular (risk for decreased cardiac output), gastrointestinal (imbalanced nutrition), genitourinary (fluid volume deficit and infection), and musculoskeletal (activity intolerance, fatigue, impaired skin integrity, and infection). Intravenous fluids and antibiotics were administered to address the identified issues.

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    Physical Assessment and Review of Systems Areas Assesse D Night 1 Night 2 Problem Identified

    Uploaded by

    Asniah Hadjiadatu Abdullah
    46 views9 pages
    The physical assessment identified several problems. The patient presented with general weakness, pale skin, weight loss, and an infected wound on the right foot. Labwork showed anemia and elevated white blood cell count, likely due to infection. Several systems were affected, including integumentary (skin impairment and infection), cardiovascular (risk for decreased cardiac output), gastrointestinal (imbalanced nutrition), genitourinary (fluid volume deficit and infection), and musculoskeletal (activity intolerance, fatigue, impaired skin integrity, and infection). Intravenous fluids and antibiotics were administered to address the identified issues.

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    The physical assessment identified several problems. The patient presented with general weakness, pale skin, weight loss, and an infected wound on the right foot. Labwork showed anemia and elevated white blood cell count, likely due to infection. Several systems were affected, including integumentary (skin impairment and infection), cardiovascular (risk for decreased cardiac output), gastrointestinal (imbalanced nutrition), genitourinary (fluid volume deficit and infection), and musculoskeletal (activity intolerance, fatigue, impaired skin integrity, and infection). Intravenous fluids and antibiotics were administered to address the identified issues.

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    Download as docx, pdf, or txt
    46 views9 pages

    Physical Assessment and Review of Systems Areas Assesse D Night 1 Night 2 Problem Identified

    Uploaded by

    Asniah Hadjiadatu Abdullah
    The physical assessment identified several problems. The patient presented with general weakness, pale skin, weight loss, and an infected wound on the right foot. Labwork showed anemia and elevated white blood cell count, likely due to infection. Several systems were affected, including integumentary (skin impairment and infection), cardiovascular (risk for decreased cardiac output), gastrointestinal (imbalanced nutrition), genitourinary (fluid volume deficit and infection), and musculoskeletal (activity intolerance, fatigue, impaired skin integrity, and infection). Intravenous fluids and antibiotics were administered to address the identified issues.

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    PHYSICAL ASSESSMENT AND REVIEW OF SYSTEMS

    AREAS NIGHT 1 NIGHT 2 PROBLEM


    ASSESSE IDENTIFIED
    D

    General o Subjective findings: Subjective findings: (Not


    health (Not Applicable) applicable)
    survey

    Objective findings:
    -Vital signs: Objective findings:
    T: 35.6- 36.2 C -Vital signs:
    BP: 90/70-100/60 mmHg T: 35.6- 36.2 C
    PR: 87-114 bpm BP: 90/70-100/60 mmHg
    RR: 21-23 bpm PR: 87-114 bpm
    O2sat: 95-- 96% RR: 21-23 bpm
    GCS:15/15 O2sat: 95-- 96%
    GCS:15/15
    o Venoclysis mainline on left
    metacarpal vein PNSS 1 L
    @80cc/hour via infusion o Venoclysis mainline on
    pump left metacarpal vein PNSS
    o With solution set Ceftriaxone 1 L @80cc/hour via
    1mg IVTT infusion pump
    o Side drip with Human albumin o With solution set
    20% v
    Ceftriaxone 1mg IVTT
    o Side drip with Human
    (+) Body weakness albumin 20% v

    (+) Weak appearance (+) Body weakness Activity intolerance


    (+)Pale skin (+) Weak appearance Fatigue
    (+) Wt. loss (+)Pale skin Impaired skin integrity

    (+)Wound @Right foot pus filled- (+) Wt. loss Fluid volume deficit
    purulent-swelling
    (+)Wound @Right foot pus
    (+)Amputated 1st and 2nd digit right filled- purulent-swelling Imbalanced Nutrition
    foot
    (+)Amputated 1st and 2nd digit Disturbed body image
    Amputated left lower extremity right foot
    (AKA)(March 03, 2019) Infection
    Altered sensory
    (+) Polyphagia perception
    (+) Polydipsia
    (+) Numbness and paresthesia on R
    foot (+)Polyuria

    (+) Polyphagia
    (+) Polydipsia
    (+)Polyuria
    Integument Subjective findings: Subjective findings:
    ary system
    (Not Applicable) (Not applicable)

    Impaired skin integrity


    Infection
    Objective findings: Objective findings: Fluid volume excess
    (+) Pale skin (+) Pale skin
    (+) Pale nailbeds (+) Pale nailbeds
    (+)(+)Wound @Right foot pus (+)(+)Wound @Right foot pus
    filled- purulent-swelling filled- purulent-swelling

    (+)Amputated 1st and 2nd digit right (+)Amputated 1st and 2nd digit
    foot right foot

    (+) Edema on right foot

    Lab test:
    Lab test: CBC:

    CBC: WBC: 25.16(5-10 x10 9/L

    WBC: 25.16(5-10 x10 9/L RBC:2.56 (4-6 x 12/L)

    RBC:2.56 (4-6 x 12/L) Hematocrit: 0.20(0.40-0.54)

