PHYSICAL ASSESSMENT

is a means of evaluating the health status of a client using a combination of history taking and clinical examination. It necessitates cooperation on the part of the client and accurate examination of the nurse. The four senses, namely: hearing, vision, sense of smell and touch are utilize by the use of : Inspection Palpation Percussion Auscultation to acquire the desired data. To achieve results as accurate as possible, the following instruments were used: tape measure, penlight, thermometer, BP apparatus and stethoscope.

DATE Oct.1,2013 Nov.18,2013

TEMPERATURE

PULSE RATE 85

RESPIRATORY RATE 19

BLOOD PRESSURE 100/60

GENERAL SURVEY

ASSESSMENT

OBSERVATIONS

Bodybuild

Unproportionate

Posture Hygiene and grooming

Asymmetrical Tidy

Attitude

Cooperative

Affect/mood

Appropriate

Quality and quantity of speech

understandable; slow

Relevance of thoughts

Logical, realistic

MEASUREMENT

Height

Weight

Computed BMI

Head circumference

cm

Chest circumference

cm

Abdominal circumference

cm

Mid arm

cm

Calf

cm

Length of lower extremities

cm

Body part Skin Hair Nails

inspection The skin is color brown; rashes noted on both upper and lower extremities. Long and Black, evenly distributed, Lices noted upon inspection. Pink in color; convex nail curve (160 deg). Untrimmed nails noted. Skull is in Normocephalic shape, equally round, symmetrical in features and movement.

palpation

percussion

auscultation

capillary refill is less than 2 seconds

Skull and face Eyes Eyebrows eyelashes Eyelids Bulbar conjunctiva Palpebral conjunctiva

transparent; some capillaries seen; white sclera shiny; pink no tenderness shiny black; equal in size; round when looking straight can see sides

Lacrimal gland Cornea Pupils Visual fields

NEUROLOGICAL SYSTEM

CATEGORY Language Orientation memory Level of consciousness- Glasglow Coma Scale

OBSERVATIONS able to name objects able to state place of residence, duration of illness and names of family members able to recall recent events eye opening- 5 (opens spontaneously as approached ) verbal response- 5 (oriented ) best motor response- 6 (obeys ) Total : 16

Cranial nervesCranial nerve I- Olfactory Cranial nerve I- Olfactory Cranial nerve II- Optic Cranial nerve III- Oculomotor able to identify aroma able to read written words such as news print able to move eyes in six directions, PERRLA (PUPIL EQUALLY ROUND REACTIVE TO LIGHT ACCOMODATION) Cranial nerve IV- Trochlear Cranial nerve V- Trigeminal Cranial nerve VI- Abducens Cranial nerve VII- Facial Cranial nerve VIII- Auditory Cranial nerve IX- Glossopharyngeal Cranial nerve X- Vagus able to move eyes positive blink reflex not assessed able to smile, raise eyebrows, frown, puff out cheeks and close eyes tightly able to hear spoken words and tick-tock of wrist watch able to move tongue from side to side and up and down able to move tongue from side to side and up and down, no hoarseness in speech

Cranial nerve XI- Accessory Cranial nerve XII- Hypoglossal

able to shrug shoulders and turn head to side against gentle resistance able to protrude tongue at midline and move from side to side