PHYSICAL ASSESSMENT: 13 FUNCTIONAL AREAS

GENERAL SURVEY:

Received this 18 year-old male patient with Osteosarcoma Left Proximal Tibia. He is a Filipino, single and Roman Catholic. He was in supine position with his mother awake, conscious and coherent; oriented to people, place and time. No contraptions upon receiving. He is 5’5 in height, weighs 55 kg.

He has brown complexion, appears to be neat and clean and shows. He is dressed appropriately to weather with bandage over the swelling left knee. He maintains good eye contact and speaks clearly and spontaneously to a soft voice.

FUNCTIONAL AREAS: FINDINGS:1. RESPIRATORY FUNCTION RR is 18 bpm, regular in rate and

rhythm No signs of respiratory distress. No adventitious breath sound heard

upon auscultation Absence of lumps mass and

tenderness upon palapation2. CIRCULATORY FUNCTION CR is 84 bpm, appropriate for age

Nailbeds and palms are pinkish Capillary refill less than 3 seconds Over the affected extremity capillary

refill is 3 seconds3. SPECIAL SENSES FUNCTION

A. EYES Has a 20/20 vision; doesn’t use any eyeglasses.

Eyes are almond in shape, irises are black in color, eyebrows and eyelashes are equally distributed.

Upper eyelid overlap the iris but not the pupil and shows no sign of inflammation, edema or infection

Scleras are whitish in color and conjunctivais pale and moist

Pupils are equally round and reactive to light accommodation

Eyelids are free from masses and tenderness.

Was able to move his eyes in six

directions; occulomotor nerve is intact

B. EARS Upper auricle is at the level of eye corner, symmetrical in size and shape.

No discharges on ear canal can be seen.

Able to hear whispered words without difficulty; 10th CN is intact

No tenderness,masses and swelling on ears and mastoid process upon palpation

C. NOSE Nose has no deviation in terms of shape and size

Nasal septum is midline and intact Swelling and bleeding is not evident Able to distinguish the smell of the

cologne from alcohol; CN 1 intact.

D. MOUTH Lips are pale, dry and free from lesions Buccal mucosa is pinkish. Almost complete set of teeth except

for second molars No bleeding and lesions on gums, teeth

are complete, no tooth decay but there are presence of tooth cavities

Tongue is moist. Palate is free from

inflammation ,redness, swelling and deviation.

Distinguishes the taste of an orange form an apple

4. REST AND COMFORT FUNCTION Uncomfortable because of his swelling left leg.

He can’t sleep because of the changes foreseen if amputation will be done.

He uncomfortable also of the environment; hot and noisy.

5. ELIMINATION FUNCTION Urinates to a yellowish urine approximately 350cc voided freely and without difficulty; six times a day

Defecates to a well-formed stool, brown in color once a day.

6. NUTRITION FUNCTION Drinks about 1,200cc of water a day

Loss of appetite can be noted; consumed 50% of the meal served.

Mother would usually give him fruits as a merienda

Active bowel sounds No tenderness, masses or distention

7. NEUROLOGIC FUNCTION Conscious and coherent and oriented to time, in bedrest

GCS is 15/15 Reflexes are intact but on the affected

limb reflexes were diminished.8. MOTOR FUNCTION Can’t walk normally because of his

swelling knee. Has a limited R.O.M. on the affected

extremity Pain is present when his affected limb

bears the weight of the body. Left leg is obviously larger than the

other leg. Cannot flex the left leg. Muscle strength is 5/5 but in the

affected limb 2/5 is the score9. REPRODUCTIVE FUNCTION Able to void freely with no difficulty

Not assessed properly; teenagers are shy when it comes to their private body parts.

10. THERMOREGULATORY FUNCTION Temperature per right axilla is 36.8°C as taken 8am and 37 °C as of 12noon; afebrile

No chills and diaphoretic; ward is hot.11. SKIN INTEGRITY OR INTEGUMENTARY

FUNCTION Color is same all throughout the body Good skin turgor He has a wavy hair and evenly

distributed no lice were seen and no presence of

dandruff during assessment nails are pinkish but no signs of

clubbing except for the affected extremity the nails are pale.

12. SOCIAL FUNCTION Can communicate well but quite hesitant to express his emotions and wishes

Speaks well in moderate tone of voice and soft voice

He is cooperative but when the topic regarding his illness will be discussed he tends to be silent so the mother supplicates the information needed.

13. MENTAL AND EMOTIONAL FUNCTION Has good immediate recall, recent and remote memory

Shows congruency in both verbal and non-verbal behavior

Aware of her illness and reasons of hospitalization

Depressed, he does not want to talk about the amputation thing. He’s silent whenever that topic will be discussed, mother gives details regarding what he feels because he is able to verbalize all his wearies and querries.

Hid under his blanket an indication that he wants to be alone.