physical assessment name: amanda caragan ong age: 45 years old

8/14/2019 Physical Assessment Name: Amanda Caragan Ong Age: 45 Years Old

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Physical Assessment

Name: Amanda Caragan Ong

Age: 45 years old

Birth Date: May 1, 1964

Temperature: 37C, oralPulse Rate: 67 bpmRespiratory Rate: 19 cycles/minute

Blood Pressure: 117/80 mmhg

Part I

Behavior Normal Findings Actual Findings Interpretation /

Analysis

1. Height - medium frame: 150cm (height) 111-123lbs

(weight)

Metric Conversion Weights and othermeasurements by A.M. Batubalani page 79

- 162cm -Normal

2. Weight - medium frame: 150cm (height) 111-123lbs

(weight)

Metric Conversion Weights and other

measurements by A.M. Batubalani page 79

- 50kg -Normal

3. BMI - 18.5 to 24.9

http://www.nhlbisupport.com/bmi/bmicalc.htm

- 19 -Normal

General Survey Normal Findings Actual Findings Interpretation / Findings

5. Body built in relation to

lifestyle and health

- Proportionate, varies

with lifestyle

Kozier and ErbsFundamentals of Nursing

8th Edition Vol.1 page 572

-The client is medium in

her body built.

-Normal

6. Clients posture, gait,

standing, sitting, and

walking

- Relaxed erect posture, sit

and stand in an upright

position, coordinatedmovement



- The client sits erect and

stand in an upright manner

with coordination of bodymovement

-Normal

7. Clients overall hygiene

and grooming

- Clean and neat

Kozier and Erbs

Fundamentals of Nursing


- Well groomed and

properly dressed

- Normal

8. Body and breath odor - No body odor or minor

body odor relative to work

or exercise; no breath odor

Kozier and Erbs



- Presence of minor body

odor. No breath odor

- Normal

9. Signs of distress in

posture of facial

expression

- No distress noted

Kozier and Erbs


- No distress noted -Normal


2/34


10. Obvious signs of

health or illness

- Healthy appearance

Kozier and Erbs



- Healthy appearance - Normal

11. Clients attitude - Cooperative, able to

follow instructionsKozier and Erbs



- The client cooperates and

follows instructions duringthe procedure

- Normal

12. Clients affect / mood;

appropriateness of the

clients response

- Appropriate to the

situation

Kozier and Erbs



- Acts appropriate to the

situation

- Normal

13. Quality and quantity of

voice

- Understandable,

moderate pace, clear tone

Kozier and Erbs

Fundamentals of Nursing8th Edition Vol.1 page 572

- The client speaks with


of voice, organization of

thoughts andunderstandable

- Normal

14. Relevance andorganization of thoughts

- Logical in sequence,makes sense, has sense of

reality

Kozier and Erbs



- The client exhibitsorganization of thought,

coherence, and sense of

reality

- Normal

Integumentary Normal Findings Actual Findings Interpretation / Findings

15. Uniformity of color - Varies from light brown,

from ruddy pink and light

pink, from yellow

overtones to olive

-Generally uniform except

in areas exposed to sun,

areas of lighter

pigmentationKozier and Erbs


- The client has a dark

brown in color, varies in

color with skin which are

not exposed to the sun

- Normal

16. Presence of edema - No edemaKozier and Erbs



- Absence of edema - Normal

17. Presence of lesions

according to location,

distribution, color,

configuration, size, shape,

type or structure

- Freckles, some

birthmarks, some flat and

raised nevi, no abrasions

or other lesions

Kozier and Erbs



- Presence of freckles and

flat nevi. No lesions or

abrasions

- Normal

18. Skin moisture - Moisture in skin folds

and the axillae (varies with

environmental

temperature, humidity,

- Presence of moisture in

the axillae

- Normal


3/34

body temperature and

activity).

Kozier and Erbs



19. Skin temperature - Uniform and with normal

rangeKozier and Erbs



- Warm skin temperature - Normal

20. Skin turgor - When pinched, skin turn

back to its previous state;

may be slower in eldersKozier and Erbs



- Skin recoils to its

original position when

pinched

- Normal

Nails

21. Finger nails plate

shape to determine itscurvature and angle

- Convex curvature; angle

of nail plate about 160Kozier and Erbs



- Convex in curvature with

160 in angle

- Normal

22. Fingernail and toe nail

bed color

- Highly vascular and pink

in light skinned clients;

dark skinned clients may

have brown or black

pigment arrow in

longitudinal streaks.






have brown or black

pigment arrow in


- Normal

23.Fingernail and toenail

structure

- Smooth texture



- Smooth texture - Normal

24. Inspect tissues

surrounding nails

- Intact epidermis

Kozier and Erbs



- No hangnails and

inflammations

- Normal

25. Blanch test of capillary

refill

- Prompt return of pink or

usual color (generally less

than 4 seconds)

Kozier and Erbs





than 4 seconds)

- Normal

Head Normal Findings Actual Findings Interpretation / Findings

Skull

26. Inspect the skull for

size, shape or symmetry

- Rounded (normocephalic

and symmetric, with

frontal, parietal, and

occipital prominences);

smooth skull contour

Kozier and Erbs

- Proportionate to body

size, symmetric, smooth

- Normal


4/34



27. Palpate for nodules,

masses, and depressions

- Smooth, uniform

consistency; absence of

nodules or masses

Kozier and Erbs


- Smooth, absence of

nodules or masses,

uniform consistency

-Normal

Scalp

28. Inspect for color and

appearance

- White and clean, absence

of lesions

Kozier and Erbs



- White and clean, no

lesions noted

- Normal

29. Palpate for areas of

tenderness

- Absence of tenderness,

masses and nodules

Kozier and Erbs



- Absence of tenderness - Normal

Hair30. Inspect for evenness of

growth, thickness, and

thinness

- Evenly distributed hair;

thick



- Evenly distributed and

thick

- Normal

31. Palpate for texture and

oiliness over the scalp

- Silky; resilient hair;

small amount of oilpresent

Kozier and Erbs



- Absence of excessive oil

production

- Normal

Face

32. Inspect facial featuresand symmetry of facial

movement

- Symmetric or slightlyasymmetric facial features.

Symmetric facial

movements

Kozier and Erbs



- Symmetric facial featuresand facial movements

- Normal

Eyes Normal Findings Actual Findings Interpretation / Findings

Visual Acuity

33. Test near vision - Able to read newsprint at

the distance of 14 inches

Kozier and Erbs



- Able to read newsprint at


- Normal

34. Test distance vision - 20 / 20 vision on Snellen

type chart

Kozier and Erbs



- 20 / 20 vision on Snellen

type chart

- Normal

Eyebrows

35. Inspect the distribution - Hair evenly distributed; - Hair in the eyebrows was - Normal


5/34

of hair and symmetry of

eyebrows

skin intact - Eyebrows

symmetrically aligned;

equal movement

Kozier and Erbs



evenly distributed.

