Physical Assessment Name: Amanda Caragan Ong Age: 45 Years Old
Transcript of Physical Assessment Name: Amanda Caragan Ong Age: 45 Years Old
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8/14/2019 Physical Assessment Name: Amanda Caragan Ong Age: 45 Years Old
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Physical Assessment
Name: Amanda Caragan Ong
Age: 45 years old
Birth Date: May 1, 1964
Temperature: 37C, oralPulse Rate: 67 bpmRespiratory Rate: 19 cycles/minute
Blood Pressure: 117/80 mmhg
Part I
Behavior Normal Findings Actual Findings Interpretation /
Analysis
1. Height - medium frame: 150cm (height) 111-123lbs
(weight)
Metric Conversion Weights and othermeasurements by A.M. Batubalani page 79
- 162cm -Normal
2. Weight - medium frame: 150cm (height) 111-123lbs
(weight)
Metric Conversion Weights and other
measurements by A.M. Batubalani page 79
- 50kg -Normal
3. BMI - 18.5 to 24.9
http://www.nhlbisupport.com/bmi/bmicalc.htm
- 19 -Normal
General Survey Normal Findings Actual Findings Interpretation / Findings
5. Body built in relation to
lifestyle and health
- Proportionate, varies
with lifestyle
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 572
-The client is medium in
her body built.
-Normal
6. Clients posture, gait,
standing, sitting, and
walking
- Relaxed erect posture, sit
and stand in an upright
position, coordinatedmovement
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 572
- The client sits erect and
stand in an upright manner
with coordination of bodymovement
-Normal
7. Clients overall hygiene
and grooming
- Clean and neat
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 572
- Well groomed and
properly dressed
- Normal
8. Body and breath odor - No body odor or minor
body odor relative to work
or exercise; no breath odor
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 572
- Presence of minor body
odor. No breath odor
- Normal
9. Signs of distress in
posture of facial
expression
- No distress noted
Kozier and Erbs
Fundamentals of Nursing
- No distress noted -Normal
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8th Edition Vol.1 page 572
10. Obvious signs of
health or illness
- Healthy appearance
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 572
- Healthy appearance - Normal
11. Clients attitude - Cooperative, able to
follow instructionsKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 572
- The client cooperates and
follows instructions duringthe procedure
- Normal
12. Clients affect / mood;
appropriateness of the
clients response
- Appropriate to the
situation
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 572
- Acts appropriate to the
situation
- Normal
13. Quality and quantity of
voice
- Understandable,
moderate pace, clear tone
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 572
- The client speaks with
moderate pace, clear tone
of voice, organization of
thoughts andunderstandable
- Normal
14. Relevance andorganization of thoughts
- Logical in sequence,makes sense, has sense of
reality
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 572
- The client exhibitsorganization of thought,
coherence, and sense of
reality
- Normal
Integumentary Normal Findings Actual Findings Interpretation / Findings
15. Uniformity of color - Varies from light brown,
from ruddy pink and light
pink, from yellow
overtones to olive
-Generally uniform except
in areas exposed to sun,
areas of lighter
pigmentationKozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 579
- The client has a dark
brown in color, varies in
color with skin which are
not exposed to the sun
- Normal
16. Presence of edema - No edemaKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 579
- Absence of edema - Normal
17. Presence of lesions
according to location,
distribution, color,
configuration, size, shape,
type or structure
- Freckles, some
birthmarks, some flat and
raised nevi, no abrasions
or other lesions
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 579
- Presence of freckles and
flat nevi. No lesions or
abrasions
- Normal
18. Skin moisture - Moisture in skin folds
and the axillae (varies with
environmental
temperature, humidity,
- Presence of moisture in
the axillae
- Normal
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body temperature and
activity).
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 579
19. Skin temperature - Uniform and with normal
rangeKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 579
- Warm skin temperature - Normal
20. Skin turgor - When pinched, skin turn
back to its previous state;
may be slower in eldersKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 580
- Skin recoils to its
original position when
pinched
- Normal
Nails
21. Finger nails plate
shape to determine itscurvature and angle
- Convex curvature; angle
of nail plate about 160Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 584
- Convex in curvature with
160 in angle
- Normal
22. Fingernail and toe nail
bed color
- Highly vascular and pink
in light skinned clients;
dark skinned clients may
have brown or black
pigment arrow in
longitudinal streaks.
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 584
- Highly vascular and pink
in light skinned clients;
dark skinned clients may
have brown or black
pigment arrow in
longitudinal streaks.
- Normal
23.Fingernail and toenail
structure
- Smooth texture
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 583
- Smooth texture - Normal
24. Inspect tissues
surrounding nails
- Intact epidermis
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 584
- No hangnails and
inflammations
- Normal
25. Blanch test of capillary
refill
- Prompt return of pink or
usual color (generally less
than 4 seconds)
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 584
- Prompt return of pink or
usual color (generally less
than 4 seconds)
- Normal
Head Normal Findings Actual Findings Interpretation / Findings
Skull
26. Inspect the skull for
size, shape or symmetry
- Rounded (normocephalic
and symmetric, with
frontal, parietal, and
occipital prominences);
smooth skull contour
Kozier and Erbs
- Proportionate to body
size, symmetric, smooth
- Normal
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Fundamentals of Nursing
8th Edition Vol.1 page 585
27. Palpate for nodules,
masses, and depressions
- Smooth, uniform
consistency; absence of
nodules or masses
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 585
- Smooth, absence of
nodules or masses,
uniform consistency
-Normal
Scalp
28. Inspect for color and
appearance
- White and clean, absence
of lesions
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 585
- White and clean, no
lesions noted
- Normal
29. Palpate for areas of
tenderness
- Absence of tenderness,
masses and nodules
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 585
- Absence of tenderness - Normal
Hair30. Inspect for evenness of
growth, thickness, and
thinness
- Evenly distributed hair;
thick
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 585
- Evenly distributed and
thick
- Normal
31. Palpate for texture and
oiliness over the scalp
- Silky; resilient hair;
small amount of oilpresent
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 585
- Absence of excessive oil
production
- Normal
Face
32. Inspect facial featuresand symmetry of facial
movement
- Symmetric or slightlyasymmetric facial features.
Symmetric facial
movements
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 585
- Symmetric facial featuresand facial movements
- Normal
Eyes Normal Findings Actual Findings Interpretation / Findings
Visual Acuity
33. Test near vision - Able to read newsprint at
the distance of 14 inches
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 592
- Able to read newsprint at
the distance of 14 inches
- Normal
34. Test distance vision - 20 / 20 vision on Snellen
type chart
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 582
- 20 / 20 vision on Snellen
type chart
- Normal
Eyebrows
35. Inspect the distribution - Hair evenly distributed; - Hair in the eyebrows was - Normal
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of hair and symmetry of
eyebrows
skin intact - Eyebrows
symmetrically aligned;
equal movement
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 588
evenly distributed.
