NRLE FORM - 06

La Salle University
College of Nursing
Ozamiz City

PHYSICAL ASSESSMENT

Name of Patient: Mr. Cooper Age: 73 years old Sex: Male Date of Admission: March 08, 2022

1ST DAY 2ND DAY 3rd DAY

1. Integumentary System Assessment -Patient is prone to develop pressure
 Inspect general skin color ulcers on the right lower leg.
 Inspect skin integrity
NORMAL FINDINGS
 Inspect for skin lesion and ulcers
-Patient’s skin tones is evenly colored
 Inspect for skin odor
 Assess for edema without unusual or prominent discolorations.
 Assess skin moisture
-Skin is intact; no reddened areas.
 Assess skin thickness
 Assess skin texture -Skin is smooth without lesions.
 Assess for skin temperature
-Patient has slight odor of perspiration.

-Patient’s skin rebound and does not remain

indented when pressure is released.

- Skin surfaces are moist.

-Skin is normally thin with calluses that are

common.

-Skin is smooth and even.

-Skin is warm.
2. Nails Assessment NORMAL FINDINGS
 Inspect nail grooming and -Nails are clean and manicured.
cleanliness

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  Inspect nail color and markings -Pink tones are seen on nails with
 Inspect nail shape longitudinal ridging.
 Assess nail texture and
consistency, whether nail plate is -Nails has 160-degree angle between the nail
attach to nail bed base and the skin.
 Test capillary refill -Patient’s nails are hard and immobile. Nails
are smooth and firm; nail plate is firmly
attached to nail bed.

-Pink tone returns immediately to blanched

nail beds when pressure is released.

3. Hair Assessment NORMAL FINDINGS

 Inspect the scalp and hair for general -Patient’s hair color is determined by the
color and condition. amount of melanin present.
 Inspect and palpate the hair and the
scalp for cleanliness, dryness, -Scalp is clean and dry. Sparse dandruff is
oiliness, parasites and lesions visible. Hair is smooth and firm, somewhat
 Inspect amount and distribution of elastic.
scalp, body, axillae, and pubic hair
-Varying amounts of terminal hair cover the
scalp, axillae, body and pubic areas, except
for the soles, palms, lips and nipples.

4. Head and Face Assessment NORMAL FINDINGS

 Inspect for head size, shape -Patient’s head is symmetric, round, erect,
 Inspect for involuntary movement and in midline related to body size. No
 Check the temporal artery lesions are visible.
 Check the temporomandibular joint
-Head can be held still and upright.

-The temporal artery is elastic and not tender.

-No swelling, tenderness, or crepitation with

movement. Mouth opens and closes fully.
Lower jaw moves laterally 1-2 cm in each

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 direction.

5. Neck Assessment NORMAL FINDINGS

 Inspect for the neck position, -Neck is symmetric, with head centered and
symmetry, lump and masses without bulging masses.
 Inspect movement of the neck
structure -Thyroid cartilage and cricoid cartilage move
 Inspect the cervical vertebrae upward symmetrically as the client swallows.
 Inspect the range of motion
 Inspect the trachea -Patient’s C7 is visible and palpable.
 Inspect the thyroid gland
 Inspect for lymph nodes -Patient’s neck movement is smooth and
controlled.

-Trachea is at midline.

-Landmarks are positioned midline. No

bruits are auscultated.

-No swelling or enlargement and no

tenderness of the lymph nodes.

6. Eyes Assessment NORMAL FINDINGS

 Check distant visual acuity -Visual acuity of 14/14.
 Inspect the eyelids and eyelashes
 Inspect for the position of eyeballs -The upper lid margin is between the upper
(alignment in sockets, protruding or margin of the iris and upper margin of pupil.
sunken) No white sclera is seen above or below the
 Inspect the bulbar conjunctiva and iris. The upper lids close easily and meet
sclera completely when closed.
 Inspect the lacrimal apparatus
 Inspect the cornea and lens -Patient’s eyeballs are symmetrically aligned
in sockets without protruding or sinking
 Inspect the iris and pupil
 Test for pupillary reaction to light -Bulbar conjunctiva is clear, moist, and
 Test for accommodation of pupils smooth.

