Physical Assessment

Physical Assessment Name: C.C. Age: 26 years old Birth Date: June 8, 1983 Temperature: °C, oral Pulse Rate: bpm Respiratory Rate: cycles/minute Blood Pressure: / mmhg Part I

Behavior 1. Height

2. Weight

3. BMI

Normal Findings - medium frame: 150cm (height) 111-123lbs (weight) Metric Conversion Weights and other measurements by A.M. Batubalani page 79 - medium frame: 150cm (height) 111-123lbs (weight) Metric Conversion Weights and other measurements by A.M. Batubalani page 79

- n/a

Interpretation / Analysis - n/a

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- 18.5 to 24.9 http://www.nhlbisupport.com/bmi/bmicalc.ht m

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General Survey 5. Body built in relation to lifestyle and health

6. Client’s posture, gait, standing, sitting, and walking

7. Client’s overall hygiene and grooming 8. Body and breath odor

9. Signs of distress in posture of facial expression

Normal Findings - Proportionate, varies with lifestyle Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 572 - Relaxed erect posture, sit and stand in an upright position, coordinated movement Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 572 - Clean and neat Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 572 - No body odor or minor body odor relative to work or exercise; no breath odor Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 572 - No distress noted Kozier and Erb’s Fundamentals of Nursing

Actual Findings

Actual Findings -The client is medium in her body built.

Interpretation / Findings -Normal

- The client’s posture, sit and stand in an

-Normal

- Well groomed and properly dressed

- Normal

- Presence of minor body odor. No breath odor

- Normal

- No distress noted

-Normal

10. Obvious signs of health or illness 11. Client’s attitude

12. Client’s affect / mood; appropriateness of the clients response 13. Quality and quantity of voice

14. Relevance and organization of thoughts

Integumentary 15. Uniformity of color

16. Presence of edema

17. Presence of lesions according to location, distribution, color, configuration, size, shape, type or structure 18. Skin moisture

8th Edition Vol.1 page 572 - Healthy appearance Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 572 - Cooperative, able to follow instructions Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 572 - Appropriate to the situation Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 572 - Understandable, moderate pace, clear tone Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 572 - Logical in sequence, makes sense, has sense of reality Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 572 Normal Findings - Varies from light brown, from ruddy pink and light pink, from yellow overtones to olive -Generally uniform except in areas exposed to sun, areas of lighter pigmentation Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 579 - No edema Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 579 - Freckles, some birthmarks, some flat and raised nevi, no abrasions or other lesions Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 579 - Moisture in skin folds and the axillae (varies with environmental temperature, humidity, body temperature and activity).

- Healthy appearance

- Normal

- The client cooperates and follows instructions during the procedure

- Normal

- Acts appropriate to the situation

- Normal

- The client speaks with moderate pace, clear tone of voice, organization of thoughts and understandable - The client exhibits organization of thought, coherence, and sense of reality

- Normal

Actual Findings - The client has a dark brown in color, varies in color with skin which are not exposed to the sun

Interpretation / Findings - Normal

- Absence of edema

- Normal

- Presence of freckles and flat nevi. No lesions or abrasions

- Normal

- Presence of moisture in the axillae

- Normal

- Normal

19. Skin temperature

20. Skin turgor

Nails 21. Finger nails plate shape to determine its curvature and angle 22. Fingernail and toe nail bed color

23.Fingernail and toenail structure 24. Inspect tissues surrounding nails 25. Blanch test of capillary refill

Head Skull 26. Inspect the skull for size, shape or symmetry

27. Palpate for nodules, masses, and depressions

Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 579 - Uniform and with normal range Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 579 - When pinched, skin turn back to its previous state; may be slower in elders Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 580

- Warm skin temperature

- Normal

- Skin recoils to its original position when pinched

- Normal

- Convex curvature; angle of nail plate about 160° Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 584 - Highly vascular and pink in light skinned clients; dark skinned clients may have brown or black pigment arrow in longitudinal streaks. Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 584 - Smooth texture Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 583 - Intact epidermis Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 584 - Prompt return of pink or usual color (generally less than 4 seconds) Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 584

- Convex in curvature with 160° in angle

- Normal

- Highly vascular and pink in light skinned clients; dark skinned clients may have brown or black pigment arrow in longitudinal streaks.

- Normal

- Smooth texture

- Normal

- No hangnails and inflammations

- Normal

- Prompt return of pink or usual color (generally less than 4 seconds)

- Normal

Normal Findings

Actual Findings

- Rounded (normocephalic and symmetric, with frontal, parietal, and occipital prominences); smooth skull contour Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 585 - Smooth, uniform consistency; absence of

Interpretation / Findings

- Proportionate to body size, symmetric, smooth

- Normal

- Smooth, absence of nodules or masses,

-Normal

Scalp 28. Inspect for color and appearance

29. Palpate for areas of tenderness

Hair 30. Inspect for evenness of growth, thickness, and thinness 31. Palpate for texture and oiliness over the scalp

Face 32. Inspect facial features and symmetry of facial movement

Eyes Visual Acuity 33. Test near vision

34. Test distance vision

Eyebrows 35. Inspect the distribution of hair and symmetry of eyebrows

nodules or masses Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 585

uniform consistency

- White and clean, absence of lesions Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 585 - Absence of tenderness, masses and nodules Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 585

- White and clean, no lesions noted

- Normal

- Absence of tenderness

- Normal

- Evenly distributed hair; thick Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 585 - Silky; resilient hair; small amount of oil present Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 585

- Evenly distributed and thick

- Normal

- Absence of excessive oil production

- Normal

- Symmetric or slightly asymmetric facial features. Symmetric facial movements Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 585

- Symmetric facial features and facial movements

- Normal

Normal Findings

Actual Findings

- Able to read newsprint at the distance of 14 inches Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 592 - 20 / 20 vision on Snellen – type chart Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 582

- Able to read newsprint at the distance of 14 inches

- Normal

- 20 / 20 vision on Snellen – type chart

- Normal

- Hair evenly distributed; skin intact - Eyebrows symmetrically aligned; equal movement Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 588

- Hair in the eyebrows was evenly distributed. Eyebrows are symmetrically aligned; equal in movement

- Normal

Interpretation / Findings

Lacrimal gland, Lacrimal Sac, and Nasolacrimal Duct 36. Inspect and palpate the Lacrimal gland

Eyelids 37. Inspect for the surface characteristics, position in relation to the cornea, ability to blink, and frequency of blinking

Eyelashes 38. Inspect the eye lashes for evenness of distribution and direction of curl Conjunctiva 39. Inspect the bulbar conjunctiva (lying above the cornea) for color, texture, and presence of lesions

