DO NOT FORGET TO OBTAIN VITAL SIGNS (Take note of time and unit of measurement)

 On the start of duty

 As ordered
 Before duty ends
Demographic Profile

Name
Age
Gender
Provider Of History/S.O/Parent/S
Address
Place of Birth
Date of Birth
Nationality
Civil Status
Educational Attainment
Religion
Language
Occupation
Weight
Height
BMI
HISTORY OF PRESENT ILLNESS
Diagnosis of the Patient
 Itanong kung anong sinabi ng doctor na sakit ni
patient.

Day of Hospitalization
 Itanong kung ilang araw na sa hospital.

Characteristics
 How does it feel?

Onset
 When did it begin?

Location
 Where is it?
 Does it radiate?
 Does it occur anywhere else?
 Where does it hurt the most?

Duration
 How long does it last?
 Does it recur?
 Does it come and go?

Severity
 If you were to rate your pain from 1 to 10, 1 as
barely noticeable to 10 worst pain ever
experienced?
Pattern
 What makes it better? What makes it worse?
Associated Factors
 Do you feel anything else aside from the
symptom? If yes, what are those?
How it affects the client
 How does the disease affect your
lifestyle/activities in your daily life?
How is your health condition treated?

How satisfied have you been with the

treatment/procedure?
Are you having a hard time with your situation?
DO NOT FORGET TO OBTAIN VITAL SIGNS (Take note of time and unit of measurement)
 On the start of duty
 As ordered
 Before duty ends
PAIN ASSESSMENT
ONSET
Kailan nagsimula?

PROVOCATION
Ano sa tingin ng patient na nagcause ng
pain?

QUALITY
Paano yung sakit?
Namimilipit?
Tumutusok?
Nasusunog?

RADIATION
Nagraradiate ba sa ibang parte ng katawan
yung pain?

RELIEVING FACTORS
Anong mga ginawang paraan upang
marelief sa pain?

SCALE
Pain Scale: 1-MInor discomfort-10-Sobrang
sakit.

TIMING
Kailan siya nakakaramdam ng pain?
DO NOT FORGET TO OBTAIN VITAL SIGNS (Take note of time and unit of measurement)
 On the start of duty
 As ordered
 Before duty ends
MEDICATIONS

NAME DOSAGE ROUTE FREQUENCY

DO NOT FORGET TO OBTAIN VITAL SIGNS (Take note of time and unit of measurement)
 On the start of duty
 As ordered
 Before duty ends
PAST HEALTH HISTORY
What problems did you have at birth?

What childhood illness did you have?

(measles?mumps?chickenpox?)

Did you complete your immunizations since birth? If maalala, what

are they;

Do you still complete your vaccines up to now?

What and when was the last shot?

COVID-19 Vaccine:
Ask if nagpavaccine na si patient?
Ask if nacomplete na yung first 2 dose?
Ask if nakapagpafirstor second booster shot?

Do you have other illnesses? If so, when were you diagnosed? How
is it treated?

Have you experienced any surgeries or accidents?What and when?

Have you been hospitalized? When and for what reason/s?

Did you experience any prolonged pain or pain patterns?

What allergies do you have? When did it started? How are these
allergies treated?

Have you done self-medicating? Whqt did you take and how?

If woman ang pt:

Have you ever been pregnant or delivered a baby? How many times
have you been pregnant/delivered?
DO NOT FORGET TO OBTAIN VITAL SIGNS (Take note of time and unit of measurement)
 On the start of duty
 As ordered
 Before duty ends
FAMILY HEALTH HISTORY

1. Age of parents; Ask if still alive? Mother:

Father:

3. Illness of the parents Mother:

Father:

4. Grandparents (Both sides, Age, If living pa o di na, Motherside

Illness) Lolo:
Lola:

Fatherside
Lolo:
Lola:

5. Aunts and Uncles (Both sides, Age, If living pa o di na, Motherside

Illness)

Fatherside

7. Children’s age and illnesses or handicaps and

longevity

8. Does your family have genetic diseases or disorder?

DO NOT FORGET TO OBTAIN VITAL SIGNS (Take note of time and unit of measurement)
 On the start of duty
 As ordered
 Before duty ends

GORDON’S
Health perception – health management
 What are the common health issues he encounters?
 What are the steps he does to cure it?
 What sickness does he think he has?
 Perception about his current health
 From 1-10 how healthy does he perceive himself?
 How does he manage his health?
 What are his measures to be healthy?
 For him, what is health and its importance?

