Physical Assessment

PHYSICAL ASSESSMENT

Patient: Marvi Fabila August 31, 2008Student Nurse: Eden D. Dimailig D31- Ms. Aileen RochaA06A22

Part I

Behavior

MEASUREMENTS NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS

Height

Weight

Proportionality of height to weight

BMI

BMI=weight(kg)t (height in m)2

18.5-25 kg/m2

Temperature 36.5-37.5 C

Pulse rate 60-100 beats/min

Respiratory Rate 12-20 breaths/minBlood Pressure 120/80 mmHg

General SurveyAREAS TO BE

ASSESSEDNORMAL FINDINGS ACTUAL FINDINGS ANALYSIS

GENERAL APPEARANCE

Body Build, height, and weight in relation to the client’s age, lifestyle, and health

Proportionate, varies with lifestyle

Posture and GaitRelaxed; erect posture; coordinated movement

Overall hygiene and grooming

Clean, and neat Neat and clean

Body odor No body odor or minor body odor relative to work or exercise.

No body odor. The client uses perfume to have pleasant smell and as part of her hygiene

Breath odor No breath odor The client has no breath odor

Signs of distress No signs of distress Presence of eye bags and presence of pimples in the face

Signs of health/illness Healthy appearance The client is healthy and no signs of illness

Client’s attitude Cooperative The client is cooperative

Affect/ mood; Appropriateness of the client’s responses

Appropriate to situation The client’s mood is ecstatic and his responses are appropriate

Speech(quantity, quality, and organization

Understandable, moderate pace, exhibits thought association

The client’s speech is understandable and exhibits thought association.

Thoughts(relevance and organization)

Logical sequence; makes sense; has sense of reality

The client has a logical sequence of thoughts and makes sense.

HEAD TO TOE PHYSICAL ASSESSMENT

BODY PART NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS

SKIN

Color, uniformity of Color

Edema

Lesions

Moisture

Temperature

Turgor

Light to deep brown; uniformcolor except the areas exposed to the sun

No edema

Freckles, birthmarks, flats and raised nevi; no other lesions

Moisture in skin folds and axillae

Uniform; with normal range

When pinched, skin springs back to previous state(Fundamentals of Nursing, 8thed., by Kozier, pp 579-580)

The client’s skin color is darkbrown

No edema

No lesions, no birthmarks

There is moisture in skin folds and axillae.

The skin temperature is uniform, and with normal

range. Both feet and hands are uniform.

When pinched, skin springs back to previous state within 3

seconds

NAILS

Shape and angle

Texture

Color

Surrounding tissue

Blanch test

Convex curvature; angle of nail plate is 160 degrees

Smooth in texture

Color is highly vascular and pink in light skinned clients; dark skinned clients may have brown or black pigmentation in longitudinal steaks

Intact epidermis

Blanch test, prompt return of usual color(Fundamentals of Nursing, 8thed., by Kozier, pp 583-584)

The shape is convex curvature and angle is 160 degrees.

Smooth texture

Pink in color

Intact epidermis

Returns to usual color for about 2 seconds.

HEAD

SKULL

Size, shape, Symmetry

Nodules, masses And depressions

Rounded(normocephalic and symmetric with frontal, parietal, temporal, and occipital prominences); smooth skull contour

Absence of nodules or masses(Fundamentals of Nursing, 8thed. by Kozier, p 585)

Rounded(normocephalic and symmetric with frontal, parietal, temporal, and occipital prominences) and smooth skull contour

No nodules or masses

SCALP

Color and Appearance

Areas of tenderness

Lighter than complexion

No lesions, lies, dandruff, and bruises or lumps found. Free from split ends(Manual of Nursing, 7th., by Lippincott, p.54

HAIR

Evenness of Growth, Thickness/ Thinness

Texture and Oiliness

Evenly distributed, thick,

Silky, and resilient(Fundamentals of Nursing, 8thed. by Kozier, p 582)

The client’s hair is evenly distributed, and it is thick. The hair cut is long.

Silky, and resilient hair

FACE

Facial features

Symmetry of facial movements

Symmetric or slightly asymmetric facial features.

Symmetric facial movements(Fundamentals of Nursing, 8thed. by Kozier, p 585)

The facial features are symmetric. Pimples are present.

The facial movements are symmetric.