40. Inspect the palpebral conjunctiva (lining the eyelids) for color, texture, and presence of lesion Sclera 41. Inspect the color and clarity Cornea 42. Inspect the cornea for clarity and texture

- No edema or tenderness over Lacrimal gland Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 589

- No edema or tenderness present over Lacrimal gland

- Normal

- Skin intact; no discharge; no discoloration - Approximately 15 – 20 involuntary blinks per minute; bilateral blinking - When lids are open, no visible sclera above corneas, and upper and lower borders of cornea are slightly covered Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 588

- Skin are intact, no excessive discharge present and discoloration - The client can blink without any alterations - Frequency: 18 blinks

- Normal

- Equally distributed; curled slightly outward Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 588

- Eyelashes are equally distributed and slightly curled outward

- Normal

- Transparent; capillaries sometimes evident; sclera appears white (darker or yellowish and with small brown macula in darkskinned clients) Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 588 - Shiny, smooth, and pink red Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 588

- Transparent and clear

- Normal

- Shiny, pink in color, no lesions present

- Normal

- White and clear Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 589

- White and clear

- Normal

- Transparent; shiny, and smooth; details of the iris are visible. In older people, a thin, grayish white ring around the margin, called arcus senilis, may be evident Kozier and Erb’s

- Transparent; shiny, and smooth; details of the iris are visible. In older people, a thin, grayish white ring around the margin, called arcus senilis, may be evident

- Normal

43. Corneal sensitivity Test (reflex); ask the client to keep both eyes open and look straight ahead. Approach from behind and lightly touch the sclera of the client with the corner of the gauze Iris 44. Inspect the color and shape

Pupil 45. Inspect for color, shape, and symmetry of size

46. Test pupil for light reaction and accommodation

Visual Field 47. Test Peripheral fields

Extraocular Muscles 48. Assess six ocular movements to determine eye alignment and coordination.

Ears Auricles 49. Inspect for color, symmetry and position

Fundamentals of Nursing 8th Edition Vol.1 page 589 - Client blinks when the cornea is touched, indicating that the trigeminal nerve is intact Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 589

- The client blinks when the cornea was touched by the gauze

- Normal

- Color varies; oval, circular and flat Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 590

- Color brown and flat

- Normal

- Black in color; equal in size; normally 3 to 7 in diameter; round; smooth border Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 590 - Illuminated pupils constrict, no illuminated pupil constrict - Pupil constrict when looking at near object; pupils dilate when looking at far object; pupils converge when near object is moved toward nose Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 589

- Black in color, 5 in diameter, equal in size

- Normal

- Both pupils react to light; pupil constrict and dilates when near object is moved toward and away to the nose

- Normal

- When looking straight ahead, client can see objects in the periphery Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 591

- When looking straight ahead, client can see objects in the periphery

- Normal

- Both eyes coordinates, move in unison, with parallel alignment Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 592

- Both eyes move in unison with parallel alignment

- Normal

Normal Findings

Actual findings

- Color same as facial skin; symmetrical. Auricle aligned with outer canthus

- Color same as facial skin; symmetrical, aligned with the outer canthus of

Interpretation / Findings - Normal

50. Palpate for texture, elasticity and areas for tenderness

External Ear Canal 51. Inspect ear canal for cerumen, skin lesions, pus, blood

Hearing Auricle Test 52. Assess client’s response to normal voice tone 53. Perform watch tick test

54. Perform Weber’s Test

55. Perform Rinne Test

Nose 56. Inspect for any deviations in shape, size, or color and flaring or discharge from nares 57. Inspect for nasal cavities for the presence of redness, swelling, growths and discharge, using the

of eye, about 10° from vertical Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 596 - Mobile, firm and not tender; pinna coils after it is folded Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 596

the eye

- Mobile, firm, not tender; pinna coils after it is folded

- Normal

- Dry cerumen, grayish tan color; or sticky, wet cerumen in various shades of brown Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 596

- Wet cerumen, yellow in color; absence of pus and blood

- Normal

- Normal voice tones audible Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 597 - Able to hear ticking in both ears Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 597 - Sound is heard in both ears or is localized at the center of the head (Weber’s Negative) Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 597 - Air conducted (AC) hearing is greater than bone conducted (BC) hearing Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 598

- Client responds to normal voice tone

- Normal

- The client was able to hear the ticking of the watch in both ears

- Normal

- Sound is heard in both ears

- Normal

- Air conducted is greater then bone conducted

- Normal

Normal Findings - Symmetric and straight; no discharge or flaring; uniform color Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 600 - Mucosa pink; clear watery discharge; no lesions Kozier and Erb’s

Actual Findings - Symmetric and straight; absence of discharge; uniform in color

Interpretation / Findings - Normal

- Mucosa pink; absence of lesions

- Normal

flashlight 58. Inspect the nasal septum between nasal chambers 59. Test patency of both nasal cavities

60. Palpate for any tenderness, masses displacements of bone and cartilage Sinuses 61. Locate/ palpate/ identify the sinuses and note for tenderness

Mouth Lips 62. Inspect for symmetry of contour, color and texture

Buccal Mucosa 63. Inspect for color, moisture, texture, and presence of lesions

Teeth 64. Inspect for color, number and condition, presence of dentures

Gums 65. Inspect for the color and condition

Fundamentals of Nursing 8th Edition Vol.1 page 600 - Nasal septum intact and in midline Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 600 - Air moves freely as the client breathes through the nares Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 600 - Not tender, no displacements of bone or cartilage Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 800 - No tenderness Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 800 Normal Findings

- Nasal septum intact and in the midline

- Normal

- Both nasal cavities are patent

- Normal

- Absence of tenderness and any kind of displacements

- Normal

- No tenderness present

- Normal

Actual findings

Interpretation / Findings

- Uniform; pink in color; moist, soft, smooth texture; symmetry of contour. Ability to purse lips Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 602

- Pink in color, moist, symmetrical, has the ability to purse lips

- Normal

- Uniform, pink in color, moist, smooth, soft, glistering and has a elastic texture Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 602

- Uniform, pink in color, moist, smooth, glistering and elastic

- Normal

- 32 adult teeth, smooth, white, shiny tooth enamel, smooth intact dentures Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 602

- 32 adult teeth, smooth, white, shiny tooth enamel, smooth intact dentures

- Normal

- Pink gums, moist, firm texture to gums, no retraction of gums Kozier and Erb’s Fundamentals of Nursing

- Pink gums, moist, firm texture to gums, no retraction of gums

- Normal

8th Edition Vol.1 page 602 Tongue/ Floor of the mouth 66. Inspect for the color and texture of the mouth floor and frenulum 67. Inspect and palpate the position, color, and texture, movement and base of the tongue

68. Palpate for any nodules, lumps, or excoriated areas Palates and Uvula 69. Inspect and palpate for color, shape, texture, and the presence of bony prominences

