Initial Vital Signs Temperature: Heart Rate: Respiratory Rate: Blood Pressure:
Appearance and Mental Status
Body Part Body built, height, and weight Posture, Gait, Standing, Sitting, Walking Techniques Used Inspection Inspection Actual Findings Interpretation
Unable to walk, stand and sit.
There¶s no indication of being tensed and slouched. No presence of trauma.
Hygiene and Grooming, body and breath odor
Clean, Neat, No body odor, no breath odor
The patient can still maintain proper hygiene by the help of significant others. Good Hygiene promotes comfort.
Attitude, mood, speech and thoughts
Cooperative; mood is appropriate to situation; speech is understandable, demonstrates normal thought association and logical sequence.
The patient has a good level of consciousness; she can be able to speak and response to questions.
Body Part Skin Color, Uniformity Techniques Used Inspection Actual Findings Brown and no discolorations Interpretation There are no discolorations that may indicate hyper or hypo pigmentation, pallor, cyanosis, jaundice or erythema.
Edema, Skin Lesion Moisture
No edema, some nevis can be
There¶s no sign of
observed, no abrasions or lesions; Dry and flaky skin; (+) Pallor
excess fluid accumulation in the body. Dry skin indicates dehydration and fluid deficiency. Pallor skin indicates inadequate circulation of blood or hemoglobin and subsequent reduction in tissue oxygenation.
Skin Turgor and Temperature
(+) poor skin turgor; normal temperature
Poor skin turgor may indicates poor circulation of blood, dehydration as well extreme weight loss. It may be due to the patient¶s age that the elasticity of the skin is not normal and has inability to return to its place promptly Normally, geriatric patients has wrinkled and sagging skin. No signs of Hyperthermia or hypothermia.
Body Part Scalp Techniques Used Inspection Actual Findings Well distributed throughout the scalp Interpretation There¶s no indication of flakes.
Hair thickness or thinness, texture, color and oiliness
Thin hair; grayish in color
There are no signs of dryness and alopecia. In geriatric patients, The hair thins a little, starts to loose pigment and turns gray.
Variable and evenly distributed
No indications of Hirsutism.
Body Part Fingernail shape, texture, and color Techniques Used Inspection Actual Findings Convex curvature; smooth texture; dirty nails; pale Interpretation Normal in shape and texture; dirty nails suggest poor selfcare; paleness of the nails is one of teh effects of anemia
Capillary Refill, Tissues near nails
Intact skin, prompt return of usual color
Prompt return and intact skin near the nails indicate an adequate circulation. No signs of cyanosis.
Skull and Face
Body Part Skull size, shape, and symmetry; nodules, masses Techniques Used Inspection Palpation Actual Findings Rounded, smooth, no masses or lumps Interpretation There are no indications of excessive growth hormone or increase in bone thickness, trauma, sebaceous cysts, and local deformities.
Facial Fractures and Movements
Symmetric, no involuntary facial movements
The client¶s face has no abnormalities; there are no signs of exopthalmus, myxedema, periorbital edema, sunken eyes. There are no involuntary facial movements that may indicate tremors.
Eye Structure and Visual Acuity
Body Part Eyebrows Techniques Used Inspection Actual Findings Intact skin, no hairloss, hair are evenly distributed, symmetric Interpretation There are no indications of scaling, loss of hair or flakiness; the
eyebrows are equal in movement; symmetric eyebrow shows no problem in the neural functions. Eyelashes and Eyelids Inspection Palpation Lids close symmetrically, no masses or lumps, no discharge or discoloration
No signs of swelling or redness that may indicate infections. Lids close bilaterally; negative discharge indicates absence of infection
Palpebral Conjunctiva and Bulbar Conjunctive
Pallor conjuntiva Pale conjuntiva indicate inadequate circulation of blood or decreased hemoglobin and subsequent reduction in tissue oxygenation. It also indicates anemia.
Pupils: color, shape, symmetry, size, reaction and accomodation
Pupils are black, symmetric, round; Pupils illuminated; Constricted when lighted and dilated when light passed
No signs of cloudiness, miosis or aniscoria. There a no abnormal reactions; pupils are able to function well; indicates proper functioning of the cranial nerves III
Occular Movements and vision
Coordinated, can¶t read without eyeglasses
Indicates that there are no nueral impairment particularly caranial nerves II, IV and VI; wearing eyeglasses is normal to geriatric patient has visual changes like decreased accomodation for near vision or presbyopia.
Lacrimal Glands, Lacrimal Sac, Nasolacrimal Duct
No edema, tenderness and discharge
No indications of infection and inflammation. Elderly¶s lacrimal glands involute, causing decreased tear production.
