PHYSICAL ASSESSMENT Date of Physical Assessment: November 23, 2011 5:00pm Height: 51 Weight: 47 kg.

Vital Signs: BP: 130/80 mmHg, lying Temperature: 36 Celsius Pulse rate: 89 bpm Respiratory rate: 20 cpm General survey: Method of Assessment Observe the clients overall hygiene and grooming Note body and breath odor Normal Findings Clean, neat Actual Findings Clean and neat

No body odor and breath odor

No manifestations of body and breath odor.

Observe for signs of distress in posture and facial expression

No distress noted

No distress noted

Note obvious signs of health or illness Assess the clients attitude Note the clients affect/mood ; assess the appropriateness of the clients responses Listen for quantity of speech, quality, and organization

Healthy appearance

The client shows weakness

Cooperative Appropriate to situation

The client is cooperative The clients manifests appropriation to situation

Understandable, moderate pace, exhibits thought association

Understandable, moderate pace, exhibit thought association

Listen for relevance and organization of thoughts

Logic sequence makes sense, has sense of reality

Logic sequence makes sense, has sense of reality

Body Parts Skin

Method of Assessment Inspection

Normal Findings Varies from light to deep brown, generally uniform except in areas exposed to the sun; areas of lighter pigmentation (palms, lips, nailbeds) Freckles, some birth marks, no abrasions ( Kozier and Erbs. techniques in clinical nursing. Physical health examination. P.58) No presence of edema Temperature is uniform Moisture in skin folds and axillae. When pinched, skin springs back to previous state.

Actual findings Brown color of the skin. No pigmentations. No birth marks and freckles. Bed soreon the sacral part, with OS dressing.

Analysis and Interpretation Poor circulation and prolong lying in beds contributes to poor wound healing and the development of bed sore. (medical-surgical vol.2,smeltzer,p.1194)

Palpation

No presence of edema Temperature is uniform Moisture in skin folds and axillae. When pinched, skin springs back to previous state.

Client manifest normal findings.

Hair

Inspection

Nails

Inspection

Resilient, evenly distributed and neither dry nor oily. Found all over the body except for the palms and sole of the feet. No presence of infestation of lice or sores. Convex curvature, angle of nail plate is about 160.

Hair is evenly distributed, it is oily. Hair is found all over the body except for the palms and sole of the feet. There is no presence of infestation of lice or sores seen by the patient. The curvature of the nails of the patient is convex, and its angle is about 160. Highly vascularized The nails are highly pink in light skinned vascularized and are color. pink in color. The blanch test was Prompt return of pink or done, nails returned to

Client manifests normal findings.

Client manifests normal findings.

usual color generally less than 4 seconds.

pink generally less than 4 seconds.

Palpation

Smooth, firm and nontender Capillary refill within three to four seconds

When palpated, the nails are smooth, firm and non-tender and its capillary refill is three seconds. The eyes of the patient are positioned symmetrically to each other, his eyebrows are in equal distribution, and his eyelashes are curl outwardly. No pigmentations, cloudiness or any presence of abnormal discharges are seen in the patients eyes. Pupils are equally rounded and are in normal sizes. Pupillary activity appears normal and is reactive to light. The pupils are equally rounded reactive to light and accommodation. Periorbital edema is seen due to fluid overload. The external surfaces of the ears are smooth and the size and shape of the ears is symmetrical and proportional to the head. The ears are in normal positioning. They are in line with the outer canthus of the eyes. No evidence of lesions, discharges, odor, bleeding, pain and pus. Ears are neither

Client manifests normal findings

Eyes

Inspection

Positioned symmetrical to each other The eyebrows have equal distribution The eyelashes curl outward There are no pigmentations, cloudiness or any presence of abnormal discharges in the eyes Pupils equally rounded and appear normal in size Pupillary activity appears normal

Client manifests normal findings

Ears

Inspection

The external surface of the ears should be smooth and the size and shape of the ears is symmetric and proportional to the head The ears are in normal positioning. They are in line with the outer canthus of the eyes There is no evidence of lesions, discharges, odor, bleeding, pain

Client manifests normal findings

and pus The ears are neither bulging nor perforated Head and Face Inspection The parts of the head and face is proportion to each other and symmetric Shape is gently curved with prominences at the frontal and parietal bones Symmetric facial movements Smooth uniform consistency; absence of nodules or masses The nose is at the midline with no presence of abnormal discharges and drainage Nose is symmetric and straight, no presence of discharges, no presence of lesions and uniform in color No swelling or redness of the nose. Nasal septum is not perforated.

bulging nor perforated. The client has no hearing aid and can hear normal voice tones The parts of the head and face are proportion to each other and are symmetrical. The shape is gently curved with prominences at the frontal and parietal bones. The patient has symmetric facial movements.

Client manifests normal findings

Palpation

Nose

Inspection

Smooth uniform consistency; absence of nodules or masses The nose of the patient is at the midline, there are no presence of abnormal discharges and drainage. The nose is symmetrical and straight, there is no presence of discharges, no lesion was seen and is uniform in color. The patient has no swelling or redness in the nose and his nasal septum is not perforated.

