Nursing Assessment (Physical Assessment)

System Normal Outcome Interpretation/

Implications
General -Appear relax and -facial grimace and Facial grimace and
Appearance comfortable distress observed distress may mean that
-Cooperative -able to follow the patient is
instructions experiencing pain
-Good overall -good
hygiene

Neurologic Oriented to time, -oriented to time, place Normal

place and person and person
Able to recall -able to recall recent
recent events of events of the day
the day -able to communicate well
Able to communicate using English and Filipino
language

Musculoskele Capable to move -limping when walking (+) Claudication, decreased

tal the whole body claudication sensation, weak and
part -decreased sensation of the atrophied leg, decreased
Able to feel right leg strength and diminished
sensation -atrophy and weakness of pulse may prevent client
Good muscle the right leg from doing usual
strength -decreased strength activities.
-diminished pedal pulses
Integumentar -feet cold to touch -May indicate a poor
-Good skin turgor,
y -skin mottled reddish-blue tissue perfusion
free from rash,
and appears thin and shiny
similar in color
at right leg
and warm to touch.
-black gangrenous areas on
the toes and heels
 -skin color turn pale when
raised; red and cyanotic
when legs are lowered
-slow nail growth
-no hair growth at right
leg

Respiratory Increased RR and use of

RR: 12-20 bpm -RR: 25 bpm/min.
accessory muscles may
Chest symmetric, -symmetric chest with no indicate distress or
spine vertically masses or tenderness pain.
aligned -Use of accessory muscles
Chest wall intact
no masses and -resonance heard upon
tenderness, quite percussion
rhythmic -no adventitious sound
effortless heard upon ausculation
respirations.
Resonance upon
percussion
No presence of
adventitious
sounds

Cardiovascul HR: 60-100 -HR upon rest: 78 Increased heart rate with
ar BP: 90-120/60-80 -HR with activity: 102 activity may indicate
Capillary refill BP: 140/90mmHg weakness and fatigue upon
<2sec -Capillary refill >3 sec. activity. Prolonged
Palpable pulses on right foot capillary refill time and
-diminished posterior absent pulse may indicate
tibial pulse that the affected part
 may have poor tissue
perfusion

Gastrointest Good appetite -ate only ¼ of food served -decreased appetite

inal Normal bowel sounds -hypoactive bowel sounds -patient could be
Normal bowel -have not defecated for 3 experiencing constipation
movement (2-3X a days
day)

References:
1) Health assessment for nursing practice. 3rd ed.,P. 400. Wilson and Giddens.
2) Mosby’s Handbook of Patient Teaching. 3rd ed., 2006. P. 174. Mary M. Canobbio.
3) Professional Guide to Disease. 9th ed., 2009. P 94. Wolters Klumer