PHYSICAL ASSESSMENT (Elnora L. Gasic) SYSTEM/PART I.

General Status y y Body Built Posture and gait y y Proportionate Relaxed, erected y y Obese Normal NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS

Hygiene and grooming Body and breath odor

Clean, neat

Normal

Absence of body and breath odor

Normal

Signs of Distress Affect or Mood Speech

No distress

Normal

y y

y y

Cooperative Understandable

y y

Normal Normal

II. Vital Signs y y Temperature Pulse Rate

For elderly (65+) y y 35.8-36.4 C 60-100 BPM, regular 15-25 CPM, regular y 24 CPM, regular 130/80 mmHg, semifowlers position y 37.0 C, axillary 90 BPM, regular

Respiratory Rate

Blood Pressure

140-160 mmHg/ 70-90 mmHg

Note: vital signs are initially taken upon

first encounter of nurse to client III. Skin y Color y Varies from light to deep brown Generally uniform y Deep brown

Symmetry of color Edema Skin Lesions

Normal

y y

y y

No edema Freckles, some birthmarks, some flat and raised nevi; no abrasions or other lesions Moisture in skin folds and the axillae (varies with environmental temperature and humidity, body temperature, and activity) Uniform; within normal range Good skin turgor (when pinched, skin springs back to previous state; may be slower in elderly)

y y

Normal No freckles, some birthmarks, no flat nevi, no abrasions or other lesions normal

Moisture

Temperature

Normal

Skin Turgor

y y

Normal

IV. Hair y y y Distribution Thickness Texture and oiliness Infestations y y y Evenly distributed Thick Silky, resilient y y y Normal Normal Normal

No infection or

No infection

infestation y Body Hair V. Nails y Curvature and Angle y Variable y

or infestation Variable

Convex curvature; angle of nail plate about 160 degrees Smooth texture Highly vascular and pinkish in color Intact epidermis

Normal

y y

Texture Nailbed color

y y

y y

Normal Normal

Surrounding tissue Capillary refill

Normal

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

Normal

VI. Skull and Face y y y Size and shape Contour Facial features y y y Normocephalic Smooth contour Symmetric or slightly asymmetric; palpebral fissures equal in size; symmetric nasolabial folds Absence of edema y y y Normal Normal Normal

Edema/ Hollowness

Normal

Facial Movements VII. Eye Structures and Visual Acuity y y Eyebrows

Symmetrical facial movements

Normal

Evenly distributed

Normal

y y

Eyelashes Eyelids

y y

Equally distributed Skin intact, no discharge / discoloration 15-20 involuntary blinks Transparent; capillaries sometimes evident; sclera appears white Shiny, smooth, andpink or red No edema or tenderness Transparent, shiny and smooth; details of iris are visible Pupils equally round and reactive to light and accommodation (PERRLA)

y y

Normal Normal

y Bulbar conjunctiva

17 involuntary blinks Normal

Palpebral conjunctiva Lacrimal Gland

Normal

Normal

Cornea

Normal

Pupils

Normal

VIII. Ears and Hearing y Pinna y Uniform color with skin; symmetry Intact y Normal

y Hearing Acuity IX. Nose y External Nose

Normal

Symmetrical; uniform in color Patent, septum in midline

Normal

Nasal Cavity

Normal

X. Mouth and Oropharynx

Lips

Pinkish, soft, moist, smooth, symmetrical, movable Complete Pinkish, moist

Normal

y y y

Teeth Gums Tongue

y y y

Using of dentures Normal Normal Normal Normal Normal Pink, smooth Intact

y Midline, pinkish, smooth, movable Light pink, smooth In midline Pink, smooth Pink, smooth Intact y y y y y y

y y y y

Palate Uvula Oropharynx Tonsils

y y y y y

y Gag reflex XI. Neck y y y Muscles Movement

y y y

Equal in size Coordinated

y y

Normal Normal

Range of Motion XII. Neck y y y y y y y Muscle Movement Range of Motion Muscle Strength Lymph Nodes Trachea Thyroid Gland

