DATE AND TIME: September 12, 2011 NAME OF CLIENT: ______________ AGE: 26y/o PHYSICAL ASSESSMENT Parts to be Examined

1. GENERAL SURVEY Body built, height & weight in relation to clients age, lifestyle and health Clients posture and gait, standing, sitting and walking Technique Inspection Normal Findings Proportionate, varies with lifestyle Relaxed, erect posture; coordinated movement Actual Findings He has a proportionate body built which is appropriate with his lifestyle He has uncoordinated movement and his not erect when standing, sitting and walking Interpretation Normal

Inspection

Clients overall hygiene and grooming Body and breath odor

Inspection

Clean, neat

He has unkempt appearance

Inspection

No body odor or minor body odor relative to work or exercise; no breath odor

There is a foul odor coming from the clients breath and with body odor.

Deviation from normal; because of having difficulties in moving due to his incisional wound in the abdomen. Deviation from Normal; Because he is unable to do personal hygiene Deviation from normal; Foul breath odor because his not able to brush his teeth and unable to take a bath because of his incisional wound. *****************

Clinical Measurements Height Weight Vital Signs Temperature Pulse rate Respiratory Rate Blood Pressure BEHAVIOR Signs of distress, in posture or facial

Inspection

Underweight-<18.5 Normal-18.5-24.9 Overweight-25-29.9 Obese->29.9 36.5-37.5 C 60-100bpm 12-21cpm 120/80mmhg

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Inspection Palpation Inspection Auscultation and Palpation Inspection

37.2 C 85bpm 18cpm 150/90mmhg

Deviation from normal; His vital signs are within normal apart from his elevated BP.

No distress noted

He make facial grimace when moving

Deviation from normal

expression Signs of health or illness Inspection Healthy appearance

his body. He doesnt appear healthy.

Clients attitude

Inspection

Cooperative, able to follow instructions

He is not fully cooperative and refuses to follow some instruction.

due to his incisional wound. Deviation from normal; Because of the presence of abdominal wound. Deviation from Normal; because of being irritated to his environment.

Clients affect/mood; appropriateness of clients response

Inspection

Appropriate to situation

Quantity of speech, quality

Inspection

Relevance and organization of thoughts 2. INTEGUMENTARY A. SKIN Color and uniformity of color

Inspection

Understandable, moderate pace; clear tone and inflection; exhibit thought association Logical sequence; makes sense; has sense of reality

Deviation from Normal; because of his behavioral attitude he view some question as very personal. His speech is understandable, clear and Normal has association of thoughts when he responds to some questions. He has relevance of thoughts that Normal makes sense and has a sense of reality

He doesnt answer to some sort of questions.

Inspection

Presence of edema Presence of lesion according to location, distribution, color, configuration, size, shape, type or structure Skin moisture

Inspection Inspection

Inspection

Varies from light to deep brown; He has brown skin but not that uniform ruddy pink to light pink; from because the areas exposed in the sun yellow overtones to olive are darker. Generally uniform except in areas exposed to the sun; areas of lighter pigmentation in darkskinned people No edema He has no edema Freckles, some birthmarks, some He has some small dark brown scars flat and raised nevi; no abrasions on his both legs and knees, and the or other lesions presence of incisional wound on his abdomen. Moisture in skin folds and axillae He has slight moisture in skin folds (varies with environmental and axillae due to warm environment

Normal

Normal Deviation from normal; due to presence of skin lesions and scars. Normal

Skin temperature Skin turgor B. NAILS Fingernails shape, curvature and angle Fingernail and toenail texture Fingernail and toenail bed color

Inspection Inspection

temperature and humidity and activity) Uniform; within normal range Skin springs back to previous state; has a good skin turgor Convex curvature; angle of nail plate about 160 No visible lines and cracks Smooth texture Highly vascular and pink in lightskinned people; dark-skinned may have brown or black pigmentation in longitudinal streaks Intact epidermis Prompt return of pink or usual color; capillary refill time 3 seconds

His skin temperature is warm and uniform but within normal range He has a good skin turgor

Normal Normal

Inspection Inspection Inspection

His nail has a convex curvature approximately 160 He has a smooth nails without any damages His nail bed color is pale especially in his toenail.

Normal Normal Deviation from Normal; Because there is poor circulation of blood in his fingers and toes Normal Deviation from Normal; Because of delayed capillary refill.

Tissues surrounding nails Blanch test of capillary refill

Inspection Palpation

He has an intact epidermis with no hangnails The blood moves back slowly to the fingernails and toenails; capillary refill time is 4 seconds.

3. HEAD A. SKULL Size, shape and symmetry Presence of nodules, masses and depressions B. SCALP Color and appearance Areas of tenderness C. HAIR Evenness of growth, thickness and thinness Texture, oiliness over the scalp

Inspection Palpation

Rounded (normocephalic); smooth skull contour Smooth, uniform consistency; absence of nodules and masses Usually white but it also depends on dark-skinned people No tenderness Evenly distributed thick hair Smooth texture; no oiliness

His skull is rounded and has a smooth skull contour He has no nodules and masses

Normal Normal

Inspection Palpation Inspection Palpation

His scalp is white and has a smooth surface There are no areas of tenderness He has thick hair and it is evenly distributed He has a smooth scalp but oily

Normal Normal Normal Deviation from normal; because he cant able to take a bath.

D. FACE Facial features, symmetry of facial movements 4. EYES A. EYEBROWS Evenness of distribution and direction of curl B. EYELASHES Evenness of distribution and direction of curl C. EYELIDS Surface characteristics, position in relation to the cornea, ability to blink and frequency of blinking D. CONJUNCTIVA Bulbar Conjunctiva for color, texture and presence of lesions Palpebral Conjunctiva for color, texture and presence of lesions E. SCLERA Color and clarity F. CORNEA Clarity and texture G. IRIS Shape and color

Inspection

Symmetrical facial features and movements

He has symmetrical facial features which has symmetrical movements

Normal

Inspection

Hair evenly distributed and the curl is outward

He have scars in his right eyebrow but they are aligned with equal movement

Deviation from Normal; Because of presence of scars Normal

Inspection

Equally distributed; curls slightly outward Skin intact; no discharge or discoloration; Lids closed symmetrically approximately 1520 involuntary blinks per minute Transparent; capillaries sometimes evident; Shiny, smooth and pink or red

His eyelashes are equally distributed and curled outward He has a smooth eyelids with no discharge; lids closed symmetrically and has 15-20 blinks per minute

Inspection

Normal

Inspection Inspection

His Bulbar Conjunctiva is transparent and has some visible small capillaries Has shiny, smooth but pale palpebral conjunctiva

Normal Deviation from Normal; Because of poor blood circulation Normal Normal

Inspection Inspection

Sclera appears white Transparent, shiny and smooth; the details of iris are visible Rounded shape which are the same in each eye; color varies depending on the race and the color is evenly distributed Black in color, equal in size and smooth border Able to read newsprints

He has white sclera He has a transparent, shiny and smooth cornea He has a dark brown iris which is uniform and they are both rounded

Inspection

Normal

H. PUPILS Color, shape and symmetry of size I. VISUAL ACUITY Near Vision

Inspection

His pupils are black, equal in size and has smooth borders He has difficulties reading newsprints

Normal

Inspection

Deviation from Normal;

Distant Vision J. PUPILS Light reaction and accommodation

Inspection Inspection

20/20 vision Illuminated pupils constricts Pupils also constricts when looking at near objects, dilate when looking at far objects and converge when near object is moved toward the nose

Procedure not done His pupils constrict when light passes and it also converge when near object is moved toward her nose

Because he has history of traumatic injury to his right eye and his left eye doesnt have clear vision as well. No equipment Normal

5. LACRIMAL GLAND / SAC & NASOLACRIMAL DUCT Lacrimal Gland A. EXTRAOCULAR MUSCLES Alignment and coordination

Inspection and palpation

No edema, tenderness or tearing

There are no edema, tenderness and tearing noted from the client Not both eyes are move coordinately

Normal

Inspection

Both eyes coordinated, move in unison, with parallel alignment

Deviation from Normal; his left eye fail to follow a penlight in specific directions Normal

B. VISUAL FIELD Peripheral visual fields

Inspection

When looking straight ahead, client can see objects in the periphery

He can see objects in the periphery

6. EARS A. AURICLES Color, symmetry of size and position

Inspection

Texture, elasticity and areas of tenderness B. EXTERNAL EAR CANAL Cerumen, skin lesions, pus and blood

Palpation

Color same as facial skin; symmetrical; auricle aligned with outer canthus of eye about 10 vertical Mobile, firm and not tender; pinna recoils after being folded Dry cerumen, grayish-tan color,

His ears skin color is same as the surrounding skin and both are symmetrical; the auricles are aligned in the outer canthus of each eye His auricles are mobile, firm and not tender; her pinna recoils when folded He had no visible cerumen, has a

Normal

Normal

Inspection

Normal

sticky or wet cerumen in various shades of brown C. HEARING ACUITY TESTS Clients response to normal voice tone Watch tick test Webers test Rinne test 7. NOSE Deviations in shape, size or color and flaring or discharge Nasal cavities for presence of redness, swelling, growths and discharge Nasal septum between the nasal chambers Patency of both nasal cavities Tenderness, masses and displacement of bones and cartilage SINUSES Tenderness 8. MOUTH A. LIPS Symmetry of contour, color and texture Inspection Inspection Inspection Inspection Normal voice tones audible Able to hear ticking sound in both ears Sound is heard at both ears or at the center (Webers negative) Air conduction is greater than the bone conduction (Rinne Positive) Symmetric and straight; no discharge or flaring; uniform color Mucosa pink; clear watery discharge; no lesions Nasal septum intact and in midline Air moves freely as the client breathes through the nares Not tender

grayish color

He can respond to normal voice tones He can hear ticking sound in both ears Procedure not done Procedure not done

