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PHYSICAL ASSESSMENT

Date of Physical Assessment: July 06, 2011 / 6:55pm 6days Post op


BMI: 30.18 obese class 1
Height:56
Weight: 85kg. 187lbs.
Vital Signs:
BP: 120/90mmhg
Temperature: 37.3C
Pulse rate: 89bpm
Respiratory rate: 29cpm
Pain Scale: 3
General Observations:
The patient was restless, conscious, coherent, oriented to time, person, and place. He has
thrombo embolic stockings on both lower extremities and had undergo laminectomy (June 30,
2011) on the thoracic (T9) and therefore completely limited in mobilization. Hemovac at the
back was noted and complain for back pain.

BODY
PARTS
METHODS
OF
ASSESSMENT
NORMAL ACTUAL
FINDINGS
INTERPRETATION
Skin Inspection






Color: skin is
uniform whitish pink
or brown in color.

No bleeding and
ecchymosis and
vascularity

Lesions: no skin
lesions are present
except for
birthmarks or moles
which may be flat or
elevated.
No edema present
The overall
appearance of the skin
is light brown

Some elevated
circumscribed fluid-
filled less than 1cm in
diameter was noted at
the upper back.
The blood supply
particularly at the back
area decreased (due to
prolong lying in bed).
Thus insufficient
amount of oxygen
cause skin lesions
(vesicle) and dry skin
is an indication of
decrease fluids in the
body and frequent
turning on the bed.

(Fundamentals of
nursing, 6
th
ed page
687).

Palpation Moisture in skin
folds varies with the
environment

Skin turgor: when
released should
return to original
contour rapidly and
no edema is present.
Generally dry and
warm



Dry skin probably due
to environment

(Kozier, Skill 30-2
p.579)


Head

a. Skull
Inspection









Rounded
(normo- cephalic)
and asymmetric with
frontal, parietal,
temporal, occipital
and prominences:





Normocephalic, with
prominences in the
frontal and occipital
area






The shape of the head
is normocephalic.

The shape is gently
curve with prominence
at the frontal and
parietal bones.

(Fundamentals of
nursing taylor 6
th
ed.
vol.1 page616 )
b. Scalp Palpation Smooth skull
contour absence of
nodules or masses
The scalp is moist,
symmetrical and firm.

No lesions and mass
noted
The scalp is moisten
showing normal for a
scalp

(Fundamentals of
nursing taylor 6
th
ed.
vol.1 page614)
c. Hair Inspection Color:
dark black to blonde;
may turn gray or
white; may be
chemically
distributed
The hair is dark brown
in color. The texture
was fine, smooth and
thin slightly curly hair.
Equally distributed
and no signs of
alopecia and lice.
Client manifests
normal findings
Face Inspection Face is symmetrical

Shape is gently
curved with
prominences at the
frontal and parietal
bones
Symmetrical. No
involuntary muscle
movement
Client manifests
normal findings
Palpation Smooth uniform
consistency; absence
of nodules or masses
Smooth uniform
consistency; absence
of nodules or masses
Client manifests
normal findings

Eyes




























Inspection


Should be
symmetrical with no
dropping infection,
tumors or other
abnormalities with
the visual acuity of
20/20

Sclera: white
without exudates,
lesions foreign
bodies in dark
skinned may have
brown patches


Pupils: deep black,
round and equal
diameter of 2-6mm
PERRLA


No tearing, swelling
or discharge in
conjunctiva
Eyebrows equally
distributed and dark
brown in color

Eyelashes slightly
curved upward
evenly distributed
and color is same
with eyebrows

Eyelids function
normally

Conjunctiva is
moist and pinkish

Cornea is smooth
and transparent

Sclera: white
without exudates

Pupil size: 4mm;
equal reaction to
light; right and left
briskly reactive to
light

Reaction to
accommodation;
uniform
constriction grossly
normal vision 20/20
intact peripheral
vision
No significant
findings
Ears Inspection









External ear gently
no pain, edema, and
lesions

Earlobes are bean
shaped, parallel, and
symmetrical. Skin is
same color as
complexion

Ear canal and the
tympanic membrane
External pinnae:
normoset

External canal has
no unusual
discharges

Tympanic
membrane is intact
and pearly gray in
color
Gross hearing are
No significant
findings
should be intact,
translucent, shiny,
and pearly gray in
color

