PHYSICAL ASSESSMENT

Measurements

MEASUREMENTS NORMS FINDINGS INTERPRETATION

1. Weight 50.80- 61.69 kgs Deviation from normal
70kg Overweight and obesity
may increase the risk of
many health problems,
including diabetes, heart
disease, and certain
cancers.

Ref: (Health Risks of

Being Overweight.
(2015, February 01).
Retrieved from
https://www.niddk.nih.g
ov/health-
information/weight-
management/health-
risks-overweight)

2. Height varies 5’3 ft. NORMAL

3. BMI ≥ 18.5 – 24.9 27.5 Deviation from normal
Overweight and obesity
may increase the risk of
many health problems,
including diabetes, heart
disease, and certain
cancers.

Ref: (Health Risks of

Being Overweight.
(2015, February 01).
Retrieved from
https://www.niddk.nih.g
ov/health-
information/weight-
management/health-
risks-overweight)
Vital Signs

MEASUREMENTS NORMS FINDINGS INTERPRETATIO

N
4. Temperature 36.5 – 37.5 °C 36.60C NORMAL
5. Pulse Rate 60 – 100 bpm 102bpm Deviation from
normal

The pulse is a wave

of blood created by
contraction of the left
ventricle of the heart.
.An excessively fast
heart rate(over
100bpm in an adult)is
reffered to as
tachycardia a heart
rate in an adult of less
than 60beats/min is
called bradycardia.if a
client has either
tachycardia or
bradycardia pulse
should be assessed.
factors affecting pulse
Age, sex, exercise,
fever, medication,
hypovolemia/dehydra
tion, stress, position.

Ref: kozier Erb pg.

546-548 unit 7.

6. Respiratory 16 – 20 cpm 19cpm NORMAL

Rate
7. Blood Pressure 120/80 ± 20 110/80 NORMAL
8. O2 Saturation 95 – 100% 98% NORMAL
 GENERAL SURVEY
Appearance and Mental Status

ASSESSMENT NORMS FINDINGS INTERPRETATION

Observe client’s Relaxed, erect
posture and gait, Relaxed, erect posture; coordinate
posture; coordinate movement. NORMAL
standing, sitting and
walking movement.

Observe client’s Clean, neat

overall hygiene and Clean, neat NORMAL
grooming.

No body odor or No body odor or

Note body and breath minor body odor minor body odor
odor in relation to relative to work or relative to work or NORMAL
activity level. exercise; no breath exercise; no breath
odor. odor.

No Sign of distress
Observe for signs of NORMAL
No distress noted
distress.

Appearance not DEVIATION FROM

healthy NORMAL

Certain illness can

also change the
client’s body image or
physical appearance
especially if there is
Note obvious signs of severe scarring or loss
Healthy appearance
health of illness. of a limb or sense
organ. The client’s
self-esteem and self-
concept may also be
affected.

Ref: Kozier erb pg

311
 Assess the client’s Cooperative; able to Cooperative; able to NORMAL
attitude. follow instructions. follow instructions.
Note the client’s Appropriate to Appropriate to NORMAL
affect or mood. situation situation
Understandable; Understandable;
Listen for quantity of
moderate pace; clear moderate pace; clear
speech. NORMAL
tone and inflection; tone and inflection;
exhibit thought exhibit thought
association. association.
Listen for Logical sequence; Logical sequence;
NORMAL
organization of make sense; has sense make sense; has sense
thought. of reality. of reality.

Skin
(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 579-580)

ASSESSMENT NORMS FINDINGS INTERPRETATION

Skin is dark brown in
Light to deep brown, color. Generally
Inspect for color, generally uniform uniform except in NORMAL
uniformity of color except in areas areas exposed to the
exposed to the sun. sun.

