V.

PHYSICAL ASSESSMENT

Date of Assessment: February 7, 2010

A. Appearance

Techniqu Normal Findings Actual Findings Interpretation

es

1. Mood Inspection Gestures and expressions Cooperative, Normal Findings

and are shown while talking. responses
Affect Responds to outside stimuli. appropriately
Does not show fatigue and
agitation. Talks at moderate
speed. Responses are
appropriate to the situation.

2. Signs Inspection No signs of pain, difficulty No distress noted Normal Findings

of on breathing, and anxiety.
distress The client is relaxed and at
ease.

3. Inspection Points between the eyes, Relaxed, erect Normal Findings

Posture collar bone, breast bone, posture
pubic area and midpoint
between the ankles are
properly aligned: The three
natural curves at the back
are visible from the sides:
The shoulders, hips and the
knees are of equal height
 from the front: Head is held
straight, not tilted or turned
to one side: the little bumps
of the spine is in straight
line down the center of the
back

4. Body Inspection There are no involuntary Movement is Normal

Moveme movements. Have coordinated.
nts coordinated movements.

5. Inspection Clothes are clean: Nails are He is well Normal Findings

Hygiene properly trimmed: There is groomed as
and no presence of bad breath. evidenced by
Groomin combed hair, clean
g clothing and no
foul odor.

6. Type Inspection Type of clothing worn is The clothing he is Normal Findings

of appropriate for the wearing is a sando
clothing temperature and weather and shorts.
condition.
B. Vital Signs

Vital Signs Normal Range Actual Findings Interpretation

Temperature 36.1– 37.6 º C 36.3 º C

Within the normal range

Heart Rate 90-150 bpm 107 bpm Within the normal range

24 to 40 breaths per Within the normal range

Respiration 30 bpm
minute

Within the normal range

Blood Pressure 100/60-115/80 mmHg 90/60 mmHg

Measurements
Normal Findings Actual Findings Interpretation
88 cm Within the normal range
Height 86-100 cm
the normal weight for
The patient lost weight because of the
Weight a toddler is between 18 kg
disease itself, nephrotic syndrome.
22 and 31 pounds.
REVIEW OF SYSTEMS
General ☺Weight loss Fatigue Anorexia Night sweats
Chills Fever Weakness
The patient experienced fever due to cough and colds.
The patient experienced fatigue due to illness and lack of sleep.
The patient experienced weakness due to fatigue.
Skin Itch Rash Lesions Bruising
Bleeding Color change
NONE
Eyes Pain Discharge Itch Vision loss Diplopia
Excessive tearing Glasses/Contact lens Date of last exam ☺EDEMA
NONE
Ears Earaches ☺ Discharges Tinnitus Hearing loss
NONE
Nose Obstruction Discharges Epistaxis
NONE
Throat and Mouth Sore throats Bleeding gums Toothache Dentures
NONE
Neck and Head Swelling Dysphagia Hoarseness
NONE
Chest Cough Sputum: Amount and Character Hemoptysis
☺Wheeze Pain on respiration Dyspnea
The patient has abnormal breath sound because of Pulmonary Congestion
Cardiovascular Precordial pain Palpitation Dyspnea on exertion Orthopnea
Dyspnea Paroxysmal nocturnal Edema Heart murmur
Claudication Thrombophlebitis
NONE
Gastrointestinal Heartburn Nausea ☺ Vomiting Diarrhea Food intolerance
Excessive gas or indication Constipation Jaundice Bloating
Change in Bowel movement Melena Hemorrhoids Hernia
NONE
Genitourinary Heartburn Nausea ☺Vomiting Diarrhea Food intolerance
Excessive gas or indication Constipation Jaundice Bloating
Change in Bowel movement Melena Hemorrhoids Hernia
NONE
Extremities Joint pains Varicose veins Claudication Back pain
Edema Stiffness Deformities
NONE
Endocrine Hot flashes Hair loss Temperature intolerance
Polydipsia Goiter
NONE
Neurology Numbness Tingling Tremor Fainting
Headaches Muscle weakness Ataxia Seizure Unconsciousness
Paralysis/Paresis Memory loss Dizziness
None
PHYSICAL ASSESSMENT
Skin Uniform skin color, no jaundice, cyanosis
Skin intact
Skin warm and dry
Hair Hair is evenly distributed over scalp
Hair color black and thin
No lesions or pediculosis
Nails Color pink, well groomed ad convex, smooth and firm

Head Normocephallic, erect and midline

Head symmetrical, no masses, nontender

Face Facial expression appropriate, no abnormal movements or lesions

Facial bones smooth, intact,symmetrical, nontender
Ears Ears aligned with eyes, symmetrical, no redness, lesions or drainage

Eyes Eyes clear and bright, equal parallel alignment

Eyelids color consistent with clients complexion
Eyelashes evenly distributed, no excessive tearing or dryness
Periorbital has edema
Nose Nose midline, symmetrical, no deviation, no flaring
No deformities or nasal tenderness
Sinuses Sinuses clear, nontender
Mouth Lips pink, moist, no lesions
Oral mucosa pink, moist, no lesions, intact
Teeth complete
Tongue pink, moist, midline
Neck Neck symmetrical, skin intact, no masses
Upper Extremities Skin color uniform; no erythema, No more edema
Abdomen Skin color consistent, no lesions, rashes, scars or discoloration.
Hair distribution appropriate for client’s age and gender.
Abdomen flat and symmetrical, no bulges or hernias
Umbilicus midline
Abdomen soft, nontender, no masses
Lower Extremities Leg hair evenly distributed; color uniform; no edema or lesions