physical assessment
TRANSCRIPT
PHYSICAL ASSESSMENT
Patient: Marvi Fabila August 31, 2008Student Nurse: Eden D. Dimailig D31- Ms. Aileen RochaA06A22
Part I
Behavior
MEASUREMENTS NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS
Height
Weight
Proportionality of height to weight
BMI
BMI=weight(kg)t (height in m)2
18.5-25 kg/m2
Temperature 36.5-37.5 C
Pulse rate 60-100 beats/min
Respiratory Rate 12-20 breaths/minBlood Pressure 120/80 mmHg
General SurveyAREAS TO BE
ASSESSEDNORMAL FINDINGS ACTUAL FINDINGS ANALYSIS
GENERAL APPEARANCE
Body Build, height, and weight in relation to the client’s age, lifestyle, and health
Proportionate, varies with lifestyle
Posture and GaitRelaxed; erect posture; coordinated movement
Overall hygiene and grooming
Clean, and neat Neat and clean
Body odor No body odor or minor body odor relative to work or exercise.
No body odor. The client uses perfume to have pleasant smell and as part of her hygiene
Breath odor No breath odor The client has no breath odor
Signs of distress No signs of distress Presence of eye bags and presence of pimples in the face
Signs of health/illness Healthy appearance The client is healthy and no signs of illness
Client’s attitude Cooperative The client is cooperative
Affect/ mood; Appropriateness of the client’s responses
Appropriate to situation The client’s mood is ecstatic and his responses are appropriate
Speech(quantity, quality, and organization
Understandable, moderate pace, exhibits thought association
The client’s speech is understandable and exhibits thought association.
Thoughts(relevance and organization)
Logical sequence; makes sense; has sense of reality
The client has a logical sequence of thoughts and makes sense.
HEAD TO TOE PHYSICAL ASSESSMENT
BODY PART NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS
SKIN
Color, uniformity of Color
Edema
Lesions
Moisture
Temperature
Turgor
Light to deep brown; uniformcolor except the areas exposed to the sun
No edema
Freckles, birthmarks, flats and raised nevi; no other lesions
Moisture in skin folds and axillae
Uniform; with normal range
When pinched, skin springs back to previous state(Fundamentals of Nursing, 8thed., by Kozier, pp 579-580)
The client’s skin color is darkbrown
No edema
No lesions, no birthmarks
There is moisture in skin folds and axillae.
The skin temperature is uniform, and with normal
range. Both feet and hands are uniform.
When pinched, skin springs back to previous state within 3
seconds
NAILS
Shape and angle
Texture
Color
Surrounding tissue
Blanch test
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)
The shape is convex curvature and angle is 160 degrees.
Smooth texture
Pink in color
Intact epidermis
Returns to usual color for about 2 seconds.
HEAD
SKULL
Size, shape, Symmetry
Nodules, masses And depressions
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)
Rounded(normocephalic and symmetric with frontal, parietal, temporal, and occipital prominences) and smooth skull contour
No nodules or masses
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)
The client’s hair is evenly distributed, and it is thick. The hair cut is long.
Silky, and resilient hair
FACE
Facial features
Symmetry of facial movements
Symmetric or slightly asymmetric facial features.
Symmetric facial movements(Fundamentals of Nursing, 8thed. by Kozier, p 585)
The facial features are symmetric. Pimples are present.
The facial movements are symmetric.
EYES
VISUAL ACUITY
Near vision
Distance vision
Able to read
20/20 vision on snellen chart
The client is able to read
The client is able to readShe has a 20/20 vision in her both eyes
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)
The hair is distributed evenly, alignment is symmetrical, and skin is intact and equal movement.
EYELASHES
Evenness of Distribution and Direction of curl
Equally distributed and curled slightly outward(Fundamentals of Nursing, 8thed., by Kozier, p 544)
Equally distributed and curled slightly outward
LACRIMAL APPARATUS
No edema/ tenderness 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)
Skin is intact, no discharges and no discoloration
Lids close symmetrically
19 blinks per minute
There is no visible sclera above corneas when lids open, upper and lower borders of cornea are slightly covered.
