PHYSICAL ASSESSMENT Areas to be Assessed General Appearance 1.

Posture/Gait Relaxed, erect posture ; coordinated movement Relaxed, erect posture ; coordinated movement Normal Normal Findings Actual Findings Interpretation and Analysis

2. Personal Hygiene/ Grooming

Clean and neat

Clean and neat

Normal

3. Nutritional Status

BMI 18-24

Non-assessable

No input of weight and height

Normal 4. Verbal behavior Understandable, moderate pace; clear tone Appropriate gestures and reactions to situation Understandable, moderate pace; clear tone Appropriate gestures and reactions to situation Normal

5. Non-verbal behavior

Measurements 1. Temperature 36.5-37.5 degrees Celsius 37 degrees Celsius Normal

2. Pulse rate 60-100 bpm 3. Respiratory rate 12-20 cpm 4. Blood pressure 120/80 90/60 mmHg Pulse pressure: 30-40 Body part:

74 bpm

Normal

18 cpm

Normal

120/90 mmhg Pulse pressure: 40

Normal

Skin

a. Color b. Presence of edema c. Skin moisture

Uniform in color

Uniform in color

Normal

No edema

No edema

Normal

Moist on skin folds

Dry skin and moist axillae Warm When pinched the skin get backs to its normal position

Normal

d. Temperature e. Skin turgor

Warm When pinched the skin get backs to its normal position

Normal

Normal

Nails

a. Plate shape b. Nail beds

Convex in curvature

Convex

Normal

Pinkish in color

Pinkish in color

Normal

c. Nail texture d. Tissues surrounding the nails e. Blanch test

Smooth texture

Smooth

Normal

Intact epidermis

Intact

Normal

Prompt return to pink or usual color with in 3-4 second

Prompt return within 2 seconds

Normal

Skull

a. Size, symmetry and shape b. Nodules, masses, depression and tenderness Scalp

Symmetrical in shape

Symmetrical in shape

Normal

No nodules, masses, depression and tenderness

No nodules and depression

Normal

a. Color and appearance Hair

Lighter in color than the face

Lighter in color

Normal

a. Evenness and thickness over the scalp b. Texture and oiliness

Evenly distributed and thick hair. Maybe thinner for elderly

Evenly distributed gray hair and thick hair

Normal

Silky and resilient hair

Silky and oily hair

Normal

Face

a. Facial features and symmetry Eyebrows

Symmetrical facial features

Symmetrical facial features

Normal

a. Hair distribution and alignment and movement

Hair is evenly distributed; symmetrically aligned; equal movement

Hair evenly distributed

Normal

Eyelashes

a. Evenness of distribution and direction of curl Eyelids

Evenly distributed; curled slightly outward

Curled slightly outward and evenly distributed

Normal

a. Surface characteristics and the ability to blink Conjunctiva

Skin intact and involuntary blinking of both eyelids

Skin intact and involuntary blinking of both eyelids

Normal

a. Bulbar conjunctiva from lesions, color, and texture b. Palpebral conjunctiva Sclera

No lesions and transparent capillaries are evident

No lesions and transparent capillaries are evident

Normal

Shiny, smooth and pink red

Shiny, smooth and pink red

Normal

a. Color and clarity Cornea a. Clarity and texture Iris

White

White

Normal

Transparent, smooth, shiny

Transparent, smooth, shiny

Normal

a. Color and shape

Oval and flat

Brown, oval and flat

Normal

Pupils

a. Color, shape

Black in color, equal in size, round and smooth Pupil constricts when illuminated No edema and tearing

Black in color, equal in size, round and smooth Pupils constrict

Normal

Normal

b. Test each pupil for light and accommodation Lacrimal glands, Lacrimal sac and Naso Lacrimal duct

No edema and tearing

Normal

Auricles

a. Color, symmetry and position

Color same as the facial color; symmetrical; auricle aligned with the outer canthus of the eye

Color same to face and symmetrical

Normal

b. Palpate texture, elasticity and tenderness

Mobile, firm and not tender; the pinna recoils after it is folded

Normal Pinna recoils

Nose

a. Shape, size, color and flaring

Symmetric and straight; no discharge or flaring; uniform in color Mucosa is pink; clear, watery discharge; no lesions

Symmetrical and no flaring

Normal

b. Nasal cavities

Mucosa is light pink; no discharges

Normal

c. Nasal septum

Nasal septum is intact

Septum in midline and intact

Normal

and in midline d. Patency of nasal cavities Air moves freely at right nares.

Air moves freely as the client breaths through the nares

Normal

Lips

a. Symmetry, contour, color and texture

Uniform pink color; soft, moist, smooth texture, symmetry contour

Uniform pink color; soft, moist, smooth texture, symmetry contour

Normal

Buccal mucosa

a. Color, moisture, texture and presence of lesions Teeth

Uniform pink color; moist smooth and soft

Uniform pink color; moist smooth and soft

Normal

a. Color, number and condition; presence of dentures b. Color and condition of gums Tongue

28 for adolescent; smooth, white and shiny tooth

28 teeth; smooth, white and shiny tooth

Normal

Pink moist gums Pink gums, moist, firm, texture to gums; no retractions

Normal

a. Color and texture of mouth floor and frenulum

Smooth tongue and pink in color

Smooth tongue and pink in color

Normal

b. Palpate for nodules, lumps and excoriated areas

Smooth with no palpable nodules

Smooth; no nodules

Normal

Palates and Uvula

a. Inspect and palpate soft and hard palate for color, shape, texture and presence of bony prominences b. Position of the uvula Lymph nodes on neck

Light pink smooth Light pink and soft palate; hard palate smooth soft palate. more regular texture Pink hard palate

Normal

Positioned in the midline of soft palate

Uvula in midline

Normal

a. Palpate for enlargement Anterior thorax

No enlargement

No enlargment

Normal

a. Breathing pattern b. Auscultate the chest using the flat disc diaphragm of the stethoscope Abdomen

Quiet, rhythmic and effortless breathing Vesicular and bronchovesicular breath sounds

Quiet, rhythmic and effortless breathing Vesicular and bronchovesicular breath sounds

Normal Normal

a. Skin integrity b. Abdominal contour

Uniform in color Flat, rounded (convex), scaphoid (concave)

Not uniform; Presence of transverse incision.

The client underwent on an Exlap appendectomy.

Abdomen rounded Normal

Joints

a. inspect for swelling of joints Feet

No swelling

No swelling

Normal

Normal a. inspect for color and temperature b. inspect for toenails and nail bed Uniform in color and warm Uniform in color and warm

Toenails trimmed and nail beds are pink

Toenails trimmed and nail beds are pink

Normal