Question

• He sought consult at the ER Department due to 2^nd degree burns on the anterior head and neck, anterior thorax, abdomen, and groin area.
• His weight is 70 kgs.Male ,34,Male
• Lactated Ringer's Solution was ordered for fluid resuscitation for a specific amount of time.
• Pain relievers were given to relieve pain. Silver sulfadiazine was also ordered for wound care.
• VS: BP – 130/80, PR – 102 BPM, RR – 24 CPM, T^o – 37.6 ^OC, SPO2 – 96%.

Case Scenario:

NOI: 2^nd Degree Burns

DOI: October 25, 2020

TOI: 5:00 pm

POI: At the University's Chemical Laboratory

Physical Assessment and Review of System

General Survey
Skin
Head, Eyes, Ears, Nose, Throat
Neck
Breast
Respiratory
Cardiovascular
Gastrointestinal
Urinary
Genital
Peripheral / Vascular
Musculoskeletal
Neurologic
Hematologic
Endocrine
Psychiatric

Case study

Answer 1

General Survey	A general survey is an overall review or first impression a nurse has of person's well being.This is done to toe , or cephalo caudal , lateral , proximal to distal and front to back. General health history, past medications, past hystory of surgeries, hospital administrations. Allergy - to any drugs, food, dust Vital signs Height and weight checking
Skin	Inspect skin colour and uniformity of color , moisture, hair pattern , rashes, lesions, pallor edema. Palpate temparature , turgor,lesion,edema,texure pale, cool, moist skin can be indicative of heat stroke, shock or other cardiac complications. Check for pallor, cyanosis, edema, ecchymosis,macule,papule,cyanosis,jaundice,alopecia
Head, Eyes, Ears, Nose, Throat	Head :Look for scars, lumps,rashes,hair loss or other lesions Look for facial asymmetry, involuntry movements or edema, palpate to identify any areas of tenderness or deformity. Ears:Inspect the ear canal and middle ear structures noting any redness, drainage, or deformity , Insufflate the ear and watch for movement of the tympanic membraine.Assessment using otoscope Eyes:Check for visual acuity, Inspect for discoloration,redness, discharge or lesions,Pupillary reactions, ophthalmoscopic exam- Nose: Inspect the visible nasal structures and note any swelling, redness, drainage, or deformity Throat:Inspect the inside of patients mouth including the buccal folds and under the tongue, note any ulcers, lekoplakia,or lesions.
Neck	Inspect the neck of asymmetry , scars or other lesions. palpate the neck to detect areas of tenderness, deformity or masses. inspect the neck looking for thyroid gland ,note wheather it is visible and symmetrycal. A visibly enlarged thyroid gland presence. Lymph nodes - note the size and location of any palpable nodes whether they were soft or hard - non tender or tender and mobile or fixed.
Breast	Check for both the breast are asymmetrical , presence of any swelling, discharge and lymphnode enlargment. observe the chest asymmetry, deformity and increased antirior posterior diameter.
Respiratory	Observe the rate, rhythm, depth, and effort of breathing. Note wheather the expiratory phase is prolonged , listen for abnormal breath sounds, like wheeze. Do palpation, percussion, auscultaion Palpation_ identify any areas of tenderness or deformity by palpating the ris and sternum. Auscultate the breath sound
Cardiovascular	Check pulse, blood pressure , check for capillary refill Check the presence of edema of the feets and lower legs, check for cyanosis of the feet and hands. check the presence of clubbing of fingers. check lymphatics-- check the presence of epitrochlear lymph nodes, axillary lymphnodes, inguinal lymph nodes
Gastrointestinal	Inspect for scars, straie,hernias, vascular changes, lesions,rashes,. movement associated with peristalsis or plusations Auscultatebowel sounds Percussion , measurment of abdominal girth
Urinary	Male_ prostate sceening. ask for his/her urinary patterns, difficulties with urination. colour of urine. Pain associated with urination any?
Genital	Check the genital area for any deformity, presence of rashes, swelling or discharge
Peripheral / Vascular	Inspect for trauma, previous surgery scars, edema, erythema, ulcers, . Check arterial pulse , auscultate for femoral artery bruits
Musculoskeletal	look for scars, deformity, asymmetry, atrophy, check for range of motion. Identify the areas of tenderness,swelling Palpate temparature, pitting edema, capillary refil
Neurologic	Check for Mental status, Cranial nerves, Motor, Coordination and gait, reflexes , sensory perception.
Hematologic	Check blood CBC, ESR, Clotting studies, iron studies
Endocrine	Basic Endocrine evaluation measurment of Blood glucose level, Thyroid function test , kidney function test etc
Psychiatric Psychologycal screening , gathering information about patient mental stutus. Collect personal hystory, any family hystory of psychiatric illness, any hystory of suicidal trials.