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: ______________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________

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:
___________________________________________________
___________________________________________________
______
___________________________________________________
______
___________________________________________________
______
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:
___________________________________________________
___________________________________________________
______
___________________________________________________
______
___________________________________________________
______
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:
___________________________________________________
___________________________________________________
______
___________________________________________________
______
___________________________________________________
______

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: ___________________________________________________
_________________________________________________________
_________________________________________________________
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: ___________________________________________________
_________________________________________________________
_________________________________________________________

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: ___________________________________________________
_________________________________________________________
_________________________________________________________

NECK
Inspection NORMAL
Midline position Erect
Full ROM No masses
Neck
Notes: ___________________________________________________
_________________________________________________________
_________________________________________________________

Palpation

Nonpalpable Nontender
Palpable (Small, smooth edge of thyroid may be palpable)

Auscultation
Thyroid Gland
No bruits

Notes: ___________________________________________________
_________________________________________________________
_________________________________________________________

Palpation

Midline No deviation

Trachea
Notes: ___________________________________________________
_________________________________________________________
_________________________________________________________

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: ___________________________________________________

_________________________________________________________

_________________________________________________________

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: ___________________________________________________

_________________________________________________________

_________________________________________________________

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: ___________________________________________________

_________________________________________________________

_________________________________________________________

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: ___________________________________________________

_________________________________________________________

_________________________________________________________

NORMAL

Axilla

Inspection

Skin intact No lesions or rashes

Hair growth appropriate to clients age & sex

Nonpalpable & nontender lymphnodes

Notes: ___________________________________________________

_________________________________________________________

_________________________________________________________

NORMAL

HEART

Precordium

Palpation

PMI at apex: _______ cm

Nonsustained Nonpalpable No diffusion

Percussion:

__________________________________________________________________________________________________________________

_________________________________________________________

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Auscultation:

_________________________________________________________

_________________________________________________________

_________________________________________________________

Notes:____________________________________________________

_________________________________________________________

_________________________________________________________
\

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: ___________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

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: ___________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

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: ___________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

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: ___________________________________________________

_________________________________________________________

_________________________________________________________

NORMAL

Muscle Tone

Palpation

Soft and pliable (at rest)

Positive muscle tone, firm, no involuntary movements or tenderness

Notes: ___________________________________________________

_________________________________________________________

_________________________________________________________

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: ___________________________________________________

________________________________________________________

_________________________________________________________

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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