70. Inspect for position of the uvula and mobility while examining the palates Oropharynx and tonsils 71. Inspect and palpate for color, and texture (one side at a time to avoid eliciting gag reflex) 72. Inspect the size of the tonsils, color, and discharge

73. Elicit the gag reflex by pressing the posterior tongue

- Smooth tongue base with prominent veins Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 603 - Central position, pink in color, moist, slightly rough, thin whitish coating, smooth lateral margins, no lesions, raised papillae, moves freely, no tenderness Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 603 - No palpable nodules Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 603

- Smooth tongue base with presence of some prominent veins

- Normal

- Located at the center, pink in color, moist with whitish coating, o lesions, no tenderness, moves freely

- Normal

- Absence of nodules

- Normal

- Light pink, smooth, soft palate: light pink hard palate: more regular in texture Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 604 - Positioned in midline of soft palate Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 603

- Light pink, smooth, soft palate: light pink hard palate: more regular in texture

- Normal

- Positioned in the midline of the soft palate

- Normal

- Pink and smooth posterior wall Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 604 - Pink and smooth, no discharge, normal size Grade 1: normal the tonsils are behind the tonsillar pillars (the soft structures supporting the soft palate) Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 604 - Present Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 604

- Pink, smooth surface

- Normal

-Pink and smooth, grade 1

- Normal

- Present

- Normal

Neck and Lymph Nodes Lymph Nodes 74. Locate/ palpate/ identify lymph nodes and note for tenderness Trachea 75. Inspect and palpate for placement

Normal Findings

Actual Findings

Interpretation / Findings

- No tenderness Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 607

- No tenderness

- Normal

- Central placement in the midline of the neck; spaces are equal in both sides Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 608

- Located at the midline of the neck

- Normal

- Not visible in palpation. Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 608 - Lobes may not be palpated. If palpated, lobes are small, smooth, centrally located, painless and rise freely with swallowing Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 609

- Not visible

- Normal

- Located at the midlines of the neck, moves freely

- Normal

Thyroid Gland 76. Inspect symmetry and visible masses 77. Palpate for smoothness and areas of enlargement, masses or nodules

Part II Thorax Posterior Thorax 78. Inspect the size, shape, symmetry, and compare the diameter of anteroposterior thorax to transverse diameter 79. Inspect the spinal alignment 80. Palpate for temperature, tenderness and masses

81. Asses respiratory excursion 82. Palpate focal fremitus

Normal Findings

Actual Findings

Interpretation / Findings

- Anteroposterior to transverse diameter with a ratio of 1:2 Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 614 - Spine vertically aligned Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 614 -Temperature is within in normal range, no tenderness and masses Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 614 - Full and symmetric Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 615 - Bilateral symmetric vocal fremitus Kozier and Erb’s

- The anteroposterior and transverse diameter has a ratio of 1:2

- Normal

- Spine vertically aligned

- Normal

- Temperature is within normal range, no tenderness and masses

- Normal

- Full and symmetric

- Normal

- Bilateral vocal fremitus

- Normal

83. Percuss the posterior thorax

84. Auscultate the posterior thorax

Anterior Thorax 85. Inspect breathing pattern

86. Palpate for temperature, tenderness and masses

87. Asses respiratory excursion 88. Palpate vocal / tactile fremitus

89. Percuss the anterior thorax

90. Auscultate the trachea

91. Auscultate the anterior thorax

Fundamentals of Nursing 8th Edition Vol.1 page 615 - Lowest point of resonance is at the diaphragm Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 616 - Vesicular and bronchovesicular breath sounds Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 616 - Quiet, rhythmic and effortless respiration Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 617 - Temperature is within in normal range, no tenderness and masses Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 617 - Full and symmetric Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 617 - Same as posterior vocal fremitus, fremitus is normally decreased over heart and breast tissue Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 617 - Percussion note resonate done to the sixth rib at the level of diaphragm but are flat over areas of heavy muscles and bone, dull on areas over the heart and liver, and tympanic over the underlying stomach Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 617 - Bronchial and tubular breath sounds Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 618 - Bronchovesicular and vesicular breath sounds Kozier and Erb’s Fundamentals of Nursing

- Lowest point of the resonance is at the diaphragm

- Normal

- Vesicular and bronchovesicular breath sounds

- Normal

- Quiet, rhythmic and effortless respiration

- Normal

- Temperature is within normal range

- Normal

- Full and symmetric

- Normal

- Same as posterior vocal fremitus

- Normal

- Percussion note resonate done to the sixth rib at the level of diaphragm but are flat over areas of heavy muscles and bone, dull on areas over the heart and liver, and tympanic over the underlying stomach

- Normal

- Bronchial and tubular breath sounds

- Normal

- Bronchovesicular and vesicular breath sounds

- Normal

8th Edition Vol.1 page 618 Cardiovascular Simultaneously INSPECT and PALPATE the precordium for the presence of abnormal pulsations, lifts and heaves 92. Aortic and Pulmonic Areas 93. Tricuspid Areas

94. Apical Area (Locate point of maximal impulse)

95. Auscultate the aortic, pulmonic, tricuspid, and apical valves

Carotid arteries 96. Palpate carotid artery with extreme caution

97. Auscultate the carotid arteries Jugular Veins 98. Inspect Jugular Veins

Normal Findings

Actual Findings

Interpretation / Findings

- No pulsations Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 621 - No pulsations Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 622 - Pulsations visible on 50% of adults and palpable in most PM/ in 5th LICS or at medial to MCL Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 622 - Usually louder at apical area - Usually louder at the base of the heart - systole: silent interval; slightly shorter duration than diastole at normal heart rate - diastole: silent interval, slightly longer duration than systole at normal heart rates Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 622

- No pulsations

- Normal

- No pulsations

- Normal

- Palpable in 5th LICS

- Normal

- Usually louder at apical area - Usually louder at the base of the heart - systole: silent interval; slightly shorter duration than diastole at normal heart rate - diastole: silent interval, slightly longer duration than systole at normal heart rates

- Normal

- Symmetric pulse volumes - Full pulsations, thrusting quality Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 622 - No sound heard Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 623