No presence of edema
No presence of edema
Inspect for presence on any part of the NORMAL
on any part of the
of edema body.
body.
Some birthmarks, Birthmark on right
Inspect, palpate, and some flat and raised hand NORMAL
describe lesions. nevi; no abrasions or
other lesions.
Observe and palpate Moisture in skin folds. NORMAL
Moisture in skin folds.
skin moisture
Palpate skin Uniform and within Warm to touch NORMAL
temperature normal range.
When pinched, skin When pinched, skin
NORMAL
Palpate skin turgor springs back to springs back to
previous state. previous state.
Nails
(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 583- 584)

ASSESSMENT NORMS FINDINGS INTERPRETATIO

N
Inspect fingernail
Convex, angle of nail Convex, angle of nail
plate shape to NORMAL
plate about 160 plate about 160
determine its
degrees. degrees.
curvature and angle
Inspect fingernail and Highly vascular, Highly vascular, light NORMAL
toe nail bed color pink. pink.
DEVIATION
FROM NORMAL

Ridges are among

the different kinds of
nail abnormalities
that can develop due
to aging, nail injury,
or trauma, or
underlying medical
conditions.

Palpate fingernail and Ref: (Stöppler, M. C.

Smooth texture. Ridges on nails
toenail texture (2018, September
15). Vertical Ridges
on Nails: Check
Your Symptoms and
Signs. Retrieved
from
https://www.medicin
enet.com/vertical_ri
dges_on_the_fingern
ails/symptoms.htm)

Inspect tissues NORMAL

Intact epidermis Intact epedermis
surrounding nails
Capillary refill goes
Perform blanch test Capillary refill goes NORMAL
back immediately or
of capillary refill back in 1 second
less than 2 seconds
 HEAD TO NECK

Skull and Face

(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 585)

ASSESSMENT NORMS FINDINGS INTERPRETATION

Rounded and Rounded and
symmetric, with symmetric, with
Inspect the skull for
frontal, parietal, frontal, parietal, NORMAL
size, shape, and
occipital occipital
symmetry
prominences; smooth prominences; smooth
skull contour. skull contour.
Palpate the skull for Smooth, uniform Smooth, uniform
nodules or masses and consistency; absence consistency; absence NORMAL
depressions of nodules or masses. of nodules or masses.
Symmetric or slightly Symmetric or slightly
Inspect the facial asymmetric facial asymmetric facial NORMAL
features features; palpebral features; palpebral
features equal in size. features equal in size.
Note symmetry of Symmetric facial Symmetric facial NORMAL
facial movements. movements. movements.
Inspect the eyes for
NORMAL
edema and No edema No edema
hollowness.

Hair
(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 582)

ASSESSMENT NORMS FINDINGS INTERPRETATIO

N
DEVIATION
FROM NORMAL

Common causes of
premature white hair
Inspect the hair for
Hair evenly Black Hair, Presence are; Genetics, Stress,
color, texture, and
distributed, resilient. of white hair Autoimmune disease,
evenness
Thyroid disorder,
vitamin B-12
deficiency and
Smoking.
 Ref. (White Hair:
Causes and
Prevention. (n.d.).
Retrieved from
https://www.healthlin
e.com/health/white-
hair)

No flaking, no No flaking, no NORMAL

Inspect the scalp
infestations. infestations.
No tenderness, No tenderness,
Palpate the scalp for
tenderness, no tenderness, no
lesions, tenderness, NORMAL
bruises, no lesions, bruises, no lesions,
bruises, masses, or
no masses, or no masses, or
nodules
nodules. nodules.
Scanty amount of
Amount of body hair Varies NORMAL
body hair.

Eye Structures and Visual Acuity

(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 588- 593)

