Physical Assessment

PHYSICAL ASSESSMENT
Physical assessment is an organized systematic process of using the techniques of inspection,

palpation, percussion, and auscultation in collecting objective data based upon a health history and
head-to-toe or general systems examination. A physical assessment should be adjusted to the patient,
based on his needs. It can be a complete physical assessment, an assessment of a body system, or an
assessment of a body part. Nursing assessment do sometimes contribute to the identification of a
medical diagnosis, the unique focus of a nursing assessment is on the patient's responses to actual or
potential problems.
Inspection to inspect, carefully look, listen, and smell to distinguish normal from abnormal
findings. It is important to deliberately practice the skill and learn to recognize all the possible pieces
of data that can be gathered through inspection alone.
Palpation involves using the sense of touch to gather information. Through touch you make
judgements about expected and unexpected findings of the skin or underlying tissue, muscle, and
bones.
Percussion involves tapping the skin with the fingertips to vibrate the underlying tissues and
organs. The vibration travels through the body tissues, and the character of the resulting sound reflects
the density of the underlying tissue. The denser the tissue, the quieter is the sound. By knowing how
various densities influence sound, it is possible to locate organs or masses, map their edges, and
determine their size.
Auscultation involves listening to sounds the body makes to detect variations from normal.
Some sounds such as speech and coughing can be heard without additional equipment, but a
stethoscope is necessary to hear internal body sounds.
Patient X.O. was immediately assessed right after receiving in the Emergency Department as
there were no previous history that might contribute to the seizure. Materials used during assessment
was tape measure, weighing scale, thermometer, bp apparatus, wrist watch and a penlight.
1
HEALTH ASSESSMENT
A health assessment is a plan of care that identifies the specific needs of a person and how
those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment
is the evaluation of the health status by performing a physical exam after taking a health history.
Assessments help to find the cause of your illness and check your ability to do day-to-day
tasks. Assessments help to keep you safe by identifying areas of risk or deterioration in one’s
health.
A. Child’s Information
Name: X.O. Date of Assessment: February 27, 2021
Address: P-1 Barangay ABC, Butuan City
Birthdate: January 14, 2018 Age: 3 Sex: Male Birth place: Butuan
City
Religion: Roman Catholic Nationality: Filipino
Temperature: 36.8 Pulse: 110 Respiratory: 28 Height: 95.3 Weight: 13.2 kg
°C bpm bpm cm
BMI: 14.1 (3rd percentile)
BMI is below the 5th percentile age, gender, and height.
Legend:
= Abnormal
= Normal
Area Assessment
Skin The skin is light cool and dry. No nail abnormalities. Skin turgor noted to be
poor.
Skin with normal turgor snaps rapidly back to its normal position

Skin with poor turgor takes time to return to its normal position
This can indicate dehydration
Head The scalp is slightly dry with evidence of small lesions. Patient has symmetrical
facial features. Upon command, patient cannot move eyebrows, frown, close
eyelids tightly and smile.
Neck The patient’s neck is symmetrical. Upon palpation, lymph nodes in the neck are
not swollen yet patient closes eyes upon palpation in the head just above the
neck. Thyroid glands are not enlarged. Trachea is positioned in the midline.
Eyes The client’s eyelids and eyebrows are symmetrical in alignment. The pupils are
reactive to light.
Ears Auricles have the same color as the facial skin. They are symmetrical and are
aligned with the outer canthus of the eyes. Auricles are flexible, firm, and
nontender. Upon assessment, no redness or purulent discharges were seen on the
external canal.
Nose The nares of the patient’s nose upon assessment appear to be normal with its
septum in midline. The mucosa is pinkish in color and both nares are patent.
Mouth and Lips appear to be slightly dry and pale. The mucosa of the oral cavity is pale and
Throat without masses, and or other lesions. The tongue is in midline and not deviate to
other side. The rest of the other parts of the mouth and throat appears to be
normal.
2
Chest & The chest upon inspection is normal in shape. The patient’s breathing is regular.
Lungs Posterior mobility and posture of the thorax upon respiration is symmetrical.
Chest expansion is symmetrical. Breath sounds upon auscultation is resonant.
Heart The apical beat of the heart is heard over the apex of the heart which is located at
the fifth intercostal space. Hearth sounds are regular at S1-S2 base. No murmurs
or skip beats noted.
Abdomen The abdomen is generally symmetrical in configuration and normal growling
sounds of 12. Upon percussion, the abdomen is tympanic in sound. No masses or
pain noted upon palpation.
Genitalia There were no lesions noted in the genital.
Anus Excretion and elimination of waste is daily. Patient is currently in diapers. Stool
yellowish in color and urine is light yellow in color.
Back and The peripheral pulses are regular when assessed. Range of motion was not noted.
Extremitie His muscle tone and strength on both extremities appear to be weak. Spine is in
s midline.
Neurologic Assessment
Behavior Patient was calm upon nurse patient interactions.
Patient was cooperative during the span of head-to-toe assessment.

Motor Muscle tone and strength on both extremities appear to be weak.
Functionin
g
Reflexes Deep Tendon Reflex was assed and the patient show slight but definitely present
response.
Sensory Can maintain eye contact during interaction.

Functionin
g GCS is 14/15 and pupils equal and reactive to light (PERLA).
Developmental Milestone
Gross Walk slightly zigzags in a straight line, and sometimes jump uncoordinatedly.
Motor
Skills
Fine Tries to grasp pencil and then drops it after few seconds.
Motor
Skills
Language Can carry a conversation using 1 to 2 sentence and sometimes drool over and
Skills talks unclearly.
Play Takes turn in games and mistakenly identifies circle as square.
3
Vital Signs
Time: 6:15 AM
Temperature 36.8 °C
Respiratory rate 28 bpm
Pulse rate 110 bpm
Oxygen Saturation 98%
Blood Pressure 105/68 mmHg
Time: 6:30 AM
Pulse rate 100 bpm
Time: 6:45 AM
Pulse rate 100 bpm
Time: 7:00 AM
Pulse rate 110 bpm
Time: 8:00 AM
Pulse rate 95 bpm
Time: 9:00 AM
Pulse rate 95 bpm
4
Time: 10:00 AM
Pulse rate 95 bpm
Time: 11:00 AM
Pulse rate 115 bpm
Time: 3:00 PM
Pulse rate 115 bpm
Time: 7:00 PM
Pulse rate 100 bpm
Time: 11:00 PM
Pulse rate 95 bpm
Time: 3:00 AM
Pulse rate 90 bpm

Physical Assessment

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PHYSICAL ASSESSMENT

Physical assessment is an organized systematic process of using the techniques of inspection,

Skin with normal turgor snaps rapidly back to its normal position

Patient was cooperative during the span of head-to-toe assessment.

Sensory Can maintain eye contact during interaction.

Play Takes turn in games and mistakenly identifies circle as square.

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