PHYSICAL ASSESSMENT BODY PART EXAMINE D

Skin

NORMAL FINDINGS

ACTUAL FINDINGS

INTERPRETATION/ ANALYSIS

Moisture in skin folds and the axillae (varies with environmental and humidity, body temperature, and activity) No Edema

Dry Skin on neck and gluteal extremities

Insufficient blood flow may cause dry skin on areas where it is contraindicated such as lying down on the bed for a long length of time and cardiovascular disorders.

Presence of Edema on both hands Thin, Bald on Frontal Hair loss occurs in elderly patients Facial nerve damage may cause weakness or paralysis of the nerve which may affect function Facial nerve damage may cause weakness or paralysis of the nerve which may affect function Excessive blinking may be accompanied with seizure disorders Medical conditions such as hypertension and hypercholesterolemia can result in damaging the optical nerve blood vessels causing the pupils to react differently The eyes are one of the target organs that are damaged by sustained hypertension causing them to

Hair

Hair is evenly distributed Thick Hair Symmetric Facial Movements

Face

Eyes opens and closes Can’t smile or frown

Eyebrows

Eyebrows symmetrically aligned; equal Approximately 15 to 20 involuntary blinks per minute; bilateral blinking Pupils constricts when looking at near object; pupils dilate when looking at far object; pupils converge when near object is moved toward the nose Both eyes coordinated, move in unison with parallel alignment

Can’t move eyebrows

Eyelids

46 involuntary blinks per minute; bilateral blinking Client’s pupil does not constrict when looking at near object; pupils don’t dilate when looking at far objects; pupils don’t converge when near object is moved toward the nose Client’s eyes are not coordinated and do not move in unison with parallel alignment

Pupil’s Reaction and Accommodat ion

Extraocular Muscles

grayishtan color. Patients with CVA and other cardiovascular problems have negative effects on the muscles due to the immobility and developing joint contractures There will be unequal muscle strength due to the severe loss of muscle motion External Ear Canal Dry cerumen. The resultant fibrinous exudate covers both pleural surfaces. Lips Able to purse lips The client is unable to purse lips Facial nerve damage may cause weakness or paralysis of the nerve which may affect function Presence of cerumen may indicate a hearing problem and self health deficit Indicates inflammation of the visceral and parietal pleural lining.not move in coordination. or stick wet cerumen in various shades of brown Absence of friction rub Presence of cerumen in both ears Abdomen Presence of friction rub Muscles No contractures on muscles and tendons Muscles are normally firm Muscles have smooth coordinated movements Muscles have equal strength on each body side Presence of contractures on muscle and tendons Muscles are not firm Muscles have no smooth coordinated movements Muscles strength are unequal . which causes congestion and edema. displacing the fluid that’s normally between them and causing the surfaces to rub together.

BSN223 Client’s name: Lopez. Felis Jerimiah Age: 11y/o . APRIL JOY F.PHYSICAL ASSESSMENT ASSESSED BY: VALDENOR.

Old Zoniga..5 °C Respiratory Rate – 16 bpm Pulse Rate – 81 bpm . 1998 Address: 436-A M Leyva St. Mandaluyong City Sex: Male Vital Signs Temperature – 36.B-day: June 24.