Client manifests normal findings Client manifests normal findings

Palpation

Frontal and maxillary sinuses not tender

Mouth, Throat, Neck

Inspection

The lips are pink, moist, smooth and are in normal symmetry The gums are pink and

When sinuses are palpated, there no tenderness reported on the maxillary and frontal area. The patients lips appear dark, moist, and smooth and are in normal symmetry, gums are pink and

Client manifests normal findings

Client manifests normal findings

smooth

smooth. The tongue is pink in color and is The tongue does not smooth; it has negative possess negative report of thrushes and thrushes and lesions lesions. No presence of odor was reported. Tongue is smooth and Tonsils are not is pink in color distended, the uvula is at midline. The color of There is no presence of the patients mouth is odor reddish to pinkish. Tonsils are not distended The uvula is at midline The mouth is generally reddish/pinkish in color There is no significant or palpable mass at the thyroid area JVD is not present The lymph nodes are not distended

Palpation

Upper extremities

Inspection

The trachea is palpable at the midline of the neck. No venous patterns, varicosities, rashes and ulcers

No significant or palpable mass was reported at the thyroid area, Jugular vein is not distended. Lymph nodes when palpated were not palpable or significantly distended. The trachea is palpable at the midline of the neck.

Client manifests normal findings.

No venous patterns, Client manifests normal varicosities, rashes and findings ulcers

Thorax and Lungs

Inspection

Chest is symmetric and skin is intact

Palpation

Quiet, rhythmic, and effortless respirations Temperature is uniform Chest wall is intact; no tenderness; no masses

Chest is symmetric and skin is intact, the respiratory rate of the patient is 20 cpm. Quiet, rhythmic, and effortless respirations Temperature is uniform Chest wall is intact; no tenderness and masses upon palpation.

Client manifests normal findings

Client manifests normal findings

Auscultation Heart Inspection

No adventitious breath sounds No visible lifts or heaves

No adventitious breath sounds No visible lifts or heaves

Client manifests normal findings Client manifests normal findings

Peripheral veins in dependent position, distention and nodular bulges at calves are present

Peripheral veins in dependent position, distention and nodular bulges at calves are present

Palpation

Full Pulsation

Has Full Pulsation

Client manifests normal findings

Auscultation

Breast

Inspection

S1; usually heard at all sites, usually louder at apical area S2; Usually heard at all sites, usually louder at base of heart Systolic; silent interval. Slightly shorter duration than diastole at normal heart rate Diastolic; silent interval. Slightly longer duration than systole at normal heart rates Breasts even with the Left brest absent, with chest wall and there scar. are presence of pigmentation Areola and nipples are rounded and dark brown Right breast, Areola and nipples are rounded and dark brown Right breast, No tenderness, masses, or nodules The abdomen is flat, and scaphoid and uniform in color, no lesion was seen and no

Left breast absent due to mastectomy (2008).

Client manifests normal findings Client manifests normal findings Client manifests normal findings

Palpation

No tenderness, masses, or nodules Flat and there are presence of pigmentation No lesions. Not visible

Abdomen

Inspection

peristaltic movements

visible peristaltic movements. Audible bowel sounds; Client manifests normal intermittent gurgling findings high pitched sound was heard. When auscultated, 23 were number of bowel sounds heard in one full minute. Tympany over the stomach and gas- filled bowels; dullness especially over the liver and spleen, or a full bladder No tenderness, relaxed abdomen with smooth, consistent tension Bladder and Liver is not palpable Muscles has equal size on both sides of the body, no contractures, no fasciculation, or tremors Bones has no deformities Joints has no swelling Muscles are firm, has smooth coordinated movements Bones has no tenderness and swelling Joints have no tenderness and swelling, crepitation or nodules. Joints moves smoothly No venous pattern, varicosities, no rashes and ulcers. Paraplegia was noted. Client manifests normal findings

Auscultation

Audible bowel sounds Not low-pitched and murmur sounds For bowel sounds, it is high pitched sound occur 5 to 30 times per minute

Percussion

Palpation

Tympany over the stomach and gas- filled bowels; dullness especially over the liver and spleen, or a full bladder No tenderness, relaxed abdomen with smooth, consistent tension Bladder and Liver is not palpable Muscles has equal size on both sides of the body, no contractures, no fasciculation, or tremors Bones has no deformities Joints has no swelling Muscles are firm, has smooth coordinated movements Bones has no tenderness and swelling Joints have no tenderness and swelling, crepitation or nodules. Joints moves smoothly No venous pattern, varicosities, rashes, ulcers

Client manifests normal findings

Musculoskeleta Inspection l

Client manifests normal findings

Palpation

Client manifests normal findings

Lower Extremities

Inspection

Paraplegia, paralysis of the legs may develop as a result of diseases of the spinal cord, In acute spinal cord

Palpation Neurologic System Inspection

Uniform temperature Glasgow coma scale is 15

Uniform temperature Glasgow coma scale of the patient was scored as 15. Positive reflexes such as biceps, triceps. There no brachioradialis, patellar, and achilles reflexes. Unable to assess

diseases, paralysis or weakness affects all muscles below a given level, often with a loss of sensation. Client manifests normal findings Client manifests normal findings No brachioradialis, patellar, and Achilles reflexes due to paraplegia.

Positive reflexes such as biceps reflex, triceps reflex, brachioradialis, patellar reflex and Achilles reflex

Rectum and Anus

Inspection

Intact perineal skin; usually slightly more pigmented than the skin of the buttocks. anal skin is normally more pigmented, coarser and moister than perianal skin and is usually hairless

Palpation

Anal sphincter has good tone Rectal wall is smooth and not tender Stool color is brown; consistency of the stool is formed semisolid and moist Stool odor is aromatic. No presence of blood

Unable to assess