Trisha Marie M.

Mangubat
BSN 1-NB
PHYSICAL ASSESSMENT PART 1

ACTION & RATIONALE NORMAL FINDINGS ABNORMAL FINDINGS

1. Explain the purpose and procedure.
R: Providing information fosters his/her
cooperation and allays anxiety.

2. Close doors and put screen.

R: To provide privacy.

3. Encourage the client to empty bladder.

R: A full bladder makes him/her
uncomfortable.

4. Perform physical examination.

A. General examination
Assess overall body appearance and
mental status.
Inspection
Observe the client’s ability to respond
to verbal commands.
R: Responses indicate the client’s
speech and cognitive function.

5. Observe the client’s level of consciousness

(LOC) and orientation. Ask the client to
state his/her own name, current location,
and approximate day, month, or year.
R: Responses indicate the client’s brain
function. LOC is the degree of awareness of
environmental stimuli. It varies from full
wakefulness and alertness to coma.
Orientation is a measure of cognitive
function or the ability to think and reason.

6. Observe the client’s ability to think,

remember, process information and
communicate.
R: These processes indicate cognitive
functioning.

Inspect articulation on speech style and

contents of speaking.

7. Observe the client’s ability to see, hear,

 smell, and distinguish tactile sensations.

8. Observe signs of distress.

R: Alert the examiner to immediate

concerns. If you note distress, the client
may require healthcare interventions
before you continue the exam.

9. Observe facial expression and mood.

R: These could be affected by disease or ill

condition.

10. Observe general appearance: posture, gait,

and movement.
R: To identify obvious changes.

11. Observe grooming, personal hygiene, and

dress.
R: Personal appearance can indicate self-
comfort. Grooming suggests his/her ability
to perform self-care.

12. Measurement
· Height
1. Ask the client to remove shoes and
stand with his/her back and heels
touching the wall.
2. Place a pencil flat on his/her head
so that it makes a mark on the
wall.
3. This shows his/her height
measured with cm tape from the
floor to the mark on the wall (or if
available , measure the height with
measuring scale).

13.
· Weight
Weigh him/her without shoes and
much clothing.

14. Take vital signs.

 · Temperature
· Pulse
· Respiration
· Blood pressure
R: Vital signs provide baseline data.

B. Skin Assessment
Assess integumentary structures (skin,
hair, nails) and function.
SKIN
Inspection and Palpation
15. Inspect the back and palms of the client’s
hands for skin color. Compare the right and
left sides. Make a similar inspection of the
feet and toes, comparing the right and left
sides.
R: Extremities indicate peripheral
cardiovascular function.
16. Palpate the skin on the back and palms of
the client’s hands for moisture, texture.

17. Palpate the skin’s temperature with the

back of your hand.

18. Pinch and release the skin on the back of

the client’s hand.
R: This palpation indicates the skin’s
degree of hydration and
turgor

19. Press suspected edematous areas with the

edge of your fingers for 10 seconds and
observe for your depression.

20. Inspect the skin for lesions. Note the

appearance, size, location, presence and
appearance of drainage.
R: Locate abnormal cell, growths or trauma
that suggests abnormal physiologic
processes.

NAIL
21. Inspect and palpate the fingernails and
toenails. Note color shape, and any lesions.

22. Check capillary refill by pressing the nail

edge to blanch and then release pressure
 quickly, noting and return of color.

HAIR AND SCALP

23. Inspect the hair for color, texture, growth,
distribution.

24. Inspect the scaly, lumps, nevi or other

lesions.

C. Head and Neck Assessment

Assess central neurologic function,
vision, hearing and mouth structures.
SKULL
25. Observe for the size, shape, and symmetry.

26. Palpate and note any deformities,

depression, lumps or tenderness.

FACE
27. Inspect the client’s facial expression,
asymmetry, involuntary movements,
edema and masses.

EYES
28. Position:
Stand in front of the client and inspect
both eyes for position and alignment.

29. Eyebrows:
Inspect the eyebrow, noting their quantity
and distribution and any scaliness.

30. Eyelids:
Inspect the position, presence of edema,
lesions, condition and direction of the
eyelashes and adequacy with eyelids doze.

31. Lacrimal apparatus:

· Inspect the region of the lacrimal
gland and lacrimal sac for swelling.

· Look for excessive tearing or

dryness of the eye.

32. Conjuctiva and Sclera:

· Expose the sclera and conjunctiva.
 · Inspect the color of palpebral
conjunctiva, vascular pattern
against the white scleral
background and any nodules or
swelling.

33. Cornea and Lens:

With oblique lighting, inspect the cornea of
each eye for opacities and note any
opacities in the lens.

34. Pupils:
Inspect the size, shape and compare
symmetry.

35. Pupillary response to light:

· Ask the client to look into the
distance and light a penlight from
the side of the eye.
· Remove it on the other side to and
observe how pupil reacts.
· Repeat other side with same
procedure.

36. Coordination of eye movements:

· Hold an object at a distance from
the client.
· Ask him/her to keep his/her head
still and follow the object with the
eyes only.
· Move the object towards his/her
right and left eye, then towards
the ceiling and floor

37. Convergence Test:

· Ask the client to follow your finger
or a pencil as you move it in
toward the bridge of the nose.

38. Snellen Eye Chart Test:

· Use the Snellen Eye Chart, which
 includes objects, letters or
numbers of different sizes in rows,
under well-light.
· Position the client 20 feet from the
chart and ask the client to identify
the items.
· Compare visual acuity of the client
with normal vision.

EAR & HEARING

39. Using otoscope, hold the helix, gently pull

the pinna upward and backward toward
the occiput.
1. Gently insert the otoscope and examine
the ear.

41. Inspect the pinna, external canal. Tympanic

membrance, landmarks (lobules, helix,
antihelix, tragus, triangular fossa, mastoid
process).
42. Papate the pinna for tenderness,
consistency of the cartialge and swelling.

43. VOICE TEST:

· Test one ear at a time.
· Stay 30-60cm from client’s ear.
· Whisper slowly some two syllable
words.

44. Do mechanical testing: WEBER and RINNE

Testing.

WEBER TEST: to assess bone conduction

by testing the lateralization of sounds.
· Hold the tuning fork at its base.
Activate it by tapping the fork gently
against the back of your hand near the
knuckles or by stroking the fork
between the thumb and the index
finger. It should be made to ring softly.
· Place the base of the vibrating fork on
top of the client’s head and ask where
the client hears the noise.

RINNE TEST: to compare air conduction to

bone conduction.
· Hold the handle of the activated tuning
fork in the mastoid process of one ear
until the client states that the vibration
can no longer be heard.
· Immediately hold still vibrating fork
prongs in front of the client’s ear canal.
Ask whether the client now hears the
sound. Sound conducted by air is heard
more readily than sound conducted by
bone. The tuning fork vibrations
conducted air is normally heard longer.