Part I Behavior MEASUREMENTS Height Weight Proportionality of height to weight BMI Temperature Pulse rate Respiratory Rate Blood

Pressure General Survey AREAS TO BE ASSESSED GENERAL APPEARANCE Body Build, height, and weight in relation to the clients age, lifestyle, and health Posture and Gait NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION/ANALYSI S

BMI=weight(kg)t (height in m)2 18.5-25 kg/m2 36.5-37.5 C 60-100 beats/min 12-20 breaths/min 120/80 mmHg NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION/ANALYSI S

Proportionate, varies with lifestyle

Relaxed; erect posture; coordinated movement

Overall hygiene and grooming Body odor Breath odor Signs of distress

Clean, and neat No body odor or minor body odor relative to work or exercise. No breath odor No signs of distress

Neat and clean No body odor. The client uses perfume to have pleasant smell and as part of her hygiene The client has no breath odor Presence of eye bags and presence of pimples in the face The client is healthy and no signs of illness The client is cooperative The clients mood is ecstatic and his responses are appropriate

Signs of health/illness Clients attitude Affect/ mood; Appropriateness of the clients responses Speech(quantity, quality, and organization Thoughts(relevance and organization)

Healthy appearance Cooperative Appropriate to situation

Understandable, moderate pace, exhibits thought association Logical sequence; makes sense; has sense of reality

The clients speech is understandable and exhibits thought association. The client has a logical sequence of thoughts and makes sense.

HEAD TO TOE PHYSICAL ASSESSMENT

BODY PART NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION/ANALYSI

S SKIN Color, uniformity of Color Light to deep brown; uniform color except the areas exposed to the sun No edema Freckles, birthmarks, flats and raised nevi; no other lesions Moisture in skin folds and axillae The clients skin color is dark brown

Edema Lesions

No edema No lesions, no birthmarks

Moisture

There is moisture in skin folds and axillae. The skin temperature is uniform, and with normal range. Both feet and hands are uniform. When pinched, skin springs back to previous state within 3 seconds

Temperature Uniform; with normal range

Turgor When pinched, skin springs back to previous state(Fundamentals of Nursing, 8thed., by Kozier, pp 579-580) NAILS

Shape and angle Texture Color

Convex curvature; angle of nail plate is 160 degrees Smooth in texture

The shape is convex curvature and angle is 160 degrees. Smooth texture

Color is highly vascular and pink in light skinned clients; dark skinned clients may have brown or black pigmentation in longitudinal steaks Intact epidermis

Pink in color

Surrounding tissue Blanch test

Intact epidermis Blanch test, prompt return of usual color(Fundamentals of Nursing, 8thed., by Kozier, pp 583-584) Returns to usual color for about 2 seconds.

HEAD SKULL Size, shape, Symmetry Rounded(normocephalic and symmetric with frontal, parietal, temporal, and occipital prominences); smooth skull contour Absence of nodules or masses(Fundamentals of Nursing, 8thed. by Kozier, p 585) Rounded(normocephalic and symmetric with frontal, parietal, temporal, and occipital prominences) and smooth skull contour No nodules or masses

Nodules, masses And depressions

SCALP Color and Appearance Areas of tenderness Lighter than complexion No lesions, lies, dandruff, and bruises or lumps found. Free from split ends(Manual of Nursing, 7th., by Lippincott, p.54

HAIR Evenness of Growth, Thickness/ Thinness Texture and Oiliness Evenly distributed, thick, The clients hair is evenly distributed, and it is thick. The hair cut is long. Silky, and resilient hair

Silky, and resilient(Fundamentals of Nursing, 8thed. by Kozier, p 582)

FACE Facial features Symmetric or slightly asymmetric facial features. Symmetric facial movements(Fundamentals of Nursing, 8thed. by Kozier, p 585) The facial features are symmetric. Pimples are present. The facial movements are symmetric.

