PEROS (Physical Assessment and Review of Systems)
Areas Subjective Objective Findings Problem Identified
Assessed Findings
General “Dako jud ni siya Inspection Imbalanced
Health pag anak, 2.7kg”, Nutrition: less than
The patient's body size is
Survey as verbalized by body requirements
the mother. small for a 3-month-old related to insufficient
girl's desired body size dietary intake (use of
“sige lang siyag
substance in place of
hilak”, as (60 cm). nutritional food) as
verbalized by the
Height: 48.5 cm evidenced by loss of
mother.
weight, pale mucous
Weight: 2.3 kg (<2.5kg:
“Balik-balik membranes, [laboratory
iyang kaso ba, ma fetal malnutrition) evidence of electrolyte
question jud Clean and appropriate imbalances, anemias].
nganong dili jud
grooming. Impaired Skin
siya maulian”, as
Integrity evidenced by
verbalized by the Odorless
risk factors of alteration
mother. No signs of distress, in fluid volume,
“mas ning grabi awake, irritable, crying, inadequate nutrition
siya, dehydrated and associated
failure to thrive. conditions of
najud kayo siya,
dili napud siya immunodeficiency, and
mo totoy, sige alteration in skin
napud siyag suka Lab Results: turgor.
og kalibang”, as
Hypogylcemia (27) N: 70-110 Risk for Infection as
verbalized by the
mg/dL evidenced by risk
mother.
factors of tissue
Hyponatremia(129.0)N:135-
“mga tulo ka 148mmol/L trauma, malnutrition,
adlaw ra nako and associated
siya na Hypokalemia (2.42) N: 3.5- conditions of decreased
breastfeed, bottle 5.3mmol/L Hb, increased
feed na dayun, Hypoalbuminemia(29.57) N: 35- environmental
kay bisag unsaon 54g/L exposure, and
paningkamot malnutrition.
wala na gyud mo
Electrolyte Imbalance
gawas gatas sa
as evidenced by risk
ako”, as
factors of vomiting,
verbalized by the
diarrhea, endocrine
mother.
dysfunction.
Impaired Attachment
related to risk factors of
interruption in bonding
process, physical
illness, perceived threat
to own survival as
evidenced by not being
breast feed, anxiety
associated with the
parental role and
demands of infant.
Ineffective
breastfeeding related
to inadequate milk
supply of the mother as
evidenced by poor
development of the
musculoskeletal
system, insufficient
infant weight gain;
sustained infant weight
loss and prone to
infection.
Deficient Knowledge
regarding
pathophysiology of
condition, nutritional
needs, growth and
development
expectations, and
parenting skills related
to lack of information,
misinformation or
misinterpretation, as
evidenced by
verbalization of
concerns, questions,
and misconceptions, or
development of
preventable
complications.
Integument “pag uli namo Inspection Impaired Comfort
ary System gikan og related to body
The skin color is pale.
Polymedic ning response to infective
taas napud iyang Nails on both the upper agent, properties of
hilanat mga 40 and lower extremities infection (e.g., skin
to”, as verbalized were oval in shape, irritation, development
by the mother pinkish in color. hematoma) as
Dry skin evidenced by
“Naunsa na iyang Hematoma/ skin irritability, and crying.
kamot? Nalata na
irritation on the left arm.
iyang kamot?” as
No presence of edema.
verbalized by the
Hyperthermia related
mother.
to increased metabolic
Palpation rate, illness, and
dehydration, as
Dry and poor skin turgor evidenced by increased
in general body temperature,
Warm to touch flushed, warm skin;
Febrile twice, 5 AM – and increased pulse and
38.5, 3 PM- 38.2 respiratory rates.
Impaired Skin
Integrity related to
associated condition of
vascular trauma,
immunodeficiency; or
related factors of
alteration in fluid
volume, inadequate
nutrition, [infection], as
evidenced by acute
pain, alteration in skin
integrity, hematoma
and redness on the left
arm,
Risk for Infection
evidenced by risk
factors alteration in
skin integrity, several
attempt to attach iv
mainline (traumatized
tissues).
HEENT Head and face – (Inspection) Risk for impaired oral
Mucous Membrane as
a. Head Head circumference:
evidenced by risk
and face 32.5 cm
b. Eyes factors of dehydration,
Normocephalic malnutrition, vitamin
c. Ears
Both lateral sides of a deficiency.
d. Nose
e. Oral face move
simultaneously Dry Mouth related to
Cavity
Fontanel not sunken dehydration or absence
of oral intake,
(Palpation) decreased saliva
production, poor or
No presence of any inadequate oral
masses. hygiene, and nutritional
deficits, as evidenced
Eyes – (inspection)
by xerostomia (dry
Opens eye mouth), oral
spontaneously. discomfort, dry lips.