Nutritional – metabolic
 Food intake (gaano kadalas kumain)
 Anong prefer nya na food?
 What type of food does he usually eat?
 24 hr recall: mga kinain niya today (include snacks and
drinks)
 What is his diet? Does he follow a specific diet plan?
 Anong mga iniiwasan nyang food?
 Typical daily fluid intake? (describe.) What type and
how much?
 Who buys and prepares (where) the food?
 Where does he eat his meals?
 Do you eat out at restaurants or order fast foods
frequently?
 Does he eat only when hungry? Does he eat because of
boredom, habit, anxiety or depression?
 Weight loss or gain? (amount) height loss or gain?
(amount)
 appetite?

Elimination
 Gaano kadalas mag poop?
 Color of the poop
 Consistency? Watery ba? Or matigas?
 Gaano siya katagal sa banyo?
 Anong oras siya madalas tumatae?
 Nahihirapan ba siya?
 May tinetake ba siyang gamot para makatae?
 Gaano kadalas umihi?
 Color and amount
 Masakit ba pag ihi nya?
 Food or eating: discomfort? Swallowing? Diet
restrictions?
 Past and current weight, height.

Activity-exercise
 What is his daily pattern of activity?
 Does your child go to school? If yes, tell me about his
experiences in school. If not, what does he usually do at
home?
 Does he exercise po? Exercise pattern? Type?
Regularity?
 Spare-time (leisure) activities?
 Child: play activities?
 Sufficient energy for desired or required activities?
 Does he play any sports?
 Is he able to read and write?
 Does your child use a tablet or phone? May schedule ba
ang paggamit niya?
 How many times maligo? Magshower? Magbrush?

Sleep-rest
DO NOT FORGET TO OBTAIN VITAL SIGNS (Take note of time and unit of measurement)
 On the start of duty
 As ordered
 Before duty ends
 Tell me about your sleeping pattern
 What time does he usually sleep?
 What time does he usually wakes up?
 What does he usually do before he sleeps?
 Does he experience difficulty sleeping at night? If yes,
what does he usually do to get some sleep?
 Does he wake up in hos sleep? If yes, ilang beses?
nakakatulog ba ulit siya?
 Does he feel rested and ready for daily activities after
sleep?
 Where does he sleep? (describe the environment)
 Does he sleep alone or with someone?
 Does he take naps during the day? How often and for
how long?
 Does he sleepwalk? Sleeptalk? Enuresis?
 Dreams (nightmares)? Early awakening?
 Rest-relaxation periods

6. Cognitive-perceptual
 Hearing difficulty? Hearing aid?
 Vision? Wear glasses? Last checked? When last
changed?
 Any change in memory lately?
 Important decision easy or difficult to make?
 Easiest way for you to learn things? Any difficulty?
 Any discomfort? Pain? When appropriate: how do you
manage it?

7. Self-perception or self-concept
 How describe self? Most of the time, feel good (not so
good) about self?
 What do you see as your talent or special abilities?
 How do you feel about yourself? About your
appearance?
 Changes in way you feel about self or body (since ill-
ness started)?
 Changes in body or things you can’t do? Problem to
you?
 Can you tell me what activities you to do keep him safe,
healthy?
 How do you keep your home safe?
 How often do you have medical check-ups or
screenings?
 Things frequently make you angry? Annoyed? Fearful?
Anxious?
 Are there times wherein he is not able to control things?
What helps?

