Areas examined Subjective

Physical Objective Assessment”

Assessment “Cephalocaudal Problems identified
INTEGUMENTARY:
Skin No problems identified.
Good turgor, no rash,
unusual bruising or
prominent lesions
Hair Normal texture and No problems identified.
distribution.
Absence of lice
Nails
Nail beds are highly No problems identified.
vascular with a pink
color in light skinned
clients and
longitudinal streaks
of brown or black
pigmentation in dark
skinned clients.
Angle between
finger-nail and base
is 160 degrees.
Nail bed is firm
Neurology Sensation to pain,
touch, and No problems identified.
proprioception
normal.
Head:
Head & Skull Round and No problems identified
symmetrical.
Smooth and not No problems identified
tender, and no
lesions or masses
Face Rounded face, No problems identified
symmetrical and no
involuntary
movements.
Eyes and Vision:
Eyebrows Eyebrows are No problems identified
symmetrically
aligned
Eyelashes Eyelashes appeared No problems identified
to be equally
distributed and
curled slightly
outward
Eyelids There was no No problems identified
presence of
discharges, no
discoloration and
lids close
symmetrically with
involuntary blinks
approximately 15-20
times per minute.
Eyes  Painless,  PERRLA  Impaired sensory
blurred vision  Snellen visual perception (visual)
 Glare (seeing acuity test related to Changes in
a halo around  Ophthalmoscopy sensory reception or
lights),  Slit-lamp sense organ of vision
especially biomicroscopic status.
when the examination.  Risk for Injury
client drive at  Ishihara Plate related to aging.
 night with  Ocular tonometry  Anxiety related to
oncoming threat of permanent
headlights. loss of
 Double vision vision/independence.
 Need for  Low self-esteem
brighter light related to impaired
to read self-image.
 Difficulty  Disturbed sensory
seeing at night perception related to
visual impairment
Ears and Hearing
Firm, smooth, free No problems identified.
from lesions and
pain.
Nose & Sinuses
Located No problems identified.
symmetrically, mid-
line of the face and is
without swelling,
bleeding.
Mouth The lips of the client No problems identified.
are uniformly pink;
moist, symmetric
and have a smooth
texture. The client
was able to purse his
lips when asked to
whistle.
Neck Movement though No problems identified.
full range of motion
without compliant of
discomfort or
limitation.
Thorax & Lungs
Heart  The patient’s
heart has no No problems identified.
palpable
pulsation over
the aortic,
pulmonic, and
mitral valves, no
noted abnormal
heaves, and
thrills.
 No abnormal
heart sounds are
heard like
murmurs.
GI System  Bowel sounds
present on No problems identified.
auscultation.
Abdomen soft on
palpation with no
pain or
tenderness.
Tolerates
prescribed diet
without nausea
and/or vomiting.
Having bowel
movements
 within normal
pattern.
Extremities No amputations or No problems identified.
deformities,
cyanosis, edema or
varicosities,
peripheral pulses
intact
Muscles Not hundred percent No problems identified.
movement against
gravity and full
resistance.
Bones No deformities
Joints Movement though No problems identified.
full range of motion
without compliant of
discomfort or
limitation.
Lymphatic System No lumps detected. No problems identified.
Hematology
RBC, WBC, No problems identified.
Platelets are normal.