IV.

Physical Assessment
Norms Actual Findings Interpretation
and Analysis
General
Appearance
Posture / Gait Relaxed, erect posture; Normal for a
coordinated movements Lying flat on bed post-operative
(ref. FON kozier et al. 8th patient
ed. Vol.1 page 572)
Skin color Color varies from light to Client’s color is dark Normal
deep brown; from ruddy or deep brown.
pink to light pink; from
yellow overtones to olive
( FON kozier et al 8th ed.
Vol 1 579) An area exposed to Normal
the sun is darker than
Generally uniform except the areas that are not
for areas exposed to the
sun; areas of lighter
pigmentation (palms, lips,
nail beds) in dark-skinned
people
(FON kozier et al. 8th ed.
Vol.1 page 579)
Personal hygiene/ Clean and neat; no foul Patient doesn’t have Normal
Grooming body odor or breath odor; any foul body or
( FON koier et al. 8th ed. breath odor
Vol. 1 page 572)

a person should take a Now that she just

bath everyday to facilitate undergone surgery Normal
blood circulation. (ref. FON it’s hard for her to
kozier et al 8th edition clean herself so she
volume 1 page 748) needs assistance in
cleaning her but she
haven’t took a bath
a person should perform since she was Normal
oral hygiene at least 3 confined.
times a day; (ref. FON
kozier et al. 8th edition
volume 1 page 772). Patient has oral care
once a day every
morning.

Nutritional Status Healthy appearance; in Patient has fat Just normal for
elders lean body mass is tissues. her age and
reduced, fat tissue height.
increases, and bone mass
decreases. (FON kozier et Patient eat or drink
 al. 8th ed. Vol. 1 page 410)
Age Acts according to age
Appropriateness (mosby primary care for
older adult, 5th ed. Page
16)
Verbal Behavior Understandable, moderate
pace, clear tone and
inflection; exhibits thought
association; logical
sequence of thought;
makes sense; has sense of
reality (FOM kozier et al.
8th ed. Vol.1 page 579)
Non-verbal Good muscle strength;
behavior uneasy fatigability,
endurance and balance
(FOM kozier et al. 8th ed.
Vol.1 page 579)
MEASUREMENTS
Temperature 36.0 C-37.5 C
(FUNDAMENTALS OF
NURSING Eight Edition by
Kozier & Erb—page 529)
Pulse rate 60-100 bpm
(FUNDAMENTALS OF
NURSING 8TH EDITION by
kozier et al. Page 539)
Respiratory rate 12-20 bpm
(FUNDAMENTALS OF
NURSING Eight Edition by
Kozier & Erb—page 547)
Blood pressure 120/80 mmHg
(FUNDAMENTALS OF
small amount of food;
and NPO after the
surgery
Patient acts Normal
according to age.
Patient can speak but Normal
in weak manner; has
logical arrangements
of thoughts and
makes sense
Patient is lying flat on Normal
bed due to her
surgery, can exhibit
facial expression well.
Initial finding: 36.5C Normal
axillary
Latest finding: 36.6 C
axillary
Initial finding: 62 Normal
bpm, radial pulse,
bounding, regular
Latest finding:67
bpm, radial pulse,
bounding, regular
Initial finding:22 cpm, Normal
shallow
Latest finding: 22
cpm, shallow
Initial finding: 100/80 Normal
mmhg
 NURSING 8th edition by Latest finding: 100/80
kozier et al. Page 551) mmhg

BODY NORMAL FINDINGS ACTUAL INTERPRETATION/AN

PART FINDINGS ALYSIS
EXAMINE
D

Integume Color varies from light to Client’s color is Normal

ntary deep brown; from ruddy dark or deep
Skin pink to light pink; from brown.
yellow overtones to olive

Generally uniform except Normal

for areas exposed to the An area exposed
sun; areas of lighter to the sun is
pigmentation (palms, darker than the
lips, nail beds) in dark- areas that are not. Normal
skinned people
No edema Normal
No edema
Client’s skin
Skin temperature is temperature is
uniform; within normal uniformly & within
range (36-37.5) normal range in
both right and left,
superior and
inferior.