Symmetry of facial movements

EYES VISUAL ACUITY Near vision Distance vision Able to read 20/20 vision on snellen chart The client is able to read The client is able to read She has a 20/20 vision in her both eyes

EYEBROWS Distribution, Alignment, skin Quality and movement Hair is evenly distributed; skin intact, eyebrows symmetrically aligned; equal movement. (Fundamentals of Nursing, 8thed., by Kozier, p 588) The hair is distributed evenly, alignment is symmetrical, and skin is intact and equal movement.

EYELASHES Evenness of Distribution and Direction of curl Equally distributed and curled slightly outward(Fundamentals of Nursing, 8thed., by Kozier, p 544) Equally distributed and curled slightly outward

LACRIMAL APPARATUS

No edema/ tenderness

No edema/ tenderness

EYELIDS Surface characteristics, position in relation to the cornea, able to blink; frequency of blinking Skin intact, no discharges and no discoloration Lids close symmetrically 15-20 blinks/min. Bilateral blinking When lids open, no visible sclera above corneas, upper and lower borders of cornea are slightly covered(Fundamentals of Nursing, 8thed., by Kozier, p 588) CONJUNTIVA Bulbar conjunctiva Color, texture, Presence of Lesions Palpebral Conjunctiva color, Texture, lesions SCLERA Transparent, capillaries sometimes evident, sclera appears white (yellowish in dark-skinned clients) Shiny, smooth, and pink or red(Fundamentals of Nursing, 8thed., by Kozier, p 588) Capillaries are seen and it is transparent. Sclera appears white The clients palpebral conjunctiva is pink in color. The texture is smooth and shinny. Skin is intact, no discharges and no discoloration Lids close symmetrically 19 blinks per minute There is no visible sclera above corneas when lids open, upper and lower borders of cornea are slightly covered.

Color and clarity CORNEA Clarity and texture

White in color

The clients sclera is white.

Transparent, shiny and smooth details of the iris are visible(Fundamentals of Nursing, 8thed., by Kozier, p 590)

It has a transparent, shiny and smooth. Details of the iris are visible

IRIS Shape and color Flat and round(Fundamentals of Nursing, 8thed., by Kozier, p590) Color is brown. And it is flat and rounded.

PUPILS Color, shape, and Size Light reaction and Accommodation Black in color, equal in size, 3 7 mm in diameter; round, smooth border. Illuminated pupil constricts(direct response) Nonilluminated pupil constricts(consensual response) Pupils constrict when looking at near object; pupils dilate when looking at far object; pupils converge when near object is Pupils are black in color; the size is 3 7 mm in diameter. Round and smooth. Illuminated pupil constricts(direct response) Nonilluminated pupil constricts(consensual response) The clients pupils constrict when looking at near object; pupils dilate when looking at far object; pupils converge when near object is moved

moved toward nose(Fundamentals of Nursing, 8thed., by Kozier, p 590) EXTRAOCULAR MUSCLES Alignment; coordination Both eyes coordinated, move in unison with parallel alignment(Fundamentals of Nursing, 8thed., by Kozier, p 592)

toward nose.

The both eyes of the client moved in unison with parallel alignment and both coordinated.

VISUAL FIELDS Peripheral visual fields When looking straight ahead, the client can see objects in the periphery(Fundamentals of Nursing, 8thed., by Kozier, p 591) The object the client is looking is a pen. The client can see objects in the periphery when looking straight ahead.

EARS AURICLES Color, symmetry, Position Color same as facial skin, symmetrical, auricle aligned with outer canthus of eye, about 10 degrees from vertical Texture, elasticity and tenderness: Mobile, firm and tender; pinna Color of the clients auricle is same as the facial skin, symmetrically in size. Aligned with outer canthus of the eye. Texture is smooth, elastic and tenderness. It is firm and mobile Pinna

Texture, elasticity And tenderness

recoils after it is folded (Fundamentals of Nursing, 8thed., by Kozier, p 596) EXTERNAL EAR CANALS Cerumen, skin Lesions Pus and blood Distal third contains hair follicles and glands dry cerumen, grayish tan color/sticky/ wet cerumen in various shades of brown(Fundamentals of Nursing, 8thed., by Kozier, p 596)

recoils after it is foded

Distal third contains hair follicles and glands, and the external ear canals has cerumen

HEARING ACUITY TEST In normal voice Ones Audible The client verbalized that she can hear clearly what the health care provider says, like ears check twice and twice awesome. The client is able to hear the ticking in both ears. The client heard in both ears.

