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POST OPERATIVE PHYSICAL ASSESSMENT

August 18, 2010

General Appearance

One day after the operation, patient, awake, flat on bed, conscious and coherent. With on going PLR 1L x

30gtts. She was post-operative total thyroidectomy. With dressing(3x5) on the neck and dressing(2x4) on the right

hand. Complaining headache and moderate pain in the post operative wound.

Time: 6p.m

Vital signs taken as follow:

Vital Sign Technique Normal Findings Actual findingsAnalysis andInterpretation

Temperature

Pulse Rate

Respiratory Rate

Blood Pressure

Height

Weight

BMI

Thermometer via axilla

Taken in left radial pulse

Abdominal breathing

Taken in left arm

Height was measured viatape measureWeight was measured viaweighing scale

Formula: BMI = weight inkg/ height in m2

36.5-37.5 C

60-100 beats per min

16-20 breaths per min

120/80 mmHg

5ft. 5 inches

70 kg

18.5-30.4 kg/m2

36.5 C

70 beats per min

16 breaths per min

120/80 mmHg

5ft. 5 inches

66 kg

18.31

Body temperature is withinnormal range

Pulse rate is within normalrate

Respiratory rate is withinnormal range

Blood Pressure is withinnormal range

Patients height is withinnormal

Patients weight isdecreased due to less

food intakePatients BMI is decreased

due to less food intake

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Kozier, B. (2004).Fundamentals of nursing

-27.5 kg/m2

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POST OPERATIVE PHYSICAL ASSESSMENTBODY PART

Techniques Used NORMAL

FINDINGS

ACTUAL

FINDINGS

ANALYSIS INTERPRETATION

SKIN

Color,

uniformity ofColor

Edema

Lesions

Moisture

Temperature

Turgor

Inspectio

n

Inspection

Inspection

Inspection

Palpation

Pinching

Light to deep

brown; uniformcolor except theareas exposedto the sun

No edema

Freckles,birthmarks, flats

and raised nevi;no other lesions

Moisture in skinfolds and axillae

Uniform; withnormal range

When pinched,skin springs back

to previousstate(Fundamentals of Nursing,8thed., by Kozier,

Fair complexion

of the skin

No presence ofedemaWith freckles ,nobirthmarks, but

with presenceof scar on themiddle part ofthe abdomen


Afebrile

Poor skin turgor and

elasticity

Light to deep

brown; uniformcolor except theareas exposedto the sun

No edema

Longitudinalincision made in

the abdomen forcaesarian sectiondelivery.(Fundamentals ofNursing by Kozierpp. 698)


Uniform; withnormal range.

When pinched, skin

springs back toprevious

state(Fundamentalsof Nursing, 8thed., by

Kozier, pp 579-580)

Normal

Normal

Due toprevious

longitudinalcesareanoperation.

Normal

Normal

There is anormal loss of

peripheralskin turgordue to aging.

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SKULLSize, shape,Symmetry

Nodules,masses

Anddepressions

Inspection

Palpation

Rounded(normocephalicand symmetricwith frontal,parietal,temporal, andoccipitalprominences);

smooth skullcontour

Absence of nodules ormasses(Fundamentals of Nursing,8thed. by Kozier, p

585)

Rounded(normocephalic andsymmetricwith frontal,parietal,temporal, andoccipitalprominences)

and smoothskull contour

No nodules ormasses

Rounded(normocephalicand symmetricwith frontal,parietal,temporal, andoccipitalprominences);

smooth skullcontour

Absence of nodules ormasses(Fundamentals

of Nursing, 8thed. byKozier, p 585)

Normal

Normal

SCALP

Color andAppearance

Areas of tenderness

Inspection

Inspectio

n

Lighter thancomplexion

No lesions, lies,dandruff, and

bruises or lumpsfound. Free fromsplit ends(Manualof Nursing, 7th., byLippincott, p.54


No lesions, lies,dandruff, and

bruise or lumpsfound.


No lesions, lies,dandruff, and bruises

or lumps found. Freefrom split

ends(Manual ofNursing, 7 th., by

Lippincott, p.54

Normal

Normal

HAIR

Evenness ofGrowth,

Thickness/Thinness

Inspection

Evenlydistributed, thick,

The clientshair is evenly

distributed,and it is thick.The hair cut isshort.

