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PLS CHECK Physical Assessment

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Republic of the Philippines

PALAWAN STATE UNIVERSITY


College of Nursing and Health Sciences
Tiniguiban Heights, Puerto Princesa City

PHYSICAL ASSESSEMENT
Name: Mrs. L.A.
Age: 72years old
Address: Magara Araoan, Roxas, Palawan
Admitting Diagnosis: T/C Ovarian New Growth
Discharge Diagnosis: G12P12 pelvoabdominal mass, ovarian new growth probably malignant
work-up done
Date of Assessment: February 06, 07, 13, and 14, 2017

DATE TIME RESPIRATOR PULSE TEMPERATUR BLOOD


Y RATE (RR) RATE E PRESSURE
8:00 A.M.
12:00 P.M.
8:00 A.M.
12:00 P.M.
8:00 A.M.
12:00 P.M.
8:00 A.M.
12:00 P.M.

ASSESSMENT CLINICAL EXAMINATION NORMAL FINDINGS

Skin is uniform in color


Appears neat & clean
GENERAL Conscious, alert and
APPEARANCE responds to questions
Facial expression is
appropriate for the situation

Skin: The clients skin is


uniform in color,
SKIN, unblemished and no
HAIR presence of any foul odor.
& He has a good skin turgor

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NAILS and skins temperature is
within normal limit (36.5-
37.5c, hydrated skin.
Hair: The hair of the client
is thick, silky hair is evenly
distributed and has a
variable amount of body
hair. There are also no signs
of infection and infestation
observed. Can be black,
brown or burgundy
depending on the race. No
evidences of Alopecia
Nails: The client has a light
brown nails and has the
shape of convex curve. It is
smooth and is intact with the
epidermis. When nails
pressed between the fingers
(Blanch Test), the nails
return to usual color in less
than 3 seconds.

Neck: The neck muscles are


HEAD equal in size. The client
& showed coordinated, smooth
NECK head movement with no
discomfort.
The lymph nodes of the
client are not palpable.
The trachea is placed in the
midline of the neck.
The thyroid gland is not
visible on inspection and the
glands ascend during
swallowing but are not
visible.
Eyebrows: Hair is evenly
distributed. The clients
eyebrows are symmetrically
aligned and showed equal
No swelling
Does not have enlarged
thyroid glands.
No presence of lymph
nodes.
Head: The head of the client
is round; normocephalic and
symmetrical.

2
Skull: There are no nodules
or masses and depressions
when palpated.
Face: The face of the client
appeared smooth and has
uniform consistency and
with no presence of nodules
or masses.

Color of the eyes depends


EYES on the race
Eyelashes: Eyelashes
appeared to be equally
distributed and curled
slightly outward.
Eyelids: There were no
presence of discharges, no
discoloration and lids close
symmetrically with
involuntary blinks
approximately 15-20 times
per minute.
Eyes
o The Bulbar conjunctiva
appeared transparent with
few capillaries evident.
o The sclera appeared
white.
o The palpebral conjunctiva
appeared shiny, smooth
and pink.
o There is no edema or
tearing of the lacrimal
gland.
o Cornea is transparent,
smooth and shiny and the
details of the iris are
visible. The client blinks
when the cornea was
touched.
o The pupils of the eyes are
black and equal in size.
The iris is flat and round.

3
PERRLA (pupils equally
round respond to light
accommodation),
illuminated and non-
illuminated pupils
constricts. Pupils
constrict when looking at
near object and dilate at
far object. Pupils
converge when object is
moved towards the nose.
o When assessing the
peripheral visual field,
the client can see objects
in the periphery when
looking straight ahead.
Ears: The Auricles are
EARS symmetrical and has the
same color with his facial
skin. The auricles are
aligned with the outer
canthus of eye. When
palpating for the texture, the
auricles are mobile, firm and
not tender. The pinna recoils
when folded.
During the assessment of
hearing such as whispering
to the other ear and then the
other one to see if the client
was able to hear properly,
she pass the test and was
able to hear the word

4
The nose appeared
symmetric, straight and
NOSE uniform in color. There was
no presence of discharge or
flaring. When lightly
palpated, there were no
tenderness and lesions

Mouth:
MOUTH The lips of the client are
uniformly pink; moist,
symmetric and have a
smooth texture. The client
was able to purse his lips
when asked to whistle.
Teeth and Gums: There are
no discoloration of the
enamels, no retraction of
gums, pinkish in color of
gums
The buccal mucosa of the
client appeared as uniformly
pink; moist, soft, glistening
and with elastic texture.
The tongue of the client is
centrally positioned. It is
pink in color, moist and
slightly rough. There is a
presence of thin whitish
coating.
The smooth palates are light
pink and smooth while the
hard palate has a more
irregular texture.
The uvula of the client is
positioned in the midline of

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the soft palate.

THORAX, Regular breathing pattern


LUNGS In a normal air-filled lung,
& vesicular sounds are heard
CARDIOVASCULAR over most of the lung fields,
bronchovesicular sounds are
heard between the 1st and
2nd interspaces on the
anterior chest,
bronchial sounds are heard
over the body of the
sternum, and
tracheal sounds are heard
over the trachea
No cough
RR should be 16-20 cpm
PR should be 60-100
BP should be 90/60-120/80
Lungs / Chest: The chest
wall is intact with no
tenderness and masses.
Theres a full and symmetric
expansion and the thumbs
separate 2-3 cm during deep
inspiration when assessing
for the respiratory
excursion. The client
manifested quiet, rhythmic
and effortless respirations.
The spine is vertically
aligned. The right and left
shoulders and hips are of the
same height.
Heart: There were no
visible pulsations on the
aortic and pulmonic areas.
There is no presence of
heaves or lifts.

BREAST Breast should be even.


May or may not be
completely symmetrical at
rest.
The areola is round or oval,
with same color, (Color
varies form light pink to

6
dark brown depending on
race).
Nipples are round, everted,
same size and equal in color.
No orange peel skin is
noted which is present in
edema.
The veins maybe visible but
not engorge and prominent.
No obvious mass noted.
Not fixated and moves
bilaterally when hands are
abducted over the head, or is
learning forward.
No retractions or dimpling.
No lumps or masses are
palpable.
No tenderness upon
palpation.
No discharges from the
nipples.

ABDOMEN Abdomen: The abdomen of


the client should have an
unblemished skin and is
uniform in color. The
abdomen has a symmetric
contour. There were
symmetric movements
caused associated with
clients respiration.
The jugular veins are not
visible.

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EXTREMITIES Skin color is normal
Fingers in both hands is
complete
Toes in both feet is complete
Voluntary movement
Flexible
Edema is normal for
pregnant woman. It is
caused by increased pressure
from their growing baby
The extremities are
symmetrical in size and
length.
Muscles: The muscles are
not palpable with the
absence of tremors. They are
normally firm and showed
smooth, coordinated
movements.
Bones: There were no
presence of bone
deformities, tenderness and
swelling.
Joints: There were no
swelling, tenderness and
joints move smoothly.

GENITALIA Pubic hair is present


No lesions, pubic lice and
warts present

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ANUS No lesions, tear and scars,
& No bleeding
RECTUM

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