PHYSICAL ASSESSMENT

Date and Tine of Initial Physical Assessment: July 29, 2019/5:30 PM

VITAL SIGNS METHOD OF NORMAL ACTUAL ANALYSIS AND INTERPRETATION

ASSESSMENT FINDINGS FINDINGS
BLOOD Auscultation 110/70 110/70 There are no noted concerns
PRESSURE
TEMPERATURE Digital 36-37.5 °C 39.1 °C Due to cytokine-induced upward
Thermometer (Childs 2011) displacement of the set point of the
hypothalamic thermoregulatory center.
( elevations in body temperature appear to
enhance immune function and inhibit
pathogen growth [Dengue virus].

PULSE RATE Palpation 60-100 bpm 113 bpm Fever causes an increase in the heart rate
and blood circulation to the skin. This is
how the body tries to reduce the heat
caused by fever.
RESPIRATORY Inspection 12-20 rpm 52 rpm Fever causes an increase in the breathing
RATE (Carol Kelly 2018) rate. This is how the body tries to reduce
the heat caused by fever.

And possible the effect of pleural effusion.

If the pleural effusion becomes large
enough, it prevents the lung from properly
expanding when breathing. This may lead
to the shortness of breath.
OXYGEN Pulse Ox meter 98%-100% 99% There are no noted concerns
SATURATION
GENERAL SURVEY

PART TO BE METHOD OF NORMAL ACTUAL ANALYSIS/INTERPRETATION

ASSESS ASSESSMENT FINDING FINDING
Appearance Inspection No dimorphic No deformities noted There are no noted concerns
features during assessment
Level of Inspection Conscious and Conscious and There are no noted concerns
consciousness responsive coherent
Speech pattern Inspection  Maintain eye Can speak clearly There are no noted concerns
contact
 Express
appropriate words
Posture gait, Inspection *Normal gait,  patient need Weak due to fever and muscle
standing ,sitting and released posture, up assistance while weakness
walking right walking w/o walking
assistance
Dressing, Grooming Inspection *Clean and Neat Wearing casual dress There are no noted concerns
and personal hygiene (short and t-shirt with
flower and pony
designed)
 PART TO BE METHOD OF NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS AND
ASSESS ASSESSMENT INTERPRETATION

Height and weight Inspection/Observation *Appropriate ht and wt of the Weight:44.8kg

(BMI) patient (depend on body build) Height:125cm
BMI:
Please indicate the age, height,
and weight of your patient and
compute the ideal BMI.

Ms. Haboc will ask for that for

sure
Skin Inspection  No lesion and pigmentation  Rash and petechiae Rupture of thin walled
present in the peripheral venules due
abdomen area to an acute rise in
venous pressure.

Face Inspection  Shape maybe oval or Rounded, face is There are no noted
rounded. symmetrical, no concerns
 Face is symmetrical involuntary muscle
 No involuntary muscle movements and can
movements move facial muscles at
 Can move facial muscles at will.
will
  Intact cranial nerve V and VII

Head Inspection  Generally round, with Normocephalic, no There are no noted

prominences in the frontal tenderness noted upon concerns
and occipital are palpation.
(Normocephalic) Oily scalp, no scars and
 No tenderness noted upon free from lice, no
palpation tenderness nor masses
on palpation.
Scalp Hair is black,thick, and
 Lighter in color than the smooth, no evidence of
complexion alopecia
 Can be moist or oily
 No scars noted
 Free from lice, nits, and
dandruff
 No lesions should be noted
 No tenderness nor masses on
palpation

Hair
 Can be black, brown or
burgundy depending on the
race.
 Evenly distributed covers the
whole scalp (No evidences of
Alopecia)
 Maybe thick or thin, course or
smooth
 Neither brittle nor dry
Eye brows Inspection  Symmetrical and in line with Symmetrical and in line There are no noted
each other with each other; black concerns
 Maybe black, brown or blond and evenly distributed
depending on race
 Evenly distributed
Eyes Inspection  Evenly placed and inline with  Redness of the eyes Due to macular
each other (conjunctivitis) hemorrhage that form
 Non protruding blot hemorrhages.
 Equal palpebral fissure

Conjuctivae
 Both conjunctivae are pinkish
or red in color
 With presence of many
minutes capillaries
 Moist
 No ulcers
 No foreign objects
Sclerae
 Sclerae is white in color
(anicteric sclera)
 No yellowish discoloration
(icteric sclera)
 Some capillaries maybe
visible
 Some people may have
pigmented positions
Cornea
 There should be no
irregularities on the surface
 Looks smooth
 The cornea is clear or
transparent. The features of
 the iris should be fully visible
through the cornea
Pupil
 Pupillary size ranges from 3-
7mm, and are equal in size
 Equally round
 Constrict briskly/sluggishly
when light is directed to the
eye, both directly and
consensual
 Pupils dilate when looking at
distant objects, and constrict
when looking at nearer
objects.

