Pinky Assessment Part2

8/10/2019 Pinky Assessment Part2

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II. Assessment

PHYSICAL ASSESSMENT

General Survey

Received lying on bed conscious, responsive and coherent. Fairly groomed. With

clean and intact top dressing at right lower quadrant. With IVF #4 !"" $ in%using

well at the right dorsal metacarpal vein regulated at &' gtts(min. )n !). *apillary

re%ill o% + sec.

Vital Signs

ate "hi%t -ime *R R RR -emp.'/0+/0& 10& 23''am 2 22 2 +(2& &1.4

+3''p

m

' + &'(2' &1.'

"5in

rown s5in generally uni%orm in color in areas e6cept in areas e6posed in the sun

!o 7aundice

!ormal capillary re%ill time +sec.

8ead

!o head and scalp lessions

"ymmetric %acial %eatures and movements

"ymmetric nasolabial %olds

9venly distributed blac5 hair

!o in%estations

9yes


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9yebrows symmetrical with equal movement

9yelashes equally distributed and curled slightly outward

"5in o% eyelids intact with no discoloration

9yelids close symmetrically

ilateral blin5ing e6hibited

!o discharges

"lightly in pale palpebral con7unctiva

Iris blac5 in color

upils equals in si:e with smooth borders

Illuminated pupils constricts

upils converge when near ob7ect is moved toward the nose

When loo5ing straight ahead, the client can see ob7ects in the periphery

oth eyes coordinated, move in unison with parallel alignment

9ars

*olor same as %acial s5in

"ymmetrically aligned

inna immediately recoils a%ter it is %olded

inna is not tender

!o lesions or discoloration

!ormal voice tones audible

;ble to hear tic5ing o% a watch in both ears


3/15

!ose

"ymmetric and straight

!asal septum intact and in the midline


4/15

*hest wall intact, no tenderness, no masses

"ymmetric chest e6pansion and e6cursion

9ndothelin0converting 9n:yme 9*9, >?@ crac5les, >?@ whee:es

Respiratory rate 2

=astrointestinal(;bdomen

=lobular

!ormoactive bowel sounds

!o splenomegaly

!o hepatomegaly

"o%t

-ympanic

!o tenderness

=enitoArinary

!o tenderness when urinating


5/15

*onscious

*oherent

G. COUSE IN THE !A"

"ate#S$i%t

Nurse&s

Assessment

Nurse&s

Interventi'n

Me(i)al

management

*+,-/-+,-*01 Ris5 %or %luid

de%iciency

Regulate IVF B

desired rate

IVF therapy

Ris5 %or in%ections


6/15

2. La3'rat'ry 2in(ings

La3'rat'ry e4am

N'rmal

Value 5H's6ital7ase(8

esult Inter6retati'n#Im6li)ati'n

Hem'gl'3in 4'01'g($ 4' !ormalHemat')rit '.4'0'.E' '.4' !ormal

Lym6$')ytes '.&E0'.EE '.2 When the lymphocyte

count is lowered, the

bodys ability to resist and

%ight o%% in%ections is

severely compromised and

its susceptibility to cancer

is increased. In addition,

low lymphocyte counts

may also lead to damage

to various organs.http3((www.md0health.com($ow0$ymphocytes.html

;uto*rea Result !ormal Values Interpretations(Implications

Gm(d$
http://www.md-health.com/Low-Lymphocytes.htmlhttp://www.md-health.com/Low-Lymphocytes.html


7/15

1E.4

!a? &&.4 &E04E m9q($ ecreased levels

>hyponatremia@ may be

caused by3 vomiting,

diarrhea, gastric suction,

e6cessive perspiration,

continuous IV EH

e6trose(water low0

sodium diet, burns,

in%lammatory reactions,

tissue in7ury, others.

D? 4.++ &.E0E.' m9q($ !ormal

*a? 'E E0'E m9q($ !ormalhttp3((www.nurseslearning.com(courses(nrp(labtest(course(section4(
http://www.nurseslearning.com/courses/nrp/labtest/course/section4/http://www.nurseslearning.com/courses/nrp/labtest/course/section4/


8/15

INTRODUCTION

The appendix is a closed-ended, narrow tube that attaches

to the cecum (the frst part o the colon) like a worm. (The

anatomical name or the appendix, vermiorm appendix,

means worm-like appendage.) The inner lining o the appendix

produces a small amount o mucus that ows through the

appendix and into the cecum. The wall o the appendix

contains lmphatic tissue that is part o the immune sstem

or making antibodies. !ike the rest o the colon, the wall othe appendix also contains a laer o muscle.

"cute appendicitis can occur when a piece o ood, stool or

ob#ect becomes trapped in the appendix, causing irritation,

inammation, and the rapid growth o bacteria and inection.

"cute appendicitis can also happen ater a gastrointestinal

inection. $arel, a tumor ma cause acute appendicitis.

%ometimes the cause o acute appendicitis is not known. The

inammation is usuall caused b a blockage, but ma be caused

b an inection. &ithout treatment, an inamed appendix can

rupture, causing inection o the peritoneal cavit (the lining

around the abdominal organs) and even death.

