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A. Physical Assessment Upon Admission Date: September 19, 2008 GCS-15 oriented to 3 spheres-(E4M6V5) Height: 62 inches V/S: BP- 90/70 mmHg, CR: 84 bpm, RR: 36 cpm, T-37.5 C Weight: 31.5 kilograms LOC: Oriented BMI: 12.5 (Severe Malnutrition)

AREA TECHNIQUE NORMS FINDINGS ANALYSIS and INTERPRETATIONA. SKULL

1. Size, shape andsymmetry of the skull

InspectionPalpation

Rounded(normocephalic andsymmetrical, withfrontal, parietal, and

occipitalprominences);Smooth skull contour

Rounded(normocephalic); smooth skullcontour

Normal

2. Presence of nodules,masses, anddepressions

PalpationInspection

Smooth, uniformconsistence; absenceof nodules or masses

Has no tenderness; nomasses nor nodules

Normal

3. Facial Features InspectionPalpation

Symmetric or slightlyasymmetric facial

features; palpebralfissure equal in size;symmetric nasolabial

Symmetrical andpalpebral fissure equal

in size, nasolabial foldsare symmetrical

Normal

4. Presence of edemaand hollowness in theeye.

Inspection No edema andhollowness

Has Hollowness Abnormal, Volume deficiency of fat withinthe orbit (the space inside of the bony eyesocket). This condition of the patient isrelated to his nutritional status, she ismalnourished. Her BMI is 12.5.(http://www.drmeronk.com/hollowed/under-eye-hollows.html)


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C. HAIR

1. Evenness of growth,thickness, or thinness of

hair

InspectionPalpation

Evenly distributedand covers the whole

scalp; Maybe thick orthin

Evenly distributed withno patches of hair loss;

thick hair

Normal

2. Texture and oilinessover the scalp

InspectionPalpation

Silky; resilient hair Silky, smooth andresilient hair

Normal.

3. Presence of infectionand infestation

InspectionPalption

No infection andinfestation

Presence of lice Abnormal, There is pediculosis, a type of parasitic infection. Lice may be contractedfrom infcetd clothes and direct contact withan infected person. The idea is that an oilysubstance, such as oil, smothers the liceand they may die. (Kozier, Fundamentals of Nursing 7 th ed. Page 733)

D. FACE

Facial features,symmetry of facialmovements

Inspection Symmetric or slightlyasymmetric facialfeatures; palpebralfissures equal in size;symmetric nasolabialfolds

Symmetrical facialfeatures while talkingor elevating theeyebrow. Equalpalpebral fissure,symmetrical nasolabialfolds.

Normal

IV. EYES

A. EYEBROWS

Hair distribution,alignment, skin quality

Inspection Symmetrical and inline with each other;

Symmetrical andaligned with each

Normal


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and movement maybe black, brownor blond dependingon race; evenlydistributed

other; black; evenlydistributed. Movementsare symmetrical.

B. EYELASHES

Evenness of distributionand direction of curl

InspectionPalpation

Evenly distributed;turned outward

Turned outwardeyelashes; hair equallydistributed

Normal

C. EYELIDS

Surface characteristicsand position (in relationto the cornea, ability toblink, and frequency of blinking)

Inspection Upper eyelids coverthe small portion of the iris, cornea, andsclera when eyes areopen; eyelids meetcompletely when theeyes are closed;symmetrical

Able to close the eyesand has the ability toblink.

Normal

D. CONJUNCTIVA

1. Color, texture, and

the presence of lesionsin the bulbar conjunctiva

Inspection

Palapation

Pinkish or red in color;

with presence of small capillaries;moist; no foreignbodies; no ulcers

Pale color; smooth in

texture

Abnormal, pale conjunctiva may be related

to the low RBC level of the patient.(Fundamentals of Nursing 5 th edition byTaylor, page 642)

2. Color, texture, andthe presence of lesionsin the palpebralconjunctiva

InspectionPalpation

Pinkish or red in color;with presence of small capillaries;moist; no foreign

Pale Abnormal, pale conjunctiva may be relatedto the low RBC level of the patient.(Fundamentals of Nursing 5 th edition by


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bodies; no ulcers Taylor, page 642)

E. SCLERA

Color and clarity Inspection White in color; clear;no yellowishdiscoloration; somecapillaries maybevisible

White sclera with somevisible capillaries,anicteric sclera.