Nails Fingernails have convex Client’s fingernails Normal

curvature; angle of nail have convex
plate about 160°; well curvature; angle of
trimmed nail and clean; nail plate
 nails in elders may approximately Deviation from normal
appear thickened and 160°.
rough. (FON kozier et al. Nails are dirty and
8th ed. Page 580) long. Client’s
fingernails and Might be causes by
toenails texture is excessive blood loss
Prompt return of pink or smooth from her operation.
usual color (generally
less than 4 seconds) Pale nailbeds
(Ref: Kozier, FON 8th returns in 3
Edition, 2008 pgs 583- seconds
584) immediately to
blanched nail beds
when the pressure
is released.

Head / Rounded (normocephalic Client’s skull is Normal

Skull and symmetric with rounded
frontal, parietal, and (normocephalic)
occipital prominences); and symmetrical
smooth skull contour
Normal
Smooth, uniform The client’s head
consistency; absence of is hard, smooth
nodules or masses w/o lesions or
(Ref: Kozier, FON 8th masses.
Edition, 2008 pg 585)

Hair Hair is evenly distributed Hair is evenly Normal

Thick hair distributed
Silky, resilient hair Client has thin hair
Dry, brittle hair
No infection or Normal
infestation No dandruff, lice or
other infestations.
Normal
th
(Ref: Kozier, FON 8 Variable amount of
Edition, 2008 pg 582) body hair
Face Symmetric or slightly Symmetrical facial Normal
asymmetric facial features; palpebral
features; palpebral features equal in
fissures equal in size; size; symmetric
symmetric nasolabial nasolabial folds
folds Normal
Symmetrical facial
Symmetric facial movements
movements
(Ref: Kozier, FON 8th
Edition, 2008 pg 585)
Eye Hair equally distributed; Hair equally Normal
 lashes curled slightly outward distributed; curled
Hair evenly distributed; slightly outward
skin intact
Normal
Eyebrows Eyebrows symmetrically Hair equally
aligned; equal movement distributed on both
sides of the eye
(Ref: Kozier, FON 8th with equal
Edition, 2008 pg 588) movement.

Nose Nose is symmetric and Nose is Normal

straight symmetrical and
straight
Normal
No flaring No flaring Normal
Uniform color Uniform in color
same as the color
of the skin Normal
No tenderness; no
lesions No tenderness
upon palpation or
presence of Normal
Air moves freely as the lesions
client breathes through
the nares The client
breathes normally Normal
without
Clear, watery discharge mechanical
or no abnormal discharge ventilation Normal

Nasal septum intact and No abnormal

in midline discharge

(Ref: Kozier, FON 8th

Edition, 2008 pgs 600) Septum is not
deviated neither to
the left or right
Lips Uniform pink color Pale lips Might be a sign of
( Darker, e.g. bluish hue, excessive blood loss
Mediterranean groups during her operation.
and dark-skinned cliets.
Symmetric contour
Symmetry of contour Normal
Mouth 6 adult teeth;
32 adult teeth Smooth, client teeth has Deviation from normal
white, shiny tooth yellowish
enamel discoloration
Special consideration Doesn’t wear
Elders usually loss their dental prostheses.
teeth as their age
 progress and teeth
becomes discolorated
with black or brown

(Ref: Kozier, FON 8th

Edition, 2008 pg 602)
Neck No palpable lymph No palpable lymph Normal
nodes) nodes

(Ref: Kozier, FON 8th

Edition, 2008 pg 591)
Trachea Trachea is in the central Trachea is in the Normal
placement in the midline central placement
of neck; spaces are equal
on both sides
(Ref: Kozier, FON 8th
Edition, 2008 pg 608)
Thyroid Not visible on palpation No visible masses Normal
gland Lobes may not be No areas of
enlargement
palpated
Trachea moved as
If palpated, lobes are she swallowed
small, smooth, centrally
located, painless, and
rise freely with
swallowing

(Fundamentals of
Nursing, Kozier et al, h
edition, vol 1, page 608-
609)