Role-relationship
 Do you both live alone? Ilan yung anak?
 How is his relationship with the father? His mother? His
siblings? The other family members? Family structure
(diagram)?
 For him, who is the most important person in his life?
Describe his relationship with that person?
 Any family problems you have difficulty handling (nu-
clear or extended)?
 Who helps you in managing his condition at home?
 How does your family feel about his condition ?
 Things generally go well at home? (school?)
 Does he have friends in the neighborhood or in school?
DO NOT FORGET TO OBTAIN VITAL SIGNS (Take note of time and unit of measurement)
 On the start of duty
 As ordered
 Before duty ends
 Does he feel part of (or isolated in) the neighborhood
where living?
 When appropriate: income sufficient for needs?
 Who is the main provider of financial support in the
family?
 Does your current income meet your needs?

Sexuality-reproductive
 How does he determine a boy from a girl?
 Curious po ba siya kung paano po siya ginawa? How do
you answer?
 Curious po ba siya kung saan siya nanggaling? How do
you answer?
 Curious po ba siya kung paano siya iniluwal sa mundo?
How do you answer?
 Is your child curious about his private part? How do you
discuss it with him?
 Do you teach or dicsuss with your child about puberty?
Or sex?

Coping-stress tolerance
 What is the biggest stressor in his life? Aside from his
condition, what else?
 Who is the person he runs/go to whenever he feels
stressed/sad/upset?

. Value-belief
 What is their religion?
 What is their culture?
 What are their health beliefs and values?
 Does their religion and culture affect his condition?
 How does he perform his role in their church?
 Is his relationship with their higher being important to
his?
 Does he pray? How, what, when?
 Does your religion help when problems arise?
 What is the most important in his life?
 What gives him strength and hope?
A. Head-to-toe Physical Assessment
Integumentary
AREA ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL FINDING INTERPRETATION
Natural hair color, as opposed to chemically colored
Hair Color Inspection hair, varies among clients from pale blond to black
grey or white

Cleanliness, Dryness, Scalp is clean and dry, Sparse dandruff may be

Scalp Inspection
Parasites, Lesions visible; Hair is smooth and firm, somewhat elastic

Nails Grooming & cleanliness Inspection Nails are clean

Color & Marking Inspection Pink tones should be seen

There is normally a 160-degree angle between the

Shape Inspection
nail base and the skin.
Nails are smooth and firm; nail plate should be
Texture & consistency Palpation
firmly attached to nail bed.
Pink tone returns immediately to blanched nail beds
Capillary Refill Palpation
when pressure is released
Eyeballs are aligned in sockets with no protrusion or
Eyes Eyeballs Inspection
sunken;
Inspection/
Lacrimal Sac and Gland No edema or increase tearing
Palpation
Pupil Inspection Pupils appear round, regular and both equal in size
Able to see the pen when moved into the client’s field
Peripheral Visual Field Inspection
of vision
Evenly colored skin tone without unusual
Inspection/
Skin Skin surface discoloration seen; Smooth with no presence of
palpation
lesion, the skin is warm, and it immediately recoil

Head and Neck

AREA ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL FINDING INTERPRETATION
Head Involuntary movement Inspection Head should be held still and upright
Consistency Palpation Head is normally hard and smooth without lesions
Symmetry, movement, The face is symmetric with round, oval, elongated, or
Inspection
expression square appearance; No abnormal movements noted
Normally there is no swelling, tenderness, or
crepitation with movement; Mouth opens and closes
Temporomandibular joint Palpation
fully; Lower jaw moves laterally 1-2cm in each
direction
 Neck is symmetric, with head centered and without
Neck Neck muscle Inspection
abnormal swelling and bulging masses.
There is no enlargement of lymph nodes; There are no
Lymph nodes Palpation
visible sign of swelling
Trachea Palpation There is no deviation
Thyroid Gland Palpation No enlargement and located in the midline
Carotid Artery Palpation Smooth and equal bilaterally

