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8/7/2019 8. V_Physical Assessment of Client Rosa
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TABLE XVI:Physical Assessment
Name: ROSA VALDEZAge:36Sex: Female
Vital SignsTemperature: 36.9C, normal, axillaryPR:, 63bpm, full, regular, left radial pulseRR: 20 cpm, rhythmic, deep, effortless, silentBp: 100/70, normal, left arm, sitting position
Weight: 40 kg/ 89 lbs.Height: 153 cmBMI: 17.091BW: 20.8
Body parts to be
Assessed
Normal Findings Actual findings Analysis andInterpretation
General SurveyBody built, height, andweight in relation toage, lifestyle andhealth
Proportionate, varieswith lifestyle
Ectomorph Abnormal
Posture and gait,standing,sitting and walking
Relaxed, Erect posture,coordinatedmovement
The client stoodstraight, and withcoordinatedmovement
Normal
Overall Hygiene and
Grooming
Clean, neat The client wears
appropriate clothesand is hygienic.
Normal
Body and Breath Odor No body odor or minorbody odor relative towork or exerciseNo breath odor
When the client isinterviewed there is aslight foul odor inbreaths but do nothave body odor.
Abnormal
Signs of distress inposture and facialexpression
No distress noted There is a distressnoted.
Abnormal
Obvious signs of
health or illness
Healthy appearance Not healthy in
appearance.
Abnormal
Attitude Cooperative, able tofollow instructions
The client iscooperative.
Normal
Mood and Affect Appropriate tosituation
The patient has thefocus to answer thequestion being asked.
Normal
Quantity, Quality, andOrganization of
Understandable,moderate pace,
The client talks in amoderate pace, and
Normal
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Speech exhibits thoughtassociation
understandable
Relevance andOrganization ofThoughts
Logical sequence,makes sense, hassense of reality
When the client istalking during theinterview there is
logical sequence, andmakes sense
Normal
IntegumentarySkin
Inspect for skin color Varies from light todeep brown;Ruddy pink to lightpink;Yellow overtones toolive
Her skin color is lightbrown
Normal
Uniformity of Color Generally uniformexcept in areasexposed to the sunAreas of lighterpigmentation
Her skin color is thesame all throughout hisbody parts
Normal
Assess for edema ifpresent
No edema There is no edemapresent duringpalpation
Normal
Inspect skin lesions Freckles, somebirthmarks, some flatand raised nevi(moles);No abrasions and
other lesions
Some moles arepresent.
Normal
Skin moisture Moisture in skin foldsand axillae (varies inenvironmentaltemperature)
Her skin is moderatelymoist.
Normal
Skin temperature Uniform;Within normal range
Her skin temperature iswarm all throughouther body parts
Normal
Note skin turgor When pinched: skinsprings back toprevious state
The pinched skinsprings back toprevious state
therefore the client hasa good skin turgor.
Normal
NailsNail plate shape Convex curvature;
Angle between nailand nail bed of about160 degrees
Her nails are convex inshape and the nailplate angle isapproximately 160
Normal
Inspect Nail Texture Smooth texture Her nails have a Normal
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smooth texture.Nail Bed Color Highly vascular and
pink in light-skinnedclients;Dark- skinned client
may have brown orblack pigmentation inlongitudinal streaks
Her nail beds arepinkish in color andhighly vascular
Normal
Inspect TissuesSurrounding Nails
Intact epidermis No hang nails arepresent
Normal
Capillary Refill Prompt return of pinkor usual color
Her nail bed capillariesquickly turn to theirusual color in less than3 seconds
Normal
HeadSkull
Inspect skull for size,shape, and symmetry
Rounded(Normocephalic andsymmetric, with frontal,parietal, and occipitalprominences)Smooth skull contour
Her head isnormocephalic andsymmetric, and has asmooth skull contour
Normal
Palpate the skull fornodules or massesand depressions
Smooth, uniformconsistency;Absence of nodules ormasses
Her skull issmooth and has nonodules or massesduring palpation
Normal
ScalpColor and
appearance
white Her scalp is white incolor
Normal
Palpate for areas oftenderness
Absence of nodules ormasses, andtenderness
During palpation thereis no tenderness,
Normal
HairInspect for evennessof growth, thickness orthinness
Thick hair, evenlydistributed
Her hair is evenlydistributed and thick
Normal
Hair texture andoiliness
Silky, resilient hair The hair is silky andresilient
Normal
Face
Inspect the facialfeatures, symmetry offacial movements
Symmetric or slightlyasymmetric facialfeatures;Palpebral fissures equalin size;Symmetric nasolabialfolds; Symmetric facialmovements
The client can elevatethe eyebrows, frown,or lower the eyebrows,close the eyes tightly,puff the cheeks, andsmile and show histeeth symmetrically.
