maegen pa q

8/8/2019 maegen PA q

1/13

Physical Assessment

I. General Appearance

Sex : Male

Race : Filipino

Religion : Catholic

Level of consciousness : Conscious and coherentSign of distress : weakness in right extremities

Body type: mesomorph

Body position :

Body movement : coordinated movement

Hygiene : clean and neat

Affect :

Speech : can answer questions with his own

knowledge

II. General survey

Vital signs ResultsTemperaturePulse rateRespiratory rateBlood Pressure

Organ Normal Findings Actual Finding Analysis /

Interpretation1. General

survey Describe the

body built

with the

client`s age,

lifestyle and

health.

Describe the

clients gait,

posture,

sitting and

walking

Describe

clients

overall

hygiene and

grooming

Note body

and breath

Proportionate;varies with the

life style

Relaxed, erect

posture;

coordinated

movements

Clean and neat

No body odor or

minor body odor

relative to work

or exercise; no

breath odor

Cooperative

Proportionateand varies with

the life style

Relaxed and

erect posture

with

coordinated

movements

Clean and neat

No body or

breath odor

Cooperative

Normal

Normal

Normal

Normal

Normal


2/13

odor in

relation to

activity level

Describe the

clientsattitude

Describe the

quantity and

quality of

speech

Understandable,

moderate pace

Understandabl

e and

moderate pace

Normal

2. Skin

Inspect for

the color,

uniformity ofthe color

Inspect for

presence of

edema

Inspect for

lesions

Palpate skin

moisture

Palpate skin

temperature

Palpate skin

turgor

Varies from light

to deep brown;

ruddy pink tolight ink; yellow

overtones to

light pink

No signs of

edema

No lesions found

Moist

Warm

Springs back to

previous state

when pinched

Uniform in

color (brown)

(-) sign of

edema

(-) lesions

Moist

Warm

Return to

previous states

when pinched

Normal

Normal

Normal

Normal

Normal

Normal

3. Nails

Inspect

fingernail

plate, shape

to

determine

its curvature

and angle

Inspect

fingernail

and toenail

bed color

Palpate

Convex

curvature angle

of 160

Highly vascular

Smooth texture

Convex

Pale

Smooth

texture

Normal

Normal

Normal


3/13

fingernail

and toenail

texture

Inspect

tissue

surroundings

Perform

blanch test

for capillary

refill

Intact epidermis

Prompt return of

usual color

Intact

epidermis

Prompt returnof its usual

color

Normal

Normal

4. Skull

Insect for

the size,

shape and

symmetry Palpate for

nodule,

masses and

depressions

Round, smooth

skull contour

Smooth, uniformconsistency;

absence of

nodules or

masses

Normocephalic

(-) nodules,masses,

depressions

Normal

Normal

5. Scalp

Inspect for

the color

and

appearance

Palpate for

areas of

tenderness

Yellow over

toned; no visible

flakes

No tenderness

(-) visible

flakes

No tenderness

Normal

Normal

6. Face

Inspect the

facial

features,

symmetry of

facial

movements

Symmetric or

slightly

asymmetric

facial features;

palpebral

fissures equal in

size; symmetric

nasolabial folds;symmetric facial

movement

Symmetrical

facial features;

symmetric

nasolabial

folds;

symmetric

facial

movement

Normal

7. Eyebrows

Inspect hair

distribution;

alignment,

skin and

quality and

Hair evenly

distributed; skin

intact; eyebrows

symmetrically

aligned; equal

Hair evenly

distributed,

skin intact,

eyebrows

symmetrically

Normal


4/13

movement movement aligned; equal

movement8. Eyelashes

Inspect hair

distribution

anddirection of

curl

Equally

distributed;

curled slightlyoutward

Equally

distributed;

curled slightlyoutward

Normal

9. Eyelids

Inspect for

the surface

characteristi

cs, position

in relation to

cornea;

ability to

blink,

frequency of

blinking

Skin intact; no

discharge; no

discoloration;

lids close

symmetrically;

bilateral blinking

Skin intact; no

discharge; no

discoloration;

lids close

symmetrically;

bilateral

blinking

Normal

10. Conj

unctiva

Inspect the

bulbar

conjunctiva

for color,texture and

presence of

lesions

Inspect

palpebral

conjunctiva

for color

texture and

presence of

lesions

Transparent;

capillaries

sometimes

evident

Shiny, smooth,

and pink or red

Transparent;

capillaries

sometimes

evident

Shiny, smooth,

and pink

Normal

Normal

11. Scler

a

Inspect the

color and

clarity

White and

vascular; clear

White and

vascular; clear

Normal

12. Corn

ea

Inspect for

Clear and

transparent;

Clear,

transparent;

