PHYSICAL ASSESSMENT

BODY PART SKIN Color, uniformity of Color

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

Light to deep brown; uniform color except the areas exposed to the sun

Edema

No edema

Lesions

Freckles, birthmarks, flats and raised nevi; no other lesions

Moisture

Moisture in skin folds and axillae

Temperature

Uniform; with normal range

Turgor

When pinched, skin springs back to previous state(Fundamentals of Nursing, 8thed., by Kozier, pp 579-580)

NAILS Shape and angle Convex curvature; angle of nail plate is 160 degrees Smooth in texture Color is highly vascular and pink in light skinned clients; dark skinned clients may have brown or black pigmentation in longitudinal steaks Intact epidermis Blanch test, prompt return of usual color(Fundamentals of Nursing, 8thed., by Kozier, pp 583-584)

Texture Color

Surrounding tissue Blanch test

HEAD SKULL Size, shape, Symmetry Rounded(normocephalic and symmetric with frontal, parietal, temporal, and occipital prominences); smooth skull contour Absence of nodules or masses(Fundamentals of Nursing, 8thed. by Kozier, p 585)

Nodules, masses And depressions

SCALP Color and Appearance Areas of tenderness Lighter than complexion

No lesions, lies, dandruff, and bruises or lumps found. Free from split ends(Manual of Nursing, 7th., by Lippincott, p.54

HAIR Evenness of Growth, Thickness/ Thinness Texture and Oiliness Evenly distributed, thick,

Silky, and resilient(Fundamentals of Nursing, 8thed. by Kozier, p 582)

FACE Facial features Symmetric or slightly asymmetric facial features.

Symmetry of facial movements

Symmetric facial movements(Fundamentals of Nursing, 8thed. by Kozier, p 585)

EYES VISUAL ACUITY Near vision Distance vision EYEBROWS Distribution, Alignment, skin Quality and movement Hair is evenly distributed; skin intact, eyebrows symmetrically aligned; equal movement. (Fundamentals of Nursing, 8thed., by Kozier, p 588) Able to read 20/20 vision on snellen chart

EYELASHES Evenness of Distribution and Direction of curl Equally distributed and curled slightly outward(Fundamentals of Nursing, 8thed., by Kozier, p 544)

LACRIMAL GLAND

No edema/ tenderness

EYELIDS

Surface characteristics, position in relation to the cornea, able to blink; frequency of blinking

Skin intact, no discharges and no discoloration Lids close symmetrically 15-20 blinks/min. Bilateral blinking When lids open, no visible sclera above corneas, upper and lower borders of cornea are slightly covered(Fundamentals of Nursing, 8thed., by Kozier, p 588)

CONJUNTIVA Bulbar conjunctiva Color, texture, Presence of Lesions Palpebral Conjunctiva color, Texture, lesions SCLERA Color and clarity CORNEA Transparent, shiny and smooth details of the iris are Transparent, capillaries sometimes evident, sclera appears white (yellowish in dark-skinned clients) Shiny, smooth, and pink or red(Fundamentals of Nursing, 8thed., by Kozier, p 588) White in color

Clarity and texture

visible(Fundamentals of Nursing, 8thed., by Kozier, p 590) IRIS Shape and color Flat and round(Fundamentals of Nursing, 8thed., by Kozier, p590)

PUPILS Color, shape, and Size Black in color, equal in size, 3 7 mm in diameter; round, smooth border. Illuminated pupil constricts(direct response) Nonilluminated pupil constricts(consensual response)

Light reaction and Accommodation

Pupils constrict when looking at near object; pupils dilate when looking at far object; pupils converge when near object is moved toward nose(Fundamentals of Nursing, 8thed., by Kozier, p 590) EXTRAOCULAR MUSCLES Alignment; Both eyes coordinated, move in

coordination

unison with parallel alignment(Fundamentals of Nursing, 8thed., by Kozier, p 592)

VISUAL FIELDS Peripheral visual fields When looking straight ahead, the client can see objects in the periphery(Fundamentals of Nursing, 8thed., by Kozier, p 591)

EARS AURICLES Color, symmetry, Position Color same as facial skin, symmetrical, auricle aligned with outer canthus of eye, about 10 degrees from vertical Texture, elasticity and tenderness: Mobile, firm and tender; pinna recoils after it is folded (Fundamentals of Nursing, 8thed., by Kozier, p 596)

Texture, elasticity And tenderness

EXTERNAL EAR CANALS Cerumen, skin Distal third contains hair follicles

Lesions Pus and blood

and glands dry cerumen, grayish tan color/sticky/ wet cerumen in various shades of brown(Fundamentals of Nursing, 8thed., by Kozier, p 596)

HEARING ACUITY TEST In normal voice Ones Audible

Watch tick test

Able to hear ticking in both ears

Webers test

Sound is heard in both ears or is localized at the center of the head Air-conducted hearing is greater than bone-conducted hearing(Fundamentals of Nursing, 8thed., by Kozier, pp 597-598)

Rinnes test

NOSE Shapes, size, color, flaring/ Symmetric and straight; no discharge or flaring; uniform in

discharge from nares.

color.

