Republic of the Philippines
Bulacan State University
City of Malolos, Bulacan
COLLEGE OF NURSING
PHYSICAL ASSESSMENT TABLE
client's Initial: ___G.DV.___ Age: __75___ Gender: __Female____ Date Performed:
_February 7, 2021
Medical Diagnosis: _______________________________ Chief Complaint: ___”di ako masyado nakakatulog”_______ Clinical Area:
________________
Height: _1.524__(m) Vital Signs:
Weight: __57___ (kg) Temp: _36.9___ (°C) PR: __88___ (bpm)
BMI: _24.5____ BP: _130/90____ (mm Hg) RR: __13___ (rpm)
BODY PARTS TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS REMARKS
ASSESSED
GENERAL SURVEY:
Body built Inspection Proportionate (Ectomorph, The client has proportionate and
Height & weight Mesomorph, Endomorph); ectomorph body built.
The height appears within normal The client's height and weight appears
range for age, genetic heritage; within normal range of age, body build NORMAL
and body fat distribution is even.
The weight appears within normal
range for height and body build;
body fat distribution is even
Posture, symmetry& gait Inspection Stands comfortably erect, normal The client stands comfortably erect,
posture, walk is smooth, even, and walk is smooth, even and well balance
well balanced; with symmetric arm with arms swing symmetrically.
swing; NORMAL
Body parts look equal bilaterally and The client's body parts looks equal
are relative in proportion to each bilaterally and proportion to each other.
other
, Physical deformities & Inspection No physical deformities, no signs of The client has no visible physical NORMAL
signs of health or illness illness deformities and no signs of any illness.
Level of consciousness Inspection Alert and oriented, attends to The client is alert and oriented,
Palpation questions and responds to verbal and appropriately responding to verbal and NORMAL
Percussion non-verbal stimulation appropriately non-verbal stimulation.
Behavioral (Mood and Inspection Comfortable and cooperative; The client is comfortable and
affect/ Speech/ Dress & cooperative.
Hygiene)Status Appropriate to the climate, culture NORMAL
and age groups; The client is dressed appropriately to
climate, culture and age group.
Looks clean and well-groomed
The client looks clean and groom.
Mental Status Inspection The person maintains eye contact; The client maintains eye contact and
expressions are appropriate to expressions are appropriate to situation. NORMAL
situation
Language & Inspection Understandable; exhibits relevance The client's language is understandable.
communication and organization of thoughts The client also exhibits relevance and NORMAL
organization of thoughts.
SKIN:
Skin color, uniformity, Inspection Color varies from light to dark The client's skin is light to brown and
presence of edema brown, uniform in color, uniform in color, no blemishes and no NORMAL
unblemished skin, no signs of edema signs of edema.
Skin lesions Inspection No lesions or abrasions. Freckles, The client's skin has no lesions and NORMAL
birthmarks & moles are normal mole are normal.
Skin moisture & Palpation Moist where the skin folds and in The client's skin is moist in skin folds NORMAL
temperature axillae and axillae.
Skin turgor Inspection Skin springs back when pinched; < 3 The client's skin turgor is 2 seconds. NORMAL
seconds is normal
NAILS:
Fingernail plate shape Inspection No clubbing or spooned; convex There are no clubbing in the client's NORMAL
curvature, about 160 degrees nails.
Fingernail color & texture Inspection & Pinkish in color, The client's nails are pinkish, highly
Palpation highly vascular, vascular and has smooth texture. NORMAL
smooth texture
Bulacan State University
City of Malolos, Bulacan
COLLEGE OF NURSING
PHYSICAL ASSESSMENT TABLE
client's Initial: ___G.DV.___ Age: __75___ Gender: __Female____ Date Performed:
_February 7, 2021
Medical Diagnosis: _______________________________ Chief Complaint: ___”di ako masyado nakakatulog”_______ Clinical Area:
________________
Height: _1.524__(m) Vital Signs:
Weight: __57___ (kg) Temp: _36.9___ (°C) PR: __88___ (bpm)
BMI: _24.5____ BP: _130/90____ (mm Hg) RR: __13___ (rpm)
BODY PARTS TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS REMARKS
ASSESSED
GENERAL SURVEY:
Body built Inspection Proportionate (Ectomorph, The client has proportionate and
Height & weight Mesomorph, Endomorph); ectomorph body built.
The height appears within normal The client's height and weight appears
range for age, genetic heritage; within normal range of age, body build NORMAL
and body fat distribution is even.
The weight appears within normal
range for height and body build;
body fat distribution is even
Posture, symmetry& gait Inspection Stands comfortably erect, normal The client stands comfortably erect,
posture, walk is smooth, even, and walk is smooth, even and well balance
well balanced; with symmetric arm with arms swing symmetrically.
swing; NORMAL
Body parts look equal bilaterally and The client's body parts looks equal
are relative in proportion to each bilaterally and proportion to each other.
other
, Physical deformities & Inspection No physical deformities, no signs of The client has no visible physical NORMAL
signs of health or illness illness deformities and no signs of any illness.
Level of consciousness Inspection Alert and oriented, attends to The client is alert and oriented,
Palpation questions and responds to verbal and appropriately responding to verbal and NORMAL
Percussion non-verbal stimulation appropriately non-verbal stimulation.
Behavioral (Mood and Inspection Comfortable and cooperative; The client is comfortable and
affect/ Speech/ Dress & cooperative.
Hygiene)Status Appropriate to the climate, culture NORMAL
and age groups; The client is dressed appropriately to
climate, culture and age group.
Looks clean and well-groomed
The client looks clean and groom.
Mental Status Inspection The person maintains eye contact; The client maintains eye contact and
expressions are appropriate to expressions are appropriate to situation. NORMAL
situation
Language & Inspection Understandable; exhibits relevance The client's language is understandable.
communication and organization of thoughts The client also exhibits relevance and NORMAL
organization of thoughts.
SKIN:
Skin color, uniformity, Inspection Color varies from light to dark The client's skin is light to brown and
presence of edema brown, uniform in color, uniform in color, no blemishes and no NORMAL
unblemished skin, no signs of edema signs of edema.
Skin lesions Inspection No lesions or abrasions. Freckles, The client's skin has no lesions and NORMAL
birthmarks & moles are normal mole are normal.
Skin moisture & Palpation Moist where the skin folds and in The client's skin is moist in skin folds NORMAL
temperature axillae and axillae.
Skin turgor Inspection Skin springs back when pinched; < 3 The client's skin turgor is 2 seconds. NORMAL
seconds is normal
NAILS:
Fingernail plate shape Inspection No clubbing or spooned; convex There are no clubbing in the client's NORMAL
curvature, about 160 degrees nails.
Fingernail color & texture Inspection & Pinkish in color, The client's nails are pinkish, highly
Palpation highly vascular, vascular and has smooth texture. NORMAL
smooth texture