Eyebrows are
symmetrically aligned;
equal in movement
Lacrimal gland,Lacrimal Sac, and
Nasolacrimal Duct
36. Inspect and palpate the
Lacrimal gland
- No edema or tenderness
over Lacrimal gland
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 589
- No edema or tenderness
present over Lacrimal
gland
- Normal
Eyelids
37. Inspect for the surface
characteristics, position in
relation to the cornea,
ability to blink, andfrequency of blinking
- Skin intact; no discharge;
no discoloration
- Approximately 15 20
involuntary blinks perminute; bilateral blinking
- When lids are open, no
visible sclera above
corneas, and upper and
lower borders of cornea
are slightly covered
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 588
- Skin are intact, no
excessive discharge
present and discoloration
- The client can blinkwithout any alterations
- Frequency: 18 blinks
- Normal
Eyelashes
38. Inspect the eye lashes
for evenness of
distribution and direction
of curl
- Equally distributed;
curled slightly outward
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 588
- Eyelashes are equally
distributed and slightly
curled outward
- Normal
Conjunctiva
39. Inspect the bulbar
conjunctiva (lying abovethe cornea) for color,
texture, and presence oflesions
- Transparent; capillaries
sometimes evident; scleraappears white (darker or
yellowish and with smallbrown macula in dark-
skinned clients)
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 588
- Transparent and clear - Normal
40. Inspect the palpebral
conjunctiva (lining the
eyelids) for color, texture,and presence of lesion
- Shiny, smooth, and pink
red
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 588
- Shiny, pink in color, no
lesions present
- Normal
Sclera
41. Inspect the color and
clarity
- White and clear
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 589
- White and clear - Normal
Cornea
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42. Inspect the cornea for
clarity and texture
- Transparent; shiny, and
smooth; details of the iris
are visible. In older
people, a thin, grayish
white ring around the
margin, called arcus
senilis, may be evidentKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 589
- Transparent; shiny, and
smooth; details of the iris
are visible. In older
people, a thin, grayish
white ring around the
margin, called arcus
senilis, may be evident
- Normal
43. Corneal sensitivityTest (reflex); ask the client
to keep both eyes open and
look straight ahead.
Approach from behind and
lightly touch the sclera of
the client with the corner
of the gauze
- Client blinks when thecornea is touched,
indicating that the
trigeminal nerve is intact
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 589
- The client blinks whenthe cornea was touched by
the gauze
- Normal
Iris
44. Inspect the color and
shape
- Color varies; oval,
circular and flat
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 590
- Color brown and flat - Normal
Pupil
45. Inspect for color,
shape, and symmetry of
size
- Black in color; equal in
size; normally 3 to 7 in
diameter; round; smooth
borderKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 590
- Black in color, 5 in
diameter, equal in size
- Normal
46. Test pupil for lightreaction and
accommodation
- Illuminated pupilsconstrict, no illuminated
pupil constrict
- Pupil constrict when
looking at near object;
pupils dilate when looking
at far object; pupils
converge when near object
is moved toward noseKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 589
- Both pupils react to light;pupil constrict and dilates
when near object is moved
toward and away to the
nose
- Normal
Visual Field
47. Test Peripheral fields - When looking straight
ahead, client can seeobjects in the periphery
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 591
- When looking straight
ahead, client can seeobjects in the periphery
- Normal
Extraocular Muscles
48. Assess six ocularmovements to determine
eye alignment and
- Both eyes coordinates,move in unison, with
parallel alignment
- Both eyes move inunison with parallel
alignment
- Normal
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coordination. Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 592
Ears Normal Findings Actual findings Interpretation / Findings
Auricles49. Inspect for color,
symmetry and position
- Color same as facial
skin; symmetrical. Auriclealigned with outer canthus
of eye, about 10 from
vertical
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 596
- Color same as facial
skin; symmetrical, alignedwith the outer canthus of
the eye
- Normal
50. Palpate for texture,
elasticity and areas for
tenderness
- Mobile, firm and not
tender; pinna coils after it
is folded
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 596
- Mobile, firm, not tender;
pinna coils after it is
folded
- Normal
External Ear Canal
51. Inspect ear canal for
cerumen, skin lesions, pus,
blood
- Dry cerumen, grayish tan
color; or sticky, wet
cerumen in various shades
of brown
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 596
- Wet cerumen, yellow in
color; absence of pus and
blood
- Normal
Hearing Auricle Test
52. Assess clients
response to normal voice
tone
- Normal voice tones
audible
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 597
- Client responds to
normal voice tone
- Normal
53. Perform watch tick test - Able to hear ticking in
both ears
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 597
- The client was able to
hear the ticking of the
watch in both ears
- Normal
54. Perform Webers Test - Sound is heard in both
ears or is localized at the
center of the head
(Webers Negative)
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 597
- Sound is heard in both
ears
- Normal
55. Perform Rinne Test - Air conducted (AC)
hearing is greater thanbone conducted (BC)
hearing
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 598
- Air conducted is greater
then bone conducted
- Normal
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Nose Normal Findings Actual Findings Interpretation / Findings
56. Inspect for any
deviations in shape, size,
or color and flaring or
discharge from nares
- Symmetric and straight;
no discharge or flaring;
uniform color
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 600
- Symmetric and straight;
absence of discharge;
uniform in color
- Normal
57. Inspect for nasal
cavities for the presence of
redness, swelling, growths
and discharge, using the
flashlight
- Mucosa pink; clear
watery discharge; no
lesions
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 600
- Mucosa pink; absence of
lesions
- Normal
58. Inspect the nasalseptum between nasal
chambers
- Nasal septum intact andin midline
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 600
- Nasal septum intact andin the midline
- Normal
59. Test patency of both
nasal cavities
- Air moves freely as the
client breathes through the
nares
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 600
- Both nasal cavities are
patent
- Normal
60. Palpate for any
tenderness, masses
displacements of bone and
cartilage
- Not tender, no
displacements of bone or
cartilage
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 800
- Absence of tenderness
and any kind of
displacements
- Normal
Sinuses
61. Locate/ palpate/
identify the sinuses and
note for tenderness
- No tenderness
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 800
- No tenderness present - Normal
Mouth Normal Findings Actual findings Interpretation / Findings
Lips
62. Inspect for symmetry
of contour, color and
texture
- Uniform; pink in color;
moist, soft, smooth
texture; symmetry of
contour. Ability to purse
lips
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 602
- Pink in color, moist,
symmetrical, has the
ability to purse lips
- Normal
Buccal Mucosa
63. Inspect for color,
moisture, texture, andpresence of lesions
- Uniform, pink in color,
moist, smooth, soft,glistering and has a elastic
texture
Kozier and Erbs
Fundamentals of Nursing
- Uniform, pink in color,
moist, smooth, glisteringand elastic
- Normal
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8th Edition Vol.1 page 602
Teeth
64. Inspect for color,
number and condition,
presence of dentures
- 32 adult teeth, smooth,
white, shiny tooth enamel,
smooth intact denturesKozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 602
- 32 adult teeth, smooth,
white, shiny tooth enamel,
smooth intact dentures
- Normal
Gums
65. Inspect for the color
and condition
- Pink gums, moist, firm
texture to gums, no
retraction of gums
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 602
- Pink gums, moist, firm
texture to gums, no
retraction of gums
- Normal
Tongue/ Floor of the
mouth
66. Inspect for the color
and texture of the mouth
floor and frenulum
- Smooth tongue base with
prominent veins
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 603
- Smooth tongue base with
presence of some
prominent veins
- Normal
67. Inspect and palpate the
position, color, and
texture, movement and
base of the tongue
- Central position, pink in
color, moist, slightly
rough, thin whitish
coating, smooth lateral
margins, no lesions, raisedpapillae, moves freely, no
tenderness
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 603
- Located at the center,
pink in color, moist with
whitish coating, o lesions,
no tenderness, moves
freely
- Normal
68. Palpate for any
nodules, lumps, or
excoriated areas
- No palpable nodules
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 603
- Absence of nodules - Normal
Palates and Uvula
69. Inspect and palpate for
color, shape, texture, and
the presence of bony
prominences
- Light pink, smooth, soft
palate: light pink
hard palate: more regular
in texture
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 604
- Light pink, smooth, soft
palate: light pink
hard palate: more regular
in texture
- Normal
70. Inspect for position of
the uvula and mobility
while examining thepalates
- Positioned in midline of
soft palate
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page
603
- Positioned in the midline
of the soft palate
- Normal
Oropharynx and tonsils
71. Inspect and palpate for
color, and texture (one side
at a time to avoid eliciting
gag reflex)
- Pink and smooth
posterior wall
Kozier and Erbs
Fundamentals of Nursing
- Pink, smooth surface - Normal
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8th Edition Vol.1 page 604
72. Inspect the size of the
tonsils, color, and
discharge
- Pink and smooth, no
discharge, normal size
Grade 1: normal the tonsils
are behind the tonsillar
pillars (the soft structures
supporting the soft palate)Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 604
-Pink and smooth, grade 1 - Normal
73. Elicit the gag reflex by
pressing the posterior
tongue
- Present
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 604
- Present - Normal
Neck and Lymph Nodes Normal Findings Actual Findings Interpretation / Findings
Lymph Nodes
74. Locate/ palpate/
identify lymph nodes andnote for tenderness
- No tenderness
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 607
- No tenderness - Normal
Trachea
75. Inspect and palpate for
placement
- Central placement in the
midline of the neck; spaces
are equal in both sides
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 608
- Located at the midline of
the neck
- Normal
Thyroid Gland
76. Inspect symmetry and
visible masses
- Not visible in palpation.
