PHYSICAL ASSESSMENT

Date of Assessment: August 31, 2011 General Survey: Client is mesomorphic with a height of 5 feet 3 inches and a weight of 120 pounds. She was wearing a house dress and on a moderate high back rest with an IV line of 1L PNSS x 31gtts/min. The patient is conscious and coherent, and has right sided body weakness. Vital signs Normal Actual Findings Analysis Interpretation

Blood pressure 120/80 mmHg 180/100 mmHG

On the disease process, any condition that Cardiac output will often affect the delivery of may affect the cardiac output, blood volume, oxygen to the cells of the body and when the blood viscosity has direct effect on the blood system or tissues does not get the required pressure. (Kozier, B. (2004). Fundamentals of Nursing p. 510). oxygen for the metabolic process cellular function will be altered.

Temperature Pulse rate

36.5-37.5 C 60-100 bpm

36.7 C 79 bpm

Normal Range Normal Range

Afebrile Pulse wave represents the stroke volume output or the output or the amount for blood

(Kozier, B. (2004). Fundamentals of Nursing that enters the arteries with each ventricular p. 496). Respiratory rate 16-20 cpm 24 cpm include stress and increase environmental temperature. (Kozier, B. (2004). Fundamentals of Nursing p. 506). contraction. for the uptake of oxygen from the air into the blood and release carbon dioxide from the blood into expired air. Several factors that increase respiratory rate The effectiveness of respiration is important

SKIN
PARTS Skin METHOD Inspection NORMAL FINDINGS Skin color varies from light to deep brown; from ruddy pink to light pink, from yellow overtimes to olive. Generally uniform except in areas exposed to sun; areas of lighter pigmentation (palms, lips nail beds) in dark skin people. ( Fundamentals of Nursing by Kozier, pp.529, 535,540,576, 1071) ACTUAL FINDINGS Fair complexion with dry and flaky skin. Presence of rashes in the face. ANALYSIS INTERPRETATION The skin is dry and flaky because sebaceous and sweat glands are less active. Dry skin is more prominent over the extremities. The patient has long fingernails and accidentally scratched her face that caused the rashes.

Palpation

No edema, abrasions, lesion. Temperature is uniform and w/in normal range

No edema, patients temperature is within normal range.

Nails

Inspection

Convex curvature; angle of nail plate about 160o - with smooth texture - color is highly vascular& pink in light skinned clients; dark skinned clients may have brown or black pigmentation in longitudinal streaks with intact epidermis on tissue surroundings - blanch test- prompt return of pink or usual color (gen. <3 sec)

Convex, smooth in texture, pink in color,

Normal findings

Pallor may reflect poor arterial circulation due to diminished circulating blood volume.

(Fundamentals of Nursing by Kozier, p542)

HEAD
PARTS Hair METHOD Inspection Palpation NORMAL FINDINGS Evenly distributed hair over the scalp with thickness, variable amount of body hair. No infection or infestation. Scalp Inspection Palpation White, clean, free from masses, lumps scars, lice, nits, dandruff, and lesions no area of tenderness Skull Inspection Palpation Rounded( normocephalic) & symmetrical, with frontal, parietal, Round (normocephalic), smooth skull contour. Smooth, absence of nodules or masses. Dry scalp. Clean, free from masses, lumps scars, lice, nits, dandruff, and lesions no area of tenderness (Kozier, B. (2004). Fundamentals of Nursing p. 541) Normal findings Normal findings Hair is white with black streaks, thin and evenly distributed over the scalp. No infection or infestation noted. It is dry and sticky. Each hair grows from a Patient has a poor hygiene due to single, live follicle has its own roots in the impaired physical mobility. The injury limits her activities of daily living. The ACTUAL FINDINGS ANALYSIS INTERPRETATION

subcutaneous tissue of grandson attends to the needs of the the skin. Oil glands next client. to hair follicle provides gloss and, to some degree water proofing of the hair.

occipital, prominences) smooth, uniform, absence of modules or masses (Fundamentals of Nursing by Kozier page 544.)