Eyebrows are


equal in movement

Lacrimal gland,Lacrimal Sac, and

Nasolacrimal Duct

36. Inspect and palpate the

Lacrimal gland

- No edema or tenderness

over Lacrimal gland

Kozier and Erbs



present over Lacrimal

gland

- Normal

Eyelids

37. Inspect for the surface

characteristics, position in

relation to the cornea,

ability to blink, andfrequency of blinking

- Skin intact; no discharge;

no discoloration

- Approximately 15 20

involuntary blinks perminute; bilateral blinking

- When lids are open, no

visible sclera above

corneas, and upper and

lower borders of cornea

are slightly covered

Kozier and Erbs


- Skin are intact, no

excessive discharge

present and discoloration

- The client can blinkwithout any alterations

- Frequency: 18 blinks

- Normal

Eyelashes

38. Inspect the eye lashes

for evenness of

distribution and direction

of curl

- Equally distributed;

curled slightly outward

Kozier and Erbs


- Eyelashes are equally

distributed and slightly

curled outward

- Normal

Conjunctiva

39. Inspect the bulbar

conjunctiva (lying abovethe cornea) for color,

texture, and presence oflesions

- Transparent; capillaries

sometimes evident; scleraappears white (darker or

yellowish and with smallbrown macula in dark-

skinned clients)

Kozier and Erbs



- Transparent and clear - Normal

40. Inspect the palpebral

conjunctiva (lining the

eyelids) for color, texture,and presence of lesion

- Shiny, smooth, and pink

red



- Shiny, pink in color, no

lesions present

- Normal

Sclera

41. Inspect the color and

clarity

- White and clear

Kozier and Erbs



- White and clear - Normal

Cornea


6/34

42. Inspect the cornea for

clarity and texture

- Transparent; shiny, and

smooth; details of the iris

are visible. In older

people, a thin, grayish

white ring around the

margin, called arcus

senilis, may be evidentKozier and Erbs








margin, called arcus

senilis, may be evident

- Normal

43. Corneal sensitivityTest (reflex); ask the client

to keep both eyes open and

look straight ahead.

Approach from behind and

lightly touch the sclera of

the client with the corner

of the gauze

- Client blinks when thecornea is touched,

indicating that the

trigeminal nerve is intact

Kozier and Erbs



- The client blinks whenthe cornea was touched by

the gauze

- Normal

Iris


shape

- Color varies; oval,

circular and flat

Kozier and Erbs



- Color brown and flat - Normal

Pupil

45. Inspect for color,

shape, and symmetry of

size

- Black in color; equal in

size; normally 3 to 7 in

diameter; round; smooth

borderKozier and Erbs



- Black in color, 5 in

diameter, equal in size

- Normal

46. Test pupil for lightreaction and

accommodation

- Illuminated pupilsconstrict, no illuminated

pupil constrict

- Pupil constrict when

looking at near object;

pupils dilate when looking

at far object; pupils

converge when near object

is moved toward noseKozier and Erbs



- Both pupils react to light;pupil constrict and dilates

when near object is moved

toward and away to the

nose

- Normal

Visual Field

47. Test Peripheral fields - When looking straight

ahead, client can seeobjects in the periphery

Kozier and Erbs



- When looking straight

ahead, client can seeobjects in the periphery

- Normal

Extraocular Muscles

48. Assess six ocularmovements to determine

eye alignment and

- Both eyes coordinates,move in unison, with

parallel alignment

- Both eyes move inunison with parallel

alignment

- Normal


7/34

coordination. Kozier and Erbs



Ears Normal Findings Actual findings Interpretation / Findings

Auricles49. Inspect for color,

symmetry and position

- Color same as facial

skin; symmetrical. Auriclealigned with outer canthus

of eye, about 10 from

vertical

Kozier and Erbs



- Color same as facial

skin; symmetrical, alignedwith the outer canthus of

the eye

- Normal

50. Palpate for texture,

elasticity and areas for

tenderness

- Mobile, firm and not

tender; pinna coils after it

is folded

Kozier and Erbs


- Mobile, firm, not tender;

pinna coils after it is

folded

- Normal

External Ear Canal

51. Inspect ear canal for

cerumen, skin lesions, pus,

blood

- Dry cerumen, grayish tan

color; or sticky, wet

cerumen in various shades

of brown



- Wet cerumen, yellow in

color; absence of pus and

blood

- Normal

Hearing Auricle Test

52. Assess clients

response to normal voice

tone

- Normal voice tones

audible



- Client responds to

normal voice tone

- Normal

53. Perform watch tick test - Able to hear ticking in

both ears

Kozier and Erbs



- The client was able to

hear the ticking of the

watch in both ears

- Normal

54. Perform Webers Test - Sound is heard in both

ears or is localized at the

center of the head

(Webers Negative)

Kozier and Erbs



- Sound is heard in both

ears

- Normal

55. Perform Rinne Test - Air conducted (AC)

hearing is greater thanbone conducted (BC)

hearing

Kozier and Erbs



- Air conducted is greater

then bone conducted

- Normal


8/34

Nose Normal Findings Actual Findings Interpretation / Findings

56. Inspect for any

deviations in shape, size,

or color and flaring or

discharge from nares

- Symmetric and straight;

no discharge or flaring;

uniform color

Kozier and Erbs



absence of discharge;

uniform in color

- Normal

57. Inspect for nasal

cavities for the presence of

redness, swelling, growths

and discharge, using the

flashlight

- Mucosa pink; clear

watery discharge; no

lesions

Kozier and Erbs


- Mucosa pink; absence of

lesions

- Normal

58. Inspect the nasalseptum between nasal

chambers

- Nasal septum intact andin midline

Kozier and Erbs



- Nasal septum intact andin the midline

- Normal

59. Test patency of both

nasal cavities

- Air moves freely as the

client breathes through the

nares

Kozier and Erbs



- Both nasal cavities are

patent

- Normal

60. Palpate for any

tenderness, masses

displacements of bone and

cartilage

- Not tender, no

displacements of bone or

cartilage



- Absence of tenderness

and any kind of

displacements

- Normal

Sinuses

61. Locate/ palpate/

identify the sinuses and

note for tenderness

- No tenderness

Kozier and Erbs


- No tenderness present - Normal

Mouth Normal Findings Actual findings Interpretation / Findings

Lips

62. Inspect for symmetry

of contour, color and

texture

- Uniform; pink in color;

