VI.

PHYSICAL ASSESSMENT

Date of Assessment: September 29, 2016

Time of Assessment: 1: 30 pm

General Appearance:

Patient M.C is a 64 years-old male was admitted on September 27, 2016, 10: 35 pm in the
evening at Cagayan Valley Medical Center. Upon assessment the patient was in semi-fowler position with
O2 and ongoing IVF of PNSS 1L at 100 ml in his Right hand with flow rate of 10 to 11 gtts/min. Patient
M.C. was awake, weak-looking and coughing frequently. He was properly groomed.

Initial Vital Signs: Vital Signs during Physical Assessment:

BP: 100/ 60 mmHg BP: 110/70 mmHg

BT: 36.7c BT: 36.5 c

PR: 80 bpm PR: 75 bpm

RR: 28cpm RR: 30 cpm

SKIN

ASSESSMENT NORMAL ACTUAL INTERPRETATION

PROCEDURE
Inspect the skin brown (depending on Brown NORMAL
color race) varies from light to
deep6
Inspect the skin odor slight or no odor of no odor of perspiration NORMAL
perspiration (depending
on activity)
Inspect the skin intact and there are no there are no reddened NORMAL
integrity reddened areas areas
Inspect for skin Smooth, without lesions. presence of birthmarks NORMAL
lesions Stretch marks, healed on left leg
scars, freckles, moles
and birthmarks
Palpate skin to smooth and equal feels smooth NORMAL
assess texture
palpate to assess thin but calluses presence of calluses in NORMAL
thickness hands and feet
palpate to assess skin surfaces vary from moisten skin NORMAL
moisture moist to dry depending
on the area assessed
Palpate to assess warm to touch warm to touch NORMAL
temperature
Palpate to assess Skin pinches easily and skin easily pinch NORMAL
skin mobility immediately returns to
its original position
Palpate to assess When pinch, skin skin snaps back NORMAL
skin turgor springs back to 1-2 immediately when
seconds pinched
Palpate to detect Skin rebounds and does no indentation to the skin NORMAL
edema not remain indented
when pressure is
released
 SCALP and HAIR

ASSESSMENT NORMAL ACTUAL INTERPRETATION

PROCEDURE
Inspect the scalp and natural hair color, as the hair of the patient is NORMAL
hair for general color opposed to chemically with distributed white hair
and condition colored hair, varies
among clients from pale
blond to block to gray or
white
Inspect and palpate Scalp is clean and dry. The scalp and hair are NORMAL
the hair and scalp for Hair is smooth and firm clean, coarse, and drier
cleanliness, dryness no parasites noted.
or oiliness, parasites
and lesions
Inspect amount and Terminalhair cover the symmetrical distribution NORMAL
distribution of scalp, scalp, axillary, body and of hair entire the body
body, axillae and pubic areas.
pubic hair.

NAILS

ASSESSMENT NORMAL ACTUAL INTERPRETATION

PROCEDURE
Inspect nail grooming nails are cleaned and nails are cleaned and NORMAL
and cleanliness manicured no manicured (male
patient)
Inspect nail color and Pink tones and Dark the nails of the patient ABNORMAL
marking skinned clients may is darken Poor oxygenation
have freckles or
pigmented streaks
Inspect shape of nails convex curvature; angle the nail of the patient is NORMAL
of nail plate about 160 160 degree angle
between the nail base
and skin
Palpate nail to assess Nails are hard and the patient`s nails are NORMAL
texture basically immobile. hard and thickened
Capillary refill time pink tones returns the pink tones returns ABNORMAL
immediately to blanched greater than 2 seconds due to poor oxygenation
nail beds when pressure when pressure released and poor perfusion
is released.(2 seconds)

HEAD

ASSESSMENT NORMAL ACTUAL INTERPRETATION

PROCEDURE
Inspect the head for Head size and shape Head is symmetrical, NORMAL
size, shape and vary, especially in rounded, erected and in
configuration accord with ethnicity. the midline
The head is symmetric,
round, erect and in
midline
inspect for involuntary head should be held still no involuntary NORMAL
movement and upright movement
Inspect the face for The face is symmetric the face is symmetric NORMAL
symmetry, features, with a round, oval, and no abnormal
movement, expression elongated or aquare movement noted
and skin condition appearance. No
abnormal movement
noted
Palpate the head for the head is normally the head is hard without NORMAL
consistency hard and smooth lesions
without lesions

