PHYSICAL ASSESSMENT

The complete physical assessment was completed on November 18, 2019 when she was day 2 post-op for a total abdominal hysterectomy. A thorough physical
assessment was not obtained on some areas as consent could not be acquired. These areas in particular were the reproductive and gastrointestinal systems. The
examiner made the best efforts of obtaining as much information through interview.
General Survey
The patient was received sitting on the edge of her bed with her husband right beside her. The overall appearance was clean and well-groomed. Sexual development
was appropriate for gender and age. Body build was ectomorph. She was pleasant and cooperative although she looked tired and stated, “saba lagi diri bisan sa gabii.”
She’s able to sleep but not for long periods. Speech was coherent and evenly paced. She was able to follow the flow of the conversation with ease. Glasgow Coma
Scale 15/15.
BP (mmHg) T (°C axilla) P (bpm) R (bpm)
Nov 17, 2019 @ 0800 132/82 36.7 66 16
Nov 17, 2019 @ 1400 120/70 35.8 64 16
Nov 18, 2019 @ 0800 130/84 36.2 62 22
Nov 18, 2019 @ 1100 114/70 36.8 64 14
Nov 18, 2019 @ 1400 110/78 36.8 60 16

Anthromorphic Measurements
The patient stands at 4’8” and her husband reported her weight as 52kg. This puts her BMI at 25.8 which is a value that puts her weight status as overweight, however,
visually she does not fit the suggested weight status ("Adult Body Mass Index or BMI", n.d.). Examiner was unable to obtain a weighing scale during the visit. Head
circumference was 54cm, chest circumference was 87cm, abdomen circumference was 91cm, bilateral midarm circumference was at 26cm, and bilateral calf
circumference was 32.5cm.
Pain
The patient has a lower abdominal incision following a total abdominal hysterectomy on Nov 16, 2019. On initial contact (Nov 17, 2018), visceral pain was rated at
5/10; worse on movement and best when stationary, and non-radiating. The patient was on IV and oral pain medication. Non-verbal cues were the following:
- Guarding
- reluctance to move
Below is a table that outlines the results of the head-to-toe assessment. Abnormal observations are highlighted in orange for immediate recognition.
AREA INSPECTION AUSCULTATION PERCUSSION PALPATION
Eyes - Facial muscle symmetric. - No tenderness on the
- Eyebrows symmetrically lacrimal glands
aligned, hair evenly
distributed, and movement
equal.
- Eyelashes curl out and
evenly distributed.
- raised, round mole near the
outer canthus of the right
lower lid.
- Eye movement was
coordinated, smooth, and
equal.
- Conjunctive was shiny,
smooth, and transparent.
- No swelling or on the
lacrimal glands. Cornea
were clear and smooth.
- PERRLA.
- Patient requires reading
glasses for fine print but she
does not own one.
Ears - Auricles are evenly
coloured and similar to her
facial skin, mobile, and
symmetrical.
- Nonimpacted cerumen
noted on the external
canals.
- patient was able to hear
normal voice tones.
Nose - externally symmetric and - Frontal and maxillary
evenly colored. sinuses were nontender
- No flaring. with no crepitus.
- able to sniff through each
nostril while the other was
occluded.
- Nasal mucosa was pink,
moist and free from
exudates.
- nasal septum was intact and
non-deviated.
Mouth and Oropharynx - Lips were of uniform pink
color and symmetrical but
slightly dry.
- Missing teeth:
- 3 on the upper set (left
2nd and 3rd molar, right
3rd molar)
- 6 on the lower set (left 2nd
and 3rd molars and right
2nd bicuspid, and 1st to 3rd
molars).
- left upper 1st molar is
decayed.
- does not wear partials.
- Jaws aligned with no
deviations seen when
biting down.
- gums were pink and
smooth with no
lesions.
 - tongue was moist and
slightly fissured.
- Heavy white coating
on the surface of the
tongue.
- Movement was
smooth.
- Frenulum at midline.
- halitosis
- palate and uvula were pink
and smooth.
- Tonsils were present, pink,
and symmetric.
- throat was pink with no
exudates or lesions.

