Physical Assessment (General Assessment)

Green- Mild signs

Red- Severe signs

Normal Findings Actual Findings Analysis

Initial Final
Assessment Assessment

(March 22, (March 24,

2023) 2023)

1. Posture Gait Upright posture, Unrelaxed due Comfortable, has Dilation and
relaxed, and to abdominal an upright posture Curettage
coordinated pain. Unable to and a steady pace,
movement. walk and and walks unaided ↓
transfer aided. while keeping
balance. Post surgical
procedure

Impaired
Physical
Mobility

2. Personal No body odor or Unsuitable Wears neat, Impaired

Hygiene bad breath; clean physical clean clothing Physical
and orderly. appearance, and has no Mobility
Women should with a mild bodily or breath
regularly wash body and breath odor. Take a ↓
their bodies, odor. bath once a day.
especially their Unable to
genitals, with perform
clean water. personal hygiene

↓
 Self-Care Deficit

1. Verbal Understandable, Make sense of Understandable, NORMAL

Behavior moderate pace; reality with an has a moderate
clear tone and understandable, pace, a clear
intonation; moderate speed, tone with a
logical sequence; clear tone, and logical
makes sense; has logical order. sequence, makes
a sense of sense, and has a
reality. sense of reality.

Vital Signs

Sympathetic
1. PR Nervous System
60-100 bpm 108 bpm 89 bpm
↓

Stimulate
electrical pain
signal

Reach CNS

Elevated Pulse
Rate

2. RR 12-20 cpm 22 cpm 20 cpm Sympathetic

Nervous System

Stimulate
electrical pain
signal

↓
 Reach CNS

Altered
breathing
pattern

Decreased
3. BP 120/80 mmHg 160/110 mmHg 140/80 mmHg cardiac output
related to
vasoconstriction
secondary to
type 2
hypertension as
evidenced by
increased blood
pressure of
160/110.

d. Temperature 36.5-37 C 36.6 C 36.8 C NORMAL

e. Pain 0/10 8/10 5/10 Severe Pain –

Disabling;
(Using the unable to
Numeric Pain perform daily
Rating Scale) living activities.

Body Built

a. Height 157.48 cm 157.48 cm

 b. Weight 77 kg 77 kg

Unhealthy diet

c. BMI 18.5-24.9 31 kg/m2 ↓

Increased body
mass

Obesity

Imbalanced
nutrition: More
than body
requirements r/t
consumption of
high calorie diet

B. Integumentary System

Body Parts Technique Normal Initial Final Analysis

Used Findings Assessment Assessment Diagnosis

Skin
Skin Inspection and Contraption Contraption Submucosal
Palpation s: IV line s: IV line myoma
located at located at
her right her right ↓
hand hand
(cephalic (cephalic Pregnancy
vein) hook to vein) hook to
D5LR D5LR ↓

Inability to
fertile

Anembryoni
c pregnancy

Bleeding

Hospital
admission

NORMAL
Skin Inspection Varieties The skin has The skin has
include a deep a deep
Color light to brown brown
deep complexion, complexion,
brown, an uneven an uneven
reddish skin tone, skin tone,
pink to and obvious and obvious
light pink, scars, and scars, and
and yellow stretchmarks stretchmarks,
overtones , particularly particularly
to olive. in the in the
underarm underarm
and knee. and knee.
Uniformity Inspection Generally, Uniform Uniform skin NORMAL
of Skin uniform skin color color except
Color except in except in in those
areas those areas areas
exposed to exposed to exposed to
the sun. the sun. the sun.

Edema Inspection and No edema No presence No presence NORMAL

Palpation of edema of edema

Skin Palpation Uniform Uniform Uniform NORMAL

temperatur within within within
e normal normal range normal range
range

(36.6) (36.8)

Skin Palpation (lifting When The skin The skin NORMAL

Turgor and pinching pinched, springs back springs back
skin on an skin returns rapidly after rapidly after
extremity) to its being being
original pinched. pinched.
state (is
elastic);
this process
may be
slower in
elderly
persons.
(Pinched
until 3
seconds
and
 released, it
goes back
within 1-2
seconds).

Hair Inspection and The entire Hair is Hair is Chemical

Palpation scalp was equally equally treatments
covered distributed distributed
and and covers and covers ↓
uniformly the entire the entire
distributed. scalp. There scalp. There Exposure to
There is no is no is no excessive
sign of indication of indication of heat and
alopecia. alopecia, alopecia, pollution
Maybe lumps, lumps,
smooth or lesions, lice, lesions, lice, ↓
gritty, or nits. The or nits. The
thick, or hair is brown hair is brown Irregular
thin, and dry. and dry. hair oiling
neither dry
nor brittle. ↓
No
infestations Dry hair
. Have
varying
amounts of
body hair.

