ASESSMENT OF FUNCTIONING
PHYSICAL ASSESSMENT:
APPEARANCE: The client’s appearance
is pleasant and was dressed beautifully,
she doesn’t look like a 50- year old
woman but looks younger that that
because she dresses “young” and she
takes good care of her appearance and
face, she has a skin care routine which
she does every day and night
GROOMING: The client was groomed
properly, she has combed her hair and
she was particular on how she looks
everyday
POSTURE: She has a good posture
especially when sitting and standing, she
is not curvy looking when she sits and
stands
EXPRESSIONS: The client has a variety
of expressions upon the interview, she
smiles and she laughs but she doesn’t
show signs of disinterest and irritation
BODY ODOR: The client did not present
any unpleasant odor because she is
conscious about her smell which is why
she makes sure she smells nice and she
also takes a bath every day.
BP SITTING: R: 100/70 mmHg
L: 100/60 mmHg
BP STANDING: R: 90/60 mmHg
L: 100/70 mmHg
SKIN: The client’s skin is bright and is
uniform in color, there is no
hyperpigmentation noted on the skin.
There are no blemishes seen, but wrinkles
are seen on the face due to aging.
COLOR: The client’s skin is bright and
pinkish in color
LESIONS: There are no lesions present
on the client’s skin
TURGOR: Client has a good skin turgor
which presents no signs of dehydration
TEXTURE: The client’s skin is smooth
and doesn’t present any roughness and
dryness
MOISTURE: Client’s skin is well
moisturized because she takes good care
of her skin and also puts on lotion daily
VARIATIONS:
EYES:
OD: Can see properly and no lesions
were noted
OS: Can also see properly and there were
also any lesions seen
OU: Both eyes were symmetrical with
each other
PERIPHERAL VISIONS: During the
assessment of peripheral vision, the client
was asked to participate in such test, the
client was able to see objects in periphery
while looking straight ahead, there are no
difficulties in periphery
BLINDSPOTS:
READING GLASSES: Client doesn’t use
and own any reading glasses because
she prefers not using one
PERRLA: Both eyes responded to light
accommodation, the pupils are also
equally round, pupils have constricted
when looking at a near object and dilated
as well
CONJUNCTIVA: It appears smooth,
shiny and pink
OTHER VARIATIONS:
SENSATIONS: The sensations of the
client were perfectly normal she
responded to all tests that were
performed.
2 POINT DISCRIMINATION: The client
was able to distinguish the 2 points that
had contact with her skin.
TEMPERATURE: The client was able to
distinguish whether the object placed in
her skin was cold or hot.
PROPRIOCEPTION: The client did not
manifest a sign of proprioception deficit
which indicates she has no problems with
balance issues, and also she does not
have trouble with standing in one foot.
PRESSURE:
TINGLING: The client was able to identify
and show tingling sensations which
means that the client is not manifesting
signs of numbness.
NAILS: The client has pinkish nails and
has a the shape of convex curve.
TRIMMED/CLEAN: The client’s nails are
trimmed and has a manicure because she
likes them having color
TEXTURE: It is smooth in texture and
does not have any cracks and roughness
NAIL CLUBBING: Client’s nails doesn’t
show any signs of clubbing
CRT: It has a normal capillary refill time, it
directly went back after 1-2 seconds