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 -No swelling or redness appear over the
areas of the lacrimal duct.

-The cornea and lens are transparent with no

opacities.

-Iris is round, flat and evenly colored. Pupils

are equal in size.

-Direct pupillary response is constriction.

-Pupils constrict and converge.

7. Ears Assessment NORMAL FINDINGS

 Inspect the auricle, tragus and lobule -Ears are equal in size. The auricle aligns
 Assess the auricle and mastoid with the corner of each eye. Earlobes are
process free, attached, or soldered.
 Inspect the external auditory canal
 Inspect the tympanic membrane -Auricle, tragus and mastoid process are not
 Inspect for any discharges and tender.
discoloration
 Perform Whisper test -Small amount of odorless cerumen is the
 Perform Weber test only discharge present.
 Perform Rinne test
 Perform RombergTest -Tympanic membrane is pearly gray, shiny
and translucent with no bulging or retraction.
Slightly concave, smooth and intact.

-Patient is able to correctly repeat the two-

syllable word as whispered.

-Vibrations are heard equally well in both

ears. No lateralization of sound to either ear.

-Air conduction sound is heard longer than

bone conduction sound.

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 - Patient maintains position for 20 seconds
without swaying or with minimal swaying.

8. Mouth, Tongue, and Teeth -Patient had difficulty speaking and

Assessment stated “I just have a touch of laryngitis is
 Inspect the teeth and gums(Note the
all’.
number of teeth, color and condition)
 Inspect the buccal mucosa -Patient has slurred speech. -Patient continues to have slurred speech.
 Inspect and palpate the tongue NORMAL FINDINGS
 Assess the ventral surface of the -Patient has thirty-two pearly whitish teeth
tongue with smooth surfaces and edges. No decayed
 Check the anterior tongue’s ability areas; no missing teeth.
to taste
 Inspect the hard and soft palate and -Gums are pink, moist, and firm with tight
uvula margins to the tooth. No lesion or masses.

-Buccal mucosa tissue is smooth and moist

without lesions.

-Tongue appear pink, moist and moderate

size with papillae present.

-Tongue’s ventral surface is smooth, shiny

with visible veins and no lesions.

-Patient can distinguish between sweet and

salty.

-Hard palate is pale or whitish with firm,

transverse rugae.

9. Nose and Sinuses Assessment NORMAL FINDINGS

 Check the external structure
 Check the patency of airflow through -Color is the same as the rest of the face;
the nostrils nasal structure is smooth and symmetric;

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 Check the internal structure reports no tenderness.
 Inspect the frontal and maxillary
sinuses -Patient is able to sniff through each nostril
 Check for nasal discharges while other is occluded.

-Nasal mucosa is dark pink, moist and free of

exudate.

-Frontal and maxillary sinuses are not tender

to palpation, no crepitus is evident.

10. Throat Assessment -Patient has discomfort in the throat.

 Inspect the tonsils appearance NORMAL FINDINGS
 Inspect the posterior pharyngeal wall -Tonsils may be present or absent; normally
 Inspect the throat for color,
pink and symmetric; may be enlarged. No
consistency
exudate, swelling or lesions present.

-Throat is normally pink, without exudate or

lesions.
11. Thoracic and Lungs Assessment -Patient is at risk for respiratory failure.
 Inspect the color of face, lips and NORMAL FINDINGS
chest
-Patient has evenly colored skin tone,
 Assess for breath sounds
without unusual or prominent discoloration.
 Inspect for shape of the sternum
 Inspect slope of the ribs -Breath sounds are auscultated—bronchial,
 Observe quality and pattern of bronchovesicular, and vesicular.
respiration
 Check for tenderness and masses -Sternum is positioned at midline and
 Check anterior chest expansion straight.

