Physical Assesment Final

MARILOU PRESTO
ASSESSMENT NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS/INTERPRETATION

*MEASUREMENTS Varies greatly with the
lifestyle of the client,
proportionate.
BMI: 18.6-22.9 kg!
2
"B#: $%.8-61.& kg
'18 ( )n*erweight
2+ ( o,erweight
2+.1 ( 2$.9 at risk for
o-esity
2%-29.9 o-ese I
26. o-ese II
/e!perat0re: +6.%-+&.%
10lse rate: 62-122 -p!
3espiration: 12-22
cycles!in
Bloo* press0re: 12282
!!4g
4eight: $5116
#eight: %2 kg
BMI: 2+.1 kg!
2
/e!perat0re: +6.1 78
13: &% -p!
33: 19 cp!
B1: 12282
9t risk for o-esity
GENERAL SURVEY
"escri-e the -o*y -0ilt, height
an* weight in relation to the
client6s age, lifestyle an*
health.
1roportionate, ,aries with
lifestyle
4eight: $5116
#eight: %2 kg
9t risk for o-esity
"escri-e the client6s post0re,
gait, an* stan*ing, sitting an*
walking.
3ela:e*; erect post0re,
coor*inate* !o,e!ent
has slo0chy post0re -0t has a
coor*inate* -o*y !o,e!ent
M0scle !ass *ecreases progressi,ely
within age an* -ones -eco!e !ore
fragile.
3eference: #e-er, <. = >elley, <.
?222&@. Health Assessment in
Nursing (3
rd
ed.@. Aippincott #illia!s
= #ilkins 10-lisher
INTEGUMENTARY:
(SKIN)
Inspect for color; 0nifor!ity of
color.
Varies fro! light to *eep
-rown; fro! r0-y pink to light
pink; fro! yellow o,ertones to
oli,e.
Bkin is -rown with age spots
*istri-0te* all o,er the -o*y;
9ppears *ry an*
flaky;
/he skin is *ry an* flaky -eca0se
se-aceo0s an* sweat glan*s are less
acti,e.
Nursing (3
rd
= #ilkins 10-lisher
(HAIR)
Inspect for e,enness of
growth, thickness or thinness.
C,enly *istri-0te*. 4air on hea* is thinning with its
white roots showing.
In el*erly people, 4air is slightly
thinning an* white hair starts to
appear.
Nursing (3
rd
= #ilkins 10-lisher
EYES:
(VISUAL ACUITY)
/est near ,ision. 9-le to rea*
newspapernewsprint.
4as *iffic0lty in rea*ing newspaper Vis0al ac0ity *ecreases as the lens of
the eye ages an* -eco!es !ore
opaD0e an* loses elasticity.
Nursing (3
rd
= #ilkins 10-lisher
/est *istant ,ision. 2222 ,ision on Bnellen chart. 4as a 1&% gra*e in -oth eyes Vis0al ac0ity *ecreases as the lens of
the eye ages an* -eco!es !ore
opaD0e an* loses elasticity
Nursing (3
rd
= #ilkins 10-lisher
NOSE: EF3M9A
Inspect the nasal ca,ities for
the presence of re*ness,
M0cosa pink, clear, watery
*ischarge, no lesion.
*ischarge with col*s, no lesion.
the presence of nasal secretions can
-e o-,io0s 0pon e:a!ination an*
swelling, growths an*
*ischarge, 0sing he flashlight.
!ay in*icate the presence of a ,iral
infection.
Nursing (3
rd
ed.@. Aippincott
#illia!s = #ilkins 10-lisher
MOUTH:
(LIPS)
Inspect for sy!!etry of
conto0r, color, an* te:t0re.
)nifor! inpk color, soft, !oist,
s!ooth te:t0re, sy!!etry of
conto0r, a-ility to p0rse lips.
4as a sy!!etric, *ry an* chappe*
pale lips; a-ility to po0t lips
3es0lts fro! n0tritional *eficiency
an* fl0i* *eficit
Nursing (3
rd
= #ilkins 10-lisher
(TEETH)
Inspect for color, n0!-er an*
con*ition an* presence of
*ent0res.
+2 a*0lt teeth, s!ooth, white,
shiny tooth ena!el.
#ith 0p an* *own *ent0res 9ging is a factor affecting loss of
teeth an* also ins0fficient calci0!
an* fl0ori*e.
1oor occl0sion of teeth can affect
chewing, wearing *own of teeth,
speech an* self-i!age.
Nursing (3
rd
= #ilkins 10-lisher
