PHYSICAL ASSESSMENT

Date Performed: January 27, 2020

Time: 1:00 pm
Patient Name: CCU 5
Age: 75 years old
Gender: Female

VITAL SIGNS
Measurements Norms Findings Analysis Interpretation
Temperature 36 – 37.5 °C 36.5 °C Normal The patient’s
body
temperature is
within normal
range.
Pulse Rate 60-100 bpm 100 Normal The patient’s
pulse is within
normal range
Respiratory Rate 15-20 cpm 20 Normal The patient’s
respiratory rate
is within normal
range
Blood Pressure 120/80 140/90 Above Normal Hypertension,
stage 1

GENERAL APPEARANCE
Measurements Norms Findings Analysis Interpretation
Observe client’s Clean and neat Patient is Normal The patient’s
overall hygiene hair, skin and wearing a overall hygiene
and grooming fingernails and hospital gown including the
clothes and has clean hair, skin and
hair, skin and fingernails is
fingernails neat and clean.
Observe for No distress No distress Normal There are no
signs of distress noted noted obvious signs
and symptoms
that indicates
sign of distress
Note obvious Healthy Unhealthy Deviation from The patient
signs of health appearance appearance normal appears to be
illnesses. weak.
Assess the Cooperative; Cooperative Normal The patient is
client’s attitude. able to follow cooperative. The
instructions patient follows
commands and
nods when
agreeing.
Note the client’s Mood is The patient’s Normal Patient shows
affect or mood appropriate for affect or mood is appropriate
the situation appropriate to mood to the
the situation. situation
Listen for Understandable; Patient has The patient’s
quantity of moderate pace; slurry speech speech is slurry,
speech clear tone and does not have a
inflection; clear tone. The
exhibit thought patient can speak
association “ayaw ko” or
“gusto ko”
Listen for Logical Cannot assessed Patient is not Due to the
organization of sequence; make able to generate client’s current
thought sense; has sense a proper condition,
of reality conversation. holding a
conversation is
difficult.

ASSESSMENT OF THE NEUROLOGICAL SYSTEM AND MENTAL STATUS

Measurements Norms Findings Analysis Interpretation
Determine The client is Conscious, Normal The patient is
client’s oriented to time coherent, conscious,
orientation to and place. Alert oriented to time, coherent and
time and place and answers to place and person oriented to time,
and listen for questions place and
lapses in person.
memory
Cranial Nerves Cranial Nerve I: Not all cranial The focused
CN I: sensory; smell nerves can be assessment
CN II: optic; sensory, vision Cranial Nerve II: assessed due to
CN III: oculomotor, motor; eyelid 2 mm, ERTL, the client’s Although a
and eyeball movement preferential gaze condition. thorough
CN IV: trochlear, motor; innervates to left neurologic
superior oblique, turns eye Cranial III, IV, assessment
downward and laterally VI: - yields valuable
CN V: trigeminal, motor; chewing. Cranial V: - information, at
Sensory; face and mouth; touch and Cranial VII: no times you'll need
pain facial to perform a
CN VI: abducens, motor; turns eye asymmetry focused
laterally Cranial VIII: - neurologic
CN VII: facial, motor; controls most Cranial IX, X: assessment. You
facial expressions, secretion of tears (+) gag reflex may have a
and saliva. Sensory; taste Cranial XI: patient with a
CN VIII: vestibulocochlear cannot assessed neurologic
(auditory) sensory; hearing, Cranial XII: diagnosis who
equilibrium sensation cannot assessed develops a
CN IX: glossopharyngeal motor; change. More
swallowing. Sensory; senses carotid likely, you may
blood pressure and taste buds have a patient
CN X: sensory; senses aortic blood with another
pressure, slows heart rate diagnosis who
Motor; stimulates digestive organs, develops a
taste neurologic
CN XI: accessory deficit. In these
Motor; controls trapezius and cases, it isn't
sternocleidomastoid necessary to
Cranial Nerve XII: hypoglossal perform the
Motor; controls tongue movement entire
assessment as
previously
described. Limit
 your
examination to
LOC, motor
strength, and
pupillary
reactivity. You'll
also want to
include other
assessments you
feel may yield
important data.
For example, if
your patient
develops slurred
speech, you'll
want to include
an examination
of the cranial
nerves involved
with speech.
Reflexes (-) Babinski Normal Upper motor
neurons
originate in the
cerebral cortex
and descend
through the
spinal cord,
where they
interact with
lower motor
neurons. A
patient with an
upper motor
neuron disease
will exhibit a
positive
Babinski reflex.

NURSING ASSESSMENT
System/Area Findings Analysis Interpretation
NEUROLOGICAL Normal Normal  The client is
Level of Consciousness Normal awake and alert:
*GCS (Write Scoring) 14-15 eyes are open and
Eye Opening 4 follow people or
Verbal Response 4-5 objects.
Motor Response 6  The client is
attentive to
questions and
responds to
commands.
 If she is sleeping,
she responds to
 verbal or physical
stimuli and
demonstrates
wakefulness and
alertness.
 The client is
aware of who she
is (orientation to
person), where
she is (orientation
to place), and
when it is
(orientation to
time).
RESPIRATORY There are no Client has pulmonary
Breath Sounds Normal adventitious breath congestion that is
Pattern Normal sounds heard but causing increased
Secretions Increased the secretions are secretions
Cough Normal increased
CARDIOVASCULAR  Rate ranges Client has
Heart Sound Normal normally from hypertension
Heart Rate Normal 60 -100 beats/
Capillary Refill Normal minute
Pulse Normal  The rhythm is
Blood Pressure 140/90 regular
 Blood Pressure
is above normal
GASTROINTESTINAL Normal sounds are Normal sounds
Abdomen Normal heard consist of clicks and
Bowel Sounds Normal gurgles, occurring at
Stool Character Normal estimated frequency
Stool Frequency Normal of 5 to 30 times per
minute
NUTRITION A nasal-gastric tube To feed client with
Appetite on NGT feeding feeding is a means fluids when oral
of providing liquid intake is not possible
nourishment
through a tube into
the intestinal tract
GENITOURINARY Normal There is no problem
Urine Amount Normal with her
Urine Color Normal genitourinary system
MUSCULOSKELETAL The client has Paralysis associated
ROM of Extremities Stiff extremities limited movement with upper motor
of the joints neuron lesions can
affect a whole
extremity, both
extremities, or an
entire half of the
body. If hemorrhage,
an embolus, or a
thrombus destroys
the fibers from the
motor area in the
internal capsule, the
 arm and the leg of
the opposite side
become stiff, weak,
or paralyzed, and the
reflexes are
hyperactive
(Brunner &
Suddarth's Textbook
of Medical-surgical
Nursing, Volume 1,
page 1840)
INTEGUMENTARY The presence of  The hematoma on
Skin Integrity Hematoma on hematoma and the upper back of
upper back and on abrasions on client the client was the
previous sites of are abnormal result from her
blood extraction findings. fall in the CR
and IV insertion;  Hematoma
concave shaped; results when
abrasions blood leaks into
tissues
surrounding the
IV insertion site.
Leakage can
result if the
opposite vein
wall is perforated
during
venipuncture, the
needle slips out
of the vein, or
insufficient
pressure is
applied to the site
after removal of
the needle or
cannula. The
signs of a
hematoma
include
ecchymosis,
immediate
swelling at the
site, and leakage
of blood at the
insertion site
(Brunner &
Suddarth's
Textbook of
Medical-surgical
Nursing, Volume
1, page 309)