Normal
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EyesVisual acuity
Near vision Able to read newsprintat a distance of 36 cm(14 in)
The client is able toread the words in thepaper.
Normal
Distance vision 20/20 vision onSnellens chart Without correctivelenses:OD 20/20OS 20/20OU 20/20
Normal
EyebrowsInspect the eyebrowsfor hair distributionand symmetry
Hair evenly distributed;skin intact;Eyebrowssymmetrically aligned;equal movement
Hair is evenlydistributed and intactskin.
Normal
Lacriminal gland, Lacriminal sac, and Nasolacrimal ductInspect and palpatethe lacrimal gland
No edema ortenderness overlacrimal glands
There is no edema ortenderness overlacrimal glands whenpalpated
Normal
Inspect and palpatethe lacrimal sac andnasolacrimal duct
No edema or tearing There is no tearingnoted when thelacrimal sac andnasolacrimal duct waspalpated.
Normal
EyelidsInspect the eyelashes
for evenness ofdistribution anddirection of curl
Equally distributed;Curled slightly outward
When the client closed
her eyes, the eyelashesare equally distributedand are curledoutward.
Normal
Inspect the eyelids forsurface characteristics
Skin intact; nodischarge; nodiscoloration;Lids closesymmetrically;Approximately 15-20involuntary blinks/ min.;
bilateral blinking;When lids open, novisible sclera abovecorneas, and upperand lower borders ofcornea are slightlycovered
The clients eyelids hasintact skin, blinks atapproximately 20 timesin a minute, and lidsclose symmetrically
Normal
Conjunctiva
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Inspect the bulbarconjunctiva
Transparent;Capillaries sometimesevident;Sclera appears white(yellowish in dark-
skinned clients)
Her bulbar conjunctivais clear and somecapillaries are evident.
Normal
Inspect the palpebralconjunctiva
Shiny, smooth, andpink or red
Her palpebralconjunctiva is shiny,and pink in color
Normal
ScleraInspect for clarity andcolor
Appears white Her sclera is white. Normal
CorneaInspect the cornea forclarity and texture
Transparent, shiny andsmooth; details of theiris are visible;
In older people, a thin,grayish white ringaround the margin,called arcus senilis,maybe evident
Her cornea is shiny anddetails of the iris arevisible.
Normal
IrisInspect for shape andcolor
Flat and round The clients iris is brownin color, flat and round
Normal
PupilInspect the pupils forcolor, shape, andsymmetry of size.
Black in color;Equal in size; 3-7 mmdiameter;Round, smooth border
The clients pupils areblack in color,approximately 4mm indiameter and is roundand has smoothborder
Normal
Pupils direct andconsensualreaction to light
Illuminated pupilconstricts (directresponse)Non-illuminated pupilconstricts (consensualresponse)
Her pupils constrictwhen illuminated bythe penlight same asto the other pupilwhich is not illuminatedby penlight
Normal
Assess each pupilsreaction to
accommodation andconvergence
Pupils constrict whenlooking at near object
Pupils dilate whenlooking at far objectsPupils converge whennear object is movedtowards nose
Her pupils constrictwhen she looked at
the penlight anddilated when lookingat the wall. Her pupilsconverged when thepenlight is movedtowards her nose.
