Physical Assessment

I. APPEARANCE
Grooming: The patient is tidy
Attire: Hospital gown
Personal hygiene: Fair hygiene
Gait: The client cannot walk independently (needs assistance)
Posture: Lying down
General Body Built: medium

II. BEHAVIOR
Level of consciousness:
Awake Alert Aware and responsive to internal and external
stimuli
Lethargic Drowsy Stupurous or unresponsive
Facial expression: congruent communication
Speech: Can speak well
Mood: Appropriate to situation: approachable and cooperative
Affect: Appropriate to situation: relays or conveys ideas and message appropriately
III. COGNITION
Oriented:
Person Place Time Confused Sedated
Alert Restless Lethargic Comatose
Recent Memory: Intact: can remember recent accident




Remote Memory: Intact:can remember his past memories

IV. THOUGHT PROCESS
Thought Content:
Logical Consistent with clients perception


Clients perceptions:
Reality based Congruent with others

Suicidal thoughts/Ideations:
Present Absent
V. SKIN/ INTEGUMENTARY
INSPECTION
Color:
Fair Flushed Pale Dusky
Cyanotic Jaundiced Others: tan
Texture: Smooth Tone: brown, firm and well-hydrated
Presence of lesion: scars present (back shoulder)
PALPATION
Moisture: Moisture was observed on skin folds and axillae, skin is moist
Temperature: C
Turgor: Fair skin tugor Lesions: Left shoulder(back)
Edema: Absent Present Site: N/A
Mild Moderate Severe







Pruritus: No Yes
Wound/Incision/Pressure Sore Site: Right Arm Dressing Type: Cast with sling
Odor: None Mild Foul
Drainage/Exudates: Serous Sanguinous Serosanguinous
Color: Yellow Creamy Green Beige/Tan
VI. NAILS
INSPECTION
Color: Pink Symmetry: Yes Configuration:Normal(Convex)
Texture: Smooth, with no excessive thickness
Cleanliness: Trimmed nails
PALPATION
The nails are smooth with uniform thickness. Capillary refill was within 3 seconds.

VII. HEAD AND NECK
INSPECTION
Head structure and symmetry: Round and symmetrical, no palpable masses, nodules or
depression
Conjunctiva: Shiny, smooth, clear in color Sclera: White
Cornea: transparent, surface smooth Iris: dark brown, uniform in color
External Nose: symmetric, not tender, no lesions noted
Mouth & throat: Mucosa: soft, moist, smooth texture and mildly pale
Tongue: Dark pink in color, moist, no lesions or masses present, moves freely, not
painful


Teeth & gums: Teeth are complete with titanium plates attached to the mandibular area

Floor of mouth: no palpable nodules
Palate: no edema or tearing Uvula: positioned in midline of soft palate
Tics: Yes No
Spasms: Yes No
Lesions: Yes No
Facial Paralysis: Yes No
Neck: It is symmetrical, no visible mass, symmetrical and no jugular venous distension
PALPATION
Cranium: symmetric
Scalp: scaling present
Hair color: white, evenly distributed Thinning: no thinning noted
Temporal Artery: strong pulsations felt, not engorged
Salivary Gland: not assessed due to immobility of the mouth because of the brace
Maxillary & Frontal Sinuses: not tender
Tragus of ear: Nontender, retracts when released
Thyroid gland size: no enlargement Shape: round and centrally positioned
Tenderness: not noted Nodules: no nodules present or visible
Position of trachea: Central placements in midline of neck, space are equal on both sides.
INSPECT and PALPATE CERVICAL LYMPH NODES




No enlarged lymph nodes upon inspection and palpation
SPECIAL TESTING:
Eyes:
Visual fields: When looking straight, client can see object in the periphery.
Extra-ocular Movements: Both eyes are coordinated; move in unison, w/ parallel
alignment.
Pupil Color: black in color Equality: both pupils are equal
Roundness: round with smooth border
Response to light & Accommodation: pupil constricts in the presence of bright light
Ears:
Inspect Ear canal & tympanic membrane:
No otoscope was used for the inspection of the ear canal, the outer ear is in uniform color
in reference to the skin and is mobile, firm and non-tender. It is also symmetric in
position. Blood discharges noted on the left ear.
Nose: No discharges were noted, tenderness was also not noted, nostrils are patent
LUNGS
INSPECTION
Respiration rate: 18 breaths/min
Even Uneven Shallow
Dyspnea Tachypnea Shortness of breath
Contour and Movement of Chest: Contour and movement are symmetric and no
abnormal protrusions are present.