Posterior Anteposterior to Ratio is 1:2 Normal

Thorax transverse diameter Chest symmetric
in ratio of 1:2 Spinal column is
aligned
Chest symmetric Normal
Skin is intact
Spine vertically aligned
Uniform
Spinal column is aligned temperature
Skin is intact No tenderness Normal
Uniform temperature No masses
Chest wall intact Full symmetric Normal
chest expansion
No tenderness
Vesicular and
No masses bronchovesicular
Full symmetric chest breath sounds
expansion
Vesicular and
 bronchovesicular breath
sounds
(Fundamentals of
Nursing, Kozier et al, h
edition, vol 1, page614-
616)
Anterior Quiet, rhythmic & Quiet, rhythmic & Normal
Thorax effortless respiration effortless
Trachea have bronchial respiration
Trachea have
and tubular breath
bronchial breath
sounds sounds
Vesicular and Vesicular and
bronchovesicular breath bronchovesicular
sounds breath sounds
(Fundamentals of
Nursing, Kozier et al, h
edition, vol 1, page617-
618)
Central No pulsations in aortic, No pulsations in Normal
Vessels pulmonic and tricuspid aortic, pulmonic
areas and tricuspid areas
No lift
No lift, no heave Normal
No heave
Aortic pulsations
(Fundamentals of
Nursing, Kozier et al, h
edition, vol 1, page 622)
Carotid Symmetric pulse Symmetric pulse Normal
arteries volumes volumes
Full pulsations Normal
Full pulsations
No sound heard on
No sound heard on
auscultation
auscultation
Veins not visible
(Fundamentals of
Nursing, Kozier et al, h
edition, vol 1, page 62)3
Jugular Veins not visible Veins not visible Normal
veins (Fundamentals of
Nursing, Kozier et al, h
edition, vol 1, page 624)
Breast Breast even with chest Breast even with Normal
wall chest wall
Skin uniform in Normal
Skin uniform in color
 Skin smooth and intact color Normal
Skin smooth and
Areola intact
Round or oval bilaterally Normal
the same
Round bilaterally
Light to pink the same
Nipples Light brown Normal

Round
Everted Round
Normal
Everted
Equal in size
Equal in size
Similar in color
Similar in color
Points in the same Points in the same
direction direction
No tenderness, masses, No tenderness,
nodules and no discharge masses, nodules
(Fundamentals of no discharge
Nursing, Kozier et al, h
edition, vol 1, page 628-
630)
Abdomen Unblemished skin There is an Normal
Uniform in color incision in the
lower part due to
Flat
her operation
Rounded(convex) Uniform in color Normal
Scaphoid (concave) Rounded(convex)
Normal
No enlargement of liver No enlargement of
or spleen liver or spleen Normal
Symmetric contour Symmetric contour
No visible vascular Normal
No visible vascular
pattern
pattern
no of arterial bruits
Absence of arterial bruits no of friction rubs
Absence of friction rubs Pain is normal for the
No tenderness first few days of post-op
There is pain when
period due to an
Relaxed abdomen touch.
invasive procedure
(Fundamentals of The client rate the done.
Nursing, Kozier et al, h pain on the
edition, vol 1, page 633- incision site as 10
636) out of ten.
Increase pressure
in abdomen.
Musculos Equal size on both sides Equal size on both Normal
keletal of the body sides of the body
System No contractures No contractures
No tremors Normal
No tremors
Firm Normal
Normally firm
Smooth coordinated
Needed support in
movements moving.
Muscles
Equal strength on each Feels weak and Due to surgery and
body side cannot move pain in incision site.
freely.

Bones No deformities No deformities Normal

No tenderness or No tenderness or
swelling Normal
swelling
Joints Normal
No swelling
No swelling
No terness, Normal
No terness, swelling, swelling,
crepitation, nodules crepitation,
Joints move smoothly No nodules
Joints move
smoothly

Range of Varies to some degree in Cannot facilitate Due to pain in her

Motion accordance w’ person’s proper movement. abdomen because of
genetic makeup and Uncoordinated the incision.
moves and needs
degree of physical
support for
activity moving.

(Fundamentals of
Nursing, Kozier et al, h
edition, vol 1, page 640-
641)