Evenlydistributed, thick,

Normal

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AURICLES

Color,symmetry,

Position

Texture,elasticity

And

tenderness

inspection

Color same asfacial skin,

symmetrical,auricle alignedwith outercanthus of eye

Texture, elasticityand tenderness:

Mobile, firm andtender; pinnarecoils after it isfolded(Fundamentals ofNursing, 8thed., byKozier, p 596)

Color of theclients auricle

is same as thefacial skin,symmetricallyin size. Alignedwith outercantus of theeye.

Texture issmooth, elastic

and tenderness.It is firm andmobile Pinnarecoils after it isfolded

Color same asfacial skin,

symmetrical,auricle alignedwith outercanthus of eye

Texture,elasticity andtenderness:

Mobile, firmand tender;pinna recoilsafter it is folded(Fundamentals of

Nursing, 8 thed., by

Kozier, p 596)

Normal

Normal

EXTERNAL

EAR CANALS

Cerumen, skinLesions PusandBlood

Inspection

Distal thirdcontains hairfollicles andglands drycerumen, grayishtan color/sticky/

Distal thirdcontains hairfollicles andglands, and theexternal earcanals has no

Distal thirdcontains hairfollicles andglands drycerumen,grayish tan

Normal

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wet cerumen invarious shades ofbrown(Fundamentals of Nursing,

8thed., by Kozier,p 596)

cerumen andthe it is dry

color/sticky/wet cerumen invarious shadesof

brown(Fundamentals of Nursing, 8thed.,by Kozier, p596)

HEARINGACUITY TEST

In normalvoiceOnes

NOSE

Shapes, size,color, flaring/

Inspection

Inspection

Audible

Symmetric andstraight; nodischarge or

The clientverbalized thatshe can hearclearly what thehealth careprovider says,like ears checktwice and twiceawesome.

The client is

able to hear theticking in bothears.

The clientheard in bothears.

Audible

Symmetric andstraight; nodischarge or

Normal

Normal

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dischargefromnares.

Nasalcavities:Redness,swelling

Growths, andDischarge

Nasal septum

Nasal cavityPatency

Tenderness,masses anddisplacementofbone and cartilage

Inspection

Inspection

Inspection

Palpation

flaring; uniform incolor.

Pink mucosa;clear waterydischarge; nolesions

Intact and in themidline

Patency, airmoves freely asthe clientbreathes throughthe nares.

No tenderness; nolesions(Fundamentals of Nursing,8thed., by Kozier,p 600)

The clientsnose issymmetric andstraight.

No dischargesor flaring. Thecolor of thenose rangesfrom medium tolight brown.Uniform to thecolor of theface.

Mucosa is pink.And no waterydischarge andlesions.

Nasal septum isin the midline

Air moves

freely as theclient breathesthrough thenares.

No tenderness;no lesions

flaring; uniformin color.

Pink mucosa;clear waterydischarge; nolesions

Intact and inthe midline

Patency, airmoves freely asthe clientbreathesthrough the

nares.

No tenderness;nolesions(Fundamentals of Nursing, 8thed.,by Kozier, p

Normal

Normal

Normal

Normal

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600)

FACIALSINUSES

Frontal,Supraobitalridges,ethmoid,sphenoid,maxillary

Inspection

Notenderness(Fundamentals of Nursing, 8thed., byKozier, p 600)

No tenderness Notenderness(Fundamentals ofNursing, 8thed.,by Kozier, p600)

Normal

MOUTH

LIPS

Symmetry ofcontour, color,texture

Inspection

Pinkish;symmetrical withlip margin.Smooth andmoist(Fundamentals of Nursing,

8th

ed., by Kozier,p 602)

Symmetrical ;pink in color;texture is dry.

Pinkish;symmetricalwith lip margin.Smooth andmoist(Fundamentals of

Nursing, 8th

ed.,by Kozier, p602)

Normal

BUCCALMUCOSA

Color, inspectio Moist, smooth, The clients Moist, smooth, There is a

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moisture,Texture andlesions

n soft, glisteringandelastic(Fundamentals of Nursing,

8thed., by Kozier,p 602)

buccal mucosais dry.

soft, glisteringandelastic(Fundamentals of

Nursing, 8thed.,by Kozier, p602)

decreasedsalivaryproductionbecause the

patient takeanti-hypertensivesdugs.

TEETH

Color, number

condition

Inspectio

n

Smooth, white,

shiny toothenamel; smooth,intact dentures.28-32 normalnumbers of teeth(Fundamentals of Nursing,8thed., by Kozier,p 602)

Yellowish in

color, andintact.