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 608
- Not visible - Normal
77. Palpate for smoothness
and areas of enlargement,
masses or nodules
- Lobes may not be
palpated. If palpated, lobes
are small, smooth,
centrally located, painless
and rise freely with
swallowing
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 609
- Located at the midlines
of the neck, moves freely
- Normal
Part II
Thorax Normal Findings Actual Findings Interpretation / Findings
Posterior Thorax
78. Inspect the size, shape,
symmetry, and compare
the diameter of
anteroposterior thorax to
transverse diameter
- Anteroposterior to
transverse diameter with a
ratio of 1:2
Kozier and Erbs
Fundamentals of Nursing
- The anteroposterior and
transverse diameter has a
ratio of 1:2
- Normal
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8th Edition Vol.1 page 614
79. Inspect the spinal
alignment
- Spine vertically aligned
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 614
- Spine vertically aligned -Normal
80. Palpate for
temperature, tendernessand masses
-Temperature is within in
normal range, notenderness and masses
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 614
- Temperature is within
normal range, notenderness and masses
- Normal
81. Asses respiratory
excursion
- Full and symmetric
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 615
- Full and symmetric -Normal
82. Palpate focal fremitus - Bilateral symmetric
vocal fremitus
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 615
- Bilateral vocal fremitus -Normal
83. Percuss the posteriorthorax
- Lowest point ofresonance is at the
diaphragm
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 616
- Lowest point of the
resonance is at the
diaphragm
-Normal
84. Auscultate the
posterior thorax
- Vesicular and
bronchovesicular breath
sounds
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 616
- Vesicular and
bronchovesicular breath
sounds
- Normal
Anterior Thorax
85. Inspect breathing
pattern
- Quiet, rhythmic and
effortless respiration
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 617
- Quiet, rhythmic and
effortless respiration
- Normal
86. Palpate for
temperature, tenderness
and masses
- Temperature is within in
normal range, no
tenderness and masses
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 617
- Temperature is within
normal range
-Normal
87. Asses respiratoryexcursion
- Full and symmetricKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 617
- Full and symmetric -Normal
88. Palpate vocal / tactilefremitus
- Same as posterior vocalfremitus, fremitus is
normally decreased over
heart and breast tissue
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 617
- Same as posterior vocal
fremitus
-Normal
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89. Percuss the anterior
thorax
- Percussion note resonate
done to the sixth rib at the
level of diaphragm but are
flat over areas of heavy
muscles and bone, dull on
areas over the heart and
liver, and tympanic overthe underlying stomach
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 617
- Percussion note resonate
done to the sixth rib at the
level of diaphragm but are
flat over areas of heavy
muscles and bone, dull on
areas over the heart and
liver, and tympanic overthe underlying stomach
-Normal
90. Auscultate the trachea - Bronchial and tubular
breath sounds
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 618
- Bronchial and tubular
breath sounds
-Normal
91. Auscultate the anterior
thorax
- Bronchovesicular and
vesicular breath sounds
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 618
- Bronchovesicular and
vesicular breath sounds
-Normal
Cardiovascular Normal Findings Actual Findings Interpretation / Findings
Simultaneously INSPECTand PALPATE the
precordium for the
presence of abnormal
pulsations, lifts and heaves
92. Aortic and Pulmonic
Areas
-No pulsations
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 621
- No pulsations -Normal
93. Tricuspid Areas -No pulsations
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 622
- No pulsations -Normal
94. Apical Area (Locate
point of maximal impulse)
- Pulsations visible on
50% of adults and palpable
in most PM/ in 5th LICS or
at medial to MCL
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 622
- Palpable in 5th LICS -Normal
95. Auscultate the aortic,
pulmonic, tricuspid, and
apical valves
- Usually louder at apical
area
- Usually louder at thebase of the heart
- systole: silent interval;
slightly shorter duration
than diastole at normal
heart rate
- diastole: silent interval,
slightly longer durationthan systole at normal
- Usually louder at apical
area
- Usually louder at thebase of the heart
- systole: silent interval;
slightly shorter duration
than diastole at normal
heart rate
- diastole: silent interval,
slightly longer durationthan systole at normal
-Normal
-
8/14/2019 Physical Assessment Name: Amanda Caragan Ong Age: 45 Years Old
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heart rates
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 622
heart rates
Carotid arteries
96. Palpate carotid artery
with extreme caution
- Symmetric pulse
volumes- Full pulsations, thrusting
quality
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 622
- Symmetric pulse
volumes with fullpulsations
-Normal
97. Auscultate the carotid
arteries
- No sound heard
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 623
- No sound heard -Normal
Jugular Veins
98. Inspect Jugular Veins - Veins not visible
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 623
- Veins not visible -Normal
(Note: the client refused to be examined at the breast and abdomen area)
Breast and Axillae Normal Findings Actual Findings Interpretation / Findings
99. Inspect breast for size,
symmetry, contour, or
shape while the client is in
sitting position
- Rounded in shape,
slightly unequal in size,
generally symmetric
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 628
- Rounded in shape,
slightly unequal in size,
generally symmetric
-Normal
100. Inspect the skin of the
breast for localized
discolorations orhyperpigmentation,
retraction, dimpling,
localized hypervascular
areas, swelling or edema
- Skin uniform in color
(same in appearance as
skin of abdomen or back)- Skin smooth and intact
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 628
- Skin uniform in color
(same in appearance as
skin of abdomen or back)- Skin smooth and intact
- Normal
101. Inspect the areola for
size, shape, symmetry,
color, surface
characteristics, and any
mass or lesions
- Round or oval and
bilaterally the same
- Color varies widely from
light pink to dark brown
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 628
-- Round or oval and
bilaterally the same
- Color varies widely from
light pink to dark brown
- Normal
102. Inspect the nipples
for size, shape, position,
color, discharge, andlesions
- Round, everted, and
equal in size, similar in
color, soft and smooth,both nipples point in same
direction
- No discharge except
from pregnant women
- Inversion of one or both
nipples that I present from
puberty
Kozier and Erbs
- Round, everted, and
equal in size, similar in
color, soft and smooth,both nipples point in same
direction
- No discharge except
from pregnant women
- Inversion of one or both
nipples that I present from
puberty
- Normal
-
8/14/2019 Physical Assessment Name: Amanda Caragan Ong Age: 45 Years Old
14/34
Fundamentals of Nursing
8th Edition Vol.1 page 628
103. Palpate the axillary,
subclavicular and
superclavicular lymph
nodes
- No tenderness, masses,
or nodules
Kozier and Erbs
Fundamentals of Nursing
8
th
Edition Vol.1 page 629
-- No tenderness, masses,
or nodules
- Normal
104. Palpate breast for
masses, tenderness
- No tenderness, masses,
nodules, or nipple
discharge
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 629
- No tenderness, masses,
nodules, or nipple
discharge
- Normal
105. Palpate nipples for
tenderness and discharges
- No tenderness, masses,
nodules, or nippledischarge
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 629
-- No tenderness, masses,
nodules, or nippledischarge
- Normal
Abdomen Normal Findings Actual Findings Interpretation / Findings
106. Inspect the abdomenfor skin integrity
- Unblemished skin- Uniform color
- Silver white striae(stretch marks) or surgical
scars
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 633
- Unblemished skin- Uniform color
- Silver white striae (stretchmarks) or surgical scars
- Normal
107. Inspect the abdominal
contour (profile the line
from rib margin to the
pubic bone) while standing
at the client is in dorsalrecumbent position
- Flat, rounded (convex),
or scaphoid (concave)
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 633
- Flat, rounded (convex), or
scaphoid (concave)
- Normal
108. Inspect for enlargedliver or spleen
- No evidence ofenlargement of liver or
spleenKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 633
- No evidence of enlargementof liver or spleen
- Normal
109. Assess the symmetry
of contour while standing
at the foot of the bed.