No redness and
discharge

Assessing hearing
sounds one ear at a
time can hear
whispered voice and
ticking watch from
distance of 1-2 feet

symmetrically
normal
Nose








Inspection















Palpation










Nose is in the
midline and is
symmetrical,
No unusual
discharges,
No nasal flaring,
Both nares are
patent,
No bones and
cartilage deviation,
Nasal septum is in
the midline,
and
Nasal mucosa is
pink in color

No pain, tenderness
and discomfort
during palpation











Septum is in the
midline,
Mucosa is pinkish,
Both nares are
patent,
Gross smell are
symmetrical and
No unusual
discharge







There is no pain
upon palpation and
no
swelling and
tenderness of the
paranasal sinuses

No significant
findings














No significant
findings
Mouth Inspection

Lips are pink and
moist with no
Lips are dry and no
edema noted.
No significant
findings








lesions or
inflammation.
Tongue is in the
midline, pink, moist,
rough without
lesions. taste buds
are white in color

Symmetrical: moves
freely. Gums are
paled red stripped
surface

No swelling or
bleeding

Gums are pink, no
gum bleeding and
no lesions noted.
Tongue is in
midline that moves
freely and no
dentures.

Buccal mucosa is
pink and moist.

Uvula is in midline.
Pink and not
swelling same as
with the tonsils

Nails Inspection















Palpation



Color: have a pink
cast in light-skinned
brown in dark
skinned

Shaped and
configuration is
surface is smooth
and slightly rounded
or flat. Curved nails
are normal. Uniform
nails thickness
throughout; no
splintering or brittle
edges

Capillary refill
present should return
to 2-3 seconds

Light pink in color,
convex in shape














Has a capillary
refill of 2-3 seconds
No significant
findings














No significant
findings
Neck Inspection









Symmetrical with
head in central
position able to
move freely without
discomfort or
noticeable limits



Muscles should be
Trachea is in the
midline
No jugular vein
engorgement
Normal range of
motion
And has a muscle
grading of 4

Cervical lymph
No significant
findings








Palpation



symmetrical without
palpable masses or
lumps

nodes are not
palpable and non-
tender


No significant
findings

Chest Inspection


























Palpation




Percussion





Auscultation



Skin is intact
without lesions,
same as skin color,
Spine vertically
aligned, No
kyphosis, scoliosis
and lordosis, Full
and symmetric chest
expansion














Without nodules



Resonant




Quiet, rhythmic and
effortless breathing
Without lesions;
with skin intact

Rapid shallow
breathing









Partial chest
expansion upon
respiration










Without nodules, no
masses upon
palpation


Resonant located at
4
th
intercostals
space right anterior
axillary


Crackles (rales) at
the right lower
lobes of
the lung during
Tachypnea is rate
of breathing
regular but
abnormally rapid
greater than 20
breaths per minute.

The patient has
respiratory rate of
29 beats per
minute.

It result from
pulmonary
irritation and
heightened oxygen
demand
result from pain
and anxiety

(kozier, skills 30-
31 p.614)

No significant
findings


No significant
findings



Rales heard upon
auscultation
indicates
pulmonary
tuberculosis

(kozier, skill 30-31
p. 616)


inspiration
Thorax
a. Ante
rior
Inspection


Palpation







Auscultation





Skin intact


No tenderness and
no masses






Bronchovesicular
and vesicular sounds
are heard above and
below the clavicles
and along the lung
periphery

Bronchial sound can
be heard over the
trachea
Skin intact


No tenderness and
no masses upon
palpation

Respiratory rate of
29 beats per minute
was noted

Bronchial sound
heard over the
trachea loud, high
pitch and hollow
sounding, with
expiration lasting
longer than
inspiration
No significant
findings

No significant
findings






No significant
findings



b. Post
erior
Inspection











Palpation









Auscultation

Anteroposterior to
transverse diameter
in ratio 1:2; chest
symmetric;
Spine vertically
aligned;
Skin intact;
Chest wall intact




Uniform
temperature; no
tenderness; no
masses; no lumps
symmetrical chest
excursion of at least
5 cm; presence of
pulsation and no
unusual movement