- Symmetric pulse volumes with full pulsations

- Normal

- No sound heard

- Normal

- Veins not visible Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 623

- Veins not visible

- Normal

(Note: the client refused to be examined at the breast and abdomen area) Breast and Axillae Normal Findings Actual Findings 99. Inspect breast for size, - Rounded in shape, - Rounded in shape, symmetry, contour, or slightly unequal in size, slightly unequal in size, shape while the client is in generally symmetric generally symmetric sitting position Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 628 100. Inspect the skin of the - Skin uniform in color - Skin uniform in color breast for localized (same in appearance as (same in appearance as discolorations or skin of abdomen or back) skin of abdomen or back) hyperpigmentation, - Skin smooth and intact - Skin smooth and intact retraction, dimpling, Kozier and Erb’s localized hypervascular Fundamentals of Nursing areas, swelling or edema 8th Edition Vol.1 page 628 101. Inspect the areola for - Round or oval and -- Round or oval and size, shape, symmetry, bilaterally the same bilaterally the same color, surface - Color varies widely from - Color varies widely from characteristics, and any light pink to dark brown light pink to dark brown mass or lesions Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 628 102. Inspect the nipples - Round, everted, and - Round, everted, and for size, shape, position, equal in size, similar in equal in size, similar in color, discharge, and color, soft and smooth, color, soft and smooth, lesions both nipples point in same both nipples point in same direction direction - No discharge except - No discharge except from pregnant women from pregnant women - Inversion of one or both - Inversion of one or both nipples that I present from nipples that I present from puberty puberty Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 628 103. Palpate the axillary, - No tenderness, masses, -- No tenderness, masses, subclavicular and or nodules or nodules superclavicular lymph Kozier and Erb’s nodes Fundamentals of Nursing 8th Edition Vol.1 page 629 104. Palpate breast for - No tenderness, masses, - No tenderness, masses, masses, tenderness nodules, or nipple nodules, or nipple discharge discharge Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 629 105. Palpate nipples for - No tenderness, masses, -- No tenderness, masses, tenderness and discharges nodules, or nipple nodules, or nipple discharge discharge Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 629 Abdomen 106. Inspect the abdomen for skin integrity

Normal Findings - Unblemished skin - Uniform color

Actual Findings - Unblemished skin - Uniform color

Interpretation / Findings -Normal

- Normal

- Normal

- Normal

- Normal

- Normal

- Normal

Interpretation / Findings - Normal

107. Inspect the abdominal contour (profile the line from rib margin to the pubic bone) while standing at the client is in dorsal recumbent position 108. Inspect for enlarged liver or spleen

109. Assess the symmetry of contour while standing at the foot of the bed. 110.Inspect the abdominal movements associated with respirations, peristalsis, or aortic pulsations

111. Observe vascular patterns

112. Auscultate the abdomen for bowel sounds, vascular sounds, and peritoneal friction rubs 113. Percuss several areas in each of the four quadrants

114. Percuss the liver to determine its size

- Silver white striae (stretch marks) or surgical scars Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 633 - Flat, rounded (convex), or scaphoid (concave) Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 633

- Silver white striae (stretch marks) or surgical scars

- Flat, rounded (convex), or scaphoid (concave)

- Normal

- No evidence of enlargement of liver or spleen Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 633 - Symmetric contour Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 633 - Symmetric movements caused by respiration - Visible peristalsis I very lean people - Aortic pulsations in thin persons at epigastric area Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 633 - No visible vascular patterns Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 634 - Audible bowel sounds - Absence of arterial bruits -Absence of friction rub Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 634 - Tympany over the stomach and gas filled bowels; dullness especially over the liver and spleen, or a full bladder Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 635 - 6 to 12 cm (2 ½ to 3 ½ inches) in the midclavicular line; 4 to 8 cm (1 ½ to 3 inches) in the midsternal line Kozier and Erb’s Fundamentals of Nursing

- No evidence of enlargement of liver or spleen

- Normal

-

- Normal

- Symmetric movements caused by respiration - Visible peristalsis I very lean people - Aortic pulsations in thin persons at epigastric area

- Normal

- No visible vascular patterns

- Normal

- Audible bowel sounds - Absence of arterial bruits -Absence of friction rub

- Normal

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

- Normal

-6 to 12 cm (2 ½ to 3 ½ inches) in the midclavicular line; 4 to 8 cm (1 ½ to 3 inches) in the midsternal line

- Normal

115. Perform light palpation

116. Perform deep palpation

117. Palpate the area above the symphysis pubis to determine possible urinary retention Musculoskeletal System Muscles 118. Inspect the muscles for size. Compare the muscles on one side of the body (arm, thigh, calf) to the same muscle on the other side 119. Inspect the muscle and tendons for contractures (shortening) 120. Inspect the muscles for fasciculation and tremors. Inspect any tremors of the hands and arms out in front of the body 121. Palpate the muscle tonicity

122. Test for strength (neck)

123. Test for strength (upper extremities)

124. Test for strength (lower extremities)

8th Edition Vol.1 page 635 - No tenderness, relaxed abdomen with smooth, consistent tension Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 636 - Tenderness may be present near xiphoid process, over cecum, and over sigmoid colon Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 636 - Not palpable Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 638 Normal Findings

- No tenderness, relaxed abdomen with smooth, consistent tension

- Normal

- Tenderness may be present near xiphoid process, over cecum, and over sigmoid colon

- Normal

- Not palpable

- Normal

Actual Findings

Interpretation / Findings

- Equal size of both sides of the body Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 640

- Equal size Arm: 10 inches Thigh: 17 inches Calf: 13 inches

- Normal

- No contractures Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 640 - No tremors Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 640

- Absence of contractures

- Normal

- No tremors

- Normal

- Normal firm; smooth coordinated movements Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 640 - Equal in strength in each body side Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 640 - Equal strength in each body side Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 640 - Equal strength in each body side Kozier and Erb’s Fundamentals of Nursing

- Normal tonicity with coordinate movements

- Normal

- Equal strength in both part

- Normal

- Equal strength in each body side

- Normal

- Equal strength in each body side

- Normal

8th Edition Vol.1 page 640 Bones 125. Inspect the skeleton for normal structure and deformities 126. Palpate the bones to locate any areas of edema or tenderness Joints 127. Inspect the joint for swelling 128. Palpate each joint for tenderness, smoothness of movement, swelling, crepitation, and presence or nodule Assess range of motion 129. Upper extremities (shoulder and scapula)

- No deformities Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 641 - No tenderness or swelling Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 641

- Absence of any deformities

- Normal

- Absence of tenderness and swelling

- Normal

- No swelling Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 641 - No tenderness, crepitation or nodules, joints move smoothly Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 641

- Absence of swelling

- Normal

- Absence of tenderness, nodules, joints move freely

- Normal

- Able to rotate - Has the ability to rotate - Normal Kozier and Erb’s her shoulders Fundamentals of Nursing 8th Edition Vol.2 page 1108 130. Upper extremities - Able to flex and extend - Has the ability to flex - Normal (elbows) Kozier and Erb’s and extend her elbows Fundamentals of Nursing 8th Edition Vol.2 page 1108 131. Upper extremities - Able to rotate, abduct, - Has the ability to rotate, - Normal (hands) and adduct abduct, and adduct her Kozier and Erb’s hands Fundamentals of Nursing 8th Edition Vol.2 page 1108 132. Lower extremities - Able to rotate, flex, - Has the ability to rotate, - Normal (acetabulum/inguinal area) extend, abduct, and adduct flex, extend, abduct and Kozier and Erb’s adduct Fundamentals of Nursing 8th Edition Vol.2 page 1108 133. Lower extremities - Able to flex and extend - Has the ability to flex - Normal (politeal) Kozier and Erb’s and extend Fundamentals of Nursing 8th Edition Vol.2 page 1108 134. Lower extremities - Able to rotate - Has the ability to rotate - Normal (ankles) Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.2 page1108 Note: Other family members were not able to be examined because they are not around.

