PHYSICAL ASSESSMENT OF CG PHYSICAL ASSESSMENT NORMS ACTUAL FINDINGS INTERPRETATION AND ANALYSIS

APPEARANCE AND MENTAL STATUS 1. Body build, height, and weight in relation to clients age, lifestyle, and health 2. Clients posture and gait, standing, sitting, and walking 3. Overall hygiene and grooming. Relate these to the persons activities prior to the assessment 4. Body and breath odor in relation Proportionate, varies with lifestyle Body build, height, and weight is proportion in age and varies with lifestyle Normal

Relaxed, erect posture; coordinated movement

Relaxed, erect posture; coordinated movement

Normal

Clean and neat

Clean and neat

Normal

No body odor or minor body odor relative to work or exercise; no breath odor No distress note

No body odor or minor body odor relative to work or exercise; no breath odor

Normal

5. Distress in posture or facial expression 6. Obvious signs of health or illness 7. Clients response

No distress note

Normal

Healthy appearance

Healthy appearance

Normal

Cooperative and able to follow instructions Appropriate to situation

Cooperative and able to follow instructions Appropriate to situation

Normal

8. Clients affect/mood; appropriateness of the clients responses

Normal

9. Quantity, quality, and organization of speech

Understandable, moderate pace; clear tone and inflection; exhibits thought association Logical sequence; makes sense; has sense of reality

Understandable, moderate pace; clear tone and inflection; exhibits thought association

Normal

10. Listen to relevance and organization of thoughts VITAL SIGNS 1. Temperature 2. Pulse rate 3. Respiratory rate 4. Blood pressure SKIN 1. Skin color

Logical sequence; makes sense; has sense of reality

Normal

35.5 - 37. 5 o c 60-100 bpm (adult) 12-20 bpm (adult) 120/80 mmHg

36.8 o c 66 bpm 14 bpm 120/80 mmHg

Normal Normal Normal Normal

Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive

Skin color varies from light to deep brown

Normal

2. Uniformity of skin color Generally uniform except in areas exposed to the sun; areas of lighter pigmentation in dark skinned people 3. Presence of edema 4. Skin lesions Absence of edema Freckles, some birthmarks, some flat and raised nevi; no abrasions or other lesions

Generally uniform except in areas exposed to the sun; there are areas of lighter pigmentation

Normal

Absence of edema Absence of freckles, some birthmarks, some flat and raised nevi; no abrasions or other lesions

Normal Normal

5. Skin moisture

Moisture in skin folds and the axillae Uniform; within normal range When pinched, skin springs back to previous state; may be slower in elders

Moisture in skin folds and the axillae Uniform; within normal range When pinched, skin springs back to previous state

Normal

6. Skin temperature

Normal

7. Skin turgor

Normal

HAIR 1. Evenness of growth over the scalp 2. Hair thickness or thinness 3. Hair texture and oiliness 4. Presence of infections or infestations 5. Amount of body hair NAILS 1. Plate shape, curvature and angle 2. Texture 3. Color Convex curvature; angle of nail about 160o Smooth texture Highly vascular and pink Convex curvature; angle of nail about 160o Smooth texture Highly vascular and pink Normal Evenly distributed Evenly distributed Normal

Thick hair

Thick hair

Normal

Silky , resilient hair

Silky , resilient hair

Normal

Absence of infection or infestation Variables

Absence of infection or infestation Variables

Normal

Normal

Normal Normal

4. Tissues surrounding the nails 5. Blanch test capillary refill

Intact epidermis

Intact epidermis

Normal

Prompt return of pink

Prompt return of pink

Normal

SKULL AND FACE 1. Skull size, shape and symmetry 2. Skull of nodules or masses and depressions 3. Facial features Rounded, smooth skull contour Smooth, uniform consistency; absence of nodules or masses Symmetric or slightly asymmetric facial features; palpebral fissures are equal in size; symmetric nasolabial folds Absence of edema and hollowness Symmetric facial movements Rounded, smooth skull contour Smooth, uniform consistency; absence of nodules or masses Symmetric facial features; palpebral fissures are equal in size; symmetric nasolabial folds Normal

Normal

Normal

4. Eyes for edema and hollowness 5. Symmetry of facial movements EYES STRUCTURES AND VISUAL ACUITY 1. Hair distribution, alignment, skin quality and movement

Absence of edema and hollowness

Normal

Symmetric facial movements Normal

Hair is evenly distributed; skin is intact; eyebrows are symmetrically aligned; equal movement

