PHYSICAL ASSESSMENT ASSESSMENT TECHNIQUE Actual Findings GENERAL SURVEY Observe body built, height and weight in relation

to the clients age, lifestyle Observe clients posture and gait, standing, sitting and walking INSPECTION Clients BMI is 31.17 that classify her as Obese Type 1. Proportionate, varies with lifestyle. ABNORMAL. The normal BMI is between 18.5 to 24.99. Reference: Kozier and Erbs Fundamentals of Nursing (Eight Edition) ABNORMAL. Initially, some 80% of all patients with stroke experience motor impairments of the contra lateral limb(s), ie, hemiparesis. In the early literature, abnormal reflexes associated with spasticity were considered to be the major determinant of these motor impairments. Reference: Kozier and Erbs Fundamentals of Nursing (Eight Edition) NORMAL Normal Findings Interpretation/Analysis

INSPECTION

Ambulatory; on her left leg, her 3 fingers are numb but can move slightly; Spastic gait

Relaxed and erect; No gait problem.

Observe the clients overall hygiene and grooming Note body and breath odor in relation to activity level Observe for signs of distress, in posture or facial expression Note clients affect/mood; assess the appropriateness of the clients responses Note clients quantity of speech, quality

INSPECTION

Appears neat and clean; well groomed with properly combed hair

INSPECTION

No body odor; no bad breath

Appears neat and clean; well groomed with properly combed hair Has no body NORMAL odor and breath odor No signs of distress NORMAL

INSPECTION

No signs of distress

INSPECTION

Relaxed and responds to question and commands

Relaxed and responds to question and commands

NORMAL

INSPECTION

Has slurred speech

Speaks clearly and no speech defect

ABNORMAL. Neurogenic disorders arise from signal problems between the brain and nerves or muscles. In neurogenic stuttering, the brain is

unable to coordinate adequately the different components of the speech mechanism. Reference: Kozier and Erbs Fundamentals of Nursing (Eight Edition) NORMAL

Uniformity of color

INSPECTION

Has a uniform brown skin color

Presence of edema Lesions according to location, distribution, color, configuration, size, shape, type of structure Skin moisture

INSPECTION INSPECTION

Has no presence of edema Has no lesions or abrasions

Uniform in color except in areas expose to the sun No edema No lesions or abrasions

NORMAL NORMAL

PALPATION

Moist skin

Skin temperature

PALPATION

Has a uniform temperature. Warm to touch Good skin turgor; springs back to previous state when pinched < 3 seconds. NAILS Good convex curvature

Skin turgor

PALPATION

Mositure in the skin folds and axilla varies with environmental situation Uniform in temperature and within normal range When pinched, skin springs back to previous state. Good convex curvature

NORMAL

NORMAL

NORMAL

Inspect fingernail plate shape to determine its curvature and angle Inspect fingernail and toenail bed color Palpate fingernail and toenail texture Inspect tissues surrounding nails Perform blanch test for capillary refill

INSPECTION

NORMAL

INSPECTION

Pink nail beds

Pink nail beds

NORMAL

PALPATION

Smooth texture

Smooth texture

NORMAL

INSPECTION

Tissues surrounding the nail are intact Good capillary refill; prompt retun to its pink or usual color less than 3 seconds. HEAD

Intact tissues

NORMAL

PALPATION

Prompt return to its usual color less than 3 seconds.

NORMAL

Size, Shape,

INSPECTION

Skull Symmetric, round and

Rounded,

NORMAL

Symmetry Presence of nodules, masses, and depressions Color and Appearance Areas of tenderness Evenness of growth, thickness or thinness Texture INSPECTION

proportional to his weight Has no presence of nodules, masses, and depressions Scalp The same as the color of the skin No areas of tenderness Hair Frontal baldness

smooth skull contour Absence of nodules or masses

NORMAL

INSPECTION PALPATION

Lighter than the skin color No signs of tenderness Evenly distributed

NORMAL NORMAL

INSPECTION

NORMAL

PALPATION

Dry withered Face Unsymmetrical facial movements

Silky, Smooth, Resilient Symmetric facial movements

NORMAL

Facial features, symmetry of facial movements

INSPECTION

ABNORMAL. Central facial palsy is the paralysis of the lower half of one side of the face. This condition is often caused by a stroke. This condition is often the result of damage of the upper motor neurons of the facial nerve. Reference: Kozier and Erbs Fundamentals of Nursing (Eight Edition)

EYES Hair distribution, alignment, skin quality, and movement INSPECTION Eyebrows Evenly distributed hair, intact skin, symmetrically aligned, equal movement Evenly distributed hair, intact skin, symmetrically aligned, equal movement Evenly distributed hair, curled outward Skin intact, no discharge, no discolorization NORMAL

