Vital Signs (mm/dd/yyyy time)

Temperature 37.6°C

Pulse Rate 84 bpm

Respiratory Rate 16 bpm

Blood Pressure 130/100 mmHg (right arm)

SPO2 97%

Pain Scale
A. PHYSICAL ASSESSMENT
The patient has been carefully checked for possible signs of problems or
any complications. We provided a complete physical assessment from head to
toe. Upon assessing, the patient shows signs of pain such as frowning, and ill-
looking. The patient is unable to walk without support.

B. Head-to-Toe Assessment
Body Part Actual Finding Normal Finding Clinical Significance
Examined
INTEGUMENTAR I: Brown skin. The integumentary system is
Y Uniform in color. I: Skin color is pink, a window to other body
Skin poor skin integrity. uniform in color, no systems. Changes in skin,
I: color, Skin is shiny. edema and lesions hair, or nails, may be the first
uniformity, edema, seen. clue to other health problems.
lesions P: Temperature is P: Temperature is
P: moisture, temp. cool. Moist skin. consistently warm or Skin can appear shiny
turgor Elastic skin turgor. cool and appropriate because it's so tight, and
for the environment. movement of the affected
Moist and smooth. Skin area may be restricted.
turgor is elastic. Retrieved from:
Scleroderma - Symptoms
and causes - Mayo Clinic
Hair I: Smooth shiny I: Equal and - If a patient has a specific
I: evenness of hair. Equally symmetrical, shafts are concern about his or her skin,
growth distributed and smooth, shiny, and no inspect the area or lesion
thickness, symmetric. No evidence of breakage. before asking questions.
texture, breakage. No No debris. Often, once you have
oiliness, evidence of identified the type of lesion
infection infestation. P: Hair is smooth and (inflammatory, infectious,
or infestation, P: Smooth not easily plucked. tumor, or altered integrity),
body you can focus questions to
hair I : Smooth, translucent, address the specific type of
consistent in coloration lesion. For instance, if a
P: smoothness and thickness, patient is scratching a deep,
I: Smooth and Diamond-shaped (nail pink, scaly lesion on his
translucent. angle is 160°). elbow, you may need to
Nail Diamond-shaped inquire about atopic illness or
I: plate shape, with a pinkish nail contact irritants instead of
texture, bed. melanoma. (Skin, Hair, and
bed color, P: Capillary refill Nails Assessment pp. 241-
surrounding takes less than 3 244, Wolters Kluwer:
tissues seconds. Nursing Health
P: Blanch test Assessment)

HEAD Examination of the head and

Skull and Face I: Head is centered, : Head is centered, neck is a fundamental part of
I: size, shape , erect, and proportional to the the standard physical
symmetry proportion to the body and erect without examination. It is typically one
: facial features body. Skull is round tremors, tics, or of the first parts of
: eyes for edema and no deformities unusual movement. the physical examination and
and hollowness are seen. Facial Skull is round without is performed with the patient
P: nodules, features are deformities. Facial in a seated position.
masses, symmetric. No features are Retrieved from:
Depressions tremors and symmetrical and https://www.amboss.com
unusual movement proportional.
of the head.
P: No nodules,
P: No nodules. masses, and
depression.

