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9 Physical Assessment Osma2
9 Physical Assessment Osma2
Assess skin
moisture. PALPATION Moisture in the The skin folds
Note skin skin folds and and the axillea
lesions in the axillae, are uniform in NORMAL
according to freckles, some moisture.
location, birthmarks, No lesions
distribution, some flat and were noted.
color, raised nevi Birthmark was
configuration, (moles); no noted on the
size, shape, abrasion or any back. Some
type or other lesion. moles were
structure seen (flat and
raised).
No abrasion or
any other
lesion.
Note skin NORMAL
temperature, Uniform, It is uniform
compare the within normal within normal
two feet and range. range.
two hands
using the
backs of your
fingers
Scalp
External eye
structures
1.Inspect the
eyebrows for hair INSPECTION Hair evenly Hair is evenly NORMAL
distribution and distributed; skin distributed; skin
alignment and skin intact intact.
quality movement
Eyebrows Eyebrows
symmetrical aligned; symmetrical aligned;
equal movement equal in movement.
Inspect the eyelids for INSPECTION Skin intact; no Skin is intact; no NORMAL
surface characteristics discharge; no discharge; no
position in relation to discoloration; lids discoloration; lids
cornea, ability to blink close symmetrically; close symmetrically;
and frequency of approximately 15-20 approximately 15-20
blinking involuntary blinks involuntary blinks per
per min.; bilateral min.; bilateral
blinking; when lids blinking; when lids
open no visible open no visible sclera
sclera above cornea above cornea and
and upper and lower upper and lower
border of cornea are border of cornea are
slightly covered slightly covered.
Transparent Transparent
capillaries; capillaries; sometimes
sometimes evident; evident; sclera
sclera appears appears white
white(yellowish in
dark skinned clients)
Inspect bulbar INSPECTION Shiny, smooth, and Pale bulbar Pale is due to
conjunctiva for color, pink or red conjunctiva decreased
texture and the visibility of
presence of lesions the the normal
oxyhemoglobi
n.
Inspect the auricles Inspection Color same as facial Color similar to NORMAL
for color, skin symmetrical, facial skin,
symmetry of size auricle aligned with symmetrical,
and position the outer cantus of auricles aligned
eyes. with the outer
cantus of eyes.
Palpate The Palpation Mobile, firm, and not Movable, firm, and NORMAL
auricles for tender; pinna recoils not tender; pinna
texture, elasticity, after it is folded returns to normal
and areas of shape after it is
tenderness folded
Using an otoscope, Inspection Distal third contains Hair follicles and NORMAL
inspect the external hair follicles and glands can be seen
ear canal for glands in the distal third
cerumen, skin
lesions pus , and Dry Cerumen, The Cerumen is dry
blood Grayish-tan color; or
sticky wet cerumen in
various shades of
brown
Inspect the Inspection Pearl gray color, Pearl gray color, NORMAL
tympanic Semitransparent Translucent
membrane for
color and gloss
Assess client’s Inspection Normal voice Patient can hear normal NORMAL
response to normal tones audible voice tones
voice tones.
Perform the watch Inspection Able to hear The client cannot hear This
tick test ticking of ticking in both Ticking sounds audible indicates a
a watch has a ears in both ears hearing less
higher pitch than in the high
the human voice. frequency
range that
may be
caused by
excessive
exposure to
loud noise
Perform Weber’s Inspection Sound is heard in Patient cannot hear The patient
test to assess bone both ears or is sound on both ears cannot hear
conduction localized at the sound due
center of the head to ototoxic
drug that
she had
taken.
NOSE &
SINUSES
Lightly palpate the Palpation Not tender; no Nose is not tender; no NORMAL
external nose to lesions lesions can be seen
determine any
areas of tenderness
masses and
displacements of
bone and cartilage
Observe for the Inspection Mucosa pink clear, Mucosa is pale, clear, Pale is due
presence of watery discharge no no discharge ,no lesions to decreased
redness swelling, lesions visibility of
the the
growths, and
normal
discharge. oxyhemoglo
bin.
Inspect the nasal Inspection Nasal septum intact Nasal septum is intact NORMAL
septum between and aligned in the and located at the
the nasal chambers midline midline
Bone and cartilage Palpation There should be no No presence of NORMAL
displacements, displacements,masses
masses and or tenderness
tenderness
Inspect the outer Inspection Uniform pink color Uniform color: pale. Pale is due
lips for symmetry Soft, moist, smooth Soft,smooth and moist. to decreased
of contour, color texture symmetry of Lips are symmetrical, visibility of
the the
and texture contour, ability to patient is able to purse
normal
purse lips lips oxyhemoglo
bin.