Head and Neck - No involuntary movements - No masses palpated on the

– the patient was able to neck
keep her head still and - Lymph nodes were non
upright. palpable.
- face was symmetric with
an oval appearance.
- neck was symmetric with
the head centered
- Neck ROMs were normal.
- C7 vertebra was visible
and palpable.
- Thyroid gland was not
visible. Thyroid cartilage
moves up and down when
swallowing.
Lungs - Breathing was rhythmic
and effortless.
- Chest symmetric.
- The spine was vertically
aligned.
- Scapulae symmetric and
equal in horizontal
position with the
shoulders.
- Chest expansion
symmetric.
- No pain or unusual
sensations reported.
Heart - No visible pulsations on
the precordium.
- Jugular veins were not
visible.
Breast - Breasts were even with the
chest wall, smooth, and
bilaterally round just like
the areola.
- Nipples were everted and
smooth with no discharges.
Upper Extremities - slight edema on her left
lower arm and hand due
to I.V. infiltration.
- Upper extremities were
bilaterally equal in size
with no tremors or
contractures.
- Air entry was noted on all - Anterior and posterior
5 lobes. No adventitious thorax: no tenderness or
sounds. masses on lung areas
- Bronchophony: soft, during respitation
muffled, distinct
- Egophony: soft and
muffled
- Whispered pectoriloquy:
faint and muffled sound
transmission
- Jugular vein: no bruit - Carotid pulsations were
- No abnormal rhythm or symmetrical and full.
sound auscultated on the
areas of auscultation.
- Pulsations were full and
symmetric in volume.
- Musculator is firm
- Arm strength was equally
strong. The handgrip was
equally strong.
 - Muscle movements were
smooth.
- Joints move smoothly with
full ROM.
- The capillary refill was
less than 2 seconds.
- Nails were convex and
smooth.

Abdomen - abdominal contour was - bowel sounds: audible on - Palpation was also limited
slightly rounded and all 4 quadrants but sluggish to the upper abdomen
relaxed. at 1-2 clicks/gurgles per only: no tenderness, no
- movements were minute. palpable liver or bladder.
symmetric. - No friction rub and arterial
- No visible aortic bruit.
pulsations.
***The assessment was limited due
to a large dressing that covers the
lower abdomen as well as the
patient’s reluctance to remove the
abdominal binder.

Lower Extremities - No edema. - Pulsations were full and

- No involuntary muscle symmetric in volume.
movements. - No tenderness
- Joints move smoothly with - Musculator – firm
full ROM. - Pedal pulses palpable
- Legs were equal in size
with no tremors or
contractures.
- Negative for Homan’s
sign.
- The capillary refill was
less than 2 seconds.
Musculoskeletal - Sitting, standing and
walking postures were
erect and comfortable.
- Gait was rhythmic and
coordinated, with arms
swinging at the side.
- able to maintain her
balance with no assistance.
- No pain reported and no
nonverbal cues observed.

Reproductive No vaginal bleeding or any

other discharges reported.

Skin - Evenly coloured with no - sufficiently moist

prominent discolorations. - even warmth
- No foul odour or sweat - Elastic with normal skin
despite the warm turgor
environments
- Tan and smooth with
scattered flat moles on her
arms and chest
- Hair: thick, resilient, silky
with no infection or
infestation
- Wound #1: lower
abdominal surgical
incision
- No discharge, no
tenderness, no spreading
redness
- Wound #2: IVF puncture
wound on the lt hand
from previous IVF
therapy which was
removed due to
infiltration
- Localized non-pitting
edema (lt hand to just
below the elbow), no
redness, 0/10 on the pain
scale, warm to touch
References:
Adult Body Mass Index or BMI. (2019). Retrieved 20 November 2019, from
https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.html
Weber, J., & Kelley, J. (2003). Health assessment in nursing (6th ed., pp. 127-136, 257-278, 289-296, 317-327, 354-355, 367-374, 393-401, 445-452, 504-519).
Philadelphia: Wolters Kluwer.