Physical Assessment Name: Mark Lester Caragan Ong Age: 20 years old Birth Date: February 26 1989 Temperature: 36.8 °C oral Pulse Rate: 70 beat per minute Respiratory Rate: 18 breaths per minute Blood Pressure: 120/80 mmhg

Part I (Note: Observers were not able to get the height and weight of Carla because she is in school) Behavior Normal Findings Actual Findings Interpretation / Analysis 1. Height - medium frame: 150cm (height) 111-123lbs - 170 cm - Normal (weight) Metric Conversion Weights and other measurements by A.M. Batubalani page 79 2. Weight - medium frame: 150cm (height) 111-123lbs - 60 kgs - Normal (weight) Metric Conversion Weights and other measurements by A.M. Batubalani page 79 3. BMI - 18.5 to 24.9 - 21 -Normal http://www.nhlbisupport.com/bmi/bmicalc.ht m

General Survey 5. Body built in relation to lifestyle and health

6. Client’s posture, gait, standing, sitting, and walking

7. Client’s overall hygiene and grooming 8. Body and breath odor

9. Signs of distress in posture of facial expression 10. Obvious signs of health or illness 11. Client’s attitude

12. Client’s affect / mood; appropriateness of the clients response 13. Quality and quantity of voice

14. Relevance and organization of thoughts

Integumentary

Normal Findings - Proportionate, varies with lifestyle Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 572 - Relaxed erect posture, sit and stand in an upright position, coordinated movement Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 572 - Clean and neat Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 572 - No body odor or minor body odor relative to work or exercise; no breath odor Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 572 - No distress noted Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 572 - Healthy appearance Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 572 - Cooperative, able to follow instructions Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 572 - Appropriate to the situation Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 572 - Understandable, moderate pace, clear tone Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 572 - Logical in sequence, makes sense, has sense of reality Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 572 Normal Findings

Actual Findings - Small body built

Interpretation / Findings - Normal

- Relaxed erect posture, sit and stand in an upright position with coordination of movement

- Normal

- Well groomed and dressed

- Normal

- No body odor and breath odor

- Normal

- No signs of distress noted

- Normal

- Absence of any signs of illness

- Normal

- Shows shyness but able to follow the instructions given

- Normal

- Responds appropriate to situation

- Normal

- Understandable, moderate pace, and with clear tone of voice

- Normal

- Has sense of reality

- Normal

Actual Findings

Interpretation / Findings

15. Uniformity of color

16. Presence of edema

17. Presence of lesions according to location, distribution, color, configuration, size, shape, type or structure 18. Skin moisture

19. Skin temperature

20. Skin turgor

Nails 21. Finger nails plate shape to determine its curvature and angle 22. Fingernail and toe nail bed color

- Varies from light brown, from ruddy pink and light pink, from yellow overtones to olive -Generally uniform except in areas exposed to sun, areas of lighter pigmentation Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 579 - No edema Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 579 - Freckles, some birthmarks, some flat and raised nevi, no abrasions or other lesions Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 579 - Moisture in skin folds and the axillae (varies with environmental temperature, humidity, body temperature and activity). Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 579 - Uniform and with normal range Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 579 - When pinched, skin turn back to its previous state; may be slower in elders Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 580

- Fair in skin color, has uniform skin tone except from areas not exposed to the sun

- Normal

- No edema

- Normal

- Absence of lesions

- Normal

- Moist skin

- Normal

- Uniform and with normal range

- Normal

- Skin turns back to its original state when pinched

- Normal

- Convex curvature; angle of nail plate about 160° Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 584 - Highly vascular and pink in light skinned clients; dark skinned clients may have brown or black pigment arrow in longitudinal streaks. Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 584

- Convex curvature with 160° angle

- Normal

- Highly vascular, colored pink

- Normal

23.Fingernail and toenail structure 24. Inspect tissues surrounding nails 25. Blanch test of capillary refill

Head Skull 26. Inspect the skull for size, shape or symmetry

27. Palpate for nodules, masses, and depressions

Scalp 28. Inspect for color and appearance

29. Palpate for areas of tenderness

Hair 30. Inspect for evenness of growth, thickness, and thinness 31. Palpate for texture and oiliness over the scalp

- Smooth texture Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 583 - Intact epidermis Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 584 - Prompt return of pink or usual color (generally less than 4 seconds) Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 584 Normal Findings

- Smooth texture

- Normal

- Intact epidermis

- Normal

- Prompt return of pink color less than 4 seconds

- Normal

Actual Findings

Interpretation / Findings

- Rounded (normocephalic and symmetric, with frontal, parietal, and occipital prominences); smooth skull contour Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 585 - Smooth, uniform consistency; absence of nodules or masses Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 585

- Rounded, smooth contour

- Normal

- Smooth with uniform consistency, absence of any nodules or masses

- Normal

- White and clean, absence of lesions Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 585 - Absence of tenderness, masses and nodules Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 585

- White and clean, absence of any kinds of lesions

- Normal

- Absence of tenderness, masses, and nodules

- Normal

- Evenly distributed hair; thick Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 585 - Silky; resilient hair; small amount of oil present Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 585

- Evenly distributed thick hair

- Normal

- Silky hair, no excessive oil

- Normal

- Symmetric or slightly

- Symmetric facial features

- Normal

Face 32. Inspect facial features

and symmetry of facial movement

Eyes Visual Acuity 33. Test near vision

34. Test distance vision

Eyebrows 35. Inspect the distribution of hair and symmetry of eyebrows

Lacrimal gland, Lacrimal Sac, and Nasolacrimal Duct 36. Inspect and palpate the Lacrimal gland

Eyelids 37. Inspect for the surface characteristics, position in relation to the cornea, ability to blink, and frequency of blinking

Eyelashes 38. Inspect the eye lashes for evenness of distribution and direction of curl Conjunctiva

asymmetric facial features. Symmetric facial movements Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 585

and movement

Normal Findings

Actual Findings

Interpretation / Findings

- Able to read newsprint at the distance of 14 inches Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 592 - 20 / 20 vision on Snellen – type chart Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 582

