REVIEW OF SYSTEMS INTEGUMENTARY MUSCULOSKELETAL Pallor Capillary refill of 3-4 seconds Use of accessory muscles

PHYSICAL ASSESSMENT

Date Performed: July 29, 2013

I. A. General Appearance The client is a male, and is sitting down in his bed, conscious, relaxed, and oriented. He are no foul odors and he is well groomed. There are no present signs of distress in facial expression, like grimace. The client is highly cooperative. The quantity and quality of the clients speech is understandable. B. Vital Signs

MEASUREMENT S

NORMAL FINDING S

ACTUAL FINDING S

INTERPRETATION/ ANALYSIS

Blood Pressure

120/80 mmHg

140/80

The finding is normal.

Pulse Rate

60-100 bpm

65bpm

The finding is normal.

Respiratory Rate

12-20 cpm

24cpm

The finding is normal.

Temperature

36.5C 37.5C

36.5

The finding is normal.

HEAD TO TOE ASSESSMENT (PART I) A. HEAD Parts Skin Normal Findings Varies from light to deep brown, general uniformity, no edema, moisture in skin folds and the axillae, skin temperature is uniform and within normal range Actual Findings Fair - tan skin color, pallor, no edema moisture in skin folds, good skin turgor, no abrasions or lesions Interpretation/Analysis INTERPRETATION: The overall skin is pallor and cool to touch ANALYSIS: Pallor is a paleness or decrease in color and can be caused by vasoconstriction, decreased blood flow, or decreased hemoglobin levels from anemia.( Kozier et al.

Fundamentals of Nursing 8th edition pp. 577) Rounded (normocephalic and symmetrical, with frontal, parietal, and occipital prominences); smooth skull contour, uniform consistency, absence of nodules or masses Normocephalic, proportional to the size of the body, round, symmetrical in all planes, gently curved and with prominences in the frontal and occipital area anteriorly and posteriorly respectively. White, clean, free from No dandruff and is free masses, lumps, scars, from lesions, lumps, nits, dandruff and and scars, nits, clean lesions and whitish. No masses of tenderness Black, evenly distributed & covers the whole scalp, thick, shiny, free from split ends Oblong, oval, square or heart-shaped, symmetrical, facial expression that is dependent on the moods and feelings, smooth and free from wrinkles, no involuntary muscle movements Covers the whole scalp, thin, evenly distributed, shiny and with a mixture of black and grayish-white hairs. square-shaped, smooth and presence of wrinkles, no involuntary muscle movements, sag face due to old age

NORMAL

Skull

Scalp

NORMAL

Hair

NORMAL

INTERPRETATION: There is sagging of the face due to old age

Face

ANALYSIS: The skin loses its elasticity and wrinkles. Wrinkles first appear on the skin of the face and neck, which are abundant in collagen and elastic fibers ( Kozier et al. Fundamentals of Nursing 8th edition pp. 580)

Eyes

Eyebrows

Eyelashes

Parallel and evenly placed, symmetrical, non-protruding, with scant amount of secretions, both eyes are black and clear Black, symmetrical, thick, can raise & lower eyebrows symmetrically and without difficulty, evenly distributed & parallel with each other Black, evenly distributed and turned outward Upper lids cover a small portion of the iris, cornea & the sclera when the eyes are open. When the eyes are closed, the lids meet completely. Symmetrical and color is the same as the surrounding skin Clear, without scaling or secretions, lacrimal duct openings (puncta) are evident at nasal ends Appear equal when the eyes are open Salmon Pink, shiny, moist and transparent

Both eyes are black and clean, symmetrical, parallel and evenly placed, non-protruding with scant amount of secretion Gray, symmetrical, thick, can raise & lower eyebrows symmetrically and without difficulty, evenly distributed & parallel with each other Turned outward, gray and evenly distributed

NORMAL

NORMAL

NORMAL

Eyelids

When eyes are open, upper lids cover a small portion of the iris, cornea and sclera. When eyes are closed, the lids meet completely. The same color as the surrounding skin.

