IV.

Physical Assessment
Head to Toe Physical Assessment

Area to be Assessed Normal Findings I. APPEARANCE AND MENTAL STATUS I. Body built, height, Proportionate, varies with lifestyle and weight( in (Kozier; 8th edition relation to clients pg.572.vol.1) age, lifestyle, and health

Actual Findings N/A N/A

Analysis

B. Posture and Gait, Standing, sitting and walking

Relaxed, erect posture; coordinated movement (Kozier; 8th edition pg.572.vol.1) Clean and neat (Kozier; 8th edition pg.572.vol.1) No body odor or minor body odor relative to work or exercise;: no breathe odor (Kozier; 8th edition pg.572.vol.1) No distress noted (Kozier; 8th edition pg.572.vol.1) Cooperative, able to follow instruction. (Kozier; 8th edition pg.572.vol.1) Appropriate to situation (Kozier; 8th edition pg.572.vol.1) Understandable, moderate pace; clear tone and inflection ;exhibits thought association (Kozier; 8th edition pg.572.vol.1) Logical sequence; makes sense; has sense of reality (Kozier; 8th edition pg.572.vol.1)

N/A

N/A

C. Over all Hygiene and Grooming D. Body and Breath Odor

Poor hygiene.

No body odor and breath odor

E. Signs of Distress

The client has facial grimace when moving The client is cooperative but her answer is not clear Appropriate to situation Has slow pace, not too understandable and clear.

Due the pain he felt in her IV insertion site and in her body

F. Attitude

G. Affect or Mood( appropriate of clients response) H. Quantity and quality of Speech

I. Relevance and Organize of Thoughts

She is realistic and sensible,

II. INTEGUMENTARY A. SKIN 1.Skin color Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive (Koizer 8th edition; pg, 579. vol. 1. Generally uniform except in areas exposed to sun; areas of lighter pigmentation in darkskinned people (Koizer 8th edition; pg, 579. vol. 1.) No edema(Kozier; 8th edition) Freckles, some birthmarks, some flat and raised nevi; no abrasions or other lesions(Koizer 8th edition; pg, 579. vol. 1. ) Moisture in skin folds and the axillae (Koizer 8th edition; pg, 579. vol. 1.) Uniform; within normal range (Koizer 8th edition; pg, 579. vol. 1.) When pinched, skin springs back to previous state (Koizer 8th edition; pg, 580. vol. 1.) Convex curvature; angle of nail plate about 160 (Koizer 8th edition; pg, 583. vol. 1.) Highly vascular and pink in light-skinned clients; dark-skinned clients may have brown or black pigmentation in longitudinal streaks (Koizer 8th edition; pg, 584. vol. 1.) The clients skin color is brown.

2. Uniformity of Skin color

Evenly brown throughout the body even the skin exposed to sun

3. Presence of edema 4. Existence of Lesion

No edema The client has a lesion her hips.

5. Skin Moisture

Dampness in skin folds and in armpits

6. Skin temperature 7. Skin Turgor

Uniform within the normal range Skin springs back to its previous state after being pinched

B. NAILS 1. Fingernail plate ( curvature and angle)

Has a convex curvature, 160 degrees nail plate Has light pink finger nails

2. Finger and toe nail bed color

3. Finger nail and toe nail texture 4. Presence of tissues surrounding nails

Smooth texture (Koizer 8th edition; pg, 583. vol. 1.) Intact epidermis (Koizer 8th edition; pg, 584. vol. 1.) Prompt return of pink or usual color( generally in 4 sec.) (Koizer 8th edition; pg, 584. vol. 1.)

It has even surface and no irregularities Epidermis is intact

5. Blanch test result of capillary refill

Quick return of original color after 3 sec.

III. HEAD A SKULL 1. Size, shape and Symmetry of the skull

rounded(Normocephalic and symmetrical, with frontal, parietal and occipital prominences; Smooth skull contour (Koizer 8th edition; pg, 585. vol. 1.) Smooth, uniform consistence; absence of nodules or masses (Koizer 8th edition; pg, 585. vol. 1.) Evenly distributed hair and covers the whole scalp. (Koizer 8th edition; pg, 582. vol. 1.) Thick hair (Koizer 8th edition; pg, 582. vol. 1.) Older clients have thinner hair because of decrease in hair follicles. (Health Assessment in Nursing; pg. 174)

Rounded (Normocephalic and symmetrical, with frontal, parietal and occipital prominences; Smooth skull contour Absence of nodules or masses; smooth and uniform consistence Evenly distributed hair

2. Presence of nodules, masses and depression

B. HAIR 1. Evenness of growth, thickness or thinness of hair 2. inspect for thickness or thinness

Has thin hair strands

3. Texture and oily ness

Silky; resilient hair (Koizer 8th edition; pg, 582. vol. 1.)