Eyes and Vision I: Equally : Equally distributed The eyes are the sensory
I: eyebrows for distributed and and symmetrical. No organs responsible for vision.
distribution & symmetric. No hair unexplained hair loss. Vision affects how an
alignment, quality loss. : Lashes curve individual interacts and
& outward away from the communicates with the world,
movement : Curved outward eyes and distributed including while learning,
: eyelashes for and equally evenly along the lid working, and playing (U.S.
evenness of distributed. margin. Department of Health and
distribution & Human Services[USDHHS],
direction of curl : Eyelids open and 2013).
: eyelids for : Open and close close completely, with Retrieved from: Health and
surface completely with spontaneous blinking. Physical Assessment 3rd
characteristics, spontaneous Edition (D’Amico,
position in relation blinking. : Conjunctiva is pink. Barbarito)
to cornea, ability to No erythema. Bulbar
blink & frequency conjunctiva is normally
: bulbar & : Color pink. Bulbar transparent with small
palpebral conjunctiva is blood vessels visible.
conjunctiva for transparent with
color, texture, and small blood vessels I/P: Lacrimal gland is
lesion visible. not enlarged or tender.
No edema.
 I/P: No edema and I: A normal angle
no tenderness. allows full illumination
of the iris. Lens is
I/P: lacrimal gland transparent.
sac, nasolacrimal
duct for edema, I: Transparent. I: Pupil is black, round,
tenderness / and equal. Both pupils
tearing constrict directly and
I: cornea for consensually.
clarity, texture & I: Color black.
* Distance vision:
sensitivity Round and
20/20 bilaterally. Near
symmetric.
vision: 14/14
Constricts
bilaterally.
consensually.
* Visual Field Test:
I: pupils for color,
Patient sees the finger
shape, symmetry
* Distance vision: at approximately the
of size, direct and
20/20 bilaterally. same time as the
consensual
Near vision: 14/14 nurse.
reaction to light, &
bilaterally. * EOM Test
accommodation
* Visual Field Test: Corneal light reflex:
Patient sees the Light reflection is in
finger at exactly the same spot
* Visual Acuity
approximately the in both eyes. Cover
(near & far vision
same time as the test: Gaze is steady
test)
nurse. and fixed. Cardinal
* Visual Field Test
*EOM test fields of gaze test:
* EOM Test
Corneal light Eyes move smoothly
reflex: Light is and symmetrically in all
symmetric in both nine cardinal fields of
eyes. gaze.
Cover test: Gaze is
steady and fixed.
Cardinal fields of
gaze test: Eyes
move smoothly and
symmetrically in all
nine cardinal fields
of gaze.

Ears and Hearing I : Symmetric and People with hearing loss are,
I: auricles for aligns with the I: Equal in size at increased risk for
color, symmetry corner of each eye. bilaterally (normally 4 depression, dissatisfaction
and position to 10 cm). The auricle with life, reduced functional
: external canal : No drainage. aligns with the corner health, and withdrawal from
for cerumen, of each eye. social activities. Children are
lesions, pus or : External meatus is especially at risk for speech
blood P: No nodules and intact. No drainage. delays.
P: auricles for no tenderness.
texture, elasticity P: Ears are firm without - For patients who wear
and areas of lumps, lymph tissue is hearing aids, accumulated
tenderness not palpable. Ears are cerumen and otitis externa
nontender.. No pain can be ongoing challenges. It
elicited during is important for this
palpation. population to have frequent
examination of their ear
* Hearing Acuity: canals to ensure patency and
Patient repeats the health and to receive
* Hearing Acuity: entire sentence without maximum benefits from their
Patient repeated errors. hearing aids. (Ear
* Gross Hearing the entire sentence * Weber test: Assessment pp, 316 -316,
Acuity Tests: without errors. Vibrations are heard Wolters Kluwer: Nursing
normal voice tone * Weber test: equally well in both Health Assessment)
and whispered Vibrations are ears.
voice heard equally well * Rinne Test: Air
* Watch Tick Test in both ears conduction sound is
* Tunning Fork according to the normally heard longer
Tests: patient. than bone conduction
- Weber for bone * Rinne Test: The sound (AC BC).
conduction patient verbalized
- Rinne’s to hearing AC sounds
compare air and longer than BC
bone conductions sound.

Nose and Sinuses I: No nodules and I: Color is the same as - Trauma to the ethmoid bone
I: nose deviation in no tenderness. the rest of the face; the in the nose may cause severe
shape size, color, nasal structure is illness and even death. The
flaring, discharge; : Pink and moist. smooth and symmetric. bone is lightweight and
: nasal mucosa No swelling and a : Pink and moist with spongy, making it vulnerable
for redness, small amount of no prominent blood to fracture, especially with
swelling, growth or drainage is clear. vessels or crust. Air upward impacts. Holes in the
discharge flow is adequate. A cribriform plate of the bone
small amount of allow bacteria to enter into
drainage is clear. the CNS and brain infection
results. If nasal drainage is
Pa: The client reports present, assume that the fluid
no tenderness. is cerebrospinal fluid, seek
Pa: No tenderness. : Nasal patency: appropriate diagnostic
Pa: tenderness, Client is able to sniff testing, and take precautions
masses, : Nasal patency: through each nostril to prevent infection.
displacements; Sniffs on each while other is occluded. Commonly, the fluid is tested
: nasal patency nostrils while other : Sinuses: Frontal for glucose, but this testing is
: maxillary and is occluded. and maxillary sinuses not sensitive or specific so
frontal sinuses for are non- tender to further testing such as CT
tenderness palpation, and no scan and MRI is
: Sinuses: No crepitus is evident. recommended. (Nose,
tenderness and no Sinuses, Mouth and Throat
crepitation. Pe: The sinuses are pp. 373-374 Wolters
not tender on Kluwer: Nursing Health
percussion. Assessment
* Transillumination
Pe: No tenderness. test: If sinus
 tenderness was
detected during
Pe: the above palpation and
sinuses for percussion.
tenderness
Transillumination
Test