Ears and Mouth

AREA ASSEESED TECHNIQUE NORMAL FINDING ACTUAL FINDING INTERPRETATION
Ears Size Inspection Ears are equal in size bilaterally 4-10cm
Position Inspection The auricle aligns with the corner of each
eye and within a 10-degree angle of the
vertical position
Tenderness Palpation The auricle, tragus, and mastoid process
are not tender
Mouth Color Inspection Pink lips are normal in light-skinned
clients
Moisture Inspection Lips are smooth and moist without lesions
or swelling
Texture Inspection/Palpation Tongue should be pink, and moist
Nodules Palpation No lesions, or nodules are apparent
Nose Shape Inspection Smooth and symmetric
Color Inspection Color is the same as the rest of the face
Tenderness Palpation No tenderness
Patency of air Inspection Client is able to sniff through each nostril
while other is occluded
Internal nose Inspection The nasal mucosa is dark pink, moist, and
free of exudate; The nasal septum is intact
and free of ulcers or perforations
Sinuses Tenderness Palpation and Percussion No tenderness
Crepitus Palpation No crepitus

Thorax and Lungs

Posterior Thorax
Shoulder and Symmetry Inspection Scapulae are symmetric; Shoulder and scapulae
Scapulae are at equal horizontal positions
Use of accessory Inspection The client does not use accessory muscle to assist
muscles breathing
Posture and Inspection Client should sit up and relaxed, breathing easily
 ability to support with arms on sides
weight
Tenderness and Palpation No tenderness, pain or unusual sensation
sensation
Crepitus Palpation No palpable crepitus
Surface Palpation Skin and subcutaneous tissue are free of lesions
Characteristics and masses
Fremitus Palpation Fremitus is symmetric and easily identified in the
upper regions of the lungs
Chest Expansion Palpation Client takes a deep breath. The examiners thumbs
should move 5-10cm apart symmetrically
Tone Percussion Resonance is the percussion tone elicited over
normal lung tissue
Diaphragmatic Percussion Excursion should be equal bilaterally and
excursion measure 3-5cm
Breath sounds Auscultatio Normal sounds are Bronchial, Broncho vesicular
n and vesicular
Adventitious Auscultatio No adventitious sound such as crackle or wheezes
Sounds n are auscultated
Voice Sounds Auscultatio Voice transmission is soft, muffled and indistinct;
n Voice may be heard but the actual phrase cannot
Bronchophony be distinguishable

Gophony Voice transmission will be is soft and muffled but

the letter ‘E’ should be distinguishable

Whispered Transmission of sound is a very faint and muffled;

Pectoriloquy It may be inaudible
Anterior Thorax Shape and Inspection The anteroposterior diameter is less than the
Configuration transverse diameter; The ratio of anteroposterior
diameter to the transverse diameter is 1:2
Position of the
Inspection Sternum is positioned at midline and straight
sternum
Respirations are relaxed, effortless, and quiet;
Quality and They are of a regular rhythm and normal depth at
Inspection
pattern a rate of 10-20 per minute in adults; Tachypnea
and bradypnea may be normal in some clients
No retraction or bulging of intercostal spaces are
Intercostal spaces Inspection
noted
Use of accessory Inspection Use of accessory muscles is not seen with normal
 respiratory effort; after strenuous exercise or
activity, clients with normal respiratory status
may use neck muscles for a short time to enhance
breathing
Tenderness,
No tenderness or pain is palpated over the lung
sensation and Palpation
area with respirations
surface masses
Tenderness at
costo-chondral Palpation Palpation does not elicit tenderness
junction of ribs
Crepitus Palpation No crepitus is palpated
Surfaces masses
Palpation No unusual surface masses or lesions palpated
and lesion.
Fremitus is symmetric and easily identified in the
upper regions of the lungs; a decrease intensity of
Fremitus Palpation
fremitus is expected toward the base of the lungs
however, fremitus should be symmetric bilaterally
Anterior chest Thumbs move outward in a symmetric fashion
Palpation
expansion from the midline
Percussion elicit dullness over breast tissue, the
heart and the liver; tympany is detected over the
Tone Percussion
stomach, and flatness is detected over the muscles
and bones
Breast and Lymphatic System
AREA ASSEESED TECHNIQUE NORMAL FINDING ACTUAL FINDING INTERPRETATION
Breast and
Size Inspection Breast can be a variety of sizes
Lymphatic System
Color Inspection Color varies depend on the client’s skin tone
Texture
Palpation Texture is smooth, with no edema