Hair distribution and direction of curl Surface characteristics position in relation to the cornea Bulbar conjunctiva for color, texture, and presence of lesions Palpebral

INSPECTION

Eyelashes Evenly distributed hair, curled outward Eyelids Skin intact, no discharge, no discolorization

NORMAL

INSPECTION

NORMAL

INSPECTION

Conjunctiva Transparent, capillaries evident, sclera appears white

INSPECTION

Shiny smooth, pale in

Transparent, capillaries sometimes evident, sclera appears white Shiny smooth,

NORMAL

NORMAL

conjunctiva for color, texture, and presence of lesions Color and clarity Shape and color Symmetry INSPECTION

color

pink in color

Sclera Appears white and clear Iris Black, flat and round Pupils Equal in size and equally round Constrict briskly to direct and consensual light and to accommodation.

Appears white and clear Black, flat and round Equal in size and equally round Constrict briskly to direct and consensual light and to accommodation. The pt can able to read newspaper even without glasses

NORMAL

INSPECTION

NORMAL

INSPECTION

NORMAL

Light reaction and accommodation

INSPECTION

NORMAL

Test Visual Acuity

INSPECTION

Visual Acuity The client has glasses. And her eye vision grade is 300 in both eyes.

ABNORMAL. The normal eye vision is 20/20. Reference: Potter And Perry Fundamentals of nursing 5th edition

Alignment and coordination

INSPECTION

Test Peripheral visual fields

Inspection

Extraocular muscles Both eyes coordinated Both eyes move in unison with coordinated parallel alignment move in unison with parallel alignment Visual Fields Intact peripheral vision Intact peripher al vision in both eyes EARS

NORMAL

NORMAL

Color, symmetry and position

INSPECTION

Matches the flesh color of the rest of the patients skin and was positioned centrally and in proportion to the head

Texture, elasticity, and areas of tenderness

PALPATION

Mobile, firm and not tender, pinna recoils after it is folded NOSE

Matches the flesh color of the rest of the patients skin and was positioned centrally and in proportion to the head Mobile, firm and not tender, pinna recoils after it is folded

NORMAL

NORMAL

Color, symmetry, location, patency of the

INSPECTION

Matches the flesh color, Located symmetrically in the midline of the face and is without swelling,

Matches the flesh color, Located symmetrically in

NORMAL

nares and diviation.

bleeding, or masses, Both nares are patent, No bone and cartilage diviation noted on palpation.

the midline of the face and is without swelling, bleeding, or masses, Both nares are patent, No bone and cartilage diviation noted on palpation.

MOUTH Symmetry of contour, color, and texture INSPECTION PALPATION Lips Dry, pink color with darkened areas, soft unsymmetrical lips Uniform pink color, soft, moist, smooth texture, unsymmetrical ABNORMAL. Central facial palsy is the paralysis of the lower half of one side of the face. This condition is often caused by a stroke. This condition is often the result of damage of the upper motor neurons of the facial nerve. Reference: Kozier and Erbs Fundamentals of Nursing (Eight Edition) Color, condition and presence of dentures INSPECTION Teeth Has Dentures White to NORMAL yellowish in color, shiny tooth enamel, no intact dentures Pink, moist, firm, no retraction and bleeding. Pink, moist, slightly rough, moves freely, the base is smooth with prominent veins and no palpable nodules. NORMAL

Color and condition

INSPECTION

Gums Pink, moist, firm, no retraction and bleeding. Tongue Pink, moist, slightly rough, moves freely, the base is smooth with prominent veins and no palpable nodules.

Color, Texture, movement and base of the tongue, presence of nodules.

INSPECTION

NORMAL

Color, shape, texture, presence of bony prominences Position of the Uvula

INSPECTION

Palates and uvula Soft palate is light pin in color, hard palate is much lighter and more irregular in texture

INSPECTION

Positioned at the midline of soft palate

Soft palate is NORMAL light pin in color, hard palate is much lighter and more irregular in texture Positioned at the NORMAL midline of soft palate

NECK AND LYMPH NODES Symmetry and tenderness INSPECTION The muscles of the neck are symmetrical with the The muscles of the neck are NORMAL

head in a central position. The patient is able to move the head through a full range of motion without complaint of discomfort or noticeable limitations. Lymph nodes are neither visible nor inflamed.

symmetrical with the head in a central position. The patient is able to move the head through a full range of motion without complaint of discomfort or noticeable limitations. Lymph nodes are neither visible nor inflamed.