-Ribs slope downward with symmetric

intercostal spaces.

-Respirations are relaxed, effortless, and

quiet; regular rhythm and normal depth at a
rate of 10-20/min in adults.

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 -No tenderness or pain is palpated over the
lung area with respirations.

-Thumbs move outward in a symmetric

fashion from the midline.

12. Breast and Lymphatic Assessment NORMAL FINDINGS

 Inspect size and symmetry -Patient’s breast are round and pendulous,
 Inspect color and texture one breast may be larger than the other.
 Inspect superficial venous pattern
 Inspect the areola -Color varies on the patient’s skin tone;
 Inspect the nipples texture is smooth with no edema.
 Check for tenderness and masses
 Inspect and palpate the axillae -Veins radiate either horizontally and toward
the axilla or vertically with a lateral flare.

-Areolas vary from dark pink to dark brown;

round and vary in size.

-Patient’s nipples are equal bilaterally in size

and are in the same location on each breast;
usually everted but may be inverted or flat.

-Increase in nodularity and tenderness; no

masses palpated.

-Patient’s axillae has no rash or infection

noted.

13. Abdominal Assessment NORMAL FINDINGS

 Observe the color of the skin
 Inspect for scars and striae -Patient’s abdominal skin is paler than the
 Assess for lesions and rashes general skin color tone.
 Inspect the umbilicus, its appearance
and location -Pale, smooth, minimally raised old scars is
 Assess abdominal symmetry seen. New striae are oink or bluish in color;
 Inspect abdominal movement

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 Check bowel sounds old striae are silvery, white, linear.
 Check internal organs
 Check for masses and abdominal -Abdomen is free of lesions or rashes.
tenderness
-Umbilicus is midline at lateral line.

-Abdomen is symmetric.

-Abdominal respiratory movement is seen.

-Bowels sounds are heard with series of

intermittent, soft clicks and gurgles.

-Abdomen is not tender and soft; no

guarding. No palpable masses are present.

14. Heart and neck vessels NORMAL FINDINGS

 Check blood pressure -Patient has normal BP of 110/80 mmHg.
 Observe and evaluate jugular venous -Patient’s jugular venous pulse in not
pulse normally visible when client sitting upright.
 Check the carotid arteries
 Check the apical pulse -No blowing or swishing or other sounds
 Check for the extra heart sounds heard on carotid arteries.

-Apical impulse is palpated in the mintral

area.

-Normally no sounds are heard.

15. Peripheral vascular Assessment -Patient complaints of “arthritis in his
 Inspect the fingers, hands, arms, and right knee”.
temperature
-Patient has right foot drop.
 Inspect the capillary refill time
 Check the brachial pulses, femoral -Patient has no strength or power in his
pulses, popliteal pulse, posterior right lower extremity from the knee
tibial pulse and dorsalis pedis pulse down.
 Perform Allen test -There is increased tone in his upper right
extremity.
 Inspect for edema, lesions or ulcers
 Inspect the superficial inguinal -Patient make use of cane.

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 lymph nodes NORMAL FINDINGS
 Inspect for varicosities and -Patient’s skin is warm to touch bilaterally
thrombophlebitits from fingertips to upper arms.

-Capillary beds refill in 2 seconds or less.

-Brachial pulses have equal strength

bilaterally; femoral pulses are strong and
equal bilaterally; popliteal pulse’s circulation
are normal; posterior tibial pulse are strong
bilaterally.

-Pink coloration returns to the palms within

3-5 seconds.

-No swelling or atrophy. Legs are free of

lesions or ulcerations.

-Nontender, movable lymph nodes up to 1-2

cm.