- Symmetric contour
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 633
- - Normal
110.Inspect the abdominal
movements associated
with respirations,
peristalsis, or aortic
pulsations
- Symmetric movements
caused by respiration
- Visible peristalsis I very
lean people
- Aortic pulsations in thin
persons at epigastric area
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 633
- Symmetric movements
caused by respiration
- Visible peristalsis I very
lean people
- Aortic pulsations in thin
persons at epigastric area
- Normal
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111. Observe vascular
patterns
- No visible vascular
patterns
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 634
- No visible vascular patterns - Normal
112. Auscultate the
abdomen for bowelsounds, vascular sounds,
and peritoneal friction rubs
- Audible bowel sounds
- Absence of arterial bruits-Absence of friction rub
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 634
- Audible bowel sounds
- Absence of arterial bruits-Absence of friction rub
- Normal
113. Percuss several areas
in each of the fourquadrants
- Tympany over the
stomach and gas filledbowels; dullness especially
over the liver and spleen,
or a full bladder
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 635
- Tympany over the stomach
and gas filled bowels;dullness especially over the
liver and spleen, or a full
bladder
- Normal
114. Percuss the liver to
determine its size
- 6 to 12 cm (2 to 3
inches) in the
midclavicular line; 4 to 8
cm (1 to 3 inches) in the
midsternal line
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 635
-6 to 12 cm (2 to 3
inches) in the midclavicular
line; 4 to 8 cm (1 to 3
inches) in the midsternal line
- Normal
115. Perform light
palpation
- No tenderness, relaxed
abdomen with smooth,
consistent tension
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 636
- No tenderness, relaxed
abdomen with smooth,
consistent tension
- Normal
116. Perform deep
palpation
- Tenderness may be
present near xiphoid
process, over cecum, and
over sigmoid colon
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 636
- Tenderness may be present
near xiphoid process, over
cecum, and over sigmoid
colon
- Normal
117. Palpate the areaabove the symphysis pubis
to determine possible
urinary retention
- Not palpableKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 638
- Not palpable - Normal
Musculoskeletal System Normal Findings Actual Findings Interpretation / FindingsMuscles
118. Inspect the muscles
for size. Compare the
muscles on one side of the
body (arm, thigh, calf) to
the same muscle on theother side
- Equal size of both sides
of the body
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 640
- Equal size
Arm: 10 inches
Thigh: 17 inches
Calf: 13 inches
- Normal
119. Inspect the muscle - No contractures - Absence of contractures - Normal
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and tendons for
contractures (shortening)
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 640
120. Inspect the muscles
for fasciculation and
tremors. Inspect any
tremors of the hands andarms out in front of the
body
- No tremors
Kozier and Erbs
Fundamentals of Nursing
8
th
Edition Vol.1 page 640
- No tremors - Normal
121. Palpate the muscle
tonicity
- Normal firm; smooth
coordinated movements
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 640
- Normal tonicity with
coordinate movements
- Normal
122. Test for strength(neck)
- Equal in strength in eachbody side
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 640
- Equal strength in bothpart
- Normal
123. Test for strength
(upper extremities)
- Equal strength in each
body side
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 640
- Equal strength in each
body side
- Normal
124. Test for strength
(lower extremities)
- Equal strength in each
body side
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 640
- Equal strength in each
body side
- Normal
Bones
125. Inspect the skeleton
for normal structure and
deformities
- No deformities
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 641
- Absence of any
deformities
- Normal
126. Palpate the bones to
locate any areas of edema
or tenderness
- No tenderness or
swelling
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 641
- Absence of tenderness
and swelling
- Normal
Joints
127. Inspect the joint for
swelling
- No swelling
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 641
- Absence of swelling - Normal
128. Palpate each joint for
tenderness, smoothness of
movement, swelling,crepitation, and presence
or nodule
- No tenderness,
crepitation or nodules,
joints move smoothlyKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 641
- Absence of tenderness,
nodules, joints move freely
- Normal
Assess range of motion
129. Upper extremities
(shoulder and scapula)
- Able to rotate
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.2 page 1108
- Has the ability to rotate
her shoulders
- Normal
-
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130. Upper extremities
(elbows)
- Able to flex and extend
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.2 page 1108
- Has the ability to flex
and extend her elbows
- Normal
131. Upper extremities
(hands)
- Able to rotate, abduct,
and adduct
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.2 page 1108
- Has the ability to rotate,
abduct, and adduct her
hands
- Normal
132. Lower extremities
(acetabulum/inguinal area)
- Able to rotate, flex,
extend, abduct, and adduct
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.2 page 1108
- Has the ability to rotate,
flex, extend, abduct and
adduct
- Normal
133. Lower extremities(politeal)
- Able to flex and extendKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.2 page 1108
- Has the ability to flexand extend
- Normal
134. Lower extremities(ankles)
- Able to rotateKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.2 page1108
- Has the ability to rotate - Normal
Note: Other family members were not able to be examined because they are not around.