y y y y y y y

Equal in size Coordinated Full Equal Not Palpable In midline Not visible

NORMAL

y y

Carotid Pulse Jugular Veins

y y

Symmetric Pulse Not Visible

II. Thorax and Lungs y y y y y y y y Breathing Pattern Coastal Angle Shape and Symmetry Spinal Alignment Skin Respiratory Excursion Fremitus y y y y y y y y y Regular Less than 90 Symmetrical Aligned Smooth Full Bilateral Resonant Clear y y y y y Smooth Full Decreased Resonant Clear y y y Regular Regular APL ratio 1:2; asymmetrical

Percussion Sound y Breath Sound III. Heart y y Precordium Heart Sound

y y

Pulsation S1 louder than S2 at base

No pulsations No Heaves Systolic heart murmur at apex

IV. Breast and Axilla y y Size and Shape Skin y y Rounded Smooth y NORMAL

y y y

Areola Nipples

y y y

Round Round

Axillary Lymph Nodes V. Abdomen y y y y y y y Skin Integrity Contour Symmetrical Bowel Sounds Other Percussion Palpitation

y y y y

Unblemished Flat; Rounded Symmetrical Normoactive

NORMAL

y y

Tympanic Relaxed

VI. Genitals y y y y y y Pubic hair Pubic skin Labial Folds Clitoris Vaginal Orifice Penile shaft and Glands Urethral Meatus Scrotum

y y

y Lymph Nodes VII. Anus and Rectum

y y y

Anus Anal Sphincter Rectal Wall

y y y

Intact Good tone Smooth

y Discharge VIII. Upper and Lower Extremities y y y y y y Muscle Size Muscle Tone Muscle Strength Bones Joints Range of Motion y y y y y y Full Equal Firm Equal y NORMAL

PHYSICAL ASSESSMENT (Cristine Mae L. Gasic)

SYSTEM/PART I. General Status y y Body Built Posture and gait

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

y y

Proportionate Relaxed, erected

y y

Flubby Normal

Hygiene and grooming Body and breath odor

Clean, neat

Normal

Absence of body and breath odor

Normal

Signs of Distress Affect or Mood Speech

No distress

Normal

y y

y y

Cooperative Understandable

y y

Normal Normal

II. Vital Signs y y Temperature Pulse Rate

For elderly (65+) y y 35.8-36.4 C 60-100 BPM, regular 15-25 CPM, regular y 27 CPM, regular y 36.0 C, axillary 80 BPM, regular

Respiratory Rate

Blood Pressure

140-160 mmHg/ 70-90 mmHg Note: vital signs are initially taken upon first encounter of nurse to patient

III. Skin y Color y Varies from light to deep brown Generally uniform y Deep brown

Symmetry of color Edema Skin Lesions

Normal

y y

y y

No edema Freckles, some birthmarks, some flat and raised nevi; no abrasions or other lesions Moisture in skin folds and the axillae (varies with environmental temperature and humidity, body temperature, and activity) Uniform; within normal range Good skin turgor (when pinched, skin springs back to previous state; may be slower in elderly)

y y

Normal No freckles, some birthmarks, no abrasions or other lesions Normal

Moisture

Temperature

Normal

Skin Turgor

y y

Normal

IV. Hair y y y Distribution Thickness Texture and oiliness Infestations y y y Evenly distributed Thick Silky, resilient y y y Normal Normal Normal

No infection or infestation

Head Lice

y Body Hair V. Nails y Curvature and Angle

Variable

Variable

Convex curvature; angle of nail plate about 160 degrees Smooth texture Highly vascular and pinkish in color Intact epidermis

Normal

y y

Texture Nailbed color

y y

y y

Normal Normal

Surrounding tissue Capillary refill

Normal

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

Normal

VI. Skull and Face y y y Size and shape Contour Facial features y y y Normocephalic Smooth contour Symmetric or slightly asymmetric; palpebral fissures equal in size; symmetric nasolabial folds Absence of edema y y y Normal Normal Normal