EYES
PARTS Eyebrows METHOD Inspection NORMAL FINDINGS Symmetrically aligned. curled slightly outward Eyelashes Inspection Equally distributed, Eyelashes are Curled slightly outward equally distributed and curled slightly outward. (Kozier, B. (2004). Fundamentals of Nursing p. 1152) Symmetrically aligned and equal evenly distributed. (Kozier, B. (2004). Fundamentals of Nursing p. 732). Normal findings. Normal findings Normal findings. Normal findings ACTUAL FINDINGS INTERPRETATION ANALYSIS

Equally distributed, movement. Hair

Eyelids

Inspection

The skin is intact, no discharge and no discoloration. The lids close symmetrically blinks involuntary and with bilateral blinking.

Lids closes symmetrically, bilateral blinking and no visible sclera above corneas when lids are open

Normal findings

Normal findings

(Kozier, B. (2004). Fundamentals of Nursing p. 548

Sclera and Conjunctiva

Inspection

Shiny, smooth & pink or red in color

Pale conjunctiva, smooth and shiny.

Normal findings

Normal Findings (Kozier, B. (2004). Fundamentals of Nursing p. 554).

Cornea

Inspection

transparent, shiny & smooth, details of the iris are visible

Opaque, presence of arcus senilis or grayish white ring around the margin.

Elder people experiences opacity of the lens.

The lens of the eyes becomes more opaque and loses elasticity as person matures. (Kozier, B. (2004). Fundamentals of Nursing p. 550, 554).

Pupils and iris

Inspection

Black in color, equal in size, normally 3-7 mm in diameter,

Iris black in color, equal in size and round in shape. Iris is flat and round.

Normal findings.

Normal findings

sound- smooth border iris flat & sound. Pupils constrict when looking at near object and dilate objects.

Pupil diameter is 3mm. Pupils constrict when light is directed towards it, and dilate when light (Kozier, B. (2004). Fundamentals of Nursing p. 554).

when looking at far is removed.

EARS
PARTS Auricles METHOD Inspection NORMAL FINDINGS The color is the same as facial skin, symmetrical, the auricles aligned with outer ACTUAL FINDINGS The color is the same as facial skin, symmetrical, the auricles aligned with outer canthus (Kozier, B. (2004). Fundamentals of Nursing pp. 596, 861) Normal findings. Normal findings. ANALYSIS INTERPRETATION

canthus of the eye. of the eye. Palpation Mobile, firm and not tender, pinna

recoils after it is folded. Ear Canal Inspection Distal third contains hair follicles and glands. Dry cerumen, grayishtan color or sticky, wet cerumen in various shades of brown. Hearing Acuity Inspection Normal voice tones audible. Sound is heard in both ears or localized at the center of the head (Weber Negative). Air conducted hearing is greater than bone conducted hearing According to Kozier page 597. audible. (Kozier, B. (2004). Fundamentals of Nursing p. 556-557) Normal Voice tones Normal findings. Normal findings. Distal third contains Normal findings. hair follicles and glands. Dry cerumen. Normal findings.

(positive Rinne)

NOSE
PARTS Nose METHOD Inspection NORMAL FINDINGS Symmetric and straight No discharge in flaring Uniform in color Not tender, no lesion Facial Sinuses Palpation No tenderness No tenderness noted. (Kozier, B. (2004). Fundamentals of Nursing p. 561) Septum Inspection Air moves freely as the client breathes through the nares. Nasal septum Nasal septum intact and in midline. Normal findings Normal findings Symmetric in shape. No discharge or flaring, uniform in color. (-) tenderness and lesions. NGT on left nares. NGT was inserted through the nose into the stomach for aspiration of fluid and introduction of material into the stomach. It is used for feeding, medications and TPN administration. Normal findings Normal findings. ACTUAL FINDINGS ANALYSIS INTERPRETATION

