Physical Assessment

A. General Survey

Interpretatio
Norms Actual findings
n
Patient is relaxed, erect Patient is irritable
Client’s posture,
posture, with coordinated and only lie on bed
gait, standing,
movement while she and doesn’t sit or Abnormal
sitting and
walks, ambulates without stand only with
walking.
difficulty mother as guide
Client’s overall
hygiene and Clean and neat untidy Abnormal
grooming.
Describe body and No body odor; no breathe No body and
Normal
breathe odor. odor breathe odor
Observe for the
signs of distress in Calm, no sign of pain, no
Slightly irritable Abnormal
posture, facial distress noted
relaxation
Note obvious signs No signs of illness; with Looks unhealthy
Abnormal
of health or illness healthy appearance and pale
Describe the
Cooperative Cooperative Normal
client’s attitude
Describe the Patient’s mood is
client’s appropriate to the
affect/mood; situation; person is Patient’s mood is
assess the comfortable and appropriate to the Normal
appropriateness of cooperative with the situation
the client’s examiner and interacts
response pleasantly.
Articulation is clear and
Describe the understandable; in
Doesn’t speak
quantity & quality moderate pace; conveys Abnormal
much
of speech ideas clearly; exhibits
thought association
Listen for The person is alert &
relevance & oriented, attends to my
Lethargic Abnormal
organization of questions and responds
thoughts appropriately.
Measurements

• Temperatur 36.5 C to 37 C 37.9’C Slightly

e Increased,
Abnormal
80-120 134 bpm
• Cardiac rate Tachycardia,
Abnormal
20-30 66 cpm Tachypnea,
 • respiratory Abnormal
rate

Head-to-Toe Assessment

Body parts/ Interpretatio

Norms Findings
techniques used n
Skin Varies from light deep Brown and Pale Abnormal
• Uniformity of brown; from ruddy pink to
color (best assess light pink; from yellow
under natural overtones to olive,
light and areas generally uniform except
not exposed to in areas exposed to sun;
the sun) areas of lighter
pigmentation
(Fundamentals of Nursing,
Kozier pp. 475- 476)
• Skin moisture Moisture skin folds and Skin is a bit dry Abnormal
axillae
(Fundamentals of Nursing,
Kozier pp. 475- 476)
• Skin Skin is warm to touch Normal
temperature.
Uniform within normal
(Compare the two
range, warm temperature
feet and the two
(Fundamentals of Nursing,
hands using the
Kozier pp. 475- 476)
back of the
finger.)
• Skin turgor When pinched, skin brings When pinched, skin Normal
back to its normal state brings back to its
(skin is tuck hydration) normal state
(Fundamentals of Nursing,
Kozier pp. 475- 476)
Posterior Thorax
• Inspect the size,
shape, symmetry
and compare the Anteroposterior to Normal
diameter of transverse diameter in Chest is symmetrical
anteroposterior ration of 1: 2; chest
thorax to symmetry
transverse
diameter

• inspect the spinal Spine is vertically

 alignment Spine vertically aligned;
spinal column is straight, Normal
right and left shoulders
aligned
and hips are at the same
length

• palpate for
Uniform temperature, no
temperature Uniform temperature, Normal
tenderness and masses
tenderness and no tenderness and
masses masses

• assess respiratory Full and symmetric chest Full and symmetric

excursion expansion chest expansion Normal

• Anterior Thorax
Quiet, rhythmic and Abnormal
• Inspect breathing effortless respirations Full of effort, Fast
patterns

• Palpate for Skin intact, uniform

Skin intact, uniform temp.
temperature, temp. chest-wall Normal
chest-wall intact; no
tenderness, and intact; no tenderness /
tenderness / masses
masses masses

• Assess respiratory Full symmetric excursion; Full symmetric Normal

excursion thumb normally separates excursion
3 to 5 cm