VI.

PHYSICAL ASSESSMENT

Date of Assessment: September 29, 2016

Time of Assessment: 1: 30 pm

General Appearance:

Patient M.C is a 64 years-old male was admitted on September 27, 2016, 10: 35 pm in the
evening at Cagayan Valley Medical Center. Upon assessment the patient was in semi-fowler position with
O2 and ongoing IVF of PNSS 1L at 100 ml in his Right hand with flow rate of 10 to 11 gtts/min. Patient
M.C. was awake, weak-looking and coughing frequently. He was properly groomed.

Initial Vital Signs: Vital Signs during Physical Assessment:

BP: 100/ 60 mmHg BP: 110/70 mmHg

BT: 36.7⁰c BT: 36.5 ⁰c

PR: 80 bpm PR: 75 bpm

RR: 28cpm RR: 30 cpm

SKIN

ASSESSMENT NORMAL ACTUAL INTERPRETATION
PROCEDURE
Inspect the skin brown (depending on Brown NORMAL
color race) varies from light to
deep6
Inspect the skin odor slight or no odor of no odor of perspiration NORMAL
perspiration (depending
on activity)
Inspect the skin intact and there are no there are no reddened NORMAL
integrity reddened areas areas
Inspect for skin Smooth, without lesions. presence of birthmarks NORMAL
lesions Stretch marks, healed on left leg
scars, freckles, moles
and birthmarks
Palpate skin to smooth and equal feels smooth NORMAL
assess texture
palpate to assess thin but calluses presence of calluses in NORMAL
thickness hands and feet
palpate to assess skin surfaces vary from moisten skin NORMAL
moisture moist to dry depending
on the area assessed
Palpate to assess warm to touch warm to touch NORMAL
temperature
Palpate to assess Skin pinches easily and skin easily pinch NORMAL
skin mobility immediately returns to
its original position
Palpate to assess When pinch, skin skin snaps back NORMAL
skin turgor springs back to 1-2 immediately when
seconds pinched
Palpate to detect Skin rebounds and does no indentation to the skin NORMAL
edema not remain indented
when pressure is
released

body and of hair entire the body body. coarse. erected and in configuration accord with ethnicity. features. as the hair of the patient is NORMAL hair for general color opposed to chemically with distributed white hair and condition colored hair. varies among clients from pale blond to block to gray or white Inspect and palpate Scalp is clean and dry.(2 seconds) HEAD ASSESSMENT NORMAL ACTUAL INTERPRETATION PROCEDURE Inspect the head for Head size and shape Head is symmetrical. especially in rounded. or oiliness. and drier cleanliness. parasites and lesions Inspect amount and Terminalhair cover the symmetrical distribution NORMAL distribution of scalp. and no abnormal . axillae and pubic areas. scalp. oval. erect and in midline inspect for involuntary head should be held still no involuntary NORMAL movement and upright movement Inspect the face for The face is symmetric the face is symmetric NORMAL symmetry. The scalp and hair are NORMAL the hair and scalp for Hair is smooth and firm clean. hard and thickened Capillary refill time pink tones returns the pink tones returns ABNORMAL immediately to blanched greater than 2 seconds due to poor oxygenation nail beds when pressure when pressure released and poor perfusion is released. dryness no parasites noted. SCALP and HAIR ASSESSMENT NORMAL ACTUAL INTERPRETATION PROCEDURE Inspect the scalp and natural hair color. axillary. NAILS ASSESSMENT NORMAL ACTUAL INTERPRETATION PROCEDURE Inspect nail grooming nails are cleaned and nails are cleaned and NORMAL and cleanliness manicured no manicured (male patient) Inspect nail color and Pink tones and Dark the nails of the patient ABNORMAL marking skinned clients may is darken Poor oxygenation have freckles or pigmented streaks Inspect shape of nails convex curvature. angle the nail of the patient is NORMAL of nail plate about 160 160 degree angle between the nail base and skin Palpate nail to assess Nails are hard and the patient`s nails are NORMAL texture basically immobile. shape and vary. round. pubic hair. NORMAL size. the midline The head is symmetric. with a round.

