PHYSICAL ASSESSMENT
I.
General Survey
Area
General appearance
Hygiene (grooming)
Manner of dressing
Body weight
Body built, stature, posture, gait,
mood, affect, speech
Normal Findings
(Bookview)
Abnormal Findings
(Actual Assessment)
General appearance: The
skin complexion of
Filipinos is fair skinned.
Patient was on semi fowlers
position during assessment
and body weakness was
noted. He is a fair skinned
Hygiene: The principle of
maintaining cleanliness
and grooming of the
external body
Filipino. His weight
during hospitalization is
187lbs. Clients height is
177cm. The client has a
normal body structure.
There were no lesions
found on his body.
Weight: A man's weight
averages 160 pounds
Body Status: The average
height of an adult man is
160 cm.
Body posture: The means
of communication in
addition facial expressions,
personal distance, gestures
and body movement
Body gait: bipedal,
biphasic forward
propulsion of center of
gravity of the human body,
in which there are alternate
sinuous movements of
different segments of the
body with least
expenditure of energy.
The patient appears clean
and well-groomed. His
hair were neatly combed.
No foul odors noted.
Cephalocaudal Approach
Skin
Normal Findings
(Book View)
No edema, no
abrasions and other
lesions; moisture in
skin folds and the
axillae (varies with
environmental
temperature and
humidity, body
temperature, and
activity); when
pinched skin back to
previous state
Assessment
(July 19, 2016)
I: No abrasion and lesions noted.
P::no dryness of skin noted
P: no lesions noted
A: not applicable
Head
Rounded
(normocephalic and
symmetrical, with
frontal, parietal, and
occipital
prominences; smooth
skull contour; absence
of nodules and
masses; symmetric or
slightly asymmetric
facial features;
palpebral fissures
equal in size;
symmetric nasolabial
folds
I: Normocephalic in shape and symmetrical. Head
is in proportion with the body.
P: No nodules, lesions and masses palpated
No protrusion of veins noted.
P: Not applicable
A: Not applicable
Hair
Evenly distributed
hair, thick, silky,
resilient, no infection
or infestation,
I: Color of hair is black and appears to be thick.
P: Not applicable
P: Not applicable
A: Not applicable
variable amount of
body hair
Face
Symmetric or slightly
asymmetric facial
features; palpebral
fissures equal in size;
symmetric nasolabial
folds
I: Face is symmetrical and has uniform color
consistency. Skin pigmentation is not noted.
P: No nodules or masses noted
P: Not applicable
A: Not applicable
Eyes
Eyelids intact, no
discharges, no
discoloration; lids
close symmetrically;
sclera appears white;
no edema or
tenderness over
lacrimal gland; pupils
constrict when
looking at near
objects, pupils dilate
when looking at far
objects, pupils
converge when near
object is moved
toward the nose.
I: Iris is dark brown in appearance. No
discoloration of sclera noted. No presence of
ocular discharges. Pupil is equal, round, reactive to
light and accommodation.
P: Not applicable
P: Not applicable
A: Not applicable
Ears
Color is same as
facial skin,
symmetrical; auricle
aligned with outer
canthus of eye, about
10 from vertical,
mobile firm, and not
tender; pinna recoils
after it is folded;
sound is heard in both
ears.
I: No discharges noted. No hearing impairment
noted
P: Not applicable
P: Not applicable
A: Not applicable
Nose
Symmetric, no
discharges or flaring;
not tender; no lesions;
mucosa is pink; nasal
septum intact and in
midline.
I: No discharges noted and no nasal flaring noted
P: No tenderness noted
P: Not applicable
A: Not applicable
Throat
Muscles equal in size;
head centered;
coordinated, smooth
movements with no
discomfort.
I: No visible mass noted
P: Not applicable
P: Not applicable
A: Not applicable
Nails
Convex curvature;
angle of nail plate
about 160; Smooth
texture; intact
epidermis; prompt
return of pink or
usual color
(generally less than 4
seconds.
Chest/Thorax
Breast
Chest symmetric,
chest wall intact, no
tenderness, no
masses
Rounded shape;
slightly unequal in
size; generally
I: Capillary refill is 2 seconds; no discoloration
noted
P: Not applicable
P: Not applicable
A: Not applicable
I: No retractions noted. No lesions noted.
P: No tenderness and masses noted.
P: not noted
A: No heart murmurs noted. No abnormal lung
sounds noted.
