TAGUM DOCTORS COLLEGE, INC.

Mahogany St., Rabe Subdivision, Tagum City

College of Allied Health Sciences | Nursing Program

PHYSICAL ASSESSMENT
Patient’s Name: Age/Sex: Room No.:
AP:
Diagnosis:
Date of Assessment:
Student Nurse/Group:

HEALTH HISTORY
Chief Complaint
Pain of the abrasion wounds on the shoulder, knee, feet, arms, hands, and back.

Present Health Status

Patient was admitted at DDOPH – Pantukan Zone with a chief complaint of injury in the right
arm and multiple abrasions.

Past Health Status

Patient stated that he doesn’t have any history of hospital admission.

Current Lifestyle
The patient mentioned that he began consuming alcohol at the age of 16 but have since quit.
He doesn’t smoke and fond of riding motorcycles or going on rides. His dietary preferences
include meat, vegetables, fruits, and fish.

Psychosocial Status
The patient expressed regret for his actions, attributing him to his passion for riding. Despite
facing the consequences of a vehicular accident, he managed to meet their needs and cover
the hospital bills.
 TAGUM DOCTORS COLLEGE, INC.
Mahogany St., Rabe Subdivision, Tagum City
College of Allied Health Sciences | Nursing Program

Family History
No data gathered.

Patient’s Name: Age/Sex: Room No.:

AP:
Diagnosis:
Date of Assessment:
Student Nurse/Group:
 TAGUM DOCTORS COLLEGE, INC.
Mahogany St., Rabe Subdivision, Tagum City
College of Allied Health Sciences | Nursing Program

Assessment Normal Findings Actual Findings

Vital Signs

Temperature 36.1°C to 37.0°C

Pulse Rate 60 to 100 bpm

Blood Pressure Range: Systolic 110-130

mmHg and Diastolic 70-90
mmHg

Respiratory Rate 16 to 20 bpm

Oxygen >96%
Saturation
Level of Awake, alert, and oriented to
consciousness person, place, and time.

Speech Speech is clear; makes and

maintains conversation
appropriately.

Comfort Level Denies pain or discomfort.

Glasgow Coma The responses are scored

Scale between 1 and 5 with a
combined total score of 3 to
15, with 15 being normal.

Eye Opening Spontaneously

Response

Verbal Response Oriented to time, person,

place

Motor Response Obeys command

Measurements

Height The average Filipino man is

163 cm tall.

Weight The ideal weight of a 5’5 man

 TAGUM DOCTORS COLLEGE, INC.
Mahogany St., Rabe Subdivision, Tagum City
College of Allied Health Sciences | Nursing Program

is around 55.3 to 68.0 kg.

<18.5 – Underweight
Body Mass Index 28.5 – 24.9 – Normal
25 – 29.9 – Overweight
30 or higher - Obese

Women: > 80 cm (31.5

Waist inches)
Circumference Men: > 90 cm (35.5 inches)
Skin (Inspection The color of normal skin
and Palpation) ranges from white to pink, as
well as yellow, brown, and
black. With no pigmentation,
rashes, or other abnormalities

Hair (Inspection) Hair that is evenly

distributed, thick, silky, and
strong. Hair structure and
distribution are normal.

Nails (Inspection There are no nail changes.

and palpation) Good color, chare, and it is
clean

Head, Face, and Head is normocephalic and

Neck symmetric. Full ROM – up,
down, and sideways. Face is
normally proportionate and
symmetric. Facial movements
are equal bilaterally.

Eyebrows The brows should be

(Inspection) symmetrical in form and
movement.

Eyelids The eyelid border for mucus

(Inspection) or fluid flow, scales, or
lumps. The lids should be
close to the eyeball.
Sclera and The sclera is white in color.
Conjunctiva Free of discharge, lesions, or
(Inspection) lacerations.
Pupils The pupil formations are
 TAGUM DOCTORS COLLEGE, INC.
Mahogany St., Rabe Subdivision, Tagum City
College of Allied Health Sciences | Nursing Program

(Inspections) typically round and

symmetric.
Visual Acuity The normal eyesight is
(Inspection) described as 20/20 vision,
which is the clarity or
sharpness of vision measured
at 20 feet.
Ears (Inspection) Color is consistent with facial
color, and has firm cartilage.
No unusual structure or
markings should appear on
the pinna. No excessive
cerumen, discharge, lesions,
or foreign body are in the
external canal.
Hearing Acuity The ability to hear different
Test sounds, pitches, or
frequencies.
Nose There is no swelling,
bleeding, sores, or masses,
and no sinus obstructions
have been detected.

Mouth and Throat Lips are smooth and moist

(Inspection) without lesions or swelling.
No external mouth defects.
Teeth are present with good
dental hygiene. Gums and
mucous membranes should be
pink without bleeding, lesions
or inflammation. The tongue
is pinkish in color. Tonsils
are not enlarged. Gag reflex
must be intact.

Lungs and The lung movements are

Thoracic Region responsive to percussion and
vesicular breath sounds
across the detection of lung
fields. There are no rales,
rhonchi, wheezes, or rubs to
be found. Normal verbal and
physical attempts were made.
 TAGUM DOCTORS COLLEGE, INC.
Mahogany St., Rabe Subdivision, Tagum City
College of Allied Health Sciences | Nursing Program

Heart No unusualities and no extra

heart sounds were heard.

Abdomen Section: Abdomen for

(Inspection, asymmetry and distension
Auscultation, Auscultation: Listen for
Palpation) bowel noises (RLQ)
Palpate: Check four quadrants
for discomfort and urinary
system distension.

Genitourinary Symmetrical and pain-free

scrotum, smooth and mobile
testicles, a normal penile
appearance and function,
uncompromised urinary
function, the absence of
hernias or masses in the
inguinal area, and a healthy
prostate gland without
palpable irregularities during
a digital rectal
examination.

Musculoskeletal Stands reasonably straight

with feet positioned fairly
widely apart to form a firm
base of support. Full ROM of
each joint and equal bilateral
resistance. Free from
tenderness, lesions, edema,
redness, and deformities.