Nasal cavities: Redness, swelling Growths, and Discharge Nasal septum Nasal cavity Patency

Pink mucosa; clear watery discharge; no lesions

Intact and in the midline Patency, air moves freely as the client breathes through the nares. No tenderness; no lesions(Fundamentals of Nursing, 8thed., by Kozier, p 600)

Tenderness, masses and displacement of bone and cartilage

FACIAL SINUSES Frontal, Supraobital ridges ,ethmoid, sphenoid, maxillary MOUTH LIPS Symmetry of Pinkish; symmetrical with lip Abnormal No tenderness(Fundamentals of Nursing, 8thed., by Kozier, p 600)

contour, color, texture

margin. Smooth and moist(Fundamentals of Nursing, 8thed., by Kozier, p 602)

BUCCAL MUCOSA Color, moisture, Texture and lesions Moist, smooth, soft, glistering and elastic(Fundamentals of Nursing, 8thed., by Kozier, p 602) Normal

TEETH Color, number condition Smooth, white, shiny tooth enamel; smooth, intact dentures. 32 normal numbers of teeth(Fundamentals of Nursing, 8thed., by Kozier, p 602)

GUMS Color condition Pink color, moist, firm texture, no retraction(Fundamentals of Nursing, 8thed., by Kozier, p 591)

TONGUE/ MOUTH FLOOR Surface of the Tongue for Pink color, slightly rough, moist. Smooth and no lesions.

position, color, Texture. And tongue movement Base of the tongue

Central positioned. Freely movable

Smooth tongue base with prominent veins Smooth with no palpable nodules(Fundamentals of Nursing, 8thed., by Kozier, pp 603-604)

Nodules, lumps or enlarged lymph nodes

PALATES AND UVULA Palate color, shape, texture and body prominence Hard palate: Lighter pink and more irregular texture Soft palate: Light pink, smooth

Position of uvula, and mobility

Positioned in midline of soft palate(Fundamentals of Nursing, 8thed., by Kozier, pp 604)

OROPHARYNX AND TONSILS Color, texture Pink in color, smooth posterior wall

Tonsils, color, Discharge Gag reflex

Pink and smooth. No discharge

Present(Fundamentals of Nursing, 8thed., by Kozier, p 604)

NECK NECK MUSCLES Neck muscles for Muscles equal in size; head abnormal swellings or centered masses Head movements Coordinated, smooth movements with no discomfort(Fundamentals of Nursing, 8thed., by Kozier, p 607)

LYMPH NODES

Occipital Postauriular Preauricular Submandibular Submental

Not palpable(Fundamentals of Nursing, 8thed., by Kozier, p 607)

Superficial anterior

TRACHEA Placement Midline of neck; spaces are equal on both sides(Fundamentals of Nursing, 8thed., by Kozier, p 608)

THYROID GLAND

Symmetry and Masses

Not visible, gland ascends during swallowing

Smoothness, Areas of Enlargement, Masses, nodules

Lobes may not be palpated. If palpated, lobes are small, smooth, centrally located, painless, and rise freely with swallowing(Fundamentals of Nursing, 8thed., by Kozier, p 609 )

PART II THORAX POSTERIOR THORAX Shape, symmetry, Anteroposterior to transverse

Diameter

diameter in ratio of 1:2,.chest symmetrical Vertically aligned Skin intact; uniform temperature

Spinal alignment Temperature, and The integrity of all Chest skin Respiratory Excursion Vocal fremitus

Full and symmetric chest expansion Fremitus is heard most clearly at the apex of the lungs. Bilateral symmetry

Percussion

Percussion notes resonate, the level of diaphragm but are flat over areas of heavy muscle and bone, dull on areas over stomach

Auscultation(posterior Vesicular and bronchovesicular thorax) breath sounds(Fundamentals of Nursing, 8thed., by Kozier, p615) ANTERIOR THORAX Breathing patterns Quiet, rhythmic, and effortless respiration

Temperature and The integrity of All chest skin Respiratory Excursion

Skin intact; uniform temperature

Full symmetric excursion; thumbs normally separate 3 to 5 cm Fremitus is normally decreased over heart and breast tissue Percussion notes resonates 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 Bronchial and tubular breath sounds Bronchovesicular and vesicular breath sounds(Fundamentals of Nursing, 8thed., by Kozier, p617)

Vocal fremitus

Percussion

Auscultation(trachea)

Auscultation(anterior thorax) CARDIOVASCULAR PALPATION Aortic and pulmonic Tricuspid area and Heaves or lifts

No pulsations No pulsation and no heaves or lifts

Normal Normal

Apical area

Pulsation visible in 50% of adults and palpable in most PMI in fifth LISC at or medial to MCL. Diameter of 1 to 2 cm. no he heave or lift

