Physical Assessment

In Partial Fulfillment of the

Requirements on NCM 207- RLE

PRE CLINICAL ROTATION

Submitted to:

Ms. Monica Kristine C. Reyes, RN

Submitted by:

Al-Khusairy A. Tuansi, St.N

BSN-2F

Group 5

September 1, 2021
Introduction

● Physical assessment is an organized systemic process of collecting objective

data based upon a health history and head-to-toe or general systems
examination. A physical assessment should be adjusted to the patient, based
on his needs.

Objectives

● Analyze the relationship of the assessment phase of the nursing process to

development of a comprehensive nursing care plan.
● Utilize assessment skills to collect data for identifying areas of actual or
potential changes in care of clients
● Analyze health data to formulate nursing diagnoses.
A. Biographical Data

Name: Aleezahran A. Tuansi

Age: 12

Gender: MALE

Ward/Unit: X

Bed: X

Examiner: AL-KHUSAIRY A. TUANSI, ST. N

Home/Address: Sultan Kudarat, Maguindanao

Birth Date: October 21, 2006

Birth Place: Cotabato City

Nationality: Filipino

Marital Status: Single

Educational Level: High School

Occupation: Student

No. of Dependents: None

Religion: Islam

B. Admission History

The patient said he has never been admitted in any hospital yet so there
weren’t any information collected for his admission history.

C. History of Present Illness

The patient did not state any current illness or pain. His vital signs were all
completely normal and he appears to be coordinated and full of energy.

D. Past Health History

The last form of sickness the patient can remember was having a cough with
phlegm last June but was instantly treated in just 3 days after home treatment.
 Other than that the patient couldn’t recall any further health problems or anything
severe.

E. Family Health History

The patient has one older brother and one older sister. They and their parents are
the ones currently living together in one household. Three of them are not facing any
form of illness and are completely healthy but not their parents. The mother has high
blood pressure and the father is struggling with insomnia.
F. Gordon’s Functional Health Patters

Health Perception/Health The patient’s health has been very good lately. He eats
Management Pattern  three full meals a day and each meal varies so that he
consumes as much different nutrients as possible. He
didn’t experience colds last year or this year nor were
there any absence from his school. He is a basketball
player which helps his overall health and physique. The
patient has no experience in consuming cigarettes,
alcohol, drugs or any substance and has no plans or
intentions to. No car or any serious accidents have
occurred to him as long as he can remember. His
parents have contact with different kinds of doctor so it
has been easy to consult and ask for advice when
experiencing any physical difficulties. He is an athlete
so proper diet and daily physical activities keep him in a
healthy state. The patient’s appeared very neat and
odourless; there were no stains in his clothes or any
dirt. He also seemed confident when answering health
related questions and kept an eye contact throughout
conversations.

Nutritional/Metabolic The patient eats three times a day, mostly rice and
Pattern  variation of usual Filipino fried viand every morning,
different chicken or beef dishes in the afternoon and
healthier options for dinner such as fish and vegetable
soups. He intakes different kinds of vitamins every night
but most commonly Cherifer. He drinks at least 8
glasses of water a day. The patient is pretty short in
comparison to his peers and has stayed that way ever
since; he gained a good amount of weight when their
classes started this year. The patient only eats when
hungry and has a healthy relationship with food. His
skin is very smooth as he applies lotion to prevent skin
dryness after bathing every morning, his teeth and oral
mucosa looks well and healthy also, no signs of
damage or discoloration. He has no injuries, or lesions
and he has an even skin colour. He is 149 cm tall and
weighs 46 kilos. The temperature is 36.5 C
Elimination Pattern  The patient defecates three times a week without any
problem or any use of laxatives. He urinates at least
three times day without any difficulty either. Amount of
sweating throughout the day appears to be normal
without odour problems. Body cavity drainage tests
were not conducted.