Tenderness Inspection/
No tenderness
Palpation
Masses Palpation No masses should be palpated
Palpation
Lymph nodes No nodules and lumps

For Male Patient Swelling Inspection

Nodules Inspection No swelling, nodules, ulceration
Ulceration Inspection
Breast Tissue Palpate Texture smooth, with no edema; No masses,
tenderness, nodules and lumps
 Axillae Palpate

Heart and Neck Vessel

AREA ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL FINDING INTERPRETATION
The radial and apical pulse rate are identical
Irregular rhythm and Palpation and The radial and apical pulse rates should be
Heart RADIAL PULSE:
pulse rate deficit auscultation identical
APICAL PULSE:
Neck vessels The jugular venous pulse is not normally
Jugular venous pulse. Inspection
visible with the client sitting upright
The jugular vein should not be distended,
Jugular venous
Inspection bulging, or protruding at 45 degrees or
pressure
greater
No blowing, swishing or other sounds are
Carotid artery Auscultate
heard
Carotid arteries Palpation Pulse are equally strong and normal
Pulsation on anterior
Inspection The apical pulse may or may not be visible
chest over heart
The apical impulse is palpated at mitral
Apical impulse Palpation
area

Rate should be 60-100 beats per min with

HR and rhythm Auscultate Rate was __ beats per min with regular rhythm
regular rhythm

Abdomen
AREA ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL FINDING INTERPRETATION
Abdominal skin may be paler than the general skin tone
Abdomen Coloration of the skin Inspection because this skin is so seldom exposed to the natural
elements
Scattered fine veins may be visible, Blood in the veins
Vascularity of the located above the umbilicus flows toward the head; blood
Inspection
abdominal skin in the veins located below the umbilicus flows toward the
lower body
New striae are pink or bluish in color; old striae are
Striae Inspection silvery, white, linear and uneven stretch marks from past
pregnancies or weight gain.
Scars Inspection Pale, smooth, minimally raised old scars may be seen
Abdomen is free of lesions or rashes, Flat or raised brown
Lesions and rashes Inspection
moles, however, are normal and may be apparent
 Umbilical skin tones are similar to surrounding abdominal
Umbilicus Inspection
skin tones or even pinkish
Umbilical location Inspection Umbilicus is midline at lateral line
Abdominal contour Inspection Abdomen is flat, rounded, or scaphoid
Symmetry Inspection Abdomen is symmetric
Abdominal movement Inspection Abdominal respiratory movement may be seen
Normally, peristaltic waves are not seen, although they
Peristaltic waves Inspection may be visible in very thin people as slight ripples on the
abdominal wall
A series of intermittent, soft clicks and gurgles are heard
at a rate of 5–30 per minute, Hyperactive bowel sounds
Bowel sounds Auscultation referred to as "borborygmus" may also be heard; These
are the loud, prolonged gurgles characteristic of one's
"stomach growling"
Bruits are not normally heard over abdominal aorta or
renal, iliac, or femoral arteries; However, bruits confined
Vascular sounds Auscultation
to systole may be normal in some clients depending on
other differentiating factors
Friction rub over the
Auscultation No friction rub over liver or spleen is present
liver and spleen
Generalized tympany predominates over the abdomen
because of air in the stomach and intestines. Dullness is
Tone Percussion
heard over the liver and spleen; Dullness may be elicited
over a non-evacuated descending colon
The lower border of liver dullness is located at the costal
Span and height of the margin to 1-2 cm below; The upper border of liver
Percussion
liver dullness is located between the left fifth and seventh
intercostal spaces
The spleen is an oval area of dullness approximately 7 cm
Spleen Percussion wide near the left tenth rib and slightly posterior to the
MAL
Blunt
Liver and kidney Normally, no tenderness is elicited
percussion
Abdomen Light palpation Abdomen is non-tender and soft, there is no guarding
Normal (mild) tenderness is possible over the xiphoid,
All quadrants Deep palpation aorta, cecum, sigmoid colon, and ovaries with deep
palpation
Masses Palpation No palpable masses are present
Umbilicus and Umbilicus and surrounding area are free of swelling,
Palpation
surrounding areas bulges, or masses
 Liver Palpation The liver is usually not palpable, although it may be felt in
some thin clients. If the lower edge is felt, it should be
firm, smooth, and even; Mild tenderness may be normal
The spleen is seldom palpable at the left costal margin;
Rarely, the tip is palpable in the presence of a low, flat
diaphragm (e.g., chronic obstructive lung disease) or with
Spleen Palpation
deep diaphragmatic descent on inspiration; If the edge of
the spleen can be palpated, it should be soft and non-
tender
The kidneys are usually not palpable, Sometimes the lower
pole of the right kidney may be palpable by the capture
Kidney Palpation method because of its lower position; If palpated, it should
feel firm, smooth, and rounded, the kidney may or may
not be slightly tender
Urinary bladder Palpation An empty bladder is neither palpable nor tender
Abdomen Fluid wave test No fluid is transmitted
Rebound
No rebound tenderness is present
tenderness
Psoas sign No abdominal pain is present
Obturator No abdominal pain is present