CONJUNTIVA
Bulbar conjunctiva Color, texture, Presence of Lesions
Palpebral Conjunctiva color, Texture, lesions
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)
Capillaries are seen and it is transparent. Sclera appears white
The client’s palpebral conjunctiva is pink in color. The texture is smooth and shinny.
SCLERAColor and clarity White in color The client’s sclera is white.
CORNEA
Clarity and texture
Transparent, shiny and smooth details of the iris are visible(Fundamentals of Nursing, 8thed., by Kozier, p 590)
It has a transparent, shiny and smooth. Details of the iris are visible
IRIS
Shape and color Flat and round(Fundamentals of Nursing, 8thed., by Kozier, p590)
Color is brown. And it is flat and rounded.
PUPILS
Color, shape, and Size
Light reaction and Accommodation
Black in color, equal in size, 3 - 7 mm in diameter; round, smooth border.
Illuminated pupil constricts(direct response)Nonilluminated pupil constricts(consensual response)
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)
Pupils are black in color; the size is 3 – 7 mm in diameter. Round and smooth.
Illuminated pupil constricts(direct response)Nonilluminated pupil constricts(consensual response)
The client’s pupils constrict when looking at near object; pupils dilate when looking at far object; pupils converge when near object is moved toward nose.
EXTRAOCULAR MUSCLES
Alignment; coordination
Both eyes coordinated, move in unison with parallel alignment(Fundamentals of Nursing, 8thed., by Kozier, p 592)
The both eyes of the client moved in unison with parallel alignment and both coordinated.
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)
The object the client is looking is a pen. The client can see objects in the periphery when looking straight ahead.
EARSAURICLES
Color, symmetry, Position
Texture, elasticity And tenderness
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)
Color of the client’s auricle is same as the facial skin, symmetrically in size. Aligned with outer canthus of the eye.
Texture is smooth, elastic and tenderness.It is firm and mobile Pinna recoils after it is foded
EXTERNAL EAR CANALS
Cerumen, skin Lesions Pus and blood
Distal third contains hair follicles and glands dry cerumen, grayish tan color/sticky/ wet cerumen in various shades of brown(Fundamentals of Nursing, 8thed., by Kozier, p 596)
Distal third contains hair follicles and glands, and the external ear canals has cerumen
HEARING ACUITY TEST
In normal voice Ones
Watch tick test
Weber’s test
Rinne’s test
Audible
Able to hear ticking in both ears
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)
The client verbalized that she can hear clearly what the health care provider says, like ears check twice and twice awesome.
The client is able to hear the ticking in both ears.
The client heard in both ears.
Air conduction is greater than bone conduction.
NOSE
Shapes, size, color, flaring/ discharge from nares.
Nasal cavities: Redness, swelling Growths, and Discharge
Nasal septum
Nasal cavity Patency
Tenderness, masses and displacement of bone and cartilage
Symmetric and straight; no discharge or flaring; uniform in color.
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)
The client’s nose is symmetric and straight. No discharges or flaring. The color of the nose ranges from medium to light brown. Uniform to the color of the face.
Mucosa is pink. And no watery discharge and lesions.
Nasal septum is in the midline
Air moves freely as the client breathes through the nares.
No tenderness; no lesions
FACIAL SINUSES
Frontal, Supraobital ridges ,ethmoid, sphenoid, maxillary
No tenderness(Fundamentals of Nursing, 8thed., by Kozier, p 600)
No tenderness
MOUTH
LIPS
Symmetry of contour, color, texture
Pinkish; symmetrical with lip margin. Smooth and moist(Fundamentals of Nursing, 8thed., by Kozier, p 602)
She has a dark lips, symmetrical with lip margin. And texture is moist and smooth.