Ears and Hearing
Body Part Texture, elasticity, color, size, position, tenderness Techniques Used Inspection Palpation Actual Findings Color is the same with the face, symmetrical, properly aligned, firm, no tenderness, recoils when folded Dry cerumen, no discharge Interpretation No swelling of the ear canal, No signs of pain when moving the ears.
External Ear Canal
No indication of infections or inflammation. No redness and swelling that indicates otitis externa.
Able to hear the tick in watch, sound is heard in both ears
The client is able to hear well, no signs of hearing problem.
Nose and Sinuses
Body Part Shape, size, color, discharge, tenderness Techniques Used Inspection Palpation Actual Findings Symmetric, no discharge, uniform color, no tenderness Interpretation No damage; No unnecessary discharges
(+) thick secretions; presence of oxygen
There is obstruction that could affect respiration and gas exchange (presence of secretions); patient has experiencing difficulty of breating
when there¶s presence of secretions. There is an alteration in her breathing pattern. Bone and Cartilage Inspection Palpation No displacement of bone and cartilage,no tenderness or masses
No manifestation of septal defect, trauma, may also indicate the absence of inflammation or tumor
Frontal and Maxillary Sinuses
No tenderness No manifestations of drainage that means infections
Mouth and Oropharynx
Body Part Lips: color, shape, texture, moisture Techniques Used Inspection Actual Findings Pallor, Dry and cracked texture; symmetric, no thrush Interpretation Indicates dehydration and fluid volume deficit. May also indicates poor blood circulation. Pallor lips indicates inadequate blood hemoglobin level and sudsequent reduction in tissue oxygenation.
Teeth and Gums
No presence of teeth; pale gums
Some tooth loss may occur owing to bone resorption ( Osteoporosis), which decreases the inner tooth structure and its outer support.
Pink, moves freely, no pain, no lesions, centered
Indicates that cranial nerve XII is functional, no signs of ulceration.
Centered No manifestationof
nerve damage (vagus nerve or X) or presence of tumors or trauma that culod deviate the uvula to one side Tonsils Inspection No discharge, not enlarged
There are no infections or inflammation
Body Part Neck Muscles Techniques Used Inspection Palpation Actual Findings Equal in size, centered and coordinated movements, equal strength, wide range of movements,no masses or lumps Not felt or palpable Interpretation No indications of muscle weakness or shortening of sternocleidomastoid
No signs of infections or tumors which would indicates absence of autoimmune disorder or metastatic disease Thyroid Gland Inspection Palpation Not visible and palpable
No indications of hyperthyroidism, hypothyridism or Endemic goiter.
Lungs and Thorax
Body Part Thorax: Alignment, shape, symmetry Techniques Palpation Actual Findings Symmetric, properly aligned, skin intact, no tenderness or masses, full chest expansion Interpretation No sings of kyphosis or lordosis, inflammed plura
(+) crackles upon auscultation
Crackles are short explosive breath sounds, usually associated with pulmonary disorders. This sounds produce when there is air passing through fluids or mucus in any air passage. (+) crackles indicates presence of secretions.
Heart, Central and Peripheral Blood Vessels
Body Part Heart: Aortic, pulmonic, Tricuspid, apical Techniques Used Auscultation Actual Findings No pulsations, no lifts or heaves, no aortic pulsation Interpretation Abnormalities are not present, no indication of heart enlargement or overactivity
Symmetric, full pulsations
Full pulsations would mean no possible stenosis or thrombosis, impaired cardiac output or arteriosclerosis
Vein not visible The absence of distention could mean that the patient is absent of CHF, liver failure that could impede the circulation to resulting to hypervolemia
Symmetric, Full pulsations
There¶s no sign of peripheral vein distention.
Body Part Liver Techniques Used Palpation Actual Findings Symmetric contour Interpretation Liver is not enlarged or inflamed Bladder Palpation Not palpable Ultrasound: Smooth, contour; wall is not thickened Can indicate the absence of urinary retention; there¶s no prensence of bladder distention
Extremities and Musculoskeletal Body Part Techniques Extremities (Color) Inspection
Actual Findings same grade of extremities; equal in size
Interpretation There¶s no indications of trauma.
Muscle: size, strength, tone, contractures, tremors
No contractures, equal in size, no tremors, firm and coordinated, less strength
No signs of muscle hypertrophy, malpositioning, flaccidity or spasicity; poor or less strength is due to her current condition, she is weak and powerless.
Bones: Structure, deformities, tenderness
Presence of osteoporosis
With aging, loss of bone matrix (resorption) occurs more rapidly than new bone growth (deposition), the net effect is a loss of bone density (osteoporosis).
Joint: Tenderness, swelling, movement
No swelling, wide range of motion, fluid movements
It would indicate that there are no swollen joints; patient has no rheumatoid arthritis.