Physical Assessment:

AREA A. SKULL 1. Size, shape and symmetry of the skull TECHNIQUE NORMS FINDINGS ANALYSIS and INTERPRETATION

Inspection Palpation

Rounded (normocephalic and symmetrical, with frontal, parietal, and occipital prominences); Smooth skull contour Smooth, uniform consistence; absence of nodules or masses Symmetric or slightly asymmetric facial features; palpebral fissure equal in size; symmetric nasolabial No edema and hollowness

Rounded(normocephali c); smooth skull contour

Normal

2. Presence of nodules, masses, and depressions

Palpation Inspection

Has no tenderness; no masses nor nodules

Normal

3. Facial Features

Inspection Palpation

Symmetrical and palpebral fissure equal in size, nasolabial folds are symmetrical

Normal

4. Presence of edema and hollowness in the eye.

Inspection

Has Hollowness

Abnormal, Volume deficiency of fat within

C. HAIR 1. Evenness of growth, thickness, or thinness of Inspection Palpation Evenly distributed and covers the whole Evenly distributed with no patches of hair loss; Normal

hair Inspection Palpation

scalp; Maybe thick or thin Silky; resilient hair

thick hair

2. Texture and oiliness over the scalp

Silky, smooth and resilient hair

Normal.

3. Presence of infection and infestation

Inspection Palption

No infection and infestation

Presence of lice

Abnormal, There is pediculosis, a type of parasitic infection. Lice may be contracted from infcetd clothes and direct contact with an infected person. The idea is that an oily substance, such as oil, smothers the lice and they may die. (Kozier, Fundamentals of Nursing 7th
ed. Page 733)

D. FACE Facial features, symmetry of facial movements Inspection Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds Symmetrical facial features while talking or elevating the eyebrow. Equal palpebral fissure, symmetrical nasolabial folds. Normal

IV. EYES A. EYEBROWS Hair distribution, alignment, skin quality and movement Inspection Symmetrical and in line with each other; maybe black, brown or blond depending Symmetrical and aligned with each other; black; evenly distributed. Movements Normal

on race; evenly distributed B. EYELASHES Evenness of distribution and direction of curl Inspection Palpation Evenly distributed; turned outward

are symmetrical.

Turned outward eyelashes; hair equally distributed

Normal

C. EYELIDS Surface characteristics and position (in relation to the cornea, ability to blink, and frequency of blinking) Inspection Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes are open; eyelids meet completely when the eyes are closed; symmetrical Able to close the eyes and has the ability to blink. Normal

D. CONJUNCTIVA 1. Color, texture, and the presence of lesions in the bulbar conjunctiva Inspection Palapation Pinkish or red in color; with presence of small capillaries; moist; no foreign bodies; no ulcers Pinkish or red in color; with presence of small capillaries; moist; no foreign bodies; no ulcers Pale color; smooth in texture Abnormal, pale conjunctiva may be related to the low RBC level of the patient. (Fundamentals of Nursing 5th edition by Taylor, page 642)

2. Color, texture, and the presence of lesions in the palpebral conjunctiva

Inspection Palpation

Pale

Abnormal, pale conjunctiva may be related to the low RBC level of the patient. (Fundamentals of Nursing 5th edition by Taylor, page 642)

E. SCLERA Color and clarity Inspection White in color; clear; no yellowish discoloration; some capillaries maybe visible White sclera with some visible capillaries, anicteric sclera. Normal

F. CORNEA Clarity and texture Inspection No irregularities on the surface; looks smooth; clear or transparent Clear and smooth in texture Normal

G. IRIS Shape and color Inspection Anterior chamber is transparent; no noted visible materials; color depends on the persons race Dark brown in color; transparent anterior chamber Normal

H. PUPILS 1. Color, shape, and symmetry of size Inspection Color depends on the persons race; size ranges from 3-7 mm, and are equal in size; equally round Constrict briskly/sluggishly when light is directed Pupil size is 3mm. Normal

2. Light reaction and accommodation

Inspection

Dilates when looking at far objects and constricts when looking

Normal

to the eye, both directly and consensual I. VISUAL ACUITY 1. Near vision Inspection Able to read newsprint

at near objects. Constricts when there is light.

Nearsightedness (Myopia)

Abnormal, it is a refractive defect of the eye in which collimated light produces image focus in front of the retina when accommodation is relaxed. It is caused by an eyeball that is longer than normal, which may be a familial trait. Transient mayopia occurs due to influenza, steroids, sever dehydration and large intake of antacids.
(Black, Medical Surgical Nursing7th edition, page 1963).