Normal


5/13

clarity and

texture

smooth in

texture

smooth in

texture13. Iris

Inspect for

the shape

and color

Flat and round;

color varies from

blue, green,brown

Flat and round;

color brown

Normal

14. Pupil

s

Test each

pupil for

light

reaction and

accomodatio

n

Illuminated pupil

constricts (direct

response); non

illuminated pupil

constricts

(consensual

response);

pupils constrict

when looking at

near object;

pupil converge

when near

object is moved

toward nose

Constricted

when lighted

and dilated

when light

passed

Normal

15. Visua

l acuity

Test near

vision

Able to read

newspaper

Able to read

newspaper

Normal

16. Lacri mal Gland,

Lacrimal

Sac, and

Naso

-lacrimal

Duct

Inspect,

palpate the

lacrimal

gland

Able to palpate

the lacrimal

gland

Able to palpate

the lacrimal

gland

Normal

17. Extra

Ocular

Muscles

Test each

eye for

alignment

and

distribution

Both eyes

coordinated,

move in unison

and parallel

alignment

Both eyes

coordinated,

move in unison

and parallel

alignment

Normal

18. Visua


6/13

l Fields

Test each

eye for

alignment

and

distribution

Sees object on

his periphery

when looking

straight ahead

Able to see

objects on the

peripheral

Normal

19. Auric

les

Inspect for

color,

symmetry

and position

Inspect for

color

symmetry

and position

Color same as

the facial skin;

symmetric

position

Nobile, firm and

not tender;

pinna recoils

after it is folded

Color same as

the facial skin;

symmetric

position

Firm, not

tender and

recoils after it

is folded

Normal

Normal

20. Exter

nal Ear

Canal

Inspect ear

canal for

cerumen,

skin lesions,

pus and

blood

Dry or Wet

cerumen, hair

follicles visible

on third distal

Dry cerumen,

hair follicles

visible

Normal

21. Heari

ng AcuityTest

Assess

clients

response to

normal

voice tones

Perform

whisper test

Normal voice

tones audible

Able to hear

whispered words

Normal voice

tones audible

Able to hear

whispered

words

Normal

Normal

22. Nose

Inspect forany

deviations in

shape, size,

or color and

flaring or

discharge

from nares

Inspect

Symmetric andstraight; no

discharge or

flaring; uniform

color

Mucosa pink;

clear watery

Symmetric andstraight; no

discharge or

flaring;

uniform color

Mucosa pink;

clear watery

Normal

Normal


7/13

nasal

cavities for

the

presence of

redness,

swelling,growths and

discharges,

using

penlight

Inspect

nasal

septum

between

nasal

chambers Test

patency for

both nasal

cavities

Palpate for

any

tenderness,

masses

displacemen

t of bones

and

cartilage

discharge; no

lesions

Nasal septum is

intact and in

midline

Air moves freely

as the client

breathes

through the

nares

Not tender; no

lesions

discharge; no

lesions

Nasal septum

is intact and in

midline

Air moves

freely as the

client breathes

through the

nares

Not tender; nolesions

Normal

Normal

Normal

23. Sinus

es

Locate/palpa

te/ identify

the sinuses

and note for

tenderness

Sinuses well

outlined, contain

air, and light up

equally

Sinuses well

outlined,

contain air,

and light up

equally

Normal

24. Lips

Inspect for

symmetry of

contour,

color, and

texture

Symmetry of

contour ;

uniform pink

color; soft,

moist, smooth

texture

Slightly dry,

dark in color

Mild

dehydration

due to

excess of

sodium in

blood

plasma


8/13

25. Bucc

al Mucosa

Inspect for

color,

moisture,

texture andpresence of

lesions

Uniform pink

color, moist,

glistening;

elastic in texture

Uniform pink

color, moist,

glistening;

elastic in

texture

Normal

26. Teet

h

Inspect for

the color,

number, and

condition

and

presence ofdentures

Smooth, white,

shiny tooth

enamel, and 32

adult teeth

Yellowish,

smooth,

Caused by

smoking

27. Gum

s

Inspect for

the color

and

condition

Pink gums;

moist and firm

in texture; no

retractions

Brown gums,

moist and firm

in texture; no

retraction

Normal

28. Tong

ue/floor of

the mouth

Insect forthe color

and texture

of the

mouth floor

and

frenulum

Inspect and

palpate the

position,

color andtexture,

movement

and base of

the tongue

Pink to reddish

with prominentveins

Central position;

pink in color;

smooth; lateral

margins; moves

freely

Pink and

smooth withprominent

veins

Pink, central

position;

smooth ;