Normal breath
sounds
Lateral deviation of
spine noted










Chest excursion
symmetrical about
5 cm apart, no
masses and
tenderness upon
palpation
Pulsation is present,
no lumps and
unusual movements

Fine crackles noted
on the right and left
The disease (Potts)
is characterized by
bone destruction
and abscess
formation

(Pathophysiology
6
th
edition by Carol
Mattson Porth p.
133)


No significant
findings








Fine crackles
signifies






heard over the
posterior thorax
includes
bronchovesicular
and vesicular sounds
heard above and
below the clavicles
and along the lung
periphery
and the abnormal
sounds or
adventitious sounds

lung bases pulmonary
tuberculosis


(Fundamentals of
Nursing, 6
th

edition, potter-
perry, p.721)
Heart Auscultation







There is no lifts and
heaves and there is
no presence of heart
murmurs
Heart murmurs
noted upon
auscultation at the
end of the systolic
and diastolic phase.
Increased blood
flow through a
normal valve,
forward flow
through a stenotic
valve or into a
dilated vessel or
heart chamber, or
backward flow
through a valve
that fails to close

(Fundamental of
Nursing, 6
th

edition, potter-
perry, p.726)

Abdomen Inspection





Auscultation










Abdominal contour
is flat or rounded,
symmetrical and
uniform in color


Normally air and
fluid move through
intestine, creating
soft gurgling or
clicking sounds that
occur 5-35 times per
minute

Sounds are generally
described as normal,
audible, absent,
The clients
abdomen is
rounded, uniform in
color, and no scars
noted

Bowel sound is
hypoactive









No significant
findings




Hypoactive bowel
sound indicate
gastrointestinal
motility

(Fundamental of
Nursing, 6
th

edition, potter-
perry, p.743)





Percussion







Palpation





hyperactive or
hypoactive

Tympany over the
stomach and gas
filled bowels;
dullness specially
over the liver and
spleen, or a full
bladder

No tenderness,
relaxed abdomen
with smooth,
consistent tension
bladder and liver is
not palpable



Dull percussion
noted over the liver






Abdominal
tenderness and
distension noted on
the lower left
quadrant of the
abdomen



No significant
findings






Tenderness and
distension signifies
decreased bowel
movement

(Fundamental of
Nursing, 6
th

edition, potter-
perry, p.744)

Musculoske
letal
Inspection













Palpation





Muscles has equal
size on both sides of
the body, no
contractures, no
fasciculation, or
tremors

Bones has no
deformities

Joints has no
swelling


Muscles are firm,
has smooth
coordinated
movements

Bones has no
Muscle weakness
noted at lower
extremities with the
grade of 4+
hyperactive and
very brisk








Acute pain noted
upon palpation of
lower extremities
Hyperactive and
very brisk muscle
grading often
associated with
spinal cord
disorders

(Fundamental of
Nursing, 6
th

edition, potter-
perry, p.767)



Spinal cord
disorders can cause
spinal nerve
compression
causing pressure
damage includes
pain


(Fundamental of
Nursing, 6
th

edition, potter-
perry, p.764)










Extremities Inspection Bilateral symmetry
without any presence
of deformities,
edema and
discoloration. Intact.
Hands are steady and
no tremor noted.

However muscle
weakness and
numbness when
hyperflexion, and
positive from joint
pain with pain scale
of 5/10 were noted on
the lower extremeties.
The most common
sensory deficit from
spinal nerve root
compression are
paresthesias and
numbness
particularly of the
leg and foot

(Pathophysiology by
Carol Matson Porth
7
th
edition page
1205)
Palpation Glasgow coma scale
is 15

Positive reflexes
such as biceps
reflex, triceps reflex,
brachioradialis
reflex, patellar reflex
and Achilles reflex
Glasgow coma scale
is 15

Positive reflexes such
as Brachioradialis
reflex, patellar reflex
and Achilles reflex
Client manifests
normal findings

Cranial Nerves
I Olfactory

By asking
patient to
close his
eyes and
identify
different
mild
aromas.