Abnormal
BUCCAL MUCOSA
Color, moisture, Texture and lesions
Moist, smooth, soft, glistering and elastic(Fundamentals of Nursing, 8thed., by Kozier, p 602)
The client’s buccal mucosa is moist, smooth, soft, glistering, and elastic
Normal
TEETH
Color, number condition
Smooth, white, shiny tooth enamel; smooth, intact dentures. 28-32 normal numbers of teeth(Fundamentals of Nursing, 8thed., by Kozier, p 602)
GUMS
Color conditionPink color, moist, firm texture, no retraction(Fundamentals of Nursing, 8thed., by Kozier, p 591)
TONGUE/ MOUTH FLOOR
Surface of the Tongue for position, color, Texture. And tongue movement
Base of the tongue
Nodules, lumps or enlarged lymph nodes
Pink color, slightly rough, moist.Smooth and no lesions.Central positioned.Freely movable
Smooth tongue base with prominent veins
Smooth with no palpable nodules(Fundamentals of Nursing, 8thed., by Kozier, pp 603-604)
The client’s tongue is pink in color, slightly rough and moist. Positioned in center. And the tongue can freely move.
PALATES AND UVULA
Palate color, shape, texture and body prominence
Position of uvula, and mobility
Hard palate: Lighter pink and more irregular textureSoft palate: Light pink, smooth
Positioned in midline of soft palate(Fundamentals of Nursing, 8thed., by Kozier, pp 604)
Hard palate: Lighter pink and more irregular textureSoft palate: Light pink, smooth
The uvula is positioned in midline of soft palate
OROPHARYNX AND TONSILS
Color, texture
Tonsils, color, Discharge
Gag reflex
Pink in color, smooth posterior wall
Pink and smooth. No discharge
Present(Fundamentals of Nursing, 8thed., by Kozier, p 604)
Oropharynx is pink in color and has a smooth posterior wall.
Pink and smooth. And no discharge. Grade 1 tonsils Present
NECK
NECK MUSCLES
Neck muscles for abnormal swellings or masses
Head movements
Muscles equal in size; head centered
Coordinated, smooth movements with no discomfort(Fundamentals of Nursing, 8thed., by Kozier, p 607)
Head centered and muscles are equal in size.
The client has a coordinated head movements and a smooth movement. No discomfort
LYMPH NODES
Occipital Postauriular Preauricular Submandibular Submental Superficial anterior
Not palpable(Fundamentals of Nursing, 8thed., by Kozier, p 607)
TRACHEA
Placement Midline of neck; spaces are equal on both sides(Fundamentals of Nursing, 8thed., by Kozier, p 608)
The placement of the trachea is in the midline of the neck and the spaces on both sides are equal.
THYROID GLAND
Symmetry and Masses
Smoothness, Areas of Enlargement, Masses, nodules
Not visible, gland ascends during swallowing
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 )
During swallowing gland ascends bit not visible.
Smoothness and nodules are not palpable. Tenderness is located centrally
PART II
THORAXPOSTERIOR THORAX
Shape, symmetry, Diameter
Spinal alignment
Temperature, and The integrity of all Chest skin
Respiratory Excursion
Vocal fremitus
Percussion
Auscultation(posterior thorax)
Anteroposterior to transverse diameter in ratio of 1:2,.chest symmetrical
Vertically aligned
Skin intact; uniform temperature
Full and symmetric chest expansion
Fremitus is heard most clearly at the apex of the lungs. Bilateral symmetry
Percussion notes resonate, the level of diaphragm but are flat over areas of heavy muscle and bone, dull on areas over stomach
Vesicular and bronchovesicular breath sounds(Fundamentals of Nursing, 8thed., by Kozier, p615)
The anteroposterior to transverse diameter in ratio is 1:2 and chest symmetrical
Vertically aligned
Skin intact; uniform temperature
During deep inspiration thumbs separate 3-5 cm
The client is high pitched voice. And the fremitus is heard most clearly at the apex of the lungs. Bilateral symmetry.
Resonate, except over the level of diaphragm but are flat over areas of heavy muscle and bone, dull on areas over stomach
Bronchial and tubular breath sounds
ANTERIOR THORAX
Breathing patterns
Temperature and The integrity of All chest skin
Respiratory Excursion
Vocal fremitus
Percussion
Auscultation(trachea)
Auscultation(anterior thorax)
Quiet, rhythmic, and effortless respiration
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)
The client has quiet, rhythmic, and effortless respiration.
Skin intact and uniform temperature.