EYES

VISUAL ACUITY

Near vision

Distance vision

Able to read

20/20 vision on snellen chart

The client is able to read

The client is able to readShe has a 20/20 vision in her both eyes

EYEBROWS

Distribution, Alignment, skin Quality and movement

Hair is evenly distributed; skin intact, eyebrows symmetrically aligned; equal movement. (Fundamentals of Nursing, 8thed., by Kozier, p 588)

The hair is distributed evenly, alignment is symmetrical, and skin is intact and equal movement.

EYELASHES

Evenness of Distribution and Direction of curl

Equally distributed and curled slightly outward(Fundamentals of Nursing, 8thed., by Kozier, p 544)

Equally distributed and curled slightly outward

LACRIMAL APPARATUS

No edema/ tenderness No edema/ tenderness

EYELIDS

Surface characteristics, position in relation to the cornea, able to blink; frequency of blinking

Skin intact, no discharges and no discoloration

Lids close symmetrically

15-20 blinks/min. Bilateral blinking

When lids open, no visible sclera above corneas, upper and lower borders of cornea are slightly covered(Fundamentals of Nursing, 8thed., by Kozier, p 588)

Skin is intact, no discharges and no discoloration

Lids close symmetrically

19 blinks per minute

There is no visible sclera above corneas when lids open, upper and lower borders of cornea are slightly covered.

CONJUNTIVA

Bulbar conjunctiva Color, texture, Presence of Lesions

Palpebral Conjunctiva color, Texture, lesions

Transparent, capillaries sometimes evident, sclera appears white (yellowish in dark-skinned clients)

Shiny, smooth, and pink or red(Fundamentals of Nursing, 8thed., by Kozier, p 588)

Capillaries are seen and it is transparent. Sclera appears white

The client’s palpebral conjunctiva is pink in color. The texture is smooth and shinny.

SCLERAColor and clarity White in color The client’s sclera is white.

CORNEA

Clarity and texture

Transparent, shiny and smooth details of the iris are visible(Fundamentals of Nursing, 8thed., by Kozier, p 590)

It has a transparent, shiny and smooth. Details of the iris are visible

IRIS

Shape and color Flat and round(Fundamentals of Nursing, 8thed., by Kozier, p590)

Color is brown. And it is flat and rounded.

PUPILS

Color, shape, and Size

Light reaction and Accommodation

Black in color, equal in size, 3 - 7 mm in diameter; round, smooth border.

Illuminated pupil constricts(direct response)Nonilluminated pupil constricts(consensual response)

Pupils constrict when looking at near object; pupils dilate when looking at far object; pupils converge when near object is moved toward nose(Fundamentals of Nursing, 8thed., by Kozier, p 590)

Pupils are black in color; the size is 3 – 7 mm in diameter. Round and smooth.

Illuminated pupil constricts(direct response)Nonilluminated pupil constricts(consensual response)

The client’s pupils constrict when looking at near object; pupils dilate when looking at far object; pupils converge when near object is moved toward nose.

EXTRAOCULAR MUSCLES

Alignment; coordination

Both eyes coordinated, move in unison with parallel alignment(Fundamentals of Nursing, 8thed., by Kozier, p 592)

The both eyes of the client moved in unison with parallel alignment and both coordinated.

VISUAL FIELDS

Peripheral visual fields

When looking straight ahead, the client can see objects in the periphery(Fundamentals of Nursing, 8thed., by Kozier, p 591)

The object the client is looking is a pen. The client can see objects in the periphery when looking straight ahead.

EARSAURICLES

Color, symmetry, Position

Texture, elasticity And tenderness

Color same as facial skin, symmetrical, auricle aligned with outer canthus of eye, about 10 degrees from vertical

Texture, elasticity and tenderness:Mobile, firm and tender; pinna recoils after it is folded(Fundamentals of Nursing, 8thed., by Kozier, p 596)

Color of the client’s auricle is same as the facial skin, symmetrically in size. Aligned with outer canthus of the eye.

