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.