Physical Assessment

NAME: Client X AGE: WEIGHT: 48 kgs. HEIGHT: 54 Vital Signs: PR: 80 bpm RR: 17 cpm PARTS TO BE TECHNIQUE ASSESSED GENERAL APPEARANCE 1. Body built, height, Inspect and weight in relation to clients age, lifestyle and health 2. Clients posture and gait standing, sitting and walking 3. Clients overall hygiene and grooming 4. Body and breath odor Inspect DATE: January 20, 2012 GENDER: Female

TEMPERATURE: 36.4 C BP: 90/70 mmHg NORMAL FINDINGS ACTUAL FINDINGS REMARKS INTERPRETATION

Inspect

Proportionate, varies with lifestyle. WEIGHT: 48 kgs. HEIGHT: 54 BMI: 16.99 (underweight) Relaxed, erect posture, Erect posture when coordinated movements, sitting and standing, slow standing erect/ straight. movement Clean, neat. Tidy. Nails are always cut. No body odor or minor body odor relative to work or exercise; no breath odors. No distress noted. No body and breath odor.

NORMAL NORMAL The client always doing hygienic practices. The client always doing hygienic practices. The clients always keep on smiling.

Inspect

NORMAL

5. Signs of distress in posture or facial expression

Inspect

No distress noted. NORMAL

6. Obvious signs of health or illness 7. Clients attitude 8. Clients affect/ mood; appropriateness of the clients response 9. Quantity of speech, quality and organization 10. Relevance and organization of thoughts SKIN 1. Skin color and uniformity

Inspect

Healthy appearance.

Inspect Inspect

Cooperative. Appropriate to situation.

Not healthy appearance due to having pale palm lips and eyes. Cooperative and pleasant. Appropriate to situation; not moody. Understandable.

DEVIATION

NORMAL NORMAL

Inspect

Inspect

Understandable, moderate pace; exhibits thought association. Logical sequence; makes sense; has sense of reality. 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, lip, nail, beds) in darkskinned people. No edema. Freckles, some birthmarks, some flat and raised nevi; no abrasions or other lesions. Moisture in skin folds and the axillae (varies with the environment

NORMAL Has sense of reality NORMAL

Inspect

Light brown; Generally uniform. NORMAL

2. Presence of edema 3. Skin lesions

Inspect and palpate Inspect, palpate

No Edema present on feet. No lesions or abrasions

NORMAL

NORMAL

4. Skin moisture

Palpate

Appropriate in the temperature of the place, dry.

NORMAL

5. Skin temperature 6. Skin turgor

Palpate Palpate

temperature and humidity; body temperature and activity) Uniform temperature; within normal range. When pinched, skin spring back to previous state. Convex curvature; angle of nail plate about 160. Highly vascular and pink and light-skinned client; dark-skinned clients may have brown or black pigmentation in longitudinal streaks. Intact epidermis. Smooth texture. Prompt return of pink or usual color generally before 4 seconds. Evenly distributed over the scalp. Thick hair. No infections or infestations.

Warm, uniform temperature. When pinched; skin spring back to previous state easily. Convex curvature; angle of nail plate is 160. Pale in color.

NORMAL NORMAL

NAILS 1. Fingernails plate Inspect shape to determine its curvature and angle 2. Fingernail and toe Inspect nail bed color

NORMAL

DEVIATION

3. Tissues surroundings Inspect nails 4. Fingernail and toenail Inspect texture 5. Blanch test of Inspect capillary refill HAIR AND SCALP 1. Evenness of growth over the scalp 2. Hair thickness or thinness 3. Presence of infections or infestations

Intact epidermis noted. Fingernail and toe nails are smooth in texture. Did not return in usual color.

NORMAL NORMAL

DEVIATION

Inspect Inspect Inspect

Evenly distributed over the scalp noted. Thick hair. No infections; no infestations

NORMAL NORMAL NORMAL

4. Texture and oiliness over the scalp SKULL 1. Size, shape and symmetry.

Palpate

Silky, resilient hair.