Edema/ Hollowness

Normal

Facial Movements VII. Eye Structures and Visual Acuity y y y Eyebrows Eyelashes

Symmetrical facial movements

Normal

y y

Evenly distributed Equally distributed

y y

Normal Normal

Eyelids

Skin intact, no discharge / discoloration 15-20 involuntary blinks Transparent; capillaries sometimes evident; sclera appears white Shiny, smooth, andpink or red No edema or tenderness Transparent, shiny and smooth; details of iris are visible Pupils equally round and reactive to light and accommodation (PERRLA)

Normal

y Bulbar conjunctiva

20 involuntary blinks Normal

Palpebral conjunctiva Lacrimal Gland

Normal

Normal

Cornea

Normal

Pupils

Normal

VIII. Ears and Hearing y Pinna y Uniform color with skin; symmetry Intact y Normal

y Hearing Acuity IX. Nose y External Nose

Normal

Symmetrical; uniform in color Patent, septum in midline

Normal

Nasal Cavity

Normal

X. Mouth and Oropharynx y Lips y Pinkish, soft, y Dark, Normal

moist, smooth, symmetrical, movable y y y Teeth Gums Tongue y y y Complete Pinkish, moist Midline, pinkish, smooth, movable Light pink, smooth y y y y Uvula Oropharynx Tonsils y y y y In midline y Pink, smooth y Pink, smooth y y Gag reflex XI. Neck y y y Muscles Movement Intact Intact Pink, smooth Normal Normal y y y y y Palate y Complete Normal Normal Normal

y y y

Equal in size Coordinated

y y

Normal Normal

Range of Motion XII. Neck y y y y y y y y Muscle Movement Range of Motion Muscle Strength Lymph Nodes Trachea Thyroid Gland Carotid Pulse

y y y y y y y y

Equal in size Coordinated Full Equal Not Palpable In midline Not visible Symmetric Pulse

y y y y y y y y

Normal Normal Normal Normal Not palpable In midline Not visible Normal

y Jugular Veins II. Thorax and Lungs y y y y y y y y Breathing Pattern Coastal Angle Shape and Symmetry Spinal Alignment Skin Respiratory Excursion Fremitus

Not Visible

Not Visible

y y y y y y y y y

Regular Less than 90 Symmetrical Aligned Smooth Full Bilateral Resonant Clear

y y y y y

Regular Normal APL ratio 1:2; asymmetrical Aligned Smooth

y y

Full Bilateral

Percussion Sound y Breath Sound III. Heart y y Precordium Heart Sound

y y

Resonant Clear

y y

Pulsation S1 louder than S2 at base

No heaves and thrills Systolic heart murmur at apex

IV. Breast and Axilla y y y y Size and Shape Skin Areola Nipples y y y y Rounded Smooth Round Round y y y y Rounded Normal Normal Normal

Axillary Lymph Nodes V. Abdomen y y y y y y y y Skin Integrity Contour Symmetrical Bowel Sounds Other Percussion Palpitation

Not palpable, no tenderness

Normal

y y y y

Unblemished Flat; Rounded Symmetrical Normo active

y y y y

Normal Normal Normal Normo Active

y y

Tympanic Relaxed

y y

Normal Normal

VI. Genitals y y y y y y Pubic hair Pubic skin Labial Folds Clitoris Vaginal Orifice Penile shaft and Glands Urethral Meatus Scrotum

y y

y Lymph Nodes VII. Anus and Rectum y y Anus Anal Sphincter y y Intact Good tone

Rectal Wall

Smooth

y Discharge VIII. Upper and Lower Extremities y y y y y y Muscle Size Muscle Tone Muscle Strength Bones Joints Range of Motion y y y y y y Full Equal Firm Equal y NORMAL

PHYSICAL ASSESSMENT (Judy L. Gasic)

SYSTEM/PART I. General Status y y Body Built Posture and gait

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

y y

Proportionate Relaxed, erected

y y

Thin Normal

Hygiene and grooming Body and breath odor

Clean, neat

Normal

Absence of body and breath odor

(+)Breath Odor

Signs of Distress Affect or Mood Speech

No distress

Normal

y y

y y

Cooperative Understandable

y y

Normal Normal

II. Vital Signs y y Temperature Pulse Rate

For elderly (65+) y y 35.8-36.4 C 60-100 BPM, regular 15-25 CPM, regular y 26 CPM, regular y 36.3 C, axillary 88 BPM, regular

Respiratory Rate

Blood Pressure

140-160 mmHg/ 70-90 mmHg Note: vital signs are initially taken upon first encounter of nurse to patient

III. Skin y Color y Varies from light to deep brown Generally uniform y Deep brown

Symmetry of color Edema Skin Lesions

Normal

y y

y y

No edema Freckles, some birthmarks, some flat and raised nevi; no abrasions or other lesions Moisture in skin folds and the axillae (varies with environmental temperature and humidity, body temperature, and activity) Uniform; within normal range Good skin turgor (when pinched, skin springs back to previous state; may be slower in elderly)

y y

Normal No freckles, some birthmarks, no abrasions or other lesions Normal

Moisture

Temperature

Normal

Skin Turgor

Normal

IV. Hair y y y Distribution Thickness Texture and oiliness Infestations y y y Evenly distributed Thick Silky, resilient y y y Normal Normal Normal

No infection or infestation

Head Lice

y Body Hair V. Nails y Curvature and Angle

Variable

Variable

Convex curvature; angle of nail plate about 160 degrees Smooth texture Highly vascular and pinkish in color Intact epidermis

Normal

y y

Texture Nailbed color

y y

y y

Normal Normal

Surrounding tissue Capillary refill

Normal

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

Normal

VI. Skull and Face y y y Size and shape Contour Facial features y y y Normocephalic Smooth contour Symmetric or slightly asymmetric; palpebral fissures equal in size; symmetric nasolabial folds Absence of edema y y y Normal Normal Normal

Edema/ Hollowness

Normal

Facial Movements VII. Eye Structures and Visual Acuity y y y Eyebrows Eyelashes

Symmetrical facial movements

Normal

y y

Evenly distributed Equally distributed

y y

Normal Normal

Eyelids

Skin intact, no discharge / discoloration 15-20 involuntary blinks Transparent; capillaries sometimes evident; sclera appears white Shiny, smooth, andpink or red No edema or tenderness Transparent, shiny and smooth; details of iris are visible Pupils equally round and reactive to light and accommodation (PERRLA)

Normal

y Bulbar conjunctiva

20 involuntary blinks Normal

Palpebral conjunctiva Lacrimal Gland

Normal

Normal

Cornea

Normal

Pupils

Normal

VIII. Ears and Hearing y Pinna y Uniform color with skin; symmetry Intact y Normal

y Hearing Acuity IX. Nose y External Nose

Normal

Symmetrical; uniform in color Patent, septum in midline

Normal

Nasal Cavity

Normal

X. Mouth and Oropharynx y Lips y Pinkish, soft, y Dark, Normal

moist, smooth, symmetrical, movable y y y Teeth Gums Tongue y y y Complete Pinkish, moist Midline, pinkish, smooth, movable Light pink, smooth y y y y y Uvula Oropharynx Tonsils Gag reflex y y y y In midline y Pink, smooth y Pink, smooth y Intact y y XI. Neck y y y Muscles Movement y y y Equal in size Coordinated y y Normal Normal Pink, smooth Intact Normal Normal Normal Normal y y Complete with dark tooth enamel Normal with whitish covering

