You are on page 1of 8

Physical Assessment

Integument

Skin: The clients skin is uniform in color, unblemished and no presence of any foul odor.
He has a good skin turgor and skins temperature is within normal limit.

Hair: The hair of the client is thick, silky hair is evenly distributed and has a variable
amount of body hair. There are also no signs of infection and infestation observed.

Nails: The client has a light brown nails and has the shape of convex curve. It is smooth
and is intact with the epidermis. When nails pressed between the fingers (Blanch Test),
the nails return to usual color in less than 4 seconds.

Head

Head: The head of the client is rounded; normocephalic and symmetrical.

Skull: There are no nodules or masses and depressions when palpated.

Face: The face of the client appeared smooth and has uniform consistency and with no
presence of nodules or masses.

Eyes and Vision

Eyebrows: Hair is evenly distributed. The clients eyebrows are symmetrically aligned
and showed equal movement when asked to raise and lower eyebrows.

Eyelashes: Eyelashes appeared to be equally distributed and curled slightly outward.

Eyelids: There were no presence of discharges, no discoloration and lids close


symmetrically with involuntary blinks approximately 15-20 times per minute.

Eyes
o The Bulbar conjunctiva appeared transparent with few capillaries evident.
o The sclera appeared white.
o The palpebral conjunctiva appeared shiny, smooth and pink.
o There is no edema or tearing of the lacrimal gland.

o Cornea is transparent, smooth and shiny and the details of the iris are visible. The
client blinks when the cornea was touched.
o The pupils of the eyes are black and equal in size. The iris is flat and round.
PERRLA (pupils equally round respond to light accommodation), illuminated and
non-illuminated pupils constricts. Pupils constrict when looking at near object and
dilate at far object. Pupils converge when object is moved towards the nose.
o When assessing the peripheral visual field, the client can see objects in the
periphery when looking straight ahead.
o When testing for the Extraocular Muscle, both eyes of the client coordinately
moved in unison with parallel alignment.
o The client was able to read the newsprint held at a distance of 14 inches.
Ears and Hearing

Ears: The Auricles are symmetrical and has the same color with his facial skin. The
auricles are aligned with the outer canthus of eye. When palpating for the texture, the
auricles are mobile, firm and not tender. The pinna recoils when folded. During the
assessment of Watch tick test, the client was able to hear ticking in both ears.

Nose and Sinus

Nose: The nose appeared symmetric, straight and uniform in color. There was no
presence of discharge or flaring. When lightly palpated, there were no tenderness and
lesions

Mouth:
o The lips of the client are uniformly pink; moist, symmetric and have a smooth
texture. The client was able to purse his lips when asked to whistle.
o Teeth and Gums: There are no discoloration of the enamels, no retraction of
gums, pinkish in color of gums
o The buccal mucosa of the client appeared as uniformly pink; moist, soft,
glistening and with elastic texture.
o The tongue of the client is centrally positioned. It is pink in color, moist and
slightly rough. There is a presence of thin whitish coating.
o The smooth palates are light pink and smooth while the hard palate has a more
irregular texture.

o The uvula of the client is positioned in the midline of the soft palate.

Neck:
o The neck muscles are equal in size. The client showed coordinated, smooth head
movement with no discomfort.
o The lymph nodes of the client are not palpable.
o The trachea is placed in the midline of the neck.
o The thyroid gland is not visible on inspection and the glands ascend during
swallowing but are not visible.

Thorax, Lungs, and Abdomen

Lungs / Chest: The chest wall is intact with no tenderness and masses. Theres a full and
symmetric expansion and the thumbs separate 2-3 cm during deep inspiration when
assessing for the respiratory excursion. The client manifested quiet, rhythmic and
effortless respirations.

The spine is vertically aligned. The right and left shoulders and hips are of the same
height.

Heart: There were no visible pulsations on the aortic and pulmonic areas. There is no
presence of heaves or lifts.

Abdomen: The abdomen of the client has an unblemished skin and is uniform in color.
The abdomen has a symmetric contour. There were symmetric movements caused
associated with clients respiration.
o The jugular veins are not visible.
o When nails pressed between the fingers (Blanch Test), the nails return to usual
color in less than 4 seconds.

Extremities

The extremities are symmetrical in size and length.

Muscles: The muscles are not palpable with the absence of tremors. They are normally
firm and showed smooth, coordinated movements.

Bones: There were no presence of bone deformities, tenderness and swelling.

Joints: There were no swelling, tenderness and joints move smoothly.

Nursing Assessment in Tabular Form


Assessment

Findings

Integumentary

Skin

Hair

Nails

Skull
Face

When skin is pinched it goes to previous state


immediately (2 seconds).
With fair complexion.
With dry skin
Evenly distributed hair.
With short, black and shiny hair.
With presence of pediculosis Capitis.
Smooth and has intact epidermis
With short and clean fingernails and toenails.
Convex and with good capillary refill time of 2
seconds.
Rounded, normocephalic and symmetrical,
smooth and has uniform consistency.Absence of
nodules or masses.
Symmetrical facial movement, palpebral
fissures equal in size, symmetric nasolabial
folds.

Eyes and Vision

Eyebrows

Hair evenly distributed with skin intact.


