Physical Assessment

Date of assessment: General appearance:

Vital sign: Temperature: Pulse rate: Respiratory rate: blood pressure:

Area assessed SKIN Color

Method used Inspection

Normal findings It is normally consistent with genetic and racial background and varies from light to dark brown Feels smooth and firm with even surface Uniform within normal range When pinched, skin goes back to previous state in 1-3 seconds Freckles, some birthmarks, some flat and raised nevi, no abrasions or other lesions Generally uniform except in areas exposed to sun: areas of lighter pigmentation (palms, lips, nail beds) in dark skinned people Pale

Actual findings

Analysis

Texture

Palpation

Smooth and Firm

Temperature Mobility and turgor

Palpation Palpation

37C When pinched, skin goes back to previous state in 2 seconds No abrasion or lesions

Lesions

Inspection

Uniformity

Inspection

Generally uniform except in areas exposed to sun: areas of lighter pigmentation (palms, lips, nail beds) in dark skinned people

Moisture

Inspection and Palpation

Thickness

Palpation and inspection

Moisture in the skin folds and axilla (varies with environmental temperature and humidity, body temp. and activity) Epidermis is uniformly thin, thickened callous normal in palms and soles of feet Pinkish Convex curve (160 degrees) Smooth Intact epidermis Prompt return of or usual color ( 1-2 seconds) Varies from race Evenly distributed No infestation No seborrhea and symmetrical No lesions and lumps Smooth and firm Appropriate with age and size; Round and no bulging and swelling Symmetrical features, symmetrical at rest Equally distributed Eyebrows moves the same way Aligned

Absence of moisture in the skin folds and axilla

The patients epidermis is uniformly thin and smooth

NAILS Color (nail bed) Shape Texture Tissue surrounding nail Capillary refill test HAIR Color Distribution Presence of parasites SCALP Appearance Texture HEAD Size, circumference and Shape FACE Symmetry, movements EYEBROWS Distribution Quality of movement Alignment

Inspection Inspection Inspection Palpation Palpation

Pale Convex curve smooth Intact epidermis Returns in 4 seconds

Inspection Inspection Inspection Inspection Inspection and palpation Palpation Inspection

Black Hair is evenly distributed Absence of infestation Presence of Sebborhea Absence of lesions and lumps Smooth and firm Round and no bulging and swelling

Inspection

Symmetrical features, symmetrical at rest Eyebrows equally distributed Eyebrows moves the same way Aligned

Inspection Inspection Inspection

Evenness Direction of growth EYELIDS Ability to blink Appearance EYES Color Conjunctiva CORNEA Appearance PUPILS Color Shape Symmetry of size PERRLA Accommodation

Inspection Inspection Inspection Inspection Inspection Inspection Inspection

Equally distributed Curled slightly outward Has the ability to blink ; 15-20 blinks/ min. No edema White sclera Pink palpebral conjunctiva Transparent, shiny and smooth; details of the iris is visible Black or brown; according to race ; no cloudiness Rounded Symmetrical Pupils dilate when focusing far objects; converge and constricts when focusing near objects Illuminated pupil constricts and non illuminated pupil constricts When looking straight ahead, the person can see objects in the periphery The eyes move in a coordinated manner and in a vision alignment Client reads print at 14 inches without difficulty Same color as the facial skin Lateral with the eyebrows and auricles, in line with the outer

Equally distributed Curled slightly outward 18 blinks/min Absence of edema White sclera Ping palpebral conjunctiva Transparent, shiny and smooth; details of the iris is visible black color with no cloudiness Rounded Symmetrical Pupils dilate when focusing far objects; converge and constricts when focusing near objects Illuminated pupil constricts and non illuminated pupil constricts The patient can see objects in the periphery The eyes move in a coordinated manner and in a vision alignment Client reads print at 14 inches without difficulty Pale Lateral with the eyebrows and auricles, in line with the outer canthus

Inspection Inspection Inspection Inspection

Reaction to light Visual fields

Inspection Inspection

Extra ocular movement Visual acuity EARS Color Position

Inspection Inspection

Inspection Inspection

Texture and elasticity of the pinna Auricle External ear canal Clients response to normal voice tones NOSE Tenderness Discharge and flaring Position

Inspection and palpation Inspection and palpation Inspection Inspection

canthus of the eye Pinna goes back immediately Mobile, Firm and not tender Distal third contains hair follicles and glands Normal voice tones audible

of the eye pinna recoils after it is folded Mobile, Firm and not tender Presence of cerumen Normal voice tones audible

Palpation Inspection and palpation Inspection

No tenderness No nasal flaring and discharge At midline of the face , nares are symmetrical Air moves freely as the client breathes through the nares Uniform; pink and smooth Moist, smooth, soft and glistening, pink in color White, no tartars, no dental carries, complete set of teeth Can move spontaneously in all directions without complaint of discomfort Centrally located between the shoulders Able to shrug the shoulders and move head to sides Central placement in midline of neck; spaces are

No tenderness With nasal flaring At the midline of the face, nares are symmetrical Air moves freely as the client breathes through the nares Uniform; Pale Dry oral mucosa Incomplete set of teeth

Patency of both nasal cavities MOUTH Lips(color) Buccal mucosa Teeth NECK Mobility

Inspection

Inspection Inspection Inspection

Inspection

Can move without complaint of discomfort Centrally located between the shoulders Able to shrug the shoulders and move head to sides Central placement in midline of neck; spaces are equal on both sides

Position Test the cranial accessory nerve Trachea

Inspection Inspection Palpation

Consistency HEART Heart rate and rhythm

Inspection

equal on both sides No enlargement

No enlargement

Auscultation

60-100bpm

75bpm

THORAX AND LUNGS Posterior thorax Use of accessory muscle Symmetry

Inspection Inspection and palpation

Chest wall Anterior thorax Breathing patterns

Inspection and palpation

Not using of accessory muscle Chest expands symmetrically during respiration; effortless respiration Intact, no tenderness; no lesions

The patient is using accessory muscle Expands Symmetrically during Respiration; With effort in respiration Intact, no tenderness; no lesions

Auscultation

Quiet, rhythmic and effortless respirations Smooth Brown or follows general body color Intact skin Light to deep brown Symmetrical Normally firm No edema Full ROM without pain No lesions Light to deep brown Symmetrical

Quiet Rhythmic and with effort in respiration Smooth Pale With incision Pale Symmetrical Normally firm No edema 3: can move against the gavity No lesions Pale Symmetrical

Skin surface ABDOMEN Skin condition Integrity UPPER EXTRIMITIES Color Symmetry Muscle tone Edema ROM Lesions LOWER EXTRIMITIES Color Symmetry

Inspection Inspection Inspection Inspection Inspection Palpation Inspection/ palpation Inspection Inspection Inspection Inspection

Edema Lesions Muscle tone NEUROLOGIC Level of consciousness Behavior and appearance Recall recent and remote memory

Inpection and Palpation Inspection Palpation Interview Interview Interview

No edema No lesions Normally firm Can follow instructions and commands Makes eye contact with the examiner Recall events readily, immediate recall of remote information

With non pitting edema No lesions Normally firm Can follow instructions and commands Makes eye contact with the examiner Recall events readily, immediate recall of remote information