MUSCULOSKELETAL SYSTEM
INTERPRETATIO
AREA ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL FINDING
N

Posture Standing Inspection Posture is erect and comfortable for age

Sitting Inspection Posture is erect and comfortable for age

-Base of support
-Weight-bearing stability
Evenly distributed weight. Client able to stand on heels
-Foot position
and toes, Toes point straight ahead, Equal on both sides,
Gait -Stride and length and Inspection
Posture erect, movements coordinated and rhythmic,
cadence of stride
arms swing in opposition, stride length appropriate
-Arm swing
-Posture
Risk of falling backward Inspection Client does not fall backward
Temporomandibul Snapping and clicking may be felt and heard in the
Muscle strength Inspection and Palpation
ar joint normal client
Range Palpation Mouth opens 1-2 inches (distance between upper and
of Motion lower teeth), The client’s mouth opens and closes
 smoothly, Jaw moves laterally 1-2 cm, Jaw protrudes and
retracts easily, no pain or spasms felt when moved against
resistance
Cervical, thoracic, Curvature Inspection Cervical and lumbar spines are concave; thoracic spine is
and lumbar curves convex. Spine is straight (when observed from behind)
from the side and
behind

Flexion of the cervical spine is 45 degrees, Extension of

Range of Motion of
Flexion and extension Inspection and palpation the cervical spine is 45 degrees, no pain when applied
Cervical Spine
with resistance
The client can bend 40 degrees to the left side and 40
Lateral bending Inspection and palpation degrees to the right side, no pain when applied with
resistance
Rotation Inspection and palpation About 70 degrees of rotation
Range of motion of Flexion of 75–90 degrees, smooth movement, lumbar
lumbar and Flexion Inspection concavity flattens out, and the spinal processes are in
thoracic spine alignment,
Clavicle, Shoulders are symmetrically round; no redness, swelling,
Shoulders and acromioclavicular joint, or deformity or heat, Muscles are fully developed,
Inspection and palpation
arms subacromial area, and Clavicles and scapulae are even and symmetric, the client
the biceps. reports no tenderness
-Extent of forward flexion should be 180 degrees;
hyperextension, 50 degrees; adduction, 50 degrees; and
abduction 180 degrees
Range of motion Inspection - Extent of external and internal rotation should be about
90 degrees, respectively
-The client can flex, extend, adduct, abduct, rotate, and
shrug shoulders against resistance
Elbows are symmetric, without deformities, redness, or
Elbow Inspection
swelling
Olecranon process and
Palpation Nontender; without nodules
epicondyles.
Normal ranges of motion are 160 degrees of flexion, 180
degrees of extension, 90 degrees of pronation, and 90
Range of motion Inspection
degrees of supination, some clients may lack 5–10 degrees
or have hyperextension
Size, shape, symmetry,
Wrists Inspection Wrists are symmetric, without redness, or swelling
color, and swelling
 Tenderness and nodules Inspection and Palpation
Anatomic snuffbox
Range of Motion Inspection and Palpation
Phalen’s Test
Size, shape, symmetry,
Hands and fingers Inspection and Palpation
swelling, and color.
Range of motion
Size, shape, symmetry,
Knees swelling, deformities,
and alignment
Position, alignment,
Ankles and foot
shape, and skin.
Tenderness, heat,
Inspection and Palpation
swelling, or nodules
Range of Motion
Wrists are nontender and free of nodules
