Physical Assessment a1g6l

ASSESSMENT

FINDINGS

Integumentary 

Skin

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Hair

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Nails

Skull

Face

When skin is pinched it goes to previous state immediately (2 seconds).With fair complexion.With dry skin Evenly distributed hair.With short, black and shiny hair.With presence of pediculosis Capitis. Smooth and has intact epidermisWith short and clean fingernails and toenails. Convex and with good capillary refill time of 2 seconds. Rounded, normocephalic and symmetrical, smooth and has uniform consistency.Absence of nodules or masses. Symmetrical facial movement, palpebral fissures equal in size, symmetric nasolabial folds.

Pupils

Visual Fields

Visual Acuity

Eyes and Vision 

Eyebrows

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Eyelashes

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Eyelids

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Bulbar conjunctiva Palpebral Conjunctiva

Hair evenly distributed with skin intact.Eyebrows are symmetrically aligned and have equal movement. Equally distributed and curled slightly outward. Skin intact with no discharges and no discoloration.Lids close symmetrically and blinks involuntary. Transparent with capillaries slightly visible

Sclera

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Lacrimal gland, Lacrimal sac, No edema or tenderness over the Nasolacrimal lacrimal gland and no tearing. duct

Clarity and texture

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Corneal sensitivity

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Auricles

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External Ear Canal

Transparent, smooth and shiny upon inspection by the use of a penlight which is held in an oblique angle of the eye and moving the light slowly across the eye.Has brown eyes. Blinks when the cornea is touched through a cotton wisp from the back of the client.

Color of the auricles is same as facial skin, symmetrical, auricle is aligned with the outer canthus of the eye, mobile, firm, non-tender, and pinna recoils after it is being folded. Without impacted cerumen.

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Hearing Acuity Test Voice sound audible.

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Watch Tick Test

Appears white.

Cornea 

Ear and Hearing

Shiny, smooth, pink



Black, equal in size with consensual and direct reaction, pupils equally rounded and reactive to light and accommodation, pupils constrict when looking at near objects, dilates at far objects, converge when object is moved toward the nose at four inches distance and by using penlight. When looking straight ahead, the client can see objects at the periphery which is done by having the client sit directly facing the student nurse at a distance of 2-3 feet. The right eye is covered with a card and asked to look directly at the student nurse’s nose. Hold penlight in the periphery and ask the client when the moving object is spotted. Able to identify letter/read in the newsprints at a distance of fourteen inches. She was able to read the newsprint at a distance of 8 inches.

Able to hear ticking on right ear at a distance of one inch and was able to hear the ticking on the left ear at the same distance

Nose and sinuses Symmetric and straight, no flaring, External Nose uniform in color, air moves freely as the clients breathes through the nares. Mucosa is pink, no lesions and nasal  Nasal Cavity septum intact and in middle with no tenderness. Mouth and Symmetrical, pale lips, brown gums Oropharynx and able to purse lips.  Teeth With dental caries and decayed lower molars 



Tongue and floor of the

Central position, pink but with whitish coating which is normal, with veins

mouth 

prominent in the floor of the mouth.

Tongue movement

Moves when asked to move without difficulty and without tenderness upon palpation. Uvula Positioned midline of soft palate. Present which is elicited through the Gag Reflex use of a tongue depressor. Positioned at the midline without Neck tenderness and flexes easily. No masses palpated. Coordinated, smooth movement with no discomfort, head laterally flexes, Head movement head laterally rotates and hyperextends. Muscle strength With equal strength Lymph Nodes Non-palpable, non tender Not visible on inspection, glands  Thyroid Gland ascend but not visible in female during swallowing and visible in males. Thorax and lungs Posterior thorax Chest symmetrical Spine vertically aligned, spinal  Spinal column is straight, left and right alignment shoulders and hips are at the same height. With normal breath sounds without Breath Sounds dyspnea.  Anterior Thorax Quiet, rhythmic and effortless respiration Unblemished skin, uniform in color, Abdomen symmetric contour, undistended. Abdominal Symmetrical movements cause by movements respirations.  Auscultation of With audible sounds of 23 bowel bowel sounds sounds/minute. Upper Extremities Lower Extremities

Muscles

Bones and ts

Without scars and lesions on both extremities. With minimal scars on lower extremities Equal in size both sides of the body, smooth coordinated movements, 100% of normal full movement against gravity and full resistance. No deformities or swelling, ts move smoothly.

Mental Status Language Orientation

Can express oneself by speech or sign. Oriented to a person, place, date or

Attention span Level of Consciousness

time. Able to concentrate as evidence by answering the questions appropriately. A total of 15 points indicative of complete orientation and alertness. E4V5M6

Motor Function Gross Motor and Balance 

Walking gait

Standing on one foot with eyes closed

Has upright posture and steady gait with opposing arm swing unaided and maintaining balance. Maintained stance for at least five (5) seconds.

Maintains a heel toe walking along a straight line Able to walk several steps in Toe or heel walking toes/heels. Fine motor test for Upper Extremities Repeatedly and rhythmically touches Finger to nose test the nose. Alternating supination and Can alternately supinate and pronate pronation of hands hands at rapid pace. on knees Finger to nose and Perform with coordinating and to the nurse’s finger rapidity. Fingers to fingers Perform with accuracy and rapidity. Rapidly touches each finger to thumb Fingers to thumb with each hand. Fine motor test for the Lower Extremities Able to discriminate between sharp Pain sensation and dull sensation when touched with needle and cotton. Heel toe walking