(PERRLA- Pupils equally round;

reactive to light, and
accommodate)
Ear/hearing Inspection  The ear lobes are bean Ear lobes are There are no noted
Palpation shaped, parallel, and symmetrical and concerns
symmetrical parallel with the outer
 The upper connection of the canthus of the eye; no
ear lobe is parallel with the lesions noted during the
outer canthus of the eye inspection; auricles are
 Skin is same in color as in the firm; no pain or
complexion tenderness during
 No lesions noted on palpation; pinna recoils
inspection when folded; presence
 The auricles are has a firm of cerumen; no
cartilage on palpation discharges or lesions in
 The pinna recoils when at the ear canal
folded
 There is no pain or tenderness
 on the palpation of the
auricles and mastoid process
 The ear canal has normally
some cerumen of inspection
 No discharges or lesions
noted at the ear canal

Nose/Sinuses Inspection  Nose in the midline
Palpation  No discharges
 No flaring alae nasi
 Both nares are patent
 No bone and cartilage
deviation noted on palpation
 No tenderness noted on
palpation
 Nasal septum in the mid line
and not perforated
 The nasal mucosa is pinkish
to red in color
 No tenderness noted on
palpation of the paranasal
sinuses
Mouth Inspection  With visible margin
 Symmetrical in appearance
and movement
 Pinkish in color
 No edema
Temporamandibular
 Moves smoothly no crepitous
 No deviation noted
 No pain or tenderness on
Nose in the midline; no There are no noted
discharges; no flaring; concerns
both nares are patent;
pinkish nasal mucosa;
and no tenderness noted
on palpation of the
paranasal sinuses
Pinkish lips; no edema; There are no noted
no pain or tenderness concerns
on palpation and jaw
movement; gums is
pinkish color and no
signs of bleeding and
receding gums;
yellowish teeth and
with dental carries in
 palpation and jaw movement (incisor and pre molar
Gums teeth); no swelling of
 Pinkish in color tonsils
 No gum bleeding
 No receding gums
Teeth
 28 for children
 White to yellowish in color
 With or without dental carries
and or dental fillings
 With or without
malocclusions
 No halitosis
Tongue
 Pinkish with white taste buds
on the surface
 No lesions noted
 No varicosities on ventral
surface
 Frenulum is thin attaches to
the posterior 1/3 of the ventral
aspect of the tongue
 Gag reflex is present
 Able to move the tongue
freely and with strength
 Surface of the tongue is rough
Uvula
 Positioned in the mid line
 Pinkish to red in color
 No swelling or lesion noted
 Moves upward and
backwards when to say “ah”
Neck Inspection  The neck is straight Symmetrical; no There are no noted
Palpation  No visible mass or lumps jugular venous concerns
 Symmetrical distension; no visible
 No jugular venous distension mass or lumps
 The trachea is palpable
 It is positioned in the line and
straight
Breast  Inspection  No lumps or masses are No lumps or masses are There are no noted
 Palpation palpable palpable; no tenderness concerns
 No tenderness upon palpation or pain during
 No discharges from the palpation; no
nipples discharges from the
nipples
Thorax  Inspection  Moves symmetrical on  Crackle sounds Due to plasma leakage
 Palpation breathing with no obvious presence during into the pleural cavity
 Auscultation masses auscultation
 No fail chest which is  52 breaths per
suggestive of rib fracture minute
 No chest retractions must be  With nasal cannula
noted oxygen 3L/min
 No bulging at the Intercostal
space must be noted
 The spine should be straight
with slightly curvature in the
thoracic area
 There should be no scoliosis,
kyphosis, or lordosis
 Breathing maybe
diaphragmatically of costally
 Expiration is usually longer
the inspiration
 Vesicular soft, low pitch
 Broncho-vesicular medium
 pitch
 Bronchial loud, high pitch
Abdomen Inspection  Skin color is uniform, no  Pain Right upper Regular thickening of
Auscultation lesions quadrant distal ileal loop in
Percussion  Some clients may have striae  Tenderness pelvis, mild right
Palpation or scar pleural effusion
 No venous engorgement
 Contour may be flat, rounded
or scapoid
 Thin clients may have visible
peristalsis
 Aortic pulsation maybe visible
on thin clients
 Peristaltic sounds presence
 No tenderness noted
 With smooth and consistent
tension
 No muscles guarding
 The liver usually can not be
palpated in a normal
individual. However, in
extremely thin but otherwise
well individuals, it may be felt
the costal margins
 When the normal liver margin
is palpated, it must be smooth,
regular in contour, firm and
non-tender
Extremities Inspection  Good range of motion in all
Palpation joints. No evidence of
swelling or deformity
 Good muscle bulk and tone.
Strength 5/5 throughout
 Romberg- maintains balance
with eyes closed. No pronator
drift
 Reflexes: 2+ and symmetric
 Presence of Edema Plasma leakage is
on both legs caused by increased
 Grade 2, pitting capillary permeability
edema on both legs and may manifest as
 Presence of rashes hemoconcentration
 Presence of scars on
the right leg

