Physical Assessment

Nursing assessment is an important step of the whole nursing process. Assessment can
be called the base or foundation of the nursing process. With a weak or incorrect
assessment, nurses can create an incorrect nursing diagnosis and plans therefore creating
wrong interventions and evaluation. To prevent those kind of scenarios, we have created a
cheat sheet that you and print and use to guide you throughout the first step of the nursing
process.

Physical Assessment
Integument

Skin: The clients skin is uniform in color, unblemished and no presence of any
foul odor. He has a good skin turgor and skins temperature is within normal limit.

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.

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 4 seconds.

Head

Head: The head of the client is rounded; normocephalic and symmetrical.

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.

Eyes and Vision

Eyebrows: Hair is evenly distributed. The clients eyebrows are symmetrically

aligned and showed equal movement when asked to raise and lower eyebrows.

Eyelashes: Eyelashes appeared to be equally distributed and curled slightly

outward.

Eyelids: There were no presence of discharges, no discoloration and lids close

symmetrically with involuntary blinks approximately 15-20 times per minute.
1

Eyes
o The Bulbar conjunctiva appeared transparent with few capillaries
evident.
o The sclera appeared white.
o The palpebral conjunctiva appeared shiny, smooth and pink.
o There is no edema or tearing of the lacrimal gland.
o Cornea is transparent, smooth and shiny and the details of the iris are
visible. The client blinks when the cornea was touched.
o The pupils of the eyes are black and equal in size. The iris is flat and
round. 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.
o When testing for the Extraocular Muscle, both eyes of the client
coordinately moved in unison with parallel alignment.
o The client was able to read the newsprint held at a distance of 14
inches.

Ears and Hearing

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. The pinna recoils when
folded. During the assessment of Watch tick test, the client was able to hear
ticking in both ears.

Nose and Sinus

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

Mouth:
o 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.
o Teeth and Gums: There are no discoloration of the enamels, no
retraction of gums, pinkish in color of gums
o The buccal mucosa of the client appeared as uniformly pink; moist,
soft, glistening and with elastic texture.
o 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.
o The smooth palates are light pink and smooth while the hard palate has
a more irregular texture.
o The uvula of the client is positioned in the midline of the soft palate.

Neck:
o The neck muscles are equal in size. The client showed coordinated,
smooth head movement with no discomfort.
o The lymph nodes of the client are not palpable.
o The trachea is placed in the midline of the neck.
o The thyroid gland is not visible on inspection and the glands ascend
during swallowing but are not visible.

Thorax, Lungs, and Abdomen

Lungs / Chest: The chest wall is intact with no tenderness and masses. Theres
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.

The spine is vertically aligned. The right and left shoulders and hips are of the
same height.

Heart: There were no visible pulsations on the aortic and pulmonic areas. There
is no presence of heaves or lifts.

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 clients respiration.
o The jugular veins are not visible.

o When nails pressed between the fingers (Blanch Test), the nails return
to usual color in less than 4 seconds.

Extremities

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.

Nursing Assessment in Tabular Form

Assessment

Findings

Integumentary
When skin is pinched it goes to previous

Skin

state immediately (2 seconds).

With fair complexion.
With dry skin
Evenly distributed hair.

Hair

With short, black and shiny hair.

With presence of pediculosis Capitis.
Smooth and has intact epidermis
With short and clean fingernails and

Nails

toenails.
Convex and with good capillary refill time of
2 seconds.
Rounded, normocephalic and symmetrical,

Skull

smooth and has uniform

consistency.Absence of nodules or masses.
Symmetrical facial movement, palpebral

Face

fissures equal in size, symmetric nasolabial

folds.

Assessment

Findings

Eyes and Vision

Hair evenly distributed with skin intact.

Eyebrows

Eyebrows are symmetrically aligned and

have equal movement.

Eyelashes

Equally distributed and curled slightly

outward.
Skin intact with no discharges and no

Eyelids

discoloration.
Lids close symmetrically and blinks
involuntary.

Bulbar conjunctiva

Transparent with capillaries slightly visible

Palpebral Conjunctiva

Shiny, smooth, pink

Sclera

Appears white.

Lacrimal gland, Lacrimal sac,

No edema or tenderness over the lacrimal

Nasolacrimal duct

gland and no tearing.

Cornea
Transparent, smooth and shiny upon
inspection by the use of a penlight which is

Clarity and texture

held in an oblique angle of the eye and

moving the light slowly across the eye.
Has [brown] eyes.

