Physical Assessment Essay Sample

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Physical assessment of client was done last August 6, 2013. General Observation
Our patient is a 13 days old infant who was diagnosed with Neonatal Sepsis. According to Sigmund Freud’s Stages of Psychosexual Development, our patient is in the Oral Stage; wherein infant’s primary source of interaction occurs through the mouth, so the rooting and sucking reflex is especially important. The mouth is vital for eating, and the infant derives pleasure from oral stimulation through gratifying activities such as tasting and sucking. Because the infant is entirely dependent on his mother and other significant others during feeding, the infant also develops a sense of trust and comfort through this oral stimulation. The primary conflict at this stage is the weaning process wherein the child must become less dependent to the ones who feeds him. If fixation occurs at this stage, Freud believed the individual would have issues with dependency or aggression. Oral fixation can result in problems with drinking, eating, smoking or nail biting. The ideal weaning of a child from breastfeeding to avoid oral fixations is up to 2 years. In relation to our client, at the age of 13 days old, he was already weaned from his mother, because the mother claims to have less breast milk that is why she opted to choose mix feeding wherein they use formula milk at the same time the breast milk is being expressed and being transferred to a bottle. * Vital signs:

The vital signs of our patient during physical assessment done last August 6, 2013 are as follows: Respiratory Rate of 69 breaths per minute, Cardiac Rate of 130 beats per minute and Temperature of 37.1ᵒC. His anthropemetric measurements are as follows: length of 53 cms, head circumference of 35 cms, chest circumference of 33 cms, abdominal circumference of 35 cms and weight of 2.9 kgs. Capillary refill time ranges from 1 – 2 seconds. Skin

The patient’s skin is warm to touch without edema, lesions or abrasions. The patient has good skin turgor. Head
The head is symmetrical and round, with no misalignment observed. The anterior and posterior fontanels are still open and are not sunken. There are no lumps, masses or lesions noted. * MOUTH – The buccal mucosa is pale in color. The buccal mucosa is dry and the lips are not chapped. * EARS – Symmetrical and aligned, tympanic membrane is grayish in color. * EYES – The conjunctiva is pinkish in color on both eyes there are no secretions observed. The sclera is white and the pupils are equally round and with good accommodation to light. Chest and Lungs

Upon inspection, the chest showed no asymmetry, deformity or increase anterior-posterior diameter. The chest rises and falls symmetrically. Chest retractions and nasal flaring was also observed upon breathing. Accessory muscles were used upon breathing. His respiratory rate ranges from 60-75 breaths per minute. * PALPATION – There were no areas of tenderness assessed during palpation. * PERCUSSION – No dullness was noted on the left anterior chest and on the posterior wall. * AUSCULTATION – With stethoscope, broncho-vesicular and bronchial sounds are heard in between, inspiration is larger than expiration. Wheezes as well as crackles were heard upon ausculation. The cardiac rate ranges from 130-135 bpm. No murmurs, palpitations or any other abnormalities were observed. Abdomen

It is slightly globular in shape, symmetrical and is soft to touch. No tenderness, scars and lumps noted. The umbilical stump of our patient has also already fallen off. * Auscultation – of the 4th quadrant, bowel sounds was present and occurred every 2-5 sec. * Palpation – no palpable masses was noted.

* Percussion – pain or discomfort was not observed from the patient. The child continues to use abdominal muscles for breathing. Spine and Extremities
* Palpation – tenderness, deformities or abnormalities were not observed. The patient is able to move head from side to side. He grasps anything that is being placed on his arm and directly puts it in his mouth and suck on it. Full extension and flexion of extremities is also noted upon assessment.

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