PHYSICAL ASSESSMENT Body Part Skin a Color Normal Findings Whitish pink or brown in color; dark skin tone

depending on patients race; no evidence of discoloration No skin lesions present except freckles, birthmarks or nevi which may be flat or raised Assessment Findings With pair complexion; no evidence of discoloration Has some acne and scar over the body. Analysis / Nursing Alert Normal

! Lesions

A primary lesions arise normal skin due to irritation or disease. "Healt# Assessment $%rd edition&

' Moisture

!ry with minimum perspiration. "oisture varies with changes in environment, stress, activity and body temperature

#kin feels dry; Warm and e$ual bilaterally.

#kin may be dry because of insufficient fluid intake "Healt# Assessment $%rd edition&

d Tenderness e Te(ture

#kin surface should be nontender %eel smooth, even and firm with rough surfaces

) Turgor/Edema #kin should return to it&s original contour rapidly when released; no edema present Hair 'olor varies from dark black to pale blonde; evenly distributed; pale white to light brown scalp with no lesions; thin, straight, coarse, thick or curly; shiny and resilient Nails (ink to brown cast; ) * seconds capillary refill; smooth, flat and slightly rounded; +,-. angle

Non tender with no evident inflammation #mooth and firm, minimal roughness on elbows and knees No edema present; with fair skin turgor

Normal Normal

Normal

Hair is short; scalp is clean and dry, color black with some white hairs, evenly distributed with moderate hair fall noted, pale white scalp with no lesions noted.

A!normal !ryness and hair fall can be ac$uired both genetic and nutritional imbalances. #ome white hairs are due to aging.

(ale nail beds; with normal capillary refill; smooth, flat and round; +,-. angle

/his is due to decrease oxygen supply in the body. An early sign of oxygen desaturation "Healt# Assessment $%rd edition&

Head

Fa'e

Mandi!le

Normocephalic and symmetrical; smooth, non tender without masses and depression %acial features should be symmetrical; shape can be oval, round or slightly s$uare; no involuntary movements; no edema and disproportion No discomfort with movement; no clicking or crepitus heard

Normocephalic and symmetrical; non tender; no masses and depression noted #ymmetrical facial features; oval in shape; no involuntary movements, edema and disproportion noted No pain or discomfort experienced upon movement of the tempomandibular 0oint; articulates smoothly #ymmetrical neck muscles with head in a central position; able to move head in full 12" without discomfort; no thyroid gland enlargement noted.

Normal

Normal

Normal

Ne'k/T#yroid gland/ Lym*# Nodes

#ymmetrical neck muscles; able to move head in full 12" without discomfort; no palpable masses or enlargement of thyroid glands and lymph nodes

Normal

Eyes a +isual A'uity

)-3)- vision; able to 5nable to read read within a near within a distance of distance of +4 inches +4 inches;

!ecrease visual acuity is due to aging.

! Eye Alignment ' Eye Mo,ement

Eyelids

Con-un'ti,a

6yes are aligned if no movements of either eyes 7oth eyes move smoothly and symmetrically in each of the six field of ga8e /he upper lid margin should be between the upper margin of the iris and the upper margin of the pupil. No white sclera is seen above or below the iris. (alpebral fissures may be hori8ontal. (ink and moist; no swelling, lesions or foreign bodies

No movements noted; eyes are aligned Able to move both eyes in six field of ga8e smoothly and symmetrical #ymmetrical; no drooping 9ptosis:, infections or tumors

Normal Normal

Normal

Pu*il

!eep black, round, e$ual in diameter 9 ) ,mm:, constrict

7ulbar con0unctiva is clear, moist and smooth. 5nderlying structures are clearly visible. #clera is white. !eep black; e$ual in diameter; e$ually reactive to direct

Normal

Normal

briskly to direct light Ears a Hearing A'uity /he patient should be able to repeat words whispered from a distance of ) feet

light; ) *mm; brisk in reaction No voice tone audible ; able to understand spoken words. Have problem in hearing. Hearing loss is increasingly common among older persons and is negatively associated with health and well being.

