III.

PHYSICAL ASSESSMENT (IPPA – Cephalocaudal Approach)

Four basic techniques are used in performing a physical assessment:

inspection, palpation, percussion and auscultation. Inspection is using the senses
of vision, smell, hearing to observe the condition of various body parts, including
any deviations to normal. Palpation is touching and feeling body parts with your
hands to determine different characteristic such as texture and consistency.
Percussion is tapping a portion of the body to elicit tenderness or sounds that vary
with the density of underlying structures. Auscultation is listening for various
breaths, heart, vasculature and bowel sounds using a stethoscope.

Date assessed: June 28, 2010 - First Nurse Patient Interaction

During the first interaction, patient was received sitting on bed. His dress is
neat and clean; posture is slightly stooped; and appears weak and restless.
Pinpoint pigments were evident all over his body.

Vital Signs taken as follows:

Temperature: 38.8°C
Respiratory rate: 35bpm
Pulse rate: 95 bpm

Height: 3’3”
Weight: 18 kgs

Ideal Body Weight

(Age in years X 7 -5)/2
= (7 X 7 – 5)/2
= (49-5)/2
=44/2
 =22 kgs

BMI
BMI= kg/m2

3 feet X 12inches = 36 inches + 3 = 39 inches X 2.54 cm = 99.06 cm

1 foot 1 inch

91.44 cm X 1m = 0.9906m  0.98m2

100 cm

18 kgs = 18.37 kgs/m2, underweight by 3.63 kgs

0.98 m2

1. Integumentary

a. Skin

Inspection:
 Fair complexion
 Mole in his neck
 Presence of bruises
 Petechiae was seen on his left arm
 Light colored palms, soles, nails and lips

Palpation:
 Smooth and soft to touch
 Warm, dry
 Skin color returns less than 2 seconds after pinching

b. Hair
 Inspection:
 Black in color
 Evenly distributed on head
 No hair noted on axilla, chest, back, or face

Palpation:
 Coarse and thin hair

c. Scalp

Inspection:
 Symmetrical and round
 Oily
 No lesions and inflammation noted
 No infestation of parasites and dandruff

Palpation:
 No masses upon palpation

d. Nails

Inspection:
 Pale nail beds
 Nails are long and dirty
 Round nails with 1600 angle

Palpation:
 Capillary refill of 2-3 seconds
 Long and hard fingernails
 Smooth and firm
 With capillary refill of less than 2 seconds

2. Head and Face

a. Head

Inspection:
 Symmetric
 Round
 Still and upright

Palpation:
 No lesions
 No masses & swelling

b. Face

Inspection:
 Symmetric

Palpation:
 No masses noted

c. Eyes

Inspection:
 Blinking symmetrical
 Eyelashes and eyebrows are evenly distributed
 Eyelashes slightly curled outward
 Cornea shiny and transparent
 Pupils are black in color, equally round ,reactive to light and accommodation and
converges when seeing near objects
 Sclera becomed reddened
 Pink palpebral conjunctiva with no discharge
 Cornea is transparent and moist
 Both eyes move in a smooth coordinated manner in all directions
 Illuminated pupils constrict symmetrically
 No lesions and discharges

Palpation:
 No edema and tenderness of the lacrimal sacs and nasolacrimal ducts

3. Ears

Inspection:
 Symmetrical
 Alignment of pinna with the outer canthus of the eyes is within 10 0 angle of vertical
position
 Smooth and without nodules
 Presence of moist, odorless, yellow earwax
 Canal walls are pink in color
 Non-tender auricle and tragus

Palpation:
 Mastoid process are non tender, warm and easily palpated

4. Nose

Inspection:
 Skin color is the same as the rest of the face
 External structure without deformity or inflammation
 Symmetrical with the face
 With presence of bleeding
 Mucosa is pink and moist with uniform color and no lesions

Palpation:
 No masses and tenderness upon palpation

5. Mouth

Inspection:
 Lips are dry and light pink in color- Lack of fluid intake
 Teeth are pearly white and shiny
 With presence of bleeding in the gums
 Buccal mucosa is moist, intact, pink in color and free of lesions
 Tongue is pink
 Uvula hangs freely on the midline
 Pharyngeal tonsils are free of lesions and swellings
 Hard plate is pink
 Soft palate is pink

6. Thorax and Lungs

a. General

Inspection:
 Client has evenly colored skin tone without unusual redness or bluish
discolorations
b. Posterior Thorax

Inspection:
 Breathes without the use of accessory muscles
 Equal temperature bilaterally
 2 cm chest expansion

Palpation:
 No tenderness upon palpation
 No palpable crepitus
 No lesions and masses

Auscultation:
 Breath sounds heard upon auscultation

c. Anterior Thorax

Inspection:
 Sternum is straight and located at the midline

Palpation:
 No tenderness upon palpation of lung area
 No crepitus and unusual bulges palpable

Auscultation:
 Breath sounds heard upon auscultation

7. Breasts and Lymphatic System

Inspection:
 Symmetrical
 No lesions
 Nipples are equal bilaterally
 Axillary skin free of rashes

Palpation:
 Smooth in texture
 No tenderness and masses upon palpation
 No palpable lymph nodes

8. Heart and Neck Vessels

Inspection:
 The glands (lymph nodes) in the neck and groin are swollen

Palpation:
 Apical pulse not visible

Auscultation:
 No swishing sounds upon auscultation
 S1 follows the long diastolic pause and precedes the short systolic pause which
corresponds to each carotid pulsations

9. Peripheral Vascular System

a. Arms

Inspection:
 Same color bilaterally
 Palpation:
 No edema
 Warm to touch
 Radial and brachial pulses equal in strength bilaterally

b. Legs

Inspection:
 Evenly distributed hair

Palpation:
 No edema
 Toes, feet and legs are warm bilaterally
 Inguinal lymph nodes non-tender
 Able to move with assistance