Normal
Extraocular MusclesAssess six ocular Both eyes Her eyes move in the Normal
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movements todetermine eyealignment andcoordination
coordinated, move inunison, with parallelalignment
same way, and iscoordinated, and withparallel alignmentwhen her eyesfollowed the
movement of thepenlight through the sixcardinal fields of gaze
Visual fieldsPeripheral visual fields When looking straight
ahead, client can seeobjects in theperiphery
The client can see thepenlight in peripherywhen looking straightahead, approximatelyabout 90 temporally,50 at the upwardfield, 70 at thedownward field, and50 at the nasal field
Normal
EarsAuricles
Inspect the auricles forcolor, symmetry ofsize, and position
Color same as facialskin; Symmetricposition;Auricle aligned withouter canthus of eyeabout 10
Her auricles has thesame color of thefacial skin, symmetric inposition, and arealigned with the outercanthus of the eyeapproximately about
10
Normal
Palpate the auriclesfor texture, elasticity,and areas oftenderness
Mobile, firm, and nottenderPinna recoils after it isfolded
The pinna recoils afterbeing folded, mobileand firm, and is freefrom tenderness
Normal
External ear canalInspect the externalear canal forcerumen, skin lesions,pus and blood andthe tympanic
membrane for color
Distal third containshair follicles andglandsDry cerumen, grayish-tan color; or sticky, wet
cerumen in variousshades of brown
The clients externalear canal containssome hair follicles andhas dry odorlesscerumen.
Normal
Hearing acuity testResponse to normalvoice tones
Normal voice tonesaudible
She can hear thenormal voice tones onboth ears.
Normal
Perform the watchtick test
Able to hear ticking inboth ears
She was not able tohear ticking on both
Abnormal
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ears.Perform Webers Test Sound is heard in both
ears or is localized atthe center of the head(Weber negative)
She heard the soundson both ears (Webernegative)
Normal
Conduct the Rinnetest Air-conducted (AC)hearing is greater thanbone-conducted (BC)hearing (positiveRinne)
The clients air-conducted (AC)hearing is greater thanbone-conducted (BC)hearing. AC = 8; BC = 5on both ears (positiveRinne)
Normal
NoseInspect the externalnose for anydeviations in shape,size, or color andflaring or dischargefrom the nares
Symmetric and straightNo discharge or flaringUniform color.
The clients nose issymmetric and straight,has no discharge orflaring and is of thesame color of theface.
Normal
Inspect the nasalcavities
Mucosa pinkClear, waterydischargeNo lesions
The clients nasalcavities is mucosa pink,clear and has nolesions
Normal
Nasal Septum Nasal septum intactand in midline
The clients nasalseptum is intact and inmidline
Normal
Test patency of bothnasal cavities
Air moves freely as theclient breathes
through the nares
The air moves freely asthe client breathes
through the nareswhen nasal cavitypatency is tested
Normal
Palpate forany areas oftenderness, masses,and displacements
Not tender;No lesions
The clients nose is freefrom tenderness andlesion when palpated
Normal
SinusesLocate/ palpate/identify the maxillary
and frontal sinuses fortenderness
Not tender Frontal sinuses.maxillarysinuses are free from
tenderness whenpalpated.
Normal
MouthLips
Inspect the outer lipsfor symmetry ofcontour, color, andtexture
Uniform pink color(darker, eg. Bluish hue,in Mediterraneangroups and dark-
Her lips is pink in color,soft, dry, has smoothtexture,Symmetry of contour,
Normal
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skinned clients)Soft, moist, smoothtextureSymmetry of contourAbility to purse lips
and has the ability topurse.
