AREA Skin

METHOD OF ASSESSMENT Inspection

LOOK FOR: Color

ACTUAL FINDINGS Hands and Feet are yellow

INTERPRETATION

Palpation

Vascularity and bruising Any lesions Temperature and moisture Edema Turgor

(- )Vascularity and bruising (- )Lesions Warm and dry. (-)edema Pinched up returns < 3 seconds to original position. Black and White Evenly distributed None Smooth and fine Symmetrical None Smooth , firm Pale Round Smooth and firm. In the feet its Brittle nails Returns immediately to normal (4sec) Head is symmetrical , round, and in midline Symmetrical Reflections of light noted at same location on both eyes.

Normal Normal Normal Normal Normal

Hair

Inspection

Scalp

Palpation Inspection Palpation Inspection Palpation

Nails

Color Distribution Presence of parasites Texture Symmetry Lesions Texture Color Shape Texture

Normal d/t Aging Normal Normal Normal Normal Normal Normal Normal Normal

Capillary refill Head Face Eyes a. Extraoc ular muscle function Cover test Inspection Inspection Inspection Generalized size and contour symmetry Corneal light reflex test

Poor tissue perfusion Normal Normal Normal

Uncovered eyes does not move as cover is removed.

Normal

b.

External eyes Eyelids and lashes Eyeballs

Inspection Position and appearance symmetry Lid margins, moist and pale, Lashes are short. Symmetrically aligned Decreased oxygen circulating in the body Normal

Conjunctiva and sclera Lacrimal gland , c. Anterior eyeball structure Cornea Pupil

color

Swelling or redness

sockets. Yellowish nodules on the bulbar conjunctiva. Sclera is white. (-) swelling and redness.

Normal due to aging

Normal

Transparency Pupil direct and consensual light reflex Accommodation Symmetry

White arc around the limbus Pupillary response is Small constriction in the Left and Normal in the Right. Symmetrical

Normal

Ears

Inspection

Normal Normal

External ears Palpation Nose a. External nose Palpation Inspection

Color Lesions Tenderness Masses Color Symmetry Test patency of nostril masses lesions Frontal sinuses Maxillary sinuses Color Color Condition

Slightly Black (-) lesions (-) tenderness (-) masses Same as the rest of the face. Symmetrical patent (-) masses (-) lesions (-) tenderness (-) tenderness Darked lips Brownish in color With dental carries and missing teeth. A thickened white patch on the mucous membrane Hard palate is brown and firm

Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Due to smoking Poor oral hygiene Poor oral hygiene Due to smoking

b.Sinus area Mouth Lips Teeth and gums Inspection

Buccal mucosa

Palate

inspection

Color

Normal

Odor

Foul odor

D/t poor oral hygiene

Lesions Uvula Inspection

Tonsils Breast and axillae Breast

Inspection Inspection

Color Grading

(-) lesions Fleshy, solid structure that hangs freely in the midline. Red 0

Normal Normal

Normal

Symmetry Color Shape Surface characteristics Lesions Tenderness Color Lesions Masses Tenderness Thoracic cage Use of accessory muscle Tenderness fremitus Breath sounds Respiratory pattern

Symmetrical Brown Small in size and flat. No sign of dippling and retraction (-) lesions (-) tenderness Brown (-) lesions (-) masses (-) tenderness

Normal Light brown due to less exposure

Areola e and nipples

Normal Normal Normal Normal Normal Normal Normal

Axillae

Palpation Inspection Palpation

Thorax and lungs

Inspection

Palpation auscultation

(-) use of accessory muscle. (-)Tenderness Tactile (-) Adventitious breath sounds RR

Normal Normal Normal Normal

Cardiovascular system Jugular venous system

Inspection External jugular veins Internal jugular vein Location of the apical pulse Extra heart sounds Murmur Color Pulsation or movement Not visible Not visible Palpated at the mitral area. (-)Extra heart sounds. (-)murmur Light brown (+) pulsation Normal Normal Normal Normal normal Due to less exposure normal

Auscultation

Abdomen

Inspection

Auscultation

Contour lesions Bowel sounds

Percussion

Abdomen is rounded (-) lesions A series of intermittent, soft clicks and gurgles are heard Generalized tympany predominates over the abdomen (+) tenderness in the umbilical area (+) enlarged Liver (-) masses (+) tenderness (-) costovertebral angle tenderness. (-)deformity (-) swelling Brown Warm (-) edema

Normal Normal Normal

Normal

Palpation a. light palpation b. deep palpation

Tenderness Enlarge organs Masses Rebound tenderness Costovertebral angel tenderness Deformity Swelling Color Temperature Edema

Normal Normal Normal Normal Normal Normal

Musculoskeletal Inspection system

Palpation
AUGUST 25,2011

N155 PHYSICAL ASSESSMENT DOCUMENTATION GUIDE

Date ________________

Client/Patient ___________________________Age ________Sex__________

General Survey

(1) Body build (measure height and weight) (2) Posture (3) Gait - coordination of movements and pattern of gait. (4) Hygiene, grooming Poor Hygiene, (+)Foul Body odor, Dress Inappropriate in the Environment

(5) Signs of illness Flat on bed, Dark Brown Hands and Feet are slightly Jaundice, will suddenly cry, (+)Tremors in the Right arms, (+) Drooling (6) Affect, attitude, mood Slurred Speech to (-) Speech, Sad and Confused (7) Cognitive process appropriate non-verbal response upon answering questions

08-26-2011

AREA Skin

METHOD OF ASSESSMENT Inspection

LOOK FOR: Color

ACTUAL FINDINGS Hands and Feet are yellow

INTERPRETATION

Palpation

Vascularity and bruising Any lesions Temperature and moisture Edema Turgor

(- )Vascularity and bruising (- )Lesions Warm and dry. (-)edema Pinched up returns < 3 seconds to original position. Black and White Evenly distributed None Smooth and fine Symmetrical None Smooth , firm Pale Round Smooth and firm. In the feet its Brittle nails Returns immediately to normal (4sec) Head is symmetrical , round, and in midline Symmetrical Reflections of light noted at same location on both eyes.

