PHYSICAL ASSESSMENT

Appeara nce and Mental Status *posture and gait

ACTUAL FINDINGS

NORMAL FINDINGS

ANALYSIS

Relaxed but needs to Relaxed, erect posture; be accompanied coordinated movement while walking By: Kozier

Abnormal Muscle mass decreases progressively within age and bones become more fragile. Normal

* overall Clean and neat hygiene and grooming * signs of No distress noted distress in posture or facial expressio n * obvious Pale and weak signs of appearance health or illness

Clean and neat By: Kozier

No distress noted By: Kozier

Normal

in Healthy appearance

Abnormal Pale and weak in appearance is an indication of illness moderate Abnormal thought Many elders have some impairment in hearing, vision

By: Kozier

* quantity Slow pace of speech of speech, and not that quality, understandable and organizati on

Understandable, pace; exhibits association

By: Kozier

and speech.

Clients attitude

Confused and was Cooperative easily distracted By: Kozier when people came in and out of the

A stress of being in unfamiliar situations can cause confusion in elders.

Measuremen Actual Findings ts Temperature PR RR BP 36.5 63 bpm 20 cpm 140/90mmHg

Normal Findings 36.5c-37.4c 60-100bpm 16-20cpm 120/80mmHg

Interpretati on/Analysis Normal Normal Normal Abnormal A BP of 140/90 is an indication of Hypertension or High Blood pressure

BODY PART

ACTUAL FINDINGS

NORMAL FINDINGS

ANALYSIS

SKIN

Skin is brown with age spots distributed all over the body; Appears dry and flaky; warm to touch, slightly moist and smooth;

Varies from light to deep brown; Generally uniform except in areas exposed to the sun; areas of lighter pigmentation; no abrasions or other lesions; Uniform temperature with normal range; When pinched, skin springs back to previous state within 3 sec.

Abnormal The skin is dry and flaky because sebaceous and sweat glands are less active.

By: Kozier Hair on head is Evenly distributed hair; Thick thinning with its hair; Silky, resilient hair; No white roots showing. infection or infestation No signs of scalp lesion or flaking. By: Kozier Abnormal In elderly people, Hair is slightly thinning and white hair starts to appear.

HAIR

NAIL

Finger nails not Smooth texture, dark-skinned Abnormal trimmed and dirty. clients may have brown or The hair Slow return of refill black pigmentation in grows more on fingers longitudinal streaks; Intact slowly and epidermis; Prompt return of thickens in pink or usual color (generally elder people. less than 4 sec.). By: Kozier Skull and face are symmetric. Skull is well-rounded. No signs of tenderness or masses noted. Rounded; Absence of nodules Normal and masses; Symmetric or slightly asymmetric facial features; Hair evenly distributed, skin intact By: Kozier

SKULL AND FACE

EYE

Eyebrows

were .

Equally

distributed Abnormal

STRUCTU RES AND VISUAL ACUITY

thinning but evenly distributed. The lid margins were clear, lacrimal duct openings were evident at the inner canthus of the eye. Eyelashes were evenly distributed and turned outwards. The sclera was white and clear. With an eyeglass and has a vision of 200/150. Pinna of both ears is symmetrical, color same as that of the skin. External canal of both ears showed no discharge with only very minimal cerumen. No lesions, masses, inflammation or foreign bodies noted. Can hear sounds but not that clear Nose appeared to be symmetric and straight. No discharges. No flaring noted. Color of the nose is same as that of the skin. No lesions and redness noted. Both nares were patent and no obstruction was seen

eyebrows and eyelashes; Skin intact; conjunctiva appears transparent; capillaries sometimes evident, shiny, smooth and pink or red; sclera appears white.

Visual acuity decreases as the lens of the eye ages and becomes more opaque and loses elasticity.

By: Kozier

EARS AND HEARING

Color same as facial skin; Abnormal symmetrical; Mobile; firm; Hearing loss and not tender, no hearing occurs in difficulty. elderly people. By: Kozier

NOSE AND SINUSES

Symmetric and straight; no discharge or flaring; uniform in color; no tenderness; no lesions; Air moves freely as the client breathes through the nares. By: Kozier

Normal

MOUTH AND OROPHA RYNX

Dry lips, Few teeth, teeth was slightly yellowish with brownish stains on the upper teeth. Tongue was midline and covered with papillae. No lesions or masses

Uniform pink color; Soft, moist, smooth texture; Moist, smooth, glistening, and elastic texture; tongue pink color (some brown pigmentation on tongue borders in dark- skinned clients ); moist slightly rough; thin whitish coating; Moves freely; no tenderness. By: Kozier

Abnormal Dryness of lips is associated with dehydration. In elderly people, tooth loss occur and may show signs of staining, erosion, chipping.

THORAX AND LUNGS

The thorax is symmetric and moves easily without impairment upon respiration. No tenderness noted. No masses, deformities or abnormal movements noted upon palpation. Respiratory expansion is equal on both sides. No rales, rhonchi, or friction rubs noted Flat, concave and symmetrical. Skin on abdomen was relatively the same color as that of the rest of the body, dryness and flakiness noted. No tenderness and pulsations noted.

The thorax is symmetric and Normal moves easily without impairment upon respiration. No tenderness noted. No masses, deformities or abnormal movements noted upon palpation. Respiratory expansion is equal on both sides. No rales, rhonchi, or friction rubs noted By: Kozier

ABDOME N

Unblemished skin; Uniform in Normal color; Flat; No evidence of enlargement of liver and spleen

By: Kozier