EAMC - Physical Assessment

PHYSICAL ASSESSMENT
Date: July 01, 2011 Client's Name: G.P. Age: 73, years old Gender: Male
Vital Signs (July 01, 2011)
Temperature: 36.6C, oral Pulse Rate: 78, regular, full, right radial Respiratory Rate: 18 cpm Blood Pressure: 120/ 80mmhg
Areas to be assessed A. GENERAL APPEARANCE a. Body built, height and weight in relation to the clients age, lifestyle, and health
Actual Finding
Norms and Standards
Analysis
The client is considered as ectomorph. Height and weight are proportionate to the body The client's posture and gait are relaxed, erect posture and he has coordinate body movements.
Proportionate to height and weight, varies with lifestyle. Normal

(Kozier and Erbs Fundamentals of Nursing 8
th
edition volume 1, page 572)
b. Posture and gait, standing, sitting, and walking
Relaxed, erect posture; coordinated body movements.

th
Normal
c. Overall hygiene and grooming
The client's hygiene and grooming are neat and clean, he has proper grooming.
Clean and neat, proper grooming

th
Normal
d. Body and breath odor
The client is negative for body or breath odor.
No body odor or minor body odor relative to work or exercise; no breath odor.
th
Normal
No distress noted. e. Signs of distress (in posture or facial expression) The client has signs of distress.
th
Abormal
Healthy appearance. f. Obvious signs of health or illness The client has sign of unhealthy appearance.
th
Abnormal
Cooperative g. Attitude The client's attitude is cooperative, ability to follow instructions. The client's mood has the appropriate to the situation; he can manage to answer during the interview.
th
Normal
h. Affect/ mood (appropriateness of clients responses)
Appropriate to the situation.

th
Normal
i. Quantity and quality of speech
The client's quantity and quality of speech is understandable, clear tone and inflection.
Understandable, moderate pace, exhibits thought association

th
Normal
j. Relevance and organization of thoughts
The client's listening for relevance has sense of reality and has logical sequence.
Logical sequence; makes sense; has sense of reality. Normal

(Kozier and Erbs Fundamentals of Nursing 8th edition volume 1, page 572)
B. INTEGUMENTARY Skin Skin Color
Light brown.
Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive
Normal
Uniformity of Skin Color
Uniform in color except in areas that is exposed to the sun. Theres no presence of hypo and hyper pigmentation. There is discolorization in skin.
Generally uniform except in areas exposed to the sun: areas of lighter pigmentation( palms, lips, nail beds) in darkskinned people
Abnormal
Presence of Edema
Theres a presence of edema There is swelling in the neck part.
No edema
Abnormal
Existence of Lesions
There are abrasions or other lesions in the left knee, left legs, right arm because of the previous IV insertions of the patient and also
Freckles, some birthmarks, some flat and raised nevi; no abrasions or other lesions
Abormal
at the axillae part.
Skin Moisture
Moisture in skin folds like the axillae.
Moisture in skin folds and the axillae ( varies with environmental temperature and humidity, body temperature, and activity)
th
Normal
Skin Temperature
The temperature is even and it is warm to touch.
Uniform: within normal range

th
Normal
Skin Turgor
Skin springs back to its previous state
When pinched, skin springs back to previous state

th
Normal
Nails Fingernail plate shape (its curvature and angle)
Convex curvature: angle of nail plate about 160
Convex curvature: angle of nail plate about 160

th
Normal
Fingernail and Toenail bed color
White. The client manifests any abnormalities in nail bed color.
Highly vascular and pink in light-skinned clients: dark-skinned clients may have brown or black pigmentation in longitudinal streaks
(Kozier and Erbs
Abormal
Fundamentals of Nursing 8th edition volume 1, page 583)
Fingernail and Toenail Texture
Smooth texture The clients nails have a continuous even surface. No inflammation or any infection in the tissues surrounding the nails.
Smooth texture
th
Normal
Presence of Tissues surrounding nails
Intact epidermis
th
Normal
Blanch test result of capillary refill of fingernail and toenail.
Prompt return to usual color in 5 seconds.
Prompt return of pink or usual color (generally less than 4 seconds)

th
Abnormal
C.HEAD Skull Size, shape and symmetry of the skull
Rounded, smooth and smooth skull contour.
Rounded (norm cephalic and symmetrical, with frontal parietal and occipital prominences): Smooth skull contour
th
Normal
Presence of nodules, masses, and depressions
There are nodules or masses found.
Smooth, uniform consistence; absence of nodules or masses

th
Abnormal
Scalp Color and appearance of scalp
Lighter in color than the complexion of his skin, no scars and free
Lighter in color than the skin complexion; no scars nor lesions;
Normal
from lice, nits and dandruff
free from lice, nits, and dandruff