Hair is evenly distributed; skin is intact; eyebrows are symmetrically aligned; equal movement Equally distributed; curled slightly outward

Normal

2. Evenness distribution Equally distributed; of the eyelashes and its curled slightly outward direction or curl 3. Surface characteristics of the eyelids Skin is intact; no discharge; no discoloration; lids close symmetrically; approximately 15 - 20 involuntary blinks per minute; bilateral blinking; when lids are open, no

Normal

Skin is intact; no discharge; no discoloration; lids close symmetrically; 13 involuntary blinks per minute; bilateral blinking; when lids are open, no visible sclera and lower borders of cornea are

Normal

visible sclera and lower borders of cornea are slightly covered 4. Bulbar conjunctiva Transparent; capillaries sometimes even evident; sclera appears white Shiny smooth and pink/red Absence of edema or tenderness over Lacrimal gland Absence of edema or tearing Transparent, shiny and smooth; details of iris are visible Blinks when cornea is touched, indicating that the trigeminal nerve is intact Transparent

slightly covered

Transparent; sclera appears white

Normal

5. Palpebral conjunctiva

Shiny smooth and pink

Normal

6. Lacrimal gland

Absence of edema or tenderness over Lacrimal gland Absence of edema or tearing

Normal

7. Lacrimal sac and nasolacrimal duct 8. Clarity and texture of the cornea

Normal

Transparent, shiny and smooth; details of iris are visible Blinks when cornea is touched, indicating that the trigeminal nerve is intact

Normal

9. Cornea sensitivity

Normal

10. Transparency and depth of the anterior chamber

Transparent

Normal

11. Color, shape and Black in color, equal in symmetry of size of the size, normally 3 - 7 pupil diameter; round, smooth border, iris flat and round 12. Third (Oculomotor) and forth (trochlear) cranial nerve pupils direct and consensual Illuminated pupil constricts (direct response)

Black in color, equal in size, 4 Normal in diameter; round, smooth border, iris flat and round

Illuminated pupil constricts (direct response)

Normal

reaction to light 13. Pupils reaction to accommodation Non-illuminated pupil constricts ( consensual response) Pupils constricts when looking at near object; pupil dilates when looking at far objects; pupils converge when near object is moved toward the nose Non-illuminated pupil constricts ( consensual response) Pupils constricts when looking at near object; pupil dilates when looking at far objects; pupils converge when near object is moved toward the nose Normal

14. Peripheral visual To determine function of the retina and neuronal visual pathways to the brain and second (optic) cranial nerve 15. Six ocular movements

Normal

When looking straight ahead, client can see objects in the periphery Both eyes coordinated, move in unison with parallel alignment Light fall symmetrically on both pupils Uncovered eye does not move 20/20 vision

When looking straight ahead, client can see objects in the periphery Both eyes coordinated, move in unison with parallel alignment Light fall symmetrically on both pupils Uncovered eye does not move 20/20 vision

Normal

16. Corneal light reflex

Normal

17. Cover test

Normal

18. Near vision test 19. Distance vision Snellens chart EARS AND HEARING 1. Auricles for color, symmertry of size and position

Normal

Normal

The color is same as facial skin; symmetrical; auricles aligned with outer canthus of the eye, about 10o from vertical

The color is same as facial skin; symmetrical; auricles aligned with outer canthus of the eye, about 10o from vertical

Normal

2. Auricles for texture, elasticity, and areas of tenderness 3. External ear canal for cerumen, skin lesions, pus and blood

Mobile, firm, and not tender;; pinna recoils after it is folded Distal third contains hair follicles and glands; dry cerumen, grayish tan color, sticky, wet cerumen in various shades of brown Pearly gray color, semitransparent Normal voice tones audible Able to hair ticking in both ears Sound is heard in both ears or is localized at the center of the head Air-conducted hearing is greater than boneconducted hearing

Mobile, firm, and not tender;; pinna recoils after it is folded Distal third contains hair follicles and glands; dry cerumen, grayish tan color, sticky, wet cerumen in various shades of brown

Normal

Normal

4. Tympanic membrane for color and gloss 5. Response to normal voice tones 6. Watch tick

Pearly gray color, semitransparent Normal voice tones audible

Normal

Normal

Able to hair ticking in both ears Sound is heard in both ears or is localized at the center of the head Air-conducted hearing is greater than boneconducted hearing

Normal

7. Webers test

Normal

8. Rinnes test

Normal

MOUTH AND OROPHARYNX 1. Symmetry of contour, color and texture of outer lips Uniform pink color; soft, moist, smooth texture; symmetry of contour; able to purse lips Uniform pink; moist, smooth, soft, glistening, and elastic texture Uniform pink color; soft, moist, smooth texture; symmetry of contour; able to purse lips Uniform pink; moist, smooth, soft, glistening, and elastic texture Normal

