III.

PHYSICAL ASSESSMENT

ACTUAL VITAL SIGNS NORMAL VALUES INTERPRETATION

RR- 20 12-20 beats/min. Normal
PR- 80 60-100 beats/min. Normal
BP- 120/70 90/60- 130/90 mmHg Normal

Height = 5’1 ft.

Weight = 57 Kg.

Body Parts Technique Normal Actual Significance

used findings findings
Head Inspection Normocephalic Normocephalic Normal
Palpation No abnormal No abnormal Normal
mass mass
Hair and scalp Inspection Evenly Even Normal
distributed, distribution of
Thick hair, hair , no
no infection infection and
and infestation infestation
Eyes Inspection Symmetric to Sunken eyeball Not Normal.
the face, Due to
both eyes dehydration
coordinated
with parallel
alignment.
External eye
Structure

Eyebrows Inspection Hair evenly Evenly Normal

distributed, distributed with
Skin intact skin intact
Eyelashes Inspection Equally Equally Normal
distributed, distributed,
Curled slightly Curled slightly
outward outward
Eyelids Inspection Skin intact, Skin intact, no Normal
No discharge, discharge, no
No discoloration,
discoloration, lids are
Lids close symmetrical.
symmetrically
Lacrimal Inspection No edema or No edema and Normal
gland tearing. tearing
Pupils (color , Inspection Black in color, Black in color, Normal
shape and equal in size equal in size
symmetry of normally 3-7 4mm in
size) mm in diameter
diameter,
round smooth
border , iris flat
and round.

Ears Inspection Symmetrically Positioned Normal

aligned to the symmetrically to
face, firm and the face,
not tender with No notable ear
no discharged discharge, clean
noted. and dry,.
Nose Inspection Symmetric and Symmetric and Normal
straight, no straight , no nasal
discharges or discharges noted,
flaring no flaring noted
Mouth

Lips Inspection Uniform pink Uniform dark color Not Normal

in color, soft dry due to
and moist and chemical
smooth content of
cigarette such
as nicotine.
Tongue Inspection Tongue at Dry and free of Normal
midline lesion
without lesion
Teeth Inspection Complete, Incomplete, Not normal.
white, shiny missing teeth, ill Aging is a
tooth enamel, fitting dentures factor affecting
free of debris loss of teeth
and also
insufficient
calcium and
fluoride.
Neck Inspection Coordinated , Coordinated Normal
smooth movement with no
movement with discomfort
no discomfort
Palpation No masses, No masses, Normal
tenderness tenderness
Upper
Extremities

Skin Inspection Pinkish in Pallor Not normal.

color It is a
manifestation
of in adequate
circulating
blood or
hemoglobin.
Palpation Slightly moist Poor skin turgor Not normal due
to dehydration
Palpation Normothermia Not warm, not cold Normal
to touch, T=36
Arms Inspection Normally firm, Normally firm, no Normal
no contracture, contracture, no
no swelling, swelling, equal size
equal size on on both sides of
both sides of body
body
Palpation Pulse Rate: 60- Pulse rate: 80 Normal
100
Nails Inspection Smooth, highly Pink, smooth Normal
vascular and texture, convex
intact curvature
epidermis
Palpation Capillary Refill Capillary refill: 2 Normal
of 1-2 seconds seconds
Chest and Inspection Symmetric Symmetric chest Normal
Lungs chest expansion, quiet,
expansion, rhythmic and
quiet, rhythmic effortless
and effortless respiration
respiration

Palpation No retraction, No retraction, no Normal

no tenderness, tenderness, no
no masses masses
Auscultation Quiet, Adventitious Not normal due
rhythmic breath sounds to presence of
secretion
Heart Auscultation Normal heart Cardiac rate of 80 Normal
rate 60-
100bpm
Abdominal Inspection Unblemished Lesions noted on Not normal
skin, uniform the surgical site because of post
in color procedure done

Auscultation Average Audible bowel Normal

normal bowel sound of 8 per
sounds 5-25 minute
per minute
Lower
extremities

Skin Inspection No lesion, can No edema, no Normal

move freely deformities and
can move freely
Palpation Capillary refill: Capillary refill: 2 Normal
1-2 seconds seconds