movement. Iris border and centered in is round. and lesions noted on swelling or lesions. Pupils are constricted when round with a regular focusing near object. inches. flat and evenly the iris colored Inspect the eyelids and Skin on both eyelids is No redness. flat and evenly equal in size and colored. EARS ASSESSMENT NORMAL ACTUAL INTERPRETATION PROCEDURE Inspect the ears for symmetric to the head Symmetric to the head NORMAL symmetry and face Lateral to the and face eyebrow and auricle Inspect the color of the Same with the color of the color is same with NORMAL ears the face facial color Inspect the position of in lined with cantus of Lateral to the eyebrow NORMAL . Eyelashes are evenly Eyelashes are evenly distributed and curve distributed outward along the lid margins Observe the position eyeball are eyeball are NORMAL and alignment of the symmetrically aligned in symmetrically aligned in eyeball in the eye sockets without sockets and no sinking socket protruding or sinking noted Assess movements of no abnormal movement no abnormal movement NORMAL the eye noted Assess visual acuity of Normal near visual Patient can`t read what ABNORMAL due to the eyes acuity is 14/14 with or normal eye can read blurred vision without corrective from the distance of 14 lenses. swelling NORMAL eyelashes without redness. the skin of both eyelid. No abnormal movement noted Palpate the head for the head is normally the head is hard without NORMAL consistency hard and smooth lesions without lesions EYES ASSESSMENT NORMAL ACTUAL INT PROCEDURE ERPRETATION Inspect the conjunctiva pink palpebral the conjunctiva is pale ABNORMAL conjunctiva poor oxygenation Inspect the sclera White in color White NORMAL Inspect lacrimal No swelling or redness no redness noted at the NORMAL apparatus appear over areas of Lacrimal gland the lacrimal gland Inspect the cornea and cornea is transparent cornea and lenses are ABNORMAL lenses with no opacities and with opacities Due to irritation lenses is free of opacities Inspect the Iris and The iris is typically Pupils are normally NORMAL pupils round. Normal distant visual Patient can`t distinguish acuity is 20/20 with or what person with normal with corrected lenses vision can distinguish from 20/20 feet away. expression elongated or aquare movement noted and skin condition appearance.

no teeth are white with ABNORMAL tartars. a moderate size moving. NORMAL mucosa glistering. the tongue is freely NORMAL tongue moist. lips are smooth and the lips are soft. smooth. centered with papillae present.the ears the ears and auricles in lined with cantus of the ears check hearing ability active and hear clearly cannot hear clearly and ABNORMAL due to not active in responding excessive earwax that cause by hearing harden and block the problem passage of sound waves in the ear canal NOSE ASSESSMENT NORMAL ACTUAL INTERPRETATION PROCEDURE Inspect the nose for at midline of the face. soft and glistering and pink in color Inspect the teeth teeth are white. NORMAL symmetry nares are symmetrical nares are symmetric Inspect for the color similar to the color of same with the color of NORMAL the face the face Inspect discharge/ no discharge/ flaring No discharge noted NORMAL flaring of the nose MOUTH ASSESSMENT NORMAL ACTUAL INTERPRETATION PROCEDURE Inspect the lips. no dental caries dental caries and due to cigarettes incomplete set of adult smoking teeth (27) Inspect the gums Pink in color. pink in color smooth. moist and the color is greenish ABNORMAL firm with tight margins to due to cigarettes the tooth. at midline of the face. smooth NORMAL Observe lip consistency moist without lesions or and moist in texture and color swelling Assess for ability to can purse can purse lips NORMAL purse lips Inspect for buccal moist. roughtened from No lesions are present papillae and no lesions noted Inspect the uvula the uvula is positioned Uvula is in the midline NORMAL in the midline NECK ASSESSMENT NORMAL ACTUAL INTERPRETATION PROCEDURE Inspect the neck centrally located neck is symmetric with NORMAL between the shoulders head centered and without bulging masses Inspect movement of cartilages (thyroid and while swallowing NORMAL the neck structures cricoids) and gland patient`s gland and while swallowing (thyroid gland) move cartilages are moving upward symmetry as upward symmetrically . No lesion or smoking masses Inspect and palpate the Tongue is pink in color. soft and buccal mucosa is moist.

