PHYSICAL ASSESSMENT

BODY PART EXAMINE SKIN Uniformity of color Presence of edema Lesions according to location distribution, color configuration,size,shap e,type of structure Skin moisture ACTUAL FINDINGS Has a uniform white skin color. Has no presence of edema on her skin Has no lesions in the skin. NORMAL FINDINGS Uniform in color except in areas expose to the sun No edema No lesions or abrasions. INTERPRETATION NORMAL NORMAL NORMAL

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

Skin temperature

Moisture in the skin folds and the axilla varies with environmental situation. Uniform in temperature and within normal range. Convex curvature: Angel of nail plate about 160 Pinkish in color

NORMAL

NORMAL

NAILS Fingernail plate shape

Fingernail and toenail bed color Fingernail and toenail texture Tissue surrounding nails Presence of capillaries

Has a convex curvature of fingernail plate , 160 Finger nail and toenail bed color are pinkish in color Fingernail and toenail texture are smooth The tissues surrounding the nails of the client are intact When blanced test is performed, color of the nail bed of the client returns into pink in less than 4 secs.

NORMAL

NORMAL

Smooth in texture Intact epidermis

NORMAL NORMAL

Highly vascular , prompt return of pink in color ( generally < 4secs)

NORMAL

HEAD SKULL

fir m and not NORMAL Presence of nodules.smooth.smooth.symmetric position. smooth skull contour Absence of nodules and masses Lighter than the color of her skin No signs of tenderness Evenly distributed . equal movement.symmetric position. shiny smooth in color sclera is white and clear Pupil is equal in size. equal movement. no discharge. thickness or thinness Texture.PHYSICAL ASSESSMENT Size. intact skin.mobile. symmetry Symmetric.and oiliness over the scalp FACE Facial features. Eyelashes are evenly distributed hair.masses and depressions SCALP Color and appearance Areas of tenderness HAIR Evenness of growth.thick hair Silky. round and proportional to her weight Has no Presence of nodules. reacted to light and accommodation . thick hair Silky.symmetrically align. curled outward Eyelids has intact. symmetry of facial movements EYES NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL EARS NORMAL . intact skin.resill ent Symmetric facial movements Eyebrows are evenly distributed. no discoloration Conjunctiva is transparent and . no discoloration Conjunctiva is transparent and . Eyelashes are evenly distributed hair. shiny smooth in color sclera is white and clear Pupil is equal in size. equally rounded.mobile. equally rounded.fir m and not Rounded.symmetrically align. Color same as facial skin. no discharge. reacted to light and accommodation .resill ent Symmetric facial movements Eyebrows are evenly distributed. Color same as facial skin. shape. curled outward Eyelids has intact.masses and depressions Lighter than the color of her skin No areas of tenderness Evenly distributed.

gums are pink in color no bleeding.patent. glistering and elastic texture. buccal mucosa is moist.pinna recoils after it is folded.clear.watery discharge.watery discharge. uvula is in midline. nasal septum intact and in midline Lips are Uniform NORMAL pink in color .PHYSICAL ASSESSMENT tender. able to hear ticking in both ears. smooth soft. of normal size no discharge.dry cerumen . nasal septum intact and in midline Lips are Uniform pink in color .dry cerumen . not tender no lesions.pinna recoils after it is folded. Muscles equal in tender. hardand soft palate are light pink in color and smoth soft palate. no discharge or flaring. air conducted hearing is greater than bone conducted hearing Symmetric and straight. Muscles equal in NORMAL NOSE AND SINUSES MOUTH AND OROPHARYNX NECK . mucosa pink. tongue are intact . gums are pink in color no bleeding.air moves freely as the client breaths through the nares . no lesions. lighter pink hard palate more irregular texture. no lesions. hardand soft palate are light pink in color and smoth soft palate. glistering and elastic texture.clear. buccal mucosa is moist.has presence of hair follicles no pus or blood. no discharge or flaring. lighter pink hard palate more irregular texture. uvula is in midline. tonsils are pink and smooth. of normal size no discharge. mucosa pink. uniform in color. air conducted hearing is greater than bone conducted hearing Symmetric and NORMAL straight. not tender no lesions. tongue are intact .has presence of hair follicles no pus or blood.air moves freely as the client breaths through the nares . tonsils are pink and smooth. able to hear ticking in both ears.patent. uniform in color. smooth soft.

slightly discoloration of the skin smooth and intact but (+) masses. head centered. uniform in color. no masses. head centered.chest wall intact.head hyper extended. And have vesicular and brochiovesicular breath sounds Breast is rounded and equally unequal. not distended. diameter in ration of 1:2. chest symmetric. coordinated. large lymph node ar not palpaple. flat. full and symmetric chest ecpansion. symmetric movements caused by respiration. flat. Shape is anteroposterior to lateral. chest symmetric. diameter in ration of 1:2. THORAX AND LUNGS NORMAL ABNORMAL ABDOMEN NORMAL . uniform in color smooth and intact. Brown nipple Unblemished skin.chest wall intact. rounded. tenderness and masses. spine vertically aligned . rounded.smoot h movements with no discomfort. laterally flexes and rotates.no tenderness. uniform temperature. Shape is anteroposterior to lateral. size.skin intact. And have vesicular and brochiovesicular breath sounds Breast is round in shape.skin intact. spine vertically aligned . no masses.no tenderness. uniform in color. uniform temperature. laterally flexes and rotates. percussion notes resonate.asymmetric . not distended. color varies to light pink to dark brown. percussion notes resonate. no nodules.head hyper extended.PHYSICAL ASSESSMENT size. full and symmetric chest ecpansion. tenderness and nodules.smoot h movements with no discomfort. symmetric movements caused by respiration. coordinated. Unblemished skin. equal strength. equal strength. large lymph node ar not palpaple.

firm when palpation has a normal muscle strength. no swelling and tenderness on joints areas.PHYSICAL ASSESSMENT audible bowel sounds. audible bowel sounds. no contractures and tremors. no tenderness. no tenderness. freely movable with no pain and discomfort. no contractures and tremors. no swelling and tenderness on joints areas. MUSCULOSKELETAL NORMAL . not palpaple Equal in size on both sides of the body.relaxe d. freely movable with no pain and discomfort.relaxe d. not palpaple Equal in size on both sides of the body.firm when palpation has a normal muscle strength.

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