NORMAL

Lid Margins Palpebral fissures Lower Palpebral Conjunctiva

Puncta are evident at nasal ends, clear, without scaling or secretions. Appear equal when the eyes are open Pale

NORMAL

NORMAL

INTERPRETATION: A change in color in the conjunctiva ANALYSIS: Pale can be related to possible anemia.

( Kozier et al. Fundamentals of Nursing 8th edition pp. 588)

Sclera

Iris

Pupils

Eye movement

White and clear Proportional to the size of the eye, round, black/brown and symmetrical Pupils are equally round and reactive to light and accommodation Able to move eyes in full range of motion or able to move in all direction Able to read newsprint

Visual Acuity

White and clear Iris are brown in color, symmetrical, proportional to the size of the eyes, round Pupils are equally round and reactive to light and accommodation Able to move eyes in full range of motion or able to move in all direction Client has difficulty reading small newsprint held at varying distances of 5 inches 15inches.

NORMAL

NORMAL

NORMAL

NORMAL

INTERPRETATION: Difficulty in reading newsprint due to aging process ANALYSIS: Visual acuity in an elderly client decreases as the lens of the eye ages and becomes more opaque and loses elasticity. (Kozier et al. Fundamentals of Nursing 8th edition pp. 594)

Field of Vision

Able to see 60 degrees superiorly, 90 degrees temporally and 70 degrees inferiorly

Able to see 60 degrees superiorly, 90 degrees temporally and 70 degrees inferiorly

NORMAL

Parallel, symmetrical, Parallel, symmetrical, proportional to the size proportional to the size

Ears

Ear Canal

of the head, beanshaped. Helix is in line with the outer canthus of the eye, skin is the same color as the surrounding skin, clean Pinkish, clean with scant amount of cerumen and a few cilia

Hearing Acuity

of the head, beanshaped. Helix is in line with the outer canthus of the eye, skin is the same color as the surrounding skin, clean Pinkish, clean with scant amount of cerumen and a few cilia, moderate amount of hair Able to hear whisper Unable to hear clearly spoken two feet away whisper spoken words two feet away

NORMAL

NORMAL

INTERPRETATION: The client has difficulty in hearing. ANALYSIS: With aging, changes occur in the ear that may eventually lead to hearing deficits. Approximately half of all people with hearing loss or deafness are 65 years of age or older. (Smeltzer et al. Brunner and Suddarth's MedicalSurgical Nursing 12th edition pp. 1810)

Nose Internal Nares Septum

Lips

Midline, symmetrical,patent Clean, pinkish, with few cilia Straight, midline Pinkish, symmetrical, lip-margin well defined. Smooth and moist

Midline, symmetrical, patent Clean, pinkish and more cilia Straight, midline pale, symmetrical, lip margin defined, smooth and moist

NORMAL NORMAL NORMAL INTERPRETATION: A change in color of the lips ANALYSIS: Pale is a manifestation of an underlying problem, eg; anemia, a change in

temperature ( Kozier et al. Fundamentals of Nursing 8th edition pp. 602) Pinkish, smooth, moist, Pinkish, smooth, moist, no swelling, no no swelling, no retraction, no discharge retraction, no discharge

Gums

NORMAL INTERPRETATION: There is a loss of permanent teeth when aging. ANALYSIS Gum muscles become inelastic when aging. This leads to lack of strength to hold on teeth. (Eliopoulus et. Al Gerontological Nursing 4th Edition pp. 396) NORMAL

Teeth

32 permanent teeth, well-aligned, free from caries or filling, no halitosis

No permantent teeth, free from caries or filing, no halitosis. Usage of dentures

Tongue Frenulum Buccal Mucosa

Large, medium, red or pink, the lateral margins moist, shiny, freely movable Midline, straight, and thin Pinkish, moist and smooth

Freely movable, pink in color and medium in size, margins are moist, shiny Midline, straight, and thin Pallor

NORMAL INTERPRETATION: There is a deviation of skin color of buccal muscosa ANALYSIS: Pallor is the result of inadequate circulating blood or hemoglobin and subsequent reduction in tissue oxygenation.( Kozier et al. Fundamentals of Nursing 8th edition pp. 577)