intact & in midline

Kozier page 560-561

MOUTH
PARTS Lips METHOD Inspection Palpation NORMAL FINDINGS Uniform pink color Soft, moist, smooth texture Symmetry of contour Ability to purse lips Buccal mucosa Inspection Uniform pink color Soft, moist, smooth texture Moist, elastic texture. Presence of foul breath odor. Hypersalivation. Foul breath odor is due to Presence of NGT hinders the gag reflex of the patient Moist and soft symmetry of contour and ability to purse lips. (Fundamentals of Nursing by Kozier, p542) Normal findings Normal findings ACTUAL FINDINGS ANALYSIS INTERPRETATION

(Fundamentals of Nursing by Kozier, p542)

Gums

Inspection

Pink gums, moist, firm texture to gums.

Pinkish gums, no retraction, moist and firm. Pink in color, moist, no lesions, tenderness and nodules.Tongue is deviated on the right side. Client wasnt able to move tongue from side to side and up and down.

Normal findings. (Fundamentals of Nursing by Kozier, p603) The tongue tends to deviate to where the affected side of the brain is. Stroke can affect any region of the brain; May be due to hemiparesis.

Normal findings.

Tongue

Inspection Palpation

Central position Pink color, moist, slightly rough; then, whitish coating Smooth; lateral margins; no lesions Raised papillae Moves freely, no tenderness Smooth tongue base with prominent veins.

(Fundamentals of Nursing by Kozier, p603)

Teeth

Inspection

32 adult teeth smooth, white, shiny tooth enamel pink gums moist.

Without dentures and incomplete teeth,

Tooth loss occurs as a result of dental disease but is

yellowish in color with preventable with good dental pink gums. 4 teeth on hygiene. upper and 7 on

lower. (Fundamentals of Nursing by Kozier p566) Uvula Inspection Soft, moist, smooth texture Pink and smooth. Tonsils Inspection No discharge. Tonsils of normal size. Pink and smooth posterior wall. No discharge. Pinkish in color. normal size (Fundamentals of Nursing by Kozier p604) (Fundamentals of Nursing by Kozier p604) Normal findings. Normal findings. Soft, moist, and pink Normal findings. Normal findings.

NECK
PARTS Neck METHOD Inspection NORMAL FINDINGS Proportional to size of the head, symmetrical and straight. Freely Proportionate to the size of head and symmetrical. Unable to move. Muscles in the neck like sternocleidomastoid and trapezius draw the head to the side and elevate the chin and Patient has limited range of motion. Unable to move the neck and limited movement on the head part because patient is weak. ACTUAL FINDINGS ANALYSIS INTERPRETATION

movable without difficulty. Palpation No palpable lumps or tenderness The trachea is in the Central placement in midline of neck, spaces are equal on both sides. There are no palpable lymph nodes. Head cannot easily flex and rotate. Trachea is in the central placement and no indication of possible neck tumor nor thyroid enlargement.

elevate the shoulders to shrug them. (Fundamentals of nursing by Kozier p5)

THORAX
PARTS Chest size and shape METHOD Inspection NORMAL FINDINGS Anteroposterior to transverse chest is symmetrical. Breath sounds Auscultation Bronchovesicular breathe sound. ACTUAL FINDINGS Anteroposterior to transverse in ratio of 1:2, chest is symmetrical Patient has a clear, bronchovesicular breath sound. Posterior Palpation Full and symmetric chest expansion. Fremitus tactile most clearly at the apex of the lungs Quiet, rhythmic and effortless respiration. Vesicular and bronchovesicular breath sound. Full and symmetric chst exapansion. Quiet and rhythmic, and effortless breathing. (Fundamentals of Nursing by Kozier p549) Normal findings. Normal findings (Fundamentals of nursing by Kozier p549) Normal Findings Normal findings Normal findings. Normal findings ANALYSIS INTERPRETATION

Percussion

Notes resonate, except over point of resonance is at the diaphragm.

