physical assessment of cg

8/4/2019 Physical Assessment of Cg

1/13

PHYSICAL ASSESSMENT OF CG

PHYSICAL ASSESSMENT NORMS ACTUAL FINDINGS INTERPRETATIO

AND ANALYSI

APPEARANCE AND MENTAL

STATUS

1. Body build, height, andweight in relation to

clients age, lifestyle,

and health

2. Clients posture andgait, standing, sitting,

and walking

3. Overall hygiene andgrooming. Relate these

to the persons

activities prior to the

assessment

4. Body and breath odorin relation

5. Distress in posture orfacial expression

6. Obvious signs of healthor illness

7. Clients response

8. Clients affect/mood;appropriateness of the

clients responses

Proportionate, varies

with lifestyle

Relaxed, erect posture;

coordinated movement

Clean and neat

No body odor or minor

body odor relative to

work or exercise; no

breath odor

No distress note

Healthy appearance

Cooperative and able to

follow instructions

Appropriate to situation

Body build, height, and

weight is proportion in age

and varies with lifestyle

Relaxed, erect posture;

coordinated movement

Clean and neat

No body odor or minor body

odor relative to work or

exercise; no breath odor

No distress note

Healthy appearance

Cooperative and able to

follow instructions

Appropriate to situation

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal


2/13

9. Quantity, quality, andorganization of speech

10.Listen to relevance andorganization of

thoughts

Understandable,

moderate pace; clear

tone and inflection;

exhibits thought

association

Logical sequence; makes

sense; has sense of

reality

Understandable, moderate

pace; clear tone and

inflection; exhibits thought

association

Logical sequence; makes

sense; has sense of reality

Normal

Normal

VITAL SIGNS

1. Temperature2. Pulse rate3. Respiratory rate4. Blood pressure

35.5 - 37. 5o

c

60-100 bpm (adult)

12-20 bpm (adult)

120/80 mmHg

36.8o

c

66 bpm

14 bpm

120/80 mmHg

Normal

Normal

Normal

Normal

SKIN

1. Skin color

2. Uniformity of skin color

3. Presence of edema4. Skin lesions

Varies from light to deep

brown; from ruddy pink

to light pink; from yellow

overtones to olive

Generally uniform except

in areas exposed to the

sun; areas of lighter

pigmentation in dark

skinned people

Absence of edema

Freckles, some

birthmarks, some flat

and raised nevi; no

abrasions or other

lesions

Skin color varies from light

to deep brown

Generally uniform except in

areas exposed to the sun;

there are areas of lighter

pigmentation

Absence of edema

Absence of freckles, some

birthmarks, some flat and

raised nevi; no abrasions or

other lesions

Normal

Normal

Normal

Normal


3/13

5. Skin moisture

6. Skin temperature

7. Skin turgor

Moisture in skin folds

and the axillae

Uniform; within normal

range

When pinched, skin

springs back to previous

state; may be slower in

elders

Moisture in skin folds and

the axillae

Uniform; within normal

range

When pinched, skin springs

back to previous state

Normal

Normal

Normal

HAIR

1. Evenness of growthover the scalp

2. Hair thickness orthinness

3. Hair texture andoiliness

4. Presence of infectionsor infestations

5. Amount of body hair

Evenly distributed

Thick hair

Silky , resilient hair

Absence of infection or

infestation

Variables

Evenly distributed

Thick hair

Silky , resilient hair

Absence of infection or

infestation

Variables

Normal

Normal

Normal

Normal

Normal

NAILS

1. Plate shape, curvatureand angle

2. Texture3. Color

4. Tissues surroundingthe nails

5. Blanch test capillaryrefill

Convex curvature; angle

of nail about 160o

Smooth texture

Highly vascular and pink

Intact epidermis

Prompt return of pink

Convex curvature; angle of

nail about 160o

Smooth texture

Highly vascular and pink

Intact epidermis

Prompt return of pink

Normal

Normal

Normal

Normal

Normal


4/13

SKULL AND FACE

1. Skull size, shape andsymmetry

2. Skull of nodules ormasses and

depressions

3. Facial features

4. Eyes for edema andhollowness

5. Symmetry of facialmovements

Rounded, smooth skull

contour

Smooth, uniform

consistency; absence of

nodules or masses

Symmetric or slightly

asymmetric facial

features; palpebral

fissures are equal in size;

