Republic of the Philippines

GOLDEN GATE COLLEGES

P.Prieto St. Batangas City
COLLEGE OF NURSING, CAREGIVING AND MIDWIFERY
____________________________________________________________________________

Name: MAY ANN G. ROSALES Date: JULY 11, 2021

Course & Section: BS-NURSING LEVEL 1 RLE Group: GROUP 1

PHYSICAL ASSESSMENT

PATIENT’S NAME: Patient X AGE: 30

ADDRESS: San Pascual Batangas BIRTHDAY: October 28, 1991
GENDER: Male

VITAL SIGNS:

BP: 140/80mmHg PR: 100bpm RR: 19breaths per minute O2 SAT: 95-100% TEMP: 38.9 °C

I. General

Area Normal findings Actual findings Analysis/Rationale

POSTURE Relaxed Sitting position The Hand of patient is in the Abnormal due to acute pain
Abdomen

BODY OROR No body odor No body odor Normal

II. SKIN
AREA Normal findings Actual findings Analysis/ Rationale

COLOR Natural brown The skin is pale Abnormal due to vomiting and excess fluid
volume

MOISTURE Smooth and dry skin fold are Increased sweet on head Abnormal due to vomiting
normally

TEMPERATURE Warm The patient skin feel cool Abnormal due to vomiting
III. HEAD AND NECK
A. HEAD/SKULL
AREA Normal findings Actual Findings Analysis/Rationale
SIZE Symmetrical Symmetrical Normal

SHAPE Round The head/skull of patient is Normal

round
CONTOUR Symmetrical Symmetrical Normal

B. EYES
Normal findings Actual findings Analysis/Rationale

Visual acuity Able to see things Able to see the things Normal

Extraocular Both eyes are in good Both eyes are in good Normal
Movement coordination and position coordination and position

Visual Fields Both eyes can see the Botha eye can see objects Normal
objects

C. EARS
Normal Findings Actual findings Analysis/Rationale
Auricles Equal in size and level with Equal in size and level with Normal
one another one another
Ear canals and Has little cerumen and is Has little cerumen and is Normal
eardrums uniformly pink w/tiny hairs in uniformly pink w/tiny hairs in
outer third of canal outer third of canal
Hearing acuity Responds W/out excessive Responds W/out excessive Normal
request to have the request to have the
questions repeated questions repeated

D. NOSE AND SINUSES

Actual Findings Analysis/Rationale Analysis/Rationale

Shape and contour Smooth and symmetrical Smooth and symmetrical Normal

Color Same skin color as the face Runny Rose Abnormal due to due to vomiting, water
also comes out
Presence of Absent mucosa is pink and Absent mucosa is pink and Normal
deformity/inflammatio moist w/out lesions moist w/out lesions
n
Sinuses No tenderness No tenderness Normal

E. MOUTH AND PHARYNX

Normal findings Actual findings Analysis/Rationale
Lips Pink, moist symmetrical and The lips of patient is pale Abnormal because of the fluids that has
 smooth been vomited

Buccal mucosa, Upper molars rest directly on Upper molars rest directly on Normal
gums, teeth the lower molars, upper the lower molars, upper
incisors slightly override the incisors slightly override the
lower incisors symmetrical lower incisors symmetrical
smile smile

Tongue and floor of Medium or dull red color Medium or dull red color Normal
mouth moist slightly rough on top moist slightly rough on top
surface and smooth along surface and smooth along
the lateral margins the lateral margins
Palate
Pharynx

F. NECK
Normal findings Actual findings Analysis/Rationale
Neck Muscles Breathing indicates that the Breathing indicates that the Normal
body is working harder than body is working harder than
usual to take in sufficient usual to take in sufficient

Lymph nodes Not visible Not visible Normal

Thyroid Gland Not visible Not visible Normal
Trachea No mass No visible Normal

IV. THORAX AND LUNGS

Normal findings Actual findings Analysis/Rationale
Chest contour Symmetrical Symmetrical Normal

Position of spine Straight without lateral Straight without lateral Normal

Thoracic Muscle No mass No mass Normal

Chest wall No tenderness A little pain Abnormal due to the vomiting

Chest excursion Symmetrical Symmetrical Normal

Breath Sound Normal bronchovesivelar Normal bronchovesivelar Normal

and vesicular sounds can and vesicular sounds can
hear hear

V. CARDIOVASCULAR
Normal findings Actual findings Analysis/Rationale
Heart sounds S1 & S2 heard, no S1 & S2 heard, no Normal
Murmurs Murmurs

Rhythm Regular Regular Normal

Carotid artery Localized and strong. Localized and strong. Normal

Sometimes, the wave of Sometimes, the wave of
the pulse is visible. the pulse is visible.

Jugular veins Supine: distends and Supine: distends and Normal

becomes easily visible becomes easily visible

VI. ABDOMEN
Normal findings Actual findings Analysis/Rationale
Posture Relaxed Sitting position The Hand of patient is in Abnormal due to acute abdominal pain
the Abdomen and have a
facial grimace in the pain
scale 9-10
Skin Same color as the rest of the Abnormal due to vomiting and excess fluid
body The skin of the patient is volume
pale
 Umbilicus Flat / concave Flat / concave Normal

Contour and Symmetrical, flat round , Symmetrical, flat round , Normal

symmetry concave concave

Enlarged Absent Absent Normal

organ/masses
Movement
Men: breath abdominally Men: breath abdominally
Bowel sounds Normal
Normal , audible Normal , audible
Vascular sounds Absent Absent Normal
Kidney Tenderness Normal
Absent Absent
Aortic Pulsation Normal
Pulsation transmitted Pulsation transmitted
forward forward

VII. MUSCULOSKELETAL
Normal Findings Actual findings Analysis/Rationale
Muscle size Equal Equal Normal

Muscle tone Firm Firm Normal

Bones No tenderness No tenderness Normal

Joints No tenderness No tenderness Normal

Range of motion Full Full Normal