Oily hair

4. Note for presence of infection or infestation by parting the hair in several areas checking behind the ears and along the hairline at the neck. 5. Inspect amount of body hair D. Face Facial Features, symmetry of facial movements

No infection or infestation (Koizer 8th edition; pg, 582. vol. 1.)

No infestation or infestation

Valuable (Koizer 8th edition; pg, 582. vol. 1.) Symmetric facial movements (Koizer 8th edition; pg, 585. vol. 1.)

Valuable

Has symmetric movement of face

IV. EYES A. Visual Acuity 1. near vision

Able to read newsprint (Koizer 8th edition; pg, 592. vol. 1.) 2020 vision on Snellentype chart (Koizer 8th edition; pg, 592. vol. 1.) Hair evenly distributed; skin intact; eyebrows symmetrically aligned; equal movement. (Koizer 8th edition; pg, 588vol. 1.) Equally distributed; curled slightly outward (Koizer 8th edition; pg, 588vol. 1.)

Cannot be able to read book

3. distance vision

The client has poor of vision and she didnt wear a reading glass Not available Snellen type chart

B. Eye Brows Inspect the eyebrows for hair distribution and alignment and skin quality and movement Black. symmetrically aligned

D. Eyelashes Inspect the eyelashes for evenness of distribution and direction of curl

Equal distribution and curled slightly out

E. Eyelids Surface characteristic s and position (In relation to cornea, ability to blink and frequency of blinking)

Skin intact; no discharge; no discoloration; lids close symmetrically; approximately 15 to 20 in voluntary blinks per minute; bilateral blinking; when lids open, no visible sclera above corneas, and upper and lower borders of cornea are slightly covered. (Koizer 8th edition; pg, 588vol. 1.)

Symmetrical; upper eyelids cover the small portion of the iris , cornea and sclera when open eyes; Eye lids meet completely when the eyes are closed;

A. SCLERA Color and Clarity

White in color; clear; no yellowish discoloration

It is white in color; clear; no yellowish discoloration appearance; some visible capillaries No deformities on the surface, looks smooth , clear and transparent

B. CORNEA Clarity and texture

Transparent, shiny and smooth; details of the iris are visible (Koizer 8th edition; pg, 589 vol. 1.) Anterior chamber is transparent; no noted visible materials; color depends on the persons race.

E. IRIS Shape and Color

Anterior chamber is transparent ; no visible materials noted; brown in color Brown; equally round and symmetrical Constrict when light is directed to eye in both directly and consensual

F. PUPILS 1. Color, Shape and symmetry of size

Color depends on the persons race, equal in size and equally round Pupil constrict when looking at near objects; pupil dilate when looking at far object; pupil converge when near object is moved toward nose. (Koizer 8th edition; pg, 590 vol.1)

2. Light reaction and accommodation

J. Extraocular muscles Eye alignment coordination and Both eyes coordinated, move in unison with parallel alignment (Koizer 8th edition; pg, 592 vol. 1) When looking straight ahead, client can see objects in the periphery (Koizer 8th edition; pg, 591vol.1) Color same as facial When checking for the movement of the right and left eyes were Coordinated Client can see objects in periphery when looking straight

K.. Visual fields Peripheral visual fields

V. EARS A. Auricles 1. Color, symmetry of size

Same with

and position

skin, symmetrical, auricle aligned with outer canthus of eye, about 10 from vertical (Koizer 8th edition; pg, 596 vol.1) Mobile, firm, and not tender; pinna recoils after its folded (Koizer 8th edition; pg, 596 vol.1)

facial skin(light pink); Symmetrical; Uricle leveled with outer canthus of the eye Elastic, firm, not tender, pinna moves back after it is folded

