PHYSICAL ASSESSMENT

Appeara
nce and
Mental
Status
*posture
and gait

ACTUAL FINDINGS

NORMAL FINDINGS

Relaxed but needs to Relaxed, erect posture;

be
accompanied coordinated movement
while walking
By: Kozier

* overall Clean and neat

hygiene
and
grooming

Clean and neat

* signs of No distress noted

distress in
posture or
facial
expressio
n

No distress noted

* obvious Pale and weak

signs
of appearance
health or
illness

in Healthy appearance

ANALYSIS

Abnormal
Muscle
mass
decreases
progressively
within age and
bones become
more fragile.
Normal

By: Kozier

Normal

By: Kozier

* quantity Slow pace of speech

of speech, and
not
that
quality,
understandable
and
organizati
on

By: Kozier

Understandable,
pace;
exhibits
association

By: Kozier

Abnormal
Pale and weak
in appearance
is an indication
of illness
moderate Abnormal
thought
Many
elders
have
some
impairment in
hearing, vision

and speech.

Clients
attitude

Confused and was Cooperative

easily
distracted
By: Kozier
when people came in
and out of the

A
stress
of
being
in
unfamiliar
situations can
cause
confusion
in
elders.

Measuremen Actual Findings

ts

Normal Findings

Interpretati
on/Analysis

Temperature

36.5

36.5c-37.4c

Normal

PR

63 bpm

60-100bpm

Normal

RR

20 cpm

16-20cpm

Normal

BP

140/90mmHg

120/80mmHg

Abnormal
A
BP
of
140/90 is an
indication of
Hypertension
or
High
Blood
pressure

BODY
PART

ACTUAL FINDINGS

NORMAL FINDINGS

ANALYSIS

SKIN

Skin is brown with

age spots distributed
all over the body;
Appears
dry
and
flaky; warm to touch,
slightly moist and
smooth;

Varies from light to deep

brown; Generally uniform
except in areas exposed to
the sun; areas of lighter
pigmentation; no abrasions or
other
lesions;
Uniform
temperature
with
normal
range; When pinched, skin
springs back to previous
state within 3 sec.

Abnormal
The skin is dry
and
flaky
because
sebaceous and
sweat
glands
are less active.

By: Kozier

HAIR

Hair on head is Evenly distributed hair; Thick

thinning
with
its hair; Silky, resilient hair; No
white roots showing. infection or infestation
No signs of scalp
lesion or flaking.
By: Kozier

NAIL

Abnormal
In
elderly
people, Hair is
slightly
thinning
and
white
hair
starts
to
appear.

Finger
nails
not Smooth texture, dark-skinned Abnormal
trimmed and dirty. clients may have brown or
The
hair
Slow return of refill black
pigmentation
in
grows
more
on fingers
longitudinal streaks; Intact
slowly
and
epidermis; Prompt return of
thickens
in
pink or usual color (generally
elder people.
less than 4 sec.).
By: Kozier

SKULL
AND
FACE

Skull and face are

symmetric. Skull is
well-rounded.
No
signs of tenderness
or masses noted.

Rounded; Absence of nodules Normal

and masses; Symmetric or
slightly asymmetric facial
features;
Hair
evenly
distributed, skin intact
By: Kozier

EYE

Eyebrows

were .

Equally

distributed Abnormal

STRUCTU
RES AND
VISUAL
ACUITY

EARS
AND
HEARING

NOSE
AND
SINUSES

thinning but evenly

distributed. The lid
margins were clear,
lacrimal
duct
openings
were
evident at the inner
canthus of the eye.
Eyelashes
were
evenly
distributed
and turned outwards.
The sclera was white
and clear. With an
eyeglass and has a
vision of 200/150.

eyebrows
and
eyelashes;
Skin
intact;
conjunctiva
appears
transparent;
capillaries
sometimes
evident, shiny, smooth and
pink or red; sclera appears
white.

Pinna of both ears is

symmetrical,
color
same as that of the
skin. External canal
of both ears showed
no discharge with
only very minimal
cerumen. No lesions,
masses,
inflammation
or
foreign bodies noted.
Can hear sounds but
not that clear

Color same as facial skin; Abnormal

symmetrical; Mobile; firm;
Hearing
loss
and not tender, no hearing
occurs
in
difficulty.
elderly people.

Nose appeared to
be symmetric and
straight.
No
discharges.
No
flaring noted. Color
of the nose is same
as that of the skin.
No
lesions
and
redness noted. Both
nares were patent
and no obstruction
was seen

Symmetric and straight; no

discharge or flaring; uniform
in color; no tenderness; no
lesions; Air moves freely as
the client breathes through
the nares.

Visual
acuity
decreases
as
the lens of the
eye ages and
becomes more
opaque
and
loses elasticity.

By: Kozier

By: Kozier

By: Kozier

Normal

MOUTH
AND
OROPHA
RYNX

Dry lips, Few teeth,

teeth was slightly
yellowish
with
brownish stains on
the
upper
teeth.
Tongue was midline
and covered with
papillae. No lesions
or masses

Uniform pink color; Soft,

moist, smooth texture; Moist,
smooth,
glistening,
and
elastic texture; tongue pink
color
(some
brown
pigmentation
on
tongue
borders in dark- skinned
clients ); moist slightly rough;
thin whitish coating; Moves
freely; no tenderness.
By: Kozier

THORAX
AND
LUNGS

ABDOME
N

Abnormal
Dryness of lips
is
associated
with
dehydration. In
elderly people,
tooth
loss
occur and may
show signs of
staining,
erosion,
chipping.

The
thorax
is
symmetric
and
moves easily without
impairment
upon
respiration.
No
tenderness noted. No
masses, deformities
or
abnormal
movements
noted
upon
palpation.
Respiratory
expansion is equal
on both sides. No
rales,
rhonchi,
or
friction rubs noted

The thorax is symmetric and Normal

moves
easily
without
impairment upon respiration.
No tenderness noted. No
masses,
deformities
or
abnormal movements noted
upon palpation. Respiratory
expansion is equal on both
sides. No rales, rhonchi, or
friction rubs noted

Flat, concave and

symmetrical. Skin on
abdomen
was
relatively the same
color as that of the
rest of the body,
dryness and flakiness
noted. No tenderness
and pulsations noted.

Unblemished skin; Uniform in Normal

color; Flat;
No
evidence
of enlargement of liver and
spleen

By: Kozier

By: Kozier