Mouth / I: Lips are pink and

Oropharynx I: Pink lips withoutmoist with no lesions. - The floor of the mouth is
I: lips for symmetry lesion. high vascular, with the largest
of contour, color, : Thirty-two pearly percentage of blood vessels
texture, moisture, : Complete teeth. whitish teeth with in the area at the base of the
lesion No repair decayed smooth surfaces and tongue. This vascularity
: teeth for areas, Missing edges. Upper molars allows rapid absorption of
alignment, loss, teeth. should rest directly on sublingual medication. (Nose,
dental fillings and the lower molars and Sinuses, Mouth and Throat
caries; the front upper incisors pp. 389-391, Wolters
should slightly override Kluwer: Nursing Health
the lower incisors. Assessment)
Some clients normally
have only 28 teeth if
the four wisdom teeth
do not erupt. No
repaired or decayed
areas; no missing teeth
or appliances.

: Gums are pink and

firm, not red and
swollen.

: Gums are pink : Tongue is pink,

and firm, not red smooth and midline.
and swollen. No tumors or lesions
: gums for present.
bleeding, color,
retraction, lesions, : Color pink. No
swelling lesions seen.
: tongue for
position, color &
texture; movement,
as well as the base
: Ducts are smooth
of the tongue, : Ducts are smooth. without inflammation.
mouth floor and No swelling and Saliva is present.
frenulum saliva is present. : Palate is pink,
: Pink, smooth and smooth and intact. - The major salivary glands
: salivary gland intact. produce about 4L/day of
ducts for swelling, : Uvula is in midline saliva (WebMD, 2017).
redness
 : palettes for : Midline and and able to rise Interestingly, they produce
color, shape, symmetrical. symmetrically with the different types of saliva, with
texture, presence patient saying “ah.” the secretions in the parotid
of bony : Pink. No : Throat is normally glands primarily liquid. The
prominences exudates or lesions. pink without exudate or submandibular glands
: uvula for position lesions. produce about two thirds of
& mobility : Pink and moist. : Tonsils are pink and saliva that is more mucus
: oropharynx for No enlargement or moist with symmetrical than liquid.
color & texture lesions. Tonsils are margins. No
: tonsils for color, absent. enlargement or lesions - Blockage of the parotid duct
discharge, and size noted. Tonsils are increases the potential for
absent or 1+. periodontal disease as a
* Test for Gag Reflex: result of pH imbalance,
* Test for Gag Soft palate elevates as dryness, and precipitation of
Reflex: Soft palate the patient vocalizes calcium.
elevates as the “ahh.” Patient nods (https://quizlet.com/920674
patient vocalizes head accurately to 01/chapter-15-nurs-226-
Test for Gag “ahh.” Patient nods pharyngeal touch. flash-cards/)
Reflex head accurately to Tongue and soft palate
pharyngeal touch. elevate, and
pharyngeal muscles
constrict with touch.
P: No nodules,
lumps, and P: No nodules, lumps,
excoriated areas. and excoriated areas

- With chronic infections,

tonsils hypertrophy and
produce chronic airway
P: nodules, lump obstruction. Hypertrophy of
and excoriated the tonsils and adenoid may
areas develop secondary to
sinusitis or otitis media
(middle ear infection). These
conditions are very
uncomfortable and can be
serious if the airway becomes
obstructed. (Nose, Sinuses,
Mouth and Throat pp. 392-
393, Wolters Kluwer;
nursing Health
Assessment)

