PHYSICAL ASSESSMENT EVALUATION TOOL (HEAD TO TOE ASSESSMENT) NAME OF THE CLIENT: Jenileen Carlette T.

Peronilla BODY PART EXAMINED ACTUAL FINDINGS NORMAL FINDINGS INTERPRETATI ON/ ANALYSIS

ANTHROPOMETRIC MEASUREMENT 1. Measurement in height 154 cm 2. Measurement in weight 42 kg 3. BMI 17 = W in kg / H in m GENERAL SURVEY 3. Body built, proportionate Proportionate, height and weight height and weight, varies with lifestyle in relation to the has a healthy and clients age, active lifestyle. lifestyle, and health 4. Posture, gait, standing, sitting, and walking 5. Overall hygiene and grooming 6. Body and breath odor 7. Signs of distress 8. Signs of health and distress 9. Attitude Relaxed, has an erect in posture and coordinated body movement. Clean and neat. Has no body odor as well as bad breath. Shows no signs of distress. Has a health appearance. cooperative Relaxed, erect in posture, coordinated movement Clear and neat No body odor or minor body odor, no breath odor No distress noted Healthy appearance Cooperative Appropriate to situation, should have appropriate response Understandable, moderate in pace

NORMAL

NORMAL

NORMAL NORMAL

NORMAL NORMAL NORMAL NORMAL

10. Mood and affect Appropriate.

11. Quantity and quality of speech SKIN

Has a fast pacing

NORMAL

13. Uniformity of color 14. Presence of edema 15. Lesions according to location distribution, color, configuration, size, shape, type of structure 16. Skin moisture

Has a uniform white skin color. Has no presence of edema on her skin. Has no lesions in the skin.

Uniform in color except in areas expose to the sun No edema No lesions or abrasions

NORMAL

NORMAL NORMAL

Are not moist because the air conditioned environment. Has a uniform temperature.

17. Skin temperature

Moisture in the skin folds and the axilla varies with environmental situation Uniform in temperature and within normal range

NORMAL

NORMAL

18. Skin

The skin springs back to previous state.

When pinched skin NORMAL springs back to previous state NORMAL NORMAL

NAILS 19. Fingernail plate shape

20. Fingernail and toenail bed color

21. Fingernail and toenail texture 22. Tissue surrounding nails

Has a convex curvature of fingernail plate, 160. Fingernail and toenail bed color are pinkish in color. Fingernail and toenail texture are smooth. The tissues surrounding the nails of the client are intact.

Convex curvature: angel of nail plate about 160 Pinkish in color

NORMAL

Smooth in texture

NORMAL

Intact epidermis

NORMAL

23. Presence of capillaries

When blanched test is performed, color of the nail bed of the client returns into pink in less than 4 seconds.

Highly vascular, prompt return of pink color (generally less than 4 seconds)

NORMAL

HEAD SKULL 24. Size, shape, symmetry 25. Presence of nodules, masses, and depressions SCALP 26. Color and appearance 27. Areas of tenderness HAIR 28. Evenness of growth, thickness or thinness 29. Texture, and oiliness over the scalp FACE 30. Facial features, symmetry of facial movements EYEBROWS 31. Hair distribution, alignment, skin, quality, and movement EYELASHES 32. Hair distribution and direction of curl EYELIDS 33. Surface Symmetric, round and proportional to her weight. Has no presence of nodules, masses, and depressions. Lighter than the color of her skin No areas of tenderness. Evenly distributed, thick hair Silky, smooth, resilient Rounded, smooth skull contour, Absence of nodules or masses NORMAL

NORMAL

Lighter than the skin color No signs of tenderness Evenly distributed, thick hair Silky, smooth, resilient

NORMAL NORMAL

NORMAL

NORMAL

Symmetric facial movements

Symmetric facial movements EYES

NORMAL

Evenly distributed hair, intact skin, symmetrically aligned, equal movement Evenly distributed hair, curled outward Skin intact, no

Evenly distributed hair, intact skin, symmetrically aligned, equal movement Evenly distributed hair, curled outward Skin intact, no