Nails Inspection and Smooth The nail has The nail has NORMAL
Palpation and has an a convex a convex
intact curve and is curve and is
epidermis evenly cut, evenly cut,
with short smooth, and smooth, and
and clean intact with intact with
nails. In the the the
shape of a epidermis, a epidermis, a
convex lunula, and a lunula, and a
curve, there pink nail pink nail
is a plate. The plate. The
presence of fingernails fingernails
lunula, and are are
a pinkish uncolored, uncolored,
 nail plate. while the while the
When toenails are toenails are
pressed painted with painted with
between brown brown
the fingers cuticles. 2- cuticles. 2-
(Blanch second second
Test), nails capillary capillary
return to refill time. refill time.
their usual
color in
less than 3
seconds.

3. Cephalo-Caudal Assessment

Body Parts Techniqu Normal Actual Final Analysis / Nsg.

e Used Findings Findings Findings Diagnosis

Head (Skull Inspection Smooth The skull is The skull is NORMAL

and Face) and skull normocephali normocephali
Palpation contour; c and c and
rounded symmetrical, symmetrical,
(normocep with a smooth with a smooth
halic and skull contour skull contour
symmetric and no and no
, with nodules, nodules,
frontal, lumps, or lumps, or
parietal, depressions depressions
and when when
occipital palpated. palpated.
prominenc
es). There
is no
tenderness
 upon
palpation.

Facial Inspection Symmetric Facial Facial Hormonal

features or slightly characteristics characteristics changes
asymmetri are somewhat are somewhat
c facial asymmetric, asymmetric, ↓
features; with palpebral with palpebral
palpebral fissures equal fissures equal Pimples
fissures of in size, and in size, and
similar symmetric symmetric ↓
size; and nasolabial nasolabial
symmetric folds. folds. Pimple drying
nasolabial
folds. ↓

Moles on the Moles on the Pimple marks

lower cheeks lower cheeks
and the lower and the lower ↓
lip have many lip have many
pimples and pimples and NORMAL
marks. marks.

Absence of Absence of
masses or masses or
soreness. soreness.

Facial Inspection Symmetric No No NORMAL

movements al facial involuntary involuntary
movement muscle muscle
(CN 7 - s and no movements, movements,
Facial) involuntar symmetrical symmetrical
y muscle facial facial
movement movements, movements,
s. and can move and can move
 facial muscles facial muscles
at will (smile at will (smile
and show the and show the
teeth, frown, teeth, frown,
and puff the and puff the
cheeks, raise, cheeks, raise,
and lower and lower
both both
eyebrows, eyebrows,
blink, and blink, and
close eyes close eyes
tightly). tightly).

Eyes and
Vision

Inspection Hair Symmetrical Symmetrical Long time usage

External (ask client evenly eye eye of cell phone
Eye to raise distributed movement, movement, especially at
Structures and lower ; skin both eyes both eyes night
the intact on blink blink
(CN 5 – eyebrows) eyebrow properly, the properly, the ↓
Trigeminal) and eyebrows are eyebrows are
symmetric symmetrical symmetrical Radiation
ally aligned with aligned with
aligned; equal equal ↓
movement, movement,
equal the eyes are the eyes are Exposure of
movement parallel and parallel and retina called
, both eyes evenly placed evenly placed “macula” causes
blinked symmetrically symmetrically deterioration
properly. , and both , and both
eyes are eyes are ↓
brown and brown and
clear. Has clear. Has Blurry vision
blurry vision. blurry vision.

Eyebrows Inspection Hair is Hair is equally Hair is equally NORMAL

and evenly distributed, distributed,
Palpation distributed curled slightly curled slightly
, the skin outward, and outward, and
is intact, brows are brows are
symmetric black, black,
 al, and symmetrically symmetrically
proportion aligned, and aligned, and
ately moved moved
aligned equally. equally.
with each
other with
equal
movement
.

Eyelashes Inspection Skin is Equally Equally NORMAL

intact, and distributed distributed
hair is and curled and curled
properly slightly slightly
distributed outward, the outward, the
; there is skin is intact, skin is intact,
no the lids are the lids are
discolorati close close
on. Lids symmetrically symmetrically
close , have no , have no
symmetric discoloration, discoloration,
ally. and the and the
eyelashes are eyelashes are
black. black.

Eyelids Inspection Approxim The patient's The patient's NORMAL

ately 15 to eyelids are eyelids are
20 symmetrical symmetrical
involuntar and don't have and don't have
y blinks any pain or any pain or
per tenderness tenderness
minute; upon upon
bilateral inspection. No inspection. No
blinking. visible sclera visible sclera
When lids above the above the
open, corneas, corneas,
there is no approximately approximately
visible 15 to 20 15 to 20
sclera involuntary involuntary
above blinks per blinks per
corneas, minute; minute;
and upper bilateral bilateral
 and lower blinking when blinking when
borders of lids open, and lids open, and
cornea are the upper and the upper and
slightly lower borders lower borders
covered. of the cornea of the cornea
are slightly are slightly
covered. covered.