J. LACRIMAL GLAND Palpability and tenderness of the lacrimal gland K. EXTRAOCULAR MUSCLES Eye alignment and coordination Inspection Both eyes coordinated, move in unison, with parallel alignment Moves in Unison Normal Palpation No edema or tenderness over lacrimal gland No tenderness and edema noted. Normal

L. VISUAL FIELDS Peripheral visual fields Inspection When looking straight ahead, client can see objects in the periphery Can see objects in the periphery. Normal

V. EARS A. AURICLES 1. Color, symmetry of size, and position Inspection Color same as facial skin; symmetrical; auricle aligned with outer canthus of eye, about 10 degrees from vertical Mobile, firm, and not tender; pinna recoils after it is folded Same color as the facial skin; tip of auricle aligned at the outer canthus of the eye. Normal

2. Texture, elasticity and areas of tenderness

Palpation

Smooth in texture, flexible and elastic pinna; no tenderness

Normal

C. HEARING ACUITY TESTS 1. Clients response to normal voice tones Inspection Normal voice tones audible Can hear normal volume tones or words. Normal

VI. NOSE 1.Any deviations in shape, size, or color and flaring or discharge from the nares 2. Nasal septum (between the nasal chambers) Inspection Symmetric and straight; no discharge or flaring; Uniform color Nasal septum intact and in midline Symmetric and straight; Uniform color with nasal flaring. Abnormal, Nasal flaring suggests airway obstruction. Nasal discharge shows the presence of mucus secretions in the air tract. Normal

Inspection Palpation

Nasal septum intact and in midline

3. Patency of both nasal cavities

Inspection

Air moves freely as the client breathes through the nares

Only left nares is patent. Right nares is with secretion.

Abnormal, not patent right nares show the presence of mucus secretions and would suggest there is an infection in the respiratory system. Normal

4. Tenderness, masses, and displacements of bone and cartilage VII. SINUSES Identification of the sinuses and for tenderness VIII. MOUTH A. LIPS Symmetry of contour, color and texture

Palpation

Not tender; no lesions

Nor tenderness nor lesions.

Inspection

Not tender

Not painful when palpated

Normal

Inspection Palpation

Uniform pink color; soft, moist, smooth texture; symmetry of contour; ability to purse lips

Pink in color, dry and cracked lips

Abnormal, May suggest cellular dehydration. (Black, Medical Surgical Nursing7th edition, page 208).

B. BUCCAL MUCOSA Color, moisture, texture, and the presence of lesions Inspection Uniform pink color; moist, smooth, soft, glistening, and elastic texture Pink color and dry. Abnormal, May suggests dehydration. (Black, Medical Surgical Nursing7th edition, page 208).

C. TEETH Color, number and condition and presence of dentures Inspection 32 adult teeth; smooth, white, shiny tooth enamel; smooth, intact dentures Has 31 adult teeth. The patient has yellowish teeth. Have bad breath. Have tooth decay in the lower right second molars. Abnormal, most unpleasant odors are known to arise from proteins trapped in the mouth which are processed by oral bacteria. The most common location for mouth-related halitosis is the tongue. (http://en.wikipedia.org/wiki/Halitosis). It is also related to dental carries and frequency of tooth brushing.

D. GUMS Color and condition Inspection Pink gums; no retraction Pink gums; has no visible retractions Normal

E. TONGUE/FLOOR OF THE MOUTH 1. Color and texture of the mouth floor and frenulum. Inspection pink color; moist; slightly rough; thin whitish coating; moves freely; no tenderness Central position; pink color; smooth tongue base with prominent veins Smooth with no palpable nodules, lumps, or excoriated Pink and moist. Tongue moves freely and no pain felt. Normal

2. Position, color and texture, movement and base of the tongue

Inspection

Located and positioned in the center.

Normal

3. Any nodules, lumps, or excoriated areas

Palpation Inspection

No tenderness nor masses

Normal

areas F. PALATES and UVULA 1. Color, shape, texture and the presence of bony prominences Inspection Palpation Light pink, smooth, soft palate; lighter pink hard palate , more irregular texture Positioned in midline of soft palate The hard palate has a lighter color than the soft palate; has quite rough texture Positioned at the center of the oropharynx Normal

2. Position of the uvula and mobility (while examining the palates) G. OROPHARYNX and TONSILS 1. Color and texture

Inspection

Normal

Inspection

Pink and smooth posterior wall

Dry, pinkish in color.

Abnormal, May suggests dehydration. (Black, Medical Surgical Nursing7th edition, page 208). Normal

2. Size, color, and discharge of the tonsils

Inspection

Pink and smooth; no discharge; of normal size Present

Has no discharge; pinkish

3. Gag reflex X. THORAX A. ANTERIOR THORAX 1. Breathing patterns

Inspection

Present

Normal

Inspection

Quiet, rhythmic, and effortless respirations

Difficulty of breathing

Abnormal, labored breathing is a common manifestation affecting clients with cardiac and pulmonary disorders. It is related to obstructed airway. It also related to the

decreased size of the lungs due to PTB. (Black, Medical Surgical Nursing7th edition, page 1566). 2. Temperature, tenderness, masses Palpation Skin intact; uniform temperature; chest wall intact; no tenderness; no masses Bronchovesicular and vesicular breath sounds Has an intact skin; has equal warmth on both sides. No masses. Normal

3. Anterior thorax auscultation

Auscultation

Has crackles sounds on the upper thorax & lower thorax

Abnormal, crackles or rales are audible when there is a sudden opening of small airways that contain fluid. It is usually heard during inspiration. (Black, Medical Surgical Nursing7th edition, page 1756).