moist, soft, smooth

texture; symmetry of

contour. Ability to purse

lips

Kozier and Erbs


- Pink in color, moist,

symmetrical, has the

ability to purse lips

- Normal

Buccal Mucosa


moisture, texture, andpresence of lesions

- Uniform, pink in color,

moist, smooth, soft,glistering and has a elastic

texture

Kozier and Erbs


- Uniform, pink in color,

moist, smooth, glisteringand elastic

- Normal


9/34


Teeth


number and condition,

presence of dentures

- 32 adult teeth, smooth,

white, shiny tooth enamel,

smooth intact denturesKozier and Erbs



white, shiny tooth enamel,

smooth intact dentures

- Normal

Gums

65. Inspect for the color

and condition

- Pink gums, moist, firm

texture to gums, no

retraction of gums

Kozier and Erbs




texture to gums, no

retraction of gums

- Normal

Tongue/ Floor of the

mouth


and texture of the mouth

floor and frenulum

- Smooth tongue base with

prominent veins




presence of some

prominent veins

- Normal


position, color, and

texture, movement and

base of the tongue

- Central position, pink in

color, moist, slightly

rough, thin whitish

coating, smooth lateral

margins, no lesions, raisedpapillae, moves freely, no

tenderness

Kozier and Erbs



- Located at the center,

pink in color, moist with

whitish coating, o lesions,

no tenderness, moves

freely

- Normal

68. Palpate for any

nodules, lumps, or

excoriated areas

- No palpable nodules

Kozier and Erbs



- Absence of nodules - Normal

Palates and Uvula

69. Inspect and palpate for

color, shape, texture, and

the presence of bony

prominences

- Light pink, smooth, soft

palate: light pink

hard palate: more regular

in texture

Kozier and Erbs



palate: light pink


in texture

- Normal

70. Inspect for position of

the uvula and mobility

while examining thepalates

- Positioned in midline of

soft palate


8th Edition Vol.1 page

603

- Positioned in the midline

of the soft palate

- Normal

Oropharynx and tonsils


color, and texture (one side

at a time to avoid eliciting

gag reflex)

- Pink and smooth

posterior wall

Kozier and Erbs


- Pink, smooth surface - Normal


10/34


72. Inspect the size of the

tonsils, color, and

discharge

- Pink and smooth, no

discharge, normal size

Grade 1: normal the tonsils

are behind the tonsillar

pillars (the soft structures

supporting the soft palate)Kozier and Erbs



-Pink and smooth, grade 1 - Normal

73. Elicit the gag reflex by

pressing the posterior

tongue

- Present

Kozier and Erbs


- Present - Normal

Neck and Lymph Nodes Normal Findings Actual Findings Interpretation / Findings

Lymph Nodes


identify lymph nodes andnote for tenderness

- No tenderness



- No tenderness - Normal

Trachea


placement

- Central placement in the

midline of the neck; spaces

are equal in both sides

Kozier and Erbs



- Located at the midline of

the neck

- Normal

Thyroid Gland

76. Inspect symmetry and

visible masses

- Not visible in palpation.

Kozier and Erbs


- Not visible - Normal

77. Palpate for smoothness

and areas of enlargement,

masses or nodules

- Lobes may not be

palpated. If palpated, lobes

are small, smooth,

centrally located, painless

and rise freely with

swallowing



- Located at the midlines

of the neck, moves freely

- Normal

Part II

Thorax Normal Findings Actual Findings Interpretation / Findings

Posterior Thorax

78. Inspect the size, shape,

symmetry, and compare

the diameter of

anteroposterior thorax to

transverse diameter

- Anteroposterior to

transverse diameter with a

ratio of 1:2

Kozier and Erbs


- The anteroposterior and

transverse diameter has a

ratio of 1:2

- Normal


11/34


79. Inspect the spinal

alignment

- Spine vertically aligned

Kozier and Erbs



- Spine vertically aligned -Normal

80. Palpate for

temperature, tendernessand masses

-Temperature is within in

normal range, notenderness and masses

Kozier and Erbs



- Temperature is within

normal range, notenderness and masses

- Normal

81. Asses respiratory

excursion

- Full and symmetric

Kozier and Erbs



- Full and symmetric -Normal

82. Palpate focal fremitus - Bilateral symmetric

vocal fremitus

Kozier and Erbs


- Bilateral vocal fremitus -Normal

83. Percuss the posteriorthorax

- Lowest point ofresonance is at the

diaphragm

Kozier and Erbs



- Lowest point of the

resonance is at the

diaphragm

-Normal

84. Auscultate the

posterior thorax

- Vesicular and

bronchovesicular breath

sounds

Kozier and Erbs



- Vesicular and


sounds

- Normal

Anterior Thorax

85. Inspect breathing

pattern

- Quiet, rhythmic and

effortless respiration

Kozier and Erbs





- Normal

86. Palpate for

temperature, tenderness

and masses

- Temperature is within in

normal range, no

tenderness and masses

Kozier and Erbs



normal range

-Normal

87. Asses respiratoryexcursion

- Full and symmetricKozier and Erbs




88. Palpate vocal / tactilefremitus

- Same as posterior vocalfremitus, fremitus is

normally decreased over

heart and breast tissue

Kozier and Erbs



- Same as posterior vocal

fremitus

-Normal


12/34

89. Percuss the anterior

thorax

- Percussion note resonate

done to the sixth rib at the

level of diaphragm but are

flat over areas of heavy

muscles and bone, dull on

areas over the heart and

liver, and tympanic overthe underlying stomach

Kozier and Erbs








areas over the heart and

liver, and tympanic overthe underlying stomach

-Normal

90. Auscultate the trachea - Bronchial and tubular

breath sounds

Kozier and Erbs



- Bronchial and tubular

breath sounds

-Normal

91. Auscultate the anterior

thorax

- Bronchovesicular and

vesicular breath sounds

Kozier and Erbs





-Normal

Cardiovascular Normal Findings Actual Findings Interpretation / Findings

Simultaneously INSPECTand PALPATE the

precordium for the

presence of abnormal

pulsations, lifts and heaves

92. Aortic and Pulmonic

Areas

-No pulsations

Kozier and Erbs



- No pulsations -Normal

93. Tricuspid Areas -No pulsations

Kozier and Erbs



- No pulsations -Normal

94. Apical Area (Locate

point of maximal impulse)