Bulbar Inspection Transpare Transparent, Transparent, NORMAL

conjunctiva nt; capillaries capillaries
capillaries sometimes sometimes
sometimes evident, sclera evident, sclera
evident; appears white. appears white.
sclera
appears
white
(darker or
yellowish
and with
small
brown
macules in
dark
Palpebral skinned
Conjunctiva Inspection clients). Pink Pink
Conjunctiva Conjunctiva

Appears
pink

Cornea Inspection Transpare The cornea is The cornea is NORMAL

nt, shiny, translucent, translucent,
and smooth, and smooth, and
smooth; clear. The iris clear. The iris
details of details are details are
the iris are visible. visible.
visible.
 Pupils Inspection Black in Pupils are Pupils are NORMAL
color; black, black,
equally symmetrical, symmetrical,
round and and equal in and equal in
symmetric size. Size 5 size. Size 5
al; mm in mm in
normally 3 diameter; the diameter; the
to 7 mm in iris is flat and iris is flat and
diameter; round; has round; has a
iris is flat smooth and smooth and
and round round border.
equally borders.
round.

CN 3 and Inspection Pupils Pupils Pupils NORMAL

CN4 constrict constrict to constrict to
(Oculomoto when direct direct
r and looking at illumination illumination
Trochlear) near and to and to
objects; illumination illumination
pupils of the of the
dilate opposite eye, opposite eye,
when pupils pupils
looking at constrict to constrict to
far illuminated illuminated
objects. and non- and non-
Pupils illuminated. illuminated.
converge Pupils Pupils
when a constrict when constrict when
near object looking at looking at
is moved near objects near objects
toward the and dilate at and dilate at
nose. far objects. far objects.
 To record Pupils Pupils
normal converge converge
assessmen when an when an
t of the object is object is
pupils, use moved moved
the towards the towards the
Inspection abbreviati nose. nose.
on
CN 2 PERRLA
(Pupils
(Optic) equally
round and
react to
light and
accommod Peripheral
ation) objects can be
seen at any Peripheral
angle, eye objects can be
motions are seen at any
When synchronized, angle, eye
looking and both eyes motions are
straight can follow a synchronized,
ahead, the penlight. and both eyes
client can can follow a
see objects penlight.
in the
periphery
and there
should be
no
nystagmus
.

CN 6 Inspection Both eyes Both eyes Both eyes NORMAL

Accommoda coordinate move move
tion d, moving symmetrically symmetrically
(Abducens) in unison, in six fields of in six fields of
with gaze; gaze;
parallel coordinated, coordinated,
 alignment and movement and movement
is symmetric is symmetric
with parallel with parallel
alignment. alignment.

Ears

Auricles Inspection Color The patient's The patient's NORMAL

and same as auricles are auricles are
Palpation facial skin symmetrical, symmetrical,
color, and color, and
Symmetric firmness firmness
al match those of match those of
her facial skin. her facial skin.
Auricles Pinna retracts Pinna retracts
aligned after being after being
with the folded. No folded. No
outer palpable palpable
canthus of tenderness tenderness
the eye. was felt. Has was felt.
When 1 piercing in
palpating both ears. Has 1 piercing
for the in both ears.
texture,
the
auricles
are
mobile,
firm, and
not tender.

External Inspection The canal There is some There is some NORMAL

Ear Canal is skin- earwax earwax
 colored visible, but no visible, but no
and redness or redness or
covered in tenderness. tenderness.
fine hairs. The client can The client can
There may hear the hear the
be whisper test. whisper test.
yellowish-
brown
earwax
present.
The
eardrum is
either light
gray or
pearly
white in
appearanc
e. The
light
should
reflect off
the surface
of the
eardrum.

Tympanic Inspection Pearly Semi- Semi- NORMAL

Membrane gray color, transparent transparent
semitransp and white in and white in
arent. color. color.
 Gross Inspection Normally, The patient The patient NORMAL
Hearing the client can hear on can hear on
Acuity Test can both sides. It both sides. It
identify can recognize can recognize
the sound sounds and sounds and
and the determine determine
side from what word what word
which it was heard. was heard.
was heard.

Was able to Was able to

Whisper repeat phrases repeat phrases
test ( to correctly in correctly in
assess Able to both ears both ears
high- repeat the during the during the
frequency phrases whisper test. whisper test.
hearing) correctly
in both
ears.

Nose

External Inspection Uniform Symmetrical, Symmetrical, NORMAL

Structure and in color, uniform in uniform in
Palpation symmetric color, has no color, has no
and flaring, flaring,
straight, masses, masses,
with no tenderness, tenderness,
discharge and discharge. and discharge.
or flaring.
Patency Inspection Air moves No difficulty No difficulty NORMAL
freely as breathing. breathing.
the client Both nares are Both nares are
breathes patent. patent.
through
the nares.

Nasal Inspection Mucosa is The patient’s The patient’s NORMAL

Cavities pink clear, nasal mucosa nasal mucosa
watery is pinkish to is pinkish to
discharge red in color red in color
and has no and has no and has no
lesions. discharge and discharge and
lesions. lesions.

Nasal Inspection Nasal The patient’s The patient’s NORMAL

Septum septum is septum is in septum is in
in the the midline the midline
midline position and position and
and intact; intact with no intact with no
no perforation. perforation.
perforatio
n.

