8. V_Physical Assessment of Client Rosa

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)


The client can doflexion approximately150 and extensionabout 150

Normal

Upper extremities(hands)


She was able to doflexion about 90,extension about 90,hyperextension about30, abduction about20 and adductionabout 20

Normal

Lower extremities(acetabulum/iguinalarea)


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

Documents

8. V_Physical Assessment of Client Rosa