College of Nursing

COLLECTING AND CLUSTERING OBJECTIVE DATA (Initial Comprehensive P.E. - IPPA)

GENERAL INFORMATION  Nutritional State  Temperature  Uniform Constriction  Mucosa

Well nourished/ Poorly Warm/Cool  Unequal Constriction  Pinkish
CLIENT: ________________________ nourished/ Others:_____________  Uniform  Pale
W/B: ____________AGE: _________ Obesity/Cachexia  Turgor Convergence  Reddish
SEX:___________ CS:_____________  Emotional State Good/Fair/Poor/ Decreased  Unequal  Discharge/Serous/
Calm/Worried/anxious/  Moisture Convergence Mucoid/Purulent/
VITAL SIGNS Restless/Tense Dry/Wet/Clammy/  Grossly normal acuity Bloody
 Temperature _________ Others:______________ Oily  Farsighted/  Patency
Oral/axilla/rectal  Others Nearsighted  Both patent
 Pulse Rate_______/min HEAD Petechiae/  Eyeglasses/Contact  R L obstructed
Regular/Irregular  Configuration Ecchymoses/Lesions/ Rashes lenses exhalation
 Blood Pressure________ Normocephalic/ Asymmetrical/  Edema  Peripheral Vision  Masses/Lesions:_____
mmHg sitting/ standing/ lying Enlarged Pitting/Non-Pitting  Intact/Full  Gross Smell
 Heart Rate  Masses: __________ Bipedal: R L  Decreased/Limited  Symmetrical
Regular/Irregular  Others: ___________ Grading:  R L olfactory
 Respiratory Rate  Facial Movements EARS deficiency
Regular/Irregular  Symmetrical EYES  External pinnae:  Sinuses
 Asymmetrical: LAG R L  Lids Normoset/symmetrical  Tenderness
GENERAL SURVEY  Fontanels:  Symmetrical  Ternderness  Maxillary/Frontal
 Anthropometric  Closed  R L Edema/Swelling  Lesions:___________
measurements  Open. Specify ________  R L Ptosis  Gross Abnormalities MOUTH
 Height ________cm  Sunken  Lesions: ____________  External Canal:  Lips
 Weigth ________kg  Bulging  Periorbital Region  Discharge Pallor/Cyanosis/ Dryness/cracks/
 Head circ __________cm  Hair: Edema/Sunken/ Discoloration  Foul smelling/ Lesions:_____________
 General Appearance  Fine  Conjuctiva Serious/Purulent/  Mucosa
Signs of distress:  Normal/Even Pink/Pale Mucoid Pinkish/Pallor/Cyanosis
Cardio respiratory/  Distribution Lesions:_____________  Cerumen:_________  Tongue
Pain/Anxiety  Alopecia Discharge:__________ Impacted Midline/R L Deviation
 Level of consciousness  Coarse  Sclera  Tympanic membrane Atrophy/Fasciculatrion
Conscious/Alert/Drowsy/  Dry Anicteric/Subicteric/  Intact  Teeth
Confused/Stuporous/  Scalp Icteric/Hemorrhages  Gross Hearing Complete/Missing
Comatose/Others: _______ Clean/Dandruff/Lice  Cornea & Lens  Symmetrical Teeth/Caries/Dentures/
 Coherence/Coherent/  Wounds/Scars/Lesion Opacity R L  R L Deafness Braces/Retainers
Incoherent/ Specify:___________ Lesions:_____________  Gums
Others:__________________  Pupils NOSE Pinkish/Pallor/Bleeding
 Development SKIN Equal: size __________  Nasolabial fold  Tenderness
Endomorph/Mesomorph  General Color Unequal: R= ___ L=___  Alar flaring  Speech
Ectomorph/Well developed/ Fairly Pinkish/Pallor/Jaundice/  Reaction to Light:  R L Shallow Intact/Slurred/Aphasic
developed/ Poorly developed/ Flushed Cyanosis Brisk R L nasolabial fold  Others
Looks according to age/Appears  Texture Sluggish R L  Septum
older/younger 4 age Smooth/Rough Fixed R L  Midline
Others:________________  Deviated
 Perforated