Activity/Exercise Pattern  The patient is a very energetic and well-rounded

person. In between online classes breaks he goes
outside to play basketball, every lunch time, and
afternoon dismissal. He is abled and does not need
assistance for normal everyday duties and choirs.
Patient has very good gait and posture developed
throughout years of playing his choice of sports. He has
firm grip and muscle and is a fast runner. Pulse rate is
60 with normal breathing sounds. Respiratory rate is 24
and blood pressure is 111/70. Patient is well groomed,
has a decent smell and seemed very attentive.

Sleep-Rest Pattern  The patient gets a good 8 hours of sleep every night as
he is very well disciplined by his parents. By 10 or 11
PM he gets to bed and wakes up energized for his 7 AM
classes. He often talks in his sleep but no experiences
of concerning occurrence such as having nightmares.
He rests at the living room and watches TV after school
dismissal.

Cognitive/Perceptual The patient’s hearing clearly normal. He only wears

Pattern  anti-radiation glasses for long exposure to computer
screens but his vision has zero damage. He is an honor
student and a multi-tasker and his firm when it comes to
his decisions as long as he knows it’s the best choice.
He likes to review every afternoon so by night he’s free
to play his mobile games.

Self-perception/Self-Conc The patient describes himself as an outgoing and an

ept Pattern  extrovert person which was very apparent during the
interview. He has no problem with his body and any
hobby he wants to pursue is provided to him. There
were no changes within his self-perception as over the
 years he’s become more close to his cousins therefore
gaining him more friends and instilled his
self-confidence. He only gets annoyed when he is being
misunderstood sometimes and likes to explain himself.
He is a hopeful and positive person. The patient
maintains good eye contact, proper body posture, fluent
providing of answers, somewhat assertive but
respectful, and is very relaxed.

Roles/Relationship The patient lives with parents and siblings. There were
Pattern  no intense family problems experienced as they like to
help each other inside the household and gets very
good emotional support. He gets provided his daily
needs and gets his wants at the same time. He has a
group of friends in school and they’ve managed to bond
using online games in these times of pandemic. The
patient has been doing good in schools lately. He feels
very much involved with his family when it comes to
deciding fun activities they get to enjoy every free time
such a weekdays free from work and school.

Sexuality/Reproductive The patient is too young to be involved in sexual

Pattern  relationships. He is focused on school and stands by his
faith.

Coping-Stress Tolerance He just entered junior high school a year ago which is a
Pattern  big change from being an elementary student but with
the help of the friends that’s been with him since
childhood everything seems to be going fine with him.
The only pressure he experiences right now is the
online setting of classes but his family is always there
for him when things get hard and he gets to vent out
any difficulties so he gets the help he needs. The
emotional support he gets is very helpful for his growth.

Values-Belief The patient wants to be a petroleum engineer in the future. He is a

s Pattern  Muslim and he believes that with hard work, faith, and prayer, he can
achieve whatever he wants in life.
 G. Physical Assessment

I. General Survey

The patient walked in the room seemingly confident and knows what he’s
in there for. He introduced himself before he sat down. He is a 12 year old male.
His body built is ectomorph with a height of 149 cm and weight of 103.4 pounds
leading to a healthy BMI of 21.6. The patient appeared to have a firm gait and
posture.
He is very well groomed and smells decent. The patient is punctual and
came at the right time.
Vital Signs 
Result

Body Temperature  36.5

Pulse Rate  60

Cardiac Rate  90

Respiratory Rate  24

Blood pressure  111/70

II. SKIN AND NAILS 

The client’s skin is uniform in color, unblemished and no presence of any foul odor.
He has a good skin turgor and skin’s temperature is within normal limit. 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 infestation observed. The client has a light brown
nails and has the shape of convex curve. It is smooth and is intact with the
epidermis.

III. HEAD 

The head of the client is rounded; normocephalic and symmetrical. There are no
nodules or masses and depressions when palpated. The face of the client appeared
smooth and has uniform consistency and with no presence of nodules or masses.

IV. EYES 

The client’s eyebrows are symmetrically aligned and showed equal movement when
asked to raise and lower eyebrows. Eyelashes appeared to be equally distributed
and curled slightly outward. The pupils of the eyes are black and equal in size. The
client was able to read the newsprint held at a distance of 14 inches.

V. EARS 

The Auricles are 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.. 