Physical Assessment
Name: Mark Lester Caragan Ong
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18/34
Age: 20 years old
Birth Date: February 26 1989
Temperature: 36.8 C oral
Pulse Rate: 70 beat per minute
Respiratory Rate: 18 breaths per minuteBlood Pressure: 120/80 mmhg
Part I
(Note: Observers were not able to get the height and weight of Carla because she is in school)
Behavior Normal Findings Actual Findings Interpretation /
Analysis
1. Height - medium frame: 150cm (height) 111-123lbs
(weight)Metric Conversion Weights and other
measurements by A.M. Batubalani page 79
- 170 cm - Normal
2. Weight - medium frame: 150cm (height) 111-123lbs
(weight)
Metric Conversion Weights and other
measurements by A.M. Batubalani page 79
- 60 kgs - Normal
3. BMI - 18.5 to 24.9
http://www.nhlbisupport.com/bmi/bmicalc.htm
- 21 -Normal
General Survey Normal Findings Actual Findings Interpretation / Findings
5. Body built in relation to
lifestyle and health
- Proportionate, varies
with lifestyle
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 572
- Small body built - Normal
6. Clients posture, gait,
standing, sitting, and
walking
- Relaxed erect posture, sit
and stand in an upright
position, coordinated
movement
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 572
- Relaxed erect posture, sit
and stand in an upright
position with coordination
of movement
- Normal
7. Clients overall hygiene
and grooming
- Clean and neat
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 572
- Well groomed and
dressed
- Normal
8. Body and breath odor - No body odor or minorbody odor relative to work
or exercise; no breath odorKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 572
- No body odor and breathodor
- Normal
9. Signs of distress inposture of facial
expression
- No distress notedKozier and Erbs
Fundamentals of Nursing
- No signs of distressnoted
- Normal
-
8/14/2019 Physical Assessment Name: Amanda Caragan Ong Age: 45 Years Old
19/34
8th Edition Vol.1 page 572
10. Obvious signs of
health or illness
- Healthy appearance
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 572
- Absence of any signs of
illness
- Normal
11. Clients attitude - Cooperative, able to
follow instructionsKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 572
- Shows shyness but able
to follow the instructionsgiven
- Normal
12. Clients affect / mood;
appropriateness of the
clients response
- Appropriate to the
situation
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 572
- Responds appropriate to
situation
- Normal
13. Quality and quantity of
voice
- Understandable,
moderate pace, clear tone
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 572
- Understandable,
moderate pace, and with
clear tone of voice
- Normal
14. Relevance andorganization of thoughts
- Logical in sequence,makes sense, has sense of
reality
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 572
- Has sense of reality - Normal
Integumentary Normal Findings Actual Findings Interpretation / Findings
15. Uniformity of color - Varies from light brown,
from ruddy pink and light
pink, from yellow
overtones to olive
-Generally uniform except
in areas exposed to sun,
areas of lighter
pigmentationKozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 579
- Fair in skin color, has
uniform skin tone except
from areas not exposed to
the sun
- Normal
16. Presence of edema - No edemaKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 579
- No edema - Normal
17. Presence of lesions
according to location,
distribution, color,
configuration, size, shape,
type or structure
- Freckles, some
birthmarks, some flat and
raised nevi, no abrasions
or other lesions
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 579
- Absence of lesions - Normal
18. Skin moisture - Moisture in skin folds
and the axillae (varies with
environmental
temperature, humidity,
- Moist skin - Normal
-
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20/34
body temperature and
activity).
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 579
19. Skin temperature - Uniform and with normal
rangeKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 579
- Uniform and with normal
range
- Normal
20. Skin turgor - When pinched, skin turn
back to its previous state;
may be slower in eldersKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 580
- Skin turns back to its
original state when
pinched
- Normal
Nails
21. Finger nails plate
shape to determine itscurvature and angle
- Convex curvature; angle
of nail plate about 160Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 584
- Convex curvature with
160 angle
- Normal
22. Fingernail and toe nail
bed color
- Highly vascular and pink
in light skinned clients;
dark skinned clients may
have brown or black
pigment arrow in
longitudinal streaks.
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 584
- Highly vascular, colored
pink
- Normal
23.Fingernail and toenail
structure
- Smooth texture
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 583
- Smooth texture - Normal
24. Inspect tissues
surrounding nails
- Intact epidermis
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 584
- Intact epidermis - Normal
25. Blanch test of capillary
refill
- Prompt return of pink or
usual color (generally less
than 4 seconds)
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 584
- Prompt return of pink
color less than 4 seconds
- Normal
Head Normal Findings Actual Findings Interpretation / Findings
Skull
26. Inspect the skull for
size, shape or symmetry
- Rounded (normocephalic
and symmetric, with
frontal, parietal, and
occipital prominences);
smooth skull contour
Kozier and Erbs
- Rounded, smooth
contour
- Normal
-
8/14/2019 Physical Assessment Name: Amanda Caragan Ong Age: 45 Years Old
21/34
Fundamentals of Nursing
8th Edition Vol.1 page 585
27. Palpate for nodules,
masses, and depressions
- Smooth, uniform
consistency; absence of
nodules or masses
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 585
- Smooth with uniform
consistency, absence of
any nodules or masses
- Normal
Scalp
28. Inspect for color and
appearance
- White and clean, absence
of lesions
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 585
- White and clean, absence
of any kinds of lesions
- Normal
29. Palpate for areas of
tenderness
- Absence of tenderness,
masses and nodules
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 585
- Absence of tenderness,
masses, and nodules
- Normal
Hair30. Inspect for evenness of
growth, thickness, and
thinness
- Evenly distributed hair;
thick
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 585
- Evenly distributed thick
hair
- Normal
31. Palpate for texture and
oiliness over the scalp
- Silky; resilient hair;
small amount of oilpresent
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 585
- Silky hair, no excessive
oil
- Normal
Face
32. Inspect facial featuresand symmetry of facial
movement
- Symmetric or slightlyasymmetric facial features.
Symmetric facial
movements
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 585
- Symmetric facial featuresand movement
- Normal
Eyes Normal Findings Actual Findings Interpretation / Findings
Visual Acuity
33. Test near vision - Able to read newsprint at
the distance of 14 inches
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 592
- Able to read newsprint at
the distance of 14 inches
- Normal
34. Test distance vision - 20 / 20 vision on Snellen
type chart
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 582
- 20 / 20 vision - Normal
Eyebrows
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35. Inspect the distribution
of hair and symmetry of
eyebrows
- Hair evenly distributed;
skin intact - Eyebrows
symmetrically aligned;
equal movement
Kozier and Erbs
Fundamentals of Nursing
8
th
Edition Vol.1 page 588
- Hair evenly distributed,
skin intact, aligned
symmetrically, equal
movement
- Normal
Lacrimal gland,
Lacrimal Sac, and
Nasolacrimal Duct
36. Inspect and palpate the
Lacrimal gland
- No edema or tenderness
over Lacrimal gland
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 589
- Absence of edema and
tenderness
- Normal
Eyelids
37. Inspect for the surface
characteristics, position in
relation to the cornea,ability to blink, and
frequency of blinking
- Skin intact; no discharge;
no discoloration
- Approximately 15 20involuntary blinks per
minute; bilateral blinking
- When lids are open, no
visible sclera above
corneas, and upper and
lower borders of cornea
are slightly covered
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 588
- Skin intact, no discharge
and discoloration
- Frequency: 15 blinks
- Normal
Eyelashes
38. Inspect the eye lashes
for evenness of
distribution and directionof curl
- Equally distributed;
curled slightly outward
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 588
- Equally distributed,
curled outward
- Normal
Conjunctiva
39. Inspect the bulbarconjunctiva (lying above
the cornea) for color,texture, and presence of
lesions
- Transparent; capillariessometimes evident; sclera
appears white (darker oryellowish and with small
brown macula in dark-
skinned clients)
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 588
- Transparent, no lesions - Normal
40. Inspect the palpebral
conjunctiva (lining theeyelids) for color, texture,
and presence of lesion
- Shiny, smooth, and pink
redKozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 588
- Shiny, smooth, pink - Normal
Sclera
41. Inspect the color and
clarity
- White and clear
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 589
- White and clear - Normal
-
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Cornea
42. Inspect the cornea for
clarity and texture
- Transparent; shiny, and
smooth; details of the iris
are visible. In older
people, a thin, grayish
white ring around the
margin, called arcussenilis, may be evident
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 589
- Transparent, shiny - Normal
43. Corneal sensitivity
Test (reflex); ask the clientto keep both eyes open and
look straight ahead.
