FAR EASTERN UNIVERSITY

Institute on Nursing
BSN 126 - 103

Name of Client: Rolando Orlante

Date: May 5, 2011

VITAL SIGNS

Temperature: _______36.5______________________
Pulse Rate: __________80_____________________
Respiratory Rate: _______18___________________
Blood Pressure: __________110/90__________________

PHYSICAL ASSESSMENT
 Body part examined
1. Describe the body
built, height and weight
in relation to the client’s
age, lifestyle and health.
2. Describe the client’s
posture, gait, standing,
sitting and walking
3. Describe the client’s
overall hygiene and
grooming
4. Describe body and
breath odor
5. Identify signs of
distress, in posture
6. Identify obvious signs
of health or illness
7. Describe the client’s
attitude
8. Describe the client’s
affect/mood; asses the
appropriateness of the
client’s response
9. Describe the quantity
and quality of speech
10. Listen for relevance
and organization of
thoughts
11. Inspect for color;
uniformity of color
12.Inspect for presence
of edema
13.Inspect for lesions
according to location,
distribution, color,
configuration, size,
shape, type or structure
14. palpate skin
moisture
15.Palpate skin
Normal Check if normal,
Findings if not;
note the deviations
Proportionate, varies with NORMAL
lifestyle
Relaxed, erect posture, NORMAL
coordinated movement
Clean and neat NORMAL
No body odor, no breath NORMAL
odor
No distress noted NORMAL
Healthy appearance His right eye has a cover
(Kozier & Erbs, from the surgical
Fundamentals of Nursing, procedure
page 572)
Cooperative, able to NORMAL
follow instructions
Appropriate to situation NORMAL
Understandable, NORMAL
moderate pace, clear tone
and inflection, exhibits
thoughts and association)
Logical sequence makes NORMAL
sense, has sense of reality
Varies from light to deep NORMAL
brown; from ruddy pink to
light pink; from yellow
overtones to olive.
No edema NORMAL
Freckles, some Have 3 small scar on his
birthmarks, some flat right leg, 1 elongated scar
raised nevi; no abrasion in his left knee, 1 irregular
or other lesions scar in hi right knee; a
brownish flat birthmark in
his back.
Moisture in skin folds and NORMAL
the axillae (varies with
the environmental
temperature and
humidity, body
temperature, and activity)
Uniform; within normal NORMAL