MICHELLE PRESTO
proportionate.
BMI: 18.6-22.9 kg!
2
"B#: $%.8-61.& kg
'18 ( )n*erweight
2+ ( o,erweight
2+.1 ( 2$.9 at risk for
o-esity
2%-29.9 o-ese I
26. o-ese II
/e!perat0re: +6.%-+&.%
10lse rate: 62-122 -p!
3espiration: 12-22
cycles!in
!!4g
4eight: %525
#eight: %1 kg
BMI: 22.% kg!
2
/e!perat0re: +6.2
78
13: &6 -p!
33: 26 cp!
B1: 122&2
/achycar*ia is present. /his is !ay -e *0e to her
col*s an* e:perience* *iffic0lty in -reathing ,
stress, an* other a-nor!al states
3eference: #e-er, <. = >elley, <. ?222&@.
Health Assessment in Nursing (3
rd
ed.@.
Aippincott #illia!s = #ilkins 10-lisher
NOSE: EF3M9A
Inspect the nasal ca,ities for the
presence of re*ness, swelling,
growths an* *ischarge, 0sing he
flashlight.
*ischarge, no lesion.
M0cosa pink, clear,
watery *ischarge with
col*s, no lesion.
the presence of nasal secretions can -e o-,io0s
0pon e:a!ination an* !ay in*icate the presence
of a ,iral infection.
rd
ed.@.
/est patency of -oth nasal
ca,ities.
9ir !o,es freely as the client
-reathes thro0gh the nares.
8lient -reaths with
*iffic0lty -eca0se of col*s
"iffic0lty -reathing thro0gh nose occ0rs *0e to
nasal congestion in col*s an* allergies.
rd
ed.@.
MOUTH:
(LIPS)
Inspect for sy!!etry of conto0r,
color, an* te:t0re.
)nifor! inpk color, soft,
!oist, s!ooth te:t0re,
sy!!etry of conto0r, a-ility
to p0rse lips.
4as a sy!!etric, *ry an*
chappe* pale lips; a-ility
to po0t lips
3es0lts fro! n0tritional *eficiency an* fl0i* *eficit
rd
ed.@.
(TEETH)
Inspect for color, n0!-er an*
con*ition an* presence of
*ent0res.
shiny tooth ena!el.
28 a*0lt teeth; 4as
!issing teeth in the
an* lower !olars
4as yellowish teeth
1oor occl0sion of teeth can affect chewing,
wearing *own of teeth, speech an* self-i!age.
3eference: #e-er, <. = >elley, <. ?222&@. Health
Assessment in Nursing (3
rd
ed.@. Aippincott
Anterir T!r"#
Breathing patterns G0iet rhyth!ic an* effortless
respiration.
Aa-ore* -reathing
-eca0se of col*s
"iffic0lty -reathing thro0gh nose occ0rs *0e to
nasal congestion in col*s an* allergies.
rd
ed.@.
Vocal fre!it0s Ba!e as posterior ,ocal
fre!it0s;
fre!it0s is nor!ally
*ecrease* o,er
heart an* -reast tiss0e.
?H@ retractions note* Bternal retractions are note* with se,erely
la-ore* -reathing.
3etractions of the intercoastal spaces
in*icate* increase* respiratory effort.
rd
ed.@. Aippincott
MELODY PRESTO
proportionate.
BMI: 18.6-22.9 kg!
2
"B#: $%.8-61.& kg
'18 ( )n*erweight
2+ ( o,erweight
2+.1 ( 2$.9 at risk for
o-esity
2%-29.9 o-ese I
26. o-ese II
/e!perat0re: +6.%-+&.%
10lse rate: 62-122 -p!
3espiration: 12-22
cycles!in
!!4g
4eight: %5+5
#eight: %& kg
BMI: 22.2 kg!
2
/e!perat0re: +6 78
13: 68 -p!
33: 22 cp!
B1: 11282
EF3M9A
MOUTH:
(LIPS)
)nifor! inpk color, soft, !oist,
chappe* pale lips; a-ility to
po0t lips
rd
= #ilkins 10-lisher
(TEETH)
Inspect for color, n0!-er
an* con*ition an* presence
of *ent0res.
shiny tooth ena!el.
26 a*0lt teeth;
4as !issing teeths.4as
yellowish teeth
1oor occl0sion of teeth can affect chewing,
wearing *own of teeth, speech an* self-i!age.
rd
= #ilkins 10-lisher
MADELYN
proportionate.
BMI: 18.6-22.9 kg!
2
"B#: $%.8-61.& kg
'18 ( )n*erweight
2+ ( o,erweight
2+.1 ( 2$.9 at risk for
o-esity
2%-29.9 o-ese I
26. o-ese II
/e!perat0re: +6.%-+&.%
10lse rate: 62-122 -p!
3espiration: 12-22