Watch tick test Webers test

Able to hear ticking in both ears Sound is heard in both ears or is localized at the center of the head Air-conducted hearing is

Rinnes test

Air conduction is greater than

greater than bone-conducted hearing(Fundamentals of Nursing, 8thed., by Kozier, pp 597-598) NOSE Shapes, size, color, flaring/ discharge from nares. Symmetric and straight; no discharge or flaring; uniform in color.

bone conduction.

The clients nose is symmetric and straight. No discharges or flaring. The color of the nose ranges from medium to light brown. Uniform to the color of the face. Mucosa is pink. And no watery discharge and lesions.

Nasal cavities: Redness, swelling Growths, and Discharge Nasal septum Nasal cavity Patency Tenderness, masses and displacement of bone and cartilage FACIAL SINUSES

Pink mucosa; clear watery discharge; no lesions

Intact and in the midline Patency, air moves freely as the client breathes through the nares. No tenderness; no lesions(Fundamentals of Nursing, 8thed., by Kozier, p 600)

Nasal septum is in the midline Air moves freely as the client breathes through the nares. No tenderness; no lesions

Frontal, Supraobital ridges ,ethmoid, sphenoid, maxillary MOUTH LIPS Symmetry of contour, color, texture

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

No tenderness

Pinkish; symmetrical with lip margin. Smooth and moist(Fundamentals of Nursing, 8thed., by Kozier, p 602)

She has a dark lips, symmetrical with lip margin. And texture is moist and smooth.

Abnormal

BUCCAL MUCOSA Color, moisture, Texture and lesions Moist, smooth, soft, glistering and elastic(Fundamentals of Nursing, 8thed., by Kozier, p 602) The clients buccal mucosa is moist, smooth, soft, glistering, and elastic Normal

TEETH Color, number condition Smooth, white, shiny tooth enamel; smooth, intact dentures. 28-32 normal numbers of teeth(Fundamentals of Nursing, 8thed., by Kozier, p 602)

GUMS

Color condition

Pink color, moist, firm texture, no retraction(Fundamentals of Nursing, 8thed., by Kozier, p 591)

TONGUE/ MOUTH FLOOR Surface of the Tongue for position, color, Texture. And tongue movement Base of the tongue Nodules, lumps or enlarged lymph nodes Pink color, slightly rough, moist. Smooth and no lesions. Central positioned. Freely movable Smooth tongue base with prominent veins Smooth with no palpable nodules(Fundamentals of Nursing, 8thed., by Kozier, pp 603-604) The clients tongue is pink in color, slightly rough and moist. Positioned in center. And the tongue can freely move.

PALATES AND UVULA Palate color, shape, texture and body prominence Hard palate: Lighter pink and more irregular texture Soft palate: Light pink, smooth Hard palate: Lighter pink and more irregular texture Soft palate: Light pink, smooth

Position of uvula, and mobility

Positioned in midline of soft palate(Fundamentals of Nursing, 8thed., by Kozier, pp 604)

The uvula is positioned in midline of soft palate

OROPHARYNX AND TONSILS Color, texture Pink in color, smooth posterior wall Pink and smooth. No discharge Present(Fundamentals of Nursing, 8thed., by Kozier, p 604) Oropharynx is pink in color and has a smooth posterior wall. Pink and smooth. And no discharge. Grade 1 tonsils Present

Tonsils, color, Discharge Gag reflex

NECK NECK MUSCLES Neck muscles for abnormal swellings or masses Head movements Muscles equal in size; head centered Coordinated, smooth movements with no discomfort(Fundamentals of Nursing, 8thed., by Kozier, p 607) Head centered and muscles are equal in size. The client has a coordinated head movements and a smooth movement. No discomfort

LYMPH NODES Occipital Postauriular Preauricular Submandibular Submental Superficial anterior TRACHEA Placement Midline of neck; spaces are equal on both sides(Fundamentals of Nursing, 8thed., by Kozier, p 608) The placement of the trachea is in the midline of the neck and the spaces on both sides are equal.