VI. NOSE 

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

VII. 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. There are no
discoloration of the enamels, no retraction of gums, pinkish in color of gums. 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 uvula of the client is positioned in the
midline of the soft palate.

VIII. PHARYNX 

The uvula of the client is positioned in the midline of the soft palate. Gag reflex is
also present which is elicited through the use of a tongue depressor.

IX. NECK 

The neck muscles are equal in size. The client showed coordinated, smooth head
movement with no discomfort. It is positioned at the midline without tenderness and
flexes easily. No masses palpated.

X. THORAX 

The chest wall is intact with no tenderness and masses. There’s 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.

XI. HEART 
There were no palpable pulsation over the aortic, pulmonic, and mitral valves. Apical
pulsation can be felt on palpation. There are also no abnormal heaves, and thrills felt
over the apex that were noted.

XII. BREAST 

There are no lumps or masses are palpable. No tenderness upon palpation were
observed. Nipples are free from any discharges.

XIII. ABDOMEN 

The abdomen of the client has an unblemished skin and is uniform in color. The
abdomen has a symmetric contour. There were symmetric movements caused
associated with client’s respiration. 

XIV. GENITO-URINARY SYSTEM 

The patient pees 3 to 4 times a day with no any problems or discomfort. The
circumcised penis is free of rashes, lesions, and lumps. No swelling, tenderness,or
masses palpated along the testicle.

XV. MUSCULOSKELETAL  

The muscles are not palpable with the absence of tremors. They are normally firm
and showed smooth, coordinated movements. There were no presence of bone
deformities, tenderness and swelling. There were no swelling, tenderness and joints
move smoothly.

XVI. NEUROLOGICAL ASSESSMENT

The patient is alert and oriented to person, place, and time with normal speech.
Memory is normal and thought process is intact.

H. Conclusion

Alee presented as a reasonably healthy man. He is active and mobile, he feels

healthy, his skin, hair and nails look nourished, and his living environment is clean,
well maintained and comfortable. Alee is aware of the need to maintain his health
and undertakes preventative measures in order to continue his good health record.
His vitamins are taken regularly. Similarly his need for anti-radiation glasses to assist
with vision is regularly worn to protect himself from strong screen exposure. He has
excellent support, and gains spiritual strength, from his family, friends and religious
beliefs. He enjoys positive relationships with many of his school friends and has
sourced alternative mechanisms for debriefing when school becomes stressful. The
benefits of Alee’s lifestyle helps him remain physically and mentally active, prevents
a mental health decline, provides a social aspect which he enjoys, and allows him
the means to ensure a comfortable lifestyle. Although Alee carries an excess amount
of need to keep up with his practice for his sports, this does not appear to detract
from his general feeling of physical wellbeing and his body image and perception of
himself were highlighted positively with no problems. Interestingly, when discussing
his self concept pattern Alee displayed a number of good behaviours suggestive of
firm self concept, i.e. good eye contact during such discussion, being comfortable
with himself, and not being overly critical of his appearance. Alee believes he
recognises when he needs to diet or make efforts to reduce his calorie intake and
assume more restrained eating habits. Alee states he felt comfortable throughout the
interview and believes the assessment process ‘effectively established, maintained
and concluded interpersonal communication openly’, and in a friendly and supportive
manner. Overall Alee felt the questions allowed him to positively reflect on his health
and wellbeing status thus, reinforcing his belief that he is being taken care of well
and maintaining his lifestyle appropriately.

I. REFERENCES

● Cureus, I.A., (2017). Importance Of Thorough Physical Examination: A Lost Art.

Retrieved May 2, 2017, from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5453739/

● Clin Med (Lond)., (2017). The value of the physical examination in clinical practice:
an international survey. Retrieved 2017 Dec; 17, from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6297700/

● H. Ösp Egilsdottir, (2019). Revitalizing physical assessment in undergraduate

nursing education - what skills are important to learn, and how are

these skills applied during clinical rotation? A cohort study.

Retrieved Sept 5, 2019, from

https://bmcnurs.biomedcentral.com/articles/10.1186/s12912-019-0364-9