    Hematocrit: 0.20(0.40-0.54) Hemoglobin::67(130-160 g/L

    Hemoglobin::67(130-160 g/L Segmenters: 0.87(0.50-0.65

    Segmenters: 0.87(0.50-0.65 Lymphocytes: 0.11(0.25-0.35

    Lymphocytes: 0.11(0.25-0.35 Platelet ccount: 690 (140-450 x


    10 0/L)
    Platelet ccount: 690 (140-450 x 10
    0/L)
    HEENT Subjective findings: Subjective findings:
    a) Hea (Not Applicable) (Not applicable)
    d
    and Fatigue
    face Objective findings:
    Objective findings: Dehydration
    b) Eye (+) Weak in appearance
    s (+) Weak in appearance
    c) Ear (+)Jaundice
    s (+)Dry oral mucosa and lips
    d) Nos (+)Dry oral mucosa and lips
    e
    e) Ora Lab result:
    l Lab result:
    Cav
    ity
    Neck Subjective findings: Subjective findings: No problem Identified
    (Not Applicable) (Not applicable)
    Objective findings:
    Objective findings:
    (-) stillness (-)stillness
    (-) lumps (-) lumps
    (-) vein engorgement (-) vein engorgement

    Respirator Subjective findings: Subjective findings:


    y system
    o Not applicable (Not applicable) No problem

    Objective findings: Objective findings:

    o RR: 20-21
    o No DOB
    o RR: 20-21bpm
    o Equal chest expansion
    o No DOB
    o Equal chest expansion

    Cardiovasc Subjective findings: Subjective findings:


    ular system
    (not applicable) (not applicable)
    Objective findings: Objective findings:
    PR: 80-90bpm PR: 80-90 bpm
    RR: 20-21 bpm RR: 20-21bpm Risk for decreased
    cardiac output
    BP: 140/70-180/100 mmH BP: 130/70-150/90 mmHg

    g
    Lab result: Lab result:

    ECG: NSTE-ACS ECG: NSTE-ACS


    Troponin: 47.7 Troponin: 47.7

    Breast and Not assessed Not assessed


    Axilla
    Gastrointes Subjective findings: Subjective findings:
    tinal
    Not applicable (Not applicable)
    system and
    the Objective findings:
    abdomen

    Objective findings: Imbalanced nutrition


    less than body
    (+) Normal bowel sounds
    requirements

    Polyphagia
    Wt. loss

    Genitourin Subjective findings: Subjective findings:


    ary/
    (Not Applicable)
    Reproducti
    ve system

    Objective findings: Objective findings: Fluid volume deficit


    (+) Polyuria
    (+) Polyuria Infection
    (+) Sweet foul smelling
    (+) Sweet foul smelling urine urine
    Lab result:
    Urinalysis

    + 3 Bacteria

    +3 sugar
    + Protein

    +Acetone

    Musculosk Subjective findings: Subjective findings:


    eletal
    (Not Applicable) (not applicable0
    system
    Objective findings:
    o
    Venoclysis mainline on
    left metacarpal vein 1L
    Objective findings: PNSS @ 80 cc/hour via
    o Venoclysis mainline on left infusion pump
    metacarpal vein 1L PNSS @ o C solution set of
    80 cc/hour via infusion pump ceftriaxone
    o C solution set of ceftriaxone  Side drip with Human
     Side drip with Human albumin 20% vial +20
    albumin 20% vial +20 mg mg Furosemide per vial
    Furosemide per vial to run to run for 2hrs q12hr
    Activity intolerance
    for 2hrs q12hr o
    o (+)Body weakness
    (+)Body weakness (+)Wound @Right foot pus Fatigue
    (+)Wound @Right foot pus filled- filled- purulent-swelling
    Infection
    purulent-swelling (+)Amputated 1st and 2nd digit
    right foot Impaired skin integrity
    (+)Amputated 1st and 2nd digit right
    foot (+) Edema on right foot Impaired physical
    mobility
    (+) Edema on right foot

    Neurologic Subjective findings: Subjective findings:


    system
    (Not Applicable (Not applicable)

    Objective findings:
    Decreased cardiac
    output
    o Coherent
    Objective findings: o Conscious
    o Conversant
    o Coherent
    o Conscious
    o Conversant
    o Dizziness

    Lymphatic/ Subjective findings: Subjective findings:


    Hematologi
    (Not Applicable)
    c system

    Objective findings:
    o Anemia Objective findings: Risk for bleeding
    o Thrombocytopenia
    o Anemia Anemia
    o Leukopenia
    o Thrombocytopenia

    Lab result:
    Lab result:

    WBC: 25.16(5-10 x10 9/L


    WBC: 25.16(5-10 x10 9/L
    RBC:2.56 (4-6 x 12/L)
    RBC:2.56 (4-6 x 12/L)
    Hematocrit: 0.20(0.40-0.54)
    Hematocrit: 0.20(0.40-0.54)
    Hemoglobin::67(130-160 g/L
    Hemoglobin::67(130-160 g/L
    Segmenters: 0.87(0.50-0.65
    Segmenters: 0.87(0.50-0.65
    Lymphocytes: 0.11(0.25-0.35
    Lymphocytes: 0.11(0.25-0.35
    Platelet ccount: 690 (140-450 x 10
    Platelet ccount: 690 (140-450 x
    0/L)
    10 0/L)

    Endocrine Subjective findings: Subjective findings:


    system (Not Applicable)

    Objective findings: Objective findings:


    o Hypoalbuminemia o Hypoalbuminemia
    Albumin: 27.1 (35-41ul/L)

    Lab result: Creatinine: 126.51(71-


    115umol/L
    Albumin: 27.1 (35-41ul/L)
    Albumin: 21.1(35-54g/L
    Creatinine: 126.51(71-115umol/L

    Albumin: 21.1(35-54g/L

    o HGT: 250(70-110mg/dL)
    o FBS:8.81 (3.3-5mmol/L
    o HGT: 250(70-110mg/dL) o Glycosylated
    o FBS:8.81 (3.3-5mmol/L hemoglobin: 7 (<7%)
    o Glycosylated hemoglobin: 7
    (<7%)

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