Facial Palpation Not tender No tenderness No tenderness NORMAL

Sinuses upon palpated on palpated on
palpation. the frontal and the frontal and
maxillary maxillary
sinuses. sinuses.

Clients Can Can

 CN 1 Inspection can accurately accurately NORMAL
(Olfactory) identify distinguish the distinguish the
different smell of the smell of the
smells materials used materials used
with each (Alcohol and (Alcohol and
nostril Vinegar). Vinegar).
separately
and with
eyes
closed.

Mouth

Lips Inspection Symmetric Pink in color, Pink in color, NORMAL

and al in partially scaly, partially scaly,
Palpation appearanc and and
e, uniform symmetrical. symmetrical.
pink in No lesions No lesions
color, soft, and can purse and can purse
moist, lips. lips.
smooth in
texture,
has no
lesions
and able to
purse lips.

Teeth Inspection Teeth The patient’s The patient’s Poor oral

should be teeth are 28, teeth are 28 hygiene
clean, no yellowish in yellowish in
decay, color, uneven color, uneven ↓
white with edges, edges, have
no loose, dentures, and dentures, and Plaque
missing, dental decay. dental decay. accumulation
Dentures Inspection chipped or No halitosis. No halitosis. and build up
broken
teeth. ↓
Adults
should The patient Tooth decay and
have a has 4 dentures cavities
total tooth The patient in the upper
of 32. has 4 dentures portion of her ↓
 in the upper mouth. Inflammation of
No portion of her teeths
dentures mouth.
↓

Loss of teeths

Dentures

Gum Inspection Pinkish in Pinkish in Pinkish in NORMAL

color, color, color,
symmetric symmetrical, symmetrical,
al, moist moist and has moist and has
and has no no gum no gum
gum bleeding and bleeding and
bleeding receding receding
and gums. gums.
receding
gums.

Tongue Inspection Moist; There are no There are no NORMAL

slightly lesions, lesions,
rough; thin elevated elevated
whitish papillae, has papillae, has
coating the capacity to the capacity to
smooth; move the move the
no lesions; tongue freely tongue freely
no and firmly on and firmly on
tenderness different different
and has sides; the sides; the
raised tongue is tongue is
papillae smooth with a smooth with a
(taste thin white thin white
buds). covering and covering and
Able to is moist. is moist.
move the
tongue
freely and
with
 strength.

Palate Inspection The soft The soft The soft NORMAL

palate is palate is light palate is light
smooth, pink and pink and
and light smooth, while smooth, while
pink. Hard the hard palate the hard palate
palate is is light pink is light pink
lighter and has more and has more
pink and irregular irregular
has a more textures. textures.
irregular
texture.

Uvula Inspection Positioned The uvula is The uvula is NORMAL

in midline, in the middle, in the middle,
pinkish to and there are and there are
red in no swelling no swelling
color, no lesions. The lesions. The
swelling color ranges color ranges
or lesion from pink to from pink to
noted and red, and when red, and when
able to asked to say asked to say
upward "ah" it moves "ah" it moves
and up and up and
backwards backward. backward.
when
asked to
say “ah”.

Oropharynx Inspection Pink and Pink and no Pink and no NORMAL

smooth presence of presence of
posterior lesions. lesions.
wall.
 Tonsils Inspection Pink and Pink and Pink and NORMAL
smooth, smooth, no smooth, no
no discharge, not discharge, not
discharge, enlarged and enlarged and
normal normal (Grade normal (Grade
size or not 1). 1).
visible

• Grade 1
(normal):
The tonsils
are behind
the
tonsillar
pillars (the
soft
structures
supporting
the soft
palate).

Neck Inspection Muscles Neck is Muscles equal NORMAL

and equal in symmetric; in size; head
Palpation size; head head centered, centered, no
centered, no bulging bulging
no bulging masses or masses or
masses. lumps and no lumps and no
JVD (Jugular JVD (Jugular
Vein Vein
Distention). Distention).

Observe Inspection Coordinat The patient The patient NORMAL

head ed, smooth can move her can move her
movement movement head with ease head with ease
s with no and and
discomfort coordination. coordination.
.
Sternocleido Inspection Head flex Has the ability Has the ability NORMAL
mastoid 45° to flex head at to flex head at
muscle least 45° least 45°
without without
discomfort. discomfort.

Trapezius Inspection Head There is no There is no NORMAL

muscle and hyperexte tenderness tenderness
Palpation nds 60° upon upon
palpation, and palpation, and
the head the head
hyperextends hyperextends
60° 60°
 Muscle Inspection Equal The patient's The patient's Dilatation and
strength and strength muscles are muscles are Curettage
Palpation on each symmetrical symmetrical
side in size, there in size, there ↓
are no are no
involuntary involuntary Post procedural
movements. movements. cramping
Unequal Unequal
strength on strength on
each body each body
side. side. Activity
Intolerance
related to pain
secondary to
Muscle Muscle dilatation and
Strength: Strength: curettage
procedure
4/5 4/5

Lymph Inspection Not Lymph nodes Lymph nodes NORMAL

Nodes and palpable are not are not
Palpation palpable, no palpable, no
enlargements enlargements
and and
tenderness. tenderness.