Normal Normal No equipment No equipment

Inspection

Inspection

His nose are uniform in color same as with the surrounding skin; there are no discharge and flaring He has a clear watery discharge and has no apparent lesions His nasal septum is in the middle His nasal cavities are patent There are no tenderness, masses or displacement of bones and cartilage His sinuses are not tender

Normal;

Normal

Inspection Inspection Palpation

Normal Normal Normal

Palpation

Not tender

Normal

Inspection

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

He has pale and dry lips; it has symmetry of contour and has the ability to purse her lips

Deviation from Normal; Because of pale and dry lips due to inadequate oral fluid intake Deviation from Normal; Because lack of oral fluid intake and he is also a cigarette smoker

B. BUCCAL MUCOSA Color, moisture, texture and presence of lesions

Inspection

Moist, smooth, soft, glistening and elastic texture

He has moist, smooth, and glistening buccal mucosa but pale in color

C. TEETH Color, number, condition and presence of dentures D. GUMS Color and condition

Inspection

32 adult teeth; smooth, white and shiny tooth enamel

He has 3 missing teeth; yellowish teeth; black discoloration of the enamel and with presence of dentures He has dark pink gums, moist and firm texture without retractions

Deviation from normal; because of poor oral hygiene Deviation from normal; Because of dark pink gums and of being cigarette smoker

Inspection

Pink gums; moist and firm texture to gums; no retractions

E. TONGUE/ FLOOR OF MOUTH Color and texture of the mouth and frenulum

Inspection

Position, color and texture, movement and base of tongue Presence of nodules, lumps or excoriated areas F. PALATES AND UVULA Color, shape, texture, and presence of bony preminences

Inspection and palpation

Palpation

Central position; Pink color, moist, slightly rough; thin whitish coating, lateral margins; no lesions; raised papillae Moves freely; no tenderness; smooth tongue base with prominent veins Smooth with no palpable nodules

His tongue is in the center, but pale in color, it is moist, slightly rough without lesions; it has a thin whitish coating and lateral margins His tongue moves freely without tenderness It has no nodules

Deviation from Normal; Because of abnormal color of his tongue which is pale in color Normal

Normal

Inspection

Light pink, smooth, soft palate Lighter pink hard palate, more irregular Positioned in midline of soft palate

he has pale and smooth soft palate while pale hard palate, more irregular

Position of uvula and mobility while examining the palates. G. OROPHARYNX AND TONSILS Color and texture Size of tonsils, color and discharge Presence of Gag reflex 9. NECK A. LYMPH NODES Lymph Nodes and tenderness

Inspection

The uvula is in the middle

Deviation from Normal; Because of pale discoloration of soft and hard palate Normal

Inspection Inspection Inspection

Pink and smooth posterior walls Pink and smooth; no discharge; of normal size Gag reflex is present

He has a smooth and pinkish posterior walls His tonsils are pink and smooth without discharge and of normal size He elicit gag reflex

Normal Normal Normal

Inspection and palpation

Not palpable

His nodes are not palpable

Normal

B. TRACHEA Placement

Inspection and palpation

Central placement in midline of neck; spaces are equal in both sides Not visible on inspection Glands ascends during swallowing; painless, centrally located and smooth

His trachea is in the middle with equal spaces on both sides

Normal

C. THYROID GLAND Symmetry and visible masses Smoothness, enlargement and nodules 10. THORAX A. POSTERIOR Shape, symmetry, compare the diameter of anteroposterior to transverse diameter Spinal alignment Temperature, tenderness and masses Respiratory excursion

Inspection Palpation

It is not visible His thyroid glands rise when swallowing; it is smooth and painless

Normal Normal

Inspection

Inspection Palpation Inspection and palpation

Chest symmetric; anteroposterior to transverse diameter in ratio of 1:2 Spine vertically aligned Skin intact; uniform temperature Full and symmetric expansion; as the client breathes, thumbs usually separates 3-5cm Bilateral symmetry of vocal fremitus; it is heard mostly at the apex of lungs Percussion notes resonance except over scapula Lowest point of resonance is at the diaphragm Vesicular and bronchovesicular sounds Quiet, rhythmic and effortless respiration

Vocal fremitus

Palpation

His chest are symmetric; anteroporterior to transverse has a diameter ratio of 1:2 His spine is vertically aligned His skin is intact and has uniform warm temperature He has a full and symmetric expansion and as he breathes, thumbs usually separate for 3-5 cm. He has a bilateral symmetry of vocal fremitus; it is heard clearly at the apex His percussion notes resonance sound except over the scapula and the lowest resonance heard is at the diaphragm There are vesicular and bronchovesicular sounds heard He has a quiet, rhythmic and slightly effort respiration

