GRACE ANNE PATUNGAN PHYSICAL ASSESSMENT ASSESSED PROCEDURE ACTUAL FINDINGS NORMAL FINDINGS INTERPRETATION/ ANALYSIS

GENERAL SURVEY 1. Body built, height and weight in relation to the clients age, lifestyle and health 2. Posture and gait, standing, sitting and walking 3. Clients overall hygiene and grooming Medium body built; height and weight appropriate for age, lifestyle and health The client has difficulty of moving around. Medium body built; height and weight appropriate for age, lifestyle and health The client has difficulty of moving around.

Proportional, varies with lifestyle

Relaxed, erect posture; coordinated movement POOR HYGIENE No body odor or minor body odor relative to work or exercise; no breath odor Facial features are symmetric with movement and no distress noted Client is alert and oriented to what is happening at that time Cooperative, able to follow instructions Appropriate to the situation

POOR HYGIENE No body odor or minor body odor relative to work or exercise; no breath odor Facial features are symmetric with movement and no distress noted

NORMAL

4. Body and breath odor in relation to activity level

NORMAL

5. Signs of distress in posture or facial expression

NORMAL

Client is alert and 6. Observe the clients oriented to what is level of consciousness happening at that time 7. Assess clients attitude Cooperative, able to follow instructions

NORMAL

NORMAL

8. Clients Appropriate to the affect/mood; assess situation the appropriateness of

NORMAL

the clients responses Understandable, moderate pace; 9. Listen to quantity of clear tone and speech, quality, and inflection; exhibits organization thought association 10. Listen for relevance and organization of thoughts Logical sequence; makes sense; has sense of reality Understandable, moderate pace; clear tone and inflection; exhibits thought association Logical sequence; makes sense; has sense of reality

NORMAL

NORMAL

BODY PARTS EXAMINED

ACTUAL FINDINGS

NORMAL FINDINGS

INTERPRETATION / ANALYSIS

ASSESSING THE SKIN Varies from light to deep brown; from ruddy pink to light pink from yellow overtones to olive Generally uniform except in areas exposed to the sun; areas of lighter pigmentation (palms, lips, nail beds) in dark skinned people No edema Freckles, some birthmarks, some

1. Inspect skin color

DARK brown

NORMAL

2. Uniformity of skin color

Generally uniform except in areas exposed to the sun

NORMAL

3. Assess edema if present 4. Inspect, palpate and describe skin

No edema Visible skin lesion and breaks in the

NORMAL Rashes on upper and lower

lesions

skin.

flat and raised nevi; no abrasion of other lesions Moisture in skin folds and the axillae

extremities

5. Observe and palpate skin moisture

Dry skin in upper and lower extremeties Skin temperature is hot to touch (38 degree celcius).

Dry skin in upper and lower extremeties Skin temperature is warm/hot to touch.

6. Palpate skin temperature.

Uniform; within normal range

ASSESSING THE HAIR 1. Inspect the evenness of growth over the scalp 2. Inspect hair thickness or thinness 3.Inspect hair texture and oiliness 4. Note presence of infections or infestations 5.Inspect amount of hair Evenly distributed hair Evenly distributed hair

NORMAL

Thick hair Straight hair and no presence of oiliness No infection or infestation

Thick hair

NORMAL

Silky, resilient hair

NORMAL

No infection or infestation

NORMAL

Variable ASSESSING THE NAILS Highly vascular and pink in light-skinned clients; dark-skinned clients may have brown or black pigmentation in longitudinal streaks Intact epidermis

NORMAL

1. Inspect fingernail and toenail bed color

Long finger nail with dirt

NORMAL

2. Inspect tissues surrounding nails

Intact epidermis

NORMAL

3. Perform blanch test of capillary refill

Unable to gather data

Prompt return of pink or usual color (generally less than 4 seconds)

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ASSESSING THE HEAD Rounded,(normocep halic and symmetric with frontal, parietal, and occipital prominences); smooth skull contour Smooth, uniform consistency; absence of nodules or masses