There ismissing teeth.

Smooth, white,

shiny toothenamel;smooth, intactdentures. 28-32normalnumbers of teeth(Fundamentals of Nursing, 8thed.,by Kozier, p

602)

Discoloration of

the teeth duestained fromthe food thatshe had beeneaten.

GUMS

Colorcondition

inspection

Pink color, moist,firm texture, no

Normal color Pink color,moist, firm

Normal

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retraction(Fundamentals of Nursing, 8thed., byKozier, p 591)

texture, noretraction(Fundamentals ofNursing, 8thed.,

by Kozier, p591)

TONGUE/MOUTHFLOOR

Surface of theTongue for

position,

color,Texture. AndtonguemovementBase of thetongue

Inspection

Pink color, slightlyrough, moist.Smooth and nolesions.

Centralpositioned.Freely movableSmooth tonguebase withprominent veins(Fundamentals of

Nursing, 8thed., byKozier, pp 603-604)

The clientstongue is pinkin color, slightlyrough and

moist.Positioned incenter. And thetongue canfreely move.

Pink color,slightly rough,moist.Smooth and no

lesions.Centralpositioned.Freely movableSmooth tonguebase withprominentveins

(Fundamentalsof Nursing,

8thed., byKozier, pp 603-604)

Normal

PALATESAND UVULA

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Palate color,shape,texture and

bodyprominence

Position ofuvula,and mobility

Inspection

Inspection

Hard palate:Lighter pink andmore irregular

textureSoft palate: Lightpink, smooth

Positioned inmidline of softpalate(Fundamentals of Nursing,8thed., by Kozier,pp 604)

Hard palate:Lighter pinkand more

irregulartextureSoft palate:Light pink,smooth

The uvula ispositioned inmidline of softpalate

Hard palate:Lighter pinkand more

irregulartextureSoft palate:Light pink,smooth

Positioned inmidline of softpalate(Fundamentals of

Nursing, 8thed.,by Kozier, pp604)

Normal

OROPHARYN X ANDTONSILS

Color, texture

Tonsils, color,Discharge

Inspection

Pink in color,smooth posterior

wall

Pink and smooth.No discharge

Oropharynx ispink in color

and has asmoothposterior wall.

Pink andsmooth. And nodischarge.

Pink in color,smooth

posterior wall

Pink andsmooth. Nodischarge

Normal

Normal

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NECKMUSCLES

Neck musclesfor abnormalswellings ormasses

Headmovements

Inspection

Muscles equal insize; headcentered

Coordinated,smooth

movements withnodiscomfort(Fundamentals of Nursing, 8thed., byKozier, p 607)

Head centeredand musclesare equal insize.

The client hasno coordinated

and hard headmovement;experiencingdiscomfortwhile movingnoted dressingon the site ofsurgery-rely on thechart due to

unable toobserve thedrainage andsuturesbecausechanging ofdressing donein the morning.

Muscles equalin size; headcentered

Restrict headmovements to

Avoidhyperextensionof the neck toprevent wounddehiscence.(Fundamentals of

Nursing, 8 thed., byKozier, p 639)

Normal

Emphasizedhealth teachingto patient to

prevent woundcomplications.

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limited headmovementsdue to post-opprocedure to

avoid strainingon the site

LYMPHNODES

OccipitalPostauriular

PreauricularSubmandibularSubmentalSuperficialanterior

Palpation Notpalpable(Fundamentals of Nursing,

8th

ed., by Kozier,p 607)

None Notpalpable(Fundamentals of

Nursing, 8th

ed.,by Kozier, p607)

Unable toobserve due tochanging of

dressing

TRACHEA

Placement Inspection Midline of neck;spaces are equalon bothsides(Fundamentals of Nursing,8thed., by Kozier,p 608)

Heard wheezing

Midline of neck;spaces areequal on bothsides(Fundamentals of Nursing, 8thed.,by Kozier, p608)

Unable toobserve due tochanging ofdressing

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Auscultation

Bronchial Sound sound onauscultation Abnormal

breath soundsheard due to

underlyingcondition.(Fundamentalsof Nursing,8thed., byKozier, p 618)

Indication forlaryngealspasm aftersurgery

THYROIDGLAND

SymmetryandMasses

Smoothness,

Areas ofEnlargement,Masses,nodules

Inpectionandpalpation

Palpationandinspectio

n

Not visible, glandascends duringswallowing

Lobes may not bepalpated.If palpated, lobes

are small,smooth, centrallylocated, painless,and rise freelywithswallowing(Fundamentals of Nursing, 8thed., by

Unable to opendressing

Unable to opendressing

Surgical suturesnot visiblebecause of thedressing

Lobes may notbe palpated.