ASSESSMENT NORMS FINDINGS INTERPRETATION

Hair evenly Hair evenly
Inspect the eyebrows
distributed; skin distributed; skin
for hair distribution
intact; eyebrows intact; eyebrows NORMAL
and alignment and
symmetrically symmetrically
skin quality and
aligned; equal aligned; equal
movement
movement. movement.
Inspect the eyelashes
Hair is evenly Hair is evenly
for evenness of NORMAL
distributed; curled distributed; curled
distribution and
slightly outward. slightly outward.
direction of curl
Skin is intact; no Skin is intact; no
discharge; no discharge; no
discoloration of discoloration of
Inspect the eyelids for eyelids’ surface. Lids eyelids’ surface. Lids NORMAL
surface characteristics close symmetrically, close symmetrically,
no pain as the lids no pain as the lids
close, blinks close, blinks
bilaterally. bilaterally.
 Inspect the bulbar Transparent; Transparent;
conjunctiva for color, capillaries are evident, capillaries are evident, NORMAL
texture, and the pinkish in color; pinkish in color;
presence of lesions. sclera appears white. sclera appears white.
Pinkish in color, Pinkish in color,
Inspect the palpebral NORMAL
shiny, moist, and shiny, moist, and
conjunctiva
smooth. smooth.
Inspect and palpate No tenderness, edema No tenderness, edema NORMAL
the lacrimal gland and swelling. and swelling.
Inspect and palpate
No tearing, edema, No tearing, edema, NORMAL
the lacrimal sac and
and tenderness. and tenderness.
nasolacrimal duct
Surface is smooth, Surface is smooth,
Inspect the cornea for NORMAL
and shiny; details of and shiny; details of
clarity and texture
iris are visible. iris are visible.
Inspect the anterior Transparent, no Transparent, no
chamber for shadows of lights on shadows of lights on NORMAL
transparency and iris, depth of about 3 iris, depth of about 3
depth mm. mm.
Black in color, round, Brown in color,
Inspect the pupils for and equal in size, round, and equal in
color, shape, and symmetric, has a size, symmetric, has a NORMAL
symmetry of size diameter of 3mm. Iris diameter of 3mm. Iris
is flat and round. is flat and round.
Assess each pupil’s Illuminated pupil Illuminated pupil
NORMAL
direct and consensual constricts; non- constricts; non-
reaction to light illuminated constrict illuminated constrict
Pupils constrict: Pupils constrict:
looking at near object; looking at near object;
Assess each pupil’s
dilate at far; dilate at far; NORMAL
reaction to
Pupils converge when Pupils converge when
accommodation
near object is moved near object is moved
towards the nose towards the nose
When looking straight When looking straight
Asses the peripheral NORMAL
ahead, client can see ahead, client can see
visual fields
object in periphery object in periphery
Assess six ocular
Both eyes Both eyes
movements to
coordinated, move in coordinated, move in NORMAL
determine aye
unison, with parallel unison, with parallel
alignment and
movement movement
coordination
Assess for location of
Reflection of the light NOT ASSESSED
light reflex by shining NOT ASSESED
is align
a penlight on the pupil
 in corneal surface
(Hirschberg test)
Assess near vison by
providing adequate
lighting and asking Able to read Able to read what is NORMAL
the client to read from newsprint written on the paper
a magazine or
newspaper
Assess distance vision
by asking the client to
wear corrective lenses 20/20 vision NOT ASSESSED NOT ASSESSED
unless they are used
for reading only

Ears and Hearing

(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 595- 598)

ASSESSMENT NORMS FINDINGS INTERPRETATION

Color same as facial Color same as facial
skin; symmetry; skin; symmetry;
Inspect the auricles
auricle is aligned with auricle is aligned with
for color, symmetry, NORMAL
the outer canthus of the outer canthus of
position
the eye about 10 the eye about 10
degree degree

Palpate the auricles

Mobile, firm, and not Mobile, firm, and not
for texture, elasticity,
tender; pinna recoils tender; pinna recoils NORMAL
and areas of
after folded after folded
tenderness.

Assess the client’s

response to normal
voice tones. If the
Normal voice tones Normal voice tones
client has difficulty NORMAL
audible audible
hearing the normal
voice, proceed with
the following tests

Perform the watch Able to hear ticking in Not able to hear DEVIATION FROM
tick test. both ears (watch tick ticking in both ears NORMAL
 test) (watch tick test)

Conduct Rinne test. AC>BC

NOT ASSESSED NOT ASSESSED
(Positive Rinne)

Nose and Sinuses

(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 599- 601)

ASSESSMENT NORMS FINDINGS INTERPRETATION

Inspect the external
nose for any Symmetric and Symmetric and
deviations in shape, straight; no discharge straight; Presence of NORMAL
size, color, flaring, or flaring; uniform scar, no discharge or
discharge from the color. flaring;
nares
Lightly palpate the No tenderness and No tenderness and NORMAL
external nose lesions. lesions.
Observe for the
Mucosa pink, clear Mucosa pink, clear
presence of redness, NORMAL
watery discharge, no watery discharge, no
swelling, growths, and
lesions. lesions.
discharge
Inspect the nasal
Nasal septum intact Nasal septum intact NORMAL
septum between the
and is in midline. and is in midline.
nasal chambers
Palpate the maxillary NORMAL
Not tender Not tender
and frontal sinuses

