3.2.
5 Nursing Physical Assessment
Date and Time of Assessment: __January 17, 2017_ Date and Time of Admission: ___January 13, 2017__
Name of Agency/Institution: ___Vicente Sotto Memorial Medical Center___
Area: ___Center for Behavioral Sciences______
Name of Patient: ___CB_____ Age: __25_years old_____ Sex: _Male__ Civil Status: __Single___
Chief Complaints: ___ agitation, decreased need for sleep and change of behavior___
Medical Diagnosis: ___Bipolar 1 Disorder________Admitting Physician: ____Dr. Adolfo_________
BODY PART SIGNIFICANT INTERPRETATION/
NORMAL FINDINGS
EXAMINED FINDINGS ANALYSIS
INTEGUMENTARY SYSTEM
Inspection NORMAL
Color: _____________Tan_________
Uniform color with slightly darker exposed areas.
No lesions
No central cyanosis No peripheral cyanosis
Palpation
Temperature: Warm Cold
Skin Texture: Soft/fine Coarse/thick
Moisture: Dry Moist
Turgor: Body Part: __arm__ Seconds: ___2 sec____
Notes: ______________________________________
________________________________________________________
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Inspection NORMAL
Color: ___Black_____
Distribution
No evidences of Alopecia Normal balding pattern
Evenly distributed covers the whole scalp
Quantity: Thick Thin
Body Hair
Fine body hair noted over most of the body
Increased hair growth on legs,axillae,and pubic area.
Quantity: Thick Thin
Hair Palpation:
Texture: Coarse Smooth
Moisture: Dry Moist/Oily
Inspection NORMAL
Lighter in color than the complexion.
Free from lice, nits and dandruff.
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Palpation
Texture: Dry Moist/Oily
Scalp No tenderness No masses No lesions
No scars noted Freely movable
Notes:
_________________________________________________________
_________________________________________________________
BODY PART SIGNIFICANT INTERPRETATION/
NORMAL FINDINGS
EXAMINED FINDINGS ANALYSIS
Inspection NORMAL
Color: Pink Light brown others: _
Condition,shape, and angle
Well grommed Convex Cuticle pink and intact
Angle of attachement 1600
Palpation
Texture: Smooth and firm No ridges
Nails Capillary Refill Test: _2 sec_ second/s
Notes:
___________________________________________________
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HEAD
Inspection NORMAL
Head Size: _____ cm
Head Position: Erect and Midline position
Head Shape: Normocephalic Symmetrical
Head Contour Rounded
Palpation
Head Contour/Facial Structures
Symmetrical No masses Non tender No
lesions
No unexpected contours or bulges
Notes:
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FACE
Inspection NORMAL
Facial Appearance
Appropriate facial expresion
Symmetrical features and movement
Hair distribution appropriate for age, sex, and ethnicity
No Lesions No Abnormal movements
Face
Nasolabial folds symmetrical Palpebral fissures
symmetrical
Palpation
Facial bones: Smooth Intact Symmetrical
Nontender
Good muscle tone No crepitation Full active ROM
Notes: _____acne and pimples observed
Palpation
Temporo-Mandibular Smooth Symmetrical motion
No pain No crepitus/Clicking
Joints
Notes:
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Inspection NORMAL
External Nose
Midline Position Symmetrical No Drainage
No Deviation No Flaring Intact Septum
Internal Nasal Mucosa
Pink Moist No Lesions No
Edema
No Discharges Septum located midline
Palpation
Non Tender No Deformities Patent Nares
Slightly mobile
Nose
Notes:
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BODY PART SIGNIFICANT INTERPRETATION/
NORMAL FINDINGS
EXAMINED FINDINGS ANALYSIS
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Inspection NORMAL
Pink in color Others: ___Slight Darkness__________
Moist Intact No Lesions No Halitosis
Midline No Pursed lip breathing
Lips
Palpation
Soft Nontender
Notes: ____Slight darkness with complaints of smoking habits___
Inspection
Pink Moist Intact Mucosa No Bleeding
Oral Mucosa
and Gums Notes: ___________________________________________________
_________________________________________________________
_________________________________________________________
Inspection
Pink Intact Smooth
Hard and Soft
Palate Notes: ___________________________________________________
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Inspection
Pink in color with white taste buds at the center
Midline position No Lesions
Full Mobility No Involuntary Movements
Intact Mucosa
Tongue Palpation
Texture: Rough Moist
Notes: ___________________________________________________
_________________________________________________________
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Teeth Inspection