Areas for tenderness
There is no tenderness nor masses
No tenderness nor masses on palpation

Normal
Hair Evenness of growth, thickness or thinness of hair
His hair is evenly distributed and covers the whole scalp.
Evenly distributed and covers the whole scalp: maybe thick or thin
th
Normal
Texture and oiliness over the scalp
Silky and resilient hair, not brittle and no excessive oil.
Silky; resilient hair

th
Normal
Face Facial features, symmetry of facial movements
Symmetric facial features and movements can raise his eyebrows puff his cheek and smile.
Symmetric or slightly asymmetric facial features: palpebral fissures equal in size; symmetric nasolabial folds
th
Normal
Eyebrows Hair distribution, alignment, skin quality and movement
Hair evenly distributed; Eyebrows symmetrical aligned. Both are coordinated. There is no hair loss in
Symmetrical and in line with each other; maybe black, brown or blond on race: evenly distributed
Normal
eyebrows and there are no lesions. Eyelashes Hair distribution and direction of curl
Equally distributed; curled slightly outward.
Evenly distributed; turned slightly outward

th
Normal
Eyelids Surface characteristics and position (in relation to the cornea, ability to blink and frequency of blinking)
Upper eyelids cover the small portion of the iris, cornea and sclera when eyes are open; eyelids meet completely when the eyes are closed; symmetrical.
Upper eyelids cover the small portion of the iris, cornea and sclera when eyes are open; eyelids meet completely when the eyes are closed; symmetrical
Normal
Conjunctiva Color texture and the presence of lesions in the bulbar conjunctiva
Bulbar conjunctiva is transparent in color; little appearance of small capillaries
Pinkish or red in color; with presence of small capillaries; moist; no foreign bodies; no ulcers
th
Normal
Color texture, and the presence of lesions in the palpebral conjunctiva
Shiny, smooth and pinkish in color.
Pinkish or red in color; with presence of small capillaries; moist; no foreign bodies; no ulcers
th
Normal
Sclera Color and clarity
Yellow in color; not
White in color; clear;
Abormal
shiny, smooth and little presence of capillaries.
no yellowish discoloration; some capillaries maybe visible

Cornea Clarity and texture
Transparent, shiny and smooth, details of the iris are visible. Equal size.
No irregularities on the surface; looks smooth; clear or transparent

th
Normal
Iris Shape and color
Round, proportion to the size of the eyes, brown and symmetrical.
Anterior chamber is transparent; no noted visible materials; color depends on the persons race
th
Normal
Pupils Color, shape, symmetry of size
Black in color, equal in size. Pupils are equally rounded and reactive to light accommodation
Color depends on the persons race; size ranges from 3-7 mm, and are equal in size; equally round
Normal
Lacrimal Gland, Lacrimal Sac and Nasolacrimal Duct Palpability and tenderness of the lacrimal gland
No presence of edema or tenderness over the lacrimal gland
No edema or tenderness over lacrimal gland
Normal
Extraocular Muscles Eye alignment and coordination
Both eyes coordinated, move in unison, with parallel alignment
Both eyes coordinated, with parallel alignment

th
Normal
Visual Fields
Peripheral visual fields
Client can see objects in the periphery when looking straight ahead. The client can see in sides and can also see ahead; can focus eye sight.
When looking straight ahead, client can see objects in the periphery.
Normal
D. Ears Auricles Color symmetry of size and position
Color of both ears is the same with the face. When a line is drawn from the inner canthus through the outer canthus to the ear the top of the ear pinna met the line.
When a line is drawn from the inner canthus through the outer canthus to the ear the top of the ear pinna should meet the line.
(Maternal & Child Health Nursing: Care of the Childbearing and Childrearing of the Family,Pillitteri, 5th edition volume2, page 1000)
Normal
Texture, elasticity and areas of tenderness
Ears are mobile and firm. No presence of tenderness. Pinna was able to recoil after being folded.
Mobile, firm and not tender, pinna recoils after it is folded.

