health assessment2.pptx

8/9/2019 health assessment2.pptx

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DOW UNIVERSITY OF

HEALTH SCIENCES


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HEALTH ASSESSMENT


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INDIVIDUAL PRESENTAIONOf

H.ACLIENT DIAGNOSED WITH

A 60 Year old lady !"# $ell%l!"!&.'Y

Far#ee( Sadr%dd!( Da"oo

Da"ed)*+a( ,0-0,Fa$%l"y)/a R%1!(a

Pro2rae)'S$N Ge(er!$ Year II Se

III


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O'+ECTIVES

• At the end of this presentation studentswill be able to:

• Dene Cellulitis

• Discuss its causes, s!pto!s "pathophsiolo#$

•Describe %atients& prole• 'dentif its chief co!plaints

• 'llustrate its re(iew of sste!s and health

e)a!ination$


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O13e$"!4e& of "#e S"%dy

Ge(eral O13e$"!4e – This case stud is desi#ned for the student

nurses to beco!e practiced, well*infor!edand !annered in deli(erin# holistic careand a #uide to phsical e)a!ination for

patients dia#nosed with Cellulitis$


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• Cellulitis is a s+in infection thatde(elops as a result of bacterialentr (ia breaches in the s+in barrier$

• Manifests as erthe!a, ede!a, andwar!th$

• %redisposin# factors includedisruption to the s+in barrier as aresult of trau!a, ina!!ation,pree)istin# s+in infection -ie tinea

pedis., and ede!a$

Denition


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Ca%&e&

• Cellulitis occurs when one or !oretpes of bacteria enter throu#h a crac+or brea+ in our s+in$

• The two !ost co!!on tpes ofbacteria that are causes of cellulitis arestreptococcus and staphlococcus$ The

incidence of a !ore seriousstaphlococcus infection called!ethicillin*resistant Staphlococcus

aureus -M/SA. is increasin#$


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Cont 0

• Althou#h cellulitis can occur anwhereon our bod, the !ost co!!onlocation is the lower le#$ 1acteria is

!ost li+el to enter disrupted areas ofs+in, such as where ou2(e had recentsur#er, cuts, puncture wounds, an

ulcer, athlete2s foot or der!atitis$


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Cont$$

• Certain tpes of insect or spider bitesalso can trans!it the bacteria thatstart the infection$ Areas of dr, a+

s+in also can be an entr point forbacteria, as can swollen s+in


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Po&&!1le &!2(& a(d &y5"o& of$ell%l!"!& !($l%de)

• /edness

• Swellin#

• Tenderness• %ain

• 3ar!th

• 4e(er


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I($%1a"!o(

• Cellulitis can de(elop in as little as67 hours or can ta+e das tode(elop$


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PATIENT HEALTHHISTORYPATIENT PROFILE


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A. '!o2ra5#!$ Da"a

Na!e: Sha8ue 1e#u!$

A#e: 9 ears old$

M/ no: 699;$Date of Ad!ission: Dec 4ar=ana$


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'./EDICAL DIAGNOSIS

• Abscess with Cellulites at ri#ht le#$


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C. C#!ef Co5la!("

'nfected 3ound at /i#ht Le#$

Swellin# at the /i#ht le#$


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N ? / S ' N @ A S S E S S M E N T

C#!ef Co5la!(")

'nfected 3ound at /i#ht Le#

H!&"ory of Pre&e(" Ill(e&&)

4our das onset of pustule li+e

lesions on the ri#ht le# which laterbeco!e enlar#ed and erthe!atouswith tenderness and local swellin#$

Pa&" /ed!$al H!&"ory)Asth!a$


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E. Fa!ly H!&"ory of Ill(e&&

'n their fa!il there is no histor ofdiseases or illness$ 1ut her husband stated

that his brother had an histor ofhpertension$


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G. So$!al Da"a

• Mrs sha8ue be#u! is a 9 ear old lad$

• She li(es with her fa!il and has two

!arried children$• 'n her spare ti!in#s she usuall dostitchin# and read reli#ious boo+s$


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H. P&y$#o&o$!al Da"a

• No hallucinations and delusions$

• Durin# ad!ission she was aware that

she&s in the hospital$• btunded LC$

• Able to recall past and recent e(ents$


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REVIEW OF SYSTE/S AND

PHYSICAL ASSESS/ENT


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A. Ge(eral A55eara($e

3ei#ht: B +#

Hei#ht: feet inches

Le(el of Consciousness: btunded1od 1uild: Endo!orphic

%osture and @ait: ?nable to stand and

wal+


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LEVEL OF CONSCIOUSNESSAND HYGIENE

• The patient was awake, lying on bed in supine position but

is less sharp or dull , but not in distress. She looks

according to age and is calm and engaging. One can seethat she is well nourished and practices good hygiene, a

well groomed personality.

• The patient was responsive to verbal and nonverbal stimuli.


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VITAL SIGNS

Temp=36.5˚C P=79/min

R=22/min

BP=120/80 mm of Hg


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Genera P!"#i$a %##e##men&

'()*+ The patient’s skin’s moisture is dry due to dehydration. The texture isrough due to aging and signs o dehydration.