Normal

Normal Normal Normal

Normal

Percuss the thorax

Percussion

Normal

Auscultate the thorax B. ANTERIOR Breathing patterns

Auscultation

Normal

Inspection

Temperature, tenderness and masses Respiratory excursion

Palpation Inspection and palpation

Skin intact; uniform temperature Full and symmetric expansion; as

His skin is intact and has uniform warm temperature He has a full and symmetric expansion

Deviation from Normal; Because when he talk too much he slightly effort to breath. Normal Normal

Vocal fremitus

Palpation

Percuss the anterior thorax

Percussion

Auscultate the trachea Auscultate the thorax 11. CARDIOVASCULAR Aortic and pulmonic areas Tricuspid area Apical area Epigastric area Auscultate aortic, pulmonic, apical, tricuspid and epigastric area

Auscultation Auscultation

the client breathes, thumbs usually separates 3-5cm Bilateral symmetry of vocal fremitus; it is heard mostly at the apex of lungs Percussion notes resonance except over ribs Lowest point of resonance is at the diaphragm Bronchial or tubular breath sounds Vesicular and bronchovesicular sounds No pulsation No pulsation; no lift or heave Some pulsations visible; no lift or heave Aortic pulsations S1-usually heard at all sites but louder at the apical area S2-usually heard at all sites but louder at the base of heart Symmetric pulse volumes; full pulsations No sounds heard Veins not visible Unblemished skin, uniform color

and as she breathes, thumbs usually separate for 3-5 cm. He has a bilateral symmetry of vocal fremitus; it is heard clearly at the apex His percussion notes resonance sound except over the ribs and the lowest resonance heard is at the diaphragm There are bronchial or tubular sounds heard There are vesicular and bronchovesicular sounds heard No pulsations felt No pulsations or lift and heave There are some pulsations felt but there are no lift or heave There are aortic pulsations There are heart sounds heard in all sites

Normal

Normal

Normal Normal

Inspection and palpation Inspection and palpation Inspection and palpation Inspection and palpation Auscultation

Normal Normal Normal Normal Normal

12. CAROTID ARTERIES Palpate with extreme caution Auscultate the carotid arteries 13. JUGULAR VEINS Presence of veins 14. ABDOMEN Skin integrity

Palpation Auscultation Inspection Inspection

His carotid artery has a full symmetric pulse volumes and pulsations There are no sounds heard There are no visible veins Skin color is not uniform and with presence of lesions

Normal Normal Normal Deviation from Normal; because of incisional wound Normal Normal

Abdominal contour Enlarged liver or spleen

Inspection Inspection

Flat, rounded or scaphoid No evidence of enlarged liver and spleen

Flat There are no evidence of enlarged liver and spleen

Symmetry of contour Abdominal movements Vascular patterns Bowel sounds, vascular sounds and peritoneal friction rubs

Inspection Inspection Inspection Auscultation

Percuss in each quadrants

Percussion

Symmetric contour Symmetric movements caused by respiration No visible vascular patterns Audible bowel sounds usually occure every 5-20 seconds; absence of arterial bruits and friction rub Tympany over stomach and gasfilled bowels; dullness over the liver and spleen or full bladder No tenderness, relaxed abdomen with smooth, consistent tension

Normal Deviation from Normal; Hypoactive sounds; soft and infrequent due to manipulation of the bowel during surgery Tympany over stomach and gas-filled Normal bowels; dullness over the liver and spleen or full bladder With slight tenderness, relaxed abdomen with smooth, consistent tension Deviation from Normal; due to presence of incisional wound

He has a symmetric contour He has symmetric movements because of respiration No visible vascular pattern noted

Normal Normal

Light palpation of quadrants

Palpation

15. MUSCULOSKELETAL A. MUSCLES Size, comparison on one side to other side Contractures Fasciculation and tremors Muscle tonicity Muscle strength B. BONES Normal structure and deformities Edema and tenderness C. JOINTS Swelling Tenderness, smoothness of movements, crepitation and nodules

Inspection Inspection Inspection Palpation Inspection and Palpation Inspection Palpation

Equal size on both sides of the body No contractures No tremors Normally firm Smooth coordinated movements No deformities No tenderness or swelling

He has equal muscle size on both sides of the body He has no contractures He has no tremors He has firm muscles He has smooth coordinated movements He has no deformities He has no edema, tenderness and swelling There are no swelling There are no tenderness, swelling, crepitation or nodules;

Normal Normal Normal Normal Normal Normal Normal

Inspection Palpation

No swelling No swelling, tenderness, crepitation or nodules

Normal Normal