Normal Normal Normal Normal Normal

Hair

Inspection

Scalp

Palpation Inspection Palpation Inspection Palpation

Nails

Color Distribution Presence of parasites Texture Symmetry Lesions Texture Color Shape Texture

Normal d/t Aging Normal Normal Normal Normal Normal Normal Normal Normal

Capillary refill Head Face Eyes d. Extraoc ular muscle function Cover test Inspection Inspection Inspection Generalized size and contour symmetry Corneal light reflex test

Poor tissue perfusion Normal Normal Normal

Uncovered eyes does not move as cover is removed.

Normal

e.

External eyes Eyelids and

Inspection Position and Lid margins, moist and Decreased oxygen

lashes Eyeballs Conjunctiva and sclera Lacrimal gland , f. Anterior eyeball structure Cornea Pupil

appearance symmetry color

Swelling or redness

pale, Lashes are short. Symmetrically aligned sockets. Yellowish nodules on the bulbar conjunctiva. Sclera is white. (-) swelling and redness.

circulating in the body Normal Normal due to aging

Normal

Transparency Pupil direct and consensual light reflex Accommodation Symmetry

White arc around the limbus Pupillary response is Small constriction in the Left and Normal in the Right. Symmetrical

Normal

Ears

Inspection

Normal Normal

External ears Palpation Nose a. External nose Palpation Inspection

Color Lesions Tenderness Masses Color Symmetry Test patency of nostril masses lesions Frontal sinuses Maxillary sinuses Color Color Condition

Slightly Black (-) lesions (-) tenderness (-) masses Same as the rest of the face. Symmetrical patent (-) masses (-) lesions (-) tenderness (-) tenderness Darked lips Brownish in color With dental carries and missing teeth. A thickened white patch on the mucous membrane Hard palate is brown and firm

Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Due to smoking Poor oral hygiene Poor oral hygiene Due to smoking

b.Sinus area Mouth Lips Teeth and gums Inspection

Buccal mucosa

Palate

inspection

Color

Normal

Odor Lesions Uvula Inspection

Tonsils Breast and axillae Breast

Inspection Inspection

Color Grading

Normal Odor (-) lesions Fleshy, solid structure that hangs freely in the midline. Red 0

Normal Normal Normal

Normal

Symmetry Color Shape Surface characteristics Lesions Tenderness Color Lesions Masses Tenderness Thoracic cage Use of accessory muscle Tenderness fremitus Breath sounds Respiratory pattern

Symmetrical Brown Small in size and flat. No sign of dippling and retraction (-) lesions (-) tenderness Brown (-) lesions (-) masses (-) tenderness

Normal Light brown due to less exposure

Areola e and nipples

Normal Normal Normal Normal Normal Normal Normal

Axillae

Palpation Inspection Palpation

Thorax and lungs

Inspection

Palpation auscultation

(-) use of accessory muscle. (-)Tenderness Tactile (-) Adventitious breath sounds RR

Normal Normal Normal Normal

Cardiovascular system Jugular venous system

Inspection External jugular veins Internal jugular vein Location of the apical pulse Extra heart sounds Murmur Not visible Not visible Palpated at the mitral area. (-)Extra heart sounds. (-)murmur Normal Normal Normal Normal normal

Auscultation

Abdomen

Inspection

Color Pulsation or movement Contour lesions Bowel sounds

Light brown (+) pulsation Abdomen is rounded (-) lesions A series of intermittent, soft clicks and gurgles are heard Generalized tympany predominates over the abdomen (+) tenderness in the umbilical area (+) enlarged Liver (-) masses (+) tenderness (-) costovertebral angle tenderness. (-)deformity (-) swelling Brown Warm (-) edema

Due to less exposure normal Normal Normal Normal

Auscultation

Percussion

Normal

Palpation c. light palpation d. deep palpation

Tenderness Enlarge organs Masses Rebound tenderness Costovertebral angel tenderness Deformity Swelling Color Temperature Edema

Normal Normal Normal Normal Normal Normal

Musculoskeletal Inspection system

Palpation

N155 PHYSICAL ASSESSMENT DOCUMENTATION GUIDE

Date ________________

Client/Patient ___________________________Age ________Sex__________

General Survey

(1) Body build (measure height and weight) (2) Posture (3) Gait - coordination of movements and pattern of gait. (4) Hygiene, grooming Good Hygiene, Pleasant Body odor, Dress appropriate in the Environment (5) Signs of illness Hands and Feet are slightly Jaundice, (-)Tremors , (-)Drooling (6) Affect, attitude, mood Slightly Slurred Speech, Happy (7) Cognitive process appropriate non-verbal response upon answering questions