Silky, resilient hair

NORMAL

Inspect

2. Nodules or masses and depressions FACE 1. Facial Features

Palpate

Rounded (normocephalic and symmetrical, with frontal, parietal, and occipital prominences); smooth skull contour. Smooth, uniform consistency; absence of nodules or masses. Symmetric or slightly symmetric facial features; palpebral fissures equal in size Symmetric nasolabial folds.

Rounded and symmetrical with fontal, parietal, and occipital prominences; smooth skull contour. Smooth; no depressions, no nodules and masses noted. Facial hair increases; slightly symmetric facial features. Symmetric facial movements.

NORMAL

NORMAL

Inspect

NORMAL

2. Symmetry of the facial movements EYEBROWS AND EYELASHES 1. Evenness of distribution and direction of curl EYELIDS 1. Surface characteristics and ability to blink CONJUCTIVA 1. Bulbar conjunctivas color, texture and presence of lesions 2. Palpebral

Inspect

NORMAL

Inspect

Hair evenly distributed; Hair evenly distributed; skin intact; slightly curled skin intact; slightly curled outward. outward, eyelashes shed. Skin intact; no discharges; no discolorization; lids close symmetrically. Transparent; capillaries sometimes evident. Shiny, smooth; pink or Appear symmetrical with no drooping.

NORMAL

Inspect

NORMAL

Inspect

Transparent; capillaries evident noted. Slightly pale in color.

NORMAL

Inspect

conjunctivas color, texture and presence of lesions SCLERA 1. Color and clarity CORNEA 1. Clarity and color

red; sclera appears white (yellowish in darkskinned clients). Inspect Inspect White or yellowish. Transparent, shiny, and smooth; details of the iris are visible. Flat and round. Clear and white Transparent, shiny, and smooth; details of the iris are visible noted. Flat, deep black and round. Black in color; equal in size; round, smooth border, iris flat and round. Pupils constrict when looking at near object; pupils dilate when looking at far object.

NORMAL

NORMAL

NORMAL

IRIS 1. Shape and color PUPILS 1. Color, shape and symmetry of size

Inspect

NORMAL

Inspect

2. Pupil light reaction and accommodation

Inspect

3. Pupils direct and consensual reaction to light

Inspect

Black in color; equal in size; normally 3 to 7mm in diameter; round, smooth border, iris flat and round. Pupils constrict when looking at near object; pupils dilate when looking at far object; pupils converge when near object is moved toward nose. Illuminated pupil constricts (direct response); nonilluminated pupil constricts (consensual response). Able to read newsprint.

NORMAL

NORMAL

Illuminated pupil constricts; nonilluminated pupil constricts.

NORMAL

VISUAL ACUITY 1. Test near vision

Inspect

Able to read newsprint.

NORMAL

2. Test distance vision

Inspect

20/20 vision on Snellen Chart.

She can read any newsprint without eyeglasses.

NORMAL

LACRIMAL GLAND, LACRIMAL SAC AND NASOLACRIMAL DUCT 1. Presence of edema

Inspect and palpate

No edema or tenderness over lacrimal gland; no tearing.

No edema or tenderness over lacrimal gland; there is no tearing.

NORMAL

EXTRAOCULAR MUSCLES 1. Test each eye for alignment and coordination VISUAL FIELDS 1. Test for peripheral visual fields EARS AURICLES 1. Color and symmetry of size and position

Inspect

Both eyes coordinated, move in unison, with parallel alignment.

Both eyes coordinated, move in unison, coordinated movements with parallel alignment. When looking straight ahead, client can see objects in the periphery. Deep brown; auricles aligned with the outer cantus of the eye.

NORMAL

Inspect

When looking straight ahead, client can see objects in the periphery. Color same as facial skin; symmetrical; auricles aligned with the outer cantus of the eyes, about 10 from vertical. Mobile, firm, and not tender; pinna recoils after it is folded.