symmetric nasolabial

folds

Absence of edema and

hollowness

Symmetric facial

movements

Rounded, smooth skull

contour

Smooth, uniform

consistency; absence of

nodules or masses

Symmetric facial features;

palpebral fissures are equal

in size; symmetric nasolabial

folds

Absence of edema and

hollowness

Symmetric facial movements

Normal

Normal

Normal

Normal

Normal

EYES STRUCTURES AND

VISUAL ACUITY

1. Hair distribution,alignment, skin quality

and movement

2. Evenness distributionof the eyelashes and its

direction or curl

3. Surface characteristicsof the eyelids

Hair is evenly distributed;

skin is intact; eyebrows

are symmetrically

aligned; equal movement

Equally distributed;

curled slightly outward

Skin is intact; no

discharge; no

discoloration; lids close

symmetrically;

approximately 15 - 20

involuntary blinks per

minute; bilateral blinking;

when lids are open, no

Hair is evenly distributed;

skin is intact; eyebrows are

symmetrically aligned; equal

movement

Equally distributed; curled

slightly outward

Skin is intact; no discharge;

no discoloration; lids close

symmetrically; 13

involuntary blinks per

minute; bilateral blinking;

when lids are open, no

visible sclera and lower

borders of cornea are

Normal

Normal

Normal


5/13

4. Bulbar conjunctiva

5. Palpebral conjunctiva

6. Lacrimal gland

7. Lacrimal sac andnasolacrimal duct

8. Clarity and texture ofthe cornea

9. Cornea sensitivity

10.Transparency anddepth of the anterior

chamber

11.Color, shape andsymmetry of size of the

pupil

12.Third (Oculomotor)and forth (trochlear)

cranial nerve

pupils directand consensual

visible sclera and lower

borders of cornea are

slightly covered

Transparent; capillaries

sometimes even evident;

sclera appears white

Shiny smooth and

pink/red

Absence of edema or

tenderness over Lacrimal

gland

Absence of edema or

tearing

Transparent, shiny and

smooth; details of iris are

visible

Blinks when cornea is

touched, indicating that

the trigeminal nerve is

intact

Transparent

Black in color, equal in

size, normally 3 - 7

diameter; round, smooth

border, iris flat and

round

Illuminated pupil

constricts (direct

response)

slightly covered

Transparent; sclera appears

white

Shiny smooth and pink

Absence of edema or

tenderness over Lacrimal

gland

Absence of edema or tearing

Transparent, shiny and

smooth; details of iris are

visible

Blinks when cornea is

touched, indicating that the

trigeminal nerve is intact

Transparent

Black in color, equal in size, 4

in diameter; round, smooth

border, iris flat and round

Illuminated pupil constricts

(direct response)

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal


6/13

reaction to light

13.Pupils reaction toaccommodation

14.Peripheral visual To determine

function of the

retina and

neuronal visual

pathways to the

brain and

second (optic)

cranial nerve

15.Six ocular movements

16.Corneal light reflex

17.Cover test

18.Near vision test19.Distance vision

Snellens chart

Non-illuminated pupil

constricts ( consensual

response)

Pupils constricts when

looking at near object;

pupil dilates when

looking at far objects;

pupils converge when

near object is moved

toward the nose

When looking straight

ahead, client can see

objects in the periphery

Both eyes coordinated,

move in unison with

parallel alignment

Light fall symmetrically

on both pupils

Uncovered eye does not

move

20/20 vision

Non-illuminated pupil

constricts ( consensual

response)

Pupils constricts when

looking at near object; pupil

dilates when looking at far

objects; pupils converge

when near object is moved

toward the nose

When looking straight

ahead, client can see objects

in the periphery

Both eyes coordinated,

move in unison with parallel

alignment

Light fall symmetrically on

both pupils

Uncovered eye does not

move

20/20 vision

Normal

Normal

Normal

Normal

Normal

Normal

Normal

EARS AND HEARING

1. Auricles for color,symmertry of size and

position

The color is same as

facial skin; symmetrical;

auricles aligned with

outer canthus of the eye,

about 10o

from vertical

The color is same as facial

skin; symmetrical; auricles

aligned with outer canthus

of the eye, about 10o

from

vertical

Normal


7/13

2. Auricles for texture,elasticity, and areas of

tenderness

3. External ear canal forcerumen, skin lesions,

pus and blood

4. Tympanic membranefor color and gloss

5. Response to normalvoice tones

6. Watch tick

7. Webers test

8. Rinnes test

Mobile, firm, and not

tender;; pinna recoils

after it is folded

Distal third contains hair

follicles and glands; dry

cerumen, grayish tan

color, sticky, wet

cerumen in various

shades of brown

Pearly gray color,

semitransparent

Normal voice tones

audible

Able to hair ticking in

both ears

Sound is heard in both

ears or is localized at the

center of the head

Air-conducted hearing is

greater than bone-

conducted hearing

Mobile, firm, and not

tender;; pinna recoils after it

is folded

Distal third contains hair

follicles and glands; dry

cerumen, grayish tan color,

sticky, wet cerumen in

various shades of brown

Pearly gray color,

semitransparent

Normal voice tones audible

Able to hair ticking in both

ears

Sound is heard in both ears

or is localized at the center

of the head

Air-conducted hearing is

greater than bone-

conducted hearing

Normal

Normal

Normal

Normal

Normal

Normal

Normal

MOUTH AND OROPHARYNX

1. Symmetry of contour,color and texture of

outer lips

2. Color, moisture,texture and presence

of lesions in the inner

lips and buccal

Uniform pink color; soft,

moist, smooth texture;

symmetry of contour;

able to purse lips

Uniform pink; moist,

smooth, soft, glistening,

and elastic texture

Uniform pink color; soft,

moist, smooth texture;

symmetry of contour; able

to purse lips

Uniform pink; moist,

smooth, soft, glistening, and

elastic texture

Normal

Normal


8/13

3. Teeth and gums

4. Dentures

5. Surface, position, colorand texture of the

tongue

6. Tongue movement

7. Base of the tongue, themouth floor and the

frenulum

8. Any nodules, lumps oroxcoriated areas in the

tongue and floor of the

mouth

9. Salivary duct openingsfor any swelling or

redness

10.Color, shape, textureand the presence of

bony prominences on

the hard and soft

palate

11.Position and mobilityof the uvula

32 adult teeth; smooth,

white, shiny tooth

enamel; pink gums;

moist, firm texture to

gums; no retractions of

gums

Smooth, intact dentures

Central position; pink

color; moist; slightly

rough; thin, whitish

coating; smooth, lateral

margins; no lesions;

raised papillae

Moves freely; Absence of

tenderness

Smooth tongue base with

prominent veins

Smooth with no palpable

nodules

Same as color of buccal

mucosa and floor of

mouth; no presence of

any swelling or redness

Light pink, smooth, soft

palate; lighter pink hard

palate, more irregular

texture

Positioned in midline of

soft palate

27 adult teeth; smooth,

white, shiny tooth enamel;

pink gums; moist, firm

texture to gums; no

retractions of gums

Presence of smooth, intact

dentures

Central position; pink color;

moist; slightly rough; thin,

whitish coating; smooth,

lateral margins; no lesions;

raised papillae

Moves freely; Absence of

tenderness

Smooth tongue base with

prominent veins

Smooth with no palpable

nodules

Same as color of buccal

mucosa and floor of mouth;