Palpation No tenderness palpated in anatomic snuffbox
The client bends the wrist down and back (flexion and
extension) even with resistance
Inspection No tingling, numbness, or pain result from Phalen’s test
Hands and fingers are symmetric, nontender, and without
nodules, Fingers lie in straight line, no swelling or
deformities, Rounded protuberance noted next to the
thumb over the thenar prominence; Smaller
protuberance seen adjacent to the small finger
Normal ranges are 20 degrees of abduction, full
adduction of fingers (touching), 90 degrees of flexion, and
30 degrees of hyperextension, the thumb should easily
Inspection
move away from other fingers and 50 degrees of thumb
flexion is normal, there is also no report of pain when
resistance is applied
Knees symmetric, hollows present on both sides of the
Inspection patella, no swelling or deformities, Lower leg in
alignment with the upper leg
Toes usually point forward and lie flat, Toes and feet are
in alignment with the lower leg, Smooth, rounded medial
malleolar prominences with prominent heels and
Inspection
metatarsophalangeal joints, Skin is smooth and free of
corns and calluses, Longitudinal arch; most of the weight
bearing is on the foot midline
No pain, heat, swelling, or nodules are noted.
Normal ranges:
• 20 degrees dorsiflexion of ankle and foot and 45 degrees
plantarflexion of ankle and foot
Inspection • 20 degrees of eversion and 30 degrees of inversion
• 10 degrees of abduction and 20 degrees of adduction
• 40 degrees of flexion and 40 degrees of extension
Client has full ROM against resistance

Neurological System
The client responds immediately when being
Level of consciousness Inspection
called
Posture and body Inspection The client posture is normal and there is no
movement extra body movement
Grooming, dress and The client wears appropriately and looks
Inspection
hygiene hygienic
The client maintains eyes contact and shows
Facial expression Inspection
appropriate facial expression

Tone, clarity and

Speech Inspection The client speaks clearly and audibly
pace of speech

Moods, Feelings and The client expresses the appropriate emotion for
Inspection
Expressions each situation
The client expresses clear understanding with
Thought, Process and Clarity, Content and
Inspection regards to her health and doesn’t have any
Perception Perception
negative thoughts

Recent Memory Inspection The client is able to recall previous memories

Remote Memory Inspection The client is able to recall past memories

The client is able to compare two objects and

Abstract Reasoning Inspection differentiate them
The client is able to explain a proverb
The client is able to express judgement in a
Judgement Inspection
particular situation
Condition and The client’s muscles is equal in size and
Size and Symmetry Inspection
Movement of Muscles symmetry
The client’s muscles is strong and right for her
Strength Inspection
age
Balance Tandem Walking Inspection The client walks in a heel to toe fashion
The client stands erect with arms and feet
Romberg Test Inspection
together
Coordination Finger to Nose Test Inspection The client performs the test smoothly
The client correctly determines where her finger
Sensitivity to position Inspection
is pointed
The client correctly identifies the object being
Stereognosis Inspection
handed to her while her eyes are closed
The client correctly identifies the number being
Graphesthesia Inspection
drawn on her palm while her eyes are closed