Change ofdressing donein the morning

Change ofdressing donein the morning

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Kozier, p 609 )

POSTERIORTHORAX

Shape,symmetry,Diameter

SpinalalignmentTemperature, andThe integrityof allChest skin

RespiratoryExcursion

Vocalfremitus

Inspection

Inspection,

palpation

Inspection

Anteroposterior totransversediameter in ratioof 1:2,.chestsymmetrical

Vertically aligned

Skin intact;uniformtemperature

Full symmetricexcursion;thumbs normallyseparate 3 to 5cm

Theanteroposterior totransverseand ratio is1:2 and chestsymmetrical

Verticallyaligned

Skin intact;uniformtemperature.

During deepinspirationthumbsseparate 3-5cm

Anteroposterior totransversediameter in ratioof 1:2,.chestsymmetrical

Vertically aligned

Skin intact;uniformtemperature

Full symmetricexcursion;thumbs normallyseparate 3 to 5cm

Normal

Normal

Normal

Normal

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Percussion

Auscultation(posteriorthorax)

Inspection

Percussi

on

auscultation

Fremitus is heardmost clearly atthe apex of the

lungs. Bilateralsymmetry

Percussion notesresonate, the

level of diaphragm butare flat over areasof heavy muscleand bone, dull onareas overstomach

Vesicular andbronchovesicularbreathsounds(Fundamentals of Nursing,

The client islow pitched

voice. And thefremitus isheard mostclearly at theapex of the

Resonate,

except overthe level ofdiaphragmbut are flatover areas ofheavy muscleand bone, dullon areas overstomach

Bronchial andtubular breathsounds

Fremitus is heardmost clearly atthe apex of the

lungs. Bilateralsymmetry

Percussion notesresonate, the

level of diaphragm butare flat over areasof heavy muscleand bone, dull onareas overstomach

Vesicular and

bronchovesicularbreath

sounds(Fundamentalsof Nursing, 8thed., by

Normal

Normal

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8thed., by Kozier,p615)

Kozier, p615)

ANTERIORTHORAX

Breathingpatterns

Temperature andThe

integrity of All chestskin

RespiratoryExcursion

Inspection

Inspection and

palpation

Inspection

Quiet, rhythmic,and effortlessrespiration

Skin intact;uniform

temperature

Full symmetricexcursion;thumbs normallyseparate 3 to 5

The client hasquiet,rhythmic, andeffortlessrespiration.

Skin intactand uniform

temperature.

During deepinspirationthumbsseparate 3-5cm

Quiet, rhythmic,and effortlessrespiration

Skin intact;uniform

temperature

Full symmetricexcursion;thumbs normallyseparate 3 to 5

Normal

Normal

Normal

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Vocal

fremitus

Percussion

Percussi

on

cm

Fremitus is

normallydecreased overheart and breasttissue

Percussion notesresonates downto the sixth rib atthe level of thediaphragm butare flat over areasof heavy muscleand bone, dull onareas over the

heart and theliver, andtympanic over theunderlyingstomach

The client islow pitched

voice. And thefremitus isheard mostlearly in theapex of thelungs.

Percussionnotesresonatesdown to thesixth rib at thelevel of thediaphragmbut are flatover areas ofheavy muscle

and bone, dullon areas overthe heart andthe liver, andtympanic overthe underlyingstomach

cm

Fremitus is

normallydecreased overheart and breasttissue

Percussion notesresonates downto the sixth rib atthe level of thediaphragm butare flat over areasof heavy muscleand bone, dull onareas over the

heart and theliver, andtympanic over theunderlyingstomach

Normal

Normal

Normal

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Auscultation(trachea)

Auscultation(anteriorthorax)

Auscultation

Auscultation


Bronchovesicular

and vesicularbreathsounds(Fundamentals of Nursing,8thed., by Kozier,p617)


Bonchovesicular andvesicular

breath sounds


Bronchovesicular and

vesicular breathsounds(Fundamentals

of Nursing, 8thed., byKozier, p617)

