PHYSICAL ASSESSMENT

GENERAL APPEARANCE 1. Posture/Gait NORMS Good posture, spinal column is straight

(Fundamentals of th Nursing 8 edition, Kozier and Erb, page 614)

ACTUAL FINDINGS Good posture No spinal deformities upon inspection

INTERPRETATION AND ANALYSIS NORMAL No deviations from normal

2.

Skin Color

From light to deep brown, uniform in color, no dermatoses, smooth and moist, when pinched, skin goes back to previous state
(Fundamentals of th Nursing 8 edition, Kozier and Erb, page 579)

Light brown ABNORMAL skin color Presence of Deviates from normal. abscess in the peri-anal skin Skin goes back when pinched

3. Personal Clean, neat hygiene/Grooming (Fundamentals of th

Nursing 8 edition, Kozier and Erb, page 572)

Hygienic in appearance

NORMAL No deviations from normal

4. Age Appropriateness

Proportionate
(Fundamentals of th Nursing 8 edition, Kozier and Erb, page 572)

Client looks appropriate for age Able to talk coherently

NORMAL No deviations from normal NORMAL No deviations from normal

5. Verbal behavior

Makes sense, exhibits thought association when speaking

(Fundamentals of th Nursing 8 edition, Kozier and Erb, page 572)

6. Nonverbal Behavior

Cooperative, able to follow instructions ((Fundamentals of

Nursing 8 edition, Kozier and Erb, page 572)
th

Cooperative, able to understand instructions

NORMAL No deviations from normal

MEASUREMENTS 1. Temperature

NORMS 360C-37.90C
(Fundamentals of th Nursing 8 edition, Kozier and Erb, page 529)

ACTUAL FINDINGS 36.2

INTERPRETATIONA ND ANALYSIS NORMAL No deviations from normal NORMAL No deviations from normal NORMAL No deviations from normal NORMAL No deviations from normal

2.

Pulse Rate

60-100 bpm
(Fundamentals of th Nursing 8 edition, Kozier and Erb, page 538)

80

3. Respiratory Rate

12-20 cpm
(Fundamentals of th Nursing 8 edition, Kozier and Erb, page 538) <120/80 mm/Hg (Fundamentals of th Nursing 8 edition, Kozier and Erb, page 552)

19

4. Blood Pressure

110/70

5.

Weight

6.

Height

160cm

BODY PARTS (CEPHALOCAUDAL) SKIN

NORMAL From light to deep brown, uniform in color, no dermatoses, smooth and moist, when pinched, skin goes back to previous state
(Fundamentals of th Nursing 8 edition, Kozier and Erb, page 579)

ACTUAL FINDINGS Light brown skin color No presence of lesions Skin goes back when pinched

INTERPRETATION AND ANALYSIS NORMAL No deviations from normal

Shiny, smooth pink or light red palpebral conjunctiva, white and smooth sclera
(Fundamentals of th Nursing 8 edition, Kozier and Erb, page

Pink palpebral conjunctivae, anicteric sclera, no naso-aural discharge, no

NORMAL No deviations from

HEENT

590)

Clear/watery discharge or no discharge

(Fundamentals of th Nursing 8 edition, Kozier and Erb, page 600)

tonsillopharyngeal congestion

normal

No discharge and congestion in pharynx and tonsils

(Fundamentals of th Nursing 8 edition, Kozier and Erb, page 604)

NECK

Muscles equal in size, smooth movements with no discomfort, no retractions, no visible vein engorgement
(Fundamentals of th Nursing 8 edition, Kozier and Erb, page 608)

Supple, no neck vein engorgement, no retractions, no lagging

NORMAL No deviations from normal

LUNGS

Quiet, rhythmic respirations, no adventitious breath sounds

(Fundamentals of th Nursing 8 edition, Kozier and Erb, page 617)

Clear breath sounds, no wheezes, no crackles

NORMAL No deviations from normal

HEART

No notable lift or heave in precordium

(Fundamentals of th Nursing 8 edition, Kozier and Erb, page 622)

Dynamic precordium, normal rate, regular rhythm, no murmurs

NORMAL No deviations from normal

No murmurs, regular and symmetric heart sounds

(Fundamentals of th Nursing 8 edition, Kozier and Erb, page 622)

No tenderness and masses, no nipple discharge,

Symmetrical contour, no dimpling, no

NORMAL No deviations from

BREASTS

no dimpling or retractions, symmetrical breasts or slightly unequal in size

(Fundamentals of th Nursing 8 edition, Kozier and Erb, page 628)

palpable mass, no tenderness, no discharge

normal

ABDOMEN

Flat or round/flabby, audible bowel sounds upon auscultation, no tenderness

(Fundamentals of th Nursing 8 edition, Kozier and Erb, page 634)

Flabby and soft upper abdominal area, normo-active bowel sounds

NORMAL No deviations from normal

EXTREMITIES

Equal in both sides of the body, no bone deformities

(Fundamentals of th Nursing 8 edition, Kozier and Erb, page 641)

No gross deformities

NORMAL No deviations from normal

GENITALIA

Pubic skin intact and no lesions, labia round and full

(Fundamentals of th Nursing 8 edition, Kozier and Erb, page 654)

Presence of abscess near the genitalia

ABNORMAL No deviations from normal