B. POSTERIOR THORAX 1. Shape, symmetry, and comparison of anteroposterior thorax to transverse diameter Inspection Palpation Anteroposterior to transverse diameter in ratio 1:2; Chest symmetric Has a anteroposterior to transverse diameter ratio of 1:2, elliptical in shape and symmetrical chest Has a vertical alignment No masses nor tenderness; has equal warmth on each side Normal

2. Spinal alignment

Inspection

Spine vertically aligned Skin intact; uniform temperature; chest wall intact; no tenderness; no

Normal

3. Temperature, tenderness, and masses

Palpation

Normal

masses 7. Posterior thorax auscultation Auscultation Vesicular and bronchovesicular breath sounds Has crackles heard on the anterior and middle part of right and left lungs. Diminished lung sound on the posterior right lung. Abnormal, the condition is related to the decreased size of the right lung and poor inspiratory effort due to pain.
(http://www.nurse411.com/Heart_Lung_Sounds.asp)

XI. CARDIOVASCULAR A. AORTIC and PULMONIC AREAS B. TRICUSPID AREA Auscultation No pulsations No pulsations felt Normal

Auscultation

No pulsations; no lift or heave Pulsations visible in 50% of adults and palpable in most PMI in fifth LICS at or medial to MCL Aortic pulsations S1: Usually heard at all sites Usually louder at the apical area S2: Usually heard at all sites Usually louder at the

No pulsations of lifts

Normal

C. APICAL AREA

Auscultation

Has full pulsation

Normal

D. EPIGASTRIC AREA E. CARDIOVASCULAR AREAS AUSCULTATION

Auscultation Auscultation

Has pulsation Has full and rapid pulsation. 84 bpm/minute. Sounds on the aortic and pulmonic areas; has a lub sound on the apex and dub sounds

Normal Normal

Normal

base of heart Systole: silent interval; slightly shorter duration than diastole at normal heart rate (60 to 90 beats/min) Diastole: silent interval; slightly longer duration than systole at normal heart rates S3: in children and young adults S4: in many older adults XII. CAROTID ARTERIES 1. Carotid artery palpation Palpation Symmetric pulse volumes; full pulsations, thrusting quality; quality remains same when the client breathes, turns head, and changes from sitting to supine position;

on the tricuspid area. Blood pressure is 90/70 mm Hg.

Normal

Has weak pulsation. Symmetrical pulse.

Abnormal, decreased amount of blood volume passing the artery. (Black, Medical Surgical Nursing7th edition, page 1574).

elastic arterial wall XIV. AXILLAE 1. Axillary, subclavicular, and supraclavicular lymph nodes Inspection No tenderness, masses, or nodules Have no masses and nodules. Presence of a foul smelling odor. Abnormal, The appocrine glands located in the axillae produces sweat. The secretion of these glands is odorless, but when decomposed or acted upon by bacteria in the skin, it takes on a musky, unpleasant odor. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 699)

XV. ABDOMEN 1. Skin integrity Inspection Unblemished skin; uniform color Flat, rounded(convex), or scaphoid(concave) No evidence of enlargement of liver or spleen Symmetric contour Uniform color and has no blemishes Has a concave abdomen. Normal

2. Abdominal contour

Inspection

Normal

3. Enlargement of liver or spleen

Inspection

No enlargement of the spleen and liver seen

Normal

4.Symmetry of contour

Inspection

Has a symmetrical abdominal contour Abdominal movements noted when inhaling.

Normal

5. Abdominal movements associated with respirations, peristalsis or aortic pulsations

Inspection

Symmetric movements caused by respiration; visible peristalsis in very lean people; aortic pulsations in thin

Normal

persons at epigastric area 6. Vascular pattern Inspection No visible vascular pattern Has no blood vessels visible Normal

XVI. MUSCULOSKELETAL SYSTEM

A. MUSCLES 1. Muscle size and comparison on the other side 2. Fasciculation and tremors in the muscles 3. Muscle tonicity Inspection Proportionate to the body; even in both sides No fasciculation and tremors Even and firm muscle tone Proportionate to the body; even in both sides Has no fasciculation and tremors Weak muscle tone Normal

Inspection

Normal Abnormal, possibly related to the amount of food that patient is eating. Possible exhaustion experienced by the patient when she coughs.
(http://en.wikipedia.org/wiki/Muscle_weakness)

Palpation

4. Muscle strength

Palpation

Has equal muscular strength on both sides

Weak muscle strength

Abnormal, possibly related to the amount of food that patient is eating. Possible exhaustion experienced by the patient when she coughs.
(http://en.wikipedia.org/wiki/Muscle_weakness)

C. JOINTS 1. Joint swelling Inspection No swelling, no warmth, no redness, no pain, no crepitus No swelling, no warmth, no redness, no pain, no crepitus Normal

EXTREMETIES

Inspection, Palpation

No swelling, no warmth, no redness, no pain.

No edema, no pain when moved.

Normal