Auscultation Aortic Pulmonic Tricuspid Apical

S1: usually heard at all sites usually louder at apical area S2: usually heard at all sites usually louder at base of heart Systole: silent interval; slightly shorter duration than diastole at normal heart rate(60-90bpm) Diastole: silent interval; slightly longer than systole at normal heart rates S3: in children and young adult S4: in many older adults. (Fundamentals of Nursing, 8thed., by Kozier, pp620-622)

Normal

CAROTID ARTERIES Palpation Symmetric pulse volumes. Full pulsations, thrusting quality. Normal

Elastic artery wall Auscultation No sound heard on auscultation(Fundamentals of Nursing, 8thed., by Kozier, pp622-623) Normal

JUGULAR VEINS Inspect Veins not visible(Fundamentals of Nursing, 8thed., by Kozier, p 623) Normal

BREAST AND AXILLAE BREAST Size, symmetry and Shape Rounded shape; slightly unequal in size; generally symmetric Skin uniform in color; skin smooth and intact. Diffuse symmetric horizontal or vertical vascular pattern in light skinned people. Striae; moles and nevi

Localized discolorations or hyperpigmentation, retraaction or dimpling, localized hypervascular areas, swelling or edema AREOLA

Shape,, color, masses or lesions

Round/oval; bilaterally the same; color varies widely from light pink to dark brown. No lumps, masses or areas of tenderness

NIPPLES Size, shape, color, Position, discharge And lesions. Round; everted/inverted; equal in size; similar in color. Soft and smooth; no discharge, masses or lesions. No lumps and masses. No tenderness, masses, or nodules

Axillary, Subclavicular and supraclavicular lymph nodes Breast for Masses, tenderness Nipples for tenderness and discharges

No tenderness, masses, nodules, or nipple discharge No tenderness, masses, nodules, or nipple discharge(Fundamentals of Nursing, 8thed., by Kozier, pp 628-630)

ABDOMEN

Inspection Abdomen skin

Unblemished skin; uniform color

Inspection Abdomen for Contour and Symmetry Inspection Enlargement of Liver/spleen Assess symmetry Of contour while standing at the foot of the bed Abdominal Movements associated w/ respiration, peristalsis, or aortic pulsations Vascular patterns Auscultation

Flat, rounded; symmetric contour.

No enlargement of the liver/spleen

Symmetric contour

Symmetric movements caused by respiration. Visible peristalsis in very lean people. Aortic pulsations in thin persons at epigastric area. No visible vascular pattern Audible bowel sounds; absence of arterial bruits; absence of friction rub Tympany over the stomach and

Percussion each Of the four Quadrants

gas-filled bowels; dullness, especially over the liver and spleen, or a full bladder

Percuss the liver To determine its Size

6 to 12 cm in the midclavicular line; 4 to 8 cm at midsternal line

Light Palpation

No tenderness; relaxed abdomen with smooth, consistent tension Tenderness may be present near xiphoid process, over cecum, and over sigmoid colon

Deep palpation

Palpate area above The symphysis Pubis to determine possible urinary retention MUSCULAR SKELETAL SYSTEM MUSCLE Size Tendons for Contractures

Not palpable(Fundamentals of Nursing, 8thed., by Kozier, pp 633-638)

Equal on both sides of body

No contractures

Fasciculation and Tremors Palpate muscle Tonicity Test for muscle Strength

No fasciculation and tremors

Normally firm

Equal strength on each body side. (Fundamentals of Nursing, 8thed., by Kozier, pp 640-641)

BONES Inspect skeleton For structure Palpate bones to Locate areas of Edema or Tenderness Inspect joint for Swelling No deformities

No tenderness or swelling

No swelling;

Palpate each joint For tenderness, Smoothness, Swelling, crepitation & presence of nodule

No tenderness, crepitation, or nodules. Joints move smoothly(Fundamentals of Nursing, 8thed., by Kozier, p 641)

Glasgow Coma Scale

Eyes

Does not open eyes

Opens eyes in response to painful stimuli

Opens eyes in response to voice

Opens eyes spontaneously

N/A

N/A

Verbal

Makes no sounds

Incomprehensible sounds

Utters inappropriate words

Confused, disoriented

Oriented, converses normally

N/A

Motor

Makes no movements

Extension to painful stimuli (decerebrate response)

Abnormal flexion to painful stimuli (decorticate response)

Flexion / Withdrawal to painful stimuli

Localizes painful stimuli

Obeys commands

Neurologic Assessment Cranial Nerve Olfactory Optic Norms Can identify smell Pupils 2-3mm equally reactive to light Both pupils reactive to light both direct and indirect consensual reflex, equal and complete opening of both eyes, intact EOM Can feel pain and light touch on both sides of the face. (+) corneal reflex, can clench teeth Can frown, raise both eyebrows, close right eye tightly Gross hearing intact Uvula in midline, equal elevation of palate on phonation Can turn head side to side, can elevate shoulders Tongue in the midline, mobile, no atrophy nor fasciculations Actual Findings Analysis

Oculomotor Trochlear Abducens Trigeminal

Facial

Auditory Glossopharyngeal Vagus

Accessory

Hypoglossal