Physical Assessment Compilation Final

PHYSICAL ASSESSMENT

Date of Physical Assessment: July 06, 2011 / 6:55pm 6days Post op

BMI: 30.18 obese class 1

Height:5’6”

Weight: 85kg. 187lbs.

Vital Signs:

BP: 120/90mmhg

Temperature: 37.3C

Pulse rate: 89bpm

Respiratory rate: 29cpm

Pain Scale: 3

General Observations:

The patient was restless, conscious, coherent, oriented to time, person, and place. He has

thrombo embolic stockings on both lower extremities and had undergo laminectomy (June 30,

2011) on the thoracic (T9) and therefore completely limited in mobilization. Hemovac at the

back was noted and complain for back pain.

BODY PARTS

METHODS OF

ASSESSMENT

NORMAL ACTUAL FINDINGS

INTERPRETATION

Skin Inspection Color: skin is uniform whitish pink or brown in color.

No bleeding and ecchymosis and vascularity

Lesions: no skin lesions are present except for birthmarks or moles which may be flat or elevated.No edema present

The overall appearance of the skin is light brown

Some elevated circumscribed fluid-filled less than 1cm in diameter was noted at the upper back.

The blood supply particularly at the back area decreased (due to prolong lying in bed). Thus insufficient amount of oxygen cause skin lesions (vesicle) and dry skin is an indication of decrease fluids in the body and frequent turning on the bed.

(Fundamentals of nursing, 6th ed page 687).

Palpation Moisture in skin Generally dry and Dry skin probably due

folds varies with the environment

Skin turgor: when released should return to original contour rapidly and no edema is present.

warm

to environment

(Kozier, Skill 30-2 p.579)

Head

a. Skull

Inspection Rounded (normocephalic) and asymmetric with frontal, parietal, temporal, occipital and prominences:

Normocephalic, with prominences in the frontal and occipital area

The shape of the head is normocephalic.

The shape is gently curve with prominence at the frontal and parietal bones.

(Fundamentals of nursing taylor 6th ed. vol.1 page616 )

b. Scalp Palpation Smooth skull contour absence of nodules or masses

The scalp is moist, symmetrical and firm.

No lesions and mass noted

The scalp is moisten showing normal for a scalp

(Fundamentals of nursing taylor 6th ed. vol.1 page614)

c.Hair Inspection Color:dark black to blonde; may turn gray or white; may be chemically distributed

The hair is dark brown in color. The texture was fine, smooth and thin slightly curly hair. Equally distributed and no signs of alopecia and lice.

Client manifests normal findings

Face Inspection Face is symmetrical

Shape is gently curved with prominences at the frontal and parietal bones

Symmetrical. No involuntary muscle movement


Palpation Smooth uniform consistency; absence of nodules or masses

Smooth uniform consistency; absence of nodules or masses


Eyes Inspection Should be Eyebrows equally No significant

symmetrical with no dropping infection, tumors or other abnormalities with the visual acuity of 20/20

Sclera: white without exudates, lesions foreign bodies in dark skinned may have brown patches

Pupils: deep black, round and equal diameter of 2-6mm PERRLA

No tearing, swelling or discharge in conjunctiva

distributed and dark brown in color

Eyelashes slightly curved upward evenly distributed and color is same with eyebrows

Eyelids function normally

Conjunctiva is moist and pinkish

Cornea is smooth and transparent

Sclera: white without exudates

Pupil size: 4mm; equal reaction to light; right and left briskly reactive to light

Reaction to accommodation; uniform constriction grossly normal vision 20/20 intact peripheral vision

findings

Ears Inspection External ear gently no pain, edema, and lesions

Earlobes are bean shaped, parallel, and symmetrical. Skin is same color as complexion

Ear canal and the tympanic membrane should be intact,

External pinnae: normoset

External canal has no unusual discharges

Tympanic membrane is intact and pearly gray in colorGross hearing are symmetrically

No significant findings

translucent, shiny, and pearly gray in color

No redness and discharge

Assessing hearing sounds one ear at a time can hear whispered voice and ticking watch from distance of 1-2 feet

normal

Nose Inspection

Palpation

Nose is in the midline and is symmetrical,No unusual discharges,No nasal flaring,Both nares are patent,No bones and cartilage deviation,Nasal septum is in the midline,andNasal mucosa is pink in color

No pain, tenderness and discomfort during palpation

Septum is in the midline, Mucosa is pinkish, Both nares are patent,Gross smell are symmetrical and No unusual discharge

There is no pain upon palpation and noswelling and tenderness of the paranasal sinuses



Mouth Inspection Lips are pink and moist with no lesions or

Lips are dry and no edema noted.


inflammation. Tongue is in the midline, pink, moist, rough without lesions. taste buds are white in color

Symmetrical: moves freely. Gums are paled red stripped surface

No swelling or bleeding

Gums are pink, no gum bleeding and no lesions noted.Tongue is in midline that moves freely and no dentures.

