PHYSICAL ASSESSMENT

Purpose:
To obtain baseline data of the client’s functional abilities
To assess the general health status of the client
To obtain data that will enable the nurse to establish nursing diagnoses and plan client care

Equipments / Materials:
Weighing Scale
Height Chart
Pen Light
Neurologic Hammer / Reflex Hammer

PROCEDURES RATIONALE/STEPS FINDINGS

Assessment:
1. Identify the client.
2. Explain the procedure and
discuss how she or he can
cooperate.
Planning:
3. Perform hand hygiene.
4. Provide privacy.
5. Position the client
comfortably allowing for easy
access to the body part being
assessed.
Implementation:
GENERAL SURVEY
6. Check the level of
consciousness and if the
patient is responding to the
tone of your voice.
7. Client’s orientation. (Ask the
name, place where u are, and
the time and date.)
8. Language and
communication. Assess for
the appropriate client’s
responses.
9. Describe the quantity and
speech.
10. You can also ask irrelevant
questions for the relevance
of organization of thoughts
of the client.
11. Check for physical
deformities and signs of
illness.
12. Behavioral status. Ask how
the client is feeling that day
or what he/she feels about
the corona virus (relevant
topic).
Ask the client his/her name
to confirm the necessity.
To build rapport and for the
patient to cooperate with the
procedure.
To prevent the spread of
microorganism.
To minimize embarrassment.
Awake, asleep, lethargic, or General:
alert. Yes or no. Eye opening, EO-
verbal response, and motor VR-
response. MR-
GCS:
To check if the patient is
oriented and aware.
If the client understands and
answers your question
clearly.
Assess if the client’s tone is
slow or fast or in normal
phase.
What happen yesterday or
what keeps him/her busy.
Check if the client if he/she
has organized thoughts.
From head to toe scan if
there are or none.
If the client has a good mood
that day and has thoughts
about the pandemic.
13. Client’s attitude. Cooperative, calm, and not
resistive or the opposite, etc.
14. Describe the face and body To check if his/her face is
built. (Ask the age). appropriate for his/her age.
Is his/her body built
endomorph, mesomorph, or
ectomorph?
15. Measure height and weight Underweight, normal,
and determine BMI. overweight, or obese.
16. Describe posture, symmetry Standing straight, rigid spine,
and gait (Observe client while or stiffed neck. Asymmetric
standing, sitting and body movements and the
walking). way he/she walks.
17. Describe over-all hygiene and
grooming (Relate these to
the persons activities prior to
the assessments.)
18. Identify signs of distress in
posture or facial expression.
INTEGUMENTARY
Skin
19. Inspect for skin color Normal: light – deep brown, Color uniformity:
uniformity, presence of ruddy pink or light pink, and
edema. yellow overtones – olive. Presence of edema:
Abnormal: pallor, jaundice,
cyanosis, or erythema.
Bruising or bleeding?
20. Inspect for lesions according Check the body parts for
to locations, distribution, lesions and discolorations.
color, configuration, size, Freckles, nevi, or birthmarks.
shape, type or structure Abrasions or lesions?
21. Palpate skin moisture and Normal, dry, or moist.
temperature (thermometer). Normal temp or low?
22. Note for skin turgor by lifting If it sprints back to normal
and pinching the skin. state or not.
Hair
23. Inspect the evenness of If there are bald areas or
growth over the scalp. none.
24. Inspect hair for volume. Thick or has loss of hair?
(Thickness and Thinness)
25. Inspect for texture and Dry, oily, moist, or normal?
oiliness over the scalp
26. Note for presence of If there are lice or
infection and infestations inflammation.
27. Inspect amount of body hair. Normal or excessive in what
parts?
Nails
28. Inspect fingernail plate shape Vertically long, broad
to determine its curvature sideways, rounded, egg-
and angle. shaped, squarish, or
triangular.
29. Inspect and palpate fingernail Yellowish, brittle, ridges, or
and toenail texture white bands, red skin around
30. Inspect tissues surrounding the moon or nails. Rough or
nails smooth? Are there ingrown,
cuts, and inflammation? Nail
bed color.
31. Perform blanch test of If after pinching the color
capillary refill brings back to normal or not.
Evaluation:
32. Evaluate if findings from the To provide proper nursing
physical assessment is care.
within normal limits.
Documentation:
33. Document and report To obtain baseline data.
significant findings.