PALPATION
Chest:
Masses Bulges Muscle tone: Good
Subcutaneous Emphysema Crepitus Areas of tenderness

Excursion: Respiratory Diaphragmatic
PERCUSSION: No resonance present
AUSCULTATION
Normal Breath sounds: Bronchial Bronchovesicular Vesicular
Adventitious: Crackles-course Stridor Crackles-fine
Rhonchi/Gurgles Wheezes Pleural friction rub
Lung sound location: Right: Within normal level Left: Within normal level
OTHER ABNORMAL FINDINGS:
Bronchophony Egophony
Whispered Pectroliloquy Pleural friction rub
Chest abnormalities location:
Secretions: None Productive Non Productive
Color of sputum: N/A
VIII. NECK VESSELS




PALPATE Carotid Artery
Left: Present of pulse volume Right: Present of pulse volume
AUSCULTATE Carotid Arteries
Bruits: Absent Present
IX. HEART
INSPECTION
Symmetry of Movement: There was symmetric movement of the heart
Anatomical Defects: No defects were present
Retractions: No retractions were noted
Point of Maximal Impulse (PMI): Within normal limits, found of 5
th
intercostal space,
midclavicular line
Thrills: Present Absent
PALPATION
No significant findings, PMI is within normal limits
Perfusion: Warm Dry Diaphoretic Cool
Capillary Refill: 3 seconds
AUSCULTATION:
S1, low pitched and dull, S2, shorter and more high pitched than S1, S3 and S4 not noted.
Murmurs: No murmurs noted
Pulses Apical Rate: 77 beats per minute
Regular Absent Doppler Pacemaker
X. GASTROINTESTINAL
Mouth: Light pink in color, lips and tongue are slightly dry.




Throat: muscles equal in size.
Abdomen: Abdomen is uniform in color, round, symmetric, no evidence of enlargement
of liver or spleen, silver-white striae noted.
INSPECTION
Contour: Symmetric, no evidence of liver enlargement.
Symmetry: Symmetric
NGT: None
Hemorrhoids: absent

AUSCULTATION
Bowel Sounds: High-pitched & gurgling Low-pitched
Hypoactive Hyperactive
Rate: 12 per minute
PALPATION
Abdomen: Tender Soft/Non-tender Firm Rigid
Mass: No Yes
Location: None Size: None
Shape: None Consistency: Within normal limits
Mobility: None Ascites: None Yes
Tenderness: No tenderness Girth: 33.5 cm
XI. MUSCULO-SKELETAL
EXTREMITIES
INSPECTION




Symmetry: Atrophy Left leg.
Deformities: No deformities
Skin Characteristics: Smooth, cool feet, warm hands
Hair Loss: Yes No Thin Shiny Skin: Yes No
Thickened Toenails: Yes No
PALPATION
Peripheral Pulses upper extremities: Pulse rhythm and volume is normal
Edema: Yes No
Temperature: 36.3
o
C, within normal limits, warm to touch

JOINT
INSPECTION:
Size: Equal Contour: Smooth, round,
firm
Masses: none
Deformity: none Discrepancy in leg length: No Yes, __________
PALPATION:
Musculature: good muscle tone Bony Articulations: none
Crepitations: none Heat: none
Sweat: none during assessment Tenderness: absent

RANGE OF MOTION





Normal ROM of extremities: Yes No
Weakness Paralysis Contractures Joint Swelling
Pain Muscle pain Joint pain Others
Hand Grasps: Equal Unequal Weakness R L
Leg Muscles: Equal Unequal Weakness R L
XII. NEUROLOGIC SYSTEM
CEREBELLAR FUNCTION:
SENSORY SYSTEM
Discriminate light pain: Yes No
Discriminate light touch: Yes No
Detect Temperature: Yes No
Detect Stereognosis: Yes No
Detect Graphesthesia: Yes No
Two-point discrimination: Yes No
CRANIAL NERVES
Olfactory Nerve (CN I): Client was able to distinguish strong odors.
Optic Nerve (CN II): Client blinks when cornea is touched; identified objects correctly
Occulomotor (CN III): Coordinated
Trochlear (CN IV): Both eyes are coordinated, moves in unison, with parallel alignment.
Trigeminal Nerve (CN V): The temporalis and masseter muscles are equally strong on
palpation; no masses noted
Abducens Nerves (CN VI): Client was able to move eyeballs bilaterally.











