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    Nursing System Review Chart

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    janna mae patriarca
    This nursing chart summarizes a 48-year-old female patient's physical assessment. The assessment found that she had normal vision, respiration, reproductive status, and neurological function. However, she was overweight and had abnormal skin findings, including swelling, lesions, pain and flushing, likely due to a recent breast operation. The patient's physical appearance and expressions were appropriate.

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    Nursing System Review Chart

    Uploaded by

    janna mae patriarca
    21 views2 pages
    This nursing chart summarizes a 48-year-old female patient's physical assessment. The assessment found that she had normal vision, respiration, reproductive status, and neurological function. However, she was overweight and had abnormal skin findings, including swelling, lesions, pain and flushing, likely due to a recent breast operation. The patient's physical appearance and expressions were appropriate.

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    This nursing chart summarizes a 48-year-old female patient's physical assessment. The assessment found that she had normal vision, respiration, reproductive status, and neurological function. However, she was overweight and had abnormal skin findings, including swelling, lesions, pain and flushing, likely due to a recent breast operation. The patient's physical appearance and expressions were appropriate.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    21 views2 pages

    Nursing System Review Chart

    Uploaded by

    janna mae patriarca
    This nursing chart summarizes a 48-year-old female patient's physical assessment. The assessment found that she had normal vision, respiration, reproductive status, and neurological function. However, she was overweight and had abnormal skin findings, including swelling, lesions, pain and flushing, likely due to a recent breast operation. The patient's physical appearance and expressions were appropriate.

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    © All Rights Reserved
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    NURSING SYSTEM REVIEW CHART

    Name of Client: DN (BC Cancer ID # 10-45678) Sex: FEMALE Age: 48 Year old Religion: N/A
    Civil Status: N/A Income: N/A Nationality: N/A
    Pulse Rate: N/A Resp. Rate: N/A BP: N/A _Height: 165.1 cm Weight: 59.1 kg

    INSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space provided. Indicate the
    location of the problem in the figure using [X].
    EENT  Visual acuity has no alterations.
    [ ] impaired vision [ ] blind [ ] drainage  Patient’s eyes are symmetrical
    [ ] gum infection [ ] difficulty of hearing [ ] deaf and round in shape.
    [ ] burning [ ] edema [ ] lesion teeth  Both scleras are whitish in color
    [ X] no problem [ ] others but the conjunctivas are pinkish
    RESPIRATION in color.
    [ ] asymmetric [ ] tachypnea [ ] barrel chest
    [ ] apnea [ ] rales [ ] cough
    [ ] bradypnea [ ] shallow [ ] rhonchi The patient has normal respiration.
    [ ] sputum [ ] diminished [ ] dyspnea wheezing
    [ ] pain [ ] cyanotic [X ] no problem
    [ ] others
    GASTROINTESTINAL TRACT
    [ ] obese [ ] distention [ ] mass Based on the standards, her nutritional
    [ ] dysphagia [ ] rigidity [ ] pain status was beyond the normal range and
    [ ] abnormal bowel habits [ ] bowel sounds
    she was overweight.
    [ x ] no problem [ ] others
    GENITO-URINARY AND GYNE
    [ ] pain [ ] urine color [ ] vaginal bleeding
    [ ] hematuria [ ] nocturia [ ] odor The patient has normal reproductive status.
    [ ] gyne bleeding [ x ] no problem [ ] others
    NEURO
    [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures_ Facial expression Her expressions were
    [ ] lethargic [ ] comatose [ ] vertigo [ ] tremors appropriate according to the content of
    [ ] confused [ ] vision [ ] grip [ x] no problem her dialogue and showed a smile during
    [ ] other
    the entire interview.
    MUSCULOSKELETAL AND SKIN
    [ ] appliance [ ] stiffness [ ] itching [ ] petechiae
    [x ] hot [ ] drainage [ ] prosthesis [x ] swelling Revealed abnormal findings based on the
    [x ] lesion [ ] poor turgor [ ] cool [ x ] flushed
    standards given due to her operation at
    [ ] atrophy [x ] pain [ ] ecchymosis [ ] diaphoretic moist
    * assess mobility, motion, gait, alignment, joint function her right breast.
    skin color, texture, turgor, integrity [ x] no problem

    Score: /20

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