Thu, February 12, 2009 2:16:53 PM

ito n ung 4mat

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From: theresa de jesus <thesa_9@yahoo.com> 
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To: theresa cruz de jesus <thesa_9@yahoo.com>
Cc: theresa cruz de jesus <thesa_9@yahoo.com>

PHYSICAL ASSESSMENT
 
GENERAL SURVEY: APPEARANCE AND MENTAL STATUS
 

ASSESSMENT NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS

Body build, height and
weight in relation to age,
lifestyle, and health
Posture and gait
Overall hygiene and
grooming
Body and breath odor
Signs of distress in posture
or facial expression
Obvious signs of illness or
health
Client's attitude
Client's affect, mood,
appropriateness of client;s
responses
Quantity , quality and
organization of speech
Relevance and organization
of thoughts
Proportionate, varies with
lifestyle
Relaxed, erect posture;
coordinated movement
Clean and neat
No body odor or minor
body odor relative to work
or exercise; no breath odor
Healthy appearance
No signs of distress
cooperative
Appropriate to situation
Understandable, moderate
pace; exhibits thought
association
Logical sequence; makes
sense; has sense of reality
Patient's body appears thin. The patient's body
structure could be related
to her present condition
Patient is on semi-fowler's Patient is maintained on
position, relaxed, and has high back rest to facilitate
coordinated movement good ventilation
considering her present
health status
Clean and neat Patient has good hygiene
No body odor or breath Indicates good hygiene
odor
Looks weak Weakness could be
because of her respiratory
condition
signs of distress noted such There is an obvious sign of
as effort in her breathing illness in the patient.
pattern.
cooperative Cooperation from the
client suggest her
willingness to get well.
Patient's affect and mood is Patient's displays
appropriate to situation appropriate reaction to a
certain situation that
justifies that the patient's
mental status is not altered
Patient's speech is Can communicate with the
understandable and exhibits nurse effectively
association of thoughts
Patient's thoughts has The thought process of the
relevance and in logical patient is in good
sequence condition
  

AREA TECHNIQUE NORMS ACTUAL ANALYSIS

ASSESSED USED FINDINGS
SKIN        
skin color inspection Varies from light to deep Light brown Normal findings
brown; ruddy pink to light
pink; yellow overtones to
olive
Skin uniformity inspection Skin color generally Uniform skin color Normal findings
uniform except in areas
exposed to sun; areas of
lighter pigmentation
(palms, lips, nail beds) in
dark-skinned people
Skin moisture Inspection and Moisture in skin folds and Skin folds and Normal findings
palpation the axillae varies with axillae are moist,
environmental other areas were not
temperature, and activity assessed..
 
Skin temperature palpation Skin temperature of the Uniform within Normal
two feet and two hands are normal range thermoregulation
uniform and within the
normal range
Skin turgor   When pinched, springs Springs back A good skin turgor
back to previous state. immediately after indicates good
being pinched hydration within the
body
 

AREA TECHNIQUE NORMS ACTUAL ANALYSIS

ASSESED USED FINDINGS
HAIR inspection Evenly distributed hair Normal findings Normal findings
thick silky resilient hair
no infection or infestation
NAILS Inspection and Convex curvature; angle of Convex curvature, Pinkish nail beds and
palpation nail plate about 160o smooth texture, prompt capillary
Smooth texture pinkish nail beds. refill on blanch test
Highly vascular and pink blanch test on indicates good
in light-skinned people; fingernails within 2 peripheral circulation
dark-skinned clients may seconds.
have brown or black
pigmentation in
longitudinal streaks.
Intact epidermis, prompt
return of pink or usual
color generally less than 4
seconds in blanch test
SKULL and Inspection Rounded smooth skull Normocephalic and Normal findings
FACE contour symmetrical, smooth
 facial features symmetrical contour of the skull,
palpebral fissures and Uniform facial
nasolobial folds, absence movement
of nodules or masses,  
symmetrical facial
movements.
 