Palate

Range of Motion XII. Neck y y y y y y Muscle Movement Range of Motion Muscle Strength Lymph Nodes Trachea

y y y y y y

Equal in size Coordinated Full Equal Not Palpable In midline

y y y y y y

Normal Normal Normal Normal Not palpable In midline

y y

Thyroid Gland Carotid Pulse

y y y

Not visible Symmetric Pulse Not Visible

y y y

Not visible Normal Not Visible

y Jugular Veins II. Thorax and Lungs y y y y y y y y Breathing Pattern Coastal Angle Shape and Symmetry Spinal Alignment Skin Respiratory Excursion Fremitus

y y y y y y y y y

Regular Less than 90 Symmetrical Aligned Smooth Full Bilateral Resonant Clear

y y y y y

Regular Normal APL ratio 1:2; asymmetrical Aligned Smooth

y y

Full Bilateral

Percussion Sound y Breath Sound III. Heart y y Precordium Heart Sound

y y

Resonant Clear

y y

Pulsation S1 louder than S2 at base

No heaves and thrills Systolic heart murmur at apex

IV. Breast and Axilla y y y Size and Shape Skin Areola y y y Rounded Smooth Round y y Rounded Normal

y y y Nipples Axillary Lymph Nodes y y Round y Not palpable, no tenderness y

Normal Normal Normal

V. Abdomen y y y y y y y Skin Integrity Contour Symmetrical Bowel Sounds Other Percussion Palpitation y y Tympanic Relaxed y y Normal Normal y y y y Unblemished Flat; Rounded Symmetrical Normo active y y y y Normal Normal Normal Normo Active

VI. Genitals y y y y y y Pubic hair Pubic skin Labial Folds Clitoris Vaginal Orifice Penile shaft and Glands Urethral Meatus Scrotum

y y

y Lymph Nodes VII. Anus and Rectum

y y y

Anus Anal Sphincter Rectal Wall

y y y

Intact Good tone Smooth

y Discharge VIII. Upper and Lower Extremities y y y y y y Muscle Size Muscle Tone Muscle Strength Bones Joints Range of Motion y y y y y y Full Equal Firm Equal y NORMAL

PHYSICAL ASSESSMENT (BJ L. Gasic)

SYSTEM/PART I. General Status y y Body Built Posture and gait

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

y y

Proportionate Relaxed, erected

y y

Flubby Normal

Hygiene and grooming Body and breath odor

Clean, neat

Normal

Absence of body and breath odor

Normal

Signs of Distress Affect or Mood Speech

No distress

Normal

y y

y y

Cooperative Understandable

y y

Normal Normal

II. Vital Signs y y Temperature Pulse Rate

For elderly (65+) y y 35.8-36.4 C 60-100 BPM, regular 15-25 CPM, regular y 24 CPM, regular y 36.4 C, axillary 116 BPM, regular

Respiratory Rate

Blood Pressure

140-160 mmHg/ 70-90 mmHg Note: vital signs are initially taken upon first encounter of nurse to patient

III. Skin y Color y Varies from light to deep brown Generally uniform y Deep brown

Symmetry of color Edema Skin Lesions

Normal

y y

y y

No edema Freckles, some birthmarks, some flat and raised nevi; no abrasions or other lesions Moisture in skin folds and the axillae (varies with environmental temperature and humidity, body temperature, and activity) Uniform; within normal range Good skin turgor (when pinched, skin springs back to previous state; may be slower in elderly)

y y

Normal No freckles, some birthmarks, no abrasions or other lesions Normal

Moisture

Temperature

Normal

Skin Turgor

y y

Normal

IV. Hair y y y Distribution Thickness Texture and oiliness Infestations y y y Evenly distributed Thick Silky, resilient y y y Normal Normal Normal

No infection or infestation

Head Lice

y Body Hair V. Nails y Curvature and Angle

Variable

Variable

Convex curvature; angle of nail plate about 160 degrees Smooth texture Highly vascular and pinkish in color Intact epidermis

