PHYSICAL ASSESSMENT

Date of Assessment: October 5, 2018

Vital Signs:
Blood Pressure (BP): 130/80 mmHg Height: 162 cm
Pulse Rate (PR): 81 bpm Weight: 50 kgs.
Respiratory Rate (RR): 22 cpm Body Mass Index (BMI): 19.49 (normal)
Temp: 38°C O2 Saturation: 98%

General Assessment:

Patient is seen conscious and coherent; garbed in hospital gown and lying on bed. He has a small built body. He has dark brown
complexion and visibly has wrinkled skin due to his age. He has mixed white and gray hair and the front part of his scalp is already
bald. He has gray mustache and scattered eyebrows. He has incomplete teeth but does not have dentures. The patient has a slightly
offensive smell and wears a pale-yellow shirt and blue maong pants upon assessment. Patient is hooked with PNSS 1000cc x KVO
infusing well on his left metacarpal vein. He exhibited mild body weakness.

Note: Assessment for this case was only limited to inspection and auscultation since there were cultural differences that should be considered in handling
Indonesian Islams such as respecting personal distance and not touching the patient (male patient and female foreign nurse).

SYSTEM/ TYPE OF NORMAL

ACTUAL FINDINGS INTERPRETATION ANALYSIS
BODY PART ASSESSMENT FINDINGS
Skin Inspection Skin is uniform Skin is brown No other significant Normal
(pp.283-304, Health whitish pink or findings
Assessment &
Physical Examination brown color
– Zator Estes)
No Bleeding No bleeding No other significant Normal
findings

No area of No area of increased No other significant Normal

increased vascularity vascularity and ecchymosis findings
and ecchymosis
 No skin lesions Infected open wound  Diabetes increases Not Normal
present except for was visible on the right susceptibility to
freckles, birthmarks foot infection. People with
or moles which diabetes may not be
may be flat or able to mount an
elevated effective
inflammatory
response due to
impaired immune
defenses, decreased
peripheral circulation
and decreased
metabolic control.

Skin is dry with a  Skin is dry with a No other significant Normal
minimum of minimum of perspiration. findings
perspiration.
Scalp and Hair Inspection Dark black to Hair appears black with No significant Normal
(pp.305-308, Health pale blonde; may some white hair findings
Assessment &
Physical Examination turn gray or white;
– Zator Estes) may be chemically
changed

Terminal hair Scattered distribution Hair distribution Not Normal

found in the of hair on eyebrows; and early baldness can
eyebrows,, Even distribution of be associated to a
eyelashes, and eyelashes, and baldness genetic condition,
scalp, and in axilla on the front part of the stress or presence of a
and pubic areas scalp diseases. It can also
after puberty. be due to aging
process.
 No signs of No infestation or No significant Normal
infestation or lesions findings
lesions.

Seborrhea/ No seborrhea/ dandruff No significant Normal

dandruff may be observed findings
present

Nails Inspection Have a pink-cast Brown-cast nails No other significant Normal
(pp.308-311, Health in light- skinned findings
Assessment &
Physical Examination and brown in dark-
– Zator Estes) skinned.

Capillary refill Capillary refill of 2 No other significant Normal

present (should seconds (as documented on findings
return to normal 2-3 patient’s chart)
sec)

Surface is Surface smooth and No other significant Normal

smooth, and slightly rounded findings
slightly rounded or
flat. Curved nails
are normal.

Uniform nail No splinters or brittle No other significant Normal

thickness edges findings
throughout; no
splintering or brittle
edges.