EYE STRUCTURES AND VISUAL ACUITY
 

AREA TECHNIQUE NORMS ACTUAL ANALYSIS

ASSESSED USED FINDINGS
eyebrows inspection Eyebrows’ hair is evenly Evenly distributed; Normal finding
distributed; eyebrows’ skin skin around are intact.
are intact; Symmetrically
eyebrows symmetrically aligned with equal
aligned; movement.
equal movement of
eyebrows
eyelashes inspection Eyelashes are equally Eyelashes are equally Normal finding
distributed and curled distributed, slightly
slightly upward curved upward
eyelids inspection Eyelids’ skin are intact; no Skin is intact; no Eyelids has
discharge; no discoloration; discharge, coordination in
Lids close symmetrically; discoloration. Closes movement.
15 to 20 involuntary blinks symmetrically. Normal findings
per minute;
bilateral blinking;
When lids open, no visible
sclera above cornea, &
upper & lower borders of
cornea are slightly covered
Bulbar conjuctiva inspection Transparent; capillaries Sclera appears white Normal finding
sometimes evident; sclera
appears white (yellowish in
dark skinned clients)
Palpebral inspection Shiny smooth and pink or Shiny and pinkish in Normal finding
conjuctiva red color
Lacrimal gland, Inspection and No edema or tenderness No edema or tearing Normal finding
lacrimal sac, palpation over the lacrimal sac. No
nasolacrimal duct tearing
pupils inspection Black in color, equal in Pupils Round, Black Normal finding
size, round, smooth border, in color, equal in size.
iris flat and round
Pupil reactions assessment Illuminated pupil constricts Normal consensual Normal findings
(direct response); Non response to light.
illuminated pupil constricts Pupil constricts when
when the other pupil is looking at near
illuminated (consensual objects and dilate
response) when looking at far
 Pupils constrict when objects.
looking at near objects;
pupils dilate when looking
at far objects; pupils
converge when near object
is moved toward nose
Peripheral visual assessment When looking straight Can see objects in the Normal finding
fields ahead, client can see periphery
objects in the periphery
Extraocular assessment Both eyes coordinated, Eyes move in unison Normal finding
muscle test move in unison with with parallel
parallel alignment alignment
Visual acuity assessment Able to read newspaper Not done  
20/20 vision on Snellen
chart
 
 
 
 
 
EARS AND HEARING

AREA TECHNIQUE NORMS ACTUAL ANALYSIS

ASSESSED USED FINDINGS
auricles Inspection and Color same as facial skin; Same color with Normal finding
palpation Symmetrical; facial skin;
Auricle aligned with outer symmetrically aligned
canthus of eye, about 10o with eyes outer
from vertical canthus.  Mobile, firm
Mobile, firm, and not and pinna recoils after
tender; it is folded.
pinna recoils after it is No tenderness
folded
 
Gross hearing assessment Normal voice tones audible Able to hear normal Normal finding
acuity tests able to hear ticking in both voice tones
ears in watch tick test
Negative Weber Test
Rinne Test Positive
 
NOSE AND SINUSES

AREA TECHNIQUE NORMS ACTUAL ANALYSIS

ASSESSED USED FINDINGS
External nose Inspection and Symmetric and Straight; Symmetrical Normal finding
palpation No discharge  or uniform in color
discoloration; no discharge
Uniform color nasal septum intact
no tenderness or lesions and in midline
nasal septum intact and in
midline
Patency of nasal assessment Air moves freely as the Air moves freely as Normal finding
cavities client breathes through the she breathes.
nares
Facial sinuses: palpation No tenderness No tenderness Normal findings
maxillary and
frontal sinuses
 