Eyebrows are symmetrically aligned and have
equal movement.

Eyelashes

Equally distributed and curled slightly outward.

Eyelids

Skin intact with no discharges and no


discoloration.
Lids close symmetrically and blinks
involuntary.

Bulbar conjunctiva

Transparent with capillaries slightly visible

Palpebral Conjunctiva

Shiny, smooth, pink

Sclera

Appears white.

Assessment

Findings

Lacrimal gland, Lacrimal sac,


Nasolacrimal duct

No edema or tenderness over the lacrimal gland


and no tearing.

Clarity and texture

Transparent, smooth and shiny upon inspection


by the use of a penlight which is held in an
oblique angle of the eye and moving the light
slowly across the eye.
Has [brown] eyes.

Corneal sensitivity

Blinks when the cornea is touched through a


cotton wisp from the back of the client.

Cornea

Pupils

Visual Fields

Visual Acuity

Black, equal in size with consensual and direct


reaction, pupils equally rounded and reactive to
light and accommodation, pupils constrict when
looking at near objects, dilates at far objects,
converge when object is moved toward the nose
at four inches distance and by using penlight.
When looking straight ahead, the client can see
objects at the periphery which is done by
having the client sit directly facing the nurse at
a distance of 2-3 feet.
The right eye is covered with a card and asked
to look directly at the student nurses nose. Hold
penlight in the periphery and ask the client
when the moving object is spotted.
Able to identify letter/read in the newsprints at
a distance of fourteen inches.
Patient was able to read the newsprint at a
distance of 8 inches.

Ear and Hearing

Auricles

Color of the auricles is same as facial skin,


symmetrical, auricle is aligned with the outer
canthus of the eye, mobile, firm, non-tender,
and pinna recoils after it is being folded.

External Ear Canal

Without impacted cerumen.

Hearing Acuity Test

Voice sound audible.

Assessment

Watch Tick Test

Findings
Able to hear ticking on right ear at a distance of
one inch and was able to hear the ticking on the
left ear at the same distance

Nose and sinuses

External Nose

Symmetric and straight, no flaring, uniform in


color, air moves freely as the clients breathes
through the nares.

Nasal Cavity

Mucosa is pink, no lesions and nasal septum


intact and in middle with no tenderness.

Mouth and Oropharynx

Symmetrical, pale lips, brown gums and able to


purse lips.

Teeth

With dental caries and decayed lower molars

Tongue and floor of the mouth

Central position, pink but with whitish coating


which is normal, with veins prominent in the
floor of the mouth.

Tongue movement

Moves when asked to move without difficulty


and without tenderness upon palpation.

Uvula
Gag Reflex
Neck
Head movement
Muscle strength
Lymph Nodes

Thyroid Gland

Thorax and lungs


Posterior thorax

Spinal alignment

Breath Sounds

Anterior Thorax

Positioned midline of soft palate.


Present which is elicited through the use of a
tongue depressor.
Positioned at the midline without tenderness
and flexes easily. No masses palpated.
Coordinated, smooth movement with no
discomfort, head laterally flexes, head laterally
rotates and hyperextends.
With equal strength
Non-palpable, non tender
Not visible on inspection, glands ascend but not
visible in female during swallowing and visible
in males.
Chest symmetrical
Spine vertically aligned, spinal column is
straight, left and right shoulders and hips are at
the same height.
With normal breath sounds without dyspnea.
Quiet, rhythmic and effortless respiration

Assessment

Abdomen
Abdominal movements

Auscultation of bowel sounds

Upper Extremities
Lower Extremities
Muscles
Bones and Joints
Mental Status
Language
Orientation
Attention span
Level of Consciousness

Findings

Unblemished skin, uniform in color, symmetric


contour, not distended.
Symmetrical movements cause by respirations.
With audible sounds of 23 bowel
sounds/minute.
Without scars and lesions on both extremities.
With minimal scars on lower extremities
Equal in size both sides of the body, smooth
coordinated movements, 100% of normal full
movement against gravity and full resistance.
No deformities or swelling, joints move
smoothly.
Can express oneself by speech or sign.
Oriented to a person, place, date or time.
Able to concentrate as evidence by answering
the questions appropriately.
A total of 15 points indicative of complete
orientation and alertness.

Motor Function
Gross Motor and Balance

Walking gait

Standing on one foot with eyes closed


Heel toe walking
Toe or heel walking
Fine motor test for Upper Extremities
Finger to nose test
Alternating supination and pronation of hands
on knees
Finger to nose and to the nurses finger
Fingers to fingers
Fingers to thumb
Fine motor test for the Lower Extremities
Pain sensation

Has upright posture and steady gait with


opposing arm swing unaided and maintaining
balance.
Maintained stance for at least five (5) seconds.
Maintains a heel toe walking along a straight
line
Able to walk several steps in toes/heels.
Repeatedly and rhythmically touches the nose.
Can alternately supinate and pronate hands at
rapid pace.
Perform with coordinating and rapidity.
Perform with accuracy and rapidity.
Rapidly touches each finger to thumb with each
hand.
Able to discriminate between sharp and dull

Assessment

Findings
sensation when touched with needle and cotton.