VIII.

PHYSICAL ASSESSMENT (REVIEW OF SYSTEMS)

AREA TECHNIQUE
ACTUAL FINDINGS ANALYSIS
ASSESSED USED
The hair of the client is silky Normal.
and evenly distributed;
Hair Inspection there are no signs of
infection and infestation
observed.
Skin is moist, uniform in Normal
Skin Inspection color, and has presence of
wrinkles normal for her age
Patient’s head is rounded, Normal
normocephalic, and
symmetrical. There are no
Head and nodules or masses and
Inspection
Face depressions when
palpated. Patient’s face
appeared smooth and has
uniform consistency.
Nails is normal in color. Its Normal
Nails Inspection surface is slightly lncurved.
No clubbed finger.
Nails are smooth and intact. Normal
Palpation Capillary refill less than 3
seconds.
Patient’s eyebrow is evenly Cataract is a clouding of
distributed, symmetrical, the eyes natural lens that
aligned and show equal causes the cloudy vision
movement when raise and of a invidual (bray 2004)
Eyes Inspection
lower eyebrows. Patient
verbalized “hayag nalang
akong makit.an” due to the
presence of cataract.
Patient’s auricle is Normal
symmetrical and has the
same color with her facial
Ears Inspection
skin. The auricles are
aligned with the outer
canthus of eye.
Patient’s ears are mobile, Normal
Palpation firm and not tender upon
palpation.
Patient’s nose is Normal
Nose Inspection
symmetrical, straight and
 AREA TECHNIQUE
ACTUAL FINDINGS ANALYSIS
ASSESSED USED
uniform in color. No
presence of discharge or
flaring.
When lightly palpated, no Normal
Palpation tenderness and lesions
were noted.
Patient’s lips are dry and Normal
symmetric. Patient’s gums
are pinkish in color and
moist. Patient’s tongue is
Mouth Inspection centrally positioned, pink in
color and moist, teeth are
complete, no presence of
decay and no discoloration
of enamels.
The neck muscles are equal Normal
in size, the patient showed
coordinated, smooth head
movement with no
Neck Inspection
discomfort; lymph nodes
are not palpable, the
trachea is placed in the
middle of the neck.
Patient’s chest wall is intact Normal
with no tenderness and
masses. The client
manifested quiet, rhythmic
Thorax Palpation and effortless respirations.
Patient’s spine is vertically
aligned. The right and left
shoulders and hips are of
the same height.
Patient’s heart had no Normal
visible pulsations on the
Heart and aortic and pulmonic areas.
Auscultation
Lungs Normal heart and lung
sounds. There is no
presence of heaves or lifts.
Patient’s breast is Normal
symmetrical in size and
Breast contour, nodular, darker
pigmentation of nipple and
areola.
Patient’s abdomen is Ascites causes when
Distended and attached fluids builds inside the
with pigtail catheter abdomen. Fluids fills the
Abdomen Inspection
spaces between the lining
of the abdomen and the
organs. Distended
 AREA TECHNIQUE
ACTUAL FINDINGS ANALYSIS
ASSESSED USED
abdomen is one of the
sings and symptoms of
Ascites (Bray, 2004)
Patients is menopause. Menopause is a normal
condition as they age.
Menopause happens
Pelvic Area Inspection when the ovaries no
longer releases an egg
every month (Weber,
2014)