PLS CHECK Physical Assessment
PLS CHECK Physical Assessment
PLS CHECK Physical Assessment
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
1
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.
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.
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
5
the soft palate.
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.
7
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.
8
ANUS No lesions, tear and scars,
& No bleeding
RECTUM