- Pulsations visible on

50% of adults and palpable

in most PM/ in 5th LICS or

at medial to MCL



- Palpable in 5th LICS -Normal

95. Auscultate the aortic,

pulmonic, tricuspid, and

apical valves

- Usually louder at apical

area

- Usually louder at thebase of the heart

- systole: silent interval;

slightly shorter duration

than diastole at normal

heart rate

- diastole: silent interval,

slightly longer durationthan systole at normal


area





heart rate


slightly longer durationthan systole at normal

-Normal


13/34

heart rates

Kozier and Erbs



heart rates

Carotid arteries

96. Palpate carotid artery

with extreme caution

- Symmetric pulse

volumes- Full pulsations, thrusting

quality

Kozier and Erbs



- Symmetric pulse

volumes with fullpulsations

-Normal

97. Auscultate the carotid

arteries

- No sound heard

Kozier and Erbs


- No sound heard -Normal

Jugular Veins

98. Inspect Jugular Veins - Veins not visible

Kozier and Erbs


- Veins not visible -Normal

(Note: the client refused to be examined at the breast and abdomen area)

Breast and Axillae Normal Findings Actual Findings Interpretation / Findings

99. Inspect breast for size,

symmetry, contour, or

shape while the client is in

sitting position

- Rounded in shape,

slightly unequal in size,

generally symmetric

Kozier and Erbs


- Rounded in shape,


generally symmetric

-Normal

100. Inspect the skin of the

breast for localized

discolorations orhyperpigmentation,

retraction, dimpling,

localized hypervascular

areas, swelling or edema

- Skin uniform in color

(same in appearance as

skin of abdomen or back)- Skin smooth and intact

Kozier and Erbs



- Skin uniform in color

(same in appearance as

skin of abdomen or back)- Skin smooth and intact

- Normal

101. Inspect the areola for

size, shape, symmetry,

color, surface

characteristics, and any

mass or lesions

- Round or oval and

bilaterally the same

- Color varies widely from

light pink to dark brown

Kozier and Erbs


-- Round or oval and




- Normal

102. Inspect the nipples

for size, shape, position,

color, discharge, andlesions

- Round, everted, and

equal in size, similar in

color, soft and smooth,both nipples point in same

direction

- No discharge except

from pregnant women

- Inversion of one or both

nipples that I present from

puberty

Kozier and Erbs

- Round, everted, and

equal in size, similar in

color, soft and smooth,both nipples point in same

direction


from pregnant women



puberty

- Normal


14/34



103. Palpate the axillary,

subclavicular and

superclavicular lymph

nodes

- No tenderness, masses,

or nodules

Kozier and Erbs


8

th

Edition Vol.1 page 629

-- No tenderness, masses,

or nodules

- Normal

104. Palpate breast for

masses, tenderness


nodules, or nipple

discharge

Kozier and Erbs




nodules, or nipple

discharge

- Normal

105. Palpate nipples for

tenderness and discharges


nodules, or nippledischarge

Kozier and Erbs



-- No tenderness, masses,

nodules, or nippledischarge

- Normal

Abdomen Normal Findings Actual Findings Interpretation / Findings

106. Inspect the abdomenfor skin integrity

- Unblemished skin- Uniform color

- Silver white striae(stretch marks) or surgical

scars

Kozier and Erbs




- Silver white striae (stretchmarks) or surgical scars

- Normal

107. Inspect the abdominal

contour (profile the line

from rib margin to the

pubic bone) while standing

at the client is in dorsalrecumbent position

- Flat, rounded (convex),

or scaphoid (concave)

Kozier and Erbs



- Flat, rounded (convex), or

scaphoid (concave)

- Normal

108. Inspect for enlargedliver or spleen

- No evidence ofenlargement of liver or

spleenKozier and Erbs



- No evidence of enlargementof liver or spleen

- Normal

109. Assess the symmetry

of contour while standing

at the foot of the bed.

- Symmetric contour

Kozier and Erbs



- - Normal

110.Inspect the abdominal

movements associated

with respirations,

peristalsis, or aortic

pulsations

- Symmetric movements

caused by respiration

- Visible peristalsis I very

lean people

- Aortic pulsations in thin

persons at epigastric area






lean people



- Normal


15/34

111. Observe vascular

patterns

- No visible vascular

patterns

Kozier and Erbs



- No visible vascular patterns - Normal

112. Auscultate the

abdomen for bowelsounds, vascular sounds,

and peritoneal friction rubs

- Audible bowel sounds

- Absence of arterial bruits-Absence of friction rub

Kozier and Erbs




- Absence of arterial bruits-Absence of friction rub

- Normal

113. Percuss several areas

in each of the fourquadrants

- Tympany over the

stomach and gas filledbowels; dullness especially

over the liver and spleen,

or a full bladder

Kozier and Erbs



- Tympany over the stomach

and gas filled bowels;dullness especially over the

liver and spleen, or a full

bladder

- Normal

114. Percuss the liver to

determine its size

- 6 to 12 cm (2 to 3

inches) in the

midclavicular line; 4 to 8

cm (1 to 3 inches) in the

midsternal line



-6 to 12 cm (2 to 3

inches) in the midclavicular

line; 4 to 8 cm (1 to 3

inches) in the midsternal line

- Normal

115. Perform light

palpation

- No tenderness, relaxed

abdomen with smooth,

consistent tension

Kozier and Erbs




abdomen with smooth,

consistent tension

- Normal

116. Perform deep

palpation

- Tenderness may be

present near xiphoid

process, over cecum, and

over sigmoid colon

Kozier and Erbs


- Tenderness may be present

near xiphoid process, over

cecum, and over sigmoid

colon

- Normal

117. Palpate the areaabove the symphysis pubis

to determine possible

urinary retention

- Not palpableKozier and Erbs



- Not palpable - Normal

Musculoskeletal System Normal Findings Actual Findings Interpretation / FindingsMuscles

118. Inspect the muscles

for size. Compare the

muscles on one side of the

body (arm, thigh, calf) to

the same muscle on theother side

- Equal size of both sides

of the body

Kozier and Erbs



- Equal size

Arm: 10 inches

Thigh: 17 inches

Calf: 13 inches

- Normal

119. Inspect the muscle - No contractures - Absence of contractures - Normal


16/34

and tendons for

contractures (shortening)

Kozier and Erbs




for fasciculation and

tremors. Inspect any

tremors of the hands andarms out in front of the

body

- No tremors

Kozier and Erbs


8

th


- No tremors - Normal

121. Palpate the muscle

tonicity

- Normal firm; smooth

coordinated movements

Kozier and Erbs


- Normal tonicity with

coordinate movements

- Normal

122. Test for strength(neck)

- Equal in strength in eachbody side

Kozier and Erbs



- Equal strength in bothpart

- Normal

123. Test for strength

(upper extremities)

- Equal strength in each

body side

Kozier and Erbs




body side

- Normal


(lower extremities)


body side

Kozier and Erbs




body side

- Normal

Bones

125. Inspect the skeleton

for normal structure and

deformities

- No deformities

Kozier and Erbs



- Absence of any

deformities

- Normal

126. Palpate the bones to

locate any areas of edema

or tenderness

- No tenderness or

swelling



- Absence of tenderness

and swelling

- Normal

Joints

127. Inspect the joint for

swelling

- No swelling

Kozier and Erbs


- Absence of swelling - Normal

128. Palpate each joint for

tenderness, smoothness of

movement, swelling,crepitation, and presence

or nodule

- No tenderness,

crepitation or nodules,

joints move smoothlyKozier and Erbs




nodules, joints move freely

- Normal

Assess range of motion

129. Upper extremities

(shoulder and scapula)

- Able to rotate

Kozier and Erbs



- Has the ability to rotate

her shoulders

- Normal


17/34


(elbows)

- Able to flex and extend

Kozier and Erbs



- Has the ability to flex

and extend her elbows

- Normal


(hands)

- Able to rotate, abduct,

and adduct



- Has the ability to rotate,

abduct, and adduct her

hands

- Normal

132. Lower extremities

(acetabulum/inguinal area)

- Able to rotate, flex,

extend, abduct, and adduct

Kozier and Erbs


- Has the ability to rotate,

flex, extend, abduct and

adduct

- Normal

133. Lower extremities(politeal)

- Able to flex and extendKozier and Erbs



- Has the ability to flexand extend

- Normal

134. Lower extremities(ankles)

- Able to rotateKozier and Erbs


8th Edition Vol.2 page1108

- Has the ability to rotate - Normal

Note: Other family members were not able to be examined because they are not around.

Physical Assessment

Name: Mark Lester Caragan Ong


18/34

Age: 20 years old

Birth Date: February 26 1989

Temperature: 36.8 C oral

Pulse Rate: 70 beat per minute

Respiratory Rate: 18 breaths per minuteBlood Pressure: 120/80 mmhg

Part I

(Note: Observers were not able to get the height and weight of Carla because she is in school)

Behavior Normal Findings Actual Findings Interpretation /

Analysis

1. Height - medium frame: 150cm (height) 111-123lbs

(weight)Metric Conversion Weights and other


- 170 cm - Normal

2. Weight - medium frame: 150cm (height) 111-123lbs

(weight)

Metric Conversion Weights and other


- 60 kgs - Normal

3. BMI - 18.5 to 24.9

http://www.nhlbisupport.com/bmi/bmicalc.htm

- 21 -Normal

General Survey Normal Findings Actual Findings Interpretation / Findings

5. Body built in relation to

lifestyle and health

- Proportionate, varies

with lifestyle



- Small body built - Normal

6. Clients posture, gait,

standing, sitting, and

walking



position, coordinated

movement

Kozier and Erbs





position with coordination

of movement

- Normal

7. Clients overall hygiene

and grooming

- Clean and neat

Kozier and Erbs



- Well groomed and

dressed

- Normal

8. Body and breath odor - No body odor or minorbody odor relative to work

or exercise; no breath odorKozier and Erbs



- No body odor and breathodor

- Normal

9. Signs of distress inposture of facial

expression

- No distress notedKozier and Erbs


- No signs of distressnoted

- Normal


19/34


10. Obvious signs of

health or illness

- Healthy appearance

Kozier and Erbs



- Absence of any signs of

illness

- Normal

11. Clients attitude - Cooperative, able to

follow instructionsKozier and Erbs



- Shows shyness but able

to follow the instructionsgiven

- Normal

12. Clients affect / mood;

appropriateness of the

clients response

- Appropriate to the

situation

Kozier and Erbs



- Responds appropriate to

situation

- Normal

13. Quality and quantity of

voice

- Understandable,


Kozier and Erbs


- Understandable,

moderate pace, and with

clear tone of voice

- Normal

14. Relevance andorganization of thoughts

- Logical in sequence,makes sense, has sense of

reality

Kozier and Erbs



- Has sense of reality - Normal

Integumentary Normal Findings Actual Findings Interpretation / Findings

15. Uniformity of color - Varies from light brown,

from ruddy pink and light

pink, from yellow

overtones to olive

-Generally uniform except

in areas exposed to sun,

areas of lighter

pigmentationKozier and Erbs


- Fair in skin color, has

uniform skin tone except

from areas not exposed to

the sun

- Normal

16. Presence of edema - No edemaKozier and Erbs



- No edema - Normal

17. Presence of lesions

according to location,

distribution, color,

configuration, size, shape,

type or structure

- Freckles, some

birthmarks, some flat and

raised nevi, no abrasions

or other lesions

Kozier and Erbs



- Absence of lesions - Normal

18. Skin moisture - Moisture in skin folds

and the axillae (varies with

environmental

temperature, humidity,

- Moist skin - Normal


20/34

body temperature and

activity).

Kozier and Erbs



19. Skin temperature - Uniform and with normal

rangeKozier and Erbs



- Uniform and with normal

range

- Normal

20. Skin turgor - When pinched, skin turn

back to its previous state;

may be slower in eldersKozier and Erbs



- Skin turns back to its

original state when

pinched

- Normal

Nails

21. Finger nails plate

shape to determine itscurvature and angle

- Convex curvature; angle

of nail plate about 160Kozier and Erbs



- Convex curvature with

160 angle

- Normal

22. Fingernail and toe nail

bed color




have brown or black

pigment arrow in




- Highly vascular, colored

pink

- Normal

23.Fingernail and toenail

structure

- Smooth texture



- Smooth texture - Normal

24. Inspect tissues

surrounding nails

- Intact epidermis

Kozier and Erbs



- Intact epidermis - Normal

25. Blanch test of capillary

refill



than 4 seconds)

Kozier and Erbs



- Prompt return of pink

color less than 4 seconds

- Normal

Head Normal Findings Actual Findings Interpretation / Findings

Skull

26. Inspect the skull for

size, shape or symmetry

- Rounded (normocephalic

and symmetric, with

frontal, parietal, and

occipital prominences);

smooth skull contour

Kozier and Erbs

- Rounded, smooth

contour

- Normal


21/34



27. Palpate for nodules,

masses, and depressions

- Smooth, uniform

consistency; absence of

nodules or masses

Kozier and Erbs


- Smooth with uniform

consistency, absence of

any nodules or masses

- Normal

Scalp

28. Inspect for color and

appearance


of lesions

Kozier and Erbs




of any kinds of lesions

- Normal

29. Palpate for areas of

tenderness


masses and nodules

Kozier and Erbs




masses, and nodules

- Normal

Hair30. Inspect for evenness of

growth, thickness, and

thinness

- Evenly distributed hair;

thick



- Evenly distributed thick

hair

- Normal

31. Palpate for texture and

oiliness over the scalp

- Silky; resilient hair;

small amount of oilpresent

Kozier and Erbs



- Silky hair, no excessive

oil

- Normal

Face

32. Inspect facial featuresand symmetry of facial

movement

- Symmetric or slightlyasymmetric facial features.

Symmetric facial

movements

Kozier and Erbs



- Symmetric facial featuresand movement

- Normal

Eyes Normal Findings Actual Findings Interpretation / Findings

Visual Acuity

33. Test near vision - Able to read newsprint at




- Able to read newsprint at


- Normal

34. Test distance vision - 20 / 20 vision on Snellen

type chart

Kozier and Erbs



- 20 / 20 vision - Normal

Eyebrows


22/34

35. Inspect the distribution

of hair and symmetry of

eyebrows

- Hair evenly distributed;

skin intact - Eyebrows


equal movement

Kozier and Erbs


8

th


- Hair evenly distributed,

skin intact, aligned

symmetrically, equal

movement

- Normal

Lacrimal gland,

Lacrimal Sac, and

Nasolacrimal Duct


Lacrimal gland


over Lacrimal gland



- Absence of edema and

tenderness

- Normal

Eyelids

37. Inspect for the surface

characteristics, position in

relation to the cornea,ability to blink, and

frequency of blinking

- Skin intact; no discharge;

no discoloration

- Approximately 15 20involuntary blinks per

minute; bilateral blinking

- When lids are open, no

visible sclera above

corneas, and upper and

lower borders of cornea

are slightly covered



- Skin intact, no discharge

and discoloration

- Frequency: 15 blinks

- Normal

Eyelashes

38. Inspect the eye lashes

for evenness of

distribution and directionof curl

- Equally distributed;

curled slightly outward



- Equally distributed,

curled outward

- Normal

Conjunctiva

39. Inspect the bulbarconjunctiva (lying above

the cornea) for color,texture, and presence of

lesions

- Transparent; capillariessometimes evident; sclera

appears white (darker oryellowish and with small

brown macula in dark-

skinned clients)

Kozier and Erbs



- Transparent, no lesions - Normal

40. Inspect the palpebral

conjunctiva (lining theeyelids) for color, texture,

and presence of lesion

- Shiny, smooth, and pink

redKozier and Erbs


- Shiny, smooth, pink - Normal

Sclera


clarity

- White and clear

Kozier and Erbs



- White and clear - Normal


23/34

Cornea

42. Inspect the cornea for

clarity and texture






margin, called arcussenilis, may be evident

Kozier and Erbs



- Transparent, shiny - Normal

43. Corneal sensitivity

Test (reflex); ask the clientto keep both eyes open and

look straight ahead.

Approach from behind and

lightly touch the sclera of

the client with the corner

of the gauze

- Client blinks when the

cornea is touched,indicating that the

trigeminal nerve is intact

Kozier and Erbs



- Client blinks when the

cornea is touched by thegauze

- Normal

Iris


shape

- Color varies; oval,

circular and flat

Kozier and Erbs



- Brown iris, circular - Normal

Pupil


shape, and symmetry of

size

- Black in color; equal in

size; normally 3 to 7 in

diameter; round; smooth

border

Kozier and Erbs



- Black in color, equal in

size, 5 in diameter, round

- Normal

46. Test pupil for light

reaction andaccommodation

- Illuminated pupils

constrict, no illuminatedpupil constrict

- Pupil constrict when

looking at near object;

pupils dilate when looking

at far object; pupils

converge when near object

is moved toward nose



- Pupils react with light

and objects

- Normal

Visual Field

47. Test Peripheral fields - When looking straightahead, client can see

objects in the peripheryKozier and Erbs



- Client can see objects inthe periphery

- Normal

Extraocular Muscles

48. Assess six ocular

movements to determine

- Both eyes coordinates,

move in unison, with

- Both eyes moves in

unison

- Normal


24/34

eye alignment and

coordination.

parallel alignment

Kozier and Erbs



Ears Normal Findings Actual findings Interpretation / FindingsAuricles

49. Inspect for color,symmetry and position

- Color same as facialskin; symmetrical. Auricle

aligned with outer canthus

of eye, about 10 from

vertical

Kozier and Erbs



- Color same as facial skin,symmetrical, aligned with

the outer canthus of eye

- Normal

50. Palpate for texture,

elasticity and areas for

tenderness

- Mobile, firm and not

tender; pinna coils after it

is folded

Kozier and ErbsFundamentals of Nursing8th Edition Vol.1 page 596

- Mobile, firm, not tender,

pinna coils

- Normal

External Ear Canal

51. Inspect ear canal for

cerumen, skin lesions, pus,

blood

- Dry cerumen, grayish tan

color; or sticky, wet

cerumen in various shades

of brownKozier and Erbs



- Wet yellowish cerumen - Normal

Hearing Auricle Test

52. Assess clients

response to normal voicetone

- Normal voice tones

audibleKozier and Erbs



- Responds to normal

voice tone

- Normal

53. Perform watch tick test - Able to hear ticking in

both ears

Kozier and Erbs



- The client hears the

ticking of the watch

- Normal

54. Perform Webers Test - Sound is heard in both

ears or is localized at the

center of the head

(Webers Negative)

Kozier and Erbs


- Sound heard in both ears - Normal

55. Perform Rinne Test - Air conducted (AC)hearing is greater than

bone conducted (BC)

hearing

Kozier and Erbs



- AC is greater than BC - Normal


25/34

Nose Normal Findings Actual Findings Interpretation / Findings

56. Inspect for any

deviations in shape, size,

or color and flaring or

discharge from nares


no discharge or flaring;

uniform color



- Symmetric, no discharge,

uniform in color

- Normal

57. Inspect for nasal

cavities for the presence of

redness, swelling, growths

and discharge, using theflashlight

- Mucosa pink; clear

watery discharge; no

lesions



- Mucosa pink, no lesions - Normal

58. Inspect the nasal

septum between nasal

chambers

- Nasal septum intact and

in midline

Kozier and Erbs



- Nasal septum are intact

and in the midline

- Normal

59. Test patency of both

nasal cavities

- Air moves freely as the

client breathes through the

nares

Kozier and Erbs



- Air moves freely - Normal

60. Palpate for any

tenderness, masses

displacements of bone andcartilage

- Not tender, no


cartilageKozier and Erbs



- Not tender, no


cartilage

- Normal

Sinuses


identify the sinuses andnote for tenderness

- No tenderness




Mouth Normal Findings Actual findings Interpretation / Findings

Lips

62. Inspect for symmetry

of contour, color and

texture

- Uniform; pink in color;

moist, soft, smooth

texture; symmetry of

contour. Ability to purse

lips



- Pink in color, moist, soft,

smooth in texture

- Normal

Buccal Mucosa

63. Inspect for color,moisture, texture, and

presence of lesions

- Uniform, pink in color,moist, smooth, soft,

glistering and has an

elastic texture

Kozier and Erbs

- Uniform, pink in color,moist, soft, glistering and

has an elastic texture

- Normal


26/34



Teeth


number and condition,presence of dentures


white, shiny tooth enamel,smooth intact dentures



- Complete set of teeth - Normal

Gums


and condition


texture to gums, no

retraction of gums

Kozier and Erbs



- Pink gums, moist, no

retraction of gums

- Normal

Tongue/ Floor of the

mouth


and texture of the mouthfloor and frenulum


prominent veinsKozier and Erbs



- Smooth tongue base,

prominent veins present

- Normal


position, color, and

texture, movement and

base of the tongue

- Central position, pink in

color, moist, slightly

rough, thin whitish

coating, smooth lateralmargins, no lesions, raised

papillae, moves freely, no

tenderness

Kozier and Erbs



- Located at the midline,

with whitish coating, no

lesions

- Normal

68. Palpate for any

nodules, lumps, or

excoriated areas

- No palpable nodules

Kozier and Erbs



- No palpable nodules - Normal

Palates and Uvula


color, shape, texture, and

the presence of bony

prominences


palate: light pink


in texture



- Light pink, smooth soft

palate, hard palate more in

regular in texture

- Normal

70. Inspect for position of

the uvula and mobilitywhile examining the

palates

- Positioned in midline of

soft palateKozier and Erbs


8th Edition Vol.1 page

603

- Positioned at the midline

of the soft palate

- Normal

Oropharynx and tonsils


color, and texture (one side

at a time to avoid eliciting

- Pink and smooth

posterior wall

Kozier and Erbs

- Pink and smooth

posterior wall

- Normal


27/34

gag reflex) Fundamentals of Nursing


72. Inspect the size of the

tonsils, color, and

discharge

- Pink and smooth, no

discharge, normal size

Grade 1: normal the tonsils

are behind the tonsillar

pillars (the soft structuressupporting the soft palate)

Kozier and Erbs



- Pink and smooth, grade 1 - Normal

73. Elicit the gag reflex by

pressing the posteriortongue

- Present



- Present - Normal

Neck and Lymph Nodes Normal Findings Actual Findings Interpretation / Findings

Lymph Nodes

74. Locate/ palpate/identify lymph nodes and

note for tenderness

- No tendernessKozier and Erbs




Trachea


placement

- Central placement in the

midline of the neck; spaces

are equal in both sides

Kozier and Erbs


- Central in placement,

spaces are equal in both

sides

- Normal

Thyroid Gland

76. Inspect symmetry and

visible masses

- Not visible in palpation.




77. Palpate for smoothness

and areas of enlargement,

masses or nodules

- Lobes may not be

palpated. If palpated, lobes

are small, smooth,

centrally located, painless

and rise freely with

swallowingKozier and Erbs



- Located at the midline of

the neck, moves freely

- Normal

Part II

Thorax Normal Findings Actual Findings Interpretation / Findings

Posterior Thorax

78. Inspect the size, shape,

symmetry, and compare

the diameter of

anteroposterior thorax to

- Anteroposterior to

transverse diameter with a

ratio of 1:2

Kozier and Erbs

- Has a ratio of 1:2 -Normal


28/34

transverse diameter Fundamentals of Nursing


79. Inspect the spinal

alignment

- Spine vertically aligned

Kozier and Erbs



- Spine vertically aligned -Normal

80. Palpate fortemperature, tenderness

and masses

-Temperature is within innormal range, no


Kozier and Erbs



- Temperature is withinnormal range, no


- Normal


excursion


Kozier and Erbs



82. Palpate focal fremitus - Bilateral symmetric

vocal fremitus



- Bilateral symmetric

vocal fremitus

- Normal

83. Percuss the posterior

thorax

- Lowest point of

resonance is at the

diaphragm

Kozier and Erbs



- Lowest point of

resonance is at the

diaphragm

-Normal

84. Auscultate the

posterior thorax

- Vesicular and


sounds

Kozier and Erbs



- Vesicular and


sounds

- Normal

Anterior Thorax

85. Inspect breathing

pattern



Kozier and Erbs



- Quiet, rhythmic,


- Normal

86. Palpate for

temperature, tenderness

and masses

- Temperature is within in

normal range, no





normal range

- Normal


excursion


Kozier and Erbs



- Full and symmetric - Normal

88. Palpate vocal / tactile

fremitus


fremitus, fremitus is



Kozier and Erbs



fremitus, fremitus is



- Normal


29/34


89. Percuss the anterior

thorax






areas over the heart andliver, and tympanic over

the underlying stomach

Kozier and Erbs







areas over the heart andliver, and tympanic over

the underlying stomach

- Normal

90. Auscultate the trachea - Bronchial and tubularbreath sounds

Kozier and Erbs



- Bronchial and tubular

breath sounds

- Normal

91. Auscultate the anterior

thorax



Kozier and Erbs





- Normal

Cardiovascular Normal Findings Actual Findings Interpretation / Findings

Simultaneously INSPECT

and PALPATE the

precordium for the

presence of abnormalpulsations, lifts and heaves

92. Aortic and PulmonicAreas

-No pulsations

Kozier and Erbs



- No pulsations - Normal

93. Tricuspid Areas -No pulsations

Kozier and Erbs



- No pulsations - Normal

94. Apical Area (Locate

point of maximal impulse)

- Pulsations visible on

50% of adults and palpable

in most PM/ in 5th LICS or

at medial to MCL

Kozier and Erbs


- Palpable in the 5th LICS - Normal

95. Auscultate the aortic,

pulmonic, tricuspid, and

apical valves


area





heart rate


slightly longer duration


area





heart rate


slightly longer duration

- Normal


30/34

than systole at normal

heart rates

Kozier and Erbs



than systole at normal

heart rates

Carotid arteries

96. Palpate carotid arterywith extreme caution - Symmetric pulsevolumes

- Full pulsations, thrusting

quality

Kozier and Erbs



- Symmetric pulsevolumes

- Full pulsations, thrusting

quality

- Normal

97. Auscultate the carotid

arteries

- No sound heard



- No sound heard - Normal

Jugular Veins

98. Inspect Jugular Veins - Veins not visible

Kozier and ErbsFundamentals of Nursing8th Edition Vol.1 page 623


(Note: the client refused to be examined at the breast and abdomen area)

Breast and Axillae Normal Findings Actual Findings Interpretation / Findings

99. Inspect breast for size,

symmetry, contour, or

shape while the client is insitting position

- Rounded in shape,


generally symmetricKozier and Erbs



- Rounded in shape,


generally symmetric

-Normal

100. Inspect the skin of thebreast for localized

discolorations or

hyperpigmentation,

retraction, dimpling,

localized hypervascular

areas, swelling or edema

- Skin uniform in color(same in appearance as

skin of abdomen or back)

- Skin smooth and intact

Kozier and Erbs



- Skin uniform in color(same in appearance as

skin of abdomen or back)

- Skin smooth and intact

-Normal

101. Inspect the areola for

size, shape, symmetry,

color, surface

characteristics, and anymass or lesions

- Round or oval and



light pink to dark brownKozier and Erbs



- Round or oval and




-Normal

102. Inspect the nipplesfor size, shape, position,

color, discharge, and

lesions

- Round, everted, andequal in size, similar in

color, soft and smooth,

both nipples point in same

direction


from pregnant women



-Round, everted, and equalin size, similar in color,

soft and smooth, both

nipples point in same

direction


from pregnant women



-Normal


31/34

puberty

Kozier and Erbs



puberty

103. Palpate the axillary,

subclavicular and

superclavicular lymphnodes


or nodules




or nodules

-Normal

104. Palpate breast for

masses, tenderness


nodules, or nipple

discharge




nodules, or nipple

discharge

-Normal

105. Palpate nipples for

tenderness and discharges


nodules, or nipple

discharge

Kozier and Erbs




nodules, or nipple

discharge

-Normal

Abdomen Normal Findings Actual Findings Interpretation / Findings

106. Inspect the abdomenfor skin integrity


- Silver white striae (stretch

marks) or surgical scars

Kozier and Erbs

Fundamentals of Nursing 8th



- Silver white striae

(stretch marks) or surgical

scars

-Normal

107. Inspect the abdominal

contour (profile the line

from rib margin to the

pubic bone) while standingat the client is in dorsal

recumbent position

- Flat, rounded (convex), or

scaphoid (concave)

Kozier and Erbs



- Flat, rounded (convex),

or scaphoid (concave)

-Normal

108. Inspect for enlarged

liver or spleen

- No evidence of enlargement

of liver or spleenKozier and Erbs



- No evidence of

enlargement of liver orspleen

-Normal

109. Assess the symmetry

of contour while standing

at the foot of the bed.

- Symmetric contour

Kozier and Erbs



- Symmetric contour -Normal

110.Inspect the abdominal

movements associated

with respirations,

peristalsis, or aortic

pulsations




lean people



Kozier and ErbsFundamentals of Nursing 8th





lean people



-Normal


32/34

111. Observe vascular

patterns

- No visible vascular patterns

Kozier and Erbs



- No visible vascular

patterns

- Normal

112. Auscultate the

abdomen for bowel

sounds, vascular sounds,and peritoneal friction rubs


- Absence of arterial bruits

-Absence of friction rubKozier and Erbs




- Absence of arterial bruits

-Absence of friction rub

-Normal

113. Percuss several areas

in each of the four

quadrants

- Tympany over the stomach

and gas filled bowels;

dullness especially over theliver and spleen, or a full

bladder

Kozier and Erbs



- Tympany over the

stomach and gas filled

bowels; dullness especiallyover the liver and spleen,

or a full bladder

-Normal

114. Percuss the liver to

determine its size

- 6 to 12 cm (2 to 3

inches) in the midclavicular

line; 4 to 8 cm (1 to 3

inches) in the midsternal line

Kozier and Erbs



-6 to 12 cm (2 to 3

inches) in the

midclavicular line; 4 to 8

cm (1 to 3 inches) in the

midsternal lin

-Normal

115. Perform light

palpation


abdomen with smooth,consistent tension

Kozier and Erbs




abdomen with smooth,consistent tension

-Normal

116. Perform deep

palpation

- Tenderness may be present

near xiphoid process, over

cecum, and over sigmoid

colon

Kozier and Erbs



- Tenderness may be

present near xiphoid

process, over cecum, and

over sigmoid colon

-Normal

117. Palpate the area

above the symphysis pubis

to determine possibleurinary retention

- Not palpable

Kozier and Erbs



- Not palpable -Normal

Musculoskeletal System Normal Findings Actual Findings Interpretation / Findings

Muscles


for size. Compare the

muscles on one side of the

body (arm, thigh, calf) to

the same muscle on the

other side

- Equal size of both sides

of the body

Kozier and Erbs



- Equal in size

Arm: 10 inches

Thigh: 13.8 inches

Calf: 7.2 inches

- Normal

119. Inspect the muscle

and tendons for

contractures (shortening)

- No contractures

Kozier and Erbs


- No contractures - Normal


33/34



for fasciculation and

tremors. Inspect any

tremors of the hands and

arms out in front of the

body

- No tremors

Kozier and Erbs



- No tremors - Normal

121. Palpate the muscle

tonicity

- Normal firm; smooth

coordinated movements

Kozier and Erbs



- Normal firm, coordinated

movements

- Normal


(neck)

- Equal in strength in each

body side




body side

- Normal


(upper extremities)


body sideKozier and Erbs




body side

- Normal


(lower extremities)


body side

Kozier and Erbs




body side

- Normal

Bones

125. Inspect the skeleton

for normal structure and

deformities

- No deformities

Kozier and Erbs



- No deformities - Normal

126. Palpate the bones to

locate any areas of edema

or tenderness

- No tenderness or

swelling

Kozier and Erbs



- No tenderness or

swelling

- Normal

Joints

127. Inspect the joint for

swelling

- No swelling

Kozier and Erbs



- No tenderness or

swelling

- Normal

128. Palpate each joint for

tenderness, smoothness of

movement, swelling,

crepitation, and presence

or nodule

- No tenderness,

crepitation or nodules,

joints move smoothly

Kozier and Erbs


- No tenderness, joints

move smoothly

- Normal

Assess range of motion


(shoulder and scapula)

- Able to rotate



- Able to rotate - Normal


(elbows)


Kozier and Erbs

- Able to flex and extend - Normal


34/34




(hands)


and adduct

Kozier and Erbs


8

th



and adduct

- Normal


(acetabulum/inguinal area)

- Able to rotate, flex,

extend, abduct, and adduct

Kozier and Erbs



- Able to rotate, flex.

Extend, abduct, and adduct

- Normal


(politeal)


Kozier and Erbs


- Able to flex and extend - Normal


(ankles)

- Able to rotate

Kozier and Erbs

Fundamentals of Nursing8th Edition Vol.2 page1108

- Able to rotate - Normal

Note: Other family members were not able to be examined because they are not around.

physical assessment name: amanda caragan ong age: 45 years old

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