Facial Nerve (CN VII): Facial movements are symmetrical, both eyes equally resist
movements to open them, client accurately identifies tastes.
Acoustic/ Vestibulocochlear Nerve (CN VIII): A normal voice tone is audible to the
clients ear
Glossopharyngeal Nerve (CN IX): Client has no in swallowing but tongue moves freely
and coordinated.
Vagus Nerve (CN X): Gag reflex is present.
Spinal Accessory Nerve (CN XI): Client was able to shrug the hand with his left shoulder
but the right shoulder has some weakness noted.
Hypoglossal Nerve (CN XII): Tongue remains in midline when asked to stick out his
tounge with no lateral deviation.
DEEP TENDON REFLEXES
Insertion of tendon to Biceps:
Slight flexion was noted upon striking the tendon.
Insertion of tendon of Triceps:
The elbow extended upon striking.
Insertion of Tendon of Brachioradialis:
The forearm rotated laterally and palm turned upward.
Insertion of Tendon of Quadriceps:
The knee extended upon striking the kneecap.
Insertion of Tendon of Achilles:
Plantar flexion of the foot noted.
SUPERFICIAL REFLEXES:
Abdominal reflex: The umbilicus winks towards the area being stroked.
Cremasteric reflex: The scrotum rises along the side where the thigh being stroked.
Plantar reflex: The foot flexed downward after being stroked.
XIII. GENITOURINARY
PERIANAL REGION
INSPECTION No abnormal findings noted
Hemorrhoids Bleeding Discharges
Fissures Scars Lesions
Rectal Prolapse Fistula Blood in stool
PALPATION
Rectal masses No masses noted
MALE GENITALIA
INSPECTION
Hair distribution: Evenly distributed
Penis: Dorsal vein Yes No
Urethral Meatus Appearance: Medially located, not inflamed with no lesions.
Bumps Yes No Blisters Yes No No
Lesion Yes No Redness Yes No
Scrotum: Right: palpable lower than the left Left: palpable
Urine: color: amber yellow Character: slightly cloudly
Frequency per day: 5x a day Amount: 500cc
Anuria Hematuria Dysuria Incontinence
Catheter type: other:






XIV. PSYCHOSOCIAL
Recent stress: Prefers close support like people visiting his, and wants to decrease
unnecessary stimuli like noise
Coping mechanism: Talks to the members of the family about his problems, and
watching news and other T.V. programs make his forget her problems even for a little
while.
Support system: wife and children are the supports.
Calm: Yes No
Anxious: Yes No
Angry: Yes No
Withdrawn: Yes No
Irritable: Yes No
Fearful: Yes No
Religion: Roman Catholicism Restrictions: None
Feeling of helplessness: Yes No
Hopelessness: Yes No
Powerlessness: Yes No
Tobacco use: Yes No
Alcohol use: Yes No
Drug use: Yes No
NUTRITION
General appearance: Well nourished Malnourished
Emaciated Other:
Body Built: medium
Diet: high salt restriction













Meal pattern:
Feeds self Assist Total feed
Mastication/swallowing problem: Yes No
Dentures: Yes No
Appetite: Increased Decreased Usual
Decreased taste sensation: Yes No
Nausea: Yes No
Vomiting: Yes No
Heartburn/indigestion: Yes No
Stool frequency: No BM since admitted Character: N/A
Last bowel movement: N/A
NGT/Gastrostomy: None

XV. PAIN ASSESSMENT
Client complains of pain on his right hand with the pain scale of :____

XVI. SPECIAL ASSISTIVE DEVICES
Wheelchair Contacts
Venous access device Braces
Hearing aid Epidural catheter
Cane/crutches Prosthesis
Walker Glasses
Others













XVII. SELF-CARE
Needs Assistance with:
Ambulating Elimination Bed mobility
Meals Dressing Hygiene
XVIII. PATIENT EDUCATION
Plan of care
Safety/restraint use
Ordered therapies
Signs and symptoms to report
Diagnosis/disease
Lifestyle changes
Pain management
Rehabilitation measures
Hygiene/Self-care
Mobility/ambulation
Hospital referrals
Medications
Community referral
Diet/Nutrition