PHYSICAL ASSESSMENT

Appeara ACTUAL FINDINGS NORMAL FINDINGS ANALYSIS

nce and
Mental
Status

*posture Relaxed but needs to Relaxed, erect posture; Abnormal

and gait be accompanied coordinated movement
Muscle mass
while walking By: Kozier decreases
progressively
within age and
bones become
more fragile.

* overall Clean and neat Clean and neat Normal

hygiene
By: Kozier
and
grooming

* signs of No distress noted No distress noted Normal

distress in
By: Kozier
posture or
facial
expressio
n

* obvious Pale and weak in Healthy appearance Abnormal

signs of appearance
Pale and weak
health or
in appearance
illness By: Kozier
is an indication
of illness

* quantity Slow pace of speech Understandable, moderate Abnormal

of speech, and not that pace; exhibits thought
Many elders
quality, understandable association
have some
and
impairment in
organizati
hearing, vision
on By: Kozier
 and speech.

Clients Confused and was Cooperative A stress of

attitude easily distracted being in
By: Kozier
when people came in unfamiliar
and out of the situations can
cause
confusion in
elders.

Measuremen Actual Findings Normal Findings Interpretati

ts on/Analysis

Temperature 36.5 36.5۫c-37.4۫c 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 ACTUAL FINDINGS NORMAL FINDINGS ANALYSIS

PART
 Skin is brown with Varies from light to deep Abnormal
age spots distributed brown; Generally uniform
SKIN The skin is dry
all over the body; except in areas exposed to
and flaky
Appears dry and the sun; areas of lighter
because
flaky; warm to touch, pigmentation; no abrasions or
sebaceous and
slightly moist and other lesions; Uniform
sweat glands
smooth; temperature with normal
are less active.
range; When pinched, skin
springs back to previous
state within 3 sec.

By: Kozier

Hair on head is Evenly distributed hair; Thick Abnormal

thinning with its hair; Silky, resilient hair; No
HAIR In elderly
white roots showing. infection or infestation
people, Hair is
No signs of scalp
slightly
lesion or flaking.
thinning and
By: Kozier
white hair
starts to
appear.

Finger nails not Smooth texture, dark-skinned Abnormal

trimmed and dirty. clients may have brown or
NAIL 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 are Rounded; Absence of nodules Normal

symmetric. Skull is and masses; Symmetric or
SKULL
well-rounded. No slightly asymmetric facial
AND
signs of tenderness features; Hair evenly
FACE
or masses noted. distributed, skin intact

By: Kozier

EYE Eyebrows were . Equally distributed Abnormal

STRUCTU thinning but evenly eyebrows and eyelashes;
RES AND distributed. The lid Skin intact; conjunctiva
Visual acuity
VISUAL margins were clear, appears transparent;
decreases as
ACUITY lacrimal duct capillaries sometimes
the lens of the
openings were evident, shiny, smooth and
eye ages and
evident at the inner pink or red; sclera appears
becomes more
canthus of the eye. white.
opaque and
Eyelashes were
loses elasticity.
evenly distributed
and turned outwards. By: Kozier
The sclera was white
and clear. With an
eyeglass and has a
vision of 200/150.

EARS Pinna of both ears is Color same as facial skin; Abnormal

AND symmetrical, color symmetrical; Mobile; firm;
Hearing loss
HEARING same as that of the and not tender, no hearing
occurs in
skin. External canal difficulty.
elderly people.
of both ears showed
no discharge with
only very minimal By: Kozier
cerumen. No lesions,
masses,
inflammation or
foreign bodies noted.
Can hear sounds but
not that clear

Nose appeared to Symmetric and straight; no Normal

be symmetric and discharge or flaring; uniform
NOSE straight. No in color; no tenderness; no
AND discharges. No lesions; Air moves freely as
SINUSES flaring noted. Color
the client breathes through
of the nose is same
the nares.
as that of the skin.
No lesions and By: Kozier
redness noted. Both
nares were patent
and no obstruction
was seen
 Dry lips, Few teeth, Uniform pink color; Soft, Abnormal
teeth was slightly moist, smooth texture; Moist,
MOUTH Dryness of lips
yellowish with smooth, glistening, and
AND is associated
brownish stains on elastic texture; tongue pink
OROPHA with
the upper teeth. color (some brown
RYNX dehydration. In
Tongue was midline pigmentation on tongue
elderly people,
and covered with borders in dark- skinned
tooth loss
papillae. No lesions clients ); moist slightly rough;
occur and may
or masses thin whitish coating; Moves
show signs of
freely; no tenderness.
staining,
By: Kozier erosion,
chipping.

The thorax is The thorax is symmetric and Normal

symmetric and moves easily without
THORAX
moves easily without impairment upon respiration.
AND
impairment upon No tenderness noted. No
LUNGS
respiration. No masses, deformities or
tenderness noted. No abnormal movements noted
masses, deformities upon palpation. Respiratory
or abnormal expansion is equal on both
movements noted sides. No rales, rhonchi, or
upon palpation. friction rubs noted
Respiratory
By: Kozier
expansion is equal
on both sides. No
rales, rhonchi, or
friction rubs noted

Flat, concave and Unblemished skin; Uniform in Normal

symmetrical. Skin on color; Flat; No evidence
ABDOME
abdomen was of enlargement of liver and
N
relatively the same spleen
color as that of the
rest of the body,
dryness and flakiness By: Kozier
noted. No tenderness
and pulsations noted.