Identify different
mild aromas such as
coffee, vanilla,
peanut butter, orange,
lime, chocolate

Able to identify
mild aromas such as
coffee, vanilla, peanut
butter, orange, lime,
chocolate

Client manifests
normal findings

II Optic

The nurse
will ask the
patient to
Ability to clearly
visualize the snellen
chart; check visual
Able to clearly
visualize the snellen
chart; check visual
Client manifests
normal findings
read snellen
chart; check
visual fields
by
confrontatio
n
fields by
confrontation

fields by
confrontation

III
Oculomotor

The nurse
will be
assessing
the six
ocular
movements
and pupil
reaction of a
patient
Ablility to perform
extraocular eye
movement (EOM);
movement of
sphincter of pupil;
movement of ciliary
muscles of lens

Able to perform
extraocular eye
movement (EOM);
movement of sphincter
of pupil; movement of
ciliary muscles of lens
Client manifests
normal findings
IV Trochlear The nurse
will be
assessing
the six
ocular
movements
of a patient.
Ablity to perform
extraocular eye
movements
specifically
movements of
eyeballs downward
laterally
Able to perform
extraocular eye
movements specifically
movements of eyeballs
downward laterally


Client manifests
normal findings
VTrigeminal

Thenurse
lightly
touches the
lateral sclera
of the eye
while the
patient is
looking
upward. To
test light
sensation,
have the
client close
eyes, wipe a
wisp of
cotton over
patients
forehead
and
paranasal
sinuses. Ask
client to
clench teeth.
Pesence of blink
reflex; can feel the
sensation of skin of
face and nasal
mucosa; able to feel
the sensation of
anterior oral cavity;
mastication of
muscles

Patient has presence
of blink reflex; can
feel the sensation of
skin of face and nasal
mucosa; able to feel
the sensation of
anterior oral cavity;
mastication of
muscles

Client manifests
normal findings
VI Abducens

The nurse
will be
Ability to move eye
balls laterally
Able to move eye
balls laterally
Client manifests
normal findings
assessing the
directions of
gaze.



VII Facial


The nurse
will ask the
patient to
smile, raise
eyebrows,
frown, and
puff out
cheeks, close
eyes tightly.
Identifying
various tastes
placed on tip
and sides of
tongue.

Ability to perform
different facial
expressions; able to
identify different
tastes

Able to perform
different facial
expressions; able to
identify different
tastes in tongue
(sweet, bitter, sour,
salty).

Client manifests
normal findings

VIII
Auditory

The nurse
will be
assessing the
patients
ability to
hear spoken
word and
vibrations of
tuning fork.
Ability to clearly
hear spoken words
and vibrations of
tuning fork
Able to clearly hear
spoken words and
vibrations of tuning
fork. Rombergs test
performed, the patient
stood up and asked to
close his eyes a loss
of balance is
interpreted.
Client manifests
normal findings
IX
Glossophary
ngeal

The nurse
will be
applying
tastes on
posterior
tongue for
identification
. Asking the
patient to
move tongue
from side to
side and up
and down.

Ablity to move the
tongue from side to
side and up and
down; no difficulty
in swallowing;; able
to identify different
taste on posterior
tongue

Able to move the
tongue from side to
side and up and
down; no difficulty
in swallowing;; able
to identify different
taste on posterior
tongue

Client manifests
normal findings
X Vagus

The nurse
will do
palpation on
the pharynx
Palpable pharynx
and larynx by
stimulating; presence
of gag reflex; no
Pharynx and larynx
are palpable; patient
swallows and says
Ah presence of gag
Patient has normal
findings
and larynx,
assessing the
gag reflex
with the use
of tongue
depressor
and assess
the presence
of
hoarseness.

presence of
hoarseness of
clients speech

reflex; there was no
presence of
hoarseness of clients
speech

XI
Accessory


The nurse
will apply
pressure on
patients
shoulders
and ask
patient to
shrug
shoulders
against
resistance
and turn head
to side
against
resistance
from the
nurse hand.

Ablity to shrug
shoulders against
resistance and able
to turn to side
against resistance
without any
difficulty

Able to shrug
shoulders against
resistance and able to
turn to side against
resistance without
any difficulty

Patient has normal
findings
XII
Hypoglossal
By asking
patient to
protrude
tongue at
midline and
move it side
to side and
up and down
Ability to protrude
tongue at midline
and move up and
down and side to
side

Able to protrude
tongue at midline and
move up and down
and side to side

Patient has normal
findings