moves freely

Normal

Normal

29. Plate

s and

Uvula

Inspect and

Light pink,

smooth to

Light pink,

smooth to

Normal


9/13

palpate for

color, shape,

texture, and

movement

and

presence ofany bony

prominence

s

Inspect for

position of

the uvula

and mobility

while

examining

the palates

irregular

texture, moves

freely, no bony

prominences

Positioned in

midline of soft

palate, mobile

irregular

texture, moves

freely, no bony

prominences

Positioned in

midline of soft

palate, mobile

Normal

30. Neck

and lymph

Nodes

Locate/palpa

te/identify

lymph nodes

and note for

tenderness

No tenderness No tenderness Normal

31. Trac

hea

Inspect andpalpate for

placement

Located at the

median of theneck

Located at the

median of theneck

Normal

32. Thyr

oid Gland

Inspect

symmetry

and visible

masses

Palpate for

tendernessand areas of

enlargement

, masses or

nodules

Symmetrical, no

visible masses

No tenderness,

no

enlargements,

no nodules

Symmetrical,

no visible

masses

No tenderness,

no

enlargements,no nodules

Normal

Normal

33. Post

erior

thorax

Inspect the

Anteroposterior

to transverse in

Anteroposterio

r to transverse

Normal


10/13

size, shape,

symmetry

and

compare the

diameter of

anteroposterior thorax to

transverse

diameter

Inspect the

spinal

alignment

Palpate for

temperature

, tenderness

and masses

Assess

respiratory

excursion

Palpate

vocal

fremitus

Percuss theposterior

thorax

Auscultate

the posterior

ratio of 1:2

Spine vertically

aligned; spinal

column is

straight, right

and left

shoulders and

hips at the same

height

Skin intact;

uniform

temperature;

chest wall

intact, no

tenderness; no

masses

Full and

symmetric chest

expansion

Bilateral

symmetry of

vocal fremitus;

fremitus is

heard most

clearly at the

apex of the

lungs

Percussion notes

resonant, except

over scapula;

lowest point of

resonance is at

the diaphragm

Vesicular and

in ratio of 1:2

Spine

vertically

aligned; spinal

column is

straight, right

and left

shoulder and

hips at the

same height Skin intact;

uniform

temperature;

chest wall

intact, no

tenderness; no

masses

Full and

symmetric

chest

expansion

Bilateral

symmetry of

vocal fremitus;

fremitus is

heard most

clearly at the

apex of the

lungs

Percussion

notesresonant,

except over

scapula;

lowest point of

resonance is at

the diaphragm

Vesicular and

bronchovesicul

Normal

Normal

Normal

Normal

Normal

Normal


11/13

thorax bronchovesicula

r breath sounds

ar breath

sounds

34. Ante

rior Thorax Inspect in

breathing

patterns

Palpate for

temperature

, tenderness

and masses

Palpate

vocalfremitus

Percussion

the anterior

thorax

Quiet, rhythmic,and effortless

respirations

Uniform in

temperature, no

tenderness, no

masses

Bilateral

symmetry of

vocal fremitus;fremitus is most

heard most

clearly at the

apex of the

lungs

Percussion notes

resonant, except

over scapula;

lowest point of

resonance is at

the diaphragm

Quiet,rhythmic,

without using

the accessory

muscles

Normal

temperature,

no tenderness,

no masses

Bilateral

symmetry ofvocal fremitus;

fremitus is

most heard

most clearly at

the apex of the

lungs

Resonant

sound was

heard at the

scapula and

diaphragm

Normal

Normal

Normal

Normal

35. Cardi

ovascular

Aortic and

pulmonic

areas

Auscultate

the aortic,

pulmonic,tricuspid,

and apical

valves

No pulsations

S1 and S2

sounds are

heard

No pulsations

S1 and S2

sounds are

heard

Normal

Normal

36. Brea

st and

Axillae

Inspect the

skin of the

Skin uniform in

color, skin

smooth and

Skin uniform in

color, skin

smooth and

Normal


12/13

breast for

localized

discoloration

or hyper

pigmentatio

n,retraction,

dimpling,

localized

hypervascul

ar areas,

swelling, or

edema

Inspect the

areola for

size, shape,symmetry,

color,

surface,

characteristi

cs, and any

masses or

lesions

Inspect

nipples for

size, shape,

position,

color,

discharge,

and lesions

Palpate theaxillary,

subclavicula

r and

supraclavicu

lar lymph

nodes

Palpate for

breast for

intact. Diffuse

symmetric

horizontal or

vertical vascular

pattern in light

skinned people

Round or oval

and bilaterally

the same, color

varies widely,

from light pink

to dark brown,irregular

placement of

sebaceous

glands on the

surface of the

areola

Round, everted,

and equal in

size; similar in

color; soft and

smooth; both

nipples point at

the same

direction

No tenderness,

masses or

nodules

No masses, no

tenderness

No discharge, no

tenderness

intact

Round in

shape and

light brown in

color

Round,

everted, and

equal in size;

similar in color

brown; soft

and smooth;

both nipples

point at the

same direction

No tenderness

and masses or

nodules

No masses, no

tenderness

No discharge,

no tenderness

Normal

Normal

Normal

Normal

Normal


13/13

masses,

tenderness

Palpate

nipple for

tenderness

anddischarges

37. Abdo

men

Inspect the

abdomen for

skin

integrity

Inspect for

an enlargedliver or

spleen

Assess the

symmetry of

contour

while

standing at

the foot of

the bed

Inspect the

abdominal

movements

associated

with

respirations,

peristalsis,

or aortic

pulsations

Observe

vascular

pattern

Unblemished

skin, uniform

color, silver

white striae or

surgical scars

No evidence or

enlargement of

the spleen Symmetric

contour

Symmetric

movements

caused by

respiration

No visible

vascular

patterns

Unblemished

skin, uniform

color

No evidence or

enlargement

of the spleen

Symmetriccontour

Symmetric

movements

caused by

respiration

No visible

vascular

patterns

Normal

Normal

Normal

Normal

Normal

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