Normal

PALPATION Aortic andpulmonic

Tricuspid

Palpation

No pulsations

No pulsation and

No pulsations

No pulsation

No pulsations

No pulsation and

Normal

Normal

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area andHeaves orlifts

Apical area

Auscultation

palpation

no heaves or lifts

Pulsation visiblein 50% of adultsand palpable inmost PMI in fifthLISC at or medialto MCL.Diameter of 1 to 2cm. no he heaveor lift

and noheaves or lifts

Pulsation isvisible andpalpable.

no heaves or lifts

Pulsation visiblein 50% of adultsand palpable inmost PMI in fifthLISC at or medialto MCL.Diameter of 1 to 2cm. no he heaveor lift

Normal

CAROTIDARTERIES

Palpation

Auscultation

Palpation

auscultation

Symmetric pulsevolumes.

Full pulsations,thrusting quality.Elastic artery wall

No sound heard

Symmetricpulse volumes.

Full pulsations,thrustingquality. Elasticartery wall

Symmetricpulse volumes.

Full pulsations,thrustingquality. Elasticartery wall

Normal

Normal

Normal

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onauscultation(Fundamentals of Nursing, 8thed., by

Kozier, pp622-623)

During

auscultation nosound heard

No sound heard on

auscultation(Fundamentals of

Nursing, 8 thed., by

Kozier, pp622-623)

JUGULARVEINS

Inspectinspection

Veins notvisible(Fundamentals of Nursing,8thed., by Kozier,p 623)

Veins are not

visibleVeins notvisible(Fundamentals of Nursing, 8thed.,by Kozier, p

623)

Normal

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BREASTSize,

symmetryandShape

Localizeddiscolorations orhyperpigmentation,

retraactionordimpling,localizedhypervascular areas,swelling oredema

AREOLA

Shape,,color,masses orlesions

Inspectio

n

Inspection

Inspection

Rounded shape;

slightly unequal insize; generallysymmetric

Skin uniform incolor; skin smoothand intact.Diffuse symmetrichorizontal orvertical vascular

pattern in lightskinned people.Striae; moles andnevi

Round/oval;bilaterally thesame; color varieswidely from lightpink to darkbrown. No lumps,masses or areasof tenderness

Flaccid

The skin isuniform incolor and it isalso smoothand intact.

Round everted

and equal insize. Similar incolor withareola andtexture issmooth andsoft, Nodischarges and

Changes of

firmness due toaging

Skin uniform incolor; skinsmooth andintact.Diffuse

symmetrichorizontal orvertical vascularpattern in lightskinned people.Striae; molesand nevi

Round/oval;bilaterally thesame; colorvaries widelyfrom light pinkto dark brown.

Lack of

firmness thathad been inyoungeryears

Normal

Normal

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NIPPLESSize, shape,color,Position,discharge

And lesions.

Axillary,Subclavicular andsupraclavicularlymph nodesBreast forMasses,tenderness

Nipples fortendernessanddischarges

Inspection

Inspection

inspection

Round;everted/inverted;equal in size;similar in color.Soft and smooth;no discharge,masses or lesions.No lumps and

masses.No tenderness,masses, ornodules

No tenderness,masses, nodules,or nippledischarge

No tenderness,masses, nodules,or nipple

lesions normasses

No masses, ornodulesNo masses,

nodules, or nippledischarge

No tenderness,masses, nodules,

or nipple

discharge.

Round evertedand equal insize. Similar incolor withareola and

No lumps,masses or areasof tenderness

Round;everted/inverted; equal in size;similar in color.Soft andsmooth; no

discharge,masses orlesions. Nolumps andmasses.No tenderness,masses, ornodules

No tenderness,

masses,nodules, ornipple discharge

Normal

Normal

Normal

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discharge(Fundamentals of Nursing, 8thed., byKozier, pp 628-

630)

texture issmooth andsoft, Nodischarges and

lesions.

No tenderness,masses, nodules, or

nipple

discharge(Fundamentals of Nursing,

8thed., by Kozier, pp628-630)

ABDOMEN

InspectionAbdomenskin

InspectionAbdomen forContour andSymmetry

Inspection

Inspectiom

Unblemished skin;uniform color

Flat, rounded;symmetriccontour.

The color islight tomedium brownand it isuniform.Unblemishedskin.