! E(ternal Ear

"atch the flesh color of the entire skin; proportional; no pain or tenderness during palpation

' Ear Canal

Sinuses

/he skin is smooth with no lesions, lumps, or nodules. 'olor is consistent with facial color. non tender auricles; no pain experienced upon palpation. No redness, No redness, swelling, lesions, swelling, lesions drainage, foreign and drainage noted; bodies or scaly with minimal non surface dry cerumen noted No evidence of No swelling and swelling around nose discomfort upon and eyes; no palpation noted discomfort during palpation #ymmetrically in the midline of the face; no lesion, swelling, bleeding and masses; no occlusion to air passage "idline ; #ymmetrical to face, no lesions, no nasal discharges or flaring uniform in color, air moves freely

Normal

Normal

Normal

Nose a E(ternal

Normal

Mout# a Li*s

(ink and moist with (ale and dry lips; no evidence of lesion no swelling and or inflammation inflammation noted

Abnormal (ale and dry lips is related to fluid volume deficit or dehydration

! Tongue

' .ums

d Teet#

"idline in the mouth; pink, moist and rough 9 from taste buds:, no lesions and swelling; moves freely (ale red stippled surface; well defined gum margins; no swelling or bleeding *) set of teeth, white with smooth edges, properly aligned and without caries

"idline in the mouth; pink, moist and rough; can move freely and stick out tongue (ink in color gums, no bleeding, inflammation and redness <ncomplete set of teeth with areas of tooth extraction; improperly aligned;

Normal

Normal

Abnormal !ental carries can be ac$uired if oral hygiene is inade$uate and with

with black patches and erosion on the surface of certain teeth

decrease in calcium and fluoride intake that makes teeth strong and free from carries

e Palate

T#roat

Hard and soft palate are concave and pink; hard palate with many ridges; soft palate is smooth; no lesion and malformations (ink, vascular and without swelling, exudates or lesions; 5vula is midline; tonsillar si8e is += to )=; 9=: gag reflex 6lliptical in shape; shoulders should be at the same height; scapula should be the same height bilaterally with no masses No accessory muscles are used in normal breathing

'oncave and pinkish; hard palate with ridges and soft palate is smooth. No lesion or malformations noted (ink, vascular with no swelling or exudates noted; 5vula is at midline> /onsillar si8e is )= with 9=: gag reflex #houlder is symmetrical expansion with inhalation, no accessory muscle used; no pain in moving 6upnea; no accessory muscles being used; no exaggerated respiratory effort upon breathing noted 7u88ing is felt on the ulnar aspect of the hand upon palpation; no increase or decrease %remitus was observed

Normal

Normal

T#ora( and Lungs a S#a*e and Symmetry

Normal

! Mus'les o) /es*iration

Normal

' Ta'tile Fremitus

Normal %remitus is felt as bu88ing on the ulnar aspect of the hand

Normal

Heart a Pre'ordium #ymmetrical; no vibrations, thrills and expansions noted Adynamic precordium; ("< at ?th <ntercostal space, left midclavicular line 1egular heart sounds; #+ and #) are distinguishable upon auscultation No discoloration and complains of pain or discomfort noted %lat abdomen; non tender; symmetrical; Normal

! Heart Sounds

Peri*#eral +as'ulature A!domen ! Contour0 Symmetry and

1hythm is regular; distinguishable #+ and #); no murmurs heard No pallor, cyanosis or ulceration noted; no complaints of pain or discomfort %lat or rounded; symmetrical

Normal

Normal

Normal

Pigmentation

bilaterally; no discoloration

uniform in color and pigmentation; no scars, striae or lesions noted symmetrical; no involuntary movement Normal

Mus'uloskeletal System a Mus'le si1e "uscle shape may and s#a*e be accentuated in certain body areas but should be symmetrical; no involuntary movement ! Mus'le 'omplete voluntary Strengt# range of 0oint motion against gravity and moderate to full resistance; strength is e$ually bilateral; no involuntary muscle movements

!ecrease muscle strength was observed on upper extremities; complete range of 0oint motion against both gravity and moderate manual resistance; good muscle strength 'an perform full range of motion but with slowed movements; no digital clubbing observed; with five fingers on each hand; symmetrical; e$ually aligned; no inflammation and swelling noted 'an perform full range of motion; with slowed gait observed; no swelling or inflammation noted; symmetrical; with five toes on each foot; no complains of calf pain; with numbness on toes both right and left foot noted

Normal

' 2**er E(tremities

Able to perform full 12"; no swelling or inflammation noted; symmetrical; with five fingers on each hand; aligned; no numbness or paralysis noted

Normal

d Lo3er E(tremities

Able to perform full range of motion; no swelling or inflammation noted; symmetrical; with five toes on each foot; aligned; no numbness or paralysis noted

Abnormal #lowed body movements may be attributed to pain or alteration in discomfort. Numbness is due to slowed or blockage of nerve impulse from the axon to another neuron through the pre synaptic to post synaptic