Mouth and Oropharynx

(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 601- 605)

ASSESSMENT NORMS FINDINGS INTERPRETATION

DEVIATION FROM
NORMAL
Inspect the outer lips Pale in color, dry, Paleness may be
Pinkish in color, dry,
for symmetry of has elastic texture, caused by reduced
has elastic texture,
contour, color, and able to purse the blood flow and
able to purse the lips. oxygen or by a
texture lips.
decreased number of
red blood cells.
Healthy lips should be
a pink or red color. If
 you notice a change
in the coloring of the
skin around your
mouth – whether it is
to brown or bluish-
gray
Because the lips take
on the hue of the
underlying tissue color
and blood flow, pale
lips can signal a
change in the redness
of the blood. This is
affected by the oxygen
levels in the body.

Ref:
ttps://www.healthline.
com/health/

Inspect and palpate

the inner lips and Uniform pink color Uniform pink color
buccal mucosa for Moist, smooth, soft, Moist, smooth, soft, NORMAL
color, moisture, glistening, and elastic glistening, and
texture, and the texture elastic texture
presence of lesions

DEVIATION FROM
26 teeth NORMAL
32 adult teeth
Inspect the teeth and
( teeth in upper right
gums while Smooth, white, shiny
and 2 teeth lower Dental caries(cavities)
examining the inner tooth enamel.
left side) yellowish and periodontal
lips and buccal
Pink gums in color disease(pyorrhea) are
mucosa.
the two problems the
Moist, firm texture to
most frequently affect
gums.
the teeth. Both
problems are
commonly associated
 with plaque and tartar

Deposits. In addition,
coffee drinking and
cigarette smoking can
stain the teeth.
Furthermore, along
with increasing
evidence that poor oral
health is the lack of
effective oral care

Reference: kozier
page.773-776.

Central position,
Central position, pink
Inspect the surface of pink color, moist,
color, moist, slightly
the tongue for slightly rough, thin
rough, thin whitish NORMAL
position, color, and whitish coating, no
coating, no lesions,
texture lesions, raised
raised papillae.
papillae.

Inspect the tongue Moves freely without

NOT ASSESSED. NOT ASSESSED
movement tenderness.

Inspect the base of

Smooth tongue base
the tongue, the mouth Smooth tongue base
with prominent NORMAL
floor, and the with prominent veins.
veins.
frenulum

Palpate the tongue

No tenderness and No tenderness and
and floor of the
rebound tenderness, rebound tenderness,
mouth for any NORMAL
no swelling, no no swelling, no
nodules, lumps, or
nodules, no lumps. nodules, no lumps.
excoriated area

Inspect salivary duct Same as color of Same as color of NORMAL

openings for any buccal mucosa and buccal mucosa and
 swelling or redness. floor of mouth floor of mouth

Inspect the hard and

Soft palate is light Soft palate is light
soft palate for color,
pink, and smooth. pink, and smooth.
shape, texture, and NORMAL
Hard palate has Hard palate has
presence of bony
lighter pink color. lighter pink color.
prominences

Inspect the uvula for

Uvula positioned in Uvula positioned in
position and mobility
the middle of soft the middle of soft NORMAL
while examining the
palate. palate.
palates

Inspect the
Pink and smooth Pink and smooth
oropharynx for color NORMAL
posterior wall. posterior wall.
and texture

Inspect the tonsils for

Pink and smooth; no
color, discharge, and NOT ASSESSED NORMAL
discharge.
size

Neck
(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 607- 610)

ASSESSMENT NORMS FINDINGS INTERPRETATION

Inspect the neck
muscles
(sternocleidomastoid Muscles equal in Muscles equal in
NORMAL
and trapezius) for size; head centered size; head centered
abnormal swellings or
masses.

Palpate the entire

No enlargements, No enlargements,
neck for enlarged NORMAL
lymph nodes lymph nodes
lymph nodes

Palpate the trachea for Central placement in Central placement in

midline of neck; midline of neck; NORMAL
lateral deviation
spaces are equal on spaces are equal on
 both sides both sides

Lobes may not be Lobes may not be

palpated palpated

Palpate the thyroid If palpated, lobes are If palpated, lobes are

small, smooth, small, smooth, NORMAL
gland for smoothness.
centrally located, centrally located,
painless, rise freely painless, rise freely
with swallowing. with swallowing.