Texture is smooth, elastic and tenderness.It is firm and mobile Pinna recoils after it is foded

EXTERNAL EAR CANALS

Cerumen, skin Lesions Pus and blood

Distal third contains hair follicles and glands dry cerumen, grayish tan color/sticky/ wet cerumen in various shades of brown(Fundamentals of Nursing, 8thed., by Kozier, p 596)

Distal third contains hair follicles and glands, and the external ear canals has cerumen

HEARING ACUITY TEST

In normal voice Ones

Watch tick test

Weber’s test

Rinne’s test

Audible

Able to hear ticking in both ears

Sound is heard in both ears or is localized at the center of the head

Air-conducted hearing is greater than bone-conducted hearing(Fundamentals of Nursing, 8thed., by Kozier, pp 597-598)

The client verbalized that she can hear clearly what the health care provider says, like ears check twice and twice awesome.

The client is able to hear the ticking in both ears.

The client heard in both ears.

Air conduction is greater than bone conduction.

NOSE

Shapes, size, color, flaring/ discharge from nares.

Nasal cavities: Redness, swelling Growths, and Discharge

Nasal septum

Nasal cavity Patency

Tenderness, masses and displacement of bone and cartilage

Symmetric and straight; no discharge or flaring; uniform in color.

Pink mucosa; clear watery discharge; no lesions

Intact and in the midline

Patency, air moves freely as the client breathes through the nares.

No tenderness; no lesions(Fundamentals of Nursing, 8thed., by Kozier, p 600)

The client’s nose is symmetric and straight. No discharges or flaring. The color of the nose ranges from medium to light brown. Uniform to the color of the face.

Mucosa is pink. And no watery discharge and lesions.

Nasal septum is in the midline

Air moves freely as the client breathes through the nares.

No tenderness; no lesions

FACIAL SINUSES

Frontal, Supraobital ridges ,ethmoid, sphenoid, maxillary

No tenderness(Fundamentals of Nursing, 8thed., by Kozier, p 600)

No tenderness

MOUTH

LIPS

Symmetry of contour, color, texture

Pinkish; symmetrical with lip margin. Smooth and moist(Fundamentals of Nursing, 8thed., by Kozier, p 602)

She has a dark lips, symmetrical with lip margin. And texture is moist and smooth.

Abnormal

BUCCAL MUCOSA

Color, moisture, Texture and lesions

Moist, smooth, soft, glistering and elastic(Fundamentals of Nursing, 8thed., by Kozier, p 602)

The client’s buccal mucosa is moist, smooth, soft, glistering, and elastic

Normal

TEETH

Color, number condition

Smooth, white, shiny tooth enamel; smooth, intact dentures. 28-32 normal numbers of teeth(Fundamentals of Nursing, 8thed., by Kozier, p 602)

GUMS

Color conditionPink color, moist, firm texture, no retraction(Fundamentals of Nursing, 8thed., by Kozier, p 591)

TONGUE/ MOUTH FLOOR

Surface of the Tongue for position, color, Texture. And tongue movement

Base of the tongue

Nodules, lumps or enlarged lymph nodes

Pink color, slightly rough, moist.Smooth and no lesions.Central positioned.Freely movable

Smooth tongue base with prominent veins

Smooth with no palpable nodules(Fundamentals of Nursing, 8thed., by Kozier, pp 603-604)

The client’s tongue is pink in color, slightly rough and moist. Positioned in center. And the tongue can freely move.

PALATES AND UVULA

Palate color, shape, texture and body prominence

Position of uvula, and mobility

Hard palate: Lighter pink and more irregular textureSoft palate: Light pink, smooth

Positioned in midline of soft palate(Fundamentals of Nursing, 8thed., by Kozier, pp 604)

Hard palate: Lighter pink and more irregular textureSoft palate: Light pink, smooth

The uvula is positioned in midline of soft palate

OROPHARYNX AND TONSILS

Color, texture

Tonsils, color, Discharge

Gag reflex

Pink in color, smooth posterior wall

Pink and smooth. No discharge

Present(Fundamentals of Nursing, 8thed., by Kozier, p 604)

Oropharynx is pink in color and has a smooth posterior wall.

Pink and smooth. And no discharge. Grade 1 tonsils Present

NECK

NECK MUSCLES

Neck muscles for abnormal swellings or masses

Head movements

Muscles equal in size; head centered

Coordinated, smooth movements with no discomfort(Fundamentals of Nursing, 8thed., by Kozier, p 607)

Head centered and muscles are equal in size.