NORMAL

Inspect

NORMAL

2. Texture, elasticity and areas of tenderness

Palpate

Mobile, elastic, firm and not tender, no lesions, pinna recoils after it is folded. Dry cerumen.

NORMAL

EXTERNAL EAR CANAL 1. Cerumen, skin Inspect lesions, pus and blood

Dry cerumen, grayish-tan color; or sticky, wet cerumen in various

NORMAL

shades of brown. HEARING ACUITY TEST 1. Clients response to Inspect normal voice tones 2. Perform watch tick test NOSE 1. Shape, size or color and flaring or discharge from the nares 2. Presence of redness, swelling, growths and discharge of nares using the flashlight 3. Position of nasal septum 4. Test patency of both nasal septum Inspect Normal voice tone audible. Able to hear the ticking of watch in both ears. The normal voice tone is not audible. Able to hear the ticking of watch in both ears when tested. Symmetric and straight, uniform color, with no discharges or flaring. Mucosa pink, clear, watery discharges, no lesions noted. Intact and in the midline. The air moves freely as the client breathes through the nares. Not tender; no lesions noted.

DEVIATION

NORMAL

Inspect

Symmetric and straight, uniform color, no discharges or flaring. Mucosa pink, clear, watery discharges, no lesions. Intact and in the midline. Air moves freely as the client breathes through the nares. Not tender; no lesions.

NORMAL

Inspect

NORMAL

Inspect Inspect

NORMAL

NORMAL

5. Tenderness, masses Lightly palpate and displacement of bone and cartilage SINUSES 1. Presence of Palpate tenderness LIPS 1. Symmetry of contour, Inspect color and texture

NORMAL

Not tender.

No tenderness.

NORMAL

Uniform pink color (freckled brown pigmentation in dark skinned clients), soft,

Uniform, pale in color, slightly dry, can purse lip.

NOT NORMAL

moist, smooth texture, symmetry of contour, ability to purse lips. BUCCAL MUCOSA 1. Color, moisture, texture and the presence of lesions Inspect and palpate Moist, smooth, soft, Pale in color. glistening, and elastic texture (drier oral mucosa in elderly due to decreased salvation). 32 adult teeth; smooth, white, shiny tooth enamel. 28 permanent teeth, yellowish

DEVIATION

TEETH 1. Inspect for color, Inspect number and condition and presence of dentures GUMS 1. Color and condition Inspect

DEVIATION

Pink gums (bluish or dark Pale in color. patches in dark-skinned client), moist, firm texture to gums, no retraction of gums (pulling away from the teeth).

DEVIATION

TONGUE/FLOOR OF THE MOUTH 1. Color and texture of the mouth floor and frenulum 2. Position, color and texture, movement and base of the tongue

Inspect and palpate

Inspect

Smooth with no palpable noodles, same as color of Buccal mucosa and floor of mouth. Central position; pink color (some brown pigmentation on tongue borders in the darkskinned clients); rough;

Smooth with no palpable noodles.

NORMAL

Smooth tongue base with prominent veins; raised papillae; has a thin whitish coating moves freely without

NORMAL

thin whitish coating, moves freely; no tenderness, smooth tongue base with prominent veins. PALATES AND UVULA 1. Color, shape, texture and the presence of bony prominences 2. Position of the uvula and mobility ORPHARYNX AND TONSILS 1. Color and texture 2. Size of the tonsils, color and discharge 3. Gag reflex NECK AND LYMPH NODES 1. Symmetry and visible mass in the thyroid gland 2. Presence of tenderness or nodules in the lymph nodes 3. Placement of the trachea 4. Smoothness and areas of enlargement, masses or nodules in Inspect Light pink, smooth, soft palate; light pink hard palate, more irregular texture. Positioned in midline of soft palate.

discomfort.

Light pink, smooth soft palate, dark pink hard palate more irregular. It is positioned in midline of soft palate.

NORMAL

Inspect

NORMAL

Inspect Inspect Inspect

Pink and smooth posterior wall. Pink and smooth; no discharges, normal size. Present Gag reflex.