cycles!in
!!4g
4eight: $5115
#eight: %8 kg
BMI: 2%.8 kg!
2
/e!perat0re: +6 78
13: 88 -p!
33: 2+ cp!
B1: 122&2
Bhe is 8 !onths pregnant so her weight was also
increase*.
Inspect of presence of
e*e!a.
Eo e*e!a. Blight e*e!a on han*s when e:cess fl0i* collects in the tiss0e, ItIs nor!al to
ha,e a certain a!o0nt of swelling *0ring pregnancy
-eca0se of retaining !ore water.
rd
ed.@. Aippincott #illia!s =
#ilkins 10-lisher
MOUTH:
(LIPS)
)nifor! pink color, soft, !oist,
chappe* pale lips; a-ility
to po0t lips
(TEETH)
an* con*ition an* presence
of *ent0res.
shiny tooth ena!el.
2& a*0lt teeth;
4as !issing teeth
4as yellowish teeth
1oor occl0sion of teeth can affect chewing, wearing
*own of teeth, speech an* self-i!age.
rd
#ilkins 10-lisher
A$DOMEN
Inspect the a-*o!en for
skin
integrity.
)n-le!ishe* skin
0nifor! color
1resence of strectch !arks
an* line nigra
/hese are the signs of pregnancy
rd
#ilkins 10-lisher
EULOGIO PRESTO
*MEASUREMENTS Varies greatly with
the lifestyle of the
client, proportionate.
BMI: 18.6-22.9
kg!
2
"B#: $%.8-61.& kg
'18 ( )n*erweight
2+ ( o,erweight
2+.1 ( 2$.9 at risk
for o-esity
2%-29.9 o-ese I
26. o-ese II
/e!perat0re: +6.%-
+&.%
10lse rate: 62-122
-p!
3espiration: 12-22
cycles!in
Bloo* press0re:
12282 !!4g
4eight: %5%5
#eight: %2 kg
BMI: 18.+kg!
2
/e!perat0re: +6.1 78
13: &2 -p!
33: 1& cp!
B1: 12282
/he client is 0n*erweight . BMI'22 is generally consi*ere*
0n*erweight altho0gh people o0tsi*e this range !ay still -e
perfectly healthy. 1eople who are 0n*erweight !ay ha,e an
increase* risk of ane!ia, heart irreg0larities an* osteoporosis.
Fne of the -etter known con*itions associate* with low -o*y
weight is anore:ia. 1eople who are 0n*erweight can fin* it
e:tre!ely *iffic0lt to p0t on weight.
3eference: #e-er, <. = >elley, <. ?222&@. Health Assessment in
Nursing (3
rd
ed.@. Aippincott #illia!s = #ilkins 10-lisher
GENERAL SURVEY
"escri-e the -o*y -0ilt,
height an* weight in
relation to the client6s age,
lifestyle an* health.
1roportionate, ,aries
with lifestyle
4eight: %5%5
#eight: %2 kg
/he client is 0n*erweight. BMI'22 is generally consi*ere*
0n*erweight altho0gh people o0tsi*e this range !ay still -e
perfectly healthy. 1eople who are 0n*erweight !ay ha,e an
increase* risk of ane!ia, heart irreg0larities an* osteoporosis.
Fne of the -etter known con*itions associate* with low -o*y
weight is anore:ia. 1eople who are 0n*erweight can fin* it
e:tre!ely *iffic0lt to p0t on weight.
Nursing (3
rd
MOUTH:
(LIPS)
conto0r, color, an*
te:t0re.
)nifor! inpk color, soft,
!oist, s!ooth te:t0re,
sy!!etry of conto0r,
a-ility to p0rse lips.
chappe* pale lips; a-ility to
po0t lips
(TEETH)
an* con*ition an*
presence of *ent0res.
+2 a*0lt teeth, s!ooth,
white, shiny tooth
ena!el.
2& a*0lt teeth;
4as !issing teeth in the
frontal area an* lower
!olars
4as yellowish teeth
1oor occl0sion of teeth can affect chewing, wearing *own of
teeth, speech an* self-i!age.
Nursing (3
rd

Physical Assesment Final

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Physical Assesment Final

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MARILOU PRESTO

ASSESSMENT NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS/INTERPRETATION

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