1. Inspect the skull for size, shape, symmetry

Rounded, symmetric, and smooth in contour

NORMAL

2. Palpate the skull for nodules or masses and depressions

Absence of nodules

NORMAL

3. Inspect facial features

Symmetric and aligned

Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds No edema and hollowness present Symmetric facial movements

NORMAL

4. Inspect the eyes for edema and hollowness 5. Note symmetry to facial movements.

No edema and hollowness present Symmetric facial movements

NORMAL

NORMAL

ASSESSING THE EYE STRUCTURES AND VISUAL ACUITY 1. Inspect the eyebrows for hair distribution and alignment and skin quality and movement Hair evenly distributed; skin intact Eyebrows symmetrically aligned; equal

Evenly distributed and aligned

NORMAL

movement 2. Inspect the eyelashes for evenness of distribution and direction of curl

Equally distributed

Equally distributed; curled slightly outward

NORMAL

3. Inspect eyelids for surface characteristics, position in relation to cornea, ability to blink and frequency of blinking

Skin intact, without discharge or discoloration; Bilaterally blinking, no visible sclera above corneas

Skin intact, no discharge and discoloration, lids close symmetrically, approximately 1520 involuntary blinks per minute, bilateral blinking. When lids are open, no visible sclera above corneas, and upper and lower borders of cornea are slightly covered

NORMAL

4. Inspect the bulbar Transparent, Transparent, conjunctive for color, capillaries evident; capillaries evident; texture and presence sclera appears white sclera appears white of lesions 5. Inspect for palpebral conjunctiva for color, texture and presence of lesions. 6. Inspect and palpate lacrimal gland

NORMAL

Shiny, smooth, pink or red, no lesions

Shiny, smooth, pink or red, no lesions

NORMAL

No edema or tenderness over lacrimal gland

No edema or tenderness over lacrimal gland

NORMAL

7. Inspect and palpate the lacrimal No edema or tearing sac and nasolacrimal duct

No edema or tearing

NORMAL

8. Inspect cornea for clarity and texture

Transparent, shiny, smooth; Black in color; equal in size; round, smooth border, iris flat and round

Transparent, shiny, smooth; details of the iris are visible Black in color; equal in size; round, smooth border, iris flat and round Illuminated pupil constricts (direct response)

NORMAL

9. Inspect pupils for color, shape, and symmetry of size

NORMAL

11. Assess pupils direct and consensual reaction to light

Unable to gather data

Nonilluminated pupil constricts (consensual response) Pupils constrict when looking at near objects, pupils dilate when looking at far objects and pupils converge when looking at near object moving towards nose When looking straight ahead, client can see objects in the periphery Both eyes coordinated, move in unison with parallel alignment Light falls symmetrically on

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12. Assess each pupils reaction to accommodation

Unable pupils to constrict

--

13. Assess visual fields

Unable to gather data

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14. Assess 6 ocular movements to determine eye alignment and coordination 15. Assess location of light reflex

Unable to gather data

--

Unable to gather data

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both pupils 16. Assess near vision Unable to gather data Able to read newsprint --

ASSESSING THE EARS AND HEARING Color same as facial skin Symmetrical 1. Inspect the auricles for color, symmetric Auricle aligned with of size and position outer canthus of the eye, about 10o from vertical 2. Palpate auricles for texture, elasticity and areas for tenderness. Color same as facial skin Symmetrical Auricle aligned with outer canthus of the eye, about 10o from vertical Mobile, firm, not tender and pinna recoils after it is folded Distal third contains hair follicles and gland Dry cerumen, grayish-tan color, sticky Wet cerumen, various shades of brown Normal voice tones audible NORMAL

Unable to gather data

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3. Inspect external ear canal for presence of cerumen, skin lesions, pus and blood

Unable to gather data

NORMAL

4. Asses clients response to normal voice tones

Unable to gather data

NORMAL

ASSESSING THE NOSE AND SINUSES 1. Inspect the external nose for any deviations in shape and size or color and flaring and discharge from the nares Symmetric and straight. Flaring, nasal congestion No discharge and flaring Uniform color NORMAL