10. Abdominal

Inspection:
 Abdomen round,symmetric,withot masses, lesions, pulsations, or peristalsis noted
 Umbilicus located at the midline
 Rounded abdomen
 No visible peristaltic waves

Palpation:
 Soft and tender upon palpation

Auscultation:
 No venous hum, friction rub and bruits heard upon auscultation
11. Genitalia

Inspection:
 No pubic hair
 Skin is the same color as stomach, even in color all throughout
 No discharge

Palpation:
 No bulging or masses in inguinal area
 No palpable lymph nodes

12. Musculoskeletal

a. Gait

 Posture slightly stooped- Due to body weakness

 Able to stand on heels and toes
 Coordinated movements

b. TMJ

 Protrudes and retracts easily

 Jaw moves laterally by 1-2 cm
 No swelling

c. Cervical, Thoracic, Lumbar Spine

 Low backache

d. Shoulders, Arms, Elbows

 Shoulders
 Symmetrically round
 No redness
 No tenderness

 Elbows
 Symmetric and non-tender

 Wrists
 No swelling
 Non-tender
 With lesion on left wrist, 2 cm long.

 Hands and fingers

 Symmetreic
 Non- tender

e. Hips
 Buttocks equally sized
 Stable
 Non-tender

f. Knees
 Symmetric
 Non-tender
 No swelling

g. Ankles and Feet

 Smooth and rounded
 No corns, calluses and nodules
13. Neurologic

a. Mental Status

 Conscious
 Awake
 Alert
 Responds appropriately but slightly irritable
 clothes appropriate for the weather, neat and clean
 facial expression is symmetric with mood
 speaks clearly and appropriate
 oriented to person, time, place and events
 Can recall significant dates and events

 Posture
 Slightly stoop

Facial expressions
 Smiles and frowns appropriately

Speech/ Mood
 Doesn’t talk much
 Can utter sentences

Thought processes
 Follows directions accurately

Cranial Nerve Client Response

CN I – Olfactory He was able to identify the different scents of the different
types of perfumes with each nostril separately and with eyes
 closed.
CN II - Optic He was able to read a print held at a distance of 14 inches.
CN III – Oculomotor Response to light:

CN IV – Trochlear The illuminated pupils of Denggoy constricted and the pupil

opposite the one illuminated also constricts simultaneously.

CN VI – Abducens Accomodation:
His pupils constricted as the object moved toward her nose.

Extraocular Movements:
He was able to move his eyes in all six cardinal fields which
are right and up, right, right and down, left and up, left, and
left and down.
CN V- Trigeminal Sensory Function:
He felt all the sensations specifically light touch, dull, and
sharp. He was able to identify them on both sides of face at
the forehead, cheek, and chin areas with eyes closed

Motor Function:
His masseter and temporal muscles contracted on both
sides as he clenched her teeth.
CN VII-Facial Sensory Function:
He was able to distinguish varied tastes (sugar, coffee, salt)
with eyes closed and tongue protruded.
Motor Function:
He was able to smile, frown, puff out cheeks, raise
eyebrows, and tightly close eyes as instructed and the
movements were symmetrical to both sides of her face.
CN VIII- Acoustic He was able to hear tickling of the watch in both ears.
CN IX- He was able to elicit gag reflex and able to swallow without
Glossopharyngeal difficulty. His uvula and soft palate rose bilaterally and
CN X- Vagus symmetrically.
CN XI- Accessory He was able to shrug her shoulders and turn his head from
one side to the other against a resistance, first to the right
then to the left.
CN XII- Hypoglossal He was able to move tongue in different directions.

Developmental Assessment

Erickson's Theory of Psychosocial Development 

Erick Erickson believed that the greater that task achievement, the healthier
the personality of the person. If the person fails that task, it will influence the
personal ability of the person to do the next task. Basing on this theory, Denggoy
still belongs to school age based on Erikson’s theory the child developmental task
is the “Industry vs. Inferiority”. Because a school age child needs to be encourage
in their efforts to do practical tasks or make practical things. They are praised and
rewarded for the finished result – sense of industry grows. The parents who don’t
show appreciation for their child’s efforts – develop inferiority.

Kohlberg's Theory of Moral Development

Moral Development theory is described in three levels. The first level is the
Pre-conventional Morality. At this stage, the child is satisfied through obeying rules
to avoid punishment. In the Conventional Morality, it is often referred to as the
"good boy-good girl" orientation. When the child would make judgment, he
considers the society as a whole. At the Post conventional Morality, it is the
development of moral principles that can be used to solve complex moral and
ethical dilemmas. Basing on this theory, Christian belongs to “Conventional
Morality” because he is satisfied on following the rules for the maintenance of
social order.

Psychosexual Theory of Sigmund Freud

 According to Sigmund Freud, personality is mostly established by the age of
seven. He believed that personality develops in a series of childhood stages during
which the pleasure-seeking energies of the id become focused on certain
erogenous areas. Basing on this theory, Denggoy belongs to the Latency wherein
he focuses on peer relations and learns to live in a group. He also prepares for the
conflicts of adolescence.

Follow up Assessment (Problem oriented)

Date: January 05, 2010 –Second and final Nurse Patient Interaction

Vital Signs taken as follows:

Temperature: 38.3°C
Respiratory rate: 32bpm
Pulse rate: 52 bpm

 Pale nail beds

 With presence of bleeding in the nose
 Lips are dry and light pink in color
 With presence of bleeding in the gums
 Soft and tender abdomen upon palpation
 Sclera becomes reddened.
 The glands (lymph nodes) in the neck and groin are swollen
 Low backache