Normal
External Ear Canal
Presence of cerumen, skin lesions, pus and blood
Distal third contains dry cerumen which appears grayish-tan in color. No presence of pus and blood.
Distal third contains hair follicles and glands; dry cerumen, grayish-tan color; wet cerumen in various shades of brown.
Normal
Nose Any deviations in shape, size or color and flaring or discharge from the nares
In the midline of the face, Symmetric and straight; no discharge or straight; no discharge flaring; uniform in color or flaring; uniform color
th
Normal
Mucous membrane color of the nose
Mucous membrane of the nose is colored pink
It should be pink; pale suggests allergies, redness suggests infection

(Maternal & Child Health Nursing: Care of the Childbearing and Childrearing of the Family,Pillitteri, 5
th
Normal
edition volume2, page 999)
Presence of redness, swelling growths and discharge in the nasal cavities
Mucosa is pink, clear, watery discharge; no lesions, no redness, and no swelling
Mucosa pink; clear ; no lesions

Normal
Nasal septum (between the nasal chambers)
Nasal septum is in midline and is intact.
Nasal septum is in the midline

Normal
Patency of nasal cavities
Air was able to move freely through the nares.
Both sides of the nose are patent. Air moves
Normal
freely as the client breaths through he nares.

Tenderness, masses No tenderness, no and displacements of masses and there is no bone and cartilage displacement of the bone or cartilage. Sinuses Identification of sinuses and presence of tenderness
No tender, no lesions
Normal
No tenderness over frontal and maxillary sinuses.
Absence of tenderness not palpable

th
Normal
Sense of smell
Identified the smell of fried chicken
Identify a familiar odor (fried chicken)

E. Mouth Lips Symmetry of contour, color and texture
Soft, moist and smooth texture and color is uniform. Able to purse the lips. Symmetry of contour, client was able to purse lips.
Uniform; pink color; soft; moist; smooth texture; symmetry of contour ability to purse lips
Normal
Buccal Mucosa Color; moisture; texture and the presence of lesions
Pink color. Moist, smooth, soft glistening and has an elastic texture. No presence of
Uniform pink color; moist; smooth; soft and elastic texture
Normal
lesions.
Teeth Color; number and condition and presence of dentures
4 missing tooth has (Lower Part)
32 adult teeth; smooth; white; shiny tooth enamel

th
Abnormal
Gums Color and condition
Uniform pink gums. No lesions nor retraction
Pink gums; no retraction

Normal
Tongue/ Floor of the mouth Color and texture of the mouth floor and the frenulum
Position, color and texture, movement and base of the tongue
Pink in color. Moist, soft and slightly rough due to presence of raised papillae (taste buds). Presence of thin white coating over tongue. Absence of lesions. Frenulum located at midline of tongue floor; pink in color Central placement and pink in color, smooth and base has prominent veins. Tongue is able to move freely. No presence of tenderness upon palpation. Smooth with no palpable nodules, lumps or excoriated areas.
Pink color; moist; slightly rough; thin whitish coating

Kozier and Erbs Fundamentals of Nursing 8
th
Normal
Central position; pink color; smooth tongue; base with prominent veins
th
Normal
Any nodules, lumps, or excoriated areas
Smooth with no palpable nodules, lumps or excoriated areas

(Kozier and Erbs
Normal
Fundamentals of Nursing 8th edition volume 1, page 603)
Palates and Uvula Color, shape, texture and the presence of the bony prominences
Soft palate- light pink in color and soft. Hard palate- lighter pink in color; has a more irregular shape.
Light pink. Smooth soft palate; lighter pink hard palate; more irregular texture
th
Normal
Position of the uvula and mobility
The uvula Positioned in the midline of soft palate. Shiny and smooth.
Positioned in the midline of soft palate

th
Normal
Oropharynx and Tonsils Color and texture
Posterior wall is smooth and pink in color. Tonsils are located behind the tonsillar pillars .No tenderness. Present
Pink and smooth posterior wall

Normal
Gag reflex
Present
Normal
Size color and discharge of the tonsils
Tonsils are pink and in normal size
Pink and smooth, no discharge of normal size

H. Neck and Lymph nodes Lymph nodes Identification of lymph nodes and for
There are palpable lymph nodes and
Not palpable
Abnormal
tenderness
tenderness felt upon palpation.
Trachea Placement of the trachea
The placement of the trachea is at the midline of the neck: equal spaces on bones. Vibrates where producing sound.
Central placement in midline of neck: spaces are equal on both sides

th
Normal
Thyroid gland Thyroid gland
After the client swallowed, his thyroid gland ascends unsymmetrically. It is not smooth and there are areas of enlargement or nodules.
Symmetry and masses are not visible and palpable. Glands ascends when swallowing but not visible, lobes are small smooth and painless.
Abnormal
Anterior thorax Inspect breathing pattern
Has quiet, rhythmic and effortless respirations
Quiet, rhythmic, and effortless respirations.

