I. Physical Assessment Vital Signs Temperature Cardiac rate Respiratory rate 3.

Head to toe Physical Assessment Body parts Integumentary Skin Skin color, uniformity of color Normal Findings Actual Findings Interpretation Normal Findings 36.8C-37.5C 80-120 bpm 20-25 cpm Actual Findings Interpretation

36.9C 104 bpm 24 cpm

Varies from light to deep brown; from rudy pink to light pink; from yellow overtones to olive Generally uniform except on areas exposed to the sun. No edema Freckles, some birthmarks, some flat and raised nevi; no abrasions or other lesions. Moisture in skin folds and the axillae Uniform; within normal range When pinched, skin springs back to previous state

Fair complexion. Skin color is deep brown.

Normal

Presence of edema Presence of lesions according to location, distribution, size, shape, type or structure. Skin moisture

Edema noted in joints. Nevi and freckles noted on part of the face. All skin area are wrinkled. Moisture present in skin. Uniform temperature Skin springs back to previous state but not immediately because of wrinkled skin.

Normal

Normal Normal

Skin temperature Skin turgor

Normal

Nails Fingernail plate shape

Fingernail and toenail texture Fingernail and

Convex curvature; angle of nail plate about 160 Smooth texture Highly vascular

Convex curvature Smooth texture with nail polish Nail beds are brown

Normal

Normal Normal

toenail bed color

Tissues surrounding nails

and pink in light skinned clients; dark-skinned clients may have brown or black pigmentation in longitudinal streaks Intact epidermis

Tissues surrounding the nails are not that intact and sloughing off. Return for 2 seconds.

Blanch test of capillary refill

Prompt return of pink or usual color (generally less than 4 seconds)

Head Skull Size, shape or symmetry

Presence of nodules, masses and depressions

Rounded (normocephalic); smooth skull contour Smooth, uniform consistency; absence of nodules or masses Light brown; no dandruff No tenderness

Normocephalic

Absence of nodules or any masses

Normal

Scalp Color and appearance Areas of tenderness Hair Evenness of growth; thickness or thinness Texture and oiliness over the scalp Face Facial features, symmetry of facial movements

Same with skin color No tenderness Proportionately distributed but there are areas with thin and dry hair Smooth texture

Normal Normal

Hair growth is proportionately distributed Smooth texture

Normal

Normal

Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds

Symmetric; facial features palpebral.

Normal

Eyes Lacrimal gland, lacrimal sac, and

nasolacrimal duct Lacrimal gland

No edema or tenderness No edema or tearing

No tenderness No edema

Normal Normal

Lacrimal sac and nasolacrimal duct Eyebrows and Eyelashes Hair distribution and direction of curl

Hair of eyebrows equally distributed; eylashes equally distributed and curved slightly outward Skin is intact; no discharge; no discoloration Lids close symmetrically Approximately 15 to 20 blinks per minute; bilateral blinking

Hair of eyebrows equally distributed.

Normal

Eyelids Surface characteristics, position in relation to the cornea, ability to blink and frequency of blinking

Skin is intact but wrinkled

Normal

Conjunctiva Bulbar conjunctiva for color, texture, and presence of lesions Palpebral conjunctiva for color, texture, and presence of lesions Sclera Inspect the color and clarity Cornea Clarity and texture; corneal reflex; shape and color

Transparent; capillaries sometimes evident sclera appears white Shinny, smooth and pink or red

Transparent; sclera appears white

Normal

Pink to pale in color

White and shinny

Reddish and visible blood vessels

Transparent, shinny and smooth Client blinks when the cornea is touched, indicating that the trigeminal nerve is intact.

Transparent, shiny and smooth

Normal

Iris Shape, color, and symmetrical size Pupils Color, shape, and symmetry of size

Round in shape, flat and evenly colored. Black in color; equal in size; normally 3 to 7 mm in diameter; round, smooth border

At the borders of the iris is colored white; somewhat cloudy.

Black in color

Normal

Extraocular Muscles Alignment and coordination

Both eyes coordinated, move in unison, with parallel alignment

Move in unison, with parallel alignment

Normal

EARS Auricle Color Symmetry and position, texture,elasticity, and areas for tenderness

The color is skin toned, symmetrical, Auricle aligned with the outer canthus of eye, no tenderness, no recoils after it is folded, mobile, firm

The color is skin toned and symmetrical. No tenderness.

Normal

External Ear Canal Cerumen, skin lesions, pus and blood

Distal third contains hair follicles and glands Dry cerumen, grayish tan color, or sticky, wet cerumen in various shades of brown Symmetric and straight No discharge of flaring Uniform color No tenderness, no lesions, no masses, no displacement of bone cartilage

Dry cerumen and is tan in color.

Normal

NOSE Deviations in shape, size, or color and flaring or discharge from nares Tenderness, masses, displacements of bone and cartilage

Symmetric and straight No discharge of flaring

Normal

No tenderness, no lesions, no masses

Normal

Patency of both nasal cavities

Presence of redness, swelling, growths, and discharge Inspect the nasal Septum between the nasal chambers MOUTH Lips Symmetry of contour, color and texture

Air moves freely as the client breathes through the nares Mucosa pink Clear, watery discharge No lesions Nasal Septum intact and in midline

Air moves freely

Normal

Mucosa pink No lesions

Normal

Nasal Septum intact

Normal

Uniform pink color Soft, moist, smooth texture Symmetry of contour Ability to purse lips Uniform pink color Moist, smooth, soft, glistening and elastic texture 32 adult teeth Smooth, white, shiny, tooth enamel Pink gums Moist, firm texture to gums No retraction of gums

Uniform pink color Soft, moist, smooth texture

Normal

Buccal Mucosa Color moisture, texture and presence of lesions

Uniform pink color Glistening texture

Normal

Teeth Color, number and condition and presence of dentures

Client wears false teeth.

Tongue/Floor of the mouth Color and texture of the mouth floor and fraenulum

Tenderness, movement and base of the tongue

Central Position Pink Color; moist; slightly rough; thin whitish coating Smooth, lateral margins; no lesions Raised papillae No tenderness; no lesions

Pink Color; moist; slightly rough; thin whitish coating

Normal

no lesions

Normal

Nodules, lumps or excoriated areas Oropharynx and tonsils Color and texture size of tonsils color and discharge NECK AND LYMPH NODES Lymph nodes Lymph nodes and for tenderness Trachea Placement

No nodules, lumps or excoriated areas

No nodules, lumps

Normal

Pink and smooth posterior wall No discharge

No discharge

Normal

Not palpable

Not palpable

Normal

Central placement in middle of neck; spaces are equal on both sides Not visible on inspection

Central placement in middle of neck

Normal

Thyroid Gland Symmetry and visible masses, Thorax Posterior Thorax Size, shape, symmetry, diameter of the anteroposterior thorax and transverse diameter. Spinal alignment Temperature, tenderness and masses Auscultation of posterior thorax Anterior Thorax Breathing patterns

Not visible on inspection

Normal

Anteroposterior to transverse diameter in ratio of 1:2 Chest symmetric Spine vertically aligned uniform temperature, no tenderness, no masses Vesicular and bronchovesicular breath sounds Quiet, rhythmic,and effortless respirations uniform temperature, no tenderness, no masses Full and symmetric chest expansion

Chest symmetric

Normal

Client is kyphotic but vertically aligned During symptoms, there is tenderness and difficulty of breathing. Vesicular and bronchovesicular sounds noted.