Resonant except on the scapula, there is resonance over scapula. Effortless Respiration. (Fundamentals of nursing by Kozier p549) Normal Findings Normal findings

scapula, the lowest lowest point of

Anterior

Inspection

Quiet, rhythmic and effortless respiration.

Palpation

Full and symmetric chest expansion. Same as posterior vocal fremitus, fremitus is normally decreased over heart and breast tissue.

Full and symmetric chest expansion.

(Fundamentals of nursing by Kozier p549 box 295; p617)

BREAST
PARTS Breast Areola METHOD Inspection Palpation Inspection Palpation NORMAL FINDINGS No masses and lumps Dark in color in contrast to surrounding skin. No masses, lumps and lesions. Nipples Inspection Palpation Size is proportional. No discharged or secretions. n/a The patient refused to be assessed n/a n/a. The patient refused to be assessed The patient refused to be assessed The patient refused to be assessed The patient refused to be assessed ACTUAL FINDINGS ANALYSIS INTERPRETATION

ABDOMEN
PARTS Skin integrity METHOD Inspection NORMAL FINDINGS Unblemished skin, uniform in color. ACTUAL FINDINGS Unblemished skin, uniform in Normal findings Normal findings ANALYSIS INTERPREATTION

color Contour and Symmetry Inspection Flat, rounded. Symmetric contour. Flat, symmetric contour.

According to Kozier page 592-598 Normal findings According to Kozier page 592-598 Normal findings

Movement

Inspection

Symmetric movements caused by respiration.

Symmetric movement caused by respiration, no visible vascular pattern.

Normal findings

Normal findings

According to Kozier page 592-598 Decreased bowel sounds in patient with stoke.

Bowel sounds

Auscultation

Audible bowel sounds. Normal bowel sounds = 5-35 per minute

Audible bowel sounds. hypoactive Bowel sounds= 4 per minute

Umbilicus

Inspection

Clean

Clean

Normal findings According to Kozier page 592-598

Normal findings

Bladder

Palpation

Not palpable

Not palpable

Normal findings

Normal findings

According to Kozier page 592-598 Liver Palpation May not be palpable. Border feels smooth No enlargement. Not palpable Normal findings According to Kozier page 592-598 Normal findings

UROGENITAL SYSTEM
METHOD Inspection NORMAL FINDINGS Pubic hair evenly distributed,pubic skin intact, no lesions Foley catheter intact. Inspection Skin of vulva area is slightly darker than the rest of the body, labia round full and relatively symmetric Inspection Clitoris does not exceed 1cm in width and 2cm in length, no inflammation, n/a The Patient refused to be assessed The Patient refused to be assessed n/a The Patient refused to be assessed Foley catheter is due to patients inability to void by herself. The Patient refused to be assessed ACTUAL FINDINGS n/a assessed ANALYSIS The Patient refused to be INTERPRETATION The Patient refused to be assessed.

swelling or discharge Palpation No enlargement and tenderness n/a The Patient refused to be assessed The Patient refused to be assessed

MUSCULOSKELETAL SYSTEM
PARTS Upper Extremities METHOD Inspection Palpable NORM AL FINDINGS Equal in size on both sides. Equal in strength, coordinated movement. Able to tolerate wide range of motion. No difficulty upon bending and stretching. No lesions, no scars and no deformity. (Fundamentals of Nursing by Kozier p1068) ACTUAL FINDINGS Difficulty in moving upper right extremities because of weakness. Inability to move the upper right extremities due to hemiparesis. ANALYSIS INTERPRETATION

Lower Extremities

Inspection Palpable

Equal in size on both sides.

Theres a weakness in the right lower extremities

. (Fundamentals of Nursing by Kozier p1068)

Inability to move the right left extremities may be due to hemiparesis.

Able to tolerate wide range of motion. No difficulty upon bending and stretching. No lesions, no scars and no deformity.

