V. PHYSICAL ASSESSMENT GENERAL APPEARANCE The patient appears to be in chronological age.

He is clean, no usual body odor and clothing is in good condition and appropriate for climate. The patient looks weak in appearance and is able to maintain good eye contact. Edema is noted on both lower extremities. VITAL SIGNS Patients blood pressure is 120/70 mmHg, temperature is 36.4 C with a heart rate of 73 beats/ minute and a respiratory rate of 19 breaths/ minute. Body Parts Skin Methods > Inspection Findings > The color is fair and evenly colored Analysis > This is normal due to the amount of melanin present in the clients skin.

>It is intact with no >Normal skin is lesions and intact and no reddened areas. lesions and reddened areas.

> Palpation

> Skin is warm to touch.

>Elevated body temperature is associated when the center for thermal regulation, hypothalamus, is affected.

>Calluses are >There are common on areas presence of of the body that calluses on the are constantly clients hands and exposed to feet. pressure. >Decreased >Skin is easily mobility and turgor pinched and is seen with return to its edema. normal state.

Hair and Scalp

>Inspection

> Hair is black in color and evenly distributed on the scalp. There are some white hairs present due to aging.

>Natural hair color varies among client. The color depends on the amount of melanin present.

Nails

> Inspection

>Nails are clean Normally, the nails and trimmed. should be clean and trimmed that indicates good hygienic practices. > Nails are pink, extend to end of fingers and wellformed. >Pink tones are normal and indicates that the client is not cyanotic.

>Palpation

Head and Face

>

Inspection

>Nails are hard, >Nails are hard, smooth and smooth and immobile. basically immobile. >Head is > Usually the head symmetric, round, is symmetric, erect and in the round, erect and midline. in the midline.

>There are no >Head is normally visible lesions and held still and no involuntary upright. movements noted. >Face is >Face is normally symmetric with symmetric and round shape depends on appearance. the clients genetic predisposition. Neck > Inspection >The patient has vascular access devices on right jugular vein. >Patient with this kind of vascular access device is usually undergoing hemodialysis.

>

Palpation

> Lymph nodes >Lymph nodes are are not palpable. usually not palpable. If palpable, they should be 1cm or less and round. >Eyes symmetrically aligned, protruding sinking and visible lesions. are >Eyes are normally not symmetric, not or protruding or no sinking and free of lesions.

Eyes

>

Inspection

>Lower lid is >An upright eyelid upright with no is a normal inward or outward condition. turning.

>Sclera and conjunctiva are clear and free of discharge, lesions, redness or lacerations.

>Normally, sclera and conjunctiva are clear and free of discharge, lesions, redness or lacerations.

>Eyebrows symmetric shape movement.

are >Eyebrows are in normally and symmetric in shape and movement. >Light causes pupils to constrict bilaterally and blink reflex occurs.

Ears

> Inspection

>Eyes pupils constrict when a light was shone directly at the eye. The eyes also blink >Ears are symmetrical, equal in size bilaterally. Earlobes are free.

>Ears are equal in size bilaterally, normally 4-10 cm. Auricle aligns with the corner of each eye. Earlobes may be free, attached or soldered. >Normally, theres no discharge in external ear

>No discharge

>Palpation >Auricle, tragus >Normally, the and mastoid auricle, tragus and process are not mastoid process
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tender. Mouth >Inspection >Lips appear dry.

are not tender. >The dryness of the lips is caused by inadequate fluid intake of the client.

>No lesions and >Normally, the swelling present in mouth together the mouth. with its structures are intact and free from inflammation.

Nose

> Inspection

>Nose is in >Nose should be midline and nares at the midline and are patent. not be occluded. Turbinates are pink and free of edema. >No Nasal flaring >Nasal flaring is observed. only seen with labored respirations and is indicative of hypoxia. >Respiratory rate >The normal is 19 breaths per respiratory rate of minute. an adult is 12-20 breaths per minute. >No unusual prominent discoloration or >Ruddy to purple complexion maybe seen in clients with COPD or CHF as a result of polycythemia. Cyanosis may be seen if the client is cold or hypoxic.

Thorax

>Inspection

>Auscultation

>No adventitious >Normally, there sounds noted shouldnt be any adventitious sound present. >Patients abdomen is flat in supine position and is symmetrical. >The client has
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Abdomen

>Inspection

>The normal contour of the abdomen are flat and rounded. >Penis should be

Male Genetalia

> Inspection

normal size of penis, no lesions, and or swelling noted. Urinary meatus at tip and no redness.

free from lesions. Foreskin of the male genitalia must be retractable and urinary meatus must be at the tip.

>No discharges >Normally, there noted. shouldnt be discharges. Any drainage --- yellow discharge is seen with gonorrhea; clear or white discharge is seen with urethritis. Musculoskeletal Arms > Inspection and Palpation

>Both arms and are symmetric in size and shape.

Extremities should be symmetric in size and shape.

>Muscle size is adequate for the age.

>Normal because inadequate muscle size indicate neurologic muscular disorder.

>Elbows are symmetric without deformities redness or swelling.

>Normally there shouldnt be any redness or swelling because redness, heat, selling may be seen with bursitis of the olecranon due to trauma or arthritis.

>Wrists are symmetric without redness or swelling. They are non-tender and free of nodules.

>Normally, there shouldnt be any redness or swelling present.

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>The client can flex his left wrist up to 90 and hyperextend up to 70 .

>Normal range s of motion are 90 flexion and 70 hyperextension.

Elbows

>Hands and fingers are symmetric, nontender and without nodules. Fingers lie in a straight line. No swelling or deformities. >Knees are symmetric, hollows present on both sides of the patella, no swelling or deformities. Lower leg is in alignment with upper leg.

>Normally, hands and fingers should be symmetric, nontender and without nodules.

>Normally, the knees should be symmetric, hollows present on both sides of the patella, no swelling and deformities.

>No pain, heat, >Normally, there swelling, or shouldnt be any nodules noted. pain, heat, swelling or nodules present.

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SUMMARY OF PHYSICAL ASSESSMENT

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