NORMAL

NORMAL

NORMAL

characteristics, position in relation to the cornea, ability to blink, frequency of blinking CONJUNCTIVA 34. Bulbar conjunctiva for color, texture, and presence of lesions 35. Palpebral conjunctiva for color, texture, and presence of lesions SCLERA 36. Color and clarity CORNEA 37. Clarity and texture

discharge, no discolorization, approximately 15 to 20 involuntary blinks per minute, bilateral blinking Transparent, capillaries sometimes evident, sclera appears white Shiny smooth, pink in color

discharge, no discolorization, approximately 15 to 20 involuntary blinks per minute, bilateral blinking Transparent, NORMAL capillaries sometimes evident, sclera appears white Shiny smooth, pink NORMAL in color

Appears white and clear

Appears white and clear

NORMAL

Transparent, shiny Transparent, shiny NORMAL and smooth, details and smooth, details of iris are visible of iris are visible Brown, flat and round Equal in size usually, 3 7 mm, equally round Able to read newsprint 20/20 vision on Snellen chart NORMAL

IRIS 38. Shape and color Brown, flat and round PUPILS 39. Color, shape, Equal in size and symmetry of usually, 3 7 mm, size equally round VISUAL ACUITY 40. Near vision Able to read newsprint 41. Distance vision 20/40 vision on Snellen chart without eyeglasses

NORMAL

NORMAL NOT NORMAL Because the client wasnt able to see the letters on the Snelle chart at 20/40 vision

PUPILS 42. Light reaction and accommodation

Constrict when looking at near object, dilate when looking at far object, converge when near object is moved tenderness

Constrict when NORMAL looking at near object, dilate when looking at far object, converge when near object is moved tenderness

over lacrimal gland and lacimal sac, no discharges in nasolacrimal duct EXTRAOCULAR MUSCLES 44. Alignment and Both eyes coordination coordinated move in unison with parallel alignment VISUAL FIELDS 45. Peripheral Able to see objects fields in the periphery AURICLES 46. Color, symmetry, and position

over lacrimal gland and lacimal sac, no discharges in nasolacrimal duct Both eyes coordinated move in unison with parallel alignment Able to see objects in the periphery EARS Color same as facial skin, symmetrical, aligned with outer canthus of eye about 10 from vertical Mobile, firm and not tender, pinna recoils after it is folded Dry cerumen, has presence of hair follicles, no pus or blood NORMAL

NORMAL

Color same as facial skin, symmetrical, aligned with outer canthus of eye about 10 from vertical 47. Texture, Mobile, firm and elasticity, and areas not tender, pinna of tenderness recoils after it is folded EXTERNAL EAR CANAL 48. Cerumen, kin Dry cerumen, has lesions, pus, blood presence of hair follicles, no pus or blood HEARING ACUITY 49. Response to Normal voice tones normal voice tones audible 50. Watch tick test Able to hear ticking in both ears 51. Webers test Sound is heard in both or is localized at the center of the head 52. Rinnes test Air-conducted hearing is greater than boneconducted hearing 53. Deviations in

NORMAL

NORMAL

NORMAL

Normal voice tones audible Able to hear ticking in both ears Sound is heard in both or is localized at the center of the head Air-conducted hearing is greater than boneconducted hearing NOSE Normal voice tones Color is the same

NORMAL NORMAL NORMAL

NORMAL

NORMAL

shape, size, color, and flaring or discharge from nares

audible

54. Nasal cavities for presence of redness, swelling, growths and discharge 55. Nasal septum between nasal chambers 56. Patency of both nasal cavities

as the facial skin, uniform in color, symmetric and straight, no nasal discharges or flaring Able to hear Absence of ticking in both ears redness, swelling, and discharge

NORMAL

57. Tenderness, masses, and displacements of bone and cartilage SINUSES 58. Tenderness

Sound is heard in both or is localized at the center of the head Air-conducted hearing is greater than boneconducted hearing No tenderness or masses

