physical assessment and gordons

8/13/2019 Physical Assessment and Gordons

http://slidepdf.com/reader/full/physical-assessment-and-gordons 1/14



Review of System

GENERAL: The patient is coherent, weak and not in cardio-respiratory distress

SKIN: warm to touch, and with maculo-papular rashHEART: Normal rate regular rhythm, (-) murmur, Normal

PR ()EXTREMETIES:Full and equal pulses

Vital Signs: Blood Pressure

120/70 mmHgPulse Rate

84 bpmRespiratory Rate

19 cpmTemperature

38.2 C



Cephalo-caudal Assessment

AREA OF

ASSESSMENT NORMAL FINDINGS METHOD OF

ASSESSMENT ACTUAL FINDINGS INTERPRETATION

Head Size, Shape & Symmetry

Rounded (normocephalic) *symmetric with

frontal, parietal and

occipital

prominences Smooth, uniform in

consistency,

absence of nodules

and mass

Inspection &

Palpation Rounded

(normocephalic) *symmetric with

frontal, parietal and

occipital

prominences Smooth, uniform in

consistency,

absence of nodules

and mass

Normal Normal

Hair Color Texture Distribution

Black - brown Silky; smooth

presence of hair Thin straight;

evenly distributed

Inspection &

Palpation Brown- black Silky; smooth

presence of hair Thin straight;

evenly distributed

Normal Normal Normal

Scalp No presence of

lesions and no sign

of infestation

No presence of

lesions and no sign

of infestation

Normal



AREA OF

ASSESSMENT NORMAL

FINDINGS METHOD OF

ASSESSMENT ACTUAL

FINDINGS INTERPRETATION

Face Symmetrical Inspection Symmetrical Normal

Eyes Eyebrows *Hair distribution and alignment Eyelashes *Evenness,

distribution and

direction of curl

Hair evenly

distributed, skin intact,

eyebrows

symmetrically

aligned Equally

distributed, Curled slightly

outward

Inspection Inspection

Hair evenly

distributed, skin intact,

eyebrows

symmetrically

aligned Equally

distributed, Curled slightly

outward

Normal Normal



AREA OF

ASSESSMENT NORMAL FINDINGS METHOD OF

ASSESSMENT ACTUAL FINDINGS INTERPRETATION

Eyeballs

Eyelids

*Surface

characteristics

( PERLLA)

*PER*/ Color

*RLA*

Conjunctiva

(-) Sunken eyeballs

Skin intact,

No discharge;

no discoloration

Pupil equally round

and of the same

size and black in

color

Pupil constricted

when

accommodated

with light

Bulbar

Conjunctiva is clear

with tiny capillaries

visible, Palpebral

conjunctiva is pink;

no discharge

Inspection

Inspection

Inspection

(-) Sunken eyeballs

Skin intact,

No discharge;

no discoloration

Pupil equally round

and of the same

size and black in

color

Pupil constricted

when

accommodated

with light

Bulbar

Conjunctiva is clear

with tiny capillaries

visible, Palpebral

conjunctiva is pink;

no discharge

Normal

Normal

Normal

Normal

Normal



AREA OF

ASSESSMENT NORMAL

FINDINGS METHOD OF

ASSESSMENT ACTUAL


Sclera

Lacrimal gland, Nasolacrimal duct.

Anicteric sclera

No edema, No Tenderness and

tearing.

Inspection

Inspection &

palpation

Red sclera

No edema, No Tenderness and

tearing.

Abnormal

Normal

Ears Color; symmetry of

size and position

Texture: elasticity

and areas of

tenderness

Color same as

facial skin;

symmetrical; Auricle aligned with

outer about 10

above ventricle

No discharge; No

lesion; Tympanic

membrane intactand pearly grey in

color Mobile, firm, no

tenderness, pinna

recoils after it is

folded

Inspection &

Palpation Color same as

facial skin;

symmetrical; Auricle aligned

with outer about

10 above ventricle

No discharge; No

lesion; Tympanicmembrane intact

and pearly grey in

color Mobile, firm, no

tenderness, pinna

recoils after it is

folded

Normal

Normal



AREA OF

ASSESSMENT NORMAL

FINDINGS METHOD OF

ASSESSMENT ACTUAL


Nose

Septum Turbinates

Nares

(-) nasal

discharge/mucus

secretion;

Patent nostrils Intact and in midline Pinkish, moist and

intact (-) nasal flaring

Inspection

Inspection

(-) nasal

discharge/mucus

secretion;

Patent nostrils Intact and in midline Pinkish, moist and

intact (-) nasal flaring

Mouth Lips; Symmetry and

color

Teeth and Gums

Tongue

Tonsils

Symmetry of

contour; Uniform pink color,

moist

White teeth and

pinkish gums Pinkish in color;