"ppendicitis is one o the most common causes o

emergenc abdominal surger. 'p to ,*** appendectomies are

done each ear in the '.%. The estimated population in the
http://www.medicinenet.com/script/main/art.asp?articlekey=2312http://www.medicinenet.com/script/main/art.asp?articlekey=2658http://www.medicinenet.com/script/main/art.asp?articlekey=2787http://www.medicinenet.com/script/main/art.asp?articlekey=4450http://www.medicinenet.com/script/main/art.asp?articlekey=3907http://www.medicinenet.com/script/main/art.asp?articlekey=2312http://www.medicinenet.com/script/main/art.asp?articlekey=2658http://www.medicinenet.com/script/main/art.asp?articlekey=2787http://www.medicinenet.com/script/main/art.asp?articlekey=4450http://www.medicinenet.com/script/main/art.asp?articlekey=3907


9/15

+hilippines is , /0, 1 and the incident rate o acute

appendicitis is 0,*/ as o ear *00. "ppendicitis is one o the

more common surgical emergencies, and it is one o the most

common causes o abdominal pain. 2n the 'nited %tates, *,***

cases o appendicitis are reported annuall, representing 0 million

patient-das o admission. The incidence o acute appendicitis has

been declining steadil since the late 01/*s, and the current

annual incidence is 0* cases per 0**,*** populations.

"ppendicitis occurs in 3 o the '% population, with an incidence

o 0.0 cases per 0*** people per ear. %ome amilialpredisposition exists.

2n "sian and "rican countries, the incidence o acute

appendicitis is probabl lower because o the dietar habits o the

inhabitants o these geographic areas. The incidence o

appendicitis is lower in cultures with a higher intake o dietar

fber. 4ietar fber is thought to decrease the viscosit o eces,

decrease bowel transit time, and discourage ormation o

ecaliths, which predispose individuals to obstructions o the

appendiceal lumen.

2n the last ew ears, a decrease in re5uenc o appendicitis

in &estern countries has been reported, which ma be related to

changes in dietar fber intake. 2n act, the higher incidence o

appendicitis is believed to be related to poor fber intake in such

countries.


10/15

There is a slight male preponderance o 67 in teenagers and

oung adults8 in adults, the incidence o appendicitis is

approximatel 0./ times greater in men than in women. The

incidence o primar appendectom is approximatel e5ual in

both sexes.

The incidence o appendicitis graduall rises rom birth,

peaks in the late teen ears, and graduall declines in the

geriatric ears. The mean age when appendicitis occurs in the

pediatric population is -0* ears. !mphoid hperplasia isobserved more oten among inants and adults and is responsible

or the increased incidence o appendicitis in these age groups.

9ounger children have a higher rate o peroration, with reported

rates o *-3. The median age at appendectom is ears.

"lthough rare, neonatal and even prenatal appendicitis have been

reported. :linicians must maintain a high index o suspicion in all

age groups.

"cute appendicitis can occur in an age group or population.

;owever, it most oten occurs in teens and oung adults. 2t is rare

in children ounger than two ears o age. :lassic smptoms o

acute appendicitis include pain in the right lower abdomen, where

the appendix is located, that gets progressivel sharp and more

intense. +ain increases when pressure is put on the area (called

the s point), and the area becomes even more painul

and tender when the pressure is released (rebound tenderness).


11/15

This is one exam a health care provider uses to diagnosis acute

appendicitis. The smptoms o acute appendicitis can var, and

not all people with acute appendicitis will experience the tpical

smptoms o abdominal pain. 2n earl acute appendicitis,

the abdominal painma be located around the navel or bell

button area, then move to s point as acute appendicitis

progresses.

"cute appendicitis that is not treated promptl leads to lie-

threatening complications. :omplications o acute appendicitisinclude7 "bdominal abscess, +eritonitis (inection o the lining that

surrounds the abdomen), $uptured appendix, %epsis, %hock.

"s teen-agers living in a ast-phased world and governed b

schedules, the too are predisposed to liestle modifcation ?

especiall diet and ood preerences which can contribute to the

disease. &ith this stud, the student nurses hope to appl their

learning in taking care not onl o their patients but also o

themselves.

"s nursing students and uture nurses, we would want to

understand and appreciate more on what is happening to a

patient with acute appendicitis. :onse5uentl, we are interested

on what will be the necessar management that will be given. "ll

in all, these will help us to become e@cient nurses and better

persons later on.
http://www.bettermedicine.com/category/digestive-system/abdominal-painhttp://www.bettermedicine.com/category/digestive-system/abdominal-pain


12/15

OBJECTIVE OF THE STUDY

The ob#ectives o this stud are as ollows8

Anow how it is maniested and how it is diagnosed.

Trace the disease process which is related to the actual condition o

the patient.

$ecogniBe the medical care o the client and know the signifcance

o the medical managements rendered.

$ecogniBe the signifcance o all diagnostic tests given to the

client.

Cormulate and implement an eDective nursing care plan especialldesigned or client>s problems as identifed in the nursing

assessment.

Encourage empath and compassion to dealing with these patients

To widen and enhance the students nurse>s knowledge and skill>s

through additional research about the nature o the disease, its sign

and smptoms, its phatophsiolog, its diagnosis and treatment.

+rovide appropriate health teachings to patients with these disease

conditions

Signs and

Symptoms

Presen

t

!sent Rationa"e

$ight !owerFuadrant +ain

#

$ight lower-5uadrant pain that isproduced with either the passive

extension o the patientGs right hip

(patient ling on let side, with knee

in exion) or b the patientGs active

exion o the right hip while supine.


13/15

The pain elicited is due to

inammation o the peritoneum

overling the iliopsoas muscles and

inammation o the psoas muscles

themselves. %traightening out theleg causes pain because it stretches

these muscles, while exing the hip

activates the iliopsoas and

thereore also causes pain.

%ource7 (http7HHwww.ree-

ed.netHsweethavenHscienceHbiologHanatomphsiolH;uman*0I!esson

Pinky Assessment Part2

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Transcript of Pinky Assessment Part2