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    Nursing Assessment Icp

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    Real Tetisora
    The patient underwent a full nursing assessment on August 23, 2018. [1] The neurological exam found the patient not oriented and intubated with a low GCS score, but responsive to pain. [2] Exams of the eyes, ears, nose, mouth, throat, respiratory, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, and integumentary systems found various abnormalities related to the patient's critical condition including edema and abnormal vital signs. [3] The patient's usual activities and present lethargic behavior were noted, along with the family's concerns over the patient's survival.

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    Nursing Assessment Icp

    Uploaded by

    Real Tetisora
    12 views3 pages
    The patient underwent a full nursing assessment on August 23, 2018. [1] The neurological exam found the patient not oriented and intubated with a low GCS score, but responsive to pain. [2] Exams of the eyes, ears, nose, mouth, throat, respiratory, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, and integumentary systems found various abnormalities related to the patient's critical condition including edema and abnormal vital signs. [3] The patient's usual activities and present lethargic behavior were noted, along with the family's concerns over the patient's survival.

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    The patient underwent a full nursing assessment on August 23, 2018. [1] The neurological exam found the patient not oriented and intubated with a low GCS score, but responsive to pain. [2] Exams of the eyes, ears, nose, mouth, throat, respiratory, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, and integumentary systems found various abnormalities related to the patient's critical condition including edema and abnormal vital signs. [3] The patient's usual activities and present lethargic behavior were noted, along with the family's concerns over the patient's survival.

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

    Nursing Assessment Icp

    Uploaded by

    Real Tetisora
    The patient underwent a full nursing assessment on August 23, 2018. [1] The neurological exam found the patient not oriented and intubated with a low GCS score, but responsive to pain. [2] Exams of the eyes, ears, nose, mouth, throat, respiratory, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, and integumentary systems found various abnormalities related to the patient's critical condition including edema and abnormal vital signs. [3] The patient's usual activities and present lethargic behavior were noted, along with the family's concerns over the patient's survival.

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    © All Rights Reserved
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    Download as docx, pdf, or txt
    of 3

    NURSING ASSESSMENT

    REVIEW OF SYSTEMS

    Date & Time of Assessment: August 23, 2018, 11:00 AM

    NEUROLOGICAL

    The patient was not oriented to time and date; he is intubated with GCS 7. Prior to admission
    patient did not experience nausea and vomiting. During assessment, the client was responsive to
    pain and moves to localized pain.

    EYE/VISION

    Periorbital edema noted, both eyes are coordinated with cloudy white sclera, lids close
    symmetrically and blinks involuntarily, with parallel alignment. Pupils are black with equal in
    size and round reactive to light and accommodation, with slightly pale lid margins and
    conjunctiva. Patient doesn’t recognized his family.

    EARS/HEARING

    The ears are symmetrical with the same color with his facial skin. When palpating for the
    textures the auricles are mobile, firm and not tender. The pinna coils when folded. Patient can
    hear with no unusualities.

    NOSE

    The nose appeared symmetric, straight and uniform in color. There was no presence of discharge
    or nasal flaring. When lightly palpated, there was no tenderness and lesions. Patient’s nasogastric
    tube is intact and patent.

    MOUTH/TONGUE/TEETH/SPEECH

    The client has endotracheal tube connected to mechanical ventilator with 90% of oxygen .The
    lips of the client appear pale and dry. His tongue is centrally located and can move freely. He
    can't speak because the patient is intubated. Tooth extraction done.

    53
    THROAT/NECK

    The neck muscles are equal in size. The client showed coordinated, smooth head movements
    with no discomfort. The lymph nodes of the client are palpable. The thyroid gland is not visible
    on inspection and the gland ascends during swallowing but is not visible.

    RESPIRATORY SYSTEM

    Patient experience tachypnea .Crackles is noted upon auscultation on both lung fields. Chest
    movements are shaky due to respiration.

    CIRCULATORY/ CARDIOVASCULAR

    Patient has electrodes attached to electrocardiogram with cardiac rate of 150 beats per minute
    and BP of 160/100 mmHg. No abnormal sounds and murmurs heard upon auscultation .Capillary
    refill time is 2 seconds and reported no chest pain.

    GASTROINTESTINAL

    The patient has no complain of gastric pain but with abdominal distended noted. The umbilicus
    is medially located with hypoactive bowel sound noted upon auscultation.

    GENITOURINARY

    The client has Foley catheter attached to urobag with dark colored urine in small amounts.

    MUSCULOSKELETAL

    No bone pain reported. He moves extremities due to pain and gravity. Pitting edema is noted on
    extremities. Both arms are free of restraints.

    INTEGUMENTARY

    The client’s hands and legs have edema. Skin’s temperature is within normal range. The hair of
    the client is thin, shiny and evenly distributed and has a variable amount of hair and the client
    has a slight brown colored nail on a convex curve shaped. It is smooth and intact to the
    epidermis.

    54
    ACTIVITIES OF DAILY LIVING

    The usual activity of patient before his admission was when he woke up early in the morning he
    fetch water and dig the flowers and vegetables at the backyard. He goes to school every
    weekdays as a Grade 7 student at Matiao National High School. After his class, he goes home to
    do household chores then plays computer games after doing it, He also asked for his mother to
    give him 10 pesos to buy junkfoods.

    PRESENT BEHAVIOR

    He was lethargic and always sleeping, reacts only when pain is introduced.

    FAMILY CONCERNS

    The family is concern with the survival rate of their patient since they was inform later in the
    morning that the patient experienced abnormalities of vital signs.

    55

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