2. texture, elasticity and areas of tenderness

B. External ear Cerumen, skin lesion, pus and blood

Dry cerumen , grayish-tan color; sticky; wet cerumen in various shade of brown (Koizer 8th edition; pg, 596 vol.1)

Dry but sticky cerumen color various shade of brown, no lesion, no pus and blood

C. Hearing Acuilty tests 1. clients response to normal voice tones

Normal voice tones audible (Koizer 8th edition; pg, 597 vol.1)

Normal voice tones was heard by the client

VII. MOUTH A. Lips Symmetry of contour, color and texture

Uniform in pink; soft; moist; smooth texture; symmetry of contour; ability to pursue lips (Koizer 8th edition; pg, 602 vol.1) Uniform pink color; moist, soft , glistening and elastic texture (Koizer 8th edition; pg, 602 vol.1) 32 adult teeth; smooth. White shiny tooth enamel; smooth, intact dentures. (Koizer 8th edition; pg, 602 vol.1) Pink gums; Moist; firm texture of

Dry lips, ability to pursue lips

B. Buccal Mucosa Color, moisture, texture and presence of lesion

Uniform in color. Dry lips

C. Teeth Color, Number and condition and presence of dentures

No dentures and has 3 tooth decay. And 4 loss of teeth

D. Gums Color and condition

Pink gums, moist firm texture of

gums No retraction of gums (Koizer 8th edition; pg, 602 vol.1) IX. NECK AND LYMPNODES A. NECK MUSCLES Inspection of neck muscle for abnormal swelling and movement. head movement

gums

Muscles equal in size; head centered (Koizer 8th edition; pg, 607 vol. 1) Coordinated, smooth movements with no discomfort (Koizer 8th edition; pg, 607 vol. 1) equal strength(Koizer 8th edition; pg, 607 vol. 1) equal strength (Koizer 8th edition; pg, 607 vol. 1) Not palpable (Koizer 8th edition; pg, 607 vol. 1) Central placement in midline of neck; spaces are equal on both sides (Koizer 8th edition; pg, 608 vol. 1) Not visible on inspection (Koizer 8th edition; pg, 608 vol. 1) Glands ascends during swallowing but is not visible ; Lobes may not be palpated If palpated, lobes are small, smooth, centrally located, painless and rise freely with swallowing (Koizer 8th edition; pg, 609 vol. 1)

Size of the muscles are equal and head at the center Coordinated, has smooth movement and has no discomforts Equal strength Equal strength

Muscle strength for sternocliedomastoid muscles And trapezius muscles B. LYMPH NODES Identification of lymph nodes and for tenderness C. TRACHEA Placement of the Trachea

No palpable lymph nodes Located in the mid-line of neck; both sides of neck are equal

D.THYROID GLAND A. Symmetry and visible masses B. Smoothness and areas of enlargement, masses or nodules

Not observable on inspection Glands ascends during swallowing but is not visible; May not be palpable

X .THORAX A. Posterior thorax

1. shape, symmetry and comparison of anteroposterior thorax to transverse diameter

Anteroposterior to transverse diameter in ratio 1:2; Chest symmetric (Koizer 8th edition; pg, 614 vol. 1) Spine vertically aligned (Koizer 8th edition; pg, 614 vol. 1)

Symmetrical chest; transverse diameter in ratio of 1:2

2.Spinal alignment

Spine aligned vertically. No curvatures Her upper thorax is warmer then as palpating down it became colder. No mass and tenderness 25 cpm full, quiet, rhythmic

3.Temperature, masses

tenderness,

Skin intact; uniform temperature; Chest wall intact; no tenderness; no masses (Koizer 8th edition; pg, 614 vol. 1) 12 to20 breaths/per minute and regular (3-minute assessment 2nd edition; Lippincott Williams & Wilkins. Pg. 54) Full and symmetric chests expansion; expansion normally separate 3 to 5 cm (Koizer 8th edition; pg, 615 vol. 1) Bilateral symmetry of vocal fremitus; Fremitus is heard mosts clearly at the apex of the lungs (Koizer 8th edition; pg, 615 vol. 1)

4.Breathing patterns

5. respiratory excursion assessment

6. Vocal fremitus palpation

Fully symmetrical excursion; thumbs normally separate and move outward and in ward Bilateral symmetry of vocal fremitus; Fremitus is heard mosts clearly at the apex of the lungs

7. posterior thorax percussion

8. Posterior auscultation

Percussion notes resonance except over scapula; Lower point of resonance is at the diaphragm; percussion on a rib normally elicits dullness (Koizer 8th edition; pg, 615 vol. 1) Vesicular and bronchovesicular breath sounds (Koizer 8th edition; pg, 616 vol.1.)