Soft Palate Hard Palate Uvula

Pinkish, moist, and smooth Slightly pinkish At the center, symmetrical, and freely movable Pinkish, non-inflamed, no exudates

Tonsils No hoarseness well modulated

Voice

Pinkish, moist, and smooth Slightly pinkish At the center, symmetrical and freely movable Pinkish, non-inflamed, no exudates with a grade of 2 means tonsils are midway. and No hoarseness and well modulated Proportional to the size of the body and head, straight and symmetrical, no other palpable lumps, masses or areas of tenderness, with skin folds at the neck region Part 2

NORMAL NORMAL NORMAL

NORMAL

NORMAL

Neck

Proportional to the size of the body and head, symmetrical and straight, no palpable lumps, masses, or areas of tenderness, Adams apple palpable

NORMAL

CHEST & ABDOMEN EXAMINATION Parts Normal Findings The chest contour is symmetrical and the chest is twice as wide as deep (anteroposterior diameter in a 1:2 ratio) the spine is straight, the ribs tend to slope across and down. The chest wall moves symmetrically during respiration Actual Findings The ratio of the anteroposterior to transverse diameter is 1:2 which signifies a symmetrical chest diameter. There is a use of accessory muscle in breathing. The chest wall moves symmetrically during respiration. Interpretation/Analysis INTERPRETATION: The use of accessory muscles is to aid patient in breathing.

Inspection of Thorax

ANALYSIS: The use of muscle other than the diaphram and intercostals is when the client has unsatisfied need for air and feels distressed.( Kozier et al. Fundamentals of Nursing 7th edition pp. 507)

When the hemoglobin level is low, the heart attempts to compensate by pumping faster and harder in an effor to deliver more blood to hypoxic tissue. This increased cardiac workload can result in such symptoms as dyspnea, dizziness, orthopnea. (Smeltzer et al. Brunner and Suddarth's MedicalSurgical Nursing 12th edition pp. 912) Palpation of Thorax No lumps, masses, areas of tenderness. Sides of the thorax expand symmetrically. The examiners thumb separate approximately 3-5 cm during expansion. Sides of the thorax expand symmetrically at about 3 cm during expansion. Considered as full symmetric excursion. NORMAL

Percussion of Thorax

Percussion note varies with the thickness of percussion the chest wall. Normal on the Resonance sound sounds posterior chest created by air filled lungs. It is clear, long, low pitch. Dull short, high pitch, soft and thudding, heard over the heart. Flat absolute dullness; absence of air in the underlying tissue. Tympany moderately loud with quality with specific pitch, noted in the upper left quadrant of the abdomen.

NORMAL

Auscultation of Thorax

Heart

Normal breath sounds differ in their character depending on the area being auscultated. Bronchovesicular sounds-medium pitched sound heard posteriorly between the scapulae. The sound has a blowing quality with the inspiratory phase equal to the expiratory phase. Vesicular sounds-heard over the lung periphery. The sounds are created by air moving through the smaller airways. They are soft, breezy and low pitched. The inspiratory phase is about 3 times longer then the expiratory phase. Bronchial sounds-hollow high pitched whistling sounds, which are normal id heard over large airways like the trachea. No pulsations on the aortic, pulmonic and tricuspid valves while pulsations are visible and palpable in the apical area. Abdominal aortic pulsations are visible and palpable in thin people. 2 heart sounds are audible in one area but loudest in the apical area.

NORMAL Presence of normal breath vesicular and bronchovesicular breath sounds

No pulsation heard or felt in aortic, pulmonic and tricuspid valve. but in the apical area, pulsations are visible and palpable. For the epigastric area, abdominal aortic pulsations are also visible and palpable. Cardiac rate varies

NORMAL

Cardiac rate ranges between 82- 96 bpm from 60-100 which is normal. beats/min. There are clicks and gurgles, the frequency of which has been estimated from 5-34 per minute. Borborygmi (loud prolonged gurgles of hyperpersitalsis) the unfamiliar sounds in the stomach heard.

