I.

PHYSICAL ASSESSMENT

A 1. GENERAL APPEARANCE/ HEALTH STATUS Appearance and mental status Body build Posture and gait, standing, sitting and walking Technique used Inspection Inspection Normal findings Proportionate Erect posture coordinated movement Actual Findings Analysis

Proportionate Proportionate

Normal Normal

MEASUREMENTS:

Level of consciousness; spontaneous Grooming: satisfactory

2VITAL SIGNS: NORMAL FINDING BODY TEMPERATURE PULSE RATE RESPIRATION BLOOD PRESSURE 37.0 OUTCOME 38.4C 132 BPM 36CPM 90/70MMHG ANALYSIS Presence of on infection Tachycardia Tachypnea NORMAL

120-160BPM 20-30CPM 100/60MMHG

Date of assessment: August 15, 2011 Time of assessment: 9; 00 am

Head to Toe assessment

AREA ASSESSED Head Skull

TECHNIQUE USED Inspection

NORMAL FINDINGS Normocephalic

ACTUAL FINDINGS

ANALYSIS

Normal Size of the proportional to size of the body

Hair

Inspection

c& smooth texture Black & smooth straight

Normal

Scalp

No wounds, no abrasion

Normal No wounds, mo abrasion

Face

Inspection Symmetrical Normal Due to fever

Eyes

Inspection

Symmetrical Flushed face

Due to fever

Sclera White Pupils Black

Teary eyes Redness of the eye

Due to fever

Red, watery

Black in color and equal in size

AREA ASSESSED

TECHNIQU E USED Inspection

NORMAL FINDINGS Normal voice Tones audible Parallel, Symmetrical, Proportional to the size of the head and bean shape

ACTUAL FINDINGS Normal voice Tones audible Parallel, Symmetrical, Proportional to the size of the head and bean shape

ANALYSI S Normal

Ears/ hearing

Normal

Pinna

Ear Canal Ear canal has no abundant cerumen/ ear wax Hair in the ear canal are visible

Ear canal has no abundant cerumen/ ear wax Hair in the ear canal are visible

Normal Nose and sinuses Inspection Nose is in midline and symmetrical (-) secretion of mucous Nose is in midline and symmetrical (-) secretion of mucous

Mouth Teeth

Inspection (-) swelling of gums and bleeding Gums is pinkish in color

Dry lips (+) swelling of gums and bleeding Gums is reddish

Tongue

In central position, freely movable, pinkish and with prominent veins on the sublingual area.

In central position, freely movable, reddish (STRAWBERY)

Because of the diffuse erythema and prominent papillae.

Moist Mucosal lining Symmetrical and lip margin is well defined Lips is pinkish Lips (-) swelling Tonsils (-) swelling Uvula

Moist Symmetrical and lip margin is well defined Lips is dry and Reddish (strawberry) (-) swelling

(-) swelling

2. Neck

Inspection

(-) rashes and visible masses No scars

(-) rashes

Normal

Inspection 3.Chest

No scars

Normal

Palpation

(-) tenderness and masses

(-) tenderness and masses

Breath sound

Auscultatio n

(+) broncho vesicular breath sound at 2nd ICS

(+) broncho vesicular breath sound at 2nd lungs

Normal

Breast Inspection

Breast is even with the chest wall

Breast is even with the chest wall

Normal

Nipple Inspection

Nipple are round, and equal in size

Nipple are round, and equal in size

Normal

Areola

Areola are round symmetrical, color brown

Areola are round symmetrical, color brown

Normal

Heart Auscultatio n

(-) arrhythmia, bounding pulse heart murmurs and any abnormal pulsation being auscultated

(-) arrhythmia, bounding pulse heart murmurs and any abnormal pulsation being auscultated

Normal

2.

Posterior thorax

Inspection

No scars

No scars

Normal

Palpation

Spine vertically align; spinal column is straight right and left shoulder and

Spine vertically align; spinal column is straight right and left shoulder and

hips are at the same height

hips are at the same height

Auscultaion

Fermitus is heard most clearly at the apex of the lungs No effort when breathing with good breathing pattern

Fermitus is heard most clearly at the apex of the lungs No effort when breathing with good breathing pattern

Lungs

Percussion (+) resonance NBS (normal lung sound) (+) resonance NBS (normal lung sound)

Normal

3.

Abdomen

Inspection

Abdominal skin is unblemished, no scars, with flat and rounded abdomen/symmetric al contour.

Abdominal skin is unblemished, no scars, with flat and rounded abdomen/symmetric al contour

Normal

Auscultatio n

Audible bowel sound

Active bowel sound (10-30 bowel sound in every 5min) tympany

Due to peristaltic activity

Percussion

(+) presence of tympany No evidence of enlargement of the liver

Normal

Palpation

No evidence of enlargement of the liver

Normal

4.

Upper Extremities

Skin Arms

Inspection

(-) scars at the lower forearm

(-) scars at the lower forearm With fine hair evenly distributed and few visible veins Normal

smooth

With fine hair evenly distributed and few visible veins Symmetrical Palpation Symmetrical

Finger

Inspection With complete five finger in each hand smooth, convex with pinkish nail bed Smooth, convex with pinkish nail bed

Desquamation of finger Peeling and erythema of the fingertips. Transverse grooves of fingers and toenails (Beaus lines).

Nail

5.

Lower extremities

Inspection

(-) negative scars

Legs

(-) negative scars

Fine hair is evenly distributed

Fine hair is evenly distributed

Muscles symmetrical, length symmetrical

Muscles symmetrical, length

Inspection

symmetrical Dorsal surface is smooth & warm

Feet Dorsal surface is smooth & warm With convex nails, pinkish nail bed and good capillary refill of 2-3 seconds

Normal

Toe Nails

With convex nails, pinkish nail bed and good capillary refill of 2-3 seconds

(-) long and dirty toe nail Normal

(+) short and with clear and white translucent tips toe nails.