V.

Physical Assessment

DATE: Jan. 30, 2020

TIME: 12:30 PM

General Survey

The client is awake, conscious, and coherent. She is sitting on the couch and
slightly dizziness. The client’s vital signs are as follows:

Temperature: 36.5°C
Respiratory Rate: 19 cpm
Heart Rate: 68 bpm
Blood Pressure: 11/70
Height: 167 cm
Weight: 60 kg
BMI: 22 kg/m^2
Diet: DAT

Organ/System Technique Actual Findings Analysis and

 Interpretation

Skin Inspection Color: Light brown Normal

complexion

(-) Rashes
Normal
(-) Edema
Normal

Palpation Moisture: Moist

Normal
Texture: Smooth
Normal
Skin quickly returns to
its original shape
Normal
Temperature: Warm to
touch

Hair Inspection Color: Blonde Normal

Evenly distributed Normal

Moist Normal

No infestations Normal

Head Inspection Symmetrical facial Normal

features

(-) Lesions
Normal

Palpation (-) Deformities

Normal
(-) Masses
Normal

Ears Inspection Symmetry Normal

 (-) Discharge

(-) Lesions Normal

(-) Nodules Normal

(-) Redness Normal

Normal

Eyes Inspection Clear conjunctiva Normal

White sclera Normal

(-) Blurred Vision Normal

(-) Discharges Normal

Eyelids:
Palpation Normal
(-) Masses

Nose Inspection Symmetrically aligned Normal

(-) Discharge Normal

Mouth and Inspection Dry lips and oral Imbalanced fluid volume
Throat mucosa has defining
characteristics and such
as having dry lips and
oral mucosa.

(Wayne, 2019)

(-) Bleeding
Normal
(-) Infection
Normal
Gums are pink
 Light yellow teeth Normal

(-) Lesion Normal

Normal
Palpation (-) Lumps

Normal

Neck Inspection (-) Lesion Normal

Palpation Palpable carotid pulse Normal

No palpable lymph Normal

nodes

Thorax and Inspection Symmetrical chest Normal

Lungs expansion with
respiration
Normal
(-) Retractions

Palpation Normal
Smooth
Normal
Warm
Normal
Dry

Auscultation Normal
Bronchial sound
Normal
(-) Crackle sound
Normal
(-) Rales

Heart Auscultation Regular rhythm Normal

 (-) Murmur Normal

Upper Inspection (-) Rashes Normal

Extremities
Fair complexion Normal

(-) Pallor Normal

Pinkish nails Normal

Palpation

Warm to touch Normal

Capillary refill goes back Normal

rapidly after 3 seconds

Radial and brachial

Normal
pulse are both palpable
and are symmetrical

Abdomen Inspection Symmetrical Normal

(-) Rashes Normal

(-) Visible marks Normal

Palpation (-) Masses Normal

(-) Rebound tenderness Normal

(-) Rovsing’s sign Normal

(-) Psoas sign Normal

(-) Obturator sign Normal

 Percussion (-) Dullness Normal

(-) Rigidity Normal

(-) Distension Normal

Lower Inspection No rashes Normal

Extremities
No pallor Normal

Palpation Palpable popliteal Normal

posterior tibial and
dorsalis pedis pulse

Anus Inspection (+) Anal opening Normal

(-) Masses Normal

(-) Discharge Normal

Genitalia Inspection No visible hair Normal

(-) Infestations Normal

(-) Edema Normal

(-) Vaginal discharge Normal

Palpation (-) Inguinal lymph nodes Normal