- Able to read newsprint at the distance of 14 inches

- Normal

- 20 / 20 vision

- Normal

- Hair evenly distributed; skin intact - Eyebrows symmetrically aligned; equal movement Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 588

- Hair evenly distributed, skin intact, aligned symmetrically, equal movement

- Normal

- No edema or tenderness over Lacrimal gland Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 589

- Absence of edema and tenderness

- Normal

- Skin intact; no discharge; no discoloration - Approximately 15 – 20 involuntary blinks per minute; bilateral blinking - When lids are open, no visible sclera above corneas, and upper and lower borders of cornea are slightly covered Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 588

- Skin intact, no discharge and discoloration - Frequency: 15 blinks

- Normal

- Equally distributed; curled slightly outward Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 588

- Equally distributed, curled outward

- Normal

39. Inspect the bulbar conjunctiva (lying above the cornea) for color, texture, and presence of lesions

40. Inspect the palpebral conjunctiva (lining the eyelids) for color, texture, and presence of lesion Sclera 41. Inspect the color and clarity Cornea 42. Inspect the cornea for clarity and texture

43. Corneal sensitivity Test (reflex); ask the client to keep both eyes open and look straight ahead. Approach from behind and lightly touch the sclera of the client with the corner of the gauze Iris 44. Inspect the color and shape

Pupil 45. Inspect for color, shape, and symmetry of size

46. Test pupil for light reaction and accommodation

- Transparent; capillaries sometimes evident; sclera appears white (darker or yellowish and with small brown macula in darkskinned clients) Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 588 - Shiny, smooth, and pink red Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 588

- Transparent, no lesions

- Normal

- Shiny, smooth, pink

- Normal

- White and clear Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 589

- White and clear

- Normal

- Transparent; shiny, and smooth; details of the iris are visible. In older people, a thin, grayish white ring around the margin, called arcus senilis, may be evident Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 589 - Client blinks when the cornea is touched, indicating that the trigeminal nerve is intact Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 589

- Transparent, shiny

- Normal

- Client blinks when the cornea is touched by the gauze

- Normal

- Color varies; oval, circular and flat Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 590

- Brown iris, circular

- Normal

- Black in color; equal in size; normally 3 to 7 in diameter; round; smooth border Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 590 - Illuminated pupils constrict, no illuminated pupil constrict - Pupil constrict when looking at near object;

- Black in color, equal in size, 5 in diameter, round

- Normal

- Pupils react with light and objects

- Normal

pupils dilate when looking at far object; pupils converge when near object is moved toward nose Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 589 Visual Field 47. Test Peripheral fields

Extraocular Muscles 48. Assess six ocular movements to determine eye alignment and coordination.

Ears Auricles 49. Inspect for color, symmetry and position

50. Palpate for texture, elasticity and areas for tenderness

External Ear Canal 51. Inspect ear canal for cerumen, skin lesions, pus, blood

Hearing Auricle Test 52. Assess client’s response to normal voice tone 53. Perform watch tick test

- When looking straight ahead, client can see objects in the periphery Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 591

- Client can see objects in the periphery

- Normal

- Both eyes coordinates, move in unison, with parallel alignment Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 592

- Both eyes moves in unison

- Normal

Normal Findings

Actual findings

Interpretation / Findings

- Color same as facial skin; symmetrical. Auricle aligned with outer canthus of eye, about 10° from vertical Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 596 - Mobile, firm and not tender; pinna coils after it is folded Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 596

- Color same as facial skin, symmetrical, aligned with the outer canthus of eye

- Normal

- Mobile, firm, not tender, pinna coils

- Normal

- Dry cerumen, grayish tan color; or sticky, wet cerumen in various shades of brown Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 596

- Wet yellowish cerumen

- Normal

- Normal voice tones audible Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 597 - Able to hear ticking in both ears Kozier and Erb’s Fundamentals of Nursing

- Responds to normal voice tone

- Normal

- The client hears the ticking of the watch

- Normal

54. Perform Weber’s Test

55. Perform Rinne Test

Nose 56. Inspect for any deviations in shape, size, or color and flaring or discharge from nares 57. Inspect for nasal cavities for the presence of redness, swelling, growths and discharge, using the flashlight 58. Inspect the nasal septum between nasal chambers 59. Test patency of both nasal cavities

60. Palpate for any tenderness, masses displacements of bone and cartilage Sinuses 61. Locate/ palpate/ identify the sinuses and note for tenderness

Mouth Lips 62. Inspect for symmetry

8th Edition Vol.1 page 597 - Sound is heard in both ears or is localized at the center of the head (Weber’s Negative) Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 597 - Air conducted (AC) hearing is greater than bone conducted (BC) hearing Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 598

- Sound heard in both ears

- Normal

- AC is greater than BC

- Normal

Normal Findings - Symmetric and straight; no discharge or flaring; uniform color Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 600 - Mucosa pink; clear watery discharge; no lesions Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 600 - Nasal septum intact and in midline Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 600 - Air moves freely as the client breathes through the nares Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 600 - Not tender, no displacements of bone or cartilage Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 800

Actual Findings - Symmetric, no discharge, uniform in color

Interpretation / Findings - Normal

- Mucosa pink, no lesions

- Normal

- Nasal septum are intact and in the midline

- Normal

- Air moves freely

- Normal

- Not tender, no displacements of bone or cartilage

- Normal

- No tenderness Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 800

- No tenderness

- Normal

Normal Findings - Uniform; pink in color;

Actual findings - Pink in color, moist, soft,

Interpretation / Findings - Normal

of contour, color and texture

Buccal Mucosa 63. Inspect for color, moisture, texture, and presence of lesions

Teeth 64. Inspect for color, number and condition, presence of dentures

Gums 65. Inspect for the color and condition

Tongue/ Floor of the mouth 66. Inspect for the color and texture of the mouth floor and frenulum 67. Inspect and palpate the position, color, and texture, movement and base of the tongue

68. Palpate for any nodules, lumps, or excoriated areas Palates and Uvula 69. Inspect and palpate for color, shape, texture, and the presence of bony prominences

moist, soft, smooth texture; symmetry of contour. Ability to purse lips Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 602

smooth in texture

- Uniform, pink in color, moist, smooth, soft, glistering and has an elastic texture Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 602

- Uniform, pink in color, moist, soft, glistering and has an elastic texture

- Normal

- 32 adult teeth, smooth, white, shiny tooth enamel, smooth intact dentures Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 602

- Complete set of teeth

- Normal

- Pink gums, moist, firm texture to gums, no retraction of gums Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 602

- Pink gums, moist, no retraction of gums

- Normal

- Smooth tongue base with prominent veins Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 603 - Central position, pink in color, moist, slightly rough, thin whitish coating, smooth lateral margins, no lesions, raised papillae, moves freely, no tenderness Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 603 - No palpable nodules Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 603