I: No visible mass or lesions noted
P: No tenderness noted
P: Not noted
A: Not noted
symmetric; skin
uniform in color,
smooth and intact;
nipples are rounded,
everted, and equal in
size; similar in color;
soft and smooth; both
nipples point in the
same direction; no
tenderness, masses, or
nodules
Abdomen
Uniform color; flat
rounded (convex), or
scapoid (concave)
contour; symmetric
contour; audible
bowel sounds;
absence of arterial
bruits; absence of
friction rub
Smooth coordinated
movements; no
deformities and
swelling
Lower Extremities
Anus
Systems Approach
Intact perianal skin;
usually slightly more
pigmented than the
skin of the buttocks;
anal skin is normally
more pigmented,
coarser, and moister
than perianal skin and
is usually hairless
I: no abdominal distention noted. No swelling
noted. No discoloration noted
A: not noted
P: not noted
P: No masses noted
I: No lesions and abrasions noted.
P: not noted
P: not noted
A: not applicable
I: presence of external hemorrhoids at 4 and 11
oclock before surgery
P: not noted
P: not noted
A: not applicable
Normal Findings
( actual )
Assessment
(July 19, 2016)
I: no skin dryness noted, nails are intact and no
discoloration noted. Capillary refill is 2 seconds,
normal skin turgor, no nodules noted.
P: No masses and tenderness noted, normal skin
temperature.
P: No abnormalities noted
A: Not applicable
Integumentary
Consist of skin, hair
and nails. Skin
provides a physical
barrier between
underlying tissues and
the external
environment;
excretion through
perspiration;
temperature
regulation and sensory
perception. Hair
protects the scalp
from excessive heat
loss. Nails protects the
dorsal tips of fingers
and toes and site of
assessing the capillary
refill.
Lymphatic System
Composed of organs
that helps maintain
homeostasis by
conserving water and
dissolved substances.
Lymphatic system
helps maintain water
balance in the body. It
also protects the body
against pathogens that
may invade the body.
I: No visible masses noted upon inspection
P: not noted
P: Not noted
A: Not applicable
Respiratory System
The purpose of the
respiratory system is
to keep the body
constantly supplied
with oxygen and to
I: No nasal discharges noted; No nasal flaring
noted. Has respiratory rate of 20 cpm.
P:Not noted
P: Not noted
A: Not noted
remove the carbon
dioxide. It consists of
the nasal passages,
pharynx, larynx,
trachea, bronchi, and
lungs. Within the
lungs are tiny air sacs.
It is through the thin
walls of these air sacs
that gases are
transported to and
from the blood. The
normal respiratory
rate is 16-20 cpm.
Cardiovascular
System
Musculoskeletal
System
The primary organ are
heart and blood
vessels. Using blood
as the transporting
fluid, the
cardiovascular system
carries oxygen,
nutrients, hormones,
or other substances to
and from tissue cells
where exchanges are
made. The heart acts
as the blood pumps,
propelling blood out
its chambers into the
blood vessels to the
transported to all body
tissue. The normal
cardiac rate is 60-100
bpm.
I: Normal chest contour, blood pressure is 130/100
mmHg.
P: Pulse rate of 86 bpm noted. Normal and regular
pulse noted.
P: Not applicable
A: Not noted
The skeletal system
serves as the
supporting framework
I: No deformities noted, no swelling noted
P: No masses and tenderness noted
P: Not noted
of the body, and it
A: Not applicable
performs several other
important functions
such as the body
shape, mechanisms of
movement, and the
erect posture in
humans. Muscle
tissue is specialized
for contraction.
Contraction of muscle
produces the
movements of the
body and body parts.
Gastrointestinal
System
Neurologic System
It is the tube running
through the body from
the mouth to anus.
The role of digestive
system is to break
down food and deliver
the products to the
blood for dispersal to
the body cells. The
undigested food that
remains in the tract
leaves the body
through the anus as
feces.
The nervous system
consists of the brain,
spinal cord, sensory
organs, and all of the
nerves that connect
these organs with the
rest of the body.
Together, these organs
are responsible for the
I: no abdominal distention noted. No swelling
noted. No discoloration noted.
A: not noted
P: not noted
P: No masses noted
I: Alert, oriented to time and place. Responds to
stimuli. Converses appropriately.
P: No abnormalities noted
P:No abnormalities noted
A: Not noted
control of the body
and communication
among the parts.
Genitourinary
System
The body produces
wastes as by-product
of its normal
functions, and these
wastes must be
disposed of. One type
of waste contains
nitrogen, which
results when the body
cell break down
proteins and nucleic
acids. The urinary
system removes the
nitrogen containing
wastes from the body
in urine. It is also
called excretory
system.
I: The client is on urinary catheter.
P: not noted
P: Not noted
A: Not noted