Pink and smooth posterior wall. Normal in size, no discharges pink; smooth. Present Gag reflex noted.

NORMAL NORMAL NORMAL

Inspect

Muscle equal in size; head centered. Not palpable.

Muscle equal in size. NORMAL Not palpable. NORMAL

Palpate

Palpate

Palpate

Central placement in midline of neck; spaces are equal in both sides. Lobes may not be palpated, if palpated, lobes are small, smooth,

Tracheal is positioned in the suprasternal notch. Thyroid gland is normal; rise freely with swallowing, not visible.

NORMAL

NORMAL

the thyroid gland

centrally located, painless, and rise freely with swallowing. Inspect Anteroposterior to transverse diameter in ratio of 1:2; chest symmetric. Spine vertically aligned; spinal column is straight, right and left shoulders and hips are at the same height. Quiet, rhythmic, and effortless respirations. Full and symmetric chest expansion (i.e., when client takes a deep breath, your thumbs should move apart an equal distance and at the same time). Skin intact; uniform temperature. Bilateral symmetry of vocal fremitus; fremitus is heard most clearly at the apex of the lungs. Percussion notes resonate except over scapula. Vesicular and Chest symmetric. NORMAL

POSTERIOR THORAX 1. Shape, symmetry, and compare the diameter of anteroposterior thorax to transverse diameter 2. Spinal alignment

Inspect

Spinal column is straight, right and left shoulders and hips are at the same height. Effortless respiration. Full symmetric excursion; thumbs separate at 4cm.

NORMAL

3. Breathing pattern

Inspect

NORMAL

4. Respiratory excursion Palpate

NORMAL

5. Temperature, tenderness, masses 6. Vocal fremitus

Palpate Palpate

7. Percuss the posterior thorax 8. Auscultate the

Percuss

Auscultate

Warm, skin intact; uniform temperature. Bilateral symmetry of vocal fremitus; fremitus is heard most clearly at the apex of the lungs; no pulsation. The percussion notes resonate except over scapula. Bronchovesticular are

NORMAL

NORMAL

NORMAL

posterior thorax

bronchovesticular breathe sounds.

heard between the scapulae vesicular over the apex of the lungs down to the base and lateral. Effortless respiration. Warm, skin intact; uniform temperature. Full symmetric excursion; thumbs normally separate at 4cm. Fremitus is normally decrease over heart and breast tissue same posterior vocal fremitus. Percussion notes resonate down to the sixth rib at the level of the diaphragm but are flat over areas of heavy muscle.

NORMAL

ANTERIOR THORAX 1. Breathing pattern

Inspect

2. Temperature, Palpate tenderness, masses 3. Respiratory excursion Palpate

4. Vocal fremitus

Palpate

5. Percuss the anterior thorax

Percuss

6. Auscultation of the trachea 7. Auscultation of the anterior thorax

Auscultate Auscultate

Quiet, rhythmic, and effortless respirations. Skin intact; uniform temperature. Full symmetric excursion; thumbs normally separate 2cm to 5cm. Same as posterior vocal fremitus; fremitus is normally decreased over heart and breast tissue. Percussion notes resonate 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. Brochial and tubular breath sounds. Brochovesticular and vesticular breathe sounds.

NORMAL NORMAL

NORMAL

NORMAL

NORMAL

Tracheal sounds heard with high pitched. Brochovesticular heard laterally over the angle of Louis; vesicular sound

NORMAL

NORMAL

over most of the anterior thorax and the periphery. CAROTID ARTERIES 1. Pulsation of carotid arteries 2. Auscultation of the carotid arteries JUGULAR VEINS 1. Visibility of jugular veins Palpate Symmetric pulse volumes; full pulsations, thrusting quality. No sound heard on auscultation. Veins not visible (indicating right side of heart is functioning normally). Rounded shape, slightly unequal in size, generally symmetric. No presence of edema. Equal in size, round or oval and bilaterally the same, color varies widely from light pink to dark brown. Equal in size, round everted, nipples point in same direction, similar in color, no discharge except from pregnant or breastfeeding females. No tenderness, masses or nodules, skin uniform in color, smooth and intact. Symmetric pulse volumes; full pulsations, thrusting quality noted. No sound heard.