EYES

ASSESSMENT NORMAL ACTUAL INT

PROCEDURE ERPRETATION
Inspect the conjunctiva pink palpebral the conjunctiva is pale ABNORMAL
conjunctiva poor oxygenation
Inspect the sclera White in color White NORMAL
Inspect lacrimal No swelling or redness no redness noted at the NORMAL
apparatus appear over areas of Lacrimal gland
the lacrimal gland
Inspect the cornea and cornea is transparent cornea and lenses are ABNORMAL
lenses with no opacities and with opacities Due to irritation
lenses is free of
opacities
Inspect the Iris and The iris is typically Pupils are normally NORMAL
pupils round, flat and evenly equal in size and
colored. Pupils are constricted when
round with a regular focusing near object. Iris
border and centered in is round, flat and evenly
the iris colored
Inspect the eyelids and Skin on both eyelids is No redness, swelling NORMAL
eyelashes without redness, and lesions noted on
swelling or lesions. the skin of both eyelid.
Eyelashes are evenly Eyelashes are evenly
distributed and curve distributed
outward along the lid
margins
Observe the position eyeball are eyeball are NORMAL
and alignment of the symmetrically aligned in symmetrically aligned in
eyeball in the eye sockets without sockets and no sinking
socket protruding or sinking noted
Assess movements of no abnormal movement no abnormal movement NORMAL
the eye noted
Assess visual acuity of Normal near visual Patient can`t read what ABNORMAL due to
the eyes acuity is 14/14 with or normal eye can read blurred vision
without corrective from the distance of 14
lenses. inches.
Normal distant visual Patient can`t distinguish
acuity is 20/20 with or what person with normal
with corrected lenses vision can distinguish
from 20/20 feet away.

EARS

ASSESSMENT NORMAL ACTUAL INTERPRETATION

PROCEDURE
Inspect the ears for symmetric to the head Symmetric to the head NORMAL
symmetry and face Lateral to the and face
eyebrow and auricle
Inspect the color of the Same with the color of the color is same with NORMAL
ears the face facial color
Inspect the position of in lined with cantus of Lateral to the eyebrow NORMAL
the ears the ears and auricles in lined
with cantus of the ears
check hearing ability active and hear clearly cannot hear clearly and ABNORMAL due to
not active in responding excessive earwax that
cause by hearing harden and block the
problem passage of sound
waves in the ear canal

NOSE

ASSESSMENT NORMAL ACTUAL INTERPRETATION

PROCEDURE
Inspect the nose for at midline of the face, at midline of the face, NORMAL
symmetry nares are symmetrical nares are symmetric
Inspect for the color similar to the color of same with the color of NORMAL
the face the face
Inspect discharge/ no discharge/ flaring No discharge noted NORMAL
flaring of the nose

MOUTH

ASSESSMENT NORMAL ACTUAL INTERPRETATION

PROCEDURE
Inspect the lips. lips are smooth and the lips are soft, smooth NORMAL
Observe lip consistency moist without lesions or and moist in texture
and color swelling
Assess for ability to can purse can purse lips NORMAL
purse lips
Inspect for buccal moist, smooth, soft and buccal mucosa is moist, NORMAL
mucosa glistering, pink in color smooth, soft and
glistering and pink in
color
Inspect the teeth teeth are white, no teeth are white with ABNORMAL
tartars, no dental caries dental caries and due to cigarettes
incomplete set of adult smoking
teeth (27)
Inspect the gums Pink in color, moist and the color is greenish ABNORMAL
firm with tight margins to due to cigarettes
the tooth. No lesion or smoking
masses
Inspect and palpate the Tongue is pink in color, the tongue is freely NORMAL
tongue moist, a moderate size moving; centered
with papillae present. roughtened from
No lesions are present papillae and no lesions
noted
Inspect the uvula the uvula is positioned Uvula is in the midline NORMAL
in the midline

NECK

ASSESSMENT NORMAL ACTUAL INTERPRETATION

PROCEDURE
Inspect the neck centrally located neck is symmetric with NORMAL
between the shoulders head centered and
without bulging masses
Inspect movement of cartilages (thyroid and while swallowing NORMAL
the neck structures cricoids) and gland patient`s gland and
while swallowing (thyroid gland) move cartilages are moving
upward symmetry as upward symmetrically
 the patient swallows
Inspect the cervical C7 is usually visible and Vertebrae prominent in NORMAL
vertebrae palpable visible and palpable with
an increase cervical
curvature because of
Kyphosis.
Inspect range of motion neck movement is the neck movement of NORMAL
smooth and controlled the patient is controlled
(45 flexion, 55 and smooth
extension, 40
abduction and 70
rotation)
Palpate the trachea trachea is midline trachea is midline NORMAL

