Physical Assessment: 13 Functional Areas: General Survey

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 55 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 palapation
2. 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 seconds
3. SPECIAL SENSES FUNCTION
A. EYES Has a 20/20 vision; doesnt 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
conjunctiva
is 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; 10
th
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 cant 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 Cant 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 score
9. 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 36.8C
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. Hes 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.

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