no presence of any swelling

or redness

Light pink, smooth, soft

palate; lighter pink hard

palate, more irregular

texture

Positioned in midline of soft

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal


9/13

12.Color and texture ofthe oropharynx

13.Color, discharge andsize of the tonsils

behind the fauces

14.Gag reflex

Pink and smooth

posterior wall

Pink and smooth; no

discharge; of normal size

or not visible

Present

palate

Pink and smooth posterior

wall

Pink and smooth; no

discharge; of normal size or

not visible

Present

Normal

Normal

Normal

NECK

1. Symmetrical size of themuscle

2. Head movement

3. Muscke strength4. Enlarged lymph nodes

on the entire neck

5. Lateral deviation of thetrachea

6. Thyroid gland7. Smoothness of the

thyroid gland

8. Bruit sound over thethyroid area

Muscles are equal in size;

head centered

Coordinated, smooth

movements with no

discomforts

Equal strength

Not palpable

Central placement in

midline of neck; spaces

are equal on both sides

Not visible

Small, smooth, centrally

located, painless, and

rise freely with

swallowing

Absence of Bruit

Muscles are equal in size;

head centered

Coordinated, smooth

movements with no

discomforts

Equal strength

Not palpable

Central placement in midline

of neck; spaces are equal on

both sides.

Not visible

Small, smooth, centrally

located, painless, and rise

freely with swallowing

Absence of Bruit

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

PERIPHERAL VASCULAR

SYSTEM

1. Peripheral veins Symmetric pulsevolumes. Full pulsations

Symmetric pulse volumes.

Full pulsations

Normal


10/13

2. Peripheral veins in thearms and legs for the

presence of superficial

veins when limbs are

dependent and

elevated

3. Skin of the hands andfeet, temperature,

edema and skin

changes (Peripheral

perfusion)

Presence of distention

and nodular bulges at

claves; limbs not tender;

symmetric in size

Skin color is pink; skin

temperature is not

excessively warm or cold;

no edema; skin texture is

moist and resilient

Presence of distention and

nodular bulges at claves;

limbs not tender; symmetric

in size

Skin color is pink; skin

temperature is not

excessively warm or cold; no

edema; skin texture is moist

and resilient

Normal

Normal

HEART AND THE CENTRAL

VESSELS

1. Carotid arteries

2. Jugular veins

Symmetric pulsations;

full pulsations, thrusting

quality; elastic artery

wall; no sound heard on

auscultation

Veins not visible

Symmetric pulsations; full

pulsations, thrusting quality;

elastic artery wall; no sound

heard on auscultation

Veins not visible

Normal

Normal

BREAST AND AXILLAE

1. Size, symmetry,contour or shape of

the breast

2. Localized discolorationor hyperpigmentation,

retraction or dimpling

on the breast

3. Presence welling andedema on the breast

Female: rounded shape;

slightly unequal in size;

generally symmetric

Male: Breast even in the

chest wall

Skin uniform in color;

skin is smoothly intact

Absence of swelling and

edema

Breast even in the chest wall

Skin uniform in color; skin is

smoothly intact

Absence of swelling and

edema

Normal

Normal

Normal


11/13

4. Presence of masses,tenderness and

nodules

5. Size, shape, symmetry,color, surface

characteristics of the

breast

6. Size, shape, symmetry,color, discharge and

lesions on the nipples

7. Presence of tendernessor nodules

Absence of tenderness,

nodules, masses or

nipple discharge

Round or oval and

bilaterally the same;

irregular placement of

sebaceous glands; color

varies from light pink to

dark brown

Round, everted and

equal in size; similar in

color; soft and smooth;

no discharge (except for

mother who is

breastfeeding)