Lobes mat not be Lobes mat not be

palpated, if palpated, palpated, if palpated,
lobes are small, lobes are small,
Palpate the thyroid
smooth, centrally smooth, centrally NORMAL
gland for smoothness
located, painless, and located, painless, and
rise freely with rise freely with
swallowing. swallowing.

Lobes may not be Lobes may not be

palpated palpated
Palpate the thyroid
gland for smoothness. If palpated, lobes are If palpated, lobes are
small, smooth, small, smooth, NORMAL
centrally located, centrally located,
painless, rise freely painless, rise freely
with swallowing. with swallowing.

CHEST TO ABDOMEN

Posterior Thorax

ASSESSMENT NORMS FINDINGS INTERPRETATION

Inspect the shape and Anteroposterior to Anteroposterior to NORMAL
symmetry of the transverse diameter in transverse diameter in
thorax from posterior ratio of 1:2 ratio of 1:2
and lateral views.
Compare the Chest symmetric Chest symmetric
anteroposterior
diameter to the
transverse diameter.

Spine vertically Spine vertically

Inspect the spinal aligned; aligned;
alignment for
deformities. Spinal column is Spinal column is NORMAL
straight, right and left straight, right and left
shoulders and hips are shoulders and hips
at the same height are at the same height

Skin intact; uniform Skin intact; uniform

Palpate the posterior
temperature temperature
thorax. NORMAL
Chest wall intact; no Chest wall intact; no
tenderness; no masses tenderness; no masses

Bilateral symmetry of
vocal fremitus;
Bilateral symmetry of
Fremitus is heard most vocal fremitus;
Palpate the chest for
clearly at the apex of
vocal (tactile) Fremitus is heard
the lungs; NORMAL
fremitus. most clearly at the
Low-pitched voices of apex of the lungs;
males are more readily
palpated than higher Higher pitched voice
pitched voices of
females

Excursion is 3 to 5 cm Excursion is 3 to 5
Percuss for bilaterally in women cm.
diaphragmatic and 5 to 6 cm in men.
excursion. Diaphragm is usually NORMAL
Diaphragm is usually slightly higher in on
slightly higher in on
the right side.
the right side.

Auscultate the chest Vesicular and Broncho Vesicular and NORMAL

using the flat-disc vesicular breath Broncho vesicular
 diaphragm of the sounds breath sounds.
stethoscope.

Anterior Thorax

ASSESSMENT NORMS FINDINGS INTERPRETATION

Inspect breathing Quiet, rhythmic, and Quiet, rhythmic, and
NORMAL
patterns. effortless respirations effortless respirations

Costal angle is less Costal angle is less

Inspect the costal than 90, and the ribs
than 90, and the ribs
angle and the angle at
insert into the spine at insert into the spine at NORMAL
which the ribs enter
approximately at 45 approximately at 45
the spine.
angle angle

Skin intact; uniform Skin intact; uniform

Palpate the anterior
temperature temperature
chest. NORMAL
Chest wall intact; no Chest wall intact; no
tenderness; no masses tenderness; no masses

Palpate the anterior

Full symmetric Full symmetric
chest for respiratory excursion; thumb excursion; thumb
excursion. NORMAL
normally separate 3 to normally separate 3
5 cm to 5 cm

Same as posterior Same as posterior

Palpate tactile fremitus; fremitus;
fremitus in the same
NORMAL
manner as for the Fremitus is normally Fremitus is normally
posterior chest. decreased over heart decreased over heart
and breast tissue and breast tissue

Percussion notes Percussion notes

resonate down to the resonate down to the
Percuss the anterior 6th rib at the level of 6th rib at the level of
chest systematically. the diaphragm but are NORMAL
the diaphragm but are
flat over areas of
flat over areas of
heavy muscle and
bone, dull on areas heavy muscle and
over the heart and the bone, dull on areas
 liver, and tympanic over the heart and the
over the underlying liver, and tympanic
stomach over the underlying
stomach

Auscultate the Bronchial and tubular

NOT ASSESSED NOT ASSESSED
trachea. breath sounds

Bronchovesicular and Bronchovesicular and

Auscultate the
vesicular breath vesicular breath NORMAL
anterior chest.
sounds sounds.