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NECK  Lung Expansion HEART  Indirect tenderness GENITO-URINARY SYSTEM
 Trachea  Symmetrical  Precordial area  Organomegaly  External genitalia (female)
 Midline  R L Decrease/Lag Flat/Bulging/Tenderness/ Liver/Spleen  Labia
 R L Deviation  Vocal/Tactile Fremitus Heave Thrill/ Normodynamic  Bladder distention - Symmetrical
 Cervical Lymph Nodes  Symmetrical precordium/ Hyperdynamic  Masses at__________ - Asymmetrical
 Lymphadenopathy  R L Decreased/ precordium - Lesions:_________
 Tenderness Increased at  PMI at _______________ BACK AND EXTREMITIES - Pinkish
 Thyroids  Percussion  Apical Beat @  Peripheral pulses - Discoloration
Nonpalpable/ Enlarged  Resonant _________ Symmetrical/Regular/ - Edema
 Others  Dullness at________  Heart Sounds Absent/Faint/weak/  Urethra
 Neck enlargement  Hyperresonant at__ Distinct/Regular/Faint/ Strong/Bounding Middle/Pink/Red/
 Normal ROM  Breath Sounds Irregular  Nails and Nails Bed Inflamed
 Neck rigidity  Vesicular  S1_____s2 at the base Pinkish/Pallor/Cyanosis/  Vaginal orifice
 NVE at_____ angle  Bronchovesicular  S1_____s2 at apex Inflammation/Clubbing/ discharge
 Masses:____________ at____  Others Delayed capillary Purulent/Bloody/ Foul
 Bronchial at______ S3/S4/Murmurs @___ refill/blanching sign Smelling
PHARYNX  Rales/crackles at__ Pericardial rub  ROM  Others
 Uvula  Wheezes at_______ Full/Symmetrical Swelling/Lumps or
 Midline  Rhonchi ABDOMEN  Decreased ROM Nodules
 R L Deviation  Pleural friction rub  General (specify joint)_______  Male
 Mucusa  Superficial veins  Tenderness/pain  Penis
Pinkish/Pallor/Reddish BREAST AND AXILLAE  Striae/Scars/lesions  Joint swelling at ____ - Discharge_________
 Tonsils  Size  Configuration  Muscle tone and strength - Nodules/growths/
 Equal Symmetrical/ Asymmetrical/ Equally strong/ Symmetrical lesions
 Not inflamed
 Unequal____________ Flat Globular/Protuberant/ in muscle size - Tenderness
 R L Inflamed
 Shape Scaphoid  R L upper lower  Scrotum
 R L with exudates
Symmetrical/ Asymmetrical  weakness/atrophy - Equal shape with L
 Posterior Pharynx Bowel Sounds
 Color  Spine lower than R
 Inflammation/ Normoactive/ Hyperactive/
Pinkish/Striae/Reddish/ Blue Midline/Kyphosis/Lordosis/ - Non tender
Congestion Hypoactive/ Absent
hue/Increased vein Scoliosis - R L enlargement
 Percussion
engorgement  Others - R L Undescended
CHEST AND LUNGS Tympanitic/ Hypertympanitic
 Surface  Costovertebral angle tested
 Breathing pattern  Dullness at__________
Smooth/Retraction/ (CVA) tenderness - Tenderness
Regular/Irregular/ Fluid wave/Shifting dullness
Dimpling/Edema/ Lesions  Gait - Nodules/growths/
Eupnea/Hyperpnea/  Palpation
 Tenderness Coordinated/smooth/ lesions
Tachypnea/Dyspnea/ Use of  Muscle guarding
 Masses at ___________ uncoordinated/ Staggering/  Others
accessory muscles/ICS  Direct tenderness
 Others ______________ Shuffling/ Stumbling Hernia/Hydrocoele
retractions/bulging
 Shape of Chest DIAGNOSTICS:
 AP___:L_____  Laboratory finding
 Barrel chested/
 Radiologic findings
Funnel/Pigeon
 Others
 Others:____________