Peripheral pulse

Palpation

Symmetric full pulsation

Weak pulse on right and left dorsalis pedis pulse

A weak pulse both feet indicates Patient has edema and may be reduced capillary perfusion (Fundamentals of Nursing by Kozier, p496) due to reduced blood circulation.

REFLEXES Part 1. biceps Method Ask client to flex elbow with the palm down, then place thumb firmly on the biceps tendon and strike finger with the reflex hammer. Ask client to hang freely the forearm while supporting the upper arm, then strike the triceps tendon above the elbow with the broad side of the hammer. Ask client to rest the forearm on the abdomen or lap, then strike the radius about 1-2 inches above the wrist. Ask client to sit or lie down with the knee flexed, then strike the patellar tendon. Dorsiflex the foot at the ankle, then strike the Achilles tendon. Right ++ left +++

2. triceps

++

+++

3. brachioradialis

++

+++

5. knee

++

+++

6. ankle

++

+++

Abnormal reflexes: 7. clonus Support the knee in a partly flexed position,with the patient relaxed, quickly dorsiflex the foot. Stroke the lateral aspect of the sole of each foot with the end of a reflex hammer or key. 0 0

8. babinski (plantar response)

++

+++

Tendon Reflex Grading Scale Grade 0 1+ or + 2+ or ++ Absent Hypoactive "Normal" Description

3+ or +++ Hyperactive without clonus 4+ or ++++ Hyperactive with clonus

Interpretation: The client has shown normal reflexes in the right side of her body while the left side of her body has shown hyperreflexia. Hyperreflexia may indicate central process abnormality or diminished influence of descending control (from cells in the cerebral cortex). After stroke, reflexes and voluntary movement are decreased initially and muscles are flaccid. Reflexes begin to return within days to weeks, and then become hyperactive over a period of weeks to months. Babinskis reflex varies with the site of the stroke. A stroke involving the cerebrum produces unilateral Babinskis reflex accompanied by hemiplegia or hemiparesis. A stroke involving the brain stem produces bilateral Babinskis reflex accompanied by bilateral weakness or paralysis, cranial nerve dysfunction, or incoordination. Negative Clonus meant there is no series of involuntary muscular contractions due to sudden stretching of the muscle. References: Practical Skills for Physical therapy chapter 23 pp. 365 Rehabilitation Medicine chapter 40 pp. 999

Cranial Nerve I. Olfactory

Function Smell reception and interpretation.

II. Optic

Visual acuity and fields.

Method Ask client to close eyes and identify different mild aromas such as alcohol, powder and vinegar. Ask client to read newsprint and determine objects about 20 ft. Away Assess ocular movements and pupil reaction.

Normal Findings Client should be able to distinguish different smells.

Clients Response Able to close eyes and distinguish different smells.

Interpretation Patient cant distinguish different odor due to aphasia

III. Oculomotor

IV. Trochlear

V. Trigeminal

Ophthalmic Branch

Extraocular eye movements, lid elevation, papillary constrictions lens shape. Downward and inward eye movement. Sensation of face, scalp, cornea, and oral and nasal mucous membrane. Chewing movements of the jaw.

Ask client to move eyeballs obliquely. Elicit blink reflex by lightly touching lateral sclera; to test sensation, wipe a wisp of cotton over clients forehead for light sensation and use alternating blunt and sharp ends of safety pin to test deep sensation.

Client should be able to read newsprint and determine far objects. Client should be able to exhibit normal EOM and normal reaction of pupils to light and accommodation. Client should be able to move eyeballs obliquely. Client blinks whenever sclera is lightly touched; able to feel the wisp of cotton over the area touched; able to clench teeth. Client is able to sense and distinguish different stimuli. Client

n/a

Patient cant verbalize or determine different objects due to aphasia

Pupils equally Normal findings. reacted to light and accommodates symmetrically, exhibits normal EOM. Clients eye Normal findings. movement is coordinated. Client blinks when Normal findings. the sclera was touched, was able to clench teeth.