Pupillary Size Left &
Risk for Aspiration
Right: 2 , Reaction: (+) related to (presence of
Sunken eyelids open to drain tube,
Pale conjunctiva increase in intragastric
pressure, delayed
gastric emptying,
treatment regimen).
Ears –(Inspection)
No presence of
discharges and no odor
and pale in color.
Nose – (Inspection)
Normal symmetry,
pointed nose.
No presence of
discharges.
Nasal cannula securely
attached with O2
inhalation at 1LPM.
No presence of masses
and displacement of
bone and cartilage.
Oral cavity–(inspection).
OGT securely attached
for open to drain.
Dry mouth and dry lips.
Pinkish gums, presence
of tiny mouth sores.
Tongue pinkish in color,
normal symmetry.
Neck Inspection Deficient Fluid
Volume related to
Poor skin turgor observe
decreased ability or
in the neck area. aversion to swallowing,
Supple OGT attached for open
Head moves to drain, presence of
spontaneously and fever, as evidenced by
purposely. dry mucous
membranes, poor skin
turgor.
Palpation
No enlargement of
cervical nodes and
enlargement of thyroid
gland of the neck.
Decrease muscle for tone
and strength, no presence
of lumps or masses.
Respiratory “Na positive siya Inspection Ineffective Airway
System sa COVID atong Clearance related to
No spinal deformities.
3 weeks old pa decreased energy,
siya”, as Equal chest rise, visible fatigue, as evidenced
verbalized by the ribcage, supraclavicular by changes in depth
mother. retractions. and rate of respirations,
Presence of coughing cough without sputum
when crying. production.
Auscultation Ineffective Breathing
Pattern related to pain,
Bibasilar crackles. muscular impairment,
decreased energy, and
fatigue, as evidenced
by coughing.
Impaired Comfort
related to muscle
contractions, physical
or psychological
exhaustion, as
evidenced by couching,
alteration in muscle
tone, irritability and
crying.
Cardio- “Pero sa balay Echocardiogram result: Decreased Cardiac
vascular naman gi monitor Output related to
Normal chamber sizes
System namo iyang 02 alteration in heart rate,
saturation pero Heart not enlarged rhythm, and conduction
okay man”, as Very minimal pericardial as evidenced by
verbalized by the fluid seen at the apical bradycardia, decreased
mother. area. peripheral pulses; cold,
Pericardial effusion clammy skin/poor
“Ning baba napud noted on LV side A4C capillary refill.
iyang O2
(0.1cm), not appreciated
saturation after 2 Ineffective Tissue
on subcostal view
days namong na Perfusion related to
Bradycrdia
discharged sa stasis, inflammatory
Polymedic”, as Palpation response,
verbalized by the atrioventricular shunts
mother. Anterior chest wall had in pulmonary and
no abnormal lifts, heaves peripheral circulation,
or vibrations. as evidenced by signs
and symptoms
dependent on system
involved, such as renal
(decreased specific
gravity and pale urine
in face of dehydration),
peripheral (poor skin
turgor), or cardiac
(arrhythima).
Breast and Inspection No problems
axilla identified.
Chest circumference: 32
cm
Normal symmetry, No
presence of lesions and
discharges.
Gastro- “Gasuka, Inspection: Risk for
intestinal kalibang siya sa Dysfunctional
Abdominal
System and balay”, as Gastrointestinal
circumference: 34 cm
the verbalized by the Motility related to
abdomen mother. Abdominal Girth: limited fluid intake,
10/24/22 , 8AM : 34 cm fluid and gas distended
“Ning dako iyang 10/25/22 , 7 AM : 31.5 small and large
tiyan maski cm intestine, suggestive
makalibang og 10/26/22 , 7 AM : 31 cm ileus as evidenced by
makaihi ra sya”,
10/27/22 , 7 AM : 26 cm acceleration of gastric
as verbalized by a
Pale and distended emptying; diarrhea,
family member.
abdominal area. distended abdomen,
“Sauna maka Visible vein and vomiting.
tolerate pa siyag Normal umbilicus Imbalanced
60cc nga fluid, position and no Nutrition: less than
karon 30cc discharge. body requirements
nalang”, as No signs of bulges or related to associated
verbalized by the
hernias. conditions of inability
mother.
