1.physical Assessment

III.

PHYSICAL ASSESSMENT

ACTUAL VITAL SIGNS RR- 20 PR- 80 BP- 120/70

NORMAL VALUES 12-20 beats/min. 60-100 beats/min. 90/60- 130/90 mmHg

INTERPRETATION Normal Normal Normal

Height = 5’1 ft. Weight = 57 Kg. Body Parts Head

Technique used Inspection Palpation

Hair and scalp

Inspection

Eyes

Inspection

Normal findings Normocephalic No abnormal mass Evenly distributed, Thick hair, no infection and infestation Symmetric to the face, both eyes coordinated with parallel alignment.

Actual findings Normocephalic No abnormal mass Even distribution of hair , no infection and infestation Sunken eyeball

Significance

Hair evenly distributed, Skin intact Equally distributed, Curled slightly outward Skin intact, No discharge, No discoloration, Lids close symmetrically No edema or tearing.

Evenly distributed with skin intact Equally distributed, Curled slightly outward Skin intact, no discharge, no discoloration, lids are symmetrical.

Normal

No edema and tearing

Normal

Normal Normal Normal

Not Normal. Due to dehydration

External eye Structure Eyebrows

Inspection

Eyelashes

Inspection

Eyelids

Inspection

Lacrimal gland

Inspection

Normal

Normal

Pupils (color , shape and symmetry of size)

Inspection

Ears

Inspection

Nose

Inspection

Black in color, equal in size normally 3-7 mm in diameter, round smooth border , iris flat and round.

Black in color, equal in size 4mm in diameter

Normal

Symmetrically aligned to the face, firm and not tender with no discharged noted. Symmetric and straight, no discharges or flaring

Positioned symmetrically to the face, No notable ear discharge, clean and dry,. Symmetric and straight , no nasal discharges noted, no flaring noted

Normal

Uniform dark color Not Normal dry due to chemical content of cigarette such as nicotine. Dry and free of Normal lesion

Normal

Mouth Lips

Inspection

Uniform pink in color, soft and moist and smooth

Tongue

Inspection

Teeth

Inspection

Tongue at midline without lesion Complete, white, shiny tooth enamel, free of debris

Neck

Inspection

Palpation

Coordinated , smooth movement with no discomfort No masses, tenderness

Incomplete, missing teeth, ill fitting dentures

Coordinated movement with no discomfort No masses, tenderness

Not normal. Aging is a factor affecting loss of teeth and also insufficient calcium and fluoride. Normal

Normal

Upper Extremities Skin

Arms

Inspection

Pinkish in color

Pallor

Palpation

Slightly moist

Poor skin turgor

Palpation

Normothermia

Inspection

Normally firm, no contracture, no swelling, equal size on both sides of body Pulse Rate: 60100 Smooth, highly vascular and intact epidermis Capillary Refill of 1-2 seconds Symmetric chest expansion, quiet, rhythmic and effortless respiration

Palpation Nails

Inspection

Palpation Chest and Lungs

Inspection

Palpation Auscultation Heart

Auscultation

Not normal. It is a manifestation of in adequate circulating blood or hemoglobin.

Not normal due to dehydration Not warm, not cold Normal to touch, T=36 Normally firm, no Normal contracture, no swelling, equal size on both sides of body Pulse rate: 80

Normal

Pink, smooth texture, convex curvature

Normal

Capillary refill: 2 seconds Symmetric chest expansion, quiet, rhythmic and effortless respiration

Normal

No retraction, no tenderness, no masses Quiet, rhythmic

No retraction, no tenderness, no masses Adventitious breath sounds

Normal

Normal heart rate 60100bpm

Cardiac rate of 80

Normal

Not normal due to presence of secretion Normal

Abdominal

Inspection

Unblemished skin, uniform in color

Lesions noted on the surgical site

Not normal because of post procedure done

Auscultation

Average normal bowel sounds 5-25 per minute

Audible bowel sound of 8 per minute

Normal

Inspection

No lesion, can move freely

Normal

Palpation

Capillary refill: 1-2 seconds

No edema, no deformities and can move freely Capillary refill: 2 seconds

Lower extremities Skin

Normal