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General Assessment

a. PHYSICAL (DILLON’S PHYSICAL ASSESSMENT TOOL).

Table 1.Physical Assessment

GENERAL NORMS ACTUAL FINDINGS INTERPRETATION/ANALYSIS

APPEARANCE
Posture/Gait Posture is erect and position is relaxed With good posture and coordination. Normal
Skin Color “Normal” varies depending on race or Skin color is dark brown. A little dry Skin texture and color can be
ethnic background, complexion, sun and has few scars. associated with altered metabolic
exposure, pigmentation tendencies. processes of the disease. CKD patient
usually has elevated phosphorus and
urea in the blood that causes dark
skin color and pruritus.
Personal Hair well-trimmed, well brushed, no foul Hair is trimmed and combed. No foul The client is able to perform hygienic
Hygiene/Grooming body odor, takes a bath at least once per bodily odor noted. Takes a bath once or practices independently.
day, does oral care after meals. twice a day and does oral care every
after meal.

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Nutritional Status Nutritional intake is per orem. Due to Client regulates his food intake but
condition intake of food and water are still lacks understanding on dietary
limited to avoid fluid overload and restrictions.
other complication. Still eats whatever
food that he likes but there’s a
limitation.

Verbal Behavior Words of choice are in relation to each Patient is respectful and Client cooperates, very attentive, and
other to form one common idea. accommodating ask questions that shows his
interested on the study.
TPR Temperature:36.5 – 37.5 oC Temperature: 36.8 0C The client temperature, pulse, and
B/P Pulse: 60 – 100 beats per minute Pulse: 84 bpm respiration are within normal range.
Weight Respirations: 15 -20 breaths per minute Respiration: 19 bpm The blood pressure is not in normal
Height Blood Pressure: Blood Pressure: range. High BP in patient undergoing
Systole 90>&<120mmHg Systole 160 mmhg dialysis or with ESRD is the result of
Diastole 60>&<80 mmHg Diastole 80 mmhg extracellular volume expansion,
Desirable BMI: Weight: 57.5kg (after dialysis 51-54kg) increased or inappropriate response
20 – 29 years old = 183.9 pounds =26.8 Height: 5’3” (160.2 centimeter) of the renin-angiotensin system and
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kg/m BMI: 19.9 (underweight) over activity of the sympathetic
system.
Body parts Norms Actual Findings Interpretation/Analysis
Hair Evenly distributed, silky, resilient, no Hair is evenly distributed and thick, no Client has normal hair distribution.
infection or infestation infection or infestation noted.
Face and Skull Skull round, smooth skull contour, absence Skull is round and no nodules and Normal
of nodules and masses. masses noted during palpitation.

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Facial feature is symmetric or slightly Symmetric facial feature and
asymmetric. Facial movements movements.
symmetrical.

Eyebrows Hair evenly distributed; skin intact. Hairs in the eyebrows are evenly Normal
Eyebrows symmetrically aligned; equal distributed but a little bit thin and skin
movement. is intact. It’s symmetrically aligned
and moves equally.

Eyelashes Equally distributed eyelashes; curled Eyelashes is equally distributed and Normal
slightly outward. slightly curled outward.

Eyelids Skin intact; no discharge; no discoloration. No discharges and discoloration noted. Normal
Lids close symmetrically. When lids open, Skin is intact and closes symmetrically
no visible sclera above corneas, and upper with bilateral involuntary blinking.
and lower and borders of the cornea are
slightly covered
Lid Margins Shiny smooth with no signs of Shiny smooth with no signs of Normal
inflammation. inflammation.

Sclera White in color. Yellow in white-skinned Sclera is white in color. With a 20/20 Normal
people. Capillaries sometimes vision.
evident.VA=20/20

Eye Movement Both eyes coordinated, move in unison, Eye movement is coordinated and in Normal
with parallel alignment. unison with parallel alignment.

Ears Color same as facial skin. Symmetrical. Ears color is same as facial skin. Normal
Auricle aligned with outer canthus of eye. Symmetrical. Auricle aligned with

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Pinna is mobile, firm, and not tender; pinna outer canthus of eye. Pinna is mobile,
recoils after it is folded. firm, and not tender; pinna recoils after
it is folded.
Ear canal Distal third contains hair follicles and Some cerumen noted and hair follicle Normal
glands. Sticky wet cerumen in various visible inside the ear canal upon
shades of brown. inspection.

Hearing Acuity Sound in heard in both ears. Hearing is good. Sounds heard in both Normal
ears.

Nose Symmetric and straight. No discharge or The nose is symmetric and straight. Normal
flaring. Air moves freely as the client Upon inspection no discharges noted.
breaths through the nares. No problem breathing. Air moves
freely as his breaths through the nares.

Mouth (lips) Pink in color. Soft, moist and smooth Soft, moist and smooth texture of the Normal
texture of the lips. Ability to purse lips. lips. Pink in color.

Gums Pink gums, moist, firm texture of gums. Moist, firm texture and pink gums Normal

Teeth Smooth, white, shiny tooth enamel. Smooth Complete dentures. White, shiny and Normal
intact dentures. smooth teeth.