Inspect range of motion neck movement is the neck movement of NORMAL smooth and controlled the patient is controlled (45⁰ flexion. irregular with that decreases oxygen presence of wheezes) entering the lungs RR: 30 cpm Observe uses of patient does not uses uses accessory muscles ABNORMAL due to accessory muscles accessory muscles when breathing more effort in expanding the chest when breathing in or to expel air when breathing out Auscultate for no adventitious sounds there is an adventitious ABNORMAL due to adventitious sounds at should be noted sound: wheezes narrowing of the airway anterior thorax in the lungs HEART ASSESSMENT NORMAL ACTUAL INTERPRETATION PROCEDURE Precordium Adynamics. 55⁰ and smooth extension. the patient swallows Inspect the cervical C7 is usually visible and Vertebrae prominent in NORMAL vertebrae palpable visible and palpable with an increase cervical curvature because of Kyphosis. position and decrease gravity pulls of breathing easily with experiencing difficulty of the diaphragm arms at sides or in lap breathing downward which not allowing greater chest and lung expansion Palpate surface skins and subcutaneous no lesions and masses NORMAL characteristics tissue are free of lesions noted and masses Auscultate for no adventitious sounds there is an adventitious ABNORMAL due to adventitious sounds sound: wheezes narrowing of the airway in the lungs ANTERIOR THORAX Observe quality and respirations are relax. patient experience ABNORMAL due to patter of respiration effortless and quiet: difficult in respiration narrowing of the airway RR: 12-20 cpm (rapid. 40⁰ abduction and 70⁰ rotation) Palpate the trachea trachea is midline trachea is midline NORMAL THORAX AND LUNGS ASSESSMENT NORMAL ACTUAL INTERPRETATION PROCEDURE POSTERIOR THORAX Inspect configuration scapulae are symmetric symmetric but ABNORMAL due to and non protruding prominent weight lose and uses accessory muscles when breathing Observe use of client does not use patient uses accessory ABNORMAL accessory muscles muscles to assist muscles in breathing due to having difficulty breathing in getting enough oxygen Inspect the client`s client is on sitting Clients is on semi fowler ABNORMAL due to positioning position and relaxed. point of Adynamic. PMI is at the NORMAL maximum impulse (PMI) fifth intercostals for adult .

Right upper minutes each quadrant.Left lower quadrant=9 . no edema arms. and note the tips to upper arms temperature LOWER EXTREMITIES ASSESSMENT NORMAL ACTUAL INTERPRETATION PROCEDURE Observe coloration of colors varies depending brown in color NORMAL the lower extremities on the client skin Observe legs size and legs are bilaterally both legs are equal NORMAL . NORMAL contour rounded Inspect the umbilicus midline and inverted. hypoactive= quadrant=6 occurs every 3 seconds . hands. and bilaterally from finger temperature.100 bpm regular: 75 cpm NORMAL ABDOMEN ASSESSMENT NORMAL ACTUAL INTERPRETATION PROCEDURE Observe the coloration brown or follows general brown in color NORMAL of the skin body color Inspect the integrity of intact skin Intact skin NORMAL the abdomen Auscultate the bowel present in all quadrants. The abdominal sound is NORMAL sound of the abdomen normal bowel sounds normal.Left upper quadrant=11 Inspect Abdominal flat. no no discoloration NORMAL sign of discoloration Tenderness no tenderness no tenderness NORMAL UPPER EXTREMITIES ASSESSMENT NORMAL ACTUAL INTERPRETATION PROCEDURE Observe coloration of colors varies depending brown in color NORMAL the upper extremities on the client skin Observe arm size and arms are bilaterally arms are equal NORMAL venous pattern symmetric with minimal variation in size and shape Assess hair distribution evenly distributed evenly distributed NORMAL Inspect lesion and absence of lesion and no lesion and NORMAL discoloration discoloration discoloration noted Assess Range of motion full ROM without pain full range of motion NORMAL without pain Palpate the client`s skin is warm to tough warm and equal NORMAL fingers.Right lower seconds. quadrant=8 occur every 15-20 . is at the fifth intercostals left midclavicular line for adult(4th intercostals for children) left midclavicular line Heart sounds no murmurs no murmurs NORMAL Hearth rate regular: 60. round or scaphoid abdomen is flat. with 5-35 times per .

and written language speech is fluent . alert and completely NORMAL consciousness oriented. and no temperature. alert and completely 15. express ideas oriented logically MENTAL STATUS: ORIENTATION ASSESSMENT NORMAL ACTUAL INTERPRETATION PROCEDURE Time Oriented Oriented NORMAL Place Oriented Oriented NORMAL Person Oriented Oriented NORMAL CEREBELLAR FUNCTION ASSESSMENT NORMAL ACTUAL INTERPRETATION PROCEDURE Motor function good Good motor function NORMAL Balance good balance Coordinated balance NORMAL Muscle tone inspection weak muscle tone ABNORMAL due to poor ventilation and perfusion Speech has the ability to Has the ability to NORMAL comprehend spoken comprehend spoken and written language. also and no lesions. no edema note the temperature edema noted NEUROLOGIC ASSESSMENT NORMAL ACTUAL INTERPRETATION PROCEDURE Check level of 15.venous pattern symmetric with minimal variation in size and shape Assess hair distribution evenly distributed evenly distributed NORMAL Inspect lesion and absence of lesion and no lesion and NORMAL discoloration discoloration discoloration noted Assess Range of motion full ROM without pain full Range of Motion NORMAL Palpate the client`s skin is warm to tough warm and equal NORMAL fingers and legs.