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Physical Assessment

The physical assessment found the patient to have: - Brown skin with good turgor and normal temperature - Short black hair that was evenly distributed - Long dirty and unkempt nails - A round head with no tenderness or masses - Clear eyes, ears, nose, and mouth with no abnormalities noted - Normal cardiac and lung sounds with symmetric chest movement - Good motor function and balance with coordinated movement of extremities

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Rachelle Anne Letran
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188 views

Physical Assessment

The physical assessment found the patient to have: - Brown skin with good turgor and normal temperature - Short black hair that was evenly distributed - Long dirty and unkempt nails - A round head with no tenderness or masses - Clear eyes, ears, nose, and mouth with no abnormalities noted - Normal cardiac and lung sounds with symmetric chest movement - Good motor function and balance with coordinated movement of extremities

Uploaded by

Rachelle Anne Letran
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Physical assessment (December 6, 2010)

GENERAL APPEARANCE

Mother Poly was seen lying on bed accompanied by her mother c ongoing IVF # 2 D5lrs 1L x
30gtts/min @ 400cc level. She was wearing a white shirt and a faded maong short. She is untidy
and her hair was not combed.

PHYSICAL ASSESSMENT

Skin, Hair and Nail

Skin

His skin is brown in complexion with no odor, uniform in color with good skin turgor.
The skin is not edematous and is in normal temperature.

Hair

He has a round skull, no contusions, bruises noted nodules and masses, and no tenderness
palpated. He has symmetrical facial movements as evidenced by client’s ability to smile, frown,
raise his forehead & eyebrows & shows his teeth. Facial features and facial movements are
symmetrical. Hair is short and black in color and is evenly distributed.

Nails

She has long dirty and unkempt nails.She has light brown, smooth, epidermis is intact,
has convex curve nails, no discoloration of the nail beds, no clubbing of nails, normal capillary
refill (<2-3 sec), and no edema.

Head and Neck


Head
Head is round in shape and symmetrical on sides. There is no tenderness noted, no lumps
upon palpation. There are no fractures noted.

Neck
There are no lumps palpated. Lymph nodes are non-palpable. Trachea is on the midline
position. Range of movement is appropriate.

Eyes
Hair is evenly distributed on eyebrows, eyebrows are symmetrically aligned and with
equal movement. The eyelashes are equally distributed and lids close symmetrically. There is no
noted cloudy discoloration around the iris. There is also an equal constriction of the pupil on
illumination and accommodation. Eyelids are intact and closed symmetrically, bilateral blinking.
His palpebral conjunctiva is shiny and pink in color. Lacrimal gland, lacrimal sac and
nasolacrimal duct has no edema or tenderness. Cornea upon inspection for clarity is shiny and
transparent.

Ears
Symmetrical in size and position, auricles are aligned with outer canthus of the eyes and
are firm and non-tender. Pinnas are elastic recoils after folded, firm and without tenderness upon
palpation, with minimal dry cerumen.

Nose and Facial Sinuses

His nose is symmetrical and uniform in color; there is no discharge or flaring, no lesions or
tenderness. Air moves freely as the client breathes through nares by asking client to exert
pressure on the nares, and breathe through the opposite. His facial sinuses are not tender.

Mouth and Pharynx


His teeth have dental carries on the upper right molar and are yellowish in color.
Halitosis noted. His tongue is pinkish in color, moves without restraint, no tenderness and no
lesions. Soft palate is light pink in color and it is smooth. His hard palate is lighter pink in color
compared to the soft palate. Uvula is positioned in the middle of the soft palate. Oropharynx and
tonsils are pink and smooth, no discharge and are not inflamed.

Cardiac
There is no irregular sound heard upon auscultation. Apical pulse is in normal rate and
there is no palpations observed.

CHEST AND BACK


Skin is intact with uniform in temperature. Chest is symmetric in volume, no tenderness and
masses, full and symmetric lung expansion, and resonant sound upon percussion over the lungs
and no adventitious breath sounds. Breathing pattern is normal with symmetrical chest
movement noted on anterior thorax. She has a regular heart beat pattern. Spinal cord is vertically
aligned. She has good posture, with right and left shoulders at the same height.

Heart: No pulsations on tricuspid area, pulsations are visible in apical area.

Peripheral Vascular System: Veins are not visible, non symmetric brachial pulsations. There is
a more full pulsation on the left brachial artery and the rest of the upper and lower limbs have
equal pulsations.

Axilla: No tenderness, nodules and lesions noted.

Abdomen: Blemished skin, uniform color, no evidence of either liver or spleen enlargement and
with audible bowel sounds noted.

Genitals, anus and rectum: presence of vaginal spotting (heavy menstrual bleeding); no
lacerations are noted
Mental Status

Client is alert and awake with eyes open and looking at the student nurse. She established eye
contact when asked questions.  She also smiles and frowns appropriately without difficulty. She
can read written prints in a moderate tone, clear and moderate pace. The client is cooperative,
when asked, can answer properly. The client was able to express free-flowing thoughts and
expresses realistic perceptions. She is aware of self, other, time, home address and current
location. She listens and can follow directions without difficulty. She was able to recall recent
event without difficulty. She recalls his birthday and answer information correctly.

MOTOR FUNCTION

Walking Gait

She has good posture with opposing arm swing upon walking; maintaining balance.

Upper Extremities

There are firm with coordinated movements; her bones and joints have no deformities,
tenderness nor swelling noted. She can sense touch, pain and temperature.

Lower Extremities

The muscles in the lower extremities are symmetrical. The client can resist against the
pressure given by the student nurse and elicited fine coordinated movements. The bones and
joints in the lower extremities have no deformities and pain, temperature and touch is felt. The
client’s gait and balance is stable. She can walk in straight line and can maintain balance.

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