16. Male/Female Genitalia NORMAL FINDINGS

Male:
 Inspect the base of the penis and - Pubic hair s coarser than the scalp hair.
pubic hair
 Inspect the skin of the shaft -Skin of the penis is wrinkled and
 Inspect the foreskin hairless and is normally free of rashes,
 inspect the glans lesions or lumps.
 Check urethral discharges
-Foreskin, which covers the glans in an
 Inspect the size, shape and position
of the scrotum uncircumcised male client, is intact and
 Check for inguinal lymph nodes and uniform in color with the penis.
hernia -Glans size and shape vary, appearing

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 o Female: rounded, broad, or even.
 Inspect for mons pubis
 Observe and palpate inguinal m
nodes
 Inspect the labia majora and
perineum
 Inspect the labia minora, clitoris,
urethral meatus and vaginal opening N/A
inspect the size of the vaginal
opening of the angle of the vagina
 Inspect the cervix
 Inspect the vaginal wall

17. Anus and rectum Assessment NORMAL FINDINGS

 Inspect for the peri-anal area(Note
for lumps, ulcers, lesions, rashes and -Anal opening appear hairless, moist and
redness) tightly close; free of redness, lumps, ulcers,
 Check the rectum lesions and rashes.
 Inspect for the stool characteristic
 Inspect for any other discharges -Rectal mucosa is soft, smooth, nontender,
and free of nodules.

-Stool is semi-solid, brown and free of blood.

-No other discharges.

18. Musculoskeletal Assessment -Uneven weight bearing is evident.

 Inspect size, shape, color and Patient cannot stand on heels or toes.
symmetry
NORMAL FINDINGS
 Check for edema, heat, tenderness,
-No deformities.
pain and nodules
 Check for ROM -No pain, heat, swelling, nodules and edema
 Observe and assess gait
noted.
 Observe the cervical, thoracic and
lumbar curves from the side, then

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 from behind -Full ROM against resistance.
 Check ROM of cervical spine,
thoracic and lumbar spine -Patient has evenly distributed weight, able
 Check ROM of elbows, wrist, hands, to stand on heels and toes.
fingers, hips, ankles and feet
-Cervical and lumbar spines are concave;
thoracic spin is convex; spine is straight.

-Flexion and extension of cervical spine is 45

degrees; flexion of 75-90 degrees, smooth
movement, and lumbar concavity flattens out
and the spinal processes are aligned.

-Patient has full ROM against resistance.

19. Neurologic Assessment

 Assess GCS -Cranial XII is affected since patient
 Check 12 cranial nerves expressed a poor pronunciation of words,
 Assess movement, balance, mumbling, or a change in speed or
coordination, sensation and reflexes rhythm during a conversation. 
 Check involuntary movements -MOTOR: Atrophy of right leg muscles
 Evaluate gait and balance is noted; weakness of right leg muscles is
 Assess for sensory system noted; unable to walk heel-to-toe and
exhibited loss of balance.
-Patient has hyperreflexia. Spastic, weak
flexor muscles with ↑ DTRs (signs of
upper motor neuron loss).
NORMAL FINDINGS
-GCS 15

-CN I, correctly identifies scent presente on

nostril; CN II, patient has 20/20 vision; CN
III and IV, eyelid covers about 2 mm of the
iris; CN V, temporal and masseter muscles
contract bilaterally; CN VII, movement are
symmetric; CN VIII, able to hear whispered
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 words; CN IX and X uvula and soft palate
rise bilaterally; CN XI, symmetric, strong
contraction of the trapezius muscles; CN XII,
tongue movement is symmetric and smooth.

-Eyes move in smooth, coordinated motion

in all directions.

-No fasciculations, tics, or tremors are noted.

-Gait is steady; opposite arm swings. Client

touches finger to nose with smooth,
accurate movements with little hesitation

-Patient correctly identifies light touch.

Submitted by: Submitted to:

Name of Student: Gallur, Ladra, Mahawan, Nacua Mr. Jan Michael R. Remolado, RN, LPT, MN, MAN
Year Level: IV Name of Clinical Instructor
Date: March 08, 2022 Date: March 08, 2022

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