Trachea Palpation Trachea is Trachea is Trachea is NORMAL

palpable, palpable, palpable,
positioned located in the located in the
in the midline, and midline, and
midline the spaces on the spaces on
and the both sides are both sides are
spaces are equal. equal.
equal on
both sides.
 Thyroid Inspection Not visible Not visible on Not visible on NORMAL
Gland and on inspection; inspection;
Palpation inspection gland ascends gland ascends
and during during
swallowing swallowing
gland but is not but is not
ascends visible visible
during
swallowin
g but is
not
visible.

Upper
Extremities

Inspection - The skin Uniform skin Uniform skin NORMAL

Skin and and of upper color except color except
nails Palpation extremitie those areas those areas
s is exposed to exposed to
uniform in sun. Has a sun. Has a
color visible scar, visible scar,
except in stretch marks stretch marks
areas particularly in particularly in
exposed to the underarm. the underarm.
the sun. No presence No presence
of edema. of edema.
- Has good Uniform Uniform
skin temperature. temperature.
turgor. Has a good Has a good
skin turgor. skin turgor.
- Skin's
temperatur
e is
normal. The nail has a The nail has a
convex curve convex curve
- Nails are and evenly and evenly
clean and cut, intact cut, intact
pink in with with
color with epidermis, epidermis,
a convex there is a there is a
curve and presence of presence of
are intact lunula and lunula and
with the pink nail pink nail
epidermis.
 - Capillary plate. 2 plate. 2
refill time seconds seconds
is usually capillary refill capillary refill
less than 3 time. time.
seconds
(Blanch
Test)

- No
lesions, no
edema.

Bones Inspection Able to There is no There is no NORMAL

and resist tenderness, tenderness,
Palpation applied swelling, or swelling, or
pressure deformities deformities
symmetric present upon present upon
ally. No palpation. palpation.
presence Able to resist Able to resist
of bone applied applied
deformitie pressure pressure
s, symmetrically symmetrically
tenderness . .
, and
swelling.
 Muscle Inspection Equal The patient's The patient's Dilatation and
strength and strength muscles are muscles are Curettage
and tone Palpation on each symmetrical symmetrical
body side in size, there in size, there ↓
are no are no
involuntary involuntary Post procedural
movements. movements. cramping
Unequal Unequal
strength on strength on
each body each body
side. side. Activity
Intolerance
related to pain
secondary to
Muscle Muscle dilatation and
Strength: Strength: curettage
procedure
4/5 4/5

Triceps Inspection Equal Equal strength Equal strength NORMAL

and strength on each body on each body
Palpation on each side and the side and the
body side patient can patient can
and can resist force. resist force.
resist force No tenderness No tenderness
upon upon
palpation. palpation.
 Bicep Inspection Equal Equal strength Equal strength NORMAL
and strength on each body on each body
Palpation on each side and the side and the
body side patient can patient can
and can resist force. resist force.
resist force No tenderness No tenderness
upon upon
palpation. palpation.

Wrist and Inspection Wrists and Both are free Both are free NORMAL
finger and fingernails of of
Palpation are unintentional unintentional
symmetric motions, motions,
al, no lesions, lesions,
involuntar abrasions, and abrasions, and
y symmetrical. symmetrical.
movement
s, no
deformitie
s, lesions,
and
abrasion.

Joint Inspection No Joints move Joints move NORMAL

and swelling, easily, no easily, no
Palpation tenderness tenderness, tenderness,
, and swelling, and swelling, and
crepitation crepitation crepitation
. Joints upon upon
move palpation. palpation.
smoothly.

Range of Inspection Varies to Limited range Limited range Dilatation and

motion some of motion and of motion and Curettage
degree in has has
accordanc restrictions on restrictions on ↓
 e with a the patient's the patient's Post procedural
person's movements. movements. cramping
genetic
makeup ↓
and degree
of physical Limited range of
activity. motion

Activity
Intolerance
related to pain
secondary to
dilatation and
curettage
procedure

Sensation Inspection The client The patient is The patient is NORMAL

and can able to able to
Palpation identify identify sharp identify sharp
the and dull and dull
difference sensations, as sensations, as
between well as the well as the
light and difference difference
deep between light between light
touch. The and deep and deep
client can touch. touch.
be able to
discrimina
te between
“sharp”
and “dull”
sensation.

Grip Inspection Equal Can grasp the Can grasp the NORMAL
Strength strength index and index and
on each middle fingers middle fingers
body sides enough to enough to
hold them. hold them.
 Chest

Posterior Inspection Anteropos The thorax The thorax NORMAL

Thorax and terior to and the 1:2 and the 1:2
Palpation transverse ratio are both ratio are both
diameter symmetrical. symmetrical.
in ratio of Right and left Right and left
1:2 hips and hips and
shoulders are shoulders are
Thorax the same the same
symmetric height. The height. The
. Spine spine is spine is
vertically straight, and straight, and
aligned; the skin is the skin is
spinal intact with a intact with a
column is constant constant
straight; temperature. temperature.
right and
left
shoulders
and hips
are at the
same
height;
skin intact
uniform
temperatur
e.