Approach from behind and
lightly touch the sclera of
the client with the corner
of the gauze
- Client blinks when the
cornea is touched,indicating that the
trigeminal nerve is intact
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 589
- Client blinks when the
cornea is touched by thegauze
- Normal
Iris
44. Inspect the color and
shape
- Color varies; oval,
circular and flat
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 590
- Brown iris, circular - Normal
Pupil
45. Inspect for color,
shape, and symmetry of
size
- Black in color; equal in
size; normally 3 to 7 in
diameter; round; smooth
border
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 590
- Black in color, equal in
size, 5 in diameter, round
- Normal
46. Test pupil for light
reaction andaccommodation
- Illuminated pupils
constrict, no illuminatedpupil constrict
- Pupil constrict when
looking at near object;
pupils dilate when looking
at far object; pupils
converge when near object
is moved toward nose
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 589
- Pupils react with light
and objects
- Normal
Visual Field
47. Test Peripheral fields - When looking straightahead, client can see
objects in the peripheryKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 591
- Client can see objects inthe periphery
- Normal
Extraocular Muscles
48. Assess six ocular
movements to determine
- Both eyes coordinates,
move in unison, with
- Both eyes moves in
unison
- Normal
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eye alignment and
coordination.
parallel alignment
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 592
Ears Normal Findings Actual findings Interpretation / FindingsAuricles
49. Inspect for color,symmetry and position
- Color same as facialskin; symmetrical. Auricle
aligned with outer canthus
of eye, about 10 from
vertical
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 596
- Color same as facial skin,symmetrical, aligned with
the outer canthus of eye
- Normal
50. Palpate for texture,
elasticity and areas for
tenderness
- Mobile, firm and not
tender; pinna coils after it
is folded
Kozier and ErbsFundamentals of Nursing8th Edition Vol.1 page 596
- Mobile, firm, not tender,
pinna coils
- Normal
External Ear Canal
51. Inspect ear canal for
cerumen, skin lesions, pus,
blood
- Dry cerumen, grayish tan
color; or sticky, wet
cerumen in various shades
of brownKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 596
- Wet yellowish cerumen - Normal
Hearing Auricle Test
52. Assess clients
response to normal voicetone
- Normal voice tones
audibleKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 597
- Responds to normal
voice tone
- Normal
53. Perform watch tick test - Able to hear ticking in
both ears
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 597
- The client hears the
ticking of the watch
- Normal
54. Perform Webers Test - Sound is heard in both
ears or is localized at the
center of the head
(Webers Negative)
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 597
- Sound heard in both ears - Normal
55. Perform Rinne Test - Air conducted (AC)hearing is greater than
bone conducted (BC)
hearing
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 598
- AC is greater than BC - Normal
-
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Nose Normal Findings Actual Findings Interpretation / Findings
56. Inspect for any
deviations in shape, size,
or color and flaring or
discharge from nares
- Symmetric and straight;
no discharge or flaring;
uniform color
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 600
- Symmetric, no discharge,
uniform in color
- Normal
57. Inspect for nasal
cavities for the presence of
redness, swelling, growths
and discharge, using theflashlight
- Mucosa pink; clear
watery discharge; no
lesions
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 600
- Mucosa pink, no lesions - Normal
58. Inspect the nasal
septum between nasal
chambers
- Nasal septum intact and
in midline
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 600
- Nasal septum are intact
and in the midline
- Normal
59. Test patency of both
nasal cavities
- Air moves freely as the
client breathes through the
nares
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 600
- Air moves freely - Normal
60. Palpate for any
tenderness, masses
displacements of bone andcartilage
- Not tender, no
displacements of bone or
cartilageKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 800
- Not tender, no
displacements of bone or
cartilage
- Normal
Sinuses
61. Locate/ palpate/
identify the sinuses andnote for tenderness
- No tenderness
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 800
- No tenderness - Normal
Mouth Normal Findings Actual findings Interpretation / Findings
Lips
62. Inspect for symmetry
of contour, color and
texture
- Uniform; pink in color;
moist, soft, smooth
texture; symmetry of
contour. Ability to purse
lips
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 602
- Pink in color, moist, soft,
smooth in texture
- Normal
Buccal Mucosa
63. Inspect for color,moisture, texture, and
presence of lesions
- Uniform, pink in color,moist, smooth, soft,
glistering and has an
elastic texture
Kozier and Erbs
- Uniform, pink in color,moist, soft, glistering and
has an elastic texture
- Normal
-
8/14/2019 Physical Assessment Name: Amanda Caragan Ong Age: 45 Years Old
26/34
Fundamentals of Nursing
8th Edition Vol.1 page 602
Teeth
64. Inspect for color,
number and condition,presence of dentures
- 32 adult teeth, smooth,
white, shiny tooth enamel,smooth intact dentures
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 602
- Complete set of teeth - Normal
Gums
65. Inspect for the color
and condition
- Pink gums, moist, firm
texture to gums, no
retraction of gums
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 602
- Pink gums, moist, no
retraction of gums
- Normal
Tongue/ Floor of the
mouth
66. Inspect for the color
and texture of the mouthfloor and frenulum
- Smooth tongue base with
prominent veinsKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 603
- Smooth tongue base,
prominent veins present
- Normal
67. Inspect and palpate the
position, color, and
texture, movement and
base of the tongue
- Central position, pink in
color, moist, slightly
rough, thin whitish
coating, smooth lateralmargins, no lesions, raised
papillae, moves freely, no
tenderness
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 603
- Located at the midline,
with whitish coating, no
lesions
- Normal
68. Palpate for any
nodules, lumps, or
excoriated areas
- No palpable nodules
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 603
- No palpable nodules - Normal
Palates and Uvula
69. Inspect and palpate for
color, shape, texture, and
the presence of bony
prominences
- Light pink, smooth, soft
palate: light pink
hard palate: more regular
in texture
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 604
- Light pink, smooth soft
palate, hard palate more in
regular in texture
- Normal
70. Inspect for position of
the uvula and mobilitywhile examining the
palates
- Positioned in midline of
soft palateKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page
603
- Positioned at the midline
of the soft palate
- Normal
Oropharynx and tonsils
71. Inspect and palpate for
color, and texture (one side
at a time to avoid eliciting
- Pink and smooth
posterior wall
Kozier and Erbs
- Pink and smooth
posterior wall
- Normal
-
8/14/2019 Physical Assessment Name: Amanda Caragan Ong Age: 45 Years Old
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gag reflex) Fundamentals of Nursing
8th Edition Vol.1 page 604
72. Inspect the size of the
tonsils, color, and
discharge
- Pink and smooth, no
discharge, normal size
Grade 1: normal the tonsils
are behind the tonsillar
pillars (the soft structuressupporting the soft palate)
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 604
- Pink and smooth, grade 1 - Normal
73. Elicit the gag reflex by
pressing the posteriortongue
- Present
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 604
- Present - Normal
Neck and Lymph Nodes Normal Findings Actual Findings Interpretation / Findings
Lymph Nodes
74. Locate/ palpate/identify lymph nodes and
note for tenderness
- No tendernessKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 607
- No tenderness - Normal
Trachea
75. Inspect and palpate for
placement
- Central placement in the
midline of the neck; spaces
are equal in both sides
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 608
- Central in placement,
spaces are equal in both
sides
- Normal
Thyroid Gland
76. Inspect symmetry and
visible masses
- Not visible in palpation.
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 608
- Not visible - Normal
77. Palpate for smoothness
and areas of enlargement,
masses or nodules
- Lobes may not be
palpated. If palpated, lobes
are small, smooth,
centrally located, painless
and rise freely with
swallowingKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 609
- Located at the midline of
the neck, moves freely
- Normal
Part II
Thorax Normal Findings Actual Findings Interpretation / Findings
Posterior Thorax
78. Inspect the size, shape,
symmetry, and compare
the diameter of
anteroposterior thorax to
- Anteroposterior to
transverse diameter with a
ratio of 1:2
Kozier and Erbs
- Has a ratio of 1:2 -Normal
-
8/14/2019 Physical Assessment Name: Amanda Caragan Ong Age: 45 Years Old
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transverse diameter Fundamentals of Nursing
8th Edition Vol.1 page 614
79. Inspect the spinal
alignment
- Spine vertically aligned
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 614
- Spine vertically aligned -Normal
80. Palpate fortemperature, tenderness
and masses
-Temperature is within innormal range, no
tenderness and masses
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 614
- Temperature is withinnormal range, no
tenderness and masses
- Normal
81. Asses respiratory
excursion
- Full and symmetric
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 615
- Full and symmetric -Normal
82. Palpate focal fremitus - Bilateral symmetric
vocal fremitus
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 615
- Bilateral symmetric
vocal fremitus
- Normal
83. Percuss the posterior
thorax
- Lowest point of
resonance is at the
diaphragm
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 616
- Lowest point of
resonance is at the
diaphragm
-Normal
84. Auscultate the
posterior thorax
- Vesicular and
bronchovesicular breath
sounds
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 616
- Vesicular and
bronchovesicular breath
sounds
- Normal
Anterior Thorax
85. Inspect breathing
pattern
- Quiet, rhythmic and
effortless respiration
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 617
- Quiet, rhythmic,
effortless respiration
- Normal
86. Palpate for
temperature, tenderness
and masses
- Temperature is within in
normal range, no
tenderness and masses
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 617
- Temperature is within
normal range
- Normal
87. Asses respiratory
excursion
- Full and symmetric
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 617
- Full and symmetric - Normal
88. Palpate vocal / tactile
fremitus
- Same as posterior vocal
fremitus, fremitus is
normally decreased over
heart and breast tissue
Kozier and Erbs
Fundamentals of Nursing
- Same as posterior vocal
fremitus, fremitus is
normally decreased over
heart and breast tissue
- Normal
-
8/14/2019 Physical Assessment Name: Amanda Caragan Ong Age: 45 Years Old
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8th Edition Vol.1 page 617
89. Percuss the anterior
thorax
- Percussion note resonate
done to the sixth rib at the
level of diaphragm but are
flat over areas of heavy
muscles and bone, dull on
areas over the heart andliver, and tympanic over
the underlying stomach
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 617
- Percussion note resonate
done to the sixth rib at the
level of diaphragm but are
flat over areas of heavy
muscles and bone, dull on
areas over the heart andliver, and tympanic over
the underlying stomach
- Normal
90. Auscultate the trachea - Bronchial and tubularbreath sounds
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 618
- Bronchial and tubular
breath sounds
- Normal
91. Auscultate the anterior
thorax
- Bronchovesicular and
vesicular breath sounds
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 618
- Bronchovesicular and
vesicular breath sounds
- Normal
Cardiovascular Normal Findings Actual Findings Interpretation / Findings
Simultaneously INSPECT
and PALPATE the
precordium for the
presence of abnormalpulsations, lifts and heaves
92. Aortic and PulmonicAreas
-No pulsations
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 621
- No pulsations - Normal
93. Tricuspid Areas -No pulsations
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 622
- No pulsations - Normal
94. Apical Area (Locate
point of maximal impulse)
- Pulsations visible on
50% of adults and palpable
in most PM/ in 5th LICS or
at medial to MCL
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 622
- Palpable in the 5th LICS - Normal
95. Auscultate the aortic,
pulmonic, tricuspid, and
apical valves
- Usually louder at apical
area
- Usually louder at thebase of the heart
- systole: silent interval;
slightly shorter duration
than diastole at normal
heart rate
- diastole: silent interval,
slightly longer duration
- Usually louder at apical
area
- Usually louder at thebase of the heart
- systole: silent interval;
slightly shorter duration
than diastole at normal
heart rate
- diastole: silent interval,
slightly longer duration
- Normal
-
8/14/2019 Physical Assessment Name: Amanda Caragan Ong Age: 45 Years Old
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than systole at normal
heart rates
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 622
than systole at normal
heart rates
Carotid arteries
96. Palpate carotid arterywith extreme caution - Symmetric pulsevolumes
- Full pulsations, thrusting
quality
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 622
- Symmetric pulsevolumes
- Full pulsations, thrusting
quality
- Normal
97. Auscultate the carotid
arteries
- No sound heard
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 623
- No sound heard - Normal
Jugular Veins
98. Inspect Jugular Veins - Veins not visible
Kozier and ErbsFundamentals of Nursing8th Edition Vol.1 page 623
- Not visible - Normal
(Note: the client refused to be examined at the breast and abdomen area)
Breast and Axillae Normal Findings Actual Findings Interpretation / Findings
99. Inspect breast for size,
symmetry, contour, or
shape while the client is insitting position
- Rounded in shape,
slightly unequal in size,
generally symmetricKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 628
- Rounded in shape,
slightly unequal in size,
generally symmetric
-Normal
100. Inspect the skin of thebreast for localized
discolorations or
hyperpigmentation,
retraction, dimpling,
localized hypervascular
areas, swelling or edema
- Skin uniform in color(same in appearance as
skin of abdomen or back)
- Skin smooth and intact
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 628
- Skin uniform in color(same in appearance as
skin of abdomen or back)
- Skin smooth and intact
-Normal
101. Inspect the areola for
size, shape, symmetry,
color, surface
characteristics, and anymass or lesions
- Round or oval and
bilaterally the same
- Color varies widely from
light pink to dark brownKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 628
- Round or oval and
bilaterally the same
- Color varies widely from
light pink to dark brown
-Normal
102. Inspect the nipplesfor size, shape, position,
color, discharge, and
lesions
- Round, everted, andequal in size, similar in
color, soft and smooth,
both nipples point in same
direction
- No discharge except
from pregnant women
- Inversion of one or both
nipples that I present from
-Round, everted, and equalin size, similar in color,
soft and smooth, both
nipples point in same
direction
- No discharge except
from pregnant women
- Inversion of one or both
nipples that I present from
-Normal
-
8/14/2019 Physical Assessment Name: Amanda Caragan Ong Age: 45 Years Old
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puberty
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 628
puberty
103. Palpate the axillary,
subclavicular and
superclavicular lymphnodes
- No tenderness, masses,
or nodules
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 629
- No tenderness, masses,
or nodules
-Normal
104. Palpate breast for
masses, tenderness
- No tenderness, masses,
nodules, or nipple
discharge
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 629
- No tenderness, masses,
nodules, or nipple
discharge
-Normal
105. Palpate nipples for
tenderness and discharges
- No tenderness, masses,
nodules, or nipple
discharge
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 629
- No tenderness, masses,
nodules, or nipple
discharge
-Normal
Abdomen Normal Findings Actual Findings Interpretation / Findings
106. Inspect the abdomenfor skin integrity
- Unblemished skin- Uniform color
- Silver white striae (stretch
marks) or surgical scars
Kozier and Erbs
Fundamentals of Nursing 8th
Edition Vol.1 page 633
- Unblemished skin- Uniform color
- Silver white striae
(stretch marks) or surgical
scars
-Normal
107. Inspect the abdominal
contour (profile the line
from rib margin to the
pubic bone) while standingat the client is in dorsal
recumbent position
- Flat, rounded (convex), or
scaphoid (concave)
Kozier and Erbs
Fundamentals of Nursing 8th
Edition Vol.1 page 633
- Flat, rounded (convex),
or scaphoid (concave)
-Normal
108. Inspect for enlarged
liver or spleen
- No evidence of enlargement
of liver or spleenKozier and Erbs
Fundamentals of Nursing 8th
Edition Vol.1 page 633
- No evidence of
enlargement of liver orspleen
-Normal
109. Assess the symmetry
of contour while standing
at the foot of the bed.