2. Palpate the external nose to determine any areas of tenderness, masses and displacement of bone and cartilage 3. Test patency of both nasal cavities 4. Inspect the nasal cavities for the presence of redness, swelling, growths and discharge 5. Inspect the nasal septum between the nasal chambers 6. Palpate the maxillary and frontal sinuses

No tenderness; no lesions

No tenderness; no lesions

NORMAL

Air patency is moving unease

Air moves freely as client breathes through the nares Mucosa pink

--

Positive watery discharges

Clear, watery discharge No lesions

NORMAL

Intact and in the midline

Intact and in the midline

NORMAL

Unable to gather data

No tender

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ASSESSING MOUTH AND OROPHARYNX 1. Inspect the outer lips for symmetry of contour, color and texture 2. Inspect and palpate the inner lips and buccal mucosa for color, moisture, texture and presence of lesions 3. Inspect teeth and Upper lip is pinkish in color while lower lip is reddish in color, was not able to purse Uniform pink color, soft, moist, smooth texture; symmetry of contour, ability to purse lips Uniform pink color Pink, smooth and elastic in texture Moist, smooth, soft, glistening and elastic texture 32 permanent teeth NORMAL Upper lip is pinkish in color while lower lip is reddish in color, was not able to purse

19 milk teeth with 4

NORMAL

gums

tooth decay

Smooth, white, shiny tooth enamel Pink gums; moist, firm texture of gums No retraction of gums

4. Inspect the dentures

Not applicable Not applicable Not applicable Central position

5. Inspect the surface of the tongue for position, color, texture

Pink tongue with pink-reddish spots and located in the center

Pink color Smooth, lateral margins No lesions/ raised papillae

Pink tongue with pink-reddish spots and located in the center

6. Inspect tongue movement 7. Inspect the base of the tongue, the mouth floor and the frenulum 8. Palpate the tongue and floor of the mouth for any nodules, lumps or, excoriated areas 9. Inspect salivary duct openings for any swelling or redness 10. Inspect the hard and soft palate for color, shape, texture and the presence of

Moves freely

Moves freely ; no tenderness Smooth tongue base with prominent veins

NORMAL

Unable to gather data

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Unable to gather data

Smooth with no palpable nodules

--

Unable to gather data Unable to gather data

Same as color of buccal mucosa and floor of the mouth Light pink, smooth, soft palate Lighter pink hard

--

--

bony prominences

palate, more irregular texture Positioned in the Positioned in midline midline of soft palate of soft palate Pink and smooth; No discharge

11. Inspect the uvula for position and mobility 12. Inspect the tonsils

--

Swollen tonsils

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ASSESSING THE NECK Muscles equal in 1. Inspect the neck muscles for abnormal size; head centered swellings or masses 2. Observe head movement 3. Palpate the entire neck for enlarged lymph nodes Unable to gather data Muscles equal in size; head centered Coordinated, smooth movements with no discomfort

NORMAL

--

Unable to gather data

Not palpable

--

4. Palpate the trachea for lateral deviation

Unable to gather data

Central placement in midline of neck; Spaces are equal on both sides Not visible on inspection

--

5. Inspect the thyroid gland 6. Palpate the thyroid gland for smoothness and areas of enlargement, masses or nodules

Unable to gather data

--

Lobes may not be palpated

Lobes may not be palpated

NORMAL

ASSESSING THE THORAX AND LUNGS 1. Inspect the shape and symmetry of the thorax. Compare the anteroposterior to the Unable to gather data Anteroposterior to transverse diameter in ratio of 1:2

--

transverse diameter Unable to gather data 2. Inspect the spinal alignment for deformities

Chest symmetric Spine vertically aligned Spinal column is straight, right and left shoulders and hips are at the same height Unable to gather data --

