IV. PHYSICAL ASSESSMENT A.
Vital Signs
VITAL SIGNS PULSE RATE RESPIRATION TEMPERATURE BLOOD PRESSURE NORMAL RANGE 60-90bmp 12-20bmp 36.6C-37.1C 130/80 FINDINGS 90bmp 34bmp 37.4C 120/70
July 18, 2011
INTERPRETATION Normal Abnormal Normal Normal
B. CEPHALOCAUDAL ASSESSMENT
Normal findings Head to Toe examination A. Head 1. Skull
a.
Actual findings
Remarks
Size, shape or symmetry
Round smooth skull contour (kozier, p.585)
Round, normocephalic and symmetrical No masses, nodules and depressions
Normal
b.
Presence of nodules, masses and depressions
Smooth, uniform consistency; absence of nodules or masses (kozier, p.585)
Normal
2. Hair a. Evenness of growth; thickness or thinness Evenly distributed hair; thick hair (kozier, p.582) b. Texture and oiliness over the scalp Silky, resilient hair Hair is evenly distributed and thick Soft and silky hair Normal
Normal
(kozier, p.582) 3. Face a. Facial features; symmetry of facial movement Symmetric or slightly asymmetrical facial features; symmetrical facial movements (kozier, p.585) B. Eyes 1. Eyebrows a. Hair distribution, alignment, skin quality and movement Hair evenly distributed; skin intact, eyebrows symmetrically aligned; equal movement (kozier, p.588) 2. Eyelashes a. Evenness of distribution and direction of curl Equally distributed; curved pointing outward (kozier, p.588) 3. Eyelids a. Surface characteristics , position in relation to the cornea, ability to blink and frequency of blinking Skin intact; no discharge; no discoloration; lids close symmetrically; approximately 15-20 involuntary blinks per minute; bilateral blinking; when lids open, no visible sclera above cornea, and upper and lower borders of cornea are slightly covered Intact skin; no Normal discharge; no discoloration; lids close symmetrically; 17 involuntary blinks in 1 minute ; bilateral blinking; when lids open, no visible sclera above cornea and upper and lower borders of cornea Equally distributed and the hair turned outward Normal Hair evenly distributed, skin intact, symmetrically aligned, equal movement Normal Symmetric facial features; symmetrical facial movements Normal
(kozier, p.588) 4. Conjunctiva a. Color, texture, and presence of lesions in the bulbar conjunctiva Transparent capillaries sometimes evident; sclera appears white (yellowish in darkskinned clients) (kozier, p.588) 5. Cornea a. Clarity and texture Transparent, shiny and smooth (kozier, p.589) 6. Visual acuity a. Near vision Able to read newsprint (kozier, p.592) C. Ears 1. Auricles a. Color, symmetry of size and position Color same as facial skin; symmetrical ; auricle aligned with outer canthus of eye, about 10 degrees from vertical (kozier, p.596) b. Palpate for texture, elasticity and areas of tenderness Mobile, firm and not tender; pinna recoils back after it is folded (kozier, p.596) D. Nose and Sinuses
are slightly covered
Transparent; Normal smooth; no lesions and capillaries are visible
Transparent and shiny; smooth
Normal
Able to read newsprint
Normal
Same with the color of the face; auricles are symmetrically aligned with outer canthus of eye
Normal
Elastic, firm, no tenderness; pinna recoils back after it is folded
Normal
a. Shape, size , color, flaring or discharge from the nose
Symmetric; no discharge; no flaring; uniform color (kozier, p.600)
Symmetric, straight, uniform in color; no discharge or flaring Mucosa is pink, clear and watery; no discharge, lesions and swelling
Normal
b. Presence of redness, swelling, growths and discharge of the nasal cavity
Mucosa is pink; clear, watery; no discharge; no lesions (kozier, p.600)
normal
c. Patency of both nasal cavities
Air moves freely as the Air moves freely Normal client breathes through as the client breath the nares out (kozier, p.600)
E. Mouth 1. Lips and Buccal Mucosa a. Symmetry of contour, color and texture
Uniform pink color; moist, soft, glistening, and elastic texture (kozier, p.602)
Pale and dry lips
Abnormal because the patient is undergo surgery that promote blood loss. Normal
F. Throat
No inflammation and difficulty of swallowing.
No inflammation
G. Neck
Muscle equal in size and head centered
Symmetrical and head cerntered
Normal
H. Chest
Symmetrical upon inspection
symmetrical
Normal
I. Abdomen
Symmetrical upon inspection, non tender
With tender upon palpation
Abnormal because of positive abdominal distention
J. Extremities
Symmetrical and proportion, not edematous
With bipedal edema.
Abnormal because of accumulation of fluid in extra cellular space.