- Smooth tongue base, prominent veins present

- Normal

- Located at the midline, with whitish coating, no lesions

- Normal

- No palpable nodules

- Normal

- Light pink, smooth, soft palate: light pink hard palate: more regular in texture Kozier and Erb’s Fundamentals of Nursing

- Light pink, smooth soft palate, hard palate more in regular in texture

- Normal

70. Inspect for position of the uvula and mobility while examining the palates Oropharynx and tonsils 71. Inspect and palpate for color, and texture (one side at a time to avoid eliciting gag reflex) 72. Inspect the size of the tonsils, color, and discharge

73. Elicit the gag reflex by pressing the posterior tongue

Neck and Lymph Nodes Lymph Nodes 74. Locate/ palpate/ identify lymph nodes and note for tenderness Trachea 75. Inspect and palpate for placement

8th Edition Vol.1 page 604 - Positioned in midline of soft palate Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 603 - Pink and smooth posterior wall Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 604 - Pink and smooth, no discharge, normal size Grade 1: normal the tonsils are behind the tonsillar pillars (the soft structures supporting the soft palate) Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 604 - Present Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 604 Normal Findings

- Positioned at the midline of the soft palate

- Normal

- Pink and smooth posterior wall

- Normal

- Pink and smooth, grade 1

- Normal

- Present

- Normal

Actual Findings

Interpretation / Findings

- No tenderness Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 607

- No tenderness

- Normal

- Central placement in the midline of the neck; spaces are equal in both sides Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 608

- Central in placement, spaces are equal in both sides

- Normal

- Not visible in palpation. Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 608 - Lobes may not be palpated. If palpated, lobes are small, smooth, centrally located, painless and rise freely with swallowing Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 609

- Not visible

- Normal

- Located at the midline of the neck, moves freely

- Normal

Thyroid Gland 76. Inspect symmetry and visible masses 77. Palpate for smoothness and areas of enlargement, masses or nodules

Part II Thorax Posterior Thorax 78. Inspect the size, shape, symmetry, and compare the diameter of anteroposterior thorax to transverse diameter 79. Inspect the spinal alignment 80. Palpate for temperature, tenderness and masses

81. Asses respiratory excursion 82. Palpate focal fremitus

83. Percuss the posterior thorax

84. Auscultate the posterior thorax

Anterior Thorax 85. Inspect breathing pattern

86. Palpate for temperature, tenderness and masses

87. Asses respiratory excursion

Normal Findings

Actual Findings

Interpretation / Findings

- Anteroposterior to transverse diameter with a ratio of 1:2 Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 614 - Spine vertically aligned Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 614 -Temperature is within in normal range, no tenderness and masses Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 614 - Full and symmetric Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 615 - Bilateral symmetric vocal fremitus Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 615 - Lowest point of resonance is at the diaphragm Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 616 - Vesicular and bronchovesicular breath sounds Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 616

- Has a ratio of 1:2

- Normal

- Spine vertically aligned

- Normal

- Temperature is within normal range, no tenderness and masses

- Normal

- Full and symmetric

- Normal

- Bilateral symmetric vocal fremitus

- Normal

- Lowest point of resonance is at the diaphragm

- Normal

- Vesicular and bronchovesicular breath sounds

- Normal

- Quiet, rhythmic and effortless respiration Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 617 - Temperature is within in normal range, no tenderness and masses Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 617 - Full and symmetric Kozier and Erb’s Fundamentals of Nursing

- Quiet, rhythmic, effortless respiration

- Normal

- Temperature is within normal range

- Normal

- Full and symmetric

- Normal

88. Palpate vocal / tactile fremitus

89. Percuss the anterior thorax

90. Auscultate the trachea

91. Auscultate the anterior thorax

Cardiovascular Simultaneously INSPECT and PALPATE the precordium for the presence of abnormal pulsations, lifts and heaves 92. Aortic and Pulmonic Areas 93. Tricuspid Areas

94. Apical Area (Locate point of maximal impulse)

95. Auscultate the aortic, pulmonic, tricuspid, and apical valves

8th Edition Vol.1 page 617 - Same as posterior vocal fremitus, fremitus is normally decreased over heart and breast tissue Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 617 - Percussion note resonate done to the sixth rib at the level of diaphragm but are flat over areas of heavy muscles and bone, dull on areas over the heart and liver, and tympanic over the underlying stomach Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 617 - Bronchial and tubular breath sounds Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 618 - Bronchovesicular and vesicular breath sounds Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 618 Normal Findings

- No pulsations Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 621 - No pulsations Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 622 - Pulsations visible on 50% of adults and palpable in most PM/ in 5th LICS or at medial to MCL Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 622 - Usually louder at apical area - Usually louder at the base of the heart - systole: silent interval;

- Same as posterior vocal fremitus, fremitus is normally decreased over heart and breast tissue

- Normal

- Percussion note resonate done to the sixth rib at the level of diaphragm but are flat over areas of heavy muscles and bone, dull on areas over the heart and liver, and tympanic over the underlying stomach

- Normal

- Bronchial and tubular breath sounds

- Normal

- Bronchovesicular and vesicular breath sounds

- Normal

Actual Findings

Interpretation / Findings

- No pulsations

- Normal

- No pulsations

- Normal

- Palpable in the 5th LICS

- Normal

- Usually louder at apical area - Usually louder at the base of the heart - systole: silent interval;

- Normal

Carotid arteries 96. Palpate carotid artery with extreme caution

97. Auscultate the carotid arteries Jugular Veins 98. Inspect Jugular Veins

slightly shorter duration than diastole at normal heart rate - diastole: silent interval, slightly longer duration than systole at normal heart rates Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 622

slightly shorter duration than diastole at normal heart rate - diastole: silent interval, slightly longer duration than systole at normal heart rates

- Symmetric pulse volumes - Full pulsations, thrusting quality Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 622 - No sound heard Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 623

- Symmetric pulse volumes - Full pulsations, thrusting quality

- Normal

- No sound heard

- Normal

- Veins not visible Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 623

- Not visible

- Normal

(Note: the client refused to be examined at the breast and abdomen area) Breast and Axillae Normal Findings Actual Findings 99. Inspect breast for size, - Rounded in shape, - Rounded in shape, symmetry, contour, or slightly unequal in size, slightly unequal in size, shape while the client is in generally symmetric generally symmetric sitting position Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 628 100. Inspect the skin of the - Skin uniform in color - Skin uniform in color breast for localized (same in appearance as (same in appearance as discolorations or skin of abdomen or back) skin of abdomen or back) hyperpigmentation, - Skin smooth and intact - Skin smooth and intact retraction, dimpling, Kozier and Erb’s localized hypervascular Fundamentals of Nursing areas, swelling or edema 8th Edition Vol.1 page 628 101. Inspect the areola for - Round or oval and - Round or oval and size, shape, symmetry, bilaterally the same bilaterally the same color, surface - Color varies widely from - Color varies widely from characteristics, and any light pink to dark brown light pink to dark brown mass or lesions Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 628 102. Inspect the nipples - Round, everted, and -Round, everted, and equal for size, shape, position, equal in size, similar in in size, similar in color, color, discharge, and color, soft and smooth, soft and smooth, both lesions both nipples point in same nipples point in same direction direction - No discharge except - No discharge except