3. Palpate thorax for temperature and integrity of all chest skin 4. Palpate for tenderness and masses 5. Palpate the posterior chest for respiratory excursion

Skin intact; uniform temperature

--

Unable to gather data

No tenderness; no masses

--

Unable to gather data

Full and symmetric chest expansion Bilateral symmetry of vocal fremitus Fremitus is heard most clearly at the apex of the lungs

--

Unable to gather data 6. Palpate for vocal fremitus

--

7. Ausculcate the posterior thorax

Unable to gather data Quiet, rhythmic and effortless respirations Unable to gather data

Vesicular and bronchovesicular breath Quiet, rhythmic and effortless respirations uniform temperature No masses and tenderness;

--

8. Inspect breathing patterns 9. Palpate anterior posterior for temperature, tenderness and

NORMAL

--

masses 10. Assess anterior posterior for respiratory excursion Unable to gather data Full symmetric chest excursion; thumbs normally separate 35cm Same as posterior vocal fremitus; fremitus is normally decreased over heart and breast tissue Bronchial and tubular breath sounds Bronchovesicular and vesicular breath sounds

--

Unable to gather data 11. Palpate tactile fremitus

--

12. Auscultate the trachea

Unable to gather data

--

13. Auscultate the anterior chest

Wheezing sounds Heard at the anterior chest, barkng cough

--

ASSESSING THE HEART Unable to gather data Symmetric pulse volumes -Full pulsations, thrusting quality Unable to gather data Veins not visible No sound heard on auscultation Veins not visible --

1. Palpate carotid artery

2. Auscultate the carotid artery 3. Inspect jugular veins

NORMAL

ASSESSING THE ABDOMEN 1. Inspect the abdomen for skin integrity Unable to gather data Unblemished skin Uniform color Silver-white striae or --

surgical scars Unable to gather data 2. Inspect the abdominal contour and symmetry Flat, rounded (convex), or scaphoid (concave) No evidence of enlargement of liver and spleen Symmetric contour 3. Inspect the abdominal movements associated with respirations, peristalsis or aortic pulsations 4. Observe vascular patterns 8. Perform light palpation first to detect areas of tenderness and/or muscle guarding. 9. Palpate the liver to detect enlargement and tenderness Unable to gather data Symmetric movements, visible peristalsis in lean people aortic pulsations in thin persons Unable to gather data Unable to gather data No visible vascular pattern No tenderness; relaxed abdomen with smooth, consistent tension May not be palpable -Border feels smooth -Abdominal pain during palpation; patient exhibits guarding during palpation --

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Unable to gather data

ASSESSING THE MUSCULOSKELETAL SYSTEM 1. Inspect the muscle size. Compare the muscle on each side of the body to the same muscle on the other side 2. Inspect the muscle and tendons for Unable to gather data Equal size on both sides of body --

Unable to gather

No contractures

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contractures 3. Inspect the muscles for tremors 4. Palpate muscles at rest to determine muscle tonicity 5. Palpate muscles while the client is active and passive for flaccidity, spasticity and smoothness of movement 6. Test muscle strength. (Neck)

data Unable to gather data Unable to gather data No tremors -Firm; patient verbalizes pain during muscle palpation

Normally firm

Unable to gather data Smooth coordinated movement --

Unable to gather data

Equal strength on each side of the body Equal strength on each side of the body Equal strength on each side of the body No deformities

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7. Test for strength. (Upper extremities) 8. Inspect for strength. (Lower extremities) 9. Inspect the skeleton for structure 10. Palpate the bones to locate any areas of edema or tenderness 11. Inspect the joint for swelling. Palpate each joint for tenderness, smoothness of movement, swelling crepitation and

Equal strength on each side of the body Equal strength on each side of the body Unable to gather data Unable to gather data

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--

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No tenderness or swelling

--

Unable to gather data

No swelling No tenderness, swelling crepitation, or nodules

No swelling and tenderness; patient verbalizes pain during joint palpation

presence of nodules

Padagdag nalang po
Hoarseness of voice