Heart and Central Vessels

(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 621-623)

ASSESSMENT NORMS FINDINGS INTERPRETATION

Simultaneously No pulsations No pulsations
inspect and palpate No pulsations No pulsations
the precordium for the
presence of abnormal No lifts to heaves No lifts to heaves
pulsations, lifts, or
Pulsations visible in Pulsations visible in
heaves.
50% of adults and 50% of adults and NORMAL
palpable in most PMI palpable in most PMI
in the 5th LICS or to in the 5th LICS or to
MCL MCL

Diameter of 1 to 2 cm Diameter of 1 to 2 cm

Aortic pulsations Aortic pulsations

Auscultate the heart in S1: Usually heard at S1: Usually heard at

all four anatomic all sites all sites
sites: aortic,
pulmonic, tricuspid, S2: Usually heard at S2: Usually heard at
and apical (mitral). all sites (usually all sites (usually NORMAL
louder at the base) louder at the base)

S3: In children & S3: In children &

young adults young adults
 S4: in many older S4: in many older
adults adults

S1- closure of S1- closure of

mitral/tricuspid valves mitral/tricuspid valves

S2- closure of aortic S2- closure of aortic

and pulmonic valves and pulmonic valves

Full pulsations have Full pulsations have

Palpate the carotid symmetric volumes. symmetric volumes. NORMAL
artery.
Elastic arterial wall. Elastic arterial wall.

Auscultate the carotid No sound heard on No sound heard on

NORMAL
artery. auscultation auscultation

Inspect the jugular

Veins not visible. Veins not visible. NORMAL
veins for distention.

Breast and Axillae

ASSESSMENT NORMS FINDINGS INTERPRETATION

Females: rounded
Inspect the breasts for shape; slightly
size, symmetry, and unequal in size;
contour or shape generally symmetric
Brreats even with the
while the client is in a NORMAL
Males: breast even chest wall
sitting position. with the chest wall;
if obese, may be
similar in shape to
female breast

Inspect the skin of the Skin uniform in Skin uniform in

breast for localized color; color;
discolorations or
hyperpigmentation, Smooth and intact; Smooth and intact; NORMAL
retraction or Presence of moles &
dimpling, localized Diffuse symmetric stretch marks
hyper vascular areas, horizontal or vertical
 swelling, or edema vascular pattern in
light-skinned people;

Striae;

Moles and nevi

Emphasize any
No retraction No retraction NORMAL
retraction

Round or oval and

Inspect the areola bilaterally the same;
area for size, shape,
Color varies widely,
symmetry, color,
from light pink to
surface Rounded; Dark
dark brown; NORMAL
characteristics, and brown in color
any masses or lesions. Irregular placement
of sebaceous glands
on the surface of the
areola

Round, everted, and

equal in size; similar
in color; soft and
smooth; both nipples
point in the same
Inspect the nipples for direction;
size, shape, position, Round everted and
color, discharge, and No discharge, except equal in size similar NORMAL
lesions. from pregnant or in color no discharge
breast-feeding
females;

Inversion of one or
both nipples that is
present from
puberty;

Abdomen
(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 633-638)
 ASSESSMENT NORMS FINDINGS INTERPRETATION
Inspect the abdomen Skin is intact; uniform Skin is intact;
NORMAL
for skin integrity. in color. uniform in color

Flat rounded
Rounded and no
Inspect the abdomen No evidence of
evidence of NORMAL
for contour and enlargement of liver or
enlargement of live
symmetry. spleen.
and spleen.
Symmetric contour.

Observe abdominal
movements Symmetric
Symmetric
associated with movements.
movements. NORMAL
respiration,
caused by
peristalsis, or aortic caused by respirations
respirations
pulsations.

Observe the vascular No visible vascular No visible vascular

NORMAL
pattern. pattern. pattern.

Bowel sounds are

Auscultate abdomen. audible. No bruits, and NOT ASSESSED NOT ASSESSED
friction rub.