Normal

y y

Texture Nailbed color

y y

y y

Normal Normal

Surrounding tissue Capillary refill

Normal

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

Normal

VI. Skull and Face y y y Size and shape Contour Facial features y y y Normocephalic Smooth contour Symmetric or slightly asymmetric; palpebral fissures equal in size; symmetric nasolabial folds Absence of edema y y y Normal Normal Normal

Edema/ Hollowness

Normal

Facial Movements VII. Eye Structures and Visual Acuity y y y Eyebrows Eyelashes

Symmetrical facial movements

Normal

y y

Evenly distributed Equally distributed

y y

Normal Normal

Eyelids

Skin intact, no discharge / discoloration 15-20 involuntary blinks Transparent; capillaries sometimes evident; sclera appears white Shiny, smooth, andpink or red No edema or tenderness Transparent, shiny and smooth; details of iris are visible Pupils equally round and reactive to light and accommodation (PERRLA)

Normal

y Bulbar conjunctiva

20 involuntary blinks Normal

Palpebral conjunctiva Lacrimal Gland

Normal

Normal

Cornea

Normal

Pupils

Normal

VIII. Ears and Hearing y Pinna y Uniform color with skin; symmetry Intact y Normal

y Hearing Acuity IX. Nose y External Nose

Normal

Symmetrical; uniform in color Patent, septum in midline

Normal

Nasal Cavity

Normal

X. Mouth and Oropharynx y Lips y Pinkish, soft, y Dark, Normal

moist, smooth, symmetrical, movable y y y Teeth Gums Tongue y y y Complete Pinkish, moist Midline, pinkish, smooth, movable Light pink, smooth y y y y Uvula Oropharynx Tonsils y y y y In midline y Pink, smooth y Pink, smooth y y Gag reflex XI. Neck y y y Muscles Movement Intact Intact Pink, smooth Normal Normal y y y y y Palate y Complete Normal Normal Normal

y y y

Equal in size Coordinated

y y

Normal Normal

Range of Motion XII. Neck y y y y y y y y Muscle Movement Range of Motion Muscle Strength Lymph Nodes Trachea Thyroid Gland Carotid Pulse

y y y y y y y y

Equal in size Coordinated Full Equal Not Palpable In midline Not visible Symmetric Pulse

y y y y y y y y

Normal Normal Normal Normal Not palpable In midline Not visible Normal

y Jugular Veins II. Thorax and Lungs y y y y y y y y y Breathing Pattern Coastal Angle Shape and Symmetry Spinal Alignment Skin Respiratory Excursion Fremitus Percussion Sound Breath Sound

Not Visible

Not Visible

y y y y y y y y y

Regular Less than 90 Symmetrical Aligned Smooth Full Bilateral Resonant Clear

y y y y y

Regular Normal APL ratio 1:2; asymmetrical Aligned Smooth

y y

Full Bilateral

y y

Dull Whezzing both Lung Fields

III. Heart y y Precordium Heart Sound y y Pulsation S1 louder than S2 at base y No heaves and thrills Systolic heart murmur at apex

IV. Breast and Axilla y y y y Size and Shape Skin Areola Nipples y y y y Rounded Smooth Round Round y y y Rounded Normal Normal

y y Axillary Lymph Nodes y Not palpable, no tenderness y

Normal Normal

V. Abdomen y y y y y y y Skin Integrity Contour Symmetrical Bowel Sounds Other Percussion Palpitation y y Tympanic Relaxed y y Normal Normal y y y y Unblemished Flat; Rounded Symmetrical Normo active y y y y Normal Normal Normal Normo Active

VI. Genitals y y y y y y Pubic hair Pubic skin Labial Folds Clitoris Vaginal Orifice Penile shaft and Glands Urethral Meatus Scrotum

y y

y Lymph Nodes VII. Anus and Rectum y Anus y Intact

y y

Anal Sphincter Rectal Wall

y y

Good tone Smooth

y Discharge VIII. Upper and Lower Extremities y y y y y y Muscle Size Muscle Tone Muscle Strength Bones Joints Range of Motion y y y y y y Full Equal Firm Equal y NORMAL