Buccal mucosa is pink and moist.

Uvula is in midline. Pink and not swelling same as with the tonsils

Nails Inspection

Palpation

Color: have a pink cast in light-skinned brown in dark skinned

Shaped and configuration is surface is smooth and slightly rounded or flat. Curved nails are normal. Uniform nails thickness throughout; no splintering or brittle edges

Capillary refill present should return to 2-3 seconds

Light pink in color, convex in shape

Has a capillary refill of 2-3 seconds



Neck Inspection

Palpation

Symmetrical with head in central position able to move freely without discomfort or noticeable limits

Muscles should be symmetrical without

Trachea is in the midlineNo jugular vein engorgementNormal range of motionAnd has a muscle grading of 4

Cervical lymph nodes are not


No significant

palpable masses or lumps

palpable and non-tender

findings

Chest Inspection

Palpation

Percussion

Auscultation

Skin is intact without lesions, same as skin color, Spine vertically aligned, No kyphosis, scoliosis and lordosis, Full and symmetric chest expansion

Without nodules

Resonant

Quiet, rhythmic and effortless breathing

Without lesions; with skin intact

Rapid shallow breathing

Partial chest expansion upon respiration

Without nodules, no masses upon palpation

Resonant located at 4th intercostals space right anterior axillary

Crackles (rales) at the right lower lobes of the lung during inspiration

Tachypnea is rate of breathing regular but abnormally rapid greater than 20 breaths per minute.

The patient has respiratory rate of 29 beats per minute.

It result from pulmonary irritation and heightened oxygen demandresult from pain and anxiety

(kozier, skills 30-31 p.614)



Rales heard upon auscultation indicates pulmonary tuberculosis

(kozier, skill 30-31 p. 616)

Thoraxa. An-

te-rior

Inspection

Palpation

Auscultation

Skin intact

No tenderness and no masses

Bronchovesicular and vesicular sounds are heard above and below the clavicles and along the lung periphery

Bronchial sound can be heard over the trachea

Skin intact

No tenderness and no masses upon palpation

Respiratory rate of 29 beats per minute was noted

Bronchial sound heard over the trachea loud, high pitch and hollow sounding, with expiration lasting longer than inspiration




b. Pos-te-rior

Inspection

Palpation

Auscultation

Anteroposterior to transverse diameter in ratio 1:2; chest symmetric;Spine vertically aligned;Skin intact; Chest wall intact

Uniform temperature; no tenderness; no masses; no lumps symmetrical chest excursion of at least 5 cm; presence of pulsation and no unusual movement

Normal breath sounds heard over the

Lateral deviation of spine noted

Chest excursion symmetrical about 5 cm apart, no masses and tenderness upon palpationPulsation is present, no lumps and unusual movements

Fine crackles noted on the right and left lung bases

The disease (Potts) is characterized by bone destruction and abscess formation

(Pathophysiology 6th edition by Carol Mattson Porth p. 133)


Fine crackles signifies pulmonary

posterior thorax includes bronchovesicular and vesicular sounds heard above and below the clavicles and along the lung peripheryand the abnormal sounds or adventitious sounds

tuberculosis

(Fundamentals of Nursing, 6th edition, potter-perry, p.721)

Heart Auscultation There is no lifts and heaves and there is no presence of heart murmurs

Heart murmurs noted upon auscultation at the end of the systolic and diastolic phase.

Increased blood flow through a normal valve, forward flow through a stenotic valve or into a dilated vessel or heart chamber, or backward flow through a valve that fails to close

(Fundamental of Nursing, 6th edition, potter-perry, p.726)

Abdomen Inspection

Auscultation

Abdominal contour is flat or rounded, symmetrical and uniform in color

Normally air and fluid move through intestine, creating soft gurgling or clicking sounds that occur 5-35 times per minute

Sounds are generally described as normal, audible, absent, hyperactive or

The clients abdomen is rounded, uniform in color, and no scars noted

Bowel sound is hypoactive


Hypoactive bowel sound indicate gastrointestinal motility


Percussion

Palpation

hypoactive

Tympany over the stomach and gas filled bowels; dullness specially over the liver and spleen, or a full bladder

No tenderness, relaxed abdomen with smooth, consistent tension bladder and liver is not palpable

Dull percussion noted over the liver

Abdominal tenderness and distension noted on the lower left quadrant of the abdomen


Tenderness and distension signifies decreased bowel movement


Musculoskeletal

Inspection

Palpation

Muscles has equal size on both sides of the body, no contractures, no fasciculation, or tremors

Bones has no deformities

Joints has no swelling

Muscles are firm, has smooth coordinated movements

Bones has no

Muscle weakness noted at lower extremities with the grade of 4+ hyperactive and very brisk

Acute pain noted upon palpation of lower extremities

Hyperactive and very brisk muscle grading often associated with spinal cord disorders


Spinal cord disorders can cause spinal nerve compression causing pressure damage includes pain


Extremities Inspection Bilateral symmetry without any presence of deformities, edema and discoloration. Intact.