THORAX Posterior Thorax Size, shape, INSPECTION symmetry, Ratio of AP diameter to transverse thorax Symmetric, ribs are sloped downward, muscle development is equal, AP to transverse diameter ratio is 1:2 Symmetric, ribs are sloped downward, muscle development is equal, AP to transverse diameter ratio is 1:2 Vertically aligned Uniform in temperature, no tenderness and masses Full and symmetric chest expansion Bilaterally equal, heard mostly at the apex of the lungs Quiet, rhythmic, effortless Warm to touch, no tenderness or masses Full and symmetric chest expansion Bilaterally equal, heard mostly at the apex of the lungs Bronchial Sound NORMAL

Spinal Alignment Temperature, tenderness, masses Respiratory excursion Vocal fremitus

INSPECTION PALPATION

Vertically aligned Warm to touch, no tenderness and masses

NORMAL NORMAL

INSPECTION PALPATION INSPECTION

Full and symmetric chest expansion Bilaterally equal, heard mostly at the apex of the lungs Anterior Thorax Quiet, rhythmic, effortless Warm to touch, no tenderness or masses Full and symmetric chest expansion Bilaterally equal, heard mostly at the apex of the lungs

NORMAL

NORMAL

Breathing Patterns Temperature, tenderness, masses Respiratory Excursion Vocal Fremitus

INSPECTION PALPATION

NORMAL NORMAL

INSPECTION PALPATION INSPECTION

NORMAL

NORMAL

Trachea

AUSCULTATION Bronchial sound ABDOMEN

NORMAL

Skin integrity, contour, enlargement of liver or spleen, symmetry of

INSPECTION

Unblemished skin, uniform in color, no signs of enlargement of the liver and spleen, symmetrical contour

Unblemished skin, uniform in color, no signs of enlargement of the liver and

NORMAL

contour

Visibility of peristalsis movement Visibility of vascular patterns Bowel sounds, vascular and peritoneal friction rubs

INSPECTION

Not visible

INSPECTION

Not visible

spleen, symmetrical contour Not visible, slightly visible on thin persons Not visible

NORMAL

NORMAL

AUSCULTATION Altered bowel sounds; decreased bowel movement

Audible bowel sounds, not audible vascular peritoneal friction rubs

ABNORMAL. Altered Bowel sounds and decreased bowel movements are caused by constipation. Reference: Kozier and Erbs Fundamentals of Nursing (Eight Edition)

MUSCULOSKELETAL SYSTEM Size, contractures, tremors INSPECTION Muscles Muscles contract in left leg; No tremors. Bilaterally symmetric, no contractures and tremors ABNORMAL. One out of five stroke survivors suffer from painful muscle spasms, which result when weakened muscles contract abnormally. These muscle contractions may interfere with walking ability. Reference: Brunner and Suddarth Medical Surgical Nursing (12th edition) ABNORMAL. The changes in muscle tone probably result from alterations in the balance of inputs from reticulospinal and other descending pathways to the motor and interneuronal circuits of the spinal cord, and the absence of an intact corticospinal system.

Tonicity, strength (neck, lower and upper extremities)

INSPECTION

Increased muscle tone in left leg; muscle strength in the right upper and lower extremities was rated 4. In the left upper extremity, it was also rated 4. While the lower left extremity was rated 2. 1 being the weakest muscle strength and 5 being the highest or strongest.

Normal muscle tension, adequate strength of the muscles (rate = 5)

Reference: Brunner and Suddarth Medical Surgical Nursing (12th edition) Structure, deformities, tenderness, edema INSPECTION PALPATION Bones Uniform in structure, no deformities, tenderness or edema Uniform in structure, no deformities, tenderness or edema NORMAL

Swelling, tenderness, smoothness of movement, crepitation, presence of nodules

INSPECTION PALPATION

Joints No tenderness and swelling; No presence of nodules but has a difficulty in movement of the joints.

Absence of tenderness and swelling, has smooth movement, no nodules

ABNORMAL. In poststroke patients. There is damage to the part of the brain or spinal cord that controls voluntary movement of the joints and muscles. Reference: Brunner and Suddarth Medical Surgical Nursing (12th edition) ABNORMAL. Muscles affected by the Upper Motor Neuron Syndrome have many potential features of altered performance including weakness, decreased motor control, clonus (a series of involuntary rapid muscle contractions), exaggerated deep tendon reflexes, spasticity, decreased endurance and inability to perform range of motion exercises in the affected part. Reference: Brunner and Suddarth Medical Surgical Nursing (12th edition)

Range of motion (Shoulder and scapula, elbows, hands, acetabulum, popliteal, ankles)

INSPECTION

The client is able to perform abduction, adduction and rotation in the right upper and lower extremities and also in the left upper extremity but cannot perform in the left lower extremity.

Able to perform the exercises in full range of motion, no tenderness, moves smoothly