Inspect and palpate Inspection Uniform pink color, Uniform color: pale. Pale is due
the inner lips and moist, smooth, Moist, smooth and to decreased
buccal mucosa for glistening and glistening. Both are visibility of
the the
color, moisture , elastic texture elastic.
normal
texture, and oxyhemoglo
presence of lesions bin.
Inspect the teeth Inspection 32 adult teeth, The client has 18 adult Pale is due
and gums while smooth, white, teeth. Gums are to decreased
examining the shiny tooth enamel, pale ,firm and shows no visibility of
the the
inner lips and pink gums, moist retraction.
normal
buccal mucosa firm texture to oxyhemoglo
gums, no retraction bin. Teeth
of gums maybe not
properly
brush.
Inspect the surface Inspection Central position Located at the center NORMAL
of the position
color and texture
Inspect the base of Inspection Smooth tongue base Tongue base is smooth NORMAL
the tongue, the with prominate with prominate veins
mouth floor, and veins
the frenulum
Palpate the tongue Palpation Smooth with no Smooth. Absence of NORMAL
and floor of the palpable nodules nodules and lumps.
mouth for any
nodules, lumps, or
excoriated areas.
To palpate the
tongue use gauze
to grasp its tip.
Inspect the hard Inspection Light pink, smooth, Soft palate: light pink, NORMAL
and soft palate for soft palate lighter smooth
color, shape, pink hard palate,
texture, and the more irregular Hard palate: light pink,
presence of bony texture. irregular texture
prominences
Inspect the Inspection Pink and smooth Color of posterior wall NORMAL
oropharynx for posterior wall is pink, texture is
color and texture smooth
inspect one side at
a time to avoid
eliciting the gag
reflex
Inspect the tonsils Inspection Pink and smooth, Tonsils are pink and NORMAL
for color, no discharge of smooth, with no
discharge, and size normal size presence of discharge
and of normal size
Inspect the neck Palpation Muscles equal size; Muscles are of equal NORMAL
muscles for head centered size; head positioned at
abnormal the center
swellings or
masses.
Move the head so Inspection Head laterally Head flexed laterally at NORMAL
the ear is moved flexes 40 degree 40 degrees
toward the
shoulder on each
side
Turn the head to Inspection Head laterally Head laterally rotated at NORMAL
the right and to the rotates 70 degree 70 degrees
left
Palpate the entire Palpation No lymph nodes No lymph nodes were NORMAL
neck for enlarged should be palpable palpated
lymph nodes,
Hyper extend the Inspection Glands ascends Glands rise while NOMAL
head and swallow during swallowing swallowing
but not visible
Palpate the thyroid Palpation Lobes may not be Glands were not NORMAL
gland for palpated if palpated, palpable, no pain is felt
smoothness lobes are small, during swallowing
smooth centrally
located, painless
and rise freely with
swallowing
ANTERIOR
THORAX
8. Inspect breathing INSPECTION Quiet, Patients shows Normal
pattern (respiratory rhythmic, and quiet, rhythmic
rate rhythm) effortless and effortless
respirations. respiration.
Inspect the skin of Inspection Skin color Skin color pink. NORMAL
the hands and feet pink. No presence of
for color, edema, has no skin
temperature, changes and
edema, and skin regular
changes. temperature
Breast
Emphasize retraction
by having client
During inspection,
Race the arms
no retraction was
above the head
present
Push the hands Inspection No presence of
together with retraction NORMAL
elbows fixed
Press the hands
down on the
hips
Placement of
sebaceous glands
Irregular
Inspect the nipples for placement of is irregular. NORMAL
size, shape, position, sebaceous
color, discharge, and glands on the
lesions. Inspection surface of the
areola
(Montogomery’s
tubercles)
Nipples are equal
Palpate the axillary , in size, same in
subclavicular, and Round, everted, color, soft and
supraclavicular lymph and equal in smooth, and both NORMAL
nodes while the clients size; similar in nipples point
Palpation
sits with the arms color; soft and forward.
abducted and supported smooth; both
on the nurse’s forearm nipples point in
the same No discharge
direction present
No nipple is
The thoracic inverted.
wall on the
midaxillary area Inversion of one
NORMAL
or both nipples
that is present
The upper part from puberty
of the humerus
No tenderness
No masses NORMAL
No nodules or
nipple discharge
No tenderness,
masses, nodules or
nipple discharge
prensent
No tenderness
No masses NORMAL
No nodules or
nipple discharge
Inspect the muscles Inspection Equal size on both The px’s muscle size NORMAL
for size and compare sides of the body on the left side is
both sides similar to the muscle
size on the right side.
Bones:
Joints: