III.

PHYSICAL ASSESSMENT NORMAL VALUES 12-20 beats/min. INTERPRETATION/ ANALYSIS Interpretation: Normal Analysis: Normally breathing is carried out automatically and effortlessly. (Fundamentals of
Nursing; Kozier; 7th edition; page 496)

ACTUAL VITAL SIGNS RR- 18

PR- 78

60-100 beats/min.

Interpretation: Normal Analysis: Generally the pulse wave represents the stroke volume output and the amount of blood that enters the arteries with each ventricular contraction. In healthy individuals, the pulse reflects the heart beat.
(Fundamentals of Nursing; Kozier; 7th edition; page 496)

BP- 120/80

90/60- 130/90 mmHg

Interpretation: Normal Analysis: In older people, elasticity of the arteries is decreased the arteries are more rigid and less yielding to the pressure of the blood. This produces an elevated systolic pressure.
(Fundamentals of Nursing; Kozier; 7th

edition; page 510)

Height = 51ft. Weight = 56Kg. Body Parts General Appearance Technique used Inspection Normal findings Able to walk (-)Facial grimace (-)Irritable Able to sit without being assisted (-)Difficulty turning in bed (-)Wasting intrinsic muscle (-)Restless Actual findings (+)Wasting intrinsic muscle Unable to walk (+)Facial grimace (+)Irritable Unable to sit without being assisted (+)Difficulty turning in bed (+)Restless Analysis and Interpretation Interpretation: Abnormal Analysis: Careful observation of the individual provides many clues about the persons body image, how he behaves and also some idea of how well or ill he is.
(The Lippincott Manual of Nursing Practice 7th Edition; Page 53)

Mental Status

Inspection

Head

Inspection Palpation

Conscious and Oriented, Emotional Status Cooperative Language: Uses Simple Words Normocephalic No abnormal mass

Conscious and Interpretation: Oriented, Normal Emotional Status Analysis: Cooperative Language: Uses Simple Words Normocephalic Interpretation: No abnormal Normal mass Analysis: Rounded (normocephali c and symmetrical; smooth skull contour, uniform, consistent.
(Fundamentals

of Nursing Kozier, pp.544)

Hair and scalp

Inspection

Evenly distributed, Thick hair, no infection and infestation

Even distribution of hair , no infection and infestation

Interpretation: Normal Analysis: Evenly distributed hair, thick, silky, resilient hair; no infection or manifestations ; coarse or texture fine.
(fundamentals of Nursing Kozier, pp541)

Eyes

Inspection

Symmetric to the face, both eyes coordinated with parallel alignment.

Symmetrically Interpretation: to the face, both Normal eyes coordinated and Analysis: parallel Black in color, alignment. equal in size; normally 3-7 mm in diameter; round with smooth border.
(fundamentals of Nursing Kozier, pp.550)

External eye Structure Eyebrows Inspection Hair evenly distributed, Skin intact Evenly distributed with skin intact Interpretation: Normal Analysis: Hair evenly distributed; skin intact; eyebrows symmetrically aligned; equal

movements.
(fundamentals of Nursing Kozier, pp.548)

Eyelashes

Inspection

Equally distributed, Curled slightly outward

Equally distributed, Curled slightly outward

Interpretation: Normal Analysis: Equally distributed curled slightly outward.

(fundamentals of Nursing Kozier, pp.548)

Eyelids

Inspection

Skin intact, No discharge, No discoloration, Lids close symmetrically

Skin intact, no discharge, no discoloration, lids are symmetrical.

Interpretation: Normal Analysis: Skin intact; no discharge; no discoloration; lids close symmetrically ; bilateral blinking when the lids open; no visible sclera above corneas. Upper and lower borders of cornea are slightly covered.
(fundamentals of Nursing Kozier, pp.548)

Lacrimal gland

Inspection

No edema or tearing.

No edema and tearing

Interpretation: Normal Analysis: No edema or tenderness and tearing over lacrimal gland.

(fundamentals of Nursing Kozier, pp. 590)

Pupils (color Inspection , shape and symmetry of size)

Black in color, equal in size normally 3-7 mm in diameter, round smooth border , iris flat and round.

Black in color, equal in size 4mm in diameter

Interpretation: Normal Analysis: Pupils are normally round and can range in size. Normally it constricts when there is light and accomodation.
(The Lippincott Manual of Nursing Practice 7th Edition; Page 55)

Ears

Inspection

Symmetrically aligned to the face, firm and not tender with no discharged noted.

Positioned symmetrically to the face, No notable ear discharge, clean and dry,.

Interpretation: Normal Analysis: Normal voice tones audible; when watch thick test performed; able to head ticking in both ears
(fundamentals of Nursing, Kozier, pp 558)

Nose

Inspection

Symmetric and straight, no discharges or flaring

Symmetric and Interpretation: straight , no Normal nasal discharges Analysis: noted, no Symmetric and flaring noted straight; no discharge or flaring; uniform color, no tenderness, no lesions.
(fundamentals of Nursing, Kozier, pp

560)

Mouth Lips Inspection Uniform pink in color, soft and moist and smooth Pink and moist gums (-) lesions Brownish pigmentation Interpretation: Normal Analysis: There may be brownish pigmentation to the gums; teeth may show sign of staining, erosion, chipping and abrasion due to loss of dentin.
(Fundamentals of Nursing; Kozier; 7th edition; page1297, 566)

Tongue

Inspection

Tongue at midline without lesion

Moist, located in the midline and free of lesion

Interpretation: Normal Analysis: Central position; pink; moist; slightly rough thick whitish coating smooth lateral margins; no lesions Interpretation: Abnormal Analysis: Normal adult teeth count is 32. smooth, white, shiny tooth enamel.
(Fundamentals of Nursing, Kozier, pp. 602)

Teeth

Inspection

Complete, white, shiny tooth enamel, free of debris

Incomplete, missing teeth, ill fitting dentures

Neck

Inspection

Coordinated , smooth movement

Coordinated movement with no

Interpretation: Normal

Palpation

with no discomfort No masses, tenderness

discomfort No masses, tenderness

Analysis: Muscles equal in size; head centered; movement coordinated with no discomfort Inspection: Equal strength against resistance of hands
(fundamentals of Nursing, Kozier, pp 558)

Upper Extremities Skin Inspection Pinkish in color With edema, Interpretation: With Abnormal deformities (Right hand Analysis: has only 3 Color varies fingers--which with lifestyle appears to be and genes; skin broken/ not the color uniform normal size) (-)abrasions, lesions Convex curvature; 160 angle; smooth texture; highly vascular and pinkish; 1-2 sec capillary refill.
(fundamentals of Nursing, Kozier, pp 600)

Interpretation: Normal Palpation Normothermia Warm to Touch Analysis: temperature not excessively

warm or cold
(fundamentals of Nursing, Kozier, pp 600)

Arms

Inspection

Normally firm, no contracture, no swelling, equal size on both sides of body

Normally firm, no contracture, no swelling, equal size on both sides of body

Interpretation: Normal Analysis: Equal size on both sides of the body; normally firm; no contractures (shortening)
(fundamentals of Nursing, Kozier, pp 600)

Chest and Lungs

Inspection

Symmetric chest expansion, quiet, rhythmic and effortless respiration

Symmetric Interpretation: chest Normal expansion, quiet, rhythmic Analysis: and effortless Chest respiration symmetrical; quiet and effortless respiration; full symmetric excursions; skin intact; no tenderness
(fundamentals of Nursing, Kozier, pp 578)

Palpation

No retraction, no tenderness, no masses

No retraction, no tenderness, no masses

Interpretation: Normal Analysis:. Skin uniform in color (some in appearance as skin of abdomen or back)

Skin smooth and intact No tenderness, masses on nodules

(fundamental of Nursing, Kozier, pp589)

Auscultation

Quiet, rhythmic

Quiet, rhythmic

Interpretation: Normal Analysis: quiet and effortless respiration; full symmetric excursions;
(fundamentals of Nursing,,Kozier, pp 578)

Abdominal

Inspection

Unblemished skin, uniform in color

Unblemished skin, uniform in color

Interpretation: Normal Analysis: Unblemished skin; uniform in color, flat round or scaphoid (concave); symmetric contour; no visible vascular pattern
(Fundamentals of Nursing, Kozier, pp 596/ 597)

Lower extremities Skin Inspection No lesion, can move freely With edema, cold to touch, cyanotic. With deformities (Right foot has only 4 toes(which is appears to be Interpretation: Abnormal Analysis: Peripheral Arterial Occlussive Disease is

broken) due to amputation of the big toe 5years ago) Left foot is gangrenous in appearance.

manifested by coldness, cyanotic in color, skin and nail changes, ulcerations, gangrene and muscle atrophy may be present.
(Handbook for Brunner and Suddharths Textbook of Medical Surgical Nursing, 11th Edition; Page 648)

Nails

Inspection

Smooth, highly vascular and intact epidermis Capillary Refill of 1-2 seconds

Pale, smooth texture, convex curvature Capillary refill: 6 seconds

Interpretation: Abnormal Analysis: A capillary refill time greater than 2 seconds suggests decreased arterial capillary perfusion
(The Lippincott Manual of Nursing Practice 7th Edition; Page 1073)

Palpation