Number: _______ Color: __________________
Smooth Edge Good Occlusion No Caries
No loose tooth No Dental Fillings
Notes: ___________________________________________________
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_________________________________________________________
Inspection
Frontal
Clear Positive Transillumination Non Tender
No periorbital Edema No Discoloration
Maxillary
Clear Positive Transillumination Non Tender
No periorbital Edema No Discoloration
Palpation/Percusion
Sinuses
Maxillary: No Tenderness Resonant Tone
Frontal: No Tenderness Resonant Tone
Notes: _________________________________________________
BODY PART SIGNIFICANT INTERPRETATION/
NORMAL FINDINGS
EXAMINED FINDINGS ANALYSIS
EYES AND EARS
Eyes Inspection NORMAL
General Appearance: Clear and Bright Equal Parallel Alignment
Eyelids
Color consistent with clients complexion No Lesions No Edema
Eyelashes
Evenly distributed No Ectropion No Entropion
Lacrimal Ducts
No excessive tearing, drainage, edema No dryness
Conjunctiva
Clear Pink Moist No lesions
Sclera
White and intact No lesions and tears
Cornea
Clear without opacities No lesiona and abrasions
Positive corneal reflex
Iris
Round and symmetrical
Puplis
Size 3-5 mm No miosis No mydriasis PERRLA
Palpation
Eyeball: Firm and tender
Lacrimal Gland: Non Tender
Notes: ___________________________________________________
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_________________________________________________________
_________________________________________________________
Inspection NORMAL
External Ear:
Vertical position with < 10 degree lateral posterior slant.
Aligned with eyes Symmetrical No redness
No lesions No drainage No foreign objects
Small amount of yellow cerumen and hair
Tympanic Membrane
Pearly gray Intact No lesions or exudates
Ears No bulging or retraction
Palpation
External Ear:
Helix is soft and pliable Notender No nodules or lesions
Notes: ___________________________________________________
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NECK
Inspection NORMAL
Midline position Erect
Full ROM No masses
Neck
Notes: ___________________________________________________
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Palpation
Nonpalpable Nontender
Palpable (Small, smooth edge of thyroid may be palpable)
Auscultation
Thyroid Gland
No bruits
Notes: ___________________________________________________
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Palpation
Midline No deviation
Trachea
Notes: ___________________________________________________
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Neck Vessels: Carotid Arteries and Jugular Veins
Inspection
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Visible carotid pulsation Jugular venous presssure at 450 <3 cm
No neck vein distention Jugular pulsation undulated
Palpation
Carotid:
Regular rhythm Equal contour
Smooth upstroke with lesss acute descent
Jugular:
Easily obliterated and fills appropriately
Auscultation
Carotid: Negative carotid bruits
Jugular Veins: Negative venous hum
Notes: ___________________________________________________
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THORAX
Chest
Inspecton
Respiratory rate:_22__cpm
Quite respiration Symmetrical Regular rythm and depth
Anteroposterior: lateral ratio 1:2 No barrel chest
No spinal deformities Skin Intact
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No Retraction or use of accessory muscles
Palpation
Non tender No masses No crepitus
Symmetrical excursion anteriorly and posteriorly
Tactile fremitus equal bilaterally
Percussion
Anterior: Resonance Lateral: Resonance
Posterior: Resonance Diaphragmatic: Resonance
Auscultation
Breath Sounds
All lung fields clear Bronchial breath sounds heard over trachea
Bronchovesicular breath sounds heard over sternum anteriorly and
between scapula posteriorly
Vesicular sounds heard in most lung fields
No abnormal or adventitious breath sounds
No abnormal voice sounds No bronchophony
No whispered pectoriloquy No egophony
Notes: ___________________________________________________
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NORMAL
Breast
Inspection
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Lobular Symmetrical Slightly symmetrical
Color Consistent with body color No masses No lesions
No edema No dimpling No retractions No orannge peel skin
Palpation
Premenopausal: more firm and elastic
During pregnancy and lactation: firm and tender
Postmenopausal: less firm and elastic with stringy ducts