Not palpable(Fundamentals of Nursing, 8thed., by Kozier, p 607)

THYROID GLAND Symmetry and Masses Smoothness, Areas of Enlargement, Not visible, gland ascends during swallowing Lobes may not be palpated. If palpated, lobes are small, smooth, centrally located, During swallowing gland ascends bit not visible. Smoothness and nodules are not palpable. Tenderness is located centrally

Masses, nodules

painless, and rise freely with swallowing(Fundamentals of Nursing, 8thed., by Kozier, p 609 )

PART II THORAX POSTERIOR THORAX Shape, symmetry, Diameter Spinal alignment Temperature, and The integrity of all Chest skin Respiratory Excursion Vocal fremitus Fremitus is heard most clearly at the apex of the lungs. Bilateral symmetry Percussion Percussion notes resonate, the level of diaphragm but are flat over areas of heavy muscle Anteroposterior to transverse diameter in ratio of 1:2,.chest symmetrical Vertically aligned Skin intact; uniform temperature The anteroposterior to transverse diameter in ratio is 1:2 and chest symmetrical Vertically aligned Skin intact; uniform temperature During deep inspiration thumbs separate 3-5 cm The client is high pitched voice. And the fremitus is heard most clearly at the apex of the lungs. Bilateral symmetry. Resonate, except over the level of diaphragm but are flat over areas of heavy muscle and bone, dull on areas over

Full and symmetric chest expansion

and bone, dull on areas over stomach Auscultation(posterio r thorax) Vesicular and bronchovesicular breath sounds(Fundamentals of Nursing, 8thed., by Kozier, p615)

stomach Bronchial and tubular breath sounds

ANTERIOR THORAX Breathing patterns Temperature and The integrity of All chest skin Respiratory Excursion Vocal fremitus Fremitus is normally decreased over heart and breast tissue Percussion Percussion notes resonates down to the sixth rib at the level of the diaphragm but are flat over areas of heavy muscle and bone, dull on areas over the heart and the liver, and tympanic over the underlying Quiet, rhythmic, and effortless respiration Skin intact; uniform temperature The client has quiet, rhythmic, and effortless respiration. Skin intact and uniform temperature. During deep inspiration thumbs separate 3-5 cm

Full symmetric excursion; thumbs normally separate 3 to 5 cm

stomach Auscultation(trachea) Bronchial and tubular breath sounds Auscultation(anterior thorax) Bronchovesicular and vesicular breath sounds(Fundamentals of Nursing, 8thed., by Kozier, p617) No pulsations No pulsation and no heaves or lifts Pulsation visible in 50% of adults and palpable in most PMI in fifth LISC at or medial to MCL. Diameter of 1 to 2 cm. no he heave or lift S1: usually heard at all sites usually louder at apical area S2: usually heard at all sites usually louder at base of heart Systole: silent interval; slightly shorter duration than diastole at normal heart rate(60-90bpm) Bronchial and tubular breath sounds Bonchovesicular and vesicular breath sounds

CARDIOVASCULAR PALPATION Aortic and pulmonic Tricuspid area and Heaves or lifts Apical area

No pulsations No pulsation and no heaves or lifts Pulsation is visible and palpable.

Normal Normal

Auscultation Aortic Pulmonic Tricuspid Apical

S1: usually heard at all sites usually louder at apical area S2: usually heard at all sites usually louder at base of heart

Normal

Diastole: silent interval; slightly longer than systole at normal heart rates S3: in children and young adult S4: in many older adults. (Fundamentals of Nursing, 8thed., by Kozier, pp620-622) CAROTID ARTERIES Palpation Symmetric pulse volumes. Full pulsations, thrusting quality. Elastic artery wall No sound heard on auscultation(Fundamentals of Nursing, 8thed., by Kozier, pp622-623) Symmetric pulse volumes. Full pulsations, thrusting quality. Elastic artery wall During auscultation no sound heard Normal

Auscultation

Normal

JUGULAR VEINS Inspect Veins not visible(Fundamentals of Nursing, 8thed., by Kozier, p 623) Veins are not visible Normal

BREAST AND AXILLAE BREAST

Size, symmetry and Shape Localized discolorations or hyperpigmentation, retraaction or dimpling, localized hypervascular areas, swelling or edema AREOLA Shape,, color, masses or lesions

Rounded shape; slightly unequal in size; generally symmetric Skin uniform in color; skin smooth and intact. Diffuse symmetric horizontal or vertical vascular pattern in light skinned people. Striae; moles and nevi

The shape is round and slightly unequal and it is generally symmetric. The skin is uniform in color and it is also smooth and intact.