Respiratory Palpation The 2-to- Equal Equal NORMAL

3-inch symmetrical symmetrical
Excursion symmetric thoracic thoracic
al thoracic expansion expansion
expansion thumbs, thumbs,
thumbs undamaged undamaged
move chest wall, no chest wall, no
apart equal noticeable noticeable
distance in discomfort. discomfort.
both
directions,
 no
tenderness
, no
masses.

Thorax for Inspection Bilateral Symmetric Symmetric NORMAL

vocal and symmetry and full thorax thorax
Palpation of vocal expansion expansion
(Tactile fremitus. during deep
fremitus) Fremitus inhalation
is heard
most
clearly at
the apex
of the
lungs.

Anterior Inspection Quiet, Quiet, Quiet, NORMAL

Thorax rhythmic, rhythmic, and rhythmic, and
and effortless effortless
effortless respirations. respirations.
respiration
s.

Full and Full and

Palpation symmetrical. symmetrical.
Full
symmetric
excursion;
thumbs
normally
separate 3 Resonant over
to 5 cm all lung fields.
(1.2 to 2 Flat over
in.) bones and
Symmetric Resonant over muscles.
al with all lung fields. Dullness over
Percussion posterior Flat over heart, liver,
thorax. bones and tympanic.
muscles.
Dullness over
heart, liver,
 Percussion tympanic.
notes
resonate
down to
the sixth
rib at the
Bronchovesic
level of
ular breath
the
sounds
diaphragm
Auscultati but are flat
on over areas
of heavy
muscle
and bone, Bronchovesic
dull on ular breath
areas over sounds
the heart
and the
liver, and
tympanic
over the
underlying
stomach.

Bronchove
sicular and
vesicular
breath
sounds

Heart

Tricuspid Auscultati No Absence of Absence of NORMAL

area and on pulsations, pulsations and pulsations and
Aortic Area No lift or heave. Aortic heave. Aortic
heave, and pulsations are pulsations are
Aortic present. 2 present. 2
pulsations. heart sounds heart sounds
S1 is heard. No heard. No
louder murmurs. murmurs.
than S2 in
the
tricuspid
 area while
in Aortic
area S2 is
louder
than S1.

Carotid Inspection Symmetric Have similar Have similar NORMAL

Arteries , pulse characteristics characteristics
Auscultati volumes as the radial as the radial
on, and full artery. artery.
Palpation pulsations, Pulsations are Pulsations are
husting symmetrical. symmetrical.
quality,
quality
remains
same
when
client
breaths,
turns,
head, and
changes
from
sitting to
supine
position
elastic
arterial
wall, no
sound
heard on
auscultatio
n.

Jugular Veins Inspection Veins not Veins are not Veins are not NORMAL
visible visible visible

Peripheral Inspection Symmetric Symmetric Symmetric

Pulses , pulse pulse pulse NORMAL
Auscultati volume, (intensity of (intensity of
on and the pulse 3+ the pulse 3+
Palpation full normal pulse) normal pulse)
pulsation

Inspection Symmetrical, Symmetrical,

Peripheral , In a no presence of no presence of
Veins Auscultati dependent distention and distention and
on and position, modular modular
Palpation there is a bulges at bulges at
presence calves, no calves, no
of swelling and swelling and
distention tenderness. tenderness.
and
nodular
bulges at
calves.
When
limbs are
elevated,
veins
collapse,
Symmetric
in size and
limbs are
not tender.

Capillary Inspection Immediate Capillary refill Capillary refill NORMAL

Refill Test and return of of 1 seconds of 1 seconds
Palpation color (less
than 2
seconds)

Breast

Size, Inspection Females: Cup size: 40C Cup size: 40C NORMAL
symmetry, and rounded
contour, or Palpation shape; Unequal size Unequal size
shape slightly of the breast. of the breast.
unequal in The right The right
size; breast is breast is
generally tenderer than tenderer than
symmetric the left. the left.
Males:
breasts
even with
the chest
wall; if
obese,
may be
similar in
shape to
female
breasts

Skin Inspection Skin The skin is The skin is NORMAL

and uniform in smooth and smooth and
Palpation color uniform. uniform.
(similar to
skin of
abdomen
if not
tanned)

Areola Inspection Skin The areola of The areola of NORMAL

smooth the patient is the patient is
and intact, round, round,
color smooth, and smooth, and
depending intact. Darker intact. Darker
on race, than the rest than the rest
rounded or of the breast. of the breast.
oval

Inspection Nipples Round, Round, NORMAL

Nipples and are everted, and everted, and
Palpation rounded, equal in size. equal in size.
everted, Similar in Similar in
and equal color, soft, color, soft,
in size; and smooth. and smooth.
similar in Both nipples Both nipples
color; soft point in the point in the
and same same
smooth; direction. direction.
both
nipples
point in
the same
direction
(out in
young
women
and men,
downward
in older
women).
No
discharge,
except
from
pregnant
or breast-
feeding
females.