The client has a coordinated head movements and a smooth movement. No discomfort

LYMPH NODES

Occipital Postauriular Preauricular Submandibular Submental Superficial anterior

Not palpable(Fundamentals of Nursing, 8thed., by Kozier, p 607)

TRACHEA

Placement Midline of neck; spaces are equal on both sides(Fundamentals of Nursing, 8thed., by Kozier, p 608)

The placement of the trachea is in the midline of the neck and the spaces on both sides are equal.

THYROID GLAND

Symmetry and Masses

Smoothness, Areas of Enlargement, Masses, nodules

Not visible, gland ascends during swallowing

Lobes may not be palpated.If palpated, lobes are small, smooth, centrally located, painless, and rise freely with swallowing(Fundamentals of Nursing, 8thed., by Kozier, p 609 )

During swallowing gland ascends bit not visible.

Smoothness and nodules are not palpable. Tenderness is located centrally

PART II

THORAXPOSTERIOR THORAX

Shape, symmetry, Diameter

Spinal alignment

Temperature, and The integrity of all Chest skin

Respiratory Excursion

Vocal fremitus

Percussion

Auscultation(posterior thorax)

Anteroposterior to transverse diameter in ratio of 1:2,.chest symmetrical

Vertically aligned

Skin intact; uniform temperature

Full and symmetric chest expansion

Fremitus is heard most clearly at the apex of the lungs. Bilateral symmetry

Percussion notes resonate, the level of diaphragm but are flat over areas of heavy muscle and bone, dull on areas over stomach

Vesicular and bronchovesicular breath sounds(Fundamentals of Nursing, 8thed., by Kozier, p615)

The anteroposterior to transverse diameter in ratio is 1:2 and chest symmetrical

Vertically aligned


During deep inspiration thumbs separate 3-5 cm

The client is high pitched voice. And the fremitus is heard most clearly at the apex of the lungs. Bilateral symmetry.

Resonate, except over the level of diaphragm but are flat over areas of heavy muscle and bone, dull on areas over stomach

Bronchial and tubular breath sounds

ANTERIOR THORAX

Breathing patterns

Temperature and The integrity of All chest skin

Respiratory Excursion

Vocal fremitus

Percussion

Auscultation(trachea)

Auscultation(anterior thorax)

Quiet, rhythmic, and effortless respiration


Full symmetric excursion; thumbs normally separate 3 to 5 cm

Fremitus is normally decreased over heart and breast tissue

Percussion notes resonates down to the sixth rib at the level of the diaphragm but are flat over areas of heavy muscle and bone, dull on areas over the heart and the liver, and tympanic over the underlying stomach


Bronchovesicular and vesicular breath sounds(Fundamentals of Nursing, 8thed., by Kozier, p617)

The client has quiet, rhythmic, and effortless respiration.

Skin intact and uniform temperature.

During deep inspiration thumbs separate 3-5 cm


Bonchovesicular and vesicular breath sounds

CARDIOVASCULAR

PALPATION Aortic and pulmonic

Tricuspid area and Heaves or lifts

Apical area

Auscultation Aortic Pulmonic Tricuspid Apical

No pulsations

No pulsation and no heaves or lifts

Pulsation visible in 50% of adults and palpable in most PMI in fifth LISC at or medial to MCL.Diameter of 1 to 2 cm. no he heave or lift

S1: usually heard at all sites usually louder at apical area

S2: usually heard at all sites usually louder at base of heart

Systole: silent interval; slightly shorter duration than diastole at normal heart rate(60-90bpm)

Diastole: silent interval; slightly longer than systole at normal heart rates

S3: in children and young adultS4: in many older adults. (Fundamentals of Nursing, 8thed., by Kozier, pp620-622)

No pulsations

No pulsation and no heaves or lifts

Pulsation is visible and palpable.

S1: usually heard at all sites usually louder at apical area

S2: usually heard at all sites usually louder at base of heart

Normal

Normal

Normal

CAROTID ARTERIES

Palpation

Auscultation

Symmetric pulse volumes. Full pulsations, thrusting quality. Elastic artery wall

No sound heard on auscultation(Fundamentals of Nursing, 8thed., by Kozier, pp622-623)

Symmetric pulse volumes. Full pulsations, thrusting quality. Elastic artery wall

During auscultation no sound heard

Normal

Normal

JUGULAR VEINS

Inspect Veins not visible(Fundamentals of Nursing, 8thed., by Kozier, p 623)

Veins are not visible Normal

BREAST AND AXILLAE

BREAST

Size, symmetry and Shape

Localized discolorations or hyperpigmentation, retraaction or dimpling, localized

Rounded shape; slightly unequal in size; generally symmetric

Skin uniform in color; skin smooth and intact.Diffuse symmetric horizontal or vertical vascular pattern in light skinned people.