Corneal sensitivity

Blinks when the cornea is touched through a

cotton wisp from the back of the client.
Black, equal in size with consensual and
direct reaction, pupils equally rounded and
reactive to light and accommodation, pupils

Pupils

constrict when looking at near objects,

dilates at far objects, converge when object
is moved toward the nose at four inches
distance and by using penlight.

Assessment

Findings
When looking straight ahead, the client can
see objects at the periphery which is done
by having the client sit directly facing the

Visual Fields

nurse at a distance of 2-3 feet.

The right eye is covered with a card and
asked to look directly at the student nurses
nose. Hold penlight in the periphery and ask
the client when the moving object is spotted.
Able to identify letter/read in the newsprints

Visual Acuity

at a distance of fourteen inches.

Patient was able to read the newsprint at a
distance of 8 inches.

Ear and Hearing

Color of the auricles is same as facial skin,

Auricles

symmetrical, auricle is aligned with the outer

canthus of the eye, mobile, firm, non-tender,
and pinna recoils after it is being folded.

External Ear Canal

Without impacted cerumen.

Hearing Acuity Test

Voice sound audible.

Able to hear ticking on right ear at a distance

Watch Tick Test

of one inch and was able to hear the ticking

on the left ear at the same distance

Nose and sinuses

Symmetric and straight, no flaring, uniform in

External Nose

color, air moves freely as the clients

breathes through the nares.
Mucosa is pink, no lesions and nasal

Nasal Cavity

septum intact and in middle with no

tenderness.

Mouth and Oropharynx

Symmetrical, pale lips, brown gums and able

to purse lips.

Assessment

Teeth

Findings
With dental caries and decayed lower molars
Central position, pink but with whitish

Tongue and floor of the mouth

coating which is normal, with veins

prominent in the floor of the mouth.

Tongue movement

Uvula

Moves when asked to move without difficulty

and without tenderness upon palpation.
Positioned midline of soft palate.

Gag Reflex

Present which is elicited through the use of a

tongue depressor.
Positioned at the midline without tenderness

Neck

and flexes easily. No masses palpated.

Coordinated, smooth movement with no

Head movement

discomfort, head laterally flexes, head

laterally rotates and hyperextends.

Muscle strength

With equal strength

Lymph Nodes

Non-palpable, non tender

Not visible on inspection, glands ascend but

Thyroid Gland

not visible in female during swallowing and

visible in males.

Thorax and lungs

Posterior thorax

Chest symmetrical
Spine vertically aligned, spinal column is

Spinal alignment

straight, left and right shoulders and hips are

at the same height.

Breath Sounds

Anterior Thorax

Abdomen
Abdominal movements

With normal breath sounds without

dyspnea.
Quiet, rhythmic and effortless respiration
Unblemished skin, uniform in color,
symmetric contour, not distended.
Symmetrical movements cause by
7

Assessment

Findings
respirations.

Auscultation of bowel sounds

Upper Extremities
Lower Extremities

With audible sounds of 23 bowel

sounds/minute.
Without scars and lesions on both
extremities.
With minimal scars on lower extremities
Equal in size both sides of the body, smooth
coordinated movements, 100% of normal full

Muscles

movement against gravity and full

resistance.

Bones and Joints

No deformities or swelling, joints move

smoothly.

Mental Status
Language

Can express oneself by speech or sign.

Orientation

Oriented to a person, place, date or time.

Attention span
Level of Consciousness

Able to concentrate as evidence by

answering the questions appropriately.
A total of 15 points indicative of complete
orientation and alertness.

Motor Function
Gross Motor and Balance
Has upright posture and steady gait with

Walking gait

opposing arm swing unaided and

maintaining balance.

Standing on one foot with eyes closed

Heel toe walking
Toe or heel walking

Maintained stance for at least five (5)

seconds.
Maintains a heel toe walking along a straight
line
Able to walk several steps in toes/heels.

Fine motor test for Upper Extremities

8

Assessment
Finger to nose test

Findings
Repeatedly and rhythmically touches the
nose.

Alternating supination and pronation of

Can alternately supinate and pronate hands

hands on knees

at rapid pace.

Finger to nose and to the nurses finger

Perform with coordinating and rapidity.

Fingers to fingers

Perform with accuracy and rapidity.

Fingers to thumb

Rapidly touches each finger to thumb with

each hand.

Fine motor test for the Lower Extremities

Able to discriminate between sharp and dull
Pain sensation

sensation when touched with needle and

cotton.