Interpretation / Findings -Normal

-Normal

-Normal

-Normal

103. Palpate the axillary, subclavicular and superclavicular lymph nodes 104. Palpate breast for masses, tenderness

105. Palpate nipples for tenderness and discharges

Abdomen 106. Inspect the abdomen for skin integrity

107. Inspect the abdominal contour (profile the line from rib margin to the pubic bone) while standing at the client is in dorsal recumbent position 108. Inspect for enlarged liver or spleen

109. Assess the symmetry of contour while standing at the foot of the bed. 110.Inspect the abdominal movements associated with respirations, peristalsis, or aortic pulsations

from pregnant women - Inversion of one or both nipples that I present from puberty Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 628 - No tenderness, masses, or nodules Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 629 - No tenderness, masses, nodules, or nipple discharge Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 629 - No tenderness, masses, nodules, or nipple discharge Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 629

from pregnant women - Inversion of one or both nipples that I present from puberty

- No tenderness, masses, or nodules

-Normal

- No tenderness, masses, nodules, or nipple discharge

-Normal

- No tenderness, masses, nodules, or nipple discharge

-Normal

Normal Findings - Unblemished skin - Uniform color - Silver white striae (stretch marks) or surgical scars Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 633 - Flat, rounded (convex), or scaphoid (concave) Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 633

Actual Findings - Unblemished skin - Uniform color - Silver white striae (stretch marks) or surgical scars

Interpretation / Findings -Normal

- Flat, rounded (convex), or scaphoid (concave)

-Normal

- No evidence of enlargement of liver or spleen Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 633 - Symmetric contour Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 633 - Symmetric movements caused by respiration - Visible peristalsis I very lean people - Aortic pulsations in thin persons at epigastric area Kozier and Erb’s Fundamentals of Nursing 8th

- No evidence of enlargement of liver or spleen

-Normal

- Symmetric contour

-Normal

- Symmetric movements caused by respiration - Visible peristalsis I very lean people - Aortic pulsations in thin persons at epigastric area

-Normal

111. Observe vascular patterns 112. Auscultate the abdomen for bowel sounds, vascular sounds, and peritoneal friction rubs 113. Percuss several areas in each of the four quadrants

114. Percuss the liver to determine its size

115. Perform light palpation

116. Perform deep palpation

117. Palpate the area above the symphysis pubis to determine possible urinary retention Musculoskeletal System Muscles 118. Inspect the muscles for size. Compare the muscles on one side of the body (arm, thigh, calf) to the same muscle on the other side 119. Inspect the muscle and tendons for contractures (shortening)

Edition Vol.1 page 633 - No visible vascular patterns Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 634 - Audible bowel sounds - Absence of arterial bruits -Absence of friction rub Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 634 - Tympany over the stomach and gas filled bowels; dullness especially over the liver and spleen, or a full bladder Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 635 - 6 to 12 cm (2 ½ to 3 ½ inches) in the midclavicular line; 4 to 8 cm (1 ½ to 3 inches) in the midsternal line Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 635 - No tenderness, relaxed abdomen with smooth, consistent tension Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 636 - Tenderness may be present near xiphoid process, over cecum, and over sigmoid colon Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 636 - Not palpable Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 638 Normal Findings

- No visible vascular patterns

- Normal

- Audible bowel sounds - Absence of arterial bruits -Absence of friction rub

-Normal

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

-Normal

-6 to 12 cm (2 ½ to 3 ½ inches) in the midclavicular line; 4 to 8 cm (1 ½ to 3 inches) in the midsternal lin

-Normal

- No tenderness, relaxed abdomen with smooth, consistent tension

-Normal

- Tenderness may be present near xiphoid process, over cecum, and over sigmoid colon

-Normal

- Not palpable

-Normal

Actual Findings

Interpretation / Findings

- Equal size of both sides of the body Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 640

- Equal in size Arm: 10 inches Thigh: 13.8 inches Calf: 7.2 inches

- Normal

- No contractures Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 640

- No contractures

- Normal

120. Inspect the muscles for fasciculation and tremors. Inspect any tremors of the hands and arms out in front of the body 121. Palpate the muscle tonicity

122. Test for strength (neck)

123. Test for strength (upper extremities)

124. Test for strength (lower extremities)

Bones 125. Inspect the skeleton for normal structure and deformities 126. Palpate the bones to locate any areas of edema or tenderness Joints 127. Inspect the joint for swelling 128. Palpate each joint for tenderness, smoothness of movement, swelling, crepitation, and presence or nodule Assess range of motion 129. Upper extremities (shoulder and scapula)

130. Upper extremities (elbows)

- No tremors Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 640

- No tremors

- Normal

- Normal firm; smooth coordinated movements Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 640 - Equal in strength in each body side Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 640 - Equal strength in each body side Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 640 - Equal strength in each body side Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 640

- Normal firm, coordinated movements

- Normal

- Equal in strength in each body side

- Normal

- Equal in strength in each body side

- Normal

- Equal in strength in each body side

- Normal

- No deformities Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 641 - No tenderness or swelling Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 641

- No deformities

- Normal

- No tenderness or swelling

- Normal

- No swelling Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 641 - No tenderness, crepitation or nodules, joints move smoothly Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.1 page 641

- No tenderness or swelling

- Normal

- No tenderness, joints move smoothly

- Normal

- Able to rotate Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.2 page 1108 - Able to flex and extend Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.2 page

- Able to rotate

- Normal

- Able to flex and extend

- Normal

1108 - Able to rotate, abduct, - Able to rotate, abduct, - Normal and adduct and adduct Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.2 page 1108 132. Lower extremities - Able to rotate, flex, - Able to rotate, flex. - Normal (acetabulum/inguinal area) extend, abduct, and adduct Extend, abduct, and adduct Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.2 page 1108 133. Lower extremities - Able to flex and extend - Able to flex and extend - Normal (politeal) Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.2 page 1108 134. Lower extremities - Able to rotate - Able to rotate - Normal (ankles) Kozier and Erb’s Fundamentals of Nursing 8th Edition Vol.2 page1108 Note: Other family members were not able to be examined because they are not around. 131. Upper extremities (hands)