PHYSICAL ASSESSMENT Date assessed: January 7, 2011 General assessment: conscious and coherent Initial vital signs: T=36.

5 C, RR=22, BP=90/60, PR=83 Area Assessed Skin Color Technique Normal Findings Actual Findings Evaluation

Inspection

Light brown, tanned skin

Light brown skin

Normal

Soles and palms

Inspection

Lighter colored palms, soles

Lighter colored palms, soles

Normal

Moisture

Inspection/ Palpation

Skin normally dry

Skin normally dry

Normal

Temperature

Palpation

Normally warm

Normally warm

Normal

Texture

Palpation

Smooth and soft

Slightly rough

Due to rashes

Turgor

Palpation

Skin snaps back immediately

Skin snaps back immediately

Normal

Skin appendages a.Nails Inspection Transparent, smooth and convex Transparent, smooth and convex Normal

Nail beds

Inspection

Pinkish

Pale

Due to decreased blood flow

Nail base

Inspection

Firm

Firm

Normal

Capillary refill

Inspection/ Palpation

White color of nail bed under pressure should return to pink within 2-3 Seconds

Returns within 2-3 seconds

Normal

b. Hair Distribution

Inspection

Evenly distributed

Evenly distributed

Normal

Color

Inspection

Black

Black

Normal

Texture

Inspection/ Palpation

Smooth

Smooth

Normal

Eyes Eyes Inspection Parallel to each other Parallel to each other Normal

Visual Acuity

Inspection (penlight)

PERRLA- Pupils equally round react to light and accommodation Symmetrical in size, extension, hair texture and movement

PERRLA- Pupils equally round react to light and accommodation Symmetrical in size, extension, hair texture and movement

Normal

Eyebrows

Inspection

Normal

Eyelashes

Inspection

Distributed evenly Distributed evenly and curved outward and curved outward

Normal

Eyelids

Inspection

Same color as the skin

Same color as the skin

Normal

Blinks involuntarily Blinks involuntarily and bilaterally up to and bilaterally up to Normal 20 times per minute 18 times per minute

Do not cover the pupil and the sclera, lids normally close symmetrically

Do not cover the pupil and the sclera, Normal lids normally close symmetrically

Conjunctiva

Inspection

Transparent with light pink color

Transparent with light pink color

Normal

Sclera

Inspection

Color is white

Color is white

Normal

Cornea

Inspection

Transparent, shiny

Transparent, shiny

Normal

Pupils

Inspection

Black, constrict briskly

Black, constrict briskly

Normal

Iris

Inspection

Clearly visible

Clearly visible

Normal

Ears Ear canal opening Inspection Free of lesions, discharge of inflammation Canal walls pink Free of lesions, discharge of inflammation Canal walls pink Normal

Normal

Hearing Acuity

Inspection

Client normally hears words when whispered

Client normally hears words when whispered

Normal

Nose Shape, size and skin color Inspection Smooth, symmetric with same color as the face Smooth, symmetric with same color as the face Normal

Nares

Inspection

Oval, symmetric and without discharge

Oval, symmetric and without discharge

Normal

Mouth and Pharynx Lips Inspection Pink, moist symmetric Light pink, dry, symmetric Lack of fluid intake

Gums

Inspection

Slightly pink color, moist and tightly fit against each tooth

Slightly pink color, moist and tightly fit against each tooth

Normal

Tongue

Inspection

Moist, slightly rough on dorsal surface medium or dull red

Moist, slightly rough on dorsal surface medium or dull red

Normal

Teeth

Inspection

Firmly set, shiny

Firmly set, shiny

Normal

Hard and soft palate

Inspection

Hard palate- domeshaped Soft Palate- light pink

Hard palate- domeshaped Soft Palate- light pink

Normal

Neck Symmetry of neck muscles, alignment of trachea Inspection Neck is slightly hyper extended, without masses or asymmetry Neck is slightly hyper extended, without masses or asymmetry Normal

Neck ROM

Inspection

Neck moves freely, without discomfort

Neck moves freely, without discomfort

Normal

Thyroid gland

Palpation

Rises freely with

Rises freely with

Normal

swallowing

swallowing

Abdomen

Inspection

Skin same color with the rest of the body

Skin same color with the rest of the body

Normal

Extremities Symmetry Skin color Inspection Inspection Symmetrical Symmetrical Normal

Same with the color Same with the color Normal of other parts of the of other parts of the body body Evenly distributed Warm to touch Evenly distributed Warm to touch Normal Normal

Hair distribution Skin Temperature Presence of lesion ROM

Inspection Palpation

Inspection

No lesions

No lesions

Normal

Inspection

Moves freely without discomfort

Able to move but with assistance

Due to body weakness

Neurology system Level of consciousness Inspection Fully conscious, respond to questions quickly, perceptive of events Fully conscious, Normal respond to questions quickly perceptive of events

Behavior and appearance

Inspection

Makes eye contact with examiner, hyperactive expresses feelings with response to the situation

Makes eye contact Normal with examiner, hyperactive expresses feelings with response to the situation