MOUTH AND OROPHARYNX

AREA ASSESED TECHNIQUE NORMS ACTUAL ANALYSIS

USED FINDINGS
Outer lips inspection Uniform pink color ( darker, Pink in color, soft, Moist lips indicates
e.g. bluish hue, in moist, and good body hydration
Mediterranean groups and symmetrical
dark-skinned people);
Soft, moist, smooth texture;
Symmetry of contour;
Ability to purse lips
Inner lips and Inspection and Uniform pink color Not done  
buccal mucosa palpation (freckled brown
pigmentation in dark-
skinned clients)
Moist, smooth, soft,
glistening, and elastic
texture (drier oral mucosa in
elderly due to decreased
salivation)
Teeth and gums inspection 32 adult teeth; smooth, Missing teeth with Missing teeth is a
white, shiny tooth enamel some dental caries. sign of aging, which
pink gums (bluish or dark is just normal to the
patches in dark skinned patient dental caries
clients) could be due to lack
moist, firm texture to gums of dental supervision.
no retraction or gums
tongue Inspection and Central position; Tongue in central Normal finding
palpation Pink color (some brown position
pigmentation on tongue pink in color, moist,
borders in dark-skinned slightly rough
clients); moist; slightly moves freely with no
rough, thin washing coating; tenderness
Smooth, lateral margins; No
lesions;
Raised papillae
moves freely: no tenderness
smooth tongue base with
prominent veins
tongue smooth with no
palpable nodules
Palates and uvula inspection Light pink, smooth, soft Uvula in midline of Normal finding
palate the soft palate,
Lighter pink hard palate light pink and
 uvula Positioned in midline smooth palates
of soft palate
Oropharynx and inspection Oropharynx Pink and Not done  
tonsils smooth posterior wall
tonsils pink and smooth with
no discharge and of normal
size
Gag Reflex assessment present Not done  
 
NECK

AREA TECHNIQUE NORMS ACTUAL ANALYSIS

ASSESSED USED FINDINGS
Neck muscles inspection Muscles equal in size; head Normal finding Normal finding
centered
Head movement inspection Coordinated, smooth Not done  
movements with no
discomfort;
Head flexes 45 degrees;
Head hyperextends 60
degrees;
Head laterally flexes 40
degrees;
Head laterally rotates 70
degrees;
Muscle strength assessment Equal strength on both sides Not done  
against resistance of the
nurse's hand
Lymph nodes palpation Lymph nodes not palpable Not done  
trachea palpation Central placement in Not done  
midline of the neck; spaces
are equal in both sides
Thyroid gland Inspection and Not visible on inspection Not done  
palpation gland ascends during
swallowing but is not
visible
lobes may not be palpated.
 
THORAX AND LUNGS

AREA TECHNIQUE NORMS ACTUAL ANALYSIS

ASSESED USED FINDINGS
Posterior thorax inspection Anteroposterior to transverse Not done  
diameter in ratio of 1:2;
Chest symmetric;
  palpation Skin intact; Not done  
uniform temperature
chest wall intact; no
tenderness; no masses
  percussion Percussion notes resonate, Not done  
except over scapula;
Lowest point of resonance is
at the diaphragm;
Percussion on a rib normally
elicits dullness
  auscultation Vesicular and Adventitious breath Air passing through a
brochovesicular breath sound heard constricted bronchus
sounds as a result of
secretions, swelling,
tumors
Spinal alignment inspection The Spine vertically aligned Not done  
Vocal fremitus palpation Bilateral symmetry of vocal Not done  
fremitus
fremitus is heard most clearly
at the apex of the lungs
Anterior thorax inspection Quiet, rhythmic, and Respiration quiet, Fast rate and effort in
effortless respirations rhythmic, fast, and breathing pattern
Costal angle is less than 90 with slight effort could indicate the
degrees, and the ribs inserted patient's
to the spine is approximately compensatory
45 degrees angle mechanism to
inadequate oxygen in
the body.
  palpation Skin intact; uniform Not done  
temperature
Full and symmetric chest
expansion;
Normally, the thumb separate
3 to 5 cm
vocal fremitus is normally
decreased over the heart and
breast tissue
  percussion Percussion notes resonate Not done  
down to the sixth rib at the
level of the diaphragm but are
flat over areas of heavy
muscle and bone, dull on
areas over the heart and the
liver, and tympanic over the
underlying stomach
  auscultation Bronchovesicular and Adventitious breath Air passing through a
vesicular breath sounds sound heard constricted bronchus
as a result of
secretions, swelling,
tumors
trachea auscultation Bronchial and tubular breath Not done  
sounds
 