Percuss several areas

in each of the four Tympany over the
quadrants to stomach and gas-filled
determine presence of bowels; dullness Tympany over the
NORMAL
tympany and specially over the liver stomach and gas-
dullness. and spleen, or a full
bladder

DEVIATION FROM
Perform light NORMAL
palpation first to No tenderness; relaxed Distended and Abdominal masses
detect areas of abdomen with smooth, palpable as smooth arise from the
tenderness and/or consistent tension round, tense mass surrounding structures,
muscle guarding. thus the importance of
topographic
relationships. The
 presence or absence of
tenderness of a mass
gives important
information as to its
etiology. An
appendiceal abscess
will be tender as it
inflames the parietal
peritoneum, whereas
carcinoma of the
cecum will be
nontender because
there is no
inflammation
involved. Tympany
over a mass implies it
is gas filled. In the
abdomen, this usually
signifies the mass is
dilated bowel, as only
NORMAL

Abdominal tenderness
occurs as a result of
irritation of the parietal
peritoneum. While
inflammation or
irritation of the
Tenderness may be visceral peritoneum
Perform deep present near xiphoid
Tenderness present in will cause abdominal
palpation overall four process, over cecum, discomfort, anorexia,
lower quadrants
quadrants and over sigmoid and poorly localized
colon pain, it will not cause
tenderness and rigidity
of the abdominal wall.
Irritation or
inflammation of the
parietal peritoneum
will stimulate the pain
fibers of the parietal
peritoneum and
 abdominal wall,
creating the symptoms
of localized pain and
the signs of
tenderness, rigidity,
and rebound
tenderness. Thus, if
there is diffuse
irritation of the
peritoneum, as in
diffuse peritonitis,
there will be diffuse
tenderness and
rigidity.

Ref:
https://www.ncbi.nlm.

nih.gov/books/NBK420
/

Palpate the liver to May not be palpable May not be palpable

detect enlargement NORMAL
and tenderness. Border feels smooth Border feels smooth

Palpate the area

above the pubic
symphysis if the
Not palpable Not palpable NORMAL
client’s history
indicates possible
urinary retention.

MUSCULOSKELETAL

Musculoskeletal System

ASSESSMENT NORMS FINDINGS INTERPRETATION

Inspect the muscles NORMAL
Equal in size on both Equal in size on both
for size.
 sides of body sides of body

Inspect the muscles

and tendons for No contractures No contractures NORMAL
contractures.

Inspect the muscles No fasciculation or No fasciculation or

NORMAL
for tremors. tremors tremors

Palpate muscles at
rest to determine Normally firm Normally firm NORMAL
muscle tonicity

Palpate muscles while

the client is active and
passive for flaccidity, Smooth coordinated Smooth coordinated
NORMAL
spasticity, and movements movements
smoothness of
movement

Test muscle strength.

Equal strength on Equal strength on
Compare the right NORMAL
each side each side
side with left side

Inspect the skeleton

for normal structure No deformities No deformities NORMAL
and deformities

No swelling, No swelling,
Inspect the joint for
swelling. No tenderness, No tenderness, NORMAL

Crepitation or nodules Crepitation or nodules

Varies to some degree

in accordance with
Assess joint range of person’s genetic
Full range motion. NORMAL
motion makeup and degree of
physical activity. Full
range motion.

LABORATORY/DIAGNOSTIC EXAMINATIONS

Date Laboratory/ Normal Values Actual Results Clinical

 Done Diagnostic Interpretation
Examination
09-02-18 Hematology Test (25-35)
Control

WBC (5-10) 10.70 Deviation from

Normal
An increased productio
n of white blood
cells to fight an
infection. A reaction to
a drug that increases
white blood
cell production. A
disease of bone
marrow, causing
abnormally high produ
ction of white blood
cells.

Deviation form
Lymphocytes 0.213 Normal Greater risk of
(0.250-0.350) developing infections
because your
lymphocytes are low.
Lymphocytes are a
type of white blood
cell and they are
essential to kill off
bacteria and viruses
and prevent infections
from getting worse. A
weakened immune
system is often caused
by a low number of
lymphocytes and other
types of white blood
cells.