2. Color, moisture, texture and presence of lesions in the inner lips and buccal

Normal

3. Teeth and gums

32 adult teeth; smooth, white, shiny tooth enamel; pink gums; moist, firm texture to gums; no retractions of gums Smooth, intact dentures

27 adult teeth; smooth, white, shiny tooth enamel; pink gums; moist, firm texture to gums; no retractions of gums

Normal

4. Dentures

Normal Presence of smooth, intact dentures

5. Surface, position, color and texture of the tongue

Central position; pink color; moist; slightly rough; thin, whitish coating; smooth, lateral margins; no lesions; raised papillae Moves freely; Absence of tenderness

Normal Central position; pink color; moist; slightly rough; thin, whitish coating; smooth, lateral margins; no lesions; raised papillae Normal Moves freely; Absence of tenderness Normal

6. Tongue movement

7. Base of the tongue, the Smooth tongue base with mouth floor and the prominent veins Smooth tongue base with frenulum prominent veins 8. Any nodules, lumps or oxcoriated areas in the tongue and floor of the mouth 9. Salivary duct openings for any swelling or redness Smooth with no palpable nodules

Normal Smooth with no palpable nodules

Same as color of buccal mucosa and floor of mouth; no presence of any swelling or redness Light pink, smooth, soft palate; lighter pink hard palate, more irregular texture

Normal Same as color of buccal mucosa and floor of mouth; no presence of any swelling or redness Normal Light pink, smooth, soft palate; lighter pink hard palate, more irregular texture Normal Positioned in midline of soft

10. Color, shape, texture and the presence of bony prominences on the hard and soft palate 11. Position and mobility of the uvula

Positioned in midline of soft palate

12. Color and texture of the oropharynx 13. Color, discharge and size of the tonsils behind the fauces 14. Gag reflex NECK 1. Symmetrical size of the muscle 2. Head movement

Pink and smooth posterior wall Pink and smooth; no discharge; of normal size or not visible Present

palate Pink and smooth posterior wall Pink and smooth; no discharge; of normal size or not visible

Normal

Normal

Normal Present

Muscles are equal in size; head centered Coordinated, smooth movements with no discomforts Equal strength Not palpable

Muscles are equal in size; head centered Coordinated, smooth movements with no discomforts Equal strength Not palpable

Normal

Normal

3. Muscke strength 4. Enlarged lymph nodes on the entire neck 5. Lateral deviation of the trachea

Normal Normal

Central placement in midline of neck; spaces are equal on both sides Not visible Small, smooth, centrally located, painless, and rise freely with swallowing Absence of Bruit

Central placement in midline of neck; spaces are equal on both sides. Not visible Small, smooth, centrally located, painless, and rise freely with swallowing

Normal

6. Thyroid gland 7. Smoothness of the thyroid gland

Normal Normal

8. Bruit sound over the thyroid area PERIPHERAL VASCULAR SYSTEM 1. Peripheral veins

Absence of Bruit

Normal

Symmetric pulse volumes. Full pulsations

Symmetric pulse volumes. Full pulsations

Normal

2. Peripheral veins in the arms and legs for the presence of superficial veins when limbs are dependent and elevated 3. Skin of the hands and feet, temperature, edema and skin changes (Peripheral perfusion) HEART AND THE CENTRAL VESSELS 1. Carotid arteries

Presence of distention and nodular bulges at claves; limbs not tender; symmetric in size

Presence of distention and nodular bulges at claves; limbs not tender; symmetric in size

Normal

Skin color is pink; skin temperature is not excessively warm or cold; no edema; skin texture is moist and resilient

Skin color is pink; skin temperature is not excessively warm or cold; no edema; skin texture is moist and resilient

Normal

Symmetric pulsations; full pulsations, thrusting quality; elastic artery wall; no sound heard on auscultation Veins not visible

Symmetric pulsations; full pulsations, thrusting quality; elastic artery wall; no sound heard on auscultation

Normal

2. Jugular veins BREAST AND AXILLAE 1. Size, symmetry, contour or shape of the breast

Veins not visible

Normal

Female: rounded shape; slightly unequal in size; generally symmetric Male: Breast even in the chest wall Skin uniform in color; skin is smoothly intact

Breast even in the chest wall

Normal

2. Localized discoloration or hyperpigmentation, retraction or dimpling on the breast 3. Presence welling and edema on the breast