NORMAL NORMAL

Auscultate

Inspect

Veins not visible. NORMAL

BREAST AND AXILLAE 1. Breast (size, symmetry, shape) 2. Breast (swelling or edema) 3. Areola (size, shape, color)

Inspect

Refused by the Client

Inspect Inspect

Refuse by the Client

Refuse by the Client

4. Nipples (size, color, shape, position, discharge)

Inspect

Refuse by the Client

5. Breast ( color, texture, for masses, tenderness)

Inspect and palpate

Refuse by the Client

6. Vascular pattern

Inspect

7. Lymph nodes ABDOMEN 1. Skin integrity

Palpate

Diffuse symmetric horizontal or vertical vascular pattern in light skinned people. No tenderness, masses or nodules. Unblemished skin; uniform color; silverwhite striae (stretch marks) or surgical scars. Presence of stretched mark at the abdomen; presence of Linea Nigra.

Refuse by the Client

Refuse by the Client

Inspect

NORMAL

Stretch Mark is normal because the skin is stretch due to pregnancy, Linea Nigra is caused by hormones responsible that caused the darkness of the areola.

2. Abdominal contour

Inspect

Flat, rounded (convex), or scaphoid (concave).

Scaphoid. NORMAL

3. Enlarged liver or spleen 4. Symmetry of contour 5. Abdominal movements

Inspect

Inspect Inspect

6. Vascular patterns 7. Auscultate the abdomen for bowel

Inspect Auscultate

No evidence of enlargement of liver or spleen. Symmetric contour. Symmetric movements caused by respiration; visible peristalsis in very lean people; aortic pulsation in thin persons at epigastric area. No visible vascular patterns. Audible bowel sounds, absence of arterial bruits,

No evidence of enlargement of liver or spleen noted. Symmetric contour. Symmetric movements caused by respiration.

NORMAL

NORMAL

NORMAL

No visible vascular patterns. Audible bowel sounds, absence of arterial bruits,

NORMAL

NORMAL

sounds, vascular sounds and peritoneal friction rubs 8. Percuss abdominal quadrants

absence of friction rub.

absence of friction rub.

Percuss

9. Light palpation of abdominal quadrants MUSCULOSKELETAL SYSTEM 1. Muscle size, compare the muscles on one side of the body (arm, thigh, calf) to the same muscle on the other side 2. Contractures (shortening) of the muscles and tendons 3. Muscle fasciculation and tremors. Presence of tremors of the hands and arms when stretched in front of the body 4. Muscle tonicity 5. Muscle strength BONES

Palpate

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.

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 noted.

NORMAL

NORMAL

Inspect

Equal size on both sides of body.

Equal size on both sides. NORMAL

Inspect

No contractures.

No shortening. NORMAL

Inspect

No tremors or fasciculation.

No tremors or fasciculation. NORMAL

Palpate Inspect

Normally firm. Equal strength on each body side.

Firm. Equal strength on each body side.

NORMAL NORMAL

1. Normal structure 2. Tenderness JOINTS 1. Swelling 2. Presence of tenderness, smoothness of movement, swelling, crepitation, and presence of nodule RANGE OF MOTION 1. Upper extremities

Inspect Palpate Inspect Palpate

No deformities. No tenderness. No swelling. No tenderness, swelling, crepitation or nodules.

No deformities noted. No tenderness noted. Joints widens, no swelling. Presence of tenderness in the joints in the knees, no presence of nodules and swelling.

NORMAL NORMAL NORMAL NORMAL

Inspect

2. Lower extremities

Inspect

Was able to perform full ROM without discomfort, strong arm muscle. Was able to extend, flex, internal rotate and external rotate, circumduction.

NORMAL

NORMAL