Soft stool. to ingest, or absorb
nutrients (defects in
organ function or
UTZ result: metabolism, as
evidenced by lack of
Fluid and gas-distended appropriate weight
small and large intestine,gain, insufficient
the liver is normal in size
muscle tone, pale
(6.33 cm) and the spleen conjunctiva or mucous
(4.5 cm) are normal in membranes, and
size and configuration. laboratory tests
The colon was likewise reflecting nutritional
filled with fluid and gas,deficiency.
still within normal in Acute Pain related to
caliber. abdominal fullness or
pressure, as evidenced
Palpation by irritability and
No demonstrable
abdominal masses. crying.
Auscultation Impaired Comfort
related to body
Hypoactive bowel sound response to infective
agent of infection (e.g.,
distended abdomen), as
evidenced by
irritability, and crying.
Genito- Inspection Imbalanced Fluid
urinary / Volume as evidenced
Urinary collector
Reproducti by risk factors of
ve system attached. excessive losses from
I&O: vomiting or diarrhea,
10/24/22 decreased intake,
IV nausea, decreased
12 AM : Cipro 20 plasma proteins,
4 AM : Vanco 10 malnutrition.
5 AM : Metro 10
Deficient Fluid
7 AM : ML 17
Volume related to
Total intake: 57 cc
dehydration, as
Total Output: 0 evidenced by dry
mucous membranes,
10/25/22 poor skin turgor,
IV decreased pulse volume
11 AM: Metro 15 and pressure, and thirst.
12 PM: Cipro 20
1 PM: Fluco 15
2 PM: Vanco 20
3 PM: ML 246
Output
12 PM: BM 906 cc,
once, green.
Total Output: 906 cc
10/26/22
IV
2 AM: Cipro 15
3 AM: KCL 10
5 AM: Metro 10
6 AM: D5NS 36
NGT, 6 AM: 5 cc
Total Intake: 76 cc
Output: URINE
5 AM: 60 cc
6 AM: 10 cc
Total Output: 70 cc
Bladder wall is not
abnormally thickened.
Palpation
No presence of masses.
M “ming gamay Inspection Risk for
gyud siya kay disproportionate
U Height: 48.5 cm
didto pami sa Growth related to risk
S Polymedic 1 Weight: 2.3 kg factors of maladaptive
week siya NPO Fists clenched, elbows feeding behaviour.
C sad didto”, as bent, hips and knees
U verbalized by the
flexed.
mother.
L Floppy, (+) skin fold
Small body size for a 3-
O
month old baby girl.
S No deformities.
K
E Palpation
L No abnormal
growth/protrusion of
E bone, crepitus in the
T whole system.
No presence of any
A masses.
L
System
Neurologic “sige lang siyag GCS 14 (E4V4M6) Impaired Comfort
System hilak”, as Irritable, cries with related to body
verbalized by the response to infective
minimal stimulation,
mother. agent of infection as
limiting her periods of
evidenced by
sleep, observed
irritability, and crying.
spontaneous eye
opening, movements of Disturbed Sleep
the face and extremities, Pattern related to
and response to environmental barrier
stimulation. [e.g., ambient
temperature, ambient
Reflexes: noise, unfamiliar
setting] and possible
(+) Palmar grasp reflex pain as evidence by
(+) Startle reflex difficulty falling and
(+) Tonic neck reflex remaining asleep,
Poor Sucking reflex crying, and mood
alterations.
Lymphatic Inspection Risk for Infection as
/ Hemato- evidenced by risk
Skin is pale in
logic factors of alteration in
System appearance. skin integrity,
Anemia malnutrition and
Hematoma circular in associated condition of
shape is observed in the present illness,
left arm. immunosuppression, as
evidenced by low rbc,
Palpation high wbc, low hct and
hb, presence of
No enlargement of the lymph
hematoma in the left
nodes.
arm.
Lab Results:
Acute Pain related to
RBC: 3.51 localized inflammation
and tissue trauma, as
WBC: 15.76 evidenced by presence
HCT: 0.26 of hematoma with
redness in the left arm,
HB: 89.0 irritable and crying.
Source: NANDA F.A. Davis, Fifteenth Edition (March 5, 2019)
Note: Risk for Infection base on NANDA, no Nursing Diagnosis of Infection alone.