Skin uniform in color; skin is smoothly intact

Normal

Absence of swelling and edema

Absence of swelling and edema

Normal

4. Presence of masses, tenderness and nodules 5. Size, shape, symmetry, color, surface characteristics of the breast

Absence of tenderness, nodules, masses or nipple discharge Round or oval and bilaterally the same; irregular placement of sebaceous glands; color varies from light pink to dark brown Round, everted and equal in size; similar in color; soft and smooth; no discharge (except for mother who is breastfeeding)

Absence of tenderness, nodules, masses or nipple discharge Round or oval and bilaterally the same; irregular placement of sebaceous glands; color varies from light pink to dark brown

Normal

Normal

6. Size, shape, symmetry, color, discharge and lesions on the nipples

Round, everted and equal in size; similar in color; soft and Normal smooth; no discharge

7. Presence of tenderness Absence of tenderness, or nodules masses or nodules THORAX AND LUNGS 1. Shape and symmetry of the thorax from posterior and lateral views 2. Spinal alignment 3. Temperature and integrity of all chest skin 4. Lateral deviation of the spine Anteroposterior to transverse diameter in ratio of 1:2

Absence of tenderness, masses or nodules

Normal

Anteroposterior to transverse diameter in ratio of 1:2

Normal

Spine vertically aligned Skin intact; uniform temperature

Spine vertically aligned Skin intact; uniform temperature

Normal Normal

Spinal column is straight; right and life shoulders and hips are at the same height Absence of edema, tenderness and masses

Spinal column is straight; right and life shoulders and hips are at the same height

Normal

5. Presence of edema, tenderness and masse

Absence of edema, tenderness and masses

Normal

6. Respiratory excursion in the posterior chest 7. Vocal fremitus

Full and symmetric chest expansion Bilateral symmetry of vocal fremitus Quiet rhythmitic, effortless respiration Costal angle is less than 90o and the ribs insert into the spine at approximately 45o Full symmetric excursion

Full and symmetric chest expansion Bilateral symmetry of vocal fremitus Quiet rhythmitic, effortless respiration Costal angle is less than 90o and the ribs insert into the spine at approximately 45o

Normal

Normal

8. Breathing patterns

Normal

9. Costal angle

Normal

10. Respiratory excursion in the anterior thorax 11. Tactile fremitus

Full symmetric excursion

Normal

Fremitus is normaly Fremitus is present decreased over heart and breast tissue Brochial and tubular breath sounds Brochial and tubular breath sounds

Normal

12. Trachea

Normal

ABDOMEN 1. Skin integrity Unblemished skin color; uniform color Absence of striae Flat, rounded (convex) or scaphoid (concave); symmetric contour Unblemished skin color; uniform color Presence of striae Flat, rounded (convex) or scaphoid (concave); symmetric contour Normal

2. Presence of striae 3. Contour and symmetry

Not normal Normal

4. Abdominal movements associated with respiration, peristalsis or aortic pulsation

Symmetric abdominal Symmetric abdominal movements caused by movements caused by respiration; visible respiration peristalsis in lean people; aortic pulsations in thin persons in epigastric area

Normal

Normal

5. Vascular pattern

No visible pattern

vascular No visible vascular pattern

6. Bowel sounds, vascular peritoneal friction rubs

Audible bowel sounds; Audible bowel sounds; absence of arterial bruits; absence of arterial bruits; absence of friction rub absence of friction rub Tympany over the stomach and gas-filled bowels; dullness over the liver and spleen 6 - 12 cm in the midclavicular; 4-8 cm at the midsternal line Absence of tenderness; relaxed abdomen with smooth, consistent tension Tenderness may be present near the xiphoid process, over cecum, and over sigmoid colon May not be palpable, borders feels smooth Not palpable Tympany over the stomach and gas-filled bowels; dullness over the liver and spleen 8 cm in the midclavicular; 8 cm at the midsternal line

Normal

7. Abdomen percussion

Normal

8. Liver percussion

Normal

9. Light palpation on the abdomen

Absence of tenderness; relaxed abdomen with smooth, consistent tension

Normal

10. Deep palpation on the abdomen

Tenderness is present near the xiphoid process, over cecum, and over sigmoid colon Not palpable

Normal

11. Liver palpation

Normal

12. Bladder palpation MUSCULOSKELETAL SYSTEM 1. Muscle size

Not palpable

Normal

Equal size on both sides of body No contractures

Equal size on both sides of body No contractures

Normal

2. Contractures in the muscles and tendons

Normal