masses or nodules


nodules, masses or nipple

discharge

Round or oval and bilaterally

the same; irregular

placement of sebaceous

glands; color varies from

light pink to dark brown

Round, everted and equal in

size; similar in color; soft and

smooth; no discharge


masses or nodules

Normal

Normal

Normal

Normal

THORAX AND LUNGS

1. Shape and symmetryof the thorax from

posterior and lateral

views

2. Spinal alignment3. Temperature and

integrity of all chest

skin

4. Lateral deviation of thespine

5. Presence of edema,tenderness and masse

Anteroposterior to

transverse diameter in

ratio of 1:2

Spine vertically aligned

Skin intact; uniform

temperature

Spinal column is straight;

right and life shoulders

and hips are at the same

height

Absence of edema,

tenderness and masses

Anteroposterior to

transverse diameter in ratio

of 1:2

Spine vertically aligned

Skin intact; uniform

temperature

Spinal column is straight;

right and life shoulders and

hips are at the same height

Absence of edema,

tenderness and masses

Normal

Normal

Normal

Normal

Normal


12/13

6. Respiratory excursionin the posterior chest

7. Vocal fremitus

8. Breathing patterns

9. Costal angle

10.Respiratory excursionin the anterior thorax

11.Tactile fremitus

12.Trachea

Full and symmetric chest

expansion

Bilateral symmetry of

vocal fremitus

Quiet rhythmitic,

effortless respiration

Costal angle is less than

90o

and the ribs insert

into the spine at

approximately 45o

Full symmetric excursion

Fremitus is normaly

decreased over heart and

breast tissue

Brochial and tubular

breath sounds

Full and symmetric chest

expansion

Bilateral symmetry of vocal

fremitus

Quiet rhythmitic, effortless

respiration

Costal angle is less than 90o

and the ribs insert into the

spine at approximately 45o

Full symmetric excursion

Fremitus is present

Brochial and tubular breath

sounds

Normal

Normal

Normal

Normal

Normal

Normal

Normal

ABDOMEN

1. Skin integrity

2. Presence of striae3. Contour and symmetry

4. Abdominal movementsassociated with

respiration, peristalsis

or aortic pulsation

Unblemished skin color;

uniform color

Absence of striae

Flat, rounded (convex) or

scaphoid (concave);

symmetric contour

Symmetric abdominal

movements caused by

respiration; visible

peristalsis in lean people;

aortic pulsations in thin

persons in epigastric area

Unblemished skin color;

uniform color

Presence of striae

Flat, rounded (convex) or

scaphoid (concave);

symmetric contour

Symmetric abdominal

movements caused by

respiration

Normal

Not normal

Normal

Normal

Normal


13/13

5. Vascular pattern

6. Bowel sounds, vascularperitoneal friction rubs

7. Abdomen percussion

8. Liver percussion

9. Light palpation on theabdomen

10.Deep palpation on theabdomen

11.Liver palpation

12.Bladder palpation

No visible vascular

pattern

Audible bowel sounds;

absence of arterial bruits;

absence of friction rub

Tympany over the

stomach and gas-filled

bowels; dullness over the

liver and spleen

6 - 12 cm in the

midclavicular; 4-8 cm at

the midsternal line

Absence of tenderness;

relaxed abdomen with

smooth, consistent

tension

Tenderness may be

present near the xiphoid

process, over cecum, and

over sigmoid colon

May not be palpable,

borders feels smooth

Not palpable

No visible vascular pattern

Audible bowel sounds;

absence of arterial bruits;

absence of friction rub

Tympany over the stomach

and gas-filled bowels;

dullness over the liver and

spleen

8 cm in the midclavicular; 8

cm at the midsternal line

Absence of tenderness;

relaxed abdomen with

smooth, consistent tension

Tenderness is present near

the xiphoid process, over

cecum, and over sigmoid

colon

Not palpable

Not palpable

Normal

Normal

Normal

Normal

Normal

Normal

Normal

MUSCULOSKELETAL SYSTEM

1. Muscle size

2. Contractures in themuscles and tendons

Equal size on both sides

of body

No contractures

Equal size on both sides of

body

No contractures

Normal

Normal

physical assessment of cg

Documents