Angle approx. Angle approx. 160° No other significant Normal

160° findings
 Eyes Inspection Symmetrical with Eyes symmetrical No significant Normal
(pp.350-362, Health no drooping, findings
Assessment &
Physical Examination infection, tumors or
– Zator Estes) other abnormalities

Visual Acuity: Visual acuity of 20/20 No significant Normal

20/20 findings

Sclera: Sclera appears white No significant Normal

White in light- findings
skinned w/o
exudates, lesions or
foreign bodies. In
dark-skinned, may
have brown patches

Pupils: equally Pupils equally round, No significant Normal

round, reactive to reactive to light and findings
light and accommodation; approx.
accommodation; 2- 4 mm
6 mm

No tearing, No tearing, swelling or No significant Normal

swelling or discharge findings
discharge
Ears Inspection Match flesh color Same color as face No significant Normal
(pp.386-389, Health of the rest of the findings
Assessment &
Physical Examination skin.
– Zator Estes)
Central position Central position No significant Normal
findings
 Proportional Proportional No significant Normal
findings

No redness, No redness, swelling, No significant Normal

lesions, swelling, or tenderness findings
tenderness
Nose Inspection Symmetrical, Symmetrical and in No significant Normal
(pp.394-397, Health midline of the face midline findings
Assessment &
Physical Examination
– Zator Estes) Without swelling, No swelling, bleeding, No significant Normal
bleeding, lesions, or lesions, or masses findings
masses.

Each nostril is Patent nostrils No significant Normal

patent findings
Mouth Inspection Breath smells Breath smell was Due to food Not Normal
(pp.398-405, Health fresh undistinguished recently ingested;
Assessment &
Physical Examination poor oral hygiene
– Zator Estes)
Lips and Lips and membranes No significant Normal
membranes pink are moist, dark flesh findings
and moist with no colored; no lesions or
lesions or inflammation
inflammation

Tongue is Tongue in midline and No significant Normal

midline. Pink, moves freely findings
moist, rough
without lesions

No swelling or No swelling or No significant Normal

bleeding bleeding findings
 Neck Inspection Symmetrical with Symmetrical with head No significant Normal
(p.331, Health head in central in central position findings
Assessment &
Physical Examination position
– Zator Estes)
Able to move Able to move head No significant Normal
head without without discomfort findings
discomfort or
noticeable limits

Without mass/es,  No mass/es, lesions No significant Normal

lesions and and distended vein findings
distended vein
Chest Inspection Without lesions; Without lesions No significant Normal
(pp.451-469, Health skin intact findings
Assessment &
Physical Examination
– Zator Estes) Quiet, rhythmic Quiet rhythmic and No significant Normal
and effortless effortless breathing findings
breathing

Auscultation Bronchial, Bronchovesicular No significant Normal

bronchovesicular breath sounds findings
or vesicular breath
sounds (as documented
in patient’s chart)
Abdomen Inspection Abdominal Abdominal contour No significant Normal
(pp.552-562, Health contour flat or rounded. findings
Assessment &
Physical Examination rounded
– Zator Estes)
Symmetrical Symmetrical No significant Normal
findings

Uniform in color Uniform in color No significant Normal

or pigmentation findings
 No abdominal No scars No significant Normal
scars findings

No organ No enlargement, No significant Normal

enlargement present masses, bulges or findings
upon inspection, or swelling
any masses, bulges,
or swelling

Auscultation Intermittent Gurgling sounds in No significant Normal

gurgling sounds abdomen findings
throughout
abdominal
quadrants (as
documented in patient’s
chart)
Upper Inspection Without lesions, Without lesions, scars No significant Normal
Extremities scars or or inflammation findings
(p.579, Fundamentals inflammation
of Nursing, Kozier)

No edema No edema No significant Normal

findings

No deformities No deformities No significant Normal

findings
Lower Inspection Without lesions,  Infected open wound  Diabetes increases Normal
Extremities scars or was visible on the right susceptibility to
(p.579, Fundamentals inflammation foot infection. People with
of Nursing, Kozier)
diabetes may not be
able to mount an
effective
inflammatory
response due to
 impaired immune
defenses, decreased
peripheral circulation
and decreased
metabolic control.

No edema No edema No significant Normal

findings

No deformities No deformities No deformities Normal