Nontender Tender and Nodular (premenstruation)
No masses No lesions
Notes: ___________________________________________________
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Nipple and Areola
Inspection
Areola
Symmetrical Round Darker than breast tissue
No masses No lesions No discharges
Spontaneous discharge (during pregnancy & lactation)
Nipples
Everted Flat or Inverted No supernumerary nipples
Palpation
Nipple elastic Nontender No discharge
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White sebaceous secretion with nipple compression
Notes: ___________________________________________________
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NORMAL
Axilla
Inspection
Skin intact No lesions or rashes
Hair growth appropriate to clients age & sex
Nonpalpable & nontender lymphnodes
Notes: ___________________________________________________
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NORMAL
HEART
Precordium
Palpation
PMI at apex: _______ cm
Nonsustained Nonpalpable No diffusion
Percussion:
__________________________________________________________________________________________________________________
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Auscultation:
_________________________________________________________
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Notes:____________________________________________________
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Pulse
Pulses:
Grade Amplitude: Pulse bpm Grade
Temporal
0 = absent Carotid
Brachial
1 = weak Radial
Apical 75 2
2 = normal Femoral
Popliteal
3 = full Dorsalis pedis
Posterior Tibialis
4 = bounding
Auscultation
Blood Pressure: _110/80 _mmhg
Notes: ___________________________________________________
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_________________________________________________________
NORMAL
ABDOMEN
Abdomen
Inspection
Skin color consistent Slightly lighter than exposed areas
No lesions No striae
No superficial veins No scars
No rashes No discoloration
Flat Slightly rounded
Symmetrical No bulges
No hernia Postive respiratory movements
No peristaltic waves Slight pulsation in epigastric region
Hair distribution appropriate for clients age and gender
Umbilicus
Midline Inverted No discoloration No discharge
Auscultation
Soft, medium-pitched bowel sounds every 5-15 seconds in all four
quadrants
No borborygmi No bruits No hums No rubs
Percussion
Tympany in all four quadrants
Dullness over organs Organs Nontender
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Palpation
Soft Nontender
Positive skin turgor Negative umbilical bulges
Positive abdominal reflexes No masses
Liver: Nonpalpable Nontender
Spleen: Nonpalpable Nontender
Kidneys: Nonpalpable Nontender
Inguinal Lymph Nodes: Nonpalpable Nontender
Notes: ___________________________________________________
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NORMAL
GENITOURINARY SYSTEM
Female Genitourinary
Inspection
External:
Pink Color (depends on clients pigmentation) others: ____________
Intact Moist No lesions No edema
No discharge No odor No prolapse
Rectal Area
Intact No inflammation No lesions No prolapse
No hemorrhoids No discharge No bleeding
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Notes: ___________________________________________________
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Male Genitourinary
Inspection
Color: _____________________
Skin intact No lesions No discharges
No lesions No pediculosis Foreskin retracts easily
Urinary meatus midline at tip of glans
Scrotum
Skin color darker than rest of body
Appropriate size for age of client
Testes hang freely Left testis slightly lower than right
Inguinal Area
Skin intact No bulges No palpable lymph nodes
Rectal Area
Rectal area intact No inflammation No lesions
No prolapse No hemorrhoids No discharge
No bleeding
Palpation
For nonerect penis: Soft Nontender No nodules
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Scrotum, testes, and epididymis:
Scrotal skin rough No swelling of epididymis
No lesions Testes rubbery, round, movable and smooth
Inguinal Area
No hernias No masses No palpable lymph nodes
Anus and Rectum
Nontender No masses No polyps
No lesions No bleeding No hemorrhoids
Positive sphincter tone
Ausculation
No bowel sounds
Notes: ___________________________________________________
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MUSCULOSKELETAL SYSTEM
Posture & Spinal curves
Inspection:
Erect posture Head midline
Normal spinal curves Knee aligned
Notes: ___________________________________________________
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_________________________________________________________
NORMAL
Gait
Gait smooth, fluid, and rhythmic Arms swings in opposition
No toeing in or out
Notes: ___________________________________________________
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NORMAL
Muscle Tone
Palpation
Soft and pliable (at rest)
Positive muscle tone, firm, no involuntary movements or tenderness
Notes: ___________________________________________________
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Muscle Strength
Hand grip strong and equal
Foot push and leg raise against resistance strong and equal
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Grade: 5
Grade:5
Grade: 5
Grade: 5
Notes: ___________________________________________________
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NORMAL
SENSORY-NEUROLOGICAL SYSTEM
Cranial Nerves
CN I Olfactory:
Sense of smell intact
Assessment:_______________________________________________
_________________________________________________________
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CN II Optic:
Extraocular muscles intact OU
PERRLA direct and consensual
Assessment: ______________________________________________
_________________________________________________________
CN III- Oculomotor, IV- Trochlear, VI Abducens:
Sense of smell intact
Assessment: ______________________________________________
_________________________________________________________
CN V Trigeminal:
Jaw muscle strenght score: + _____
Facial sensation intact Positive corneal reflex
Assessment: ______________________________________________
_________________________________________________________
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CN VII Facial:
Facial movements symmetrical Taste on anterior tongue intact
Assessment:_______________________________________________
_________________________________________________________
CN VIII Acoustic:
Hearing intact Balance intact
Assessment:_______________________________________________
_________________________________________________________
CN IX Glossopharyngeal and X Vagus:
Strong and clear voice Symmetrical rise of uvula
Able to swallow and cough Positive gag reflex
Taste on posterior tongue intact
Assessment:_______________________________________________
_________________________________________________________
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CN XI - Spinal
Muscle strenght of neck and shoulders: + _____
Assessment:_______________________________________________
_________________________________________________________
CN XII - Hypoglossal:
Full ROM of tongue Midline tongue
No atrophy
Assessment:_______________________________________________
_________________________________________________________
Cerebral Functions
Behavior
Well-groomed Erect Posture
Pleasant facial expression Appropriate affect
Level of consciuosness
Awake Alert Oriented
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1 2 3 4 5 6
Opens eyes in
Does not open Opens eyes in Opens eyes
Eye eyes
response to
response to voice spontaneously
N/A N/A
painful stimuli
Oriented, Glasgow Coma Scale
Makes no Incomprehensible Utters inappropriate Confused,
Verbal sounds sounds words disoriented
converses N/A
normally
Extension to Score: __15___
Abnormal flexion to Flexion /
Makes no painful stimuli Localizes painful Obeys
Motor movements (decerebrate
painful stimuli Withdrawal to
stimuli commands
(decorticate response) painful stimuli
response)
NORMAL
Memory
Immediate memory intact Recent memory intact
Remote memory intatct
Mathematical/Calculative ability
Calculative skill intacts
NORMAL
General knowledge
Vocabulary appreopriate General knowledge intact
Thought process
Clear Responds appropriately
Speech coherent and logical
NORMAL
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Abstract thinking
Abstract thinking intact
Judgement
Judgement intact
Communication
Clear speech Fluent No dysarthria
No dysphasia No dysphonia No neologism
No circumlocution Intact communication skills
NORMAL
Sensory Function
Light touch, pain, and temperature
Intact
Discriminatrory Sensation:
Stereognosis: Intact
Grapesthesia: Intact
Two-point discrimination: Intact
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Point localization: Intact
Extinction: Intact
Deep Tendon Reflexes
(Grade DTRs on 0-4 scale)
Biceps: Score ______
Triceps: Score ______
Brachioradialis: Score ______
Patellar: Score ______
Achilles: Score ______
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