Round/oval; bilaterally the same; color varies widely from light pink to dark brown. No lumps, masses or areas of tenderness

NIPPLES Size, shape, color, Position, discharge And lesions. Round; everted/inverted; equal in size; similar in color. Soft and smooth; no discharge, masses or lesions. No lumps and masses. No tenderness, masses, or nodules Round everted and equal in size. Similar in color with areola and texture is smooth and soft, No discharges and lesions nor masses. No tenderness, masses, or nodules

Axillary, Subclavicular and supraclavicular lymph nodes

Breast for Masses, tenderness Nipples for tenderness and discharges ABDOMEN Inspection Abdomen skin Inspection Abdomen for Contour and Symmetry Inspection Enlargement of Liver/spleen Assess symmetry Of contour while standing at the foot of the bed Abdominal Movements associated w/ respiration,

No tenderness, masses, nodules, or nipple discharge No tenderness, masses, nodules, or nipple discharge(Fundamentals of Nursing, 8thed., by Kozier, pp 628-630) Unblemished skin; uniform color

No tenderness, masses, nodules, or nipple discharge No tenderness, masses, nodules, or nipple discharge

The color is light to medium brown and it is uniform. Unblemished skin. The abdomen is flat and rounded and has a symmetric contour. There is no enlargement of the liver/spleen The client has a symmetric contour

Flat, rounded; symmetric contour.

No enlargement of the liver/spleen Symmetric contour

Symmetric movements. Symmetric movements caused by respiration. Visible peristalsis in very lean

peristalsis, or aortic pulsations Vascular patterns

people. Aortic pulsations in thin persons at epigastric area. Vascular pattern is not visible No visible vascular pattern Absence of arterial bruits and Audible bowel sounds; absence friction rub. The bowel sounds of arterial bruits; absence of are audible friction rub Tympany is heard over the Tympany over the stomach and stomach and gas-filled gas-filled bowels; dullness, bowels; dullness, sound is especially over the liver and heard over the liver and spleen, or a full bladder spleen, or a full bladder 6 to 12 cm in the midclavicular line; 4 to 8 cm at midsternal line No tenderness; relaxed abdomen with smooth, consistent tension Tenderness may be present near xiphoid process, over cecum, and over sigmoid colon No tenderness relaxed abdomen w/ smooth, consistent tension.

Auscultation

Percussion each Of the four Quadrants Percuss the liver To determine its Size Light Palpation Deep palpation

Palpate area above The symphysis Pubis to determine possible urinary retention

Not palpable(Fundamentals of Nursing, 8thed., by Kozier, pp 633-638)

MASCULAR SKELETAL SYSTEM MUSCLE Size Tendons for Contractures Fasciculation and Tremors Palpate muscle Tonicity Test for muscle Strength Equal on both sides of body No contractures No fasciculation and tremors Normally firm Equal strength on each body side. (Fundamentals of Nursing, 8thed., by Kozier, pp 640-641) Muscle is equal on both sides of the body No contractures No fasciculation and tremors Muscle is firm Muscle strength is equal on both sides.

BONES Inspect skeleton For structure Palpate bones to Locate areas of Edema or Tenderness No deformities No deformities

No tenderness or swelling

No tenderness or swelling

Inspect joint for Swelling Palpate each joint For tenderness, Smoothness, Swelling, crepitation & presence of nodule

No swelling;

Joints of the client do not have swelling. No tenderness or nodules. Joints move smoothly

No tenderness, crepitation, or nodules. Joints move smoothly(Fundamentals of Nursing, 8thed., by Kozier, p 641)