th
Normal
Palpate for temperature, tenderness and masses
Temperature is warm to touch. No presence of tenderness and masses.
Skin intact; uniform temperature; Chest wall intact; no tenderness

th
Normal
Assess respiratory excursion
It is not asymmetric and when the client takes a deep breath the thumb separates 3 to 5 cm.
Full and symmetric chest expansion; thumbs normally separates 3-5 cm
Normal
Palpate vocal fremitus
Has low pitched voice because he is a male client; fremitus is heard most clear in the apex if the lungs Resonate down from the six rib at the diaphragm and flat over the areas of heavy muscles and bone, dull on areas over the heart and the liver and tympanic over the underlying stomach
Bilateral symmetry of vocal fremitus

th
Normal
Percuss the anterior thorax
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 over the heart and the liver, and tympanic over the underlying stomach.
th
Has no areas of dullness and flatness on the lung tissue and symmetric in percussion notes
Auscultate trachea
Difficult to distinguish the sound
Brochial and tubular breath sounds.

Abnormal
Auscultate the anterior thorax
Has a vesicular and broncho-vesicular breath sound
Vesicular and broncho vesicular breath sounds.

th
Cardiovascular Aortic and pulmonic areas
No pulsations
No pulsations.
Tricuspid areas
Has no pulsations, lift and heave
No pulsations
Normal
Apical area(Locate point of maximal impulse)
Has pulsations but has no lift, and heave
Pulsations visible in 50% for adults abs palpable in most PMI in fifth LICS at or medial to MCL
Normal
No lift and heave

Auscultate the aortic, pulmonic, tricuspid and apical valves
S1 is louder in the apical areas of the heart and S2 is louder in the base area of the heart Has no increased or decreased in the intensity in the areas of the apical and base
S1 usually heard at all sides(usually louder at the apical area) S2 usually heard at all sides(usually louder at the base area)
Normal
Carotid Arteries Palpate the carotid artery with extreme caution
Has full pulsations and symmetric pulse volume
Symmetric pulse volume ;full pulsations, thrusting quality; elastic arterial wall
Normal
Auscultate the carotid artery
There are no sound heard upon auscultation
No sound heard on auscultation

Normal
Jugular Vein Inspect Jugular Vein
The veins in the internal and external jugular veins are not visible Actual Findings
Veins not visible

Normal
Norms and Standards

)
Actual Findings
Abdomen
Inspect skin integrity
The skin is unblemished. The skin of the abdomen is light brown in color. No surgical scars or stretch marks upon inspection
Unblemished skin; Uniform color; Silverwhite striae (stretch marks) or surgical scars
Normal
Inspect abdominal contour
The abdomen is flat
Flat , rounded (convex) or scaphoid (concave)

Normal
Inspect for enlarged liver or spleen
No signs of enlargement of spleen and liver.
No evidence of enlargement of liver or spleen

Normal
Assess the symmetry of contour while
The contour is symmetric
Symmetric contour
Normal
standing at the foot of the bed Inspect abdominal movements associated with respirations, peristalsis or aortic pulsations
Respiratory movement Symmetric movements is symmetric, no visible caused by peristalsis; aortic respirations; Visible pulsation is visible. peristalsis in very lean people; Aortic pulsations in thin persons at epigastric area
Normal
Inspect vascular pattern
The vascular pattern is not visible.
No visible vascular pattern

Normal
Auscultation of abdomen for bowel sounds, vascular sounds, and peritoneal friction rubs Percuss several areas in each of the four quadrants
The bowel sound is audible. There is no presence of arterial bruits sound and friction rub.
Audible bowel sounds; Absence of arterial bruits; Absence of friction rub

Normal
There is tymphany over the stomach and other gas-filled bowels. Dullness is present over the liver and spleen.
Tymphany over the stomach and gas filled bowels; dullness, especially over the liver and spleen or a full bladder
Normal
Perform light palpations first all four quadrants
There is no presence of tenderness. The abdomen was relaxed
No tenderness; relaxed abdomen with smooth, consistent
Normal
with smooth consistent tensions.
tension
Musculoskeletal System Muscles Contracture of tendons.
No contractures
No contractures
Normal
Inspect for fasciculation and tremors,
There is no tremor and fasciculation
No tremors and fasciculation

Normal
Muscle tonicity.
Normally firm.
Normally firm
Normal
Muscle flaccidity, spasticity and smoothness of movement.
Muscles of the hands are smooth and with coordinated in moving. No visible shaking of hands. As tested the muscles on the left and right part of the body has equal strength
Smooth coordinated movements

Normal
Muscle strength.
Equal strength on both body side

Normal
Sternocleidomastoid
The client can resist the force being exerted on the head.
Equal strength on each muscle

Normal
Trapezius
Client can resist the force being exerted on the shoulder.