Normal

F. CORNEA

Clarity and texture Inspection No irregularities onthe surface; lookssmooth; clear ortransparent

Clear and smooth intexture

Normal

G. IRIS

Shape and color Inspection Anterior chamber istransparent; no notedvisible materials;color depends on thepersons race

Dark brown in color;transparent anteriorchamber

Normal

H. PUPILS

1. Color, shape, andsymmetry of size

Inspection Color depends on thepersons race; sizeranges from 3-7 mm,and are equal in size;equally round

Pupil size is 3mm. Normal

2. Light reaction and Inspection Constrict Dilates when looking at Normal


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accommodation briskly/sluggishlywhen light is directedto the eye, bothdirectly and

consensual

far objects andconstricts when lookingat near objects.Constricts when there

is light.

I. VISUAL ACUITY

1. Near vision Inspection Able to readnewsprint

Nearsightedness(Myopia)

Abnormal, it is a refractive defect of the eye in which collimated light produces imagefocus in front of the retina whenaccommodation is relaxed. It is caused byan eyeball that is longer than normal, whichmay be a familial trait. Transient mayopiaoccurs due to influenza, steroids, severdehydration and large intake of antacids.(Black, Medical Surgical Nursing7th edition, page1963).

J. LACRIMAL GLAND

Palpability andtenderness of thelacrimal gland

Palpation No edema ortenderness overlacrimal gland

No tenderness andedema noted.

Normal

K. EXTRAOCULARMUSCLES

Eye alignment andcoordination

Inspection Both eyescoordinated, move inunison, with parallelalignment

Moves in Unison Normal

L. VISUAL FIELDS

Peripheral visual fields Inspection When looking straightahead, client can see

Can see objects in the Normal
http://en.wikipedia.org/wiki/Refractive_errorhttp://en.wikipedia.org/wiki/Eyehttp://en.wikipedia.org/wiki/Collimated_lighthttp://en.wikipedia.org/wiki/Focus_(optics)http://en.wikipedia.org/wiki/Retinahttp://en.wikipedia.org/wiki/Accommodation_(eye)http://en.wikipedia.org/wiki/Refractive_errorhttp://en.wikipedia.org/wiki/Eyehttp://en.wikipedia.org/wiki/Collimated_lighthttp://en.wikipedia.org/wiki/Focus_(optics)http://en.wikipedia.org/wiki/Retinahttp://en.wikipedia.org/wiki/Accommodation_(eye)


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objects in theperiphery

periphery.

V. EARS

A. AURICLES

1. Color, symmetry of size, and position

Inspection Color same as facialskin; symmetrical;auricle aligned withouter canthus of eye,about 10 degreesfrom vertical

Same color as thefacial skin; tip of auricle aligned at theouter canthus of theeye.

Normal

2. Texture, elasticity andareas of tenderness

Palpation Mobile, firm, and nottender; pinna recoilsafter it is folded

Smooth in texture,flexible and elasticpinna; no tenderness

Normal

C. HEARING ACUITY TESTS

1. Clients response tonormal voice tones

Inspection Normal voice tonesaudible

Can hear normalvolume tones or words.

Normal

VI. NOSE

1.Any deviations inshape, size, or color andflaring or discharge fromthe nares

Inspection Symmetric andstraight; no dischargeor flaring; Uniformcolor

Symmetric andstraight; Uniform colorwith nasal flaring .

Abnormal, Nasal flaring suggests airwayobstruction. Nasal discharge shows thepresence of mucus secretions in the airtract.

2. Nasal septum Inspection Nasal septum intact Nasal septum intact Normal


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(between the nasalchambers)

Palpation and in midline and in midline

3. Patency of both nasal

cavities

Inspection Air moves freely as

the client breathesthrough the nares

Only left nares is

patent. Right nares iswith secretion.

Abnormal, not patent right nares show the

presence of mucus secretions and wouldsuggest there is an infection in therespiratory system.

4. Tenderness, masses,and displacements of bone and cartilage

Palpation Not tender; no lesions Nor tenderness norlesions.

Normal

VII. SINUSES

Identification of thesinuses and fortenderness

Inspection Not tender Not painful whenpalpated

Normal

VIII. MOUTH

A. LIPS

Symmetry of contour,color and texture

InspectionPalpation

Uniform pink color;soft, moist, smoothtexture; symmetry of

contour; ability topurse lips

Pink in color, dry andcracked lips

Abnormal, May suggest cellular dehydration.(Black, Medical Surgical Nursing7th edition,page 208).

B. BUCCAL MUCOSA

Color, moisture, texture,and the presence of lesions

Inspection Uniform pink color;moist, smooth, soft,glistening, and elastictexture

Pink color and dry. Abnormal, May suggests dehydration.(Black, Medical Surgical Nursing7th edition,page 208).


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C. TEETH

Color, number andcondition and presenceof dentures

Inspection 32 adult teeth;smooth, white, shinytooth enamel;smooth, intactdentures

Has 31 adult teeth. Thepatient has yellowishteeth. Have badbreath. Have toothdecay in the lower rightsecond molars.

Abnormal, most unpleasant odors are knownto arise from proteins trapped in the mouthwhich are processed by oral bacteria. Themost common location for mouth-relatedhalitosis is the tongue .(http://en.wikipedia.org/wiki/Halitosis ). It isalso related to dental carries and frequencyof tooth brushing.

D. GUMS

Color and condition Inspection Pink gums; noretraction

Pink gums; has novisible retractions

Normal

E. TONGUE/FLOOR OFTHE MOUTH

1. Color and texture of the mouth floor and

frenulum.

Inspection pink color; moist;slightly rough; thin

whitish coating;moves freely; notenderness

Pink and moist. Tonguemoves freely and nopain felt.

Normal

2. Position, color andtexture, movement andbase of the tongue

Inspection Central position; pinkcolor; smooth tonguebase with prominentveins

Located and positionedin the center.

Normal
http://en.wikipedia.org/wiki/Odorhttp://en.wikipedia.org/wiki/Odorhttp://en.wikipedia.org/wiki/Proteinhttp://en.wikipedia.org/wiki/Tonguehttp://en.wikipedia.org/wiki/Halitosishttp://en.wikipedia.org/wiki/Odorhttp://en.wikipedia.org/wiki/Proteinhttp://en.wikipedia.org/wiki/Tonguehttp://en.wikipedia.org/wiki/Halitosis


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3. Any nodules, lumps,or excoriated areas

PalpationInspection

Smooth with nopalpable nodules,lumps, or excoriatedareas

No tenderness normasses

Normal

F. PALATES andUVULA

1. Color, shape, textureand the presence of bony prominences

InspectionPalpation

Light pink, smooth,soft palate; lighterpink hard palate ,more irregular texture

The hard palate has alighter color than thesoft palate; has quiterough texture

Normal

2. Position of the uvulaand mobility (whileexamining the palates)

Inspection Positioned in midlineof soft palate

Positioned at thecenter of theoropharynx

Normal

G. OROPHARYNX andTONSILS

1. Color and texture Inspection Pink and smoothposterior wall

Dry, pinkish in color. Abnormal, May suggests dehydration.(Black, Medical Surgical Nursing7th edition,page 208).

2. Size, color, and

discharge of the tonsils

Inspection Pink and smooth; no

discharge; of normalsize

Has no discharge;

pinkish

Normal

3. Gag reflex Inspection Present Present Normal

X. THORAX

A. ANTERIOR THORAX

1. Breathing patterns Inspection Quiet, rhythmic, and Difficulty of breathing Abnormal, labored breathing is a common


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effortless respirations manifestation affecting clients with cardiacand pulmonary disorders. It is related toobstructed airway. It also related to thedecreased size of the lungs due to PTB.

(Black, Medical Surgical Nursing7th edition,page 1566).