Tongue Central position. Pink color. Smooth lateral Tongue moves freely. Is in central Normal
margins; no lesions. Moist, moves freely, no position. Moist, no lesions and no
tenderness. tenderness noted.
Neck Neck muscles are equal in size and head is Neck muscles are equal in size and Normal
centered. When asked to move head it is head is centered. Head moves in

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coordinated. Trachea is in central placement coordination. Upon palpation and
in midline of the neck and spaces are equal inspection thyroid gland Is not visible.
on both. Thyroid gland is not visible upon
inspection and ascends during swallowing.
Neck ROM Coordinated smooth movements with no Coordinated smooth movements with Normal
discomfort. Head flexes 45 degrees; no discomfort. Equal strength when
hyperextend 60 degrees; laterally flexes 40 turning head to one side against the
degrees and laterally rotates 70 degrees. resistance of hand.
Equal strength when turning head to one
side against the resistance of a hand.
Thorax/ lungs Anteroposterior diameter of the thorax in Thorax is symmetric, no problem on Normal
relation to the lateral diameter is respiration and moves effortlessly. Full
approximately 1:2. Chest is symmetric. and symmetric chest expansion. Skin
Spinal column is straight, right and left intact and uniform in temperature.
shoulders and hips are the same height. Skin Bilateral symmetry vocal fremitus.
intact and uniform in temperature. Full and Clear breath sound was heard upon
symmetric chest expansion. Bilateral auscultation.
symmetry vocal fremitus. Clear breath
sounds.
Heart Heart sounds indicate of S1 and S2 and no Heart sounds indicate of S1 and S2 and Normal
other murmurs upon auscultation. EKG no other murmurs upon auscultation.
reading shows regular rhythm, no Upon auscultation there’s no
prolongation in waves P, R, S, T, no irregularity noted with the heart sound.
prominent Q wave and no PVC. Heart rate of 87 beats per minute.
Abdomen Unblemished skin, uniform color, flat Unblemished skin, uniform color, soft Normal
rounded; no evidence of enlargement of flabby rounded. Movements symmetric
liver, symmetric countour, abdominal, caused by respiration. Audible bowel
movements symmetric caused by sound at 7 per minute. No tenderness

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respiration. Audible bowel sounds at 5- noted.
30/per minute.
Upper Extremities Skin color generally uniform except in areas Skin color generally uniform except in Normal
exposed to sun. Skin intact and no edema. areas exposed to sun. Skin intact and no
Evenly distributed hair, flexing 45 degrees edema. Evenly distributed hair, flexing
and extending, supinate and pronate. When 45 degrees and extending, supinate and
pinched, skin springs back to previous state. pronate. When pinched, skin springs
back to previous state.
Nails Convex shape and nail plate angle of about Convex shape and nail plate angle of Normal
160 degrees. about 160 degrees
Shoulders and Arms Shoulders are symmetrically round, no Shoulders are symmetrically round, no Normal. Arterovenous fistula usually
redness, swelling, or deformity or heat. redness, swelling, or deformity or heat. done in patient’s non dominant arm
Clavicles and scapulae are even and Clavicles and scapulae are even and to avoid it from lifting heavy objects.
symmetric. symmetric. An aterovenous fistula in The presence of bruit and thrill
his left arm, with presence of bruit indicates that the fistula is working
upon auscultation and thrill upon and patent.
palpation.
Elbows Elbows are symmetric without deformities. Elbows are symmetric without Normal
Redness or swelling. No nodules deformities. Redness or swelling. No
nodules
Hands and wrist Hand and fingers are symmetric, non- Hand and fingers are symmetric, non- Normal
tender, and without nodules. Fingers lie in tender, and without nodules. Fingers lie
straight line. No swelling or deformities. in straight line. No swelling or
Rounded protuberance noted next to the deformities.
thumb over thenar prominence.
Lower Extremities Bothe extremities are equal size. Both extremities are equal size. Color In this situation, patients who have
Have the same contour with prominences of is even. Temperature is warm and even. kidney diseases that impair renal
joints. Can counter act gravity and resistance function develop edema because of a
No involuntary movements. on ROM. Mild bipedal edema noted. limitation in the kidneys' ability to

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No edema. Complains of both knee pain with mild excrete sodium into the urine. Thus,
Color is even. swelling. patients with kidney failure from
Temperature is warm and even. whatever cause will develop edema if
Has equal contraction and even. their intake of sodium exceeds the
Can perform complete range of motion. ability of their kidneys to excrete the
No crepitus must be noted on joints. sodium. The more advanced the
Can counter act gravity and resistance on kidney failure, the greater the
ROM. problem of salt retention is likely to
become.
Knee pain and swelling is cause by
accumulation of urate crystals in the
knee joints. An elevated blood uric
acid of 481.95 umol/L is revealed in
his laboratory test.
ROM Joint motion should cause no tenderness, Mild knee pain on both knees Knee pain and swelling is cause by
pain, or crepitation. accumulation of urate crystals in the
knee joints. An elevated blood uric
acid of 481.95 umol/L is revealed in
his laboratory test.

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