Moves freely; (-)

presence of sore

Not inflamed

Inspection

Inspection

Symmetry of

contour; Uniform pink color,

moist

White teeth and

pinkish gums Pinkish in color;

Moves freely; (-)presence of

sores

Inflamed

Normal

Normal

Normal

Abnormal



AREA OF

ASSESSMENT NORMAL

FINDINGS METHOD OF

ASSESSMENT ACTUAL

FINDINGS INTERPRETATIO

N Cervical/ neck Symmetrical,

flexible, full

range of motion,

with out lumps,tenderness or

pain

Inspection &

Palpation Symmetrical,

flexible, full

range of motion,

with out lumps,tenderness or

pain

normal

Thyroid gland (-) jugular vein

distention Inspection/ palpation

(-) jugular vein

distention Normal

Skin Color

Texture

Fair; No

deviation

Smooth Skin;

without any

lesions and

infestations

Inspection

Palpation &

Inspection

Fair but with red

spots

With confluent

bumps because

of macula

papular rash

Abnormal

Abnormal



AREA OF

ASSESSMENT NORMAL

FINDINGS METHOD OF

ASSESSMENT ACTUAL

FINDINGS INTERPRETATIO

N Skin turgor Elastic and full;

skin springs

back

immediately

when pinched

Inspection/Palpat

ion Palpation

Elastic and full;

skin springs

back

immediately

when pinched

Normal

Nail Color

Shape and

texture

Capillary refill

Pinkish

Smooth, convex

in curvature,

long

Prompt return ofpink or usual

colour

Inspection

Inspection and Palpitation

Performedblanched test

Pinkish

Smooth, convex

in curvature,

long

Prompt return ofpink or usual

colour

Normal

Normal

Normal



AREA OF

ASSESSMENT NORMAL

FINDINGS METHOD OF

ASSESSMENT ACTUAL


Thorax Physical

appearance /

Color

Light to deep

brown

symmetrical

chest wall withno

wounds/lesions

Inspection With maculo

popular rash abnormal

Breath sound

Chest expansion

(No adventitious

sound heard

upon

auscultation

Symmetrical Chest wall intact;

no tenderness

Auscultation

Inspection and Palpitation

(No adventitious

sound heard

upon

auscultation

Symmetrical Chest wall

intact; no

tenderness

Normal

Normal

AREA OF NORMAL METHOD OF ACTUAL INTERPRETATION



AREA OF

ASSESSMENT NORMAL

FINDINGS METHOD OF

ASSESSMENT ACTUAL


Heart NRRR (normal rate

regular rhythm) (-) murmur

Auscultation NRRR (normal rate

regular rhythm) (-) murmur

Normal

Abdomen contour Symmetrical/ Flat

abdominal contour

Audible bowel

sounds Over the stomach

and gas filled

Inspection

Auscultation

Percussion

Symmetrical/ Flat

abdominal contour

Audible bowel

sounds Over the stomach

and gas filled

Normal

Normal

Upper Extremities No lesion seen : (-) Edema; no

tenderness:

symmetrical

Inspection &

Palpation With macula

popular rash Abnormal

lower Extremities

No lesion seen : (-) Edema; no

tenderness:

symmetrical

Inspection &

Palpation No lesion seen :

(-) Edema; no

tenderness:

symmetrical

Normal



Functional Health Pattern Before Hospitalization Hospitalization

Health Perception/ Health

management

The relative stated that

our patient used to eatfoods that are high in fats.

But he knows that to

maintain his health status

he always eat right.

Poor health status and

shows signs of weakness.

Nutritional-Metabolic The client eatwith her

family thrice a day. He

eats all the foods that was

serve to him. On a Hypoallergenic diet.

Elimination He usually urinates 3-4

times a day and defecates

once a day.

Patient experienced Loose

Bowel Movements (7-12x

per day) for a period of 3

days.

Activity &Exercise He doesn’t have time toexercise every day.

Further decrease in

physical activity due to



Cognitive-Perceptual He has good eyesight and

no other sensory defects.

Patient is Lethargic and

having difficulty

communicating.

Sleep-Rest He sleeps 6-7 hours a day,

but sometimes he’s

having a hard time

sleeping when he’s

thinking about problems

in his life.

Intermittent sleep and

been very lethargic.

Self-Perception / Self

Concept His wife stated that thepatient is comfortable with

his self.

He looks weak.

Value-Belief He seldom goes to church

because of his work

everyday Still unable to go to

church.

physical assessment and gordons

Documents