Buccal MucosaInspect and palpatethe inner lips andbuccal mucosa forcolor, moisture,texture, and thepresence of lesions
Uniform pink color(freckled brownpigmentation in dark-skinned clients)Moist, smooth, soft,glistening, and elastictexture (drier oralmucosa in elderly dueto decreasedsalivation)
Her buccal mucosa ispink in color, moist,smooth, soft, andglistening
Normal
TeethInspect teeth andgums
32 adult teethSmooth, white, shinytooth enamel
The client has 15yellowish teeth withcavities and dentalcarries.
Abnormal
GumsColor and condition Pink gums (bluish or
dark patches in dark-skinned clients)Moist, firm texture togumsNo retraction of gums
(pulling away from theteeth)
Her gums are pink,moist, have firmtexture, and have noretraction of gums.
Normal
Tongue/Floor of the mouthInspect for color andtexture of the mouthfloor and frenulum
Central positionPink color (some brownpigmentation ontongue borders indark-skinned clients);moist; slightly rough;thin whitish coatingSmooth, lateral
margins; no lesions
Her tongue is in centralpositionpink in color, moist, nolesions, has no lesions,and has raisedpapillae.
Normal
Inspect and palpatethe position, color andtexture, movementand the base of thetongue
Smooth tongue basewith prominent veins
The client has smoothtongue base withprominent veins
Normal
Palpate for anynodule, lumps, or
Smooth with nopalpable nodules
The clients tongue/floor of the mouth is
Normal
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excoriated areas. smooth and has nopalpable nodules.
Palates and Uvula
Inspect and palpatefor color, shape,texture and thepresence of bonyprominences
Light pink, smooth, softpalateLighter pink hardpalate, more irregulartexture
Her soft palate is pinkin color, and hardpalate is lighter pink incolor.
Normal
Inspect the uvula forposition and mobilitywhile examining thepalates
Positioned in midline ofsoft palate
Her uvula is positionedin the midline.
Normal
Oropharynx and tonsilsInspect and palpate
for color, and texture(one side at a time toavoid eliciting gagreflex)
Pink and smooth
posterior wall
Not performed
Inspect the tonsils forcolor, discharge, andsize
Pink and smoothNo dischargeOf normal size
Not performed
Neck and lymph nodesLymph nodes
Locate/ palpate/identify lymph nodesand note fortenderness
No enlarged orpalpable lymph nodesNot tender
Lymph nodes arepalpable and nottender.
Normal
TracheaInspect and palpatefor placement
Central placement inmidline of neckSpaces are equal onboth sides
The clients trachea isin central position andis in midline of theneck, spaces areequal on both sideswhen palpated.
Normal
Thyroid glandInspect the thyroidgland
Not visible oninspectionGland ascends duringswallowing but it is notvisible
The clients thyroidgland is not visible on
inspection and glandascends duringswallowing but it is notvisible.