Maxillary Branch

Sensation of skin of face and anterior oral cavity (tongue and teeth).

should be able to do different facial expressions .

Mandibular Branch

VI.

Muscles of mastication; sensation of skin of face. Abducens Lateral eye movement. Facial Taste on anterior 2/3 with the tongue. Facial movement, eye closure, labial speech.

Ask client to move eyeball laterally. Ask client to do different facial expressions such as smiling, frowning and raising of eyebrows; ask client to identify various tastes placed on the tip and sides of the mouth: sugar, salt and coffee. Assess clients ability to hear loud and soft spoken words; do the watch tick test.

VII.

VIII.

Auditory

Vestibular Branch Cochlear Branch IX. Glossoph aryngeal

Equilibrium Hearing Taste on posterior 1/3 of the tongue, pharyngeal gag

Apply taste on posterior tongue for identification (sugar, salt and coffee); ask

Client should be able to move eyeballs laterally. Client should be able to do different facial expressions such as smiling, frowning and raising of eyebrows; able to identify different tastes such as sweet, salty, and bitter taste. Client should be able to hear loud and soft spoken words; able to hear ticking of watch on both ears. Client should be able to identify different tastes such as sweet, salty and

Client was able to move her eyeballs laterally. Client was able to close eyes tightly and raise eyebrows. Clients smile was drooping.

Normal findings.

Normal findings.

Due to hemiparesis.

Normal voice tones audible.

Normal findings.

Client wasnt able to move tongue from side to side and up and down. The

Stroke can affect any region of the brain; May be due to

reflex, sensation from the eardrum and ear canal. Swallowing and phonation muscles of the pharynx. X. Vagus Sensation from pharynx, viscera, carotid body and carotid sinus. Trapezius and sternocledoma stoid muscle movement.

client to move tongue from side to side and up and down; ask client to swallow and elicit gag reflex through sticking a clear tongue depressor into clients mouth. Ask client to swallow; sensation of pharynx and larynx; assess clients speech for hoarseness. Ask client to shrug shoulders and turn head from side to side against resistance from nurses hands.

bitter taste; able to move tongue from side to side and up and down; able to swallow without difficulty, with (+) gag reflex.

client wasnt able to swallow and gag reflex is absent.

hemiparesis.

XI.

Accessor y

XII.

Hypoglos sal

Tongue movement for speech, sound articulation and swallowing.

Ask client to protrude tongue at midline, and then move it side to side.

Client should be able to swallow without difficulty, has absence of hoarseness in speech. Client should be able to shrug shoulders and turn head from side to side against resistance from nurses hands. Client should be able to protrude tongue at midline and move it side to side.

n/a

Wasnt able to assessed due to presence of nasogastric tube.

Client wasnt able to turn head from side to side, was only able to shrug the right shoulder slightly. Client wasnt able to move and protrude tonguedeviated on the right side.

May be due to hemiparesis.

The tongue tends to deviate to where the affected side of the brain is.

Levels of Consciousness: Glasgow Coma Scale

FACULTY MEASURED Eye Opening RESPONSE Spontaneous To verbal command To pain No response Verbal Response Oriented, converses Disoriented, converse Uses inappropriate words Unintelligible ` Motor response No response To verbal command To localized pain Flexes and withdraws Flexes abnormally Extends abnormally No response 5 4 3 2 1 4 3 3 2 1 SCORE

2
1

Total: Interpretation: Mild (13-15): Client is awake. Moderate Disability (9-12):

15

Loss of consciousness greater than 30 minutes Physical or cognitive impairments which may or may resolve Benefit from Rehabilitation
Severe Disability (3-8):

Coma: unconscious state. No meaningful response, no voluntary activities

Vegetative State (Less Than 3):

Sleep wake cycles Arousal, but no interaction with environment No localized response to pain
Brain Death:

No brain function