Intact in midline

NORMAL

Air moves freely through the nares

NORMAL

No tenderness or masses

NORMAL

No tenderness on sinuses

No tenderness on sinuses MOUTH Uniform pink color, soft, moist, smooth texture, symmetry of contour, ability to purse lips Uniform pink color, moist, smooth, soft, glistening, and elastic in texture, no lesions 32 adult teeth, white to yellowish in color, shiny tooth enamel, no intact dentures

NORMAL

LIPS 59. Symmetry of contour, color, and texture

Uniform pink color, soft, moist, smooth texture, symmetry of contour, ability to purse lips

NORMAL

BUCCAL MUCOSA 60. Color, Uniform pink moisture, texture, color, moist, presence of lesions smooth, soft, glistening, and elastic in texture, no lesions TEETH 61. Color, number 31 adult teeth, and condition, and white to yellowish presence of in color, shiny dentures tooth enamel, no intact dentures

NORMAL

NORMAL

GUMS 62. Color and condition

Pink, moist, firm, Pink, moist, firm, no retraction and no retraction and bleeding of gums bleeding of gums TONGUE/FLOOR OF THE MOUTH 63. Color and Pink, moist, Pink, moist, texture of the slightly rough, has slightly rough, has mouth floor and thin whitish color thin whitish color frenulum 64. Texture, Moves freely, the Moves freely, the movement and base is smooth with base is smooth with base of the tongue prominent veins prominent veins 65. Presence of No palpable No palpable nodules, lumps, or nodules or lumps nodules or lumps excoriated areas PALATES AND UVULA 66. Color, shape, Soft palate is light Soft palate is light texture, presence of pin in color, hard pin in color, hard bony prominences palate is much palate is much lighter and more lighter and more irregular in texture irregular in texture 67. Position of the Positioned in Positioned in uvula and mobility midline of soft midline of soft palate palate OROPHARYNX AND TONSILS 68. Color and Pink and smooth Pink and smooth texture posterior wall posterior wall 69. Size of the Pink in color, no Pink in color, no tonsils, color, and discharges discharges discharge NECK AND LYMPH NODES LYMPH NODES 70. Tenderness Absence of Absence of tenderness tenderness TRACHEA 71. Placement Central placement Central placement in midline of neck, in midline of neck, spaces are equal on spaces are equal on both sides both sides THYROID GLAND 72. Symmetry and Not visible in Not visible in visible masses inspection, gland inspection, gland ascends during ascends during swallowing, no swallowing, no masses masses 73. Smoothness and Smooth, no areas Smooth, no areas

NORMAL

NORMAL

NORMAL

NORMAL

NORMAL

NORMAL

NORMAL NORMAL

NORMAL

NORMAL

NORMAL

NORMAL

areas of enlargement, masses, or nodules

of enlargement, or nodules

of enlargement, or nodules

THORAX POSTERIOR THORAX 74. Size, shape, Symmetric, ribs Symmetric, ribs symmetry, are sloped are sloped compare the downward at 45 downward at 45 diameter of the relative to the relative to the anteroposterior spine, muscle spine, muscle thorax to the development is development is transverse thorax equal, equal, anteroposterior to anteroposterior to transverse transverse diameter in ratio of diameter in ratio of 1:2 1:2 75. Spinal Slightly Vertically aligned alignment 76. Temperature, Uniform in Uniform in tenderness, masses temperature, no temperature, no tenderness and tenderness and masses masses 77. Respiratory Full and Full and excursion symmetric chest symmetric chest expansion expansion 78. Vocal fremitus Bilaterally equal, Bilaterally equal, heard mostly at the heard mostly at the apex of the lungs apex of the lungs 79. Sounds Percussion notes Percussion notes resonant except resonant except over the scapula, over the scapula, bronchovesicular bronchovesicular and vesicular and vesicular ANTERIOR THORAX 80. Breathing Quiet, rhythmic, Quiet, rhythmic, patterns effortless effortless 81. Temperature, Warm, no Warm, no tenderness, masses tenderness or tenderness or masses masses 82. Respiratory Full and Full and excursion symmetric chest symmetric chest expansion expansion 83. Vocal fremitus Bilaterally equal, Bilaterally equal, mostly heard at the mostly heard at the apex of the lungs apex of the lungs 84. Sounds Flat sound on the Flat sound on the part with heavy part with heavy