H,%-+ The patient’s head was round and in proportion w! the body. "aircolor is white and has no dandru and lice. The patient’s general

appearance o ace indicates a eeling o weakness.

*,C( an 'H-,R'+ The veins and clavicle are visible. The shouldersare asymmetrical. The neck muscles are weak.

,,'+The patient’s eyes are symmetrical to the ears. She maniested ablurred vision due to aging. #ale con$unctivae was noted. Sunken eyeswas observed. The eyes appeared dry due to dehydration.


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,%R'+The client’s ear maniested a good hearing balance. There wereno discharges noted.

*',+ The client’s nasal septum is intact and in the midline. Therewere no discharges noted. %irs move reely as the client breathesthrough the nose.

TH an THR%T+ The client’s mouth has presence o lesions dueto re&uent vomiting. The lips were dry due to dehydration. The throat

was unctioning well. 'entures present. There is a black discolorationin the enamel.

CH,'T+ The chest is symmetric. The skin was sagged. The thorax iselliptical.

%B-,*+ The skin o the abdomen is unblemished and uniorm incolor. Symmetric abdominal contour lattened and rounded. %udiblebowel sounds. Symmetric movements cause by respiration. (otenderness noted. )licks * gurgles sounds were + times per minute.


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,4TR,)T),'+ The ingers in both hands and eet are complete.

-n lower extremities ,the has so many scars and lesions.

-n lower xtremities/ Swelling erythema.


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Bo" Par&

%##e##e

Te$!nie

#e

%$&a ining )n&erpre&a&ion

Skin -nspection

#alpation

#t Skin color was air and even

Skin was dry, poor skin turgour

(ormal

'ue to

dehydraion

Bo" Par& Te$!nie %$&a ining )n&erpre&a&ion


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"

%##e##e

#e

g p

HEENT Head'nspection

%alpation

Eye&

'nspection

Nor!ocephalicE(enl distributed hair, nodandru> or Se1orr#eadera"!"!& lesions$

Sinuses non*tender

S!!etrical eelidsClear and !oist conucti(a

Anicteric sclera Nearsi#htness*%E//LA*(isual elds nor!al

Nor!alNor!al

Nor!al

Nor!alNor!al

Nor!al

Si#ns of

A#in#

Nor!al


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Bo" Par&

%##e##e

Te$!nie

#e


Ear&

No&e

'nspection %alpation

'nspection

%alpation

No dischar#eNon tenderNo presence of !ass ornodules

S!!etrical nasal foldsNasal septu! at !idlineMucosa is !oist, pin+ish,intact and no dischar#e

Non tender sinuses

Nor!alNor!alNor!alNor!al

Nor!alNor!alNor!alNor!al

Nor!al


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Bo" Par&

%##e##e

Te$!nie #e %$&a ining )n&erpre&a&ion

Mouth,%harn)and Nec+

/o%"#'nspection

P#ary(7'nspection

Ne$8 'nspection

%alpation

Lips pin+ish and dr Ton#ue at !idline@u!s and !ucosa pin+%resence of dentures

?(ula at !idline Tonsils not ina!ed

Nec+ s!!etrical with full/M Trachea at !idlineL!ph nodes non tender

Nor!alNor!alNor!alA#in#-decalcication.

Nor!alNor!al

Nor!al

Nor!alNor!alNor!al


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Bo" Par&

%##e##e

Te$!nie

#e


%ul!onar 'nspection

%alpation

Auscultation

S!!etric

S!!etrical lun# e)pansionS!!etrical tactile fre!itus

Clear lun# soundsNo ad(entitious breathsounds

Nor!alNor!al

Nor!alNor!al

Nor!alNor!alNor!al


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Bo" Par&

%##e##e

Te$!nie

#e


Cardio(ascular

Abdo!en

Auscultation

'nspection

Auscultation

%ercussion

Pal5a"!o(

S< " S6 best heard at th 'CSMCLNo !ur!urs or hea(es heard$

4lat and s!!etricalNo lesions

Clic+ o #ur#les heard at 9ti!es per !inutes$

T!panic o(er LLF

Dull at /?F, L?F and /LF

No tenderness

Nor!al

Nor!alNor!alNor!al

Nor!al Nor!al

Nor!al


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Bo" Par&

%##e##e

Te$!nie

#e


E)tre!ities

@enitourinar

'nspection

%alpation

S+in drS+in intact

Nails con(e) cur(ed%in+ nail beds

Nor!al capillar rellS+in cool to touchMuscles with sli#ht atroph

!uscle stren#th wea+nessDiGcult in standin# "wal+in#

%t refusal, as per patientstate!ent #enitourinarsste! was nor!al$ Noproble! associated with it$

Due todehdration

Nor!alNor!alNor!al

< secA#in# process

Nor!al'nfection

Motor

Sensor

'nspection


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/E4E/ENCES

• http:JJwww$!aoclinic$co!JhealthJcellulitis

• Habif T%, ed$ Clinical Dermatology $th ed$ %hiladelphia, %a: MosbElse(ierK 6K chap $


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health assessment2.pptx

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