Deviation from
Monocytes 0.188 Normal
(0.020-0.60) A heightened
percentage of
 monocytes in your
blood can be caused
by: chronic
inflammatory disease,
such as inflammatory
bowel disease
a parasitic or viral
infection
a bacterial infection in
your heart
a collagen vascular
disease, such as lupus,
vasculitis, or
rheumatoid arthritis
certain types of
leukemia
(Blood Differential
Test: Purpose,
Procedure &
Complications. (n.d.).
Retrieved from
https://www.healthline.
com/health/blood-
differential#10)

Deviation from
Eosinophils 0.013 Normal
(0.030-0.050) A low number of
eosinophils in the
blood (eosinopenia)
can occur with Cushing
syndrome, bloodstream
infections (sepsis), and
treatment with
corticosteroids.
However, a low
number of eosinophils
does not usually cause
problems because other
parts of the immune
system compensate
adequately.
(Eosinophilic
Disorders - Blood
 Disorders - Merck
Manuals Consumer
Version. (n.d.).
Retrieved from
https://www.merckman
uals.com/home/blood-
disorders/white-blood-
cell-
disorders/eosinophilic-
disorders)

If you have too few or

abnormal red blood
RBC Count 4.30 cells, or your
(5.50- 6.50) hemoglobin is
abnormal or low, the
cells in your body will
not get enough oxygen.
Anemia is a condition
that develops when
your blood lacks
enough healthy red
blood cells or
hemoglobin.
(Understanding
Anemia -- the Basics.
(n.d.). Retrieved from
https://www.webmd.co
m/a-to-z-
guides/understanding-
anemia-basics#1)

Deviation from
Normal
Hemoglobin If you have too few or
(140-160) 114 abnormal red blood
cells, or your
hemoglobin is
abnormal or low, the
cells in your body will
not get enough oxygen.
Anemia is a condition
that develops when
 your blood lacks
enough healthy red
blood cells or
hemoglobin.
(Understanding
Anemia -- the Basics.
(n.d.). Retrieved from
https://www.webmd.co
m/a-to-z-
guides/understanding-
anemia-basics#1)

Deviation from
Normal
Lower hematocrit can
Hematocrit indicate; An
(0.420-0.520) 0.345 insufficient supply of
healthy red blood cells
(anemia)
A large number of
white blood cells due
to long-term illness,
infection or a white
blood cell disorder
such as leukemia or
lymphoma
Vitamin or mineral
deficiencies
Recent or long-term
blood loss. (Hematocrit
test. (2018, January
06). Retrieved from
https://www.mayoclinic
.org/tests-
procedures/hematocrit/
about/pac-20384728)

Deviation from
MCH (27-34) 26.5 Normal
Low amounts of iron in
the blood can also
 cause low MCH levels.
The body uses iron to
make hemoglobin. If
the body runs out of
iron, iron deficiency
anemia can cause low
MCH levels.
(Johnson, J. (n.d.).
MCH levels in
complete blood count
tests: High and low
levels, treatment and
outlook. Retrieved from
https://www.medicalne
wstoday.com/articles/3
18192.php)

Deviation from
Platelet Count 463 Normal
(160-380) A high platelet count
can cause blood
clots to develop
spontaneously.
Normally, your blood
begins to clot to
prevent a massive loss
of blood after an
injury. In people with
primary
thrombocythemia,
however, blood clots
can form suddenly and
for no apparent reason.
Abnormal blood
clotting can be
dangerous. Blood clots
may block the flow of
blood to the brain,
liver, heart, and other
vital organs.
08-27-18 Urinalysis
Macroscopic:

Color Amber
Character Hazy
Blood +1
Bilirubin Negative
Urobilinogen Normal
Ketone Negative Deviation form
Protein +2 Normal
Two plus protein
means that you have a
oritein in your urine.
This can be sign of
kidney disease.

Nitrite Negative
Glucose Negative
pH 6.0
Specific Gravity 1.025
Leukocytes Negative
08-28-18 Fecalysis
Macroscopic:

Character Soft
Color Greenish brown
Reaction Acidic

Microscopic

Parasites or Ova No helminthic ova nor

protozoan parasite
seen.

Pus Cells 30-35

Red Blood Cells 0-2
Bacteria Plenty
Remarks: Yeast cells: Moderate