THORAX AND LUNGS

ASSESSMENT NORMAL ACTUAL INTERPRETATION

PROCEDURE
POSTERIOR THORAX
Inspect configuration scapulae are symmetric symmetric but ABNORMAL due to
and non protruding prominent weight lose and uses
accessory muscles
when breathing
Observe use of client does not use patient uses accessory ABNORMAL
accessory muscles muscles to assist muscles in breathing due to having difficulty
breathing in getting enough
oxygen
Inspect the client`s client is on sitting Clients is on semi fowler ABNORMAL due to
positioning position and relaxed, position and decrease gravity pulls of
breathing easily with experiencing difficulty of the diaphragm
arms at sides or in lap breathing downward which not
allowing greater chest
and lung expansion
Palpate surface skins and subcutaneous no lesions and masses NORMAL
characteristics tissue are free of lesions noted
and masses
Auscultate for no adventitious sounds there is an adventitious ABNORMAL due to
adventitious sounds sound: wheezes narrowing of the airway
in the lungs
ANTERIOR THORAX
Observe quality and respirations are relax, patient experience ABNORMAL due to
patter of respiration effortless and quiet: difficult in respiration narrowing of the airway
RR: 12-20 cpm (rapid, irregular with that decreases oxygen
presence of wheezes) entering the lungs
RR: 30 cpm
Observe uses of patient does not uses uses accessory muscles ABNORMAL due to
accessory muscles accessory muscles when breathing more effort in expanding
the chest when
breathing in or to expel
air when breathing out
Auscultate for no adventitious sounds there is an adventitious ABNORMAL due to
adventitious sounds at should be noted sound: wheezes narrowing of the airway
anterior thorax in the lungs

HEART

ASSESSMENT NORMAL ACTUAL INTERPRETATION

PROCEDURE
Precordium Adynamics, point of Adynamic, PMI is at the NORMAL
maximum impulse (PMI) fifth intercostals for adult
 is at the fifth intercostals left midclavicular line
for adult(4th intercostals
for children) left
midclavicular line
Heart sounds no murmurs no murmurs NORMAL
Hearth rate regular: 60- 100 bpm regular: 75 cpm NORMAL

ABDOMEN

ASSESSMENT NORMAL ACTUAL INTERPRETATION

PROCEDURE
Observe the coloration brown or follows general brown in color NORMAL
of the skin body color
Inspect the integrity of intact skin Intact skin NORMAL
the abdomen
Auscultate the bowel present in all quadrants, The abdominal sound is NORMAL
sound of the abdomen normal bowel sounds normal;
with 5-35 times per - Right upper
minutes each quadrant, quadrant=8
occur every 15-20 - Right lower
seconds, hypoactive= quadrant=6
occurs every 3 seconds - Left lower
quadrant=9
- Left upper
quadrant=11
Inspect Abdominal flat, round or scaphoid abdomen is flat, NORMAL
contour rounded
Inspect the umbilicus midline and inverted, no no discoloration NORMAL
sign of discoloration
Tenderness no tenderness no tenderness NORMAL

UPPER EXTREMITIES

ASSESSMENT NORMAL ACTUAL INTERPRETATION

PROCEDURE
Observe coloration of colors varies depending brown in color NORMAL
the upper extremities on the client skin
Observe arm size and arms are bilaterally arms are equal NORMAL
venous pattern symmetric with minimal
variation in size and
shape
Assess hair distribution evenly distributed evenly distributed NORMAL
Inspect lesion and absence of lesion and no lesion and NORMAL
discoloration discoloration discoloration noted
Assess Range of motion full ROM without pain full range of motion NORMAL
without pain
Palpate the client`s skin is warm to tough warm and equal NORMAL
fingers, hands, and bilaterally from finger temperature; no edema
arms, and note the tips to upper arms
temperature

LOWER EXTREMITIES

ASSESSMENT NORMAL ACTUAL INTERPRETATION

PROCEDURE
Observe coloration of colors varies depending brown in color NORMAL
the lower extremities on the client skin
Observe legs size and legs are bilaterally both legs are equal NORMAL
venous pattern symmetric with minimal
variation in size and
shape
Assess hair distribution evenly distributed evenly distributed NORMAL
Inspect lesion and absence of lesion and no lesion and NORMAL
discoloration discoloration discoloration noted
Assess Range of motion full ROM without pain full Range of Motion NORMAL
Palpate the client`s skin is warm to tough warm and equal NORMAL
fingers and legs, also and no lesions, and no temperature; no edema
note the temperature edema noted

NEUROLOGIC

ASSESSMENT NORMAL ACTUAL INTERPRETATION

PROCEDURE
Check level of 15, alert and completely 15, alert and completely NORMAL
consciousness oriented; express ideas oriented
logically

MENTAL STATUS: ORIENTATION

ASSESSMENT NORMAL ACTUAL INTERPRETATION

PROCEDURE
Time Oriented Oriented NORMAL
Place Oriented Oriented NORMAL
Person Oriented Oriented NORMAL

CEREBELLAR FUNCTION

ASSESSMENT NORMAL ACTUAL INTERPRETATION

PROCEDURE
Motor function good Good motor function NORMAL
Balance good balance Coordinated balance NORMAL
Muscle tone inspection weak muscle tone ABNORMAL due to
poor ventilation and
perfusion
Speech has the ability to Has the ability to NORMAL
comprehend spoken comprehend spoken
and written language, and written language
speech is fluent