Physical Assessment

Front 1

General Appearance

Back 1

1. Patient's general appearence is good with good posture and gait and no signs of illness. Patient has a positive attitude!

Front 2

Introduction

Back 2

'Hi my name is Dave your nurse today. We are going to do a physical assessment today. And your name is (looking at name band).Can you tell me your birthday and what year you were born?

Front 3

Vitals

Back 3

temp of 98.6 normal
pulse of 75
Respirations 18
BP 120/80
Pain Verbally rated 0
patient is 6 ' 190

Front 4

Skin

Back 4

Action:Observe front and back:Good turger, no bleeding, skin is olive toned, no bruises.. no leisions or visble scars or rashes. (action: palpate back for
temp texture moisture edema. none found.

Front 5

Nails

Back 5

Action grab hands:'Nails have good color texture and curvature"

Front 6

Hair and Scalp

Back 6

Action: rub hair:"Hair has good color thickness and with no dryness or scales or lice noted"

Front 7

Skull

Back 7

(Action palpate skull) Skull has good symmetry and shape

Front 8

Face:

Back 8

Action:1. observe good symmetry in face:
2.Test Cranial facial nerve 7 Raise eybrows puff cheeks smile!
3. 'We are going to test Trigeminal nerve 5 please clench jaw try to open (hold)

Front 9

Eyes:

Back 9

Actions:
1. "Cornea is clear.. pupils black.. sclera white..good symmetry.
2. Test: Oculamoter nerve 3: light test hold hand by nose normal pupillary constriction. 3.Test: Cranial 6 Abducens for lateral eye movement: follow my pen light in all directions please: 4.
Test: Earlier we tested Optic nerve 2 with the Snellen Chart test for visual accuity

Front 10

Ears:

Back 10

"External ears have good shape with no lesions" internal ear has some ceruman. "When palpating ears no lesions found"

Front 11

Nose:

Back 11

'Nose is patent with no growths visible. Action: palpate sinuses for pain. No tenderness.

Front 12

Mouth Neck:

Back 12

'Smile for me show me your teeth? Good gums no sign of paradontal disease.. Your lymph nodes(palpate) are normal with no tenderness."

Front 13

thorax Lungs

Back 13

"Thorax has normal contour and good chest expansion(while palpating chest) during respirations." Please say 99 as I test for Fremitus. Lungs percussed to determine lung any presence of air or solids. Ausiltate breath sounds for type duration pitch and intensity.

Front 14

CardioVascular

Back 14

Action; inspection of neck and pericardium shows no visible pulsations. I will now papate pericardium with my palm. No papations found. Now I will ausccultate Pericardium. (aptm) and erbs pt. Normal rate and rythem found and normal heart sounds. Now I will papate periphreal pulses radial and Dorsalis pedis. pulse sounds normal. Palpate Apical/ radial no pulse deficit. Cap refill normal less then 3 seconds

Front 15

Breasts

Back 15

Assesment of breasts using circular techniquie find normal
no lumps discharge.

Front 16

Abdomen

Back 16

1.abdomen has good color contour and symmetry no masses or lesions.
2. Ausciltate bowel sounds on 4 quadrants finding no hyper or brut sounds.
3. percussing finds no fluid
4. Palpate for tenderness noen found. Last bowel movement was normal

Front 17

Genitila

Back 17

1.Genitila free of impaction and lumps findings normal.
2. Client has no voiding issues and normal range of urine produced

Front 18

Musculsleltal

Back 18

1. inspection of upper and lower extrmities finds good muscle tone and joint movement.
2. Papate bones normal contour
3. no spinal curvature.

Front 19

Mental Status

Back 19

1. patient is oriented with good use of English language and level of consciousness. Can you tell me what city we are in?
2. Cranial nerves have been tested and normal.
3. Test sensory function close your eyes and tell me if you feel this. touch arm. Explain to me "early bird catches the worm."
5. Test tendon reflexes normal findings