Hands are steady and no tremor noted.

However muscle weakness and numbness when hyperflexion, and positive from joint pain with pain scale of 5/10 were noted on the lower extremeties.

The most common sensory deficit from spinal nerve root compression are paresthesias and numbness particularly of the leg and foot

(Pathophysiology by Carol Matson Porth 7th edition page 1205)

Palpation Glasgow coma scale is 15

Positive reflexes such as biceps reflex, triceps reflex, brachioradialis reflex, patellar reflex and Achilles reflex

Glasgow coma scale is 15

Positive reflexes such as Brachioradialis reflex, patellar reflex and Achilles reflex


Cranial Nerves I Olfactory By asking

patient to close his eyes and identify different mild aromas.

Identify different mild aromas such as coffee, vanilla, peanut butter, orange, lime, chocolate

Able to identifymild aromas such as coffee, vanilla, peanut butter, orange, lime, chocolate


II Optic The nurse will ask the patient to read snellen

Ability to clearly visualize the snellen chart; check visual fields by

Able to clearly visualize the snellen chart; check visual fields by


chart; check visual fields by confrontation

confrontation confrontation

III Oculomotor

The nurse will be assessing the six ocular movements and pupil reaction of a patient

Ablility to perform extraocular eye movement (EOM); movement of sphincter of pupil; movement of ciliary muscles of lens

Able to perform extraocular eye movement (EOM); movement of sphincter of pupil; movement of ciliary muscles of lens


IV Trochlear The nurse will be assessing the six ocular movements of a patient.

Ablity to perform extraocular eye movements specifically movements of eyeballs downward laterally

Able to perform extraocular eye movements specifically movements of eyeballs downward laterally


VTrigeminal Thenurse lightly touches the lateral sclera of the eye while the patient is looking upward. To test light sensation, have the client close eyes, wipe a wisp of cotton over patient’s forehead and paranasal sinuses. Ask client to clench teeth.

Pesence of blink reflex; can feel the sensation of skin of face and nasal mucosa; able to feel the sensation of anterior oral cavity; mastication of muscles

Patient has presence of blink reflex; can feel the sensation of skin of face and nasal mucosa; able to feel the sensation of anterior oral cavity; mastication of muscles


VI Abducens The nurse will be assessing the

Ability to move eye balls laterally

Able to move eye balls laterally


directions of gaze.

VII Facial The nurse will ask the patient to smile, raise eyebrows, frown, and puff out cheeks, close eyes tightly. Identifying various tastes placed on tip and sides of tongue.

Ability to perform different facial expressions; able to identify different tastes

Able to perform different facial expressions; able to identify different tastes in tongue (sweet, bitter, sour, salty).


VIII Auditory

The nurse will be assessing the patient’s ability to hear spoken word and vibrations of tuning fork.

Ability to clearly hear spoken words and vibrations of tuning fork

Able to clearly hear spoken words and vibrations of tuning fork. Romberg’s test performed, the patient stood up and asked to close his eyes a loss of balance is interpreted.


IX Glossopharyngeal

The nurse will be applying tastes on posterior tongue for identification. Asking the patient to move tongue from side to side and up and down.

Ablity to move the tongue from side to side and up and down; no difficulty in swallowing;; able to identify different taste on posterior tongue

Able to move the tongue from side to side and up and down; no difficulty in swallowing;; able to identify different taste on posterior tongue


X Vagus The nurse will do palpation on the pharynx and larynx,

Palpable pharynx and larynx by stimulating; presence of gag reflex; no presence of

Pharynx and larynx are palpable; patient swallows and says “Ah” presence of gag reflex; there was no

Patient has normal findings

assessing the gag reflex with the use of tongue depressor and assess the presence of hoarseness.

hoarseness of client’s speech

presence of hoarseness of client’s speech

XI Accessory The nurse

will apply pressure on patient’s shoulders and ask patient to shrug shoulders against resistance and turn head to side against resistance from the nurse hand.

Ablity to shrug shoulders against resistance and able to turn to side against resistance without any difficulty

Able to shrug shoulders against resistance and able to turn to side against resistance without any difficulty


XII Hypoglossal

By asking patient to protrude tongue at midline and move it side to side and up and down

Ability to protrude tongue at midline and move up and down and side to side

Able to protrude tongue at midline and move up and down and side to side


Documents

Physical Assessment Compilation Final