Abdomen
 Skin Inspection Skin color The skin is The skin is NORMAL
and is uniform, uniform, there uniform, there
Palpation contour is no presence is no presence
may be of lesions, of lesions,
flat, stretchmarks, stretchmarks,
rounded or tenderness, tenderness,
scaphoid, and distension and distension
no upon upon
presence palpation. palpation
of lesions,
tenderness
, and
distension.

Abdominal Inspection Symmetric Visible Visible NORMAL

movements movement peristalsis and peristalsis and
associated caused by symmetrical symmetrical
with respiration respiration respiration
respiratory . Visible movement. movement.
or peristalsis.
peristalsis

Vascular Inspection No visible No visible No visible NORMAL

pattern and vascular vascular vascular
Palpation pattern pattern pattern

Bowel Auscultati Bowel Audible bowel Audible bowel NORMAL

sounds on (use sound sound, gurgle sound, gurgle
diaphragm consists of can be heard can be heard
of clicks and at about 5-30 at about 5-30
stethoscop gurgles per minute per minute
e) and 5-30
per
minute.
 An
occasional
borboryg
mus (loud
prolonged
gurgle)
may be
heard

Vascular Auscultati Absence No bruits No bruits NORMAL

sound on (use of bruits
the bell of
the
stethoscop
e)

Peritoneal Auscultati Absence No friction No friction NORMAL

Friction on of friction rub rub
Rubs rub

Urinary Palpation Not The client’s The client’s NORMAL

bladder palpable bladder is not bladder is not
palpable palpable

Musculoskel
etal System

Equal size The patient’s The patient’s NORMAL

Muscle on both muscles are muscles are
Inspection sides of equal size on equal size on
the body. both sides of both sides of
No the body, the body,
 tremors there is no there is no
and presence of presence of
contractur tremors and tremors and
es. contractures. contractures.

Muscle Palpation Equal Decreased of Unequal Dilatation and

strength strength normal strength on Curettage
on each strength due each body
body to right lower side pain ↓
quadrant pain (5/10)
8/10 Post procedural
cramping

Activity
Intolerance
related to pain
secondary to
dilatation and
curettage
procedure

Bones Inspection No The patient The patient NORMAL

deformitie has no bone has no bone
s deformities deformities

Joints Inspection No The patient’s The patient’s NORMAL

and tenderness joint moves joint moves
, swelling smoothly. No smoothly. No
Palpation or nodules tenderness, tenderness,
swelling or swelling or
nodules. nodules.
 Female
Genitals and
Inguinal Area

Pubic area Inspection Pubic hair Pubic hair is Pubic hair is NORMAL
is present present, skin present, skin
and pubic intact in the intact in the
skin is vulva and vulva and
intact, no labia. Skin of labia. Skin of
lesions. the vulva is the vulva is
slightly darker slightly darker
Skin of the than the rest than the rest
vulva is of the body. of the body.
slightly
darker
than the
rest of the
body.

Clitoris, Inspection Labia Small and Small and Dilatation and

urethral and round, everted down, everted down, Curettage
orifice, and Palpation full, and there is there is
vaginal relatively inflammation, inflammation, ↓
orifice symmetric swelling, and swelling, and
in adult tenderness. tenderness. Surgical removal
females. Have Have part of the lining
Clitoris discharged discharged of the uterus by
does not Lochia Rubra. Lochia Rubra. scooping and
exceed 1 scraping
cm (0.4
in.) in ↓
width and
2 cm (0.8 Pain in genitalia
in.) in
length. ↓
Urethral
orifice Inflammation
appears as and swelling
a small slit
and is the
same color
as Acute pain
surroundin related to post
Dilatation and
 g tissues. Curettage
procedure
No
inflammati
on,
swelling,
or
discharge.

Inguinal Inspection No The patient The patient NORMAL

lymph and presence has no has no
nodes Palpation of palpable palpable
swelling lymph nodes. lymph nodes.
and
tenderness
of lymph
nodes.
 Lower
Extremities NORMAL

Inspection The skin The skin of The skin of

Skin and and of lower the lower the lower
Nails Palpation extremitie extremities is extremities is
s is uniform in uniform in
uniform in color. Has a color. Has a
color darker knee. darker knee.
except in No edema. No edema.
areas Has good skin Has good skin
exposed to turgor and the turgor and the
the sun. temperature is temperature is
Has a within normal. within normal.
good skin There is a There is a
turgor and presence of presence of
skin’s stretch marks, stretch marks,
temperatur scars on both scars on both
e is within legs. legs.
normal.

The nails have The nails have

a convex a convex
curve and are curve and are
evenly cut, evenly cut,
smooth, and smooth, and
Nails are intact with the intact with the
pinkish in epidermis. epidermis.
color, have Toenails are Toenails are
a convex painted with painted with
curve, brown brown
smooth, cuticles. 2- cuticles. 2-
clean, and second second
intact with capillary refill capillary refill
the time. time.
epidermis.
Capillary
refill time is
usually less
than 3
seconds.
 Bones Inspection Able to The client was The client was NORMAL
and resist able to resist able to resist
Palpation applied pressure pressure
pressure symmetrically symmetrically
symmetric . Has no bone . Has no bone
ally. No deformities, deformities,
presence tenderness and tenderness and
of bone swelling. swelling.
deformitie
s,
tenderness
and
swelling.