During deep inspiration thumbs separate 3-5 cm
Bronchial and tubular breath sounds
Bonchovesicular and vesicular breath sounds
CARDIOVASCULAR
PALPATION Aortic and pulmonic
Tricuspid area and Heaves or lifts
Apical area
Auscultation Aortic Pulmonic Tricuspid Apical
No pulsations
No pulsation and no heaves or lifts
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
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 adultS4: in many older adults. (Fundamentals of Nursing, 8thed., by Kozier, pp620-622)
No pulsations
No pulsation and no heaves or lifts
Pulsation is visible and palpable.
S1: usually heard at all sites usually louder at apical area
S2: usually heard at all sites usually louder at base of heart
Normal
Normal
Normal
CAROTID ARTERIES
Palpation
Auscultation
Symmetric pulse volumes. Full pulsations, thrusting quality. Elastic artery wall
No sound heard on auscultation(Fundamentals of Nursing, 8thed., by Kozier, pp622-623)
Symmetric pulse volumes. Full pulsations, thrusting quality. Elastic artery wall
During auscultation no sound heard
Normal
Normal
JUGULAR VEINS
Inspect Veins not visible(Fundamentals of Nursing, 8thed., by Kozier, p 623)
Veins are not visible Normal
BREAST AND AXILLAE
BREAST
Size, symmetry and Shape
Localized discolorations or hyperpigmentation, retraaction or dimpling, localized
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.
The shape is round and slightly unequal and it is generally symmetric.
The skin is uniform in color and it is also smooth and intact.
hypervascular areas, swelling or edema
AREOLA
Shape,, color, masses or lesions
NIPPLES
Size, shape, color, Position, discharge And lesions.
Axillary, Subclavicular and supraclavicular lymph nodes
Breast for Masses, tenderness
Nipples for tenderness and discharges
Striae; moles and nevi
Round/oval; bilaterally the same; color varies widely from light pink to dark brown. No lumps, masses or areas of tenderness
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
No tenderness, masses, nodules, or nipple discharge
No tenderness, masses, nodules, or nipple discharge(Fundamentals of Nursing, 8thed., by Kozier, pp 628-630)
Round everted and equal in size. Similar in color with areola and texture is smooth and soft, No discharges and lesions nor masses.
No tenderness, masses, or nodules
No tenderness, masses, nodules, or nipple discharge
No tenderness, masses, nodules, or nipple discharge
ABDOMEN
Inspection Abdomen skin
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
Unblemished skin; uniform color
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
The color is light to medium brown and it is uniform.Unblemished skin.
The abdomen is flat and rounded and has a symmetric contour.
There is no enlargement of the liver/spleen
The client has a symmetric contour
Symmetric movements.
Vascular pattern is not visible
Absence of arterial bruits and friction rub. The bowel sounds are audible
Tympany is heard over the
Percussion each Of the four Quadrants
Percuss the liver To determine its Size
Light Palpation
Deep palpation
Palpate area above The symphysis Pubis to determine possible urinary retention
gas-filled bowels; dullness, especially over the liver and spleen, or a full bladder
6 to 12 cm in the midclavicular line; 4 to 8 cm at midsternal line
No tenderness; relaxed abdomen with smooth, consistent tension
Tenderness may be present near xiphoid process, over cecum, and over sigmoid colon
Not palpable(Fundamentals of Nursing, 8thed., by Kozier, pp 633-638)
stomach and gas-filled bowels; dullness, sound is heard over the liver and spleen, or a full bladder
No tenderness relaxed abdomen w/ smooth, consistent tension.
MASCULAR SKELETAL SYSTEM
MUSCLE
Size
Tendons for Contractures
Equal on both sides of body
No contractures
Muscle is equal on both sides of the 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)
No fasciculation and tremors
Muscle is firm
Muscle strength is equal on both sides.
BONES
Inspect skeleton For structure
Palpate bones to Locate areas of Edema or Tenderness
Inspect joint for Swelling
Palpate each joint For tenderness, Smoothness, Swelling, crepitation & presence of nodule
No deformities
No tenderness or swelling
No swelling;
No tenderness, crepitation, or nodules. Joints move smoothly(Fundamentals of Nursing, 8thed., by Kozier, p 641)
No deformities
No tenderness or swelling
Joints of the client do not have swelling.
No tenderness or nodules. Joints move smoothly