2. Temperature,tenderness, masses

Palpation Skin intact; uniformtemperature; chestwall intact; notenderness; nomasses

Has an intact skin; hasequal warmth on bothsides. No masses.

Normal

3. Anterior thorax

auscultation

Auscultation Bronchovesicular and

vesicular breathsounds

Has crackles sounds on

the upper thorax &lower thorax

Abnormal, crackles or rales are audible

when there is a sudden opening of smallairways that contain fluid. It is usually heardduring inspiration. (Black, Medical SurgicalNursing7th edition, page 1756).

B. POSTERIORTHORAX

1. Shape, symmetry,and comparison of anteroposterior thoraxto transverse diameter

InspectionPalpation

Anteroposterior totransverse diameterin ratio 1:2; Chestsymmetric

Has a anteroposteriorto transverse diameterratio of 1:2, elliptical inshape and symmetricalchest

Normal

2. Spinal alignment Inspection Spine verticallyaligned

Has a verticalalignment

Normal

3. Temperature, Palpation Skin intact; uniform No masses nor Normal


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tenderness, and masses temperature; chestwall intact; notenderness; nomasses

tenderness; has equalwarmth on each side

7. Posterior thoraxauscultation

Auscultation Vesicular andbronchovesicularbreath sounds

Has crackles heard onthe anterior and middlepart of right and leftlungs. Diminishedlung sound on theposterior right lung.

Abnormal, the condition is related to thedecreased size of the right lung and poorinspiratory effort due to pain.(http://www.nurse411.com/Heart_Lung_Sounds.asp)

XI. CARDIOVASCULAR

A. AORTIC andPULMONIC AREAS

Auscultation No pulsations No pulsations felt Normal

B. TRICUSPID AREA Auscultation No pulsations; no liftor heave

No pulsations of lifts Normal

C. APICAL AREA Auscultation Pulsations visible in50% of adults andpalpable in most PMIin fifth LICS at ormedial to MCL

Has full pulsation Normal

D. EPIGASTRIC AREA Auscultation Aortic pulsations Has pulsation Normal

E. CARDIOVASCULARAREASAUSCULTATION

Auscultation S1: Usually heard atall sites

Usually louder at theapical area

Has full and rapidpulsation. 84bpm/minute.

Sounds on the aorticand pulmonic areas;

Normal

Normal


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S2: Usually heard atall sites

Usually louder at thebase of heart

Systole: silentinterval; slightlyshorter duration thandiastole at normalheart rate (60 to 90beats/min)

Diastole: silentinterval; slightlylonger duration thansystole at normalheart rates

S3: in children andyoung adults

S4: in many olderadults

has a lub sound on theapex and dub soundson the tricuspid area.

Blood pressure is 90/70mm Hg.

Normal

XII. CAROTIDARTERIES

1. Carotid arterypalpation

Palpation Symmetric pulsevolumes; fullpulsations, thrustingquality; qualityremains same whenthe client breathes,

Has weak pulsation.Symmetrical pulse.

Abnormal, decreased amount of bloodvolume passing the artery. (Black, MedicalSurgical Nursing7th edition, page 1574).


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peristalsis or aorticpulsations

peristalsis in verylean people; aorticpulsations in thinpersons at epigastric

area

6. Vascular pattern Inspection No visible vascularpattern

Has no blood vesselsvisible

Normal

XVI.MUSCULOSKELETALSYSTEM

A. MUSCLES

1. Muscle size andcomparison on the otherside

Inspection Proportionate to thebody; even in bothsides

Proportionate to thebody; even in bothsides

Normal

2. Fasciculation andtremors in the muscles

Inspection No fasciculation andtremors

Has no fasciculationand tremors

Normal

3. Muscle tonicity Palpation Even and firm muscletone

Weak muscle tone Abnormal, possibly related to the amount of food that patient is eating. Possible

exhaustion experienced by the patient whenshe coughs.(http://en.wikipedia.org/wiki/Muscle_weakness)

4. Muscle strength Palpation Has equal muscularstrength on bothsides

Weak muscle strength Abnormal, possibly related to the amount of food that patient is eating. Possibleexhaustion experienced by the patient whenshe coughs.(http://en.wikipedia.org/wiki/Muscle_weakness)

C. JOINTS


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1. Joint swelling Inspection No swelling, nowarmth, no redness,no pain, no crepitus

No swelling, nowarmth, no redness, nopain, no crepitus

Normal

EXTREMETIES Inspection,Palpation

No swelling, nowarmth, no redness,no pain.

No edema, no painwhen moved.

Normal

Neurologic Assessment:

Category Normal Findings Actual Findings Analysis and interpretation

Mental Status

Level of Consciousness

Orientation

Language test

Recall

Alert

Oriented

Coherent

Able to remember

Alert

Oriented to person, timeand place.Coherent

Able to state whathappened to her in thepast.

Normal

Normal

Normal

Normal


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Cranial Nerves

CN 1Olfactory

CN 11Optic

CN III, IV, VIOcculomotorTrochlearAbducens

CN VTrigeminal

CN VII

Facial

CN VIIIVestibulocochlear

CN IX, XGlossopharyngealVagus

Able to smell andrecognize stimuli

20x20 vision, able toread, 3-5 mm [pupilsize]

(+) ExtraoccularMovement (EOM);Lateral Upward anddownward; pupils

reactive to light.

Able to feel andclearly identifystimulus, withbilateral facialsensation. Withactive corneal reflex.

(+) Corneal reflex ,Facial asymmetry

Able to hear clearly,can maintain balance

(+) gag reflex, uvula

Able to identify the scentof the alcohol

Pupil size is 3 mm, able toread, myopia ornearsightedness.

Pupils react to light. Thereis constriction andconsensualaccommodation. Able to

move the eyes in anydirection in unison.

Able to feel my finger onher face while covering hereyes.

(+) Facial symmetry

Can hear clearly and canwalk.

Present gag reflex, able to

Normal

Abnormal, it is a refractive defect of the eye inwhich collimated light produces image focus in frontof the retina when accommodation is relaxed. It iscaused by an eyeball that is longer than normal,which may be a familial trait. Transient mayopiaoccurs due to influenza, steroids, sever dehydrationand large intake of antacids. (Black, Medical SurgicalNursing7th edition, page 1963).Normal

Normal

Normal

Normal

Normal
http://en.wikipedia.org/wiki/Refractive_errorhttp://en.wikipedia.org/wiki/Eyehttp://en.wikipedia.org/wiki/Collimated_lighthttp://en.wikipedia.org/wiki/Focus_(optics)http://en.wikipedia.org/wiki/Retinahttp://en.wikipedia.org/wiki/Accommodation_(eye)http://en.wikipedia.org/wiki/Refractive_errorhttp://en.wikipedia.org/wiki/Eyehttp://en.wikipedia.org/wiki/Collimated_lighthttp://en.wikipedia.org/wiki/Focus_(optics)http://en.wikipedia.org/wiki/Retinahttp://en.wikipedia.org/wiki/Accommodation_(eye)


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CN XIAccessory (Spinal)

CN XIIHypoglossal

at the center, softpalate rises

Able to shrug

shoulders againstresistance and ableto turn the head sideand againstresistance.

Able to move tonguefrom side to side

swallow and able toidebtify the taste of thefood.

Can shrug shouldersagainst resistance and canturn the head fro right toright.

Able to protrude thetongue and move it side toside.

Normal

Normal

Muscle Strength

Left Arm

Right Arm

Left Leg

Right Leg

MNT Grading System:

(+5) Active motionagainst fullresistance

(+5) Active motionagainst fullresistance

(+5) Active motion

against fullresistance(+5) Active motionagainst fullresistance

+4 active motion againstsome resistance.

+4 active motion againstsome resistance.

+4 active motion againstsome resistance.+4 active motion against

some resistance.

Abnormal, possibly related to the amount of foodthat patient is eating. Possible exhaustionexperienced by the patient when she coughs.(http://en.wikipedia.org/wiki/Muscle_weakness)Abnormal

Abnormal

Abnormal

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