V.

PHYSICAL ASSESSMENT General Appearance and Mental Status Parts to be Assessed Hygiene and Grooming Actual Findings Clean and neat Norms and Standards Clean and neat Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.572 No body odor or minor body odor relative to work or exercise. No breath odor Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.572 No distress noted Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.572 Healthy appearance Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.572 Cooperative, able to follow instructions Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.572 Analysis Normal

Breath and body odor

No body odor and breath odor

Normal

Signs of distress

Signs of distress noted.

Deviation from Normal

Signs of illness or health

Weak looking

Deviation from Normal

Clients attitude

Cooperative and can able to follow instructions

Normal

Affect/Mood

Appropriate to the situation.

Uniformity of color

Uneven skin color

Turgor

Delayed skin turgor

Appropriate to situation Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.572 Integument (Skin) Generally uniform except in areas exposed to the sun Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.580 Skin pinches easily and immediately returns to its original position. .(Health assessment in nursing 3rd edt. , Lippincott, Pg. 171) Skin is normally a warm temperature. .(Health assessment in nursing 3rd edt., Lippincott, Pg. 171) Skin surfaces vary from moist to dry depending on the area assessed and the environment. .(Health assessment in nursing 3rd edt. , Lippincott, Pg. 170) Skin is smooth and even. .(Health assessment in nursing 3rd edt., Lippincott, Pg. 170) Skin should be smooth without lesions, stretch marks, healed scars, freckles, and moles. Birth marks are common findings. .(Health assessment in nursing 3rd

Normal

Deviation from normal

Deviation from Normal

B. Temperature

Her skin is warm to touch and have even body temp Her skin moisture is dry as it was assessed

Normal

C. Moisture

Normal

D. Texture

Skin is rough and dry

Deviation from Normal Deviation from Normal

Lesions

Presence of healed scars on clients extremities

Edema

Skin remains slightly intended when pressure is released

edt., Lippincott, Pg. 170) Skin rebounds and does not remain indented when pressure is released. .(Health assessment in nursing 3rd edt. , Lippincott, Pg. 172) Integument (Nail)

Deviation from Normal

Texture

No fingers and toes because of the disease therefore not applicable

Color

No fingers and toes because of the disease therefore not applicable

Tissue surrounding nails

Not applicable to the client

Blanch test of capillary refill

Not applicable to the client

Smooth texture Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.584 Highly vascular and pink in light-skinned clients; darkskinned clients may have brown or black pigmentation in longitudinal streaks. Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.584 Intact epidermis Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.584 Prompt return of pink or usual color. Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.584 Integument (Hair)

Deviation From Normal

Deviation From Normal

Deviation From Normal

Deviation From Normal

Evenness of growth

Evenly distributed hair

Thickness and thinness

Thick hair

Texture and oiliness

Slightly dry hair

Eyebrows

Thinning of eyebrows

Eyelashes

Eyelashes not equally distributed

Eyelids

Skin intact, Lids close symmetrically; bilateral blinking

Evenly distributed hair Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.582 Thick hair Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.582 Silky, resilient hair Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.582 Integument (Eyes) Eyebrows symmetrically aligned; equal movement. Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.588 Equally distributed; curled slightly outward. Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.588 Skin intact; no discharge; no discoloration. Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore,

Normal

Normal

Deviation from normal

Deviation from normal

Deviation from normal

Normal

Bulbar conjunctiva

Palpebral conjunctiva

Lacrimal gland

Lacrimal sac and nasolacrimal duct

Auricles

Texture and

Vol.1,p.588 Yellowish in Transparent; capillaries color sometimes evident ; sclera appears white (darker or yellowish and with small brown macules in darkskinned clients) Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.588 Shiny and Shiny, smooth, pink or red smooth Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.588 No edema or No edema or tenderness tenderness over lacrimal gland. over lacrimal Kozier and gland Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.589 No edema or No edema or tearing tearing on Kozier and lacrimal sac Erbs.(2008).Fundamentals and of Nursing, 8th nasolacrimal Ed.,Prentice duct Hall:Singapore, Vol.1,p.589 Integument (Ears and Hearing) Color same as Color same as facial skin; facial skin Symmetrical; Symmetrical Kozier and Aligned with Erbs.(2008).Fundamentals the outer of Nursing, 8th canthus of the Ed.,Prentice eye Hall:Singapore, Vol.1,p.596 Pinna recoils Mobile, firm, and not

Normal

Normal

Normal

Normal

Normal

Normal

elasticity

External ear canal and tympanic membrane

Lips

Gums

Inspection

tender; pinna recoils after folded. Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.596 Dry cerumen Distal third contains No blood or follicles and glands; pus Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.596 Integument (Mouth) Pale color and Uniform pink color ; Soft, dry moist; smooth texture Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.602 Slightly Pink Pink gums (bluish or gums brown patches in darkskinned clients) Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.602 Chest and Lungs AP diameter Anteroposterior to not assessed, spine vertically aligned transverse diameter in ration of 1:2 Spine vertically aligned Kozier and Erbs.(2008).Fundamentals of Nursing, 8th

back, firm

Normal

Deviation from normal

Normal

Normal

Ed.,Prentice Hall:Singapore, Vol.1,p.614 Palpation No tenderness, no abnormalities Auscultation Bronchial breath sounds Bronchial and tubular breath sounds; Bronchovesidular and vesicular breath sounds Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.618 Size Not equal in size because of the disease Muscles Equal size on both sides o the body Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.640 No contractures Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.640 Equal in strength. (Fundamental of nursing 8th edt., Kozier and Erbs, pg.606) Bones Deviation from Normal Normal No tenderness , no abnormalities Normal

Contractures

No contractures

Normal

B. Muscle strengths

Decreased muscle strength on right and left leg

Deviation from Normal

Normal structures and deformities

No deformities

No deformities Kozier and Erbs.(2008).Fundamentals of Nursing, 8th Ed.,Prentice Hall:Singapore, Vol.1,p.641

Normal