- Symmetric contour
Kozier and Erbs
Fundamentals of Nursing 8th
Edition Vol.1 page 633
- Symmetric contour -Normal
110.Inspect the abdominal
movements associated
with respirations,
peristalsis, or aortic
pulsations
- Symmetric movements
caused by respiration
- Visible peristalsis I very
lean people
- Aortic pulsations in thin
persons at epigastric area
Kozier and ErbsFundamentals of Nursing 8th
Edition Vol.1 page 633
- Symmetric movements
caused by respiration
- Visible peristalsis I very
lean people
- Aortic pulsations in thin
persons at epigastric area
-Normal
-
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111. Observe vascular
patterns
- No visible vascular patterns
Kozier and Erbs
Fundamentals of Nursing 8th
Edition Vol.1 page 634
- No visible vascular
patterns
- Normal
112. Auscultate the
abdomen for bowel
sounds, vascular sounds,and peritoneal friction rubs
- Audible bowel sounds
- Absence of arterial bruits
-Absence of friction rubKozier and Erbs
Fundamentals of Nursing 8th
Edition Vol.1 page 634
- Audible bowel sounds
- Absence of arterial bruits
-Absence of friction rub
-Normal
113. Percuss several areas
in each of the four
quadrants
- Tympany over the stomach
and gas filled bowels;
dullness especially over theliver and spleen, or a full
bladder
Kozier and Erbs
Fundamentals of Nursing 8th
Edition Vol.1 page 635
- Tympany over the
stomach and gas filled
bowels; dullness especiallyover the liver and spleen,
or a full bladder
-Normal
114. Percuss the liver to
determine its size
- 6 to 12 cm (2 to 3
inches) in the midclavicular
line; 4 to 8 cm (1 to 3
inches) in the midsternal line
Kozier and Erbs
Fundamentals of Nursing 8th
Edition Vol.1 page 635
-6 to 12 cm (2 to 3
inches) in the
midclavicular line; 4 to 8
cm (1 to 3 inches) in the
midsternal lin
-Normal
115. Perform light
palpation
- No tenderness, relaxed
abdomen with smooth,consistent tension
Kozier and Erbs
Fundamentals of Nursing 8th
Edition Vol.1 page 636
- No tenderness, relaxed
abdomen with smooth,consistent tension
-Normal
116. Perform deep
palpation
- Tenderness may be present
near xiphoid process, over
cecum, and over sigmoid
colon
Kozier and Erbs
Fundamentals of Nursing 8th
Edition Vol.1 page 636
- Tenderness may be
present near xiphoid
process, over cecum, and
over sigmoid colon
-Normal
117. Palpate the area
above the symphysis pubis
to determine possibleurinary retention
- Not palpable
Kozier and Erbs
Fundamentals of Nursing 8th
Edition Vol.1 page 638
- Not palpable -Normal
Musculoskeletal System Normal Findings Actual Findings Interpretation / Findings
Muscles
118. Inspect the muscles
for size. Compare the
muscles on one side of the
body (arm, thigh, calf) to
the same muscle on the
other side
- Equal size of both sides
of the body
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 640
- Equal in size
Arm: 10 inches
Thigh: 13.8 inches
Calf: 7.2 inches
- Normal
119. Inspect the muscle
and tendons for
contractures (shortening)
- No contractures
Kozier and Erbs
Fundamentals of Nursing
- No contractures - Normal
-
8/14/2019 Physical Assessment Name: Amanda Caragan Ong Age: 45 Years Old
33/34
8th Edition Vol.1 page 640
120. Inspect the muscles
for fasciculation and
tremors. Inspect any
tremors of the hands and
arms out in front of the
body
- No tremors
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 640
- No tremors - Normal
121. Palpate the muscle
tonicity
- Normal firm; smooth
coordinated movements
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 640
- Normal firm, coordinated
movements
- Normal
122. Test for strength
(neck)
- Equal in strength in each
body side
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.1 page 640
- Equal in strength in each
body side
- Normal
123. Test for strength
(upper extremities)
- Equal strength in each
body sideKozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 640
- Equal in strength in each
body side
- Normal
124. Test for strength
(lower extremities)
- Equal strength in each
body side
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 640
- Equal in strength in each
body side
- Normal
Bones
125. Inspect the skeleton
for normal structure and
deformities
- No deformities
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 641
- No deformities - Normal
126. Palpate the bones to
locate any areas of edema
or tenderness
- No tenderness or
swelling
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 641
- No tenderness or
swelling
- Normal
Joints
127. Inspect the joint for
swelling
- No swelling
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.1 page 641
- No tenderness or
swelling
- Normal
128. Palpate each joint for
tenderness, smoothness of
movement, swelling,
crepitation, and presence
or nodule
- No tenderness,
crepitation or nodules,
joints move smoothly
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.1 page 641
- No tenderness, joints
move smoothly
- Normal
Assess range of motion
129. Upper extremities
(shoulder and scapula)
- Able to rotate
Kozier and ErbsFundamentals of Nursing
8th Edition Vol.2 page 1108
- Able to rotate - Normal
130. Upper extremities
(elbows)
- Able to flex and extend
Kozier and Erbs
- Able to flex and extend - Normal
-
8/14/2019 Physical Assessment Name: Amanda Caragan Ong Age: 45 Years Old
34/34
Fundamentals of Nursing
8th Edition Vol.2 page 1108
131. Upper extremities
(hands)
- Able to rotate, abduct,
and adduct
Kozier and Erbs
Fundamentals of Nursing
8
th
Edition Vol.2 page 1108
- Able to rotate, abduct,
and adduct
- Normal
132. Lower extremities
(acetabulum/inguinal area)
- Able to rotate, flex,
extend, abduct, and adduct
Kozier and Erbs
Fundamentals of Nursing
8th Edition Vol.2 page 1108
- Able to rotate, flex.
Extend, abduct, and adduct
- Normal
133. Lower extremities
(politeal)
- Able to flex and extend
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.2 page 1108
- Able to flex and extend - Normal
134. Lower extremities
(ankles)
- Able to rotate
Kozier and Erbs
Fundamentals of Nursing8th Edition Vol.2 page1108
- Able to rotate - Normal
Note: Other family members were not able to be examined because they are not around.