NECK I: Symmetric and I: Neck muscles are The major neck muscles may
Neck Muscles no abnormal symmetric and no be used as accessory
I: abnormal swelling. Neck can abnormal swelling. muscles of respiration when
swelling or move freely. Neck can move freely. the patient has difficulty
masses, head breathing.
movement, and https://www.newhealthadvi
muscle strength sor.org/Muscles-of-
P: inguinal and iliac Respiration.html
Lymph Nodes lymph nodes P: No lymph nodes are
P: enlargement palpated. palpable.
It is important to understand
P: Trachea is in the drainage patterns of the
Trachea midline. lymphatics because
P: Trachea is in
P: lateral deviation midline. enlargement of a node may
I: Symmetric. No be a sign of pathology.
masses and no Because of the flow, the node
Thyroid Gland I: Symmetrical without may not be directly adjacent
tenderness. Up-
I: symmetry and discrete masses, to the affected area.
and-down
visible masses, rise nodularity, or - Palpation of the thyroid
movement during
during swallowing tenderness. Up-and- gland reveals important
swallowing.
P: smoothness down movement during landmarks of the trachea.
P: Smooth, soft and
A: bruit swallowing. Such landmarks are noted
rubbery.
P: The thyroid, if when assessing for tracheal
A: No vascular
palpable, is normally deviation, which accompanies
sound heard.
smooth, soft, and a potentially life threatening
rubbery. condition related to a
A: No bruits or collapsed lung called tension
vascular sounds are pneumothorax. (Thorax and
audible. Lung Assessment pp. 415-
416, Wolters Kluwer:
Nursing Health
Assessment)

THORAX & I: Chest expansion I: AP to transverse - In women, it may be

LUNGS is symmetric. Chest ratio 1:2 (between 1:2 necessary to displace the
Posterior Thorax wall is cone shaped & 5:7). Chest breast laterally (or ask the
I: shape & and oval. AP to expansion is patient to move it) and stay
symmetry from transverse ratio 1:2 symmetric. Chest wall closer to the sternum to avoid
posterior-lateral is cone shaped, breast tissue. Avoid pressing
views; spinal symmetric, and oval. tender breast tissue too hard
alignment for because it is painful.
deformities - It is important to note that
Pa: temperature, Pa: Thorax is the RML is auscultated using
Pa: Thorax is
bulges, nontender. No an anterior approach.
nontender without any
tenderness, lesion, lumps, Although a small portion of it
lesions, lumps,
abnormal masses, or crepitus can be auscultated laterally.
masses, or crepitus.
movements, palpated. Accurate auscultation of the
Respiratory
respiratory Respiratory RML can be challenging in
excursion: The thumb
excursion, vocal excursion: women, however, because of
move apart
fremitus Symmetric its location underlying the
symmetrically,
Vocal fremitus: right breast. (Thorax and
approximately
Fremitus is Lung Assessment pp. 413
5-10 cm. Vocal
Pe: for symmetry of symmetrical. Wolters Kluwer; Nursing
fremitus: Fremitus is
resonance; symmetrical. Health Assessment)
diaphragmatic Pe: Lungs resonant
Pe: Lungs resonant. In
excursion Diaphragmatic
obese patient and
excursion:
those with extremely
Symmetric
 large chests,
percussion sounds
may become dull.
Diaphragmatic
excursion: Excursion
A: Soft, low pitched 3-5 cm, symmetrical.
A: breath sounds or vesicular sound.
No crackles, A: Breath sounds
wheezes and vesicular without
rhonchi. adventitious sound. No
crackles, wheezes and
I: Chest is oval and rhonchi
Anterior Thorax symmetric. No
I: breathing pattern, chest deformities.
coastal and I: No chest deformity.
costovertebral Chest shape is oval
angle and symmetrical.
Costal angle less than
Pa: 90
Respiratory Degrees. No barrel
Pa: respiratory excursion: chest.
excursion, tactile Symmetric.
fremitus Tactile fremitus: Pa: Respiratory
Fremitus is excursion: Excursion
Pe: symmetry of symmetrical. 3-5 cm, symmetrical.
resonance Pe: Lungs Tactile fremitus:
resonant. Fremitus is
symmetrical.
Pe: Lungs resonant.
Percussion over lung
tissue produces
resonance. Percussing
over the heart
produces dullness from
the
3rd-5th ICS to the left
of the sternum. The
upper border of liver
dullness is
percussed in the 5th
A: breath sounds A: Sounds are ICS in
muffled and difficult the left MCL
to distinguish
A: No egophony,
bronchophony, or
whispered
pectoriloquy. Sounds
are muffled and difficult
to distinguish.

Heart I: No impulse I: Impulse are absent One cause of reduced

I : precordium for located. No or located in the 4 th -5 cardiac output is the medical
pulsations & lifts or lifts/heaves. th ICS at the MCL with diagnosis of heart failure. In
heaves no lifts/ heaves. PMI 5 this clinical syndrome,
th ICS at the MCL. The reduced contractility causes
PMI may or may not be preload to increase. Blood
palpable in adults. No backs up, causing
pulsations are palpated congestion. Congestion on
A: heart sounds in other areas. the left back blood into the
(S1, S2, etc.) lungs, whereas congestion on
A: S1 is greater than the right backs blood into the
A: Heart rate and S2 in the mitral & body, especially the legs and
rhythm is regular. tricuspid areas; S2 is feet. Signs and symptoms of
no gallops, greater than S1 in the heart failure are shortness of
murmurs. aortic and pulmonic breath, weight gain, and
areas; S1 is equal to swollen ankles with
S2 at Erb point. Heart decreased cardiac output.
Central Vessels: rate & rhythm is Source:
Carotid Arteries regular. No gallops, https://www.mayoclinic.org
PA: volume, quality murmurs or rubs. /diseases-conditions/heart-
A: bruit failure/symptoms-
Jugular Veins PA: Symmetric PA: Symmetric pulse causes/syc-20373142
I: distention pulse volume. volumes.
A. No sound heard A: No sound heard on - Arterioles have more
auscultation smooth muscle, and it is here
I: Distended neck I: No distention. that BP is controlled
Peripheral vein (Grossman & Poth, 2014).
Vessels - Because veins are
I: presence or capacitance vessels and are
appearance of I: No prominent venous less muscular than arteries,
superficial veins, pattern. blood tends to collect in them.
I: Engorged Vein in
signs of phlebitis the left leg When moving from lying to
*Buerger’s Test * Buerger’s Test: standing or when standing
*Capillary Refill Original color returns in suddenly, dizziness may
* Capillary refill:
10 seconds; veins in result until the calf and leg
takes less than 3
feet or hands fill in muscles contract to increase
seconds.
about 15 seconds. the venous return to the
* Capillary refill: less central part of the body and
than 3 seconds brain.
Retrieved from:
https://quizlet.com/2789863
16/peripheral-vascular-and-
lymphatic-assessment-
flash-cards/
Breast & Axillae I: breast; size and I: breast; size and A clinical breast exam is a
I: breast for size, shape are normal, shape are normal, key step in the diagnosis and
symmetry, contour symmetric, and no symmetric, and no surveillance of a number of
or shape, discoloration, skin discoloration, skin benign and malignant breast
discoloration, turgor is normal. turgor is normal. diseases. When used as part
retraction, of a multimodal evaluation,
hypervascularity, the breast exam provides
swelling, edema important information that is
 : areola for size, Areola; no swelling, Areola; no swelling, utilized in both the workup
shape, symmetry, ulceration, and ulceration, and and management of many
color, surface drainage. Size and drainage. Size and diseases of the breast.
characteristics, shape are normal. shape are normal. Retrieved from:
masses, lesions Breast Examination
: nipples for size, Nipples: nipple is Techniques - StatPearls -
brown in color, Nipples: nipple is
shape, position, NCBI Bookshelf (nih.gov)
position, shape, brown in color,
color, discharge,
and size are position, shape, and
lesion
normal, no size are normal, no
discharge and discharge and lesion.
lesion.
PA: lymph nodes,
 PA: lymph nodes,  PA: lymph nodes,
breast, areola &
breast, areola, and breast, areola, and
nipples for
nipples; no nipples; no tenderness,
tenderness,
tenderness, masses, nodules.
masses, nodules,
masses, nodules. no discharge when
discharge
no discharge when nipples are palpated.
nipples are
palpated.

ABDOMEN I: Abdomen is I: Abdomen is uniform The importance of

I: skin integrity, rounded with in color with symmetric assessment Performing an
contour & uniform skin color contour. Round or abdominal assessment will
symmetry, hernia, and symmetric protuberant abdomen. help you detect health
distention (girth), contour. No lesions, There is an absence of problems in your patients
movements no tenderness. lesions and earlier and prevent further
associated w/ Umbilicus is in tenderness. complications from
respiration, midline. Unexpected skin developing with existing
peristalsis & aortic findings include scars, disease. And now you've
pulsations striae, or varicosity. learned how to do a thorough
Umbilicus midline and physical assessment of the
inverted. No hernias abdomen and the importance
noted. No distention, of systematically
visible pulsations, or documenting your findings.
peristaltic wave noted. Retrieved from:
Respirations even, no https://journals.lww.com/nu
use of accessory rsingmadeincrediblyeasy/F
muscles. ulltext/2009/09000/Making_
sense_of_abdominal_asse
ssment.
A: bowel, vascular, A: Bowel sounds
& peritoneal friction are present in all A: Bowel sounds are Abdominal bruits are
rub sounds quadrants. No present in all four murmurs heard over the
bruits and friction quadrants. No bruits. abdomen. In healthy persons,
rub sounds. No venous hums. No abdominal bruits confined
Pe: all quadrants / Pe: Abdomen is friction rubs. to systole may be heard in
regions for tympanic. Dullness Pe: Over most of the the epigastrium. This finding
tympany and over the liver in abdomen, tympanic does not necessarily indicate
deviations RUQ and other sounds are heard. disease.
Retrieved from:
 organs https://www.sciencedirect.c
Pa: light to deep Pa: Light om/topics/medicine-and-
palpation ALL palpation: No Pa: Light palpation: dentistry/bruit )
quadrants from tenderness. Deep No tenderness. Deep
least painful to palpation: palpation: Abdomen
most painful for Abdomen without without masses.
masses, masses. Tenderness near the
tenderness, muscle xiphoid process, over
guarding; liver If necessary / the cecum, or over the
(bimanual) and applicable / sigmoid colon may be
bladder palpation significant normal.
* Leopold’s
Maneuver for OB
clients for
presentation, lie,
engagement,
attitude, position

MUSCULOSKELE I: Muscles in the left I: Muscles are fully A flexion deformity of the
TAL thigh are not developed and knee is the inability to fully
Muscles symmetric in size. symmetric in size. No straighten or extend the
I: size, No fasciculation fasciculation and knee, also known as flexion
contractures, and tremors noted. tremors noted. contracture. Normal active
fasciculations, range of motion (AROM) of
tremors P: The muscles are P: The muscles are the knee is 0° extension and
P: tonicity, asymmetrical in the symmetrical, smooth, 140° flexion. In people with
flaccidity, leg area; they are and nontender. a flexion deformity, AROM
spasticity, also smooth, and of one or both knees is
smoothness of tender. The patient reduced. It develops as a
movement, also complained of result of failure of knee
strength pain in the upper flexors to lengthen in
left knee joint while tandem with the bone,
doing the palpation. especially when there is
inadequate physical therapy
Bones to provide active and
I: deformities seen I: No deformities.
I: structure, passive mobilization of the
in the left knee. P: No presence of
deformity affected joint. Flexion
P: tender and edema and no
P: edema, Deformity of the Knee -
evidence of edema tenderness.
tenderness Physiopedia (physio-
in the left knee and
pedia.com)
thigh.
Joints Knee swelling is a sign that
I: swelling in the left I: No swelling or
I: swelling there’s a problem within the
knee joint but no trauma.
P: tenderness, knee. It can be the body’s
trauma P: Joints surfaces are
smoothness of response to damage to a part
P: Joints surfaces smooth and nontender.
movement, of the knee, an overuse
are not smooth in No nodules, swelling,
swelling, injury, or a symptom of an
the left knee. and crepitation.
crepitation, nodules underlying disease or
tenderness,
condition. Knee swelling
nodules, swelling
happens when fluid collects in
and crepitation
or around the joint of a knee.
 palpated in the left How to Quickly Reduce
leg. Knee Swelling
(healthline.com)
NEUROLOGIC The patient is Mental status: Assessment of the neurologic
Mental Status oriented as she * The patient is system of the client ensures
- Language recalls her name oriented as she recalls other
- Orientation and the time, date, her name, the time, complications/symptoms that
- Memory and place during date, and place of the might be related to his/her
- Attention Span / the interview. interview. current condition. These
Calculation complications can greatly
affect the present illness.
* The client had * Upright posture.
Gross (Neurological and Mental
difficulty in Steady gait with
Motor/Balance Status pp. 629-631, Wolters
maintaining a opposing arms swing.
* Walking Gait Kluwer, Nursing Health
steady gait as the Walks unaided and
* Romberg Assessment)
opposite arms maintains balance
* Standing on 1
foot w/ eyes closed swing. Upper body
* Heel-toe walking is bent forward
when standing and
walking, walking
needs aid like poles
or anything that can
support or help her
to maintain
balance.

GENITALIA I: no redness, the I: no redness, the skin Normal female genitalia are

I: Skin color, skin is intact, pubic is intact, pubic hair ischaracterized by two
integrity and pubic hair is normally normally distributed at echogenic parallel lines in a
hair distribution,, distributed at the the mons pubis, cervix transverse section in the
Cervix and vaginal mons pubis, cervix and vaginal walls are midtrimester. A clitoris may
walls for and vaginal walls smooth and pink, and be seen between
abnormalities are smooth and is positioned midline these labia and should be
pink, and is directed caudally.
positioned midline Retrieved from: Female
PA: no tenderness and Genitalia - an overview |
PA: no tenderness
PA: Mons pubis, masses palpated, the ScienceDirect Topics
inguinal area for and masses
lymph nodes are not
masses and lymph palpated, the lymph
swollen, no pain during
nodes nodes are not
the whole palpation
swollen, no pain
during the whole
palpation

RECTAL I: no edema, I: no edema, lesions, The rectal exam is important

I: sacrococcygeal lesions, discharge discharge or lesions. to make sure causes of rectal
area, perineal area or lesions. No gross No gross deformities bleeding such as
and anus for gross deformities and and discoloration. hemorrhoids are not missed.
deformities and discoloration. Additionally, understanding
surface how to palpate the prostate
 characteristics I: no gross deformities. gland is important for looking
I: no gross Skin is clear and not for cancer and diagnosis
deformities. Skin is dimpling. Skin Retrieved from:
clear and not surrounding the anus is prostatitis.https://stanford
dimpling. Skin coarse with darker medicine25.stanford.edu/th
surrounding the pigmentation and anal e25/rectal.html
anus is coarse with sphicter is closed.
darker pigmentation
and anal sphicter is PA: anal ring should
closed. feel smooth without
nodules, masses or
PA:anal ring is irregularities,
PA: anal ring and smooth without inspection of rectal
rectal walls nodules, masses or walls shoul feel smooth
irregularities,rectal and uninterrupted,
wall is smooth and internal hemorrhoids
is not interrupted by are not palpable, no
any mass, internal polyps and masses.
hemorrhoids are
not palpable.

References:
● Grossman & Porth: Porth's Pathophysiology, Ninth Edition
● https://journals.lww.com/nursingmadeincrediblyeasy/Fulltext/2009/09000/Making_sense
_of_abdominal_assessment.
● https://quizlet.com/278986316/peripheral-vascular-and-lymphatic-assessment-flash-
cards
● https://www.mayoclinic.org/diseases-conditions/heart-failure/symptoms-causes/syc-
20373142
● https://www.newhealthadvisor.org/Muscles-of-Respiration.html
● https://stanfordmedicine25.stanford.edu/the25/rectal.html
● Nurse key, www.nursekey.com
● Wolters Kluwer: Nursing Health Assessment 3rd Edition
● WebMD, 2017
● https://www.amboss.com/us/knowledge/Head_and_neck_examination#:~:text=Examinat
ion%20of%20the%20head,-Inspect%20the%20skull&text=Inspect%20the%20skin
%20and%20scalp,facial%20sensation%20and%20motor%20function.&text=function
%3A%20Lightly%20touch%20the%20forehead,cheek%20with%20the%20index
%20finger.
● Female Genitalia - an overview | ScienceDirect Topics
● Health and Physical Assessment D’Amico, Barbarito
● Scleroderma - Symptoms and causes - Mayo Clinic
● Breast Examination Techniques - StatPearls - NCBI Bookshelf (nih.gov)
● Flexion Deformity of the Knee - Physiopedia (physio-pedia.com)