HEART AND CENTRAL VESSELS
 AREA TECHNIQUE NORMS ACTUAL ANALYSIS
ASSESSED USED FINDINGS
Heart Inspection and No pulsations on aortic and No pulsation on Normal findings
palpation pulmonic areas aortic and pulmonic
Pulsation is visible in 50% areas, no lift or
of adults and palpable in heave.
most PMI in fifth LICS at
or medial to MCL;
Diameter of 1 to 2 cm; No
lift or heave
  auscultation S1: usually heard at all S1 and S2 heart Normal heart
sites and usually louder at sounds heard upon functioning
apical area; auscultation
S2: usually heard at all
sites and usually louder at
the base of the heart
Systole: silent interval,
slightly shorter duration
than diastole at normal
heart rate;
Diastole: silent interval,
slightly longer duration
than diastole at normal
heart rate;
S3 in children and young
adults;
S4 in many older adults
Carotid arteries palpation Symmetric pulse volumes Full pulsation Indicates that there is
full pulsations, thrusting a good blood flow to
quality the brain.
quality remains same when
client breathes, turns head
and changes from sitting to
supine position
  auscultation No sound (carotid bruit) Not done  
heard
Jugular vein inspection Veins not visible Veins not visible Indicates that the
right side of the heart
is functioning
normally
 
 
BREAST AND AXILLAE

AREA ASSESSED TECHNIQUE NORMS ACTUAL ANALYSIS

USED FINDINGS
breast inspection Females: Not done  
Rounded shape, slightly
unequal in size, generally
symmetric
Males:
 Breast even with the chest
wall, obese may be similar
to female
Uniform color; skin
smooth and intact;
Diffuse symmetric
horizontal or vertical
vascular pattern in light-
skinned people;
Striae, moles and nevi
no retractions
  palpation No tenderness, masses, Not done  
nodules, or nipple
discharge
areola inspection Round or oval and Not done  
bilaterally the same;
Light pink to dark brown;
Irregular placement of
sebaceous gland on the
surface of areola
nipples inspection Round, everted, and equal Not done  
in size, similar color, soft
and smooth;
Both nipples point in the
same direction;
No discharge except from
pregnant or breast-feeding
females
No tenderness or nodules
Axillary, palpations No tenderness, masses or Not done  
subclavicular and nodules
supraclavicular
lymph nodes
 
ABDOMEN

AREA TECHNIQUE NORMS ACTUAL ANALYSIS

ASSESSED USED FINDINGS
Abdomen inspection Unblemished skin, uniform Not done  
in color
flat, rounded contour
no evidence of enlargement
of liver or spleen
symmetric contour
symmetric movements
caused by respiration
  Auscultation Audible bowel sounds Not done  
absence of arterial bruits
and friction rub
  percussion Tympany over the stomach Not done  
and gas-filled bowels;
 dullness. Especially over the
liver and spleen, or a full
bladder
  palpation No tenderness; relaxed Not done  
abdomen with smooth,
consistent tension
 
MUSCULOSKELETAL SYSTEM

AREA TECHNIQUE NORMS ACTUAL ANALYSIS

ASSESSED USED FINDINGS
muscles inspection Equal size on both sides of Muscles Equal in size Normal finding
the body on both sides of the
no contractures body
no fasciculations or tremors no contractures
  no fasciculations or
tremors
  palpation Normally firm Not done  
smooth coordinated
movements
  Muscle strength Equal strength on each body Not done  
test side
bones inspection No deformities No deformities Normal finding
  palpation No tenderness or swelling Not done  
joints inspection No swelling, tenderness, Not done  
crepitation or nodules
joints move freely
  Assess joint range Varies to some degree in Not done  
of motion accordance with person's
genetic makeup and degree
of physical activity
 
VITAL SIGNS
 

Vital sign Norms Actual findings Analysis and interpretation

temperature 36.5-37.5 C 37.2 C Normal body temperature
Pulse rate 60-100 bpm 104 bpm tachycardia
Respiratory rate 12-20 cpm 36 cpm Tachypnea – this could be a result from the
body's compensatory mechanism against
imbalance between oxygen supply and demand.
Blood pressure 120/80 mmHg 90/60 mmHg Below normal