NECK: The client shows no any lesions in
the neck and it is uniform in color, also the
muscles on both sides are equal
ROM: The client showed coordinated,
smooth movement of her neck, she did
not complain about pain in doing such
movements
PALPABLE MASS: There were no noted
masses in the neck of the client.
PAIN: No pain were noted in the client in
doing movements, also her expressions
didn’t show any signs of pain
HT: 5’2 ft.
WT: 63 kg
PR: 75 bpm
RR: 17 cpm
TEMP: 36.9 C
HAIR: The hair of the client is pretty thick
and h is well distributed to all parts of the
scalp
ALOPECIA: No signs of alopecia are
seen
SCALP LESIONS: There were no lesions
seen in the scalp
LICE: The client doesn’t have any
parasitic organisms living in her hair
COLOR: The client has a bright brown
hair due to hair dye but has normally
brown black hair
TEXTURE: The hair was smooth in
texture and is silky, the client is very
particular with her shampoo, making it
sure it has a silky effect
LENGTH: Hair length is up to her chest
EAR: Both ears are normal and don’t
have any lesions or allergies.
CERUMEN: Cerumen is present inside
the ears with normal amount and not
found outside the ears.
APPEARANCE: The client’s ears are with
the same color as her face. Both ears are
symmetrical with each other and they are
aligned with the outer eye canthi.
HEARING AIDE: The client is not using
any hearing aide since her hearing sense
is normal.
DEAFNESS: ( x ) L ( x ) R
WEBER: The results showed by the
patient is normal, both ears were able to
hear.
RINNE: The results showed the patient’s
hearing is normal, the client was able to
hear the sound longer through air than the
bone conduction (AC > BC)
CRANIAL NERVES:
I. OLFACTORY R- Was able to smell
properly and distinguish the object
L- Was also able to smell and properly
distinguish the object
II. OPTIC: The client was able to read with
each eye and both eyes
V.TRIGEMINAL: The client was able to
elicit corneal reflex, sensitive to pain
stimuli and distinguish hot from cold
III, IV, VI. :
- The client showed that her pupils were
equally round and reactive to light and
accommodation.
- Both eyes of the client were able to
move as necessary
- Both eyes of the client moved in
coordination with each other.
VII. : The client was able to perform a
variety of facial expressions without any
difficulty and was able to distinguish
varied tastes.
VIII. : The client was able to hear tickling
in both ears and also the client was able
to stand and walk in an upright position
and able to maintain her balance really
well.
IX. : The client was able to elicit the gag
reflex and she was able to swallow without
any difficulty shown.
X. : The results showed that the patient
was able to swallow without any difficulty
and was able to speak the words audibly.
XI. The client was able to shrug her
shoulders and turn her head from one side
to the other.
XII. : The client was able to move her
tongue in different directions
ORAL MUCOSA:
ODOR: There was no unpleasant odor
observed
TASTE: The client has a functioning
sense of taste
SWEET: The client was able to taste
sweet foods such as candy and sugar
SOUR: The client was able to identify the
taste of sour
BITTER: The client was able to taste
bitterness
SALTY: The client was able to taste
saltiness of a food such as chips
LESIONS: There are no lesions found in
the client’s oral mucosa
GUM BLEEDING: No signs of bleeding
were seen upon brushing teeth and eating
different types of food.
NO. OF TEETH: The client has an overall
total of 24 teeth up and down
TONGUE: The tongue of the client is in
central position, it is pink in color, moist
and slightly rough, glistening with elastic
texture
DENTURES: The client owns dentures
that she will attach on the upper part
GUM COLOR: There is no retraction of
gums and the gums are pinkish in color
ABDOMEN: The client’s abdomen is
unblemished and is uniform in color
CONTOUR: The client’s abdomen is
symmetrical contour and is not distended
UMBILICUS: The umbilicus is positioned
in the center and is clean and doesn’t
have any allergies and lesions
STRIAE: Stretch marks are visible in the
lower part of the abdomen
VEINS: Veins are not really that visible in
