CVA Physical Assessment
Physical Assessment
Date:
Time:
General Appearance: The patient is female, lying in bed, with #5 0.9 NaCl @ 80 gtts per minute @ 900 cc hooked @ left metacarpal vein, patent and infusing well. The patient is wearing white shirt and blue pajama. The patient is slightly well groomed even though she can’t do her daily activities and hygienic activities such as combing her hair, brushing her teeth, changing her clothes, trimming her nails and even bathing. The patient has impaired verbal communication. With Foley catheter attached to urobag, draining 100 cc yellow color urine.
Vital Sign:
Blood Pressure:
Respiratory Rate:
Pulse Rate:
Temperature:
Head/Hair/Scalp: Inspection: Skull is rounded, no dandruff and lice noted. The hair is black and slightly smells bad. Hair is evenly distributed. Palpation: No tenderness noted.
Eyes: Inspection: The condition of eyes is slightly normal; the eye brows are evenly distributed with skin intact, and eyelashes are equally distributed with intact eyelids. No discharges or discoloration noted. Pink conjunctiva noted and the patient looks at her left steadily.
Ears: Inspection: Auricles are in the same color as facial skin color, symmetrical, lymph nodes are enlarged. Palpation: Lymph nodes are palpable.
Nose: Inspection: Nose is symmetrical and at the midline. No discharges noted. No abrasion. Palpation: No tenderness noted upon palpation of maxillary and frontal sinuses.
Moth: Inspection: Lips is slightly pale in color and dry, tongue is slightly in left position. Gums are intact and pinkish in color.
Chest and Respiratory: Inspection: Normal chest wall. Patient has spontaneous breathing with respiratory rate of ___cpm noted. Cough is noted. Palpation: No bulges noted, no tenderness, masses noted. Auscultation: Wheezing noted upon auscultation.
Cardiovascular: Auscultation: The heart is within ___bpm cardiac rate.
Abdomen: Inspection: Skin is of normal racial tone which is brown; the contour is flat,
Date:
Time:
General Appearance: The patient is female, lying in bed, with #5 0.9 NaCl @ 80 gtts per minute @ 900 cc hooked @ left metacarpal vein, patent and infusing well. The patient is wearing white shirt and blue pajama. The patient is slightly well groomed even though she can’t do her daily activities and hygienic activities such as combing her hair, brushing her teeth, changing her clothes, trimming her nails and even bathing. The patient has impaired verbal communication. With Foley catheter attached to urobag, draining 100 cc yellow color urine.
Vital Sign:
Blood Pressure:
Respiratory Rate:
Pulse Rate:
Temperature:
Head/Hair/Scalp: Inspection: Skull is rounded, no dandruff and lice noted. The hair is black and slightly smells bad. Hair is evenly distributed. Palpation: No tenderness noted.
Eyes: Inspection: The condition of eyes is slightly normal; the eye brows are evenly distributed with skin intact, and eyelashes are equally distributed with intact eyelids. No discharges or discoloration noted. Pink conjunctiva noted and the patient looks at her left steadily.
Ears: Inspection: Auricles are in the same color as facial skin color, symmetrical, lymph nodes are enlarged. Palpation: Lymph nodes are palpable.
Nose: Inspection: Nose is symmetrical and at the midline. No discharges noted. No abrasion. Palpation: No tenderness noted upon palpation of maxillary and frontal sinuses.
Moth: Inspection: Lips is slightly pale in color and dry, tongue is slightly in left position. Gums are intact and pinkish in color.
Chest and Respiratory: Inspection: Normal chest wall. Patient has spontaneous breathing with respiratory rate of ___cpm noted. Cough is noted. Palpation: No bulges noted, no tenderness, masses noted. Auscultation: Wheezing noted upon auscultation.
Cardiovascular: Auscultation: The heart is within ___bpm cardiac rate.
Abdomen: Inspection: Skin is of normal racial tone which is brown; the contour is flat,