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Sheryl Ann B. Pedines Bsn-Iv Physical Assessment

The patient is a 32-year-old male who suffered thermal burns over 27% of his total body surface area, including burns on his right arm and right leg. He has pain and blistering on the burned areas of his body. His vital signs show an elevated pulse and blood pressure. The physical assessment examines his overall physical condition and notes the burns and their effects on his range of motion.

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Sheryl Ann Barit Pedines
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23 views

Sheryl Ann B. Pedines Bsn-Iv Physical Assessment

The patient is a 32-year-old male who suffered thermal burns over 27% of his total body surface area, including burns on his right arm and right leg. He has pain and blistering on the burned areas of his body. His vital signs show an elevated pulse and blood pressure. The physical assessment examines his overall physical condition and notes the burns and their effects on his range of motion.

Uploaded by

Sheryl Ann Barit Pedines
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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SHERYL ANN B.

PEDINES BSN-IV

PHYSICAL ASSESSMENT

Date of Assessment: June 07, 2021


GENERAL APPEARANCE: Patient Mario is 32 years old, lying on his bed and awake,
with an IVF of PLR inserted at the left dorsum of his hand, an IFC connected to a urine
bag and with oxygen inhalation of 2-3 LPM via nasal cannula. His look is congruent to
his actual age. His height appears normal for his age and weight inappropriate for his
height. He is endomorphic. He has a facial grimacing because of pain. His skin at the
anterior and posterior torso and the entire right arm and right leg has a stage 2 burn
wounds and his anterior neck has a stage 1 burn wounds. A diagnosis of thermal burn,
TBSA 27%. He communicates with maintained eye contact with expressions
appropriately suited with the situation. He was conscious and well oriented. Overall
health state was weak.
VITAL SIGNS
 Body Temperature – 37.0 C
 Respiratory Rate – 30 breaths/min
 Pulse Rate – 100 beats/min
 Blood Pressure – 140/90 mmHg
 Weight – 60 kg
HEAD TO TOE ASSESSMENT

HEAD
• Skull is round, symmetrical (normocephalic).
• No masses noted.
• Facial movement is symmetrical.
• Hair is dry in texture; its color is black.
• Scalp is clear from dandruff and lice.
• Face is symmetric, oval in shape appearance.
• No limited range of motion of flex, extend and side to side.

EYES
• Has symmetrical eyebrows movement, shape and hair distribution.
• Eyebrows have same color with hair.
• Eyelashes are evenly distributed and curled outward.
• Eyelids have no discharges and bilaterally blink.
• Upper lid covers the small portion of the iris and cornea.
• Lacrimal duct openings (puncta) are evident at nasal ends of upper and
lower lid with no tenderness noted.
• Palpebral conjunctiva is pinkish in color while the pupils constricted to
light (2mm), round in shape, isochoric, shows uniform convergence.
• Able to rotate eyes and has coordinated eye movements.
EARS
• Equal in size bilaterally
• Auricle aligns with the corner of each eye
• Auricle, and tragus are not tender
• With bean shaped, symmetrical earlobes
• Positive Whisper Test: able to identify the two syllable words with three trials
(shower, later)

NOSE
• Nasal septum is on midline.
• No tenderness palpated
• No lesion and pain frontal and maxillary sinuses
• With patent air way
• Able to determine the scent of perfume
• No discharges

NECK AND SHOULDER


• No presence of lumps or bulging masses.
• Thyroid cartilage and cricoid moves upward as the patient swallow
• Trachea is in midline
• No lymph nodes noted
• No limited ROM with smooth movements
• Carotid pulses are equally strong
• with pain, redness, and mild swelling, dry skin, and blanching erythema
at the anterior neck
• with blisters, redness/splotchy and severe pain at the anterior and
posterior shoulder.

MOUTH AND THROAT


• No foul or unusual odor noted
• Lips are dry
• Buccal is pink but dry
• Gums are pink, dry with no lesion noted
• Tongue is pink, dry with no lesions are present
• Frenulum is in midline
• Side of the tongue has no lesion
• Gag reflex elicited
• With pinkish throat, free of lesions
• Uvula hangs freely in midline

CHEST (Anterior and Posterior)


• Chest wall movement is symmetric.
• with blisters, redness/splotchy and severe pain at the anterior and
posterior chest.
• Scapulae are symmetric and non-protruding.
• Symmetric chest expansion
• Areolas are darker than the skin tone
• Sternum is at the midline and more prominent.
• Respiratory rate is 30 breaths per minute.
• Cardiac rate is 100 beats per minute.
ABDOMEN
• with blisters, redness/splotchy and severe pain at the anterior and
posterior abdomen.
• Umbilicus is at midline.
• Slightly rounded and symmetric
• Umbilicus and surrounding area are free of swellings, bulges, or masses.

GENITALIA
• With an IFC connected into a urine bag
• Urine Output of 250 ml.

UPPER EXTREMITIES
• with blisters, redness/splotchy and severe pain at the right arm.
• IV insertion site on the left dorsum of the hand
• Shoulder, arms, elbows, wrists, hands and fingers are symmetric
• No lesions, edema, lumps, or nodules noted.
• Skin is warm bilaterally from fingertips to upper arms
• With good capillary refill of 2 seconds
• Radial and brachial pulses are weak
• Limited range of motion in the right arms, elbows, wrist, hands and fingers
with smooth movements
• Limited range of motion against resistance with muscle strength in arms is
slightly good due to burn.

LOWER EXTREMITIES
• with blisters, redness/splotchy and severe pain at the right leg.
• No lesions, non-tender, are noted.
• Toes, feet and legs are equal warm bilaterally
• Hips are stable, non-tender and without crepitus
• No movement of the patella is noted
• With good capillary refill of 2 seconds
• Difficult to palpate popliteal pulse, dorsalis pedis pulse
• Limited range of motion in legs, hips, knees, ankles and feet against resistance
with muscle strength weak.

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