PHYSICAL ASSESSMENT

Date and Tine of Initial Physical Assessment: July 30, 2019/5:00 PM

VITAL SIGNS METHOD OF NORMAL ACTUAL ANALYSIS AND INTERPRETATION

ASSESSMENT FINDINGS FINDINGS
BLOOD Auscultation 100/60-120/80 90/70 Normal
PRESSURE (PALS guidelines
 2015)
TEMPERATURE Digital 36.5-37.5 °C 36. 9 °C Normal
Thermometer (PALS guidelines
2015)
PULSE RATE Palpation 60-95 bpm 99 bpm Tachycardia
-due to fever
RESPIRATORY Inspection 12-20 bpm 57 bpm Tachypnea
RATE (Carol Kelly 2018)
OXYGEN Pulse Ox meter 95%-100% 99% Normal
SATURATION

PART TO BE ASSESS METHOD OF NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS AND

ASSESSMENT INTERPRETATION

Height and weight Inspection/Observation *Appropriate ht and wt of Weight:44.8kg

(BMI) the patient (depend on Height:125cm
body build) BMI:
Skin: color, Inspection *The skin is moisture,
texture ,moisture, lesion temperature in within
or scar normal range
*No lesion and
pigmentation

Face *Inspection *face is symmetry position *face is symmetry *Normal

*No involuntary muscle position
facial movement *No involuntary muscle
*rounded facial movement
*rounded
Head Inspection

Eye brows *Inspection *Equal distributed and *Equal distributed and *Normal
long long

Eyes & Vision Inspection *No edema and

hollowness
*pupil equal around
&reactive to light &
accommodation(PERRLA)
*symmetrical & aligned
equal movement when
asked to raise or lower

Ear/hearing *Inspection *Color brown and able to *Color brown and able *Normal
*palpation hear whisper on both side to hear whisper on both
*No pain side
*No lesion *No pain
*No lesion
Nose/Sinuses *Inspection *symmetrical in shape *symmetrical in shape *Normal
*palpation *No presence discharge *No presence discharge
*No tenderness and lesion *No tenderness and
lesion

Mouth *Inspection *symmetrical appearance

and movement
*the color of mucous is
pink and shiny
*No broken or loose teeth
*Underneath the tongue
don’t have lesion or sores

neck *Inspection *the neck is straight *the neck is straight *Normal

*No lateral deviation *No lateral deviation
*palpation *No tenderness(-) lump *No tenderness(-) lump
and lesion and lesion
Breast symmetry and  Inspection  Breast are round  Breast are round Normal
contour  Palpation and generally and generally
symmetric, no symmetric, no
tenderness, masses tenderness,
and lesions masses and
lesions

Nipple condition and  Inspection  Size is  Size is Normal

presence of discharges  Palpation proportional, no proportional, no
discharged or discharged or
secretions, no secretions, no
masses and lesions masses and
lesions
Lungs  Inspection  Quiet, rhythmic,  Presence of
 Auscultation effortless crackle sounds
 Vesicular and on both lungs
Bronchovesicular
Abdomen Skin  Inspection  Unblemished skin,  She has Distraction of platelet
Condition uniform in color erthematous rash
in the skin of the
abdomen

 Palpation  No masses  Pain (RUQ)

presence, pain and
tenderness  Tenderness

 Auscultation  Audible bowel  No significant Normal

Sound findings

External female Inspection  Normal hair  Presence of

genitalia distribution lesions on labia
 No lesions and no majora
swelling Presence of pain 4/10
 No discharge
 No pain
No foul smell
Lower Extremities Inspection  Bilaterally  Presence of
(right & left Leg) symmetrical Edema on both
 & equal legs
 Right & Left foot  Grade 2, pitting
has no lesions, no edema on both
swelling legs
Skin color as the same as  Presence of
the other part of the body rashes
Presence of scars on the
right leg
Lower Extremities Inspection  No presence of  Nail bed is pale
(Nail Beds) parasites (lice)
 Fine texture
 No masses
 Round nail with
160 degrees nail
base
Pink nail bed