Muscle Inspection Able to Decreased Decreased Dilatation and

strength and resist muscle muscle Curettage
and tone Palpation applied strength on strength on
pressure both sides. both sides. ↓
symmetric Unable to Unable to
ally. resist force on resist force on Post procedural
Symmetric both legs. both legs. cramping
muscle
tone. ↓

Lower muscle
weakness

Altered physical
mobility related
to insufficient
muscle strength
secondary to
dilatation and
curettage
procedure

Hip Muscles Inspection Equal Decreased Decreased Dilatation and

and strength muscle muscle Curettage
 Palpation on each strength on strength on ↓
body side both sides both sides
Post procedural
cramping

Lower muscle
weakness

Altered physical
mobility related
to insufficient
muscle strength
secondary to
dilatation and
curettage
procedure

Hip Inspection Equal Decreased Decreased Dilatation and

abduction and strength muscle muscle Curettage
Palpation on each strength on strength on
body side both sides both sides ↓

Post procedural
cramping

Lower muscle
weakness

Altered physical
mobility related
to insufficient
muscle strength
secondary to
dilatation and
curettage
procedure
Hamstring Inspection Can resist Unequal Unequal Dilatation and
and while strength on strength on Curettage
Palpation straighteni each body each body
ng the legs side side ↓

Post procedural
cramping

Lower muscle
weakness

Altered physical
mobility related
to insufficient
muscle strength
secondary to
dilatation and
curettage
procedure

Muscle of Inspection Equal There are no There are no NORMAL

the feet and and strength deformities, deformities,
ankles Palpation on each swelling, swelling,
body side tenderness. tenderness.
Equal muscle Equal muscle
strength on strength on
both sides. both sides.

Joint Inspection Equal Joints move Joints move NORMAL

and strength smoothly smoothly
Palpation on each
body side.
Able to
move
smoothly.
 Range of Inspection The range The patient’s The patient’s NORMAL
motion, and of motion range of range of
popliteal, Palpation are 160 motion is motion is
posterior degrees of equal strength equal strength
tibial, and flexion, on both sides. on both sides.
dorsalis 180 No swelling, No swelling,
pedis pulse degrees of tenderness, tenderness,
extension, and nodules and nodules
90 degrees
of
pronation
and
supination

Sensation Inspection The client The patient The patient NORMAL

and can can feel the can feel the
Palpation identify cotton ball cotton ball
light and bilaterally and bilaterally and
deep able to able to
touch. The determine determine
client can light to deep light to deep
discrimina touch, and soft touch, and soft
te between to sharp to sharp
“sharp” sensation sensation
and “dull”
sensations

ANATOMY AND PHYSIOLOGY

 Passageway for an Submucosal myoma

egg and a sperm
to meet and for a
FALLOPIAN fertilized egg
TUBE (embryo) to make Pregnancy
its way to the
uterus.
 Site where the
fertilization
 happens
 A holding place
for your egg
Fibrosis blocks fallopian
tube

Fibrosis impact the lining

of the uterine cavity

Affected blood flow to

the uterine cavity

Decrease the ability of an

embryo to stick (implant) to the
uterine wall or to develop

Anembryonic
pregnancy

 Pregnancy: Your
UTERUS uterus stretches to
grow your baby
Submucosal
during pregnancy.
myoma
It can also
contract to help
Pregnancy
push your baby
out of your
Affect
vagina. Nourish
Fertility
the developing
fetus prior to birth
Anembryonic
pregnancy

 Fertility: Your Vaginal

uterus is where a bleeding
fertilized egg
implants during Dilation and
conception and Curettage
where your baby
 grows.
 Menstrual cycle:
Your uterine
lining is where
blood and tissue
come from during
menstruation.

 Ovaries produce Secretes excessive

eggs and estrogen and progesterone
OVARY hormones for
menstruation and Myometrial
pregnancy tissue
 Secretes estrogen
and progesterone Fibroids
 Maintain the growth
health of the
LEIOMYOMA
female
reproductive
system
 Play a critical role
in both
menstruation and
conception

 Producing
cervical mucus Evening primrose
CERVIX during the most suppository
fertile phase of the
menstrual cycle, Soften the cervix and
efface
which helps sperm
travel from the Vaginal bleeding
vagina into the
uterus Dilation and
curettage
 Opening during labor
to allow the baby to
 pass through the birth
canal
 Protecting the uterus
from bacteria and
other foreign objects

 Secretes mucosal Submucosal myoma grow

tissue, the beneath uterine lining
VAGINA passageway of
blood in the Fibroids press against
menstrual period, the uterine lining
and receives penis
for sexual Vaginal
intercourse bleeding
 It also acts as the
passageway for
childbirth