The shape is round and slightly unequal and it is generally symmetric.

The skin is uniform in color and it is also smooth and intact.

hypervascular areas, swelling or edema

AREOLA

Shape,, color, masses or lesions

NIPPLES

Size, shape, color, Position, discharge And lesions.

Axillary, Subclavicular and supraclavicular lymph nodes

Breast for Masses, tenderness

Nipples for tenderness and discharges

Striae; moles and nevi

Round/oval; bilaterally the same; color varies widely from light pink to dark brown. No lumps, masses or areas of tenderness

Round; everted/inverted; equal in size; similar in color.Soft and smooth; no discharge, masses or lesions. No lumps and masses.

No tenderness, masses, or nodules

No tenderness, masses, nodules, or nipple discharge

No tenderness, masses, nodules, or nipple discharge(Fundamentals of Nursing, 8thed., by Kozier, pp 628-630)

Round everted and equal in size. Similar in color with areola and texture is smooth and soft, No discharges and lesions nor masses.

No tenderness, masses, or nodules



ABDOMEN

Inspection Abdomen skin

Inspection Abdomen for Contour and Symmetry

Inspection Enlargement of Liver/spleen

Assess symmetry Of contour while standing at the foot of the bed

Abdominal Movements associated w/ respiration, peristalsis, or aortic pulsations

Vascular patterns

Auscultation

Unblemished skin; uniform color

Flat, rounded; symmetric contour.

No enlargement of the liver/spleen

Symmetric contour

Symmetric movements caused by respiration.Visible peristalsis in very lean people.Aortic pulsations in thin persons at epigastric area.

No visible vascular pattern

Audible bowel sounds; absence of arterial bruits; absence of friction rub

Tympany over the stomach and

The color is light to medium brown and it is uniform.Unblemished skin.

The abdomen is flat and rounded and has a symmetric contour.

There is no enlargement of the liver/spleen

The client has a symmetric contour

Symmetric movements.

Vascular pattern is not visible

Absence of arterial bruits and friction rub. The bowel sounds are audible

Tympany is heard over the

Percussion each Of the four Quadrants

Percuss the liver To determine its Size

Light Palpation

Deep palpation

Palpate area above The symphysis Pubis to determine possible urinary retention

gas-filled bowels; dullness, especially over the liver and spleen, or a full bladder

6 to 12 cm in the midclavicular line; 4 to 8 cm at midsternal line

No tenderness; relaxed abdomen with smooth, consistent tension

Tenderness may be present near xiphoid process, over cecum, and over sigmoid colon

Not palpable(Fundamentals of Nursing, 8thed., by Kozier, pp 633-638)

stomach and gas-filled bowels; dullness, sound is heard over the liver and spleen, or a full bladder

No tenderness relaxed abdomen w/ smooth, consistent tension.

MASCULAR SKELETAL SYSTEM

MUSCLE

Size

Tendons for Contractures

Equal on both sides of body

No contractures

Muscle is equal on both sides of the body

No contractures

Fasciculation and Tremors

Palpate muscle Tonicity

Test for muscle Strength

No fasciculation and tremors

Normally firm

Equal strength on each body side. (Fundamentals of Nursing, 8thed., by Kozier, pp 640-641)

No fasciculation and tremors

Muscle is firm

Muscle strength is equal on both sides.

BONES

Inspect skeleton For structure

Palpate bones to Locate areas of Edema or Tenderness

Inspect joint for Swelling

Palpate each joint For tenderness, Smoothness, Swelling, crepitation & presence of nodule

No deformities

No tenderness or swelling

No swelling;

No tenderness, crepitation, or nodules. Joints move smoothly(Fundamentals of Nursing, 8thed., by Kozier, p 641)

No deformities

No tenderness or swelling

Joints of the client do not have swelling.

No tenderness or nodules. Joints move smoothly

Physical Assessment

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