CHAPTER III

PHYSICAL ASSESSMENT

Last February 27, 2017 at around 5:20pm, a Head-to-toe Physical Examination

to client A.A was conducted.

General Assessment

The patient is awake and conscious. He is attentive and cooperative, and in a

good grooming. The patients vital signs are: PR = 71bpm, BP = 110/70, RR = 22 bpm,

Temp= 36.3C which were obtained during the said date and time. There is an infusion

of D5LRS 1L at the right metacarpal vein.

A. Head and Face

absence of nodules or masses

symmetric facial features and movements

evenly distributed black hair.

B. Skin

brown skin generally uniform in color except in areas exposed to the sun.

no cyanosis

no jaundice

good fair skin turgor.

C. Eyes

eyebrows symmetrically aligned with equal movement

eyelashes equally distributed and curled slightly outward

skin of eyelids intact with no discoloration

lids close symmetrically

bilateral blinking exhibited

 no discharge, edema, or tearing

D. Ears

color same as facial skin

symmetrically aligned

pinna immediately recoils after it is folded

pinna is not tender

no lesions or discoloration

dry cerumen, grayish-tan color

normal voice tones audible

able to hear ticking of a watch in both ears

E. Nose

symmetric and straight

no discharge or flaring

absence of lesions and tenderness

nasal septum intact and in the midline

F. Chest and Lungs

The clients chest contour is symmetrically aligned.
Chest wall are intact, no tenderness and no masses noted.

G. Heart
The patient has normal heart rhythm when auscultated.
No murmurs noted.

H. Abdomen

no tenderness

active bowel sound

I. Extremities

No gross deformities

No edema

Full thread and presence of equal peripheral pulses

J. Genital and Rectal

No lesions

No rashes

Buttock intact