Normal
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Palpate forsmoothness and areasof enlargement,masses or nodules
Lobes may not bepalpatedIf palpated, lobes aresmall, smooth, centrallylocated, painless, and
rise freely withswallowing
Small lobes whenpalpated are smooth,centrally located,painless, and rise freelywith swallowing
Normal
Thorax
Posterior Thorax
Shape, symmetry,
diameter ofanteroposterior thoraxto transverse diameter;color; lesions
Anteroposterior to
transverse diameter inratio of 1:2; chestsymmetric(kozier, p.614)
Diameter in ratio is
20:40, chest issymmetric
Normal
Spinal alignment Spine vertically aligned(kozier, p.614)
No deformities Normal
Temperature,tenderness, masses
Uniform temperature;no tenderness; nomasses(kozier, p.614)
No heat present; nopain upon palpation;no presence of masses
Normal
Respiratory excursion Full and symmetricchest expansion;thumbs separate 3-5cm (1.5-2 inches) asthe client takes a deepbreath(kozier, p. 615)
Not performed
Vocal fremitus Bilateral symmetry ofvocal fremitus; fremitusis heard most clearly inthe apex of the lungs(kozier, p.615)
Not performed
Percussion of posterior
thorax
Percussion notes
resonate except overthe scapula; lowestpoint of resonance isat the diaphragm(kozier, p.615)
Not performed
Auscultation of theposterior thorax
Vesicular andbronchovesicularbreath sounds
Not performed
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(kozier, p. 616)
Anterior Thorax
Breathing patterns Quiet, rhythmic andeffortless respiration
(kozier, p.617)
Not performed
Temperature,tenderness, masses
Uniform temperature;no tenderness; nomasses(kozier, p.617)
Not performed
Respiratory excursion Full and symmetricchest expansion;thumbs separate 3-5cm (1.5-2 inches) asthe client takes a deepbreath(kozier, p.617)
Tactile fremitus Same as the posteriorvocal fremitus; fremitusis normally decreasedover heart and breasttissue(kozier, p.617)
Not performed
Percussion of anteriorthorax
Percussion notesresonate down to the6th rib at the level ofthe diaphragm but flatover areas of heavy
muscles and bones,dull on areas over theheart and the liver,and tympanic over thestomach(kozier, p. 617)
Not performed
Auscultation of thetrachea
Bronchial and tubularbreath sounds(kozier, p. 618)
Not performed
Auscultation of theanterior thorax
Bronchovesicular andvesicular breath
sounds(kozier, p.618)
Not performed
Cardiovascular, Carotid Arteries, Jugular Veins
Cardiovascular
Aortic and pulmonicareas
No pulsations(kozier, p.621)
Not performed
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Tricuspid area No pulsations(kozier, p.622)
Not performed
Apical area Pulsations visible in 50%of adults and palpablein most PMI in 5th LICS
or medial to MCL(kozier, p.622)
Not performed
Auscultation of theaortic, pulmonic,tricuspid and apicalvalves
S1 (usually heard at allsites usually louder atapical area);S2 (usually heard at allsites usually heardlouder at the base ofthe heart);S3 (in children andyoung adult);S4 (in older adults)(kozier, p.622)
Not performed
Carotid Arteries
Palpation of carotidartery
Symmetry pulsevolumes; full pulsations,thrusting quality(kozier, p.622)
Not performed
Auscultation of carotidareas
No sounds heard onauscultation(kozier,p.623)
Not performed
Jugular VeinsInspection of jugularveins
Veins not visible(kozier,p.623)
Veins are not visible Normal
Breast and Axillae
Breast size, symmetry,contour or shape whilethe client is in sittingposition
Rounded shape;slightly unequal in size;generally symmetric.(kozier,p.628)
Not performed
Skin of the breast forlocalization ofhyperpigmentation,
retraction or dimpling,,localizedhypervascular areas,swelling or edema.
Skin uniform in color(same appearance asskin of abdomen or
back); skin smooth andintact; diffusesymmetrical horizontalor vertical vascularpattern in l ight-skinnedpeople(kozier,p.628)
Not performed
Size, shape, symmetry, Round or oval and Not performed
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color, characteristics,masses and lesions onthe areola
bilaterally the same;color varies widelyfrom light pink to darkbrown. Irregularplacement of
sebaceous glands onthe surface of theareola(kozier, p.628)
Size, shape, position,color, discharge andlesions on the nipples.
Round, everted andequal in size; similar incolor; both nipplespoint on the samedirection.(kozier, p. 628)No discharge, exceptfrom pregnant or
breast-feedingfemales.Inversion of one orboth nipples that ispresent to puberty.