the abdomen
BOWEL SOUNDS: Bowel sounds are
present upon assessment
PALPABLE MASS: There aren’t palpable
masses noted in the client’s skin
SCARS: There were no scars present in
the client’s abdomen
RESPIRATIONS:
THORAX SHAPE: Thorax is oval and
normal without any signs of barrel chest
and kyphosis
SYMMETRY: Both sides are symmetrical
with each other
RETRACTIONS: There were no signs of
difficulty in breathing such as distractions
TENDERNESS: There were no
tenderness felt by the client around the
thorax
BREATH SOUNDS: Normal breath
sounds were noted.
- Vesicular sounds were noted at over
most of both lungs
- Broncho-vesicular sounds were noted
often in the 1st and 2nd interspaces
anteriorly between the scapulae
- Bronchial sounds are noted over the
manubrium
- Tracheal sounds were noted over the
trachea in the neck
ADVENTITIOUS SOUNDS: Adventitious
sounds weren’t heard upon auscultation
BREATHING PATTERNS: The client has
a normal breathing pattern of 17 breaths
per minute
DYSPNEA: There is no sign of dyspnea of
the client
DYSPNEIC (SPECIFY:
BREAST: Both has the same size and
shape
SBE: The client doesn’t perform SBE and
isn’t aware of its importance
SHAPE: Both has the exact same shape
NIPPLES: Nipples are slight darker in
color than the chest color
MASSES: There are no felt masses upon
palpation
SYMMETRY: Both are symmetrical to
each other
DISCHARGES: There are no noted
discharges on the client’s nipples
FEMALE GENITALIA:
SWELLING: There is no swelling on the
genitalia of the client
COLOR: The genital of the patient is
slightly red in color
DISCHARGES: Discharges are often
experienced especially days before and
after menstruation
LESIONS: There are no lesions noted in
the client’s genitalia
LICE: There are no lice in the client’s
genitalia
GROOMING: The client usually trims her
pubic hair and doesn’t do shaving
because she thinks pubic hair is important
and should not be removed
STRUCTURAL DEFECT: No structural
defect is noted
MENOPAUSE: The client is on her
menopause now
CLITORAL SWELLING: No such swelling
is experienced by the client
MUSCULO SKELETAL: R- Felt and present
GAIT: The client can stand erect L- Felt and present
PARALYSIS: The client has no paralysis BRUITS:
POSTURE: Client’s posture is with normal R- Felt and present
curvatures, hips, knees and ankles in a L- Felt and present
straight line RADIAL:
DEFECT: No defects are seen R- Felt and present
EDEMA: There is no edema on the L- Felt and present
client’s body BRACHIAL:
STRENGTH: Client’s strength for the R- Felt and present
muscle was tested and they are bilaterally L- Felt and present
symmetric and full resistance to FEMORAL:
opposition, there was no muscle R- Felt and present
weakness observed and also muscle L- Felt and present
cramming POSTERIOR TIBIAL:
ROM: Active rom exercises were done by R- Felt and present
the client L- Felt and present
DTR: The client has a result of 2+ in the
DTR test which means within normal
range MALE GENITALIA:
TONE: Normal body tone is observed TSE:
SYMMETRY: The client’s body is MASSES:
relatively symmetric SWELLING:
ASSISTIVE DEVICE: There are no ERECTILE DYSFUNCTION:
assistive devices utilized by the patient DISCHARGES:
TREMORS: The client doesn’t show any STRUCTURAL PROBLEM:
tremors LYMPH NODE:

CARDIOVASCULAR: RECTUM: It is patent and doesn’t have

PALPABLE JUGULAR VEIN: The jugular
vein is visualized
URINE OUTPUT: The client’s urine output
per day as she estimated is 1500 ml which
is within the normal range
CYANOSIS: Cyanosis is not seen in the
client
PULSATIONS: Pulsations are felt
HEAVES: Heaves are not present
HEART SOUNDS: Heart sounds were
heard upon auscultation, there were no
noted abnormal heart sounds
any difficulties ejecting waste
RASHES: There are no rashes on the
client’s rectum
LESIONS/HEMORRHOIDS: Hemorrhoids
are not present on client’s rectum
BLEEDINGS: The client hasn’t
experienced any bleeding in her rectum
STRUCTURAL DEFECTS: The client’s
rectum is normal and doesn’t have any
structural defect.
OTHER FINDINGS:

PERIPHERAL VASCULAR PULSES

CAROTID:
R- Felt and present
L- Felt and present
ULNAR:
R- Felt and present
L- Felt and present
POPLITEAL:
R- Felt and present
L- Felt and present
PEDAL: