CHAPTER III
PHYSICAL ASSESSMENT
Date: September 20, 2018
Time: 11:00 am
GENERAL SURVEY
Patient is H.B.P 44 year old male. He is conscious, alert, irritable and not on
cardiopulmonary distress. The patient has an IVF of PNSS 1L X 30 gtts/min infusing well
at the left hand. With initial vital signs taken and recorded as follows: T=37 °C;
BP=150/100mmhg; RR=20bpm; PR=92bpm; and O2 saturation= 98%.
SKIN, HAIR, AND NAILS
SKIN: client skin was soft warm to touch and has a fair complexion. He has good
skin turgor. No presence of jaundice, abrasion or other lesions, and no hematoma
observed.
HAIR: hair was black, equally distributed and fine texture. His scalp
appeared clean and no lumps or lesions noted. No tenderness or masses upon
palpation noted. His hair is free from lice, nits and dandruff.
NAILS: Fingernails and toenails were pink in color. No lesions or
abnormalities noted. The nails are short and clean. It is smooth and intact with
epidermis. Nails has good capillary refill of less than 2 seconds.
HEAD AND FACE
Eyes are symmetrical or in line with each other. No cataract observed on both
eyes. The sclera appeared white in color and has a pale conjunctiva. No lesions,
swelling and secretions noted on both eyelids, inner and outer cantus. No edema on
lacrimal glands also. The pupils of the eyes are black and equal in size. The client’s
eyebrows are symmetrically aligned and showed equal movement when eyebrows are
raised and lowered. Eyelashes are equally distributed, curled slightly outward and black
in color. both eyes could move in coordination with outer cantus parallel with the pinna of
the ears. eyes voluntarily blink. Pupils constrict when looking at near object and dilate at
far object. Pupils converge when object is move towards the nose. When assessing the
peripheral visual field, the client can see objects in the periphery when looking straight
ahead. When testing for the extraocular muscle, both eyes of the client coordinately
moved in unison with parallel alignment.
EARS
The external surfaces of the ears are smooth. The size and shape are
proportional to the head and are symmetrical. No lesions and discharges are noted. The
patient responds to whispered messages by nodding or shaking his head.
NOSE
The nose is in the midline; there are presence of nasal discharge of blood on left
nostril; no further asessment on the left nostril due to the presence of guaze that place in
the nose. There is no pain on sinuses when palpated. Nasal flaring is not observed
during the assessment.
MOUTH, THROAT, AND NECK
The patient’s lips are dry. Tongue and gums are pinkish in color. There is no
noted gum bleeding.
THORAX AND LUNGS
Client’ respiration is regular, chest contour is symmetric and no use of accessory
muscle upon inspiration and expiration. No lesion and abnormal deformity noted dyeing
inspection. Respiratory expansion symmetrical. Tactile fremitus over the mainstream
bronchi in front and between the scapulae in the back of the chest is felt when the
patient is asked to say ninety nine. There are no abnormal breath sounds notes upon
auscultation.
ABDOMEN
The patient’s abdomen is soft, flat and distended. Hyperactive bowel sounds are
heard upon auscultation. Tympany, predominant sound heard. No organ enlargement
palpable, or any masses, bulges, or swelling . No pain upon light and deep palpation in
all four quadrant.
HEART: There are no murmurs heard upon auscultation.
GENITALS: NOT ASSESSED
EXTREMITIES:
ARMS: full and equal pulses. No edema observed. The color is same with the
body, smooth, warm and dry to touch. With an ongoing PNSS of 1L infusing well on left
cephalic vein. No pain was experienced while performing the range of Motion.
LEGS: equal in size has the same contour with the rest of the body. Warm to
touch. No presence of lesions seen. No edema observed. No pain was experienced
while performing the range of motion.