No tenderness, massesor nodules(kozier, p.629)
Not performed
Palpation of the
axillary, subclvicular,and supraclavicularlymph nodes
No tenderness, masses
or nodules(kozier, p.629)
Not performed
Palpation of breast formasses, tendernessand any dischargefrom the nipples
No tenderness, masses,nodules and nippledischarge(kozier, p.629)
Not performed
Palpation of the areolaand nipples for masses
No tenderness, masses,nodules and nippledischarge(kozier, p.630)
Not performed
AbdomenSkin integrity Unblemished skin;
uniform color(kozier, p.633)
Not performed
Abdominal contour Flat, rounded (convex)or scaphoid (concave)(kozier, p.633)
Not performed
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Enlargement of theliver and spleen
No evidence ofenlargement of liver orspleen(kozier, p.633)
Not performed
Symmetry of contour Symmetric contour
(kozier, p.633)
Not performed
Abdominal movementassociated withrespirations, peristalsisor aortic pulsations
Symmetric movementscaused by respiration;visible peristalsis in verylean people; aorticpulsation in thin personat epigastric area(kozier, p.633)
Not performed
Vascular pattern No vascular pattern(kozier, p.634)
Not performed
Bowel sound, vascularsound and peritonealfriction rubs
Audible bowel sounds(kozier, p.634)
Not performed
Percussion of theabdomens fourquadrants
Tympanic over thestomach and gas-filledbowels; dullness,especially over theliver and spleen, or afull bladder(kozier, p.635)
Not performed
Light palpation on theabdomens fourquadrants
No tenderness; relaxedabdomen with smoothconsistent tension
(kozier, p.636)
Not performed
Musculoskeletal System
MusclesInspect the musclesfor size
Equal sizes on bothsides of the body
Her muscles haveEqual sizes on bothsides of the body.
Normal
Inspect the musclesand tendons forcontractures
No contractures Her muscles andtendons have nocontractures.
Normal
Inspect the musclesfor fasciculations andtremors
No fasciculations ortremors
She has nofasciculation ortremors.
Normal
Palpate muscletonicity.
Normally firm Her muscle tonicity isfirm.
Normal
Test for strength (neck) Equal strength Her neck strength is ofequal strength
Normal
Test for strength(upper extremities)
Equal strength oneach body side
She has equal strengthon each body side.
Normal
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Test for strength (lowerextremities)
Equal strength oneach body side
She has equal strengthon each body side.
Normal
BonesInspect the skeletonfor normal structure
and deformities
No deformities Her skeleton has nodeformities.
Normal
Palpate the bones tolocate any areas ofedema or tenderness
No tenderness orswelling
Her bones arenegative fortenderness or swelling.
Normal
JointsInspect the joint forswelling.
No swelling Normal
Palpate each joint fortenderness,smoothness ofmovement, swelling,
crepitation, andpresence of nodule
No tenderness,swelling, crepitation, ornodulesJoints moves smoothly
Normal
Assess range of motionUpper extremities(shoulder andscapula)
Varies to some degreein accordance withpersons geneticmakeup and degreeof physical activity
She was also able todo flexion about 180from the side,extension about 180from vertical positionbeside the head,hyperextension about50
Normal
Upper extremities(elbows)
Varies to some degreein accordance withpersons geneticmakeup and degreeof physical activity
The client can doflexion approximately150 and extensionabout 150
Normal
Upper extremities(hands)
Varies to some degreein accordance withpersons geneticmakeup and degreeof physical activity
She was able to doflexion about 90,extension about 90,hyperextension about30, abduction about20 and adductionabout 20
Normal
Lower extremities(acetabulum/iguinalarea)
Varies to some degreein accordance withpersons geneticmakeup and degreeof physical activity
She was able toabduct and adducthis inguinal area.
Normal
Lower extremities(popliteal)
Varies to some degreein accordance withpersons genetic
She was able to doflexion and extension.
Normal
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makeup and degreeof physical activity
Lower extremities(ankles)
Varies to some degreein accordance withpersons genetic
makeup and degreeof physical activity
She can do plantarflexion and dorsalflexion.
Normal