Physical Assessment
I.
General Appearance / Survey
The client looks weak but ambulatory (with assistance) due to right side hemiplegia,
with contraptions of IVF-0.9NaCl 1L,@950cc level inserted at right metacarpal vein. He
is conscious and coherent, and eagerly participates and cooperates in activities.
II.
Measurement
Height: 55
Weight: 65 kg
III.
Vital Signs
NORMAL
FINDINGS
BP:
VITAL SIGNS
Systolic <120
Diastolic < 80
TEMP: 36.5-37.5 c
PR: 60-100bpm
RR: 12-20 cpm
O2 sat. : 97-100%
PATIENT
FINDINGS
BP=150/90 mmHg
T=36.3 C
PR=143bpm
RR=24 CPM
O2 sat. : 97%
IV.
ANALYSIS/
INTERPRETATION
Classified as
stage 1
hypertension
indicates
Tachycardia
indicates
Tachypnea
Cephalo-Caudal Assessment
Area of
Assessment
HEAD
Size, shape and
symmetry
Normal Findings
Round
(normocephalic)
Posterior and
anterior fontanelles
are closed No
depression upon
palpation
Actual Findings
Interpretation and
Analysis
Round
(normocephalic)
(+) parasagittal
suture upon
inspection ; 2-3
cm in length
Due to
history of
craniectomy
HAIR
Color
Brown/Black (*
Black with partial
hair color depends white strands of
normally on race
hair
and age)
Texture
Silky and Smooth
Distribution
Evenly Distributed
Silky and Smooth
Related to
aging
process
NORMAL
Evenly Distributed
FACE
Symmetrical
Symmetrical
- Cranial Nerve
VII: facial
asymmetry
Presence of
epidermoid cyst
at the forehead
at around 0.5
inches
Due to left
sided body
weakness
related to
stroke
Due to the
build-up of
keratin
EYES
EYEBROWS
Hair Distribution,
Alignment and
Appearance
Hair evenly
distributed
Hair evenly
distributed
Skin Intact
Skin Intact
Eyebrows
symmetrically
aligned
Eyebrows
symmetrically
aligned
NORMAL
EYELASHEs and
EYELIDS
Hair Distribution
Evenly Distributed
Evenly Distributed
NORMAL
Symmetry
Symmetrical
Symmetrical
NORMAL
Skin turgor
Intact
Intact and can
close eyelids
completely
NORMAL
Equally round and
of the same size
Equally round and
of the same size
Brown/ black
Brown/ black
Constricts
Pupils 2- 3 mm
reactive
Bulbar
conjunctiva is
clear with tiny
capillaries visible
Bulbar conjunctiva
is clear with tiny
capillaries visible
PUPILS
Size and color
Pupillary Reaction
to light
NORMAL
CONJUNCTIVA
SCLERA
Characteristics
and Appearance
Palpebral
conjunctiva is
pink
Palpebral
conjunctiva is pink
NORMAL
NORMAL
No discharge
No discharge
NORMAL
Anecteric Sclera
Anecteric Sclera
EARS
Color, Symmetry
& Position
Same as facial
skin
Texture &
Elasticity
Symmetrical
aligned with the
outer canthus of
eye
Presence of
discharge
Smooth & Firm
Pinna recoils after
it is folded
( - ) Negative
Skin Integrity
Same as facial skin
Symmetrical
aligned with the
outer canthus of
eye
Smooth & Firm
Pinna recoils after
it is folded
NORMAL
( - ) Negative
Without lesion
Without lesion
NOSE SEPTUM
Position
Midline
Midline
NORMAL
TURBINATES
Color and
Characteristics
Pinkish in color
Moist and Intact
Pinkish in Color
Contour is
symmetrical
Contour is
symmetrical
Moist and Intact
MOUTH
LIPS
Symmetry and
color
NORMAL
Uniform pink in
color
Uniform pink in
color
Moist
Moist
Pinkish in color
Pinkish in color
Color &
Characteristics
Color &
Characteristics
Moist
Mobility
Mobility
GUMS AND
BUCCAL
MUCOSA
Color and
characteristic
NORMAL
NORMAL
TONGUE
Presence of sore
(-) Negative
NORMAL
Pinkish in color
Can protrude
tongue
NORMAL
CN XII: Tongue at
the midline
( - ) Negative
NECK
Not Palpable
Not Palpable
NORMAL
LYMPH NODES
Not Palpable
Not Palpable
NORMAL
THYROID GLAND
Not Distended
Not Distended
NORMAL
Pinkish and
Smooth
(+) Dry skin
JUGULAR VEIN
SKIN
Color & Texture
(+) pallor
Related to aging
process
- Due to localized
poor blood
circulation
NAILS
Color
Pinkish
(+)pale nail bed
Smooth and
convex in
curvature
Smooth and
convex in
curvature
No adventitious
sounds
Normal breath
sounds
( - ) Mucus and
clear airway
passage
(+) Crackles upon
Auscultation
Symmetrical chest
expansion
Symmetrical chest
expansion
( - ) Negative
( - ) negative
( - ) Negative
( - ) negative
N/A
( - ) negative
Shape and Texture
Due to
localized
poor blood
circulation
NORMAL
CHEST/LUNGS
Breath Sounds
Mucus secretions
Respiratory
movement (Chest
expansion)
Use of accessory
muscles
Shortness of
Breath
Presence of chest
pain
NORMAL
- Due to
presence of
mucus
secretions
NORMAL
NORMAL
NORMAL
NORMAL
HEART APICAL
PULSE
Location
Precordium
5th intercostal
space, left
midclavicular line
5th intercostal
space, left
midclavicular line
Adynamic
Precordium
Adynamic
Precordium
(+) regular
irregular rhythm
NORMAL
NORMAL
-
Due to an
error in a
hearts
electrical
impulses
ABDOMEN
Symmetry and
contour
Abdominal
Sounds
Symmetrical/ Flat
abdominal
contour
Normoactive
sounds
UPPER AND
Distended
abdomen
- dull sounds
upon auscultation
- Hyper-active
Bowel Sounds
-Due to altered
bowel movement
LOWER
EXTREMITIES
FINDINGS
Presence of
Lesions
Presence of
Edema
( - ) Negative
( - ) Negative
(+) bruise on right
antecubital fossa
of around 0.3mm
(+) non-pitting
edema on left arm
Due IV
insertion
Due to
localized
poor blood
circulation
Flaccid, Due
to left sided
hemiplegia
Motor response:
RA 5/5
RL 5/5
LA 1/5
LL 1/5