Auscultation of the Abdomen

There are 6-8 bowel sounds per minute . Absence of atrerial bruits and friction rubs.

NORMAL

Percussion in the Abdomen

Palpation of the Abdomen

Tympany Tympany sounds predominates because heard over the of the presence of air stomach and dullness in the stomach and heard over the liver intestines. Percussion and spleen is dull at the livers lower border. Livers edge feels firm Light palpating, and non-tender. no tenderness, relaxed abdomen with smooth, consistent tension

NORMAL

NORMAL

Part 3 UPPER EXTREMITIES Parts Normal Findings Skin color varies (pinkish, tan, dark brown), symmetrical, fine hair evenly distributed, presence/absence of visible veins. Warm, dry and elastic, Actual Findings Interpretation/Analysis Skin color is fair-tan, symmetrical, fine hair evenly distributed no NORMAL presence of visible veins, warm, elastic

Arms

Performs motion with Performs motion relative ease with relative ease

NORMAL

Elbows Nails are transparent, smooth & convex with pink nail beds & white translucent tips, 5 fingers in each hand. As pressure is applied to the nail bed, it appears blanched, & pink color returns immediately as pressure is released. Nails are transparent, smooth & convex with pallor/pale nail beds & white translucent tips, and smooth. 5 fingers in each hand. Appears blanched when pressure is applied and color returns immediately after 34 seconds. INTERPRETATION: There is a deviation in the nail color ANALYSIS: Pallor is the result of inadequate circulating blood or hemoglobin and subsequent reduction in tissue oxygenation.( Kozier et al. Fundamentals of Nursing 8th edition pp. 577) INTERPRETATION: There is a deviation in rapid capillary refill time ANALYSIS: Prolonged capillary refill time suggest diminished artierial perfusion. (Smeltzer et al. Brunner and Suddarth's MedicalSurgical Nursing 12th edition pp. 2090)

Nails

Palms and dorsal surfaces

Palms pinkish (dorsal Palms are pallor and surface), warm, thick cool

INTERPRETATION: There is a deviation in the skin color ANALYSIS: Pallor is the result of inadequate circulating blood or hemoglobin and subsequent reduction in tissue oxygenation. (Smeltzer

et al. Brunner and Suddarth's MedicalSurgical Nursing 12th edition pp. 912) Symmetrical to the size of the body.Performs motion with relative ease Symmetrical to the size of the body. Patient can permform motion

Shoulders

NORMAL

Lower Extremities Parts Normal Findings Skin varies (pinkish, tan, dark brown) skin is smooth, muscles symmetrical, length symmetrical. Muscles appear equal, warm & with good muscle tone, performs motion with relative ease Actual Findings Skin color is fair-tan , Dry skin Muscles appear equal and symmetrical Length is also symmetrical. Can perform motion. Analysis NORMAL

Legs

Knees

Performs motion with Performs motion with relative ease relatve ease

NORMAL

Ankles

Performs motion with Performs motion with relative ease relative ease Five toes in each foot, sole and dorsal surface is smooth: With pink nail beds & translucent tips. As pressure is applied, the nail bed appears white or blanched; pink color

NORMAL

Toes/Soles of feet

Five toes in each foot, INTERPRETATION sole and dorsal : surface is smooth: There is a deviation in With pale nail beds & the nail color translucent tips. As pressure is applied, ANALYSIS: the nail bed appears Pallor is the result of white or blanched;

returns when pressure is released. Performs motion with relative ease.

pale color returns after 3-4 sec when pressure is released. Performs motion with relative ease. Soles of feet are pallor and cool to touch

inadequate circulating blood or hemoglobin and subsequent reduction in tissue oxygenation.( Kozier et al. Fundamentals of Nursing 8th edition pp. 577) INTERPRETATION : There is a deviation in rapid capillary refill time ANALYSIS: Prolonged capillary refill time suggest diminished artierial perfusion. (Smeltzer et al. Brunner and Suddarth's MedicalSurgical Nursing 12th edition pp. 2090)