Resonance is heard upon percussion except over scapula; lowest point of resonance at the diaphragm, rib naturally dull Has breath sounds in vesicular and bronchovesicular but has crackles

B. Anterior thorax

1. Breathing patterns

Quite, rhythmic, and effortless respiration (Koizer 8th edition; pg, 617vol. 1) Skin intact; uniform temperature, no tenderness and masses

Breaths quietly, rhythmically and without difficulty respiration Has intact skin;but has few papule ; even temperature, no tenderness and masses It is Fully symmetrical excursion; thumbs normally separate and move outward and in ward Vocal fremitusis systematic bilateral; fremitus normally is heard least over heart and breast tissue

2. Temperature, tenderness and masses

3. Respiratory assessment

excursion

4. Vocal fremitus palpation

Full and symmetric chests expansion; expansion normally separate 3 to 5 cm (Koizer 8th edition; pg, 617vol. 1) Bilateral symmetry of vocal fremitus; Fremitus is decreased over the heart and breast tissue (Koizer 8th edition; pg, 617vol. 1)

5. Anterior thorax percussion

Percussion notes resonance down to the sixth rib at the level of the diaphragm but are flat over areas of heavy muscle and bone; dull on areas over heart and the liver and tympanic over the underlying stomach (Koizer 8th edition; pg, 617vol.1.)

Resonance is heard down to the sixth rib at the level of diaphragm; flat over areas of bone and muscles; dullness on the areas of heart and liver; and tympanic over the stomach

A. Trachea auscultation

Bronchial and tubular breath sounds (Koizer 8th edition; pg, 618 vol.1) Bronchovesicular and vesicular breath sounds (Koizer 8th edition; pg, 618 vol.1)

Breath sounds are bronchial and tubular Hears bronchovesicular and vesicular breath sounds upon auscultation Both sides are proportion

B. Anterior thorax auscultation

XVI. MUSCULOSKELETAL SYSTEM A. MUSCLES 1. Muscle size and Equal size on both sides comparison on the other of body side (Koizer 8th edition;

pg, 640 vol.1) 2. Contractures in the muscles and tendons No contractures (Koizer 8th edition; pg, 640 vol.1) No tremors (Koizer 8th edition; pg, 640 vol.1) Normally firm; smooth coordinated movement (Koizer 8th edition; pg, 640 vol.1) Grading Muscles strength 5: 100% of normal strength; normal full movement against gravity and against full resistance Neck Head flexes 45 head hyper extends 60 head laterally flexes 40 head laterally rotates 70 (Koizer 8th edition; pg, 607 vol. 1) Upper extremities Lower extremities (Koizer 8th edition; pg, 640 vol.1) B. BONES 1. Normal structures and deformities in the skeleton Areas of edema or tenderness in the bones No deformities (Koizer 8th edition; pg, 641 vol.1) No tenderness or swelling (Koizer 8th edition; pg, 641 vol.1) No visible abnormalities Contracts are none

3. Fasciculations and tremors in the muscles 4. Muscle tonicity

No fasciculations and tremors seen Muscles are even and firm

5. Muscle strength

Has strong muscles in every part Grading Muscles strength of 5

Flexed 45 Hyper extended at 60 Laterally flexed 40 Laterally rotes 70

No edema; not tender and no nodules and muscle palpated Joints are not

C.JOINTS Joint swelling

No swelling, no warmth,

redness Joints move smoothly (Koizer 8th edition; pg, 641 vol.1) Tenderness, smoothness of movement, swelling, crepitation and presence of nodules Joint range and motion No tenderness, swelling, crepitation and nodules, (Koizer 8th edition; pg, 641 vol.1) varies to some degree in accordance with persons genetic makeup and degree of physical activity. (Koizer 8th edition; pg, 641 vol.1)

swelled, no warmth, redness noticed

Not tender and no nodules and muscle palpated. Smooth movement