NORMAL

NOT NORMAL because the client has scoliosis. NORMAL

NORMAL

NORMAL

NORMAL

NORMAL NORMAL

NORMAL

NORMAL

NORMAL

85. Trachea

muscles and bony muscles and bony prominences, prominences, tympani on the tympani on the stomach, dullness stomach, dullness on the liver and on the liver and spleen, spleen, bronchovesicular, bronchovesicular, vesicular vesicular Bronchial sound Bronchial sound CARDIOVASCULAR No pulsation

NORMAL

PRECORDIUM 86. Aortic, No pulsation pulmonic, tricuspid area 87. Apical area With palpable pulsation (point of maximal impulse) 88. Sounds of S2 is louder than tricuspid and S1 apical 89. Sounds of S1 is lauder than Tricuspid and S2 apical area CAROTID ARTERIES 90. Pulsations and Symmetric pulse sounds volumes, full pulsation, no sound 91. Visibility BREAST 92. Size, symmetry, contour, shape Not visible

NORMAL

With palpable pulsation (point of maximal impulse) S2 is louder than S1 S1 is lauder than S2

NORMAL

NORMAL

NORMAL

Symmetric pulse NORMAL volumes, full pulsation, no sound NORMAL

BREAST AND AXILLA Slightly unequal, symmetric, convex, round 93. Skin color, Lighter color hyperpigmentation, because of less retraction, swelling exposure, evenly or edema, lumps pigmented, no swelling, edema, or lumps AREOLA 94. Size, shape, Equal, round, symmetry, color, symmetric, dark surface brown, smooth, characteristics, has no lesions mass or lesions Slightly unequal, symmetric, convex, round Lighter color because of less exposure, evenly pigmented, no swelling, edema, or lumps Equal, round, symmetric, dark brown, smooth, has no lesions NORMAL

NORMAL

NORMAL

Equal, round, Equal, round, NORMAL everted in the same everted in the same direction, brown, direction, brown, has no discharges, has no discharges, lesions, or lesions, or tenderness tenderness AXILLARY, SUBCLAVICULAR AND SUPRACVICALAR LYMPH NODES 96. Masses or Absence of masses Absence of masses NORMAL lumps or lumps or lumps ABDOMEN 97. Skin integrity, Unblemished skin, Unblemished skin, NORMAL contour, uniform in color, uniform in color, enlargement of no signs of no signs of liver or spleen, enlargement of the enlargement of the symmetry of liver and spleen, liver and spleen, contour symmetrical symmetrical contour contour 98. Visibility of Not visible, slightly Not visible, slightly NORMAL peristalsis visible on thin visible on thin movement persons persons 99. Visibility of Not visible Not visible NORMAL vascular patterns 100. Bowel sounds, Audible bowel Audible bowel NORMAL vascular and sounds, not audible sounds, not audible peritoneal friction vascular and vascular and rubs peritoneal friction peritoneal friction rubs rubs MUSCULOSKELETAL SYSTEM MUSCLES 101. Size, Bilaterally Bilaterally NORMAL contractures, symmetric, no symmetric, no tremors contractures and contractures and tremors tremors 102. Tonicity, Normal muscle Normal muscle NORMAL strength (neck, tension, adequate tension, adequate upper, lower strength of the strength of the extremities) muscles muscles BONES 103. Structure, Uniform in Uniform in NORMAL deformities, structure, no structure, no tenderness, edema deformities, deformities, tenderness or tenderness or edema edema JOINTS 104. Swelling, Absence of Absence of NORMAL

NIPPLES 95. Size, shape, position, color, discharges, lesions, tenderness

tenderness, smoothness of movement, crepitation, presence of nodule 105. Range of motion (shoulder and scapula, elbows, hands, acetabulum, popliteal, ankles)

tenderness and swelling, has smooth movement, no nodules Able to perform the exercises in full range of motion, no tenderness, moves smoothly

tenderness and swelling, has smooth movement, no nodules Able to perform the exercises in full range of motion, no tenderness, moves smoothly NORMAL