The abdomenis rounded andhas asymmetriccontour;

Unblemishedskin; uniformcolor

Abdomencontour variesin giving birth.

Normal

Increaseadipose tissueand decreasemuscle tone;Due topreviouslongitudinalcesarean

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InspectionEnlargementofLiver/spleen

AbdominalMovementsassociated

w/respiration,

peristalsis,or aortic

pulsations

Vascularpatterns

Auscultation

Inspection

Inspection

Auscultation

Auscultation

No enlargementof the liver/spleen

Symmetricmovementscaused byrespiration.

Visible peristalsisin very leanpeople.Aortic pulsationsin thin persons atepigastric area.

No visible

vascular pattern

Audible bowelsounds; absenceof arterial bruits;absence of

with presenceof scar on themiddle part ofthe abdomen.

Noenlargement oftheliver/spleen

Symmetricmovements.

Vascularpattern is notvisible

Noenlargement oftheliver/spleen

Symmetricmovements

caused byrespiration.Visibleperistalsis invery leanpeople.Aorticpulsations inthin persons atepigastric

area.

No visiblevascularpattern

operation.

Normal

Normal

Normal

Normal

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Percussion

eachOf the fourQuadrants

LightPalpation

Percussion

palpation

friction rub

Tympany over thestomach and gas-filled bowels;dullness,especially overthe liver andspleen, or a fullbladder

No tenderness;relaxed abdomenwith smooth,consistent tension

Audible bowelsounds;absence of arterial bruits;

absence of friction rub

Tympany overthe stomachand gas-filledbowels;dullness,

especially overthe liver andspleen, or afull bladder

No tendernessnoted .

Audible bowelsounds;absence of arterial bruits;

absence of friction rub

Tympany overthe stomachand gas-filledbowels;dullness,

especially overthe liver andspleen, or afull bladder

No tenderness;relaxed abdomen

with smooth,

consistent tension

Normal

Normal

MUSCLE

Size Inspection

Equal on bothsides of body

Muscle is equalon both sidesof the body

Equal on bothsides of body

Normal

Normal

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Tendons forContractures

Fasciculation andTremors

PalpatemuscleTonicity

Test for muscle

Strength

Inspection

Inspection

Inspection

Palpation

No contractures

No fasciculationand tremors

Normally firm

Equal strength oneach body side.(Fundamentals of

Nursing, 8th

ed., byKozier, pp 640-641)

Nocontractures

Nofasciculationand tremors

Muscle is firm

Muscle strength is

equal on bothsides.

Nocontractures

Nofasciculationand tremors

Normally firm

Equal strength

on each bodyside.(Fundamentalsof Nursing,8thed., byKozier, pp 640-641)

Normal

Normal

Normal

Normal

Inspect

skeletonFor structure

Palpatebones toLocate areasofEdema or

Inspectio

n

Inspection

No deformities

No tenderness orswelling

No deformities

No tendernessor swelling

No deformities

No tendernessor swelling

Normal

Normal

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Tenderness

Inspect jointfor

Swelling

Palpate eachjointFortenderness,Smoothness,Swelling,crepitation

& presenceofNodule

ASSESSMENT OF THEEXTREMITIES

Upperextremities

Inspection

Palpation

Inspection

No swelling;

No tenderness,crepitation, ornodules. Jointsmovesmoothly(Fundamentals of Nursing,8thed., by Kozier,p 641)

Equal in size andsymmetricallybilateral

Dry and warm totouchWithout edemaformation,bruising or lesions

Joints of theclient do nothave swelling.

No tendernessor nodules.

Joints movesmoothly

With PLR 1L x30gts on theLeft arm.

Presence of dressing on theright hand.

Equal in size and

No swelling;

No tenderness,crepitation, ornodules. Jointsmovesmoothly(Fundamentals ofNursing, 8thed.,by Kozier, p641)

Equal in sizeandsymmetricallybilateral

Dry and warmto touchWithout edemaformation,bruising orlesions

Normal

Normal

Replacementfor fluid andelectrolytesimbalance

Removal of themass presenton the righthand.

Normal

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Lower

extremities

Inspection

Equal in size andsymmetricallybilateralDry and warm to

touchWithout edemaformation,bruising or lesions

symmetrically

bilateral. Dry and

warm to tough,without edema

formation orbruising. With

some lesions

Equal in sizeandsymmetricallybilateral

Dry and warmto touchWithout edemaformation, bruising

or lesions

post-op pa

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