Normal

Normal

Quiet, irregular breathing Uniform temperature, no tenderness and massess Partial, symmetric lung expansion

Normal

Temperature, tenderness and masses Respiratory excursion

Normal

Normal

Vocal fremitus

Percussion of anterior thorax

Auscultation of the trachea Auscultation of the anterior thorax Cardiovascular Aortic and pulmonic areas Tricuspid areas Apical area

Same as posterior vocal fremitus; fremitus is normally decreased over heart and breast tissue Percussion notes resonate down to the sixth rib at the level of the diaphragm but are flat over areas of heavy muscle and bone, dull on areas of the heart and the liver, and tympanic over the underlying stomach Bronchial and tubular breath sounds Bronchovesicular and vesicular breath sounds No pulsations No pulsations, lift or heave Pulsations visible in 50% adults; no lift or heave S1: usually heard at all times and usually louder at apical area S2: usually heard at all sites and usually louder at the base of the heart S3 in children and young adults S4 in many older adults

Vocal fremitus decreased over heart and breast

Normal

Resonate at the level of diaphragm but flat over mascular areas and bone, dull sounds are heard on areas of heart and liver, tympanic sounds on stomach.

Normal

Bronchial and tubular sounds present Bronchovesicular and vesicular sounds No pulsations No pulsations, lift or heave no lift or heave

Normal Normal

Normal Normal Normal

Auscultation of the aortic, pulmonic, tricuspid and apical valves

S1 and s2 sounds present at the sites where they are usually heard louder

Normal

Carotid arteries Palpation of carotid artery

Symmetric pulse volumes; full pulsations, thrusting quality No sound heard on auscultation Unblemished skin; uniform color; silver white striae Symmetric contour Audible bowel sounds Absence of arterial bruits Absence of friction rub Tympany over the stomach and gas filled bowels; dullness especially over the liver and spleen or a full bladder No tenderness; relaxed abdomen with smooth, consistent tension

Auscultation of carotid artery Abdomen Skin integrity

Carotid arteries palpable with symmetric pulse volumes and thrusing quality No sounds auscultated Striation present, wrinkled abdomenal skin Symmetric contour

Normal

Normal

Symmetry of contour Auscultation of the abdomen for bowel sounds, vascular sounds, and peritoneal friction rub Percussion of the four quadrants

Normal

Audible bowel sounds, no bruits and friction rubs

Normal

Tympany over the stomach, dullness on liver and spleen

Normal

Palpation of the four quadrants

No tenderness relaxed abdomen with consistent tension

Normal

Musculoskeletal system Muscles Muscles size

Inspection of the muscle and tendons for contractures Fasciculations and tremors Muscle tonicity Bones Inspection of skeleton for structure Palpation of bones to locate

Equal size on both sides of the body No contractures

Equal size on both sides of the body No contractures

Normal

Normal No tremors Normally firm No deformities No tremors Normally firm

Normal Normal

No tenderness or swelling

Swelling seen on the areas near the

Normal

any areas of edema or tenderness Joints Swelling Tenderness, smoothness of movement, swelling, crepitation, ad presence of nodule. Range of motion

joints

No swelling No tenderness, swelling, crepitation, or nodules Joints move smoothly Varies to some degree in accordance with persons genetic makeup and degree of physical activity.

With swelling joints

Normal

Limited range of motion

Normal

General Appearance Body Build, Height, Weight Posture, Gait, Standing, Sitting, Walking Overall Hygiene and Grooming Body and Breath Odor

Proportionate, varies with lifestyle Relaxed, erect posture, coordinated movement Clean and Neat No body odor or minor body relative to work or exercise; no breath odor. No distress noted Healthy appearance Cooperative, able to follow instructions Appropriate to situation Understandable, moderate pace; clear tone and inflection; exhibits thought association Logical sequence; makes sense, has sense of

Slouch back walking

Clean and Neat No body odor

Normal Normal

Signs of Distress Obvious signs of Health or Illness Attitude

No distress Healthy appearance Cooperative with instructions Appropriate to situation Speech is easy to understand, with clear thought and association

Normal Normal Normal

Affect / Mood Quantity / Quality of Speech

Normal Normal

Reverence and Organization of Thought

Though on logical sequence, with a sense of reality.

Normal

reality