Normal
Biceps
Client can flex biceps while trying to exert force against it.

Normal
Triceps
Client can extend his triceps against the force being exerted.

Normal
Wrist and finger muscles
Client can spread his fingers, and can resist while trying to push the fingers together.

Normal
Grip strength
Client can grasp the object.

Normal
Hip muscle
Client can raise both legs, one at a time while trying to hold it down.

Normal
Hip abduction
Client can spread his legs while trying to put them together.

Normal
Hip adduction
Client can bring his legs together while trying to open it

Normal
Bones Inspect for the skeleton for normal structure and deformities Areas of edema and tenderness on bones.
There are no deformities found
No deformities
Normal
There is no presence of edema and there is no tenderness.
No tenderness
Normal
Joints Swelling of joints.
There is no swelling of joints.
No swelling
Normal
Tenderness, smoothness of movement, swelling, crepitation and presence of nodule on the joint.
There are no nodules, No tenderness, tenderness and swelling, crepitation, or presence of swelling of nodules. Joints move joints. There is no smoothly crepitation. There are (Kozier and Erbs no restricted Fundamentals of Nursing 8th movements.
Normal
Range of motion of the joint.
He is able to move his joints freely. There is no restriction in movement.
Varies to some degree in accordance with persons genetic makeup and degree of physical activity
Normal
Range of Motion Upper extremities.
The client has
Able to perform
Normal
performed range of motion in all joints in the upper extremities.
without pain
Lower extremities.
The client has performed range of motion in all joints in the lower extremities.
Able to perform without pain

Normal

EAMC - Physical Assessment

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

EAMC - Physical Assessment

Uploaded by

Copyright:

Available Formats

PHYSICAL ASSESSMENT

Vital Signs (July 01, 2011)

Norms and Standards

Proportionate to height and weight, varies with lifestyle. Normal

edition volume 1, page 572)

b. Posture and gait, standing, sitting, and walking

Relaxed, erect posture; coordinated body movements.

edition volume 1, page 572)

c. Overall hygiene and grooming

Clean and neat, proper grooming

edition volume 1, page 572)

d. Body and breath odor

The client is negative for body or breath odor.

edition volume 1, page 572)

edition volume 1, page 572)

edition volume 1, page 572)

edition volume 1, page 572)

h. Affect/ mood (appropriateness of clients responses)

Appropriate to the situation.

edition volume 1, page 572)

i. Quantity and quality of speech

Understandable, moderate pace, exhibits thought association

edition volume 1, page 572)

j. Relevance and organization of thoughts

Logical sequence; makes sense; has sense of reality. Normal

B. INTEGUMENTARY Skin Skin Color

Uniformity of Skin Color

Theres a presence of edema There is swelling in the neck part.

at the axillae part.

Moisture in skin folds like the axillae.

edition volume 1, page 579)

The temperature is even and it is warm to touch.

Uniform: within normal range

edition volume 1, page 579)

Skin springs back to its previous state

When pinched, skin springs back to previous state

edition volume 1, page 580)

Nails Fingernail plate shape (its curvature and angle)

Convex curvature: angle of nail plate about 160

Convex curvature: angle of nail plate about 160

edition volume 1, page 583)

Fingernail and Toenail bed color

White. The client manifests any abnormalities in nail bed color.

Fundamentals of Nursing 8th edition volume 1, page 583)

Fingernail and Toenail Texture

edition volume 1, page 584)

Presence of Tissues surrounding nails

edition volume 1, page 584)

Blanch test result of capillary refill of fingernail and toenail.

Prompt return to usual color in 5 seconds.

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

edition volume 1, page 584)

C.HEAD Skull Size, shape and symmetry of the skull

Rounded, smooth and smooth skull contour.

edition volume 1, page 585)

Presence of nodules, masses, and depressions

There are nodules or masses found.

Smooth, uniform consistence; absence of nodules or masses

edition volume 1, page 585)

Scalp Color and appearance of scalp

Lighter in color than the skin complexion; no scars nor lesions;

from lice, nits and dandruff