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PHYSICAL ASSESSMENT

NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION


SKIN
Inspect skin color. Varies from light to deep brown; Brown in color normal
from ruddy pink to light pink; from
yellow overtones to olive.
Inspect uniformity of skin color. Generally uniform except in areas Generally uniform except in areas Normal
exposed to the sun. exposed to the sun.
Inspect presence of edema No edema No edema normal
Observe and palpate skin Moisture in skin folds and the Moist in skin folds normal
moisture. axillae (varies with environmental
temperature and humidity, body
temperature, and activity.)
Palpate skin temperature. Uniform; within normal range. Uniform; within normal range Normal
Note skin turgor (fullness or When pinched, skin springs back Skin spring back to previous state normal
elasticity) by lifting and pinching to previous state. when pinched
the skin on an extremity.
NAILS
Inspect fingernail plate shape to Convex curvature; angle of nail Convex curvature, angle Normal
determine its curvature and angle. about 160 o. approximately 160º
Inspect fingernail texture. Smooth texture. Smooth normal
Inspect fingernail bed color. Highly vascular and pink in light- Pinkish in color
skinned clients; dark-skinned
clients may have brown or black
pigmentation in longitudinal
streaks.
Inspect tissues surrounding nails. Intact epidermis. Intact epidermis Normal
Perform blanch test of capillary Prompt return of pink or usual Return to pink color in 2 seconds normal
refill. color (generally less than 4
seconds.)

HEAD
Inspect the skull for size, shape Rounded (normocephalic and Normocephalic, smooth skull Normal
and symmetry. symmetric, with frontal, parietal, contour
and occipital prominences);
smooth skull contour.
Palpate the skull for nodules, Smooth, uniform consistency; Smooth, uniform consistency, no Normal
masses and depressions. absence of nodules or masses. nodules or masses
Color and appearance of scalp Scalp lighter than the color of the Scalp lighter than the color of the Normal
facial skin facial skin
Areas of tenderness No tenderness No tenderness Normal
Hair evenness of growth Evenly distributed Evenly distributed Normal
Hair thickness or thinness Thick hair Thick hair normal
Texture and oiliness Silky, resilient hair Silky, resilient hair
Inspect the facial features. Symmetric or slightly asymmetric Symmetric facial features normal
facial features; palpebral fissures
equal in size; symmetric
nasolabial folds.
Note symmetry of facial Symmetric facial movements Symmetric facial movements normal
movements.
EYES
Inspect the eyebrows for hair Hair evenly distributed; skin intact; Hair evenly distributed; skin intact; Normal
distribution and alignment and eyebrows symmetrically aligned; eyebrows symmetrically aligned;
skin quality and movement. equal movement. equal movement.
Inspect the eyelashes for Equally distributed; curled slightly Equally distributed; curled slightly normal
evenness of distribution and outward. outward.
direction of curl.
Inspect the eyelids for surface Skin intact, no discharge, no Skin intact, no discharge, no normal
characteristics, ability to blink, and discoloration; lids close discoloration; lids close
frequency of blinking. symmetrically;, bilateral blinking. symmetrically; bilateral blinking.
Color, texture, and presence of Transparent Transparent Normal
lesion in bulbar conjunctiva
Color, texture, and presence of Shiny, smooth, pink or red Shiny, smooth, pink Normal
lesion in palpebral conjunctiva
Color and clarity of sclera White White Normal
Inspect the cornea for clarity and Transparent, shiny and smooth; Transparent, shiny and smooth; normal
texture. details of the iris are visible. details of the iris are visible.
Inspect the pupils for color, shape Black in color; equal in size, Black in color; equal in size; Normal
and symmetry of size. round, smooth border. round, smooth border.
Light reaction and accommodation Illuminated pupil constricts and Illuminated pupil constricts and normal
non-illuminated pupil constricts, non-illuminated pupil constricts,
pupil constricts when looking at pupil constricts when looking at
near object and dilate when near object and dilate when
looking at far object; pupil looking at far object; pupil
converge when near object is converge when near object is
moved toward the nose moved toward the nose
Eye alignment and coordination Both eyes move in coordination Both eyes move in coordination normal
and unison, with parallel alignment and unison, with parallel alignment
EARS
Inspect the auricles for color, Color same as facial skin; Color same as facial skin; normal
symmetry of size and position. symmetrical; auricle aligned with symmetrical; auricle aligned with
o
outer canthus of eye about 10 outer canthus of eye about 10o
from vertical. from vertical.
Palpate the auricles for texture, Mobile, firm, and not tender; pinna Mobile, firm, and not tender; pinna normal
elasticity, and areas of recoils after it is folded. recoils after it is folded.
tenderness.
Inspect ear canal for cerumen, Dry cerumen, grayish-tan color, or Dry cerumen, grayish-tan color normal
skin lesions, pus, and blood. sticky.
Assess client’s response to Normal voice tones audible. Normal voice tones audible. Normal
normal voice tones.
Perform watch tick test. Able to hear ticking in both ears. Able to hear ticking in both ears. normal
NOSE
Inspect the external nose for any Symmetric and straight; no Symmetric and straight; no normal
deviations in shape, size, or color discharge or flaring; uniform color. discharge or flaring; uniform color.
and flaring or discharge from the
nares.
Presence of redness, swelling, Mucosa is pink; clear watery Mucosa is pink and no lesion normal
growth and discharge in nasal discharge; no lesion
cavity
Lightly palpate the external nose Not tender; no lesions. Not tender; no lesions. normal
to determine any areas of
tenderness, masses, and
displacements of bone and
cartilage.
Test patency of both nasal Air moves freely as the client Air moves freely as the client Normal
cavities. breathes through nares. breathes through nares.
Inspect nasal septum between the Nasal septum intact and in Nasal septum intact and in normal
nasal chambers. midline. midline.
Palpate for tenderness of sinuses. Not tender. No tenderness normal
MOUTH
Inspect the outer lips for symmetry Uniform pink color; soft, moist and Uniform pink color; soft, moist and Normal
of contour, color and texture. smooth texture; symmetry of smooth texture; symmetry of
contour. contour.
Inspect and palpate the inner lips Uniform pink color; moist, smooth, Uniform pink color; moist, smooth, normal
and buccal mucosa for color, soft, glistening, and elastic texture. soft, glistening, and elastic texture.
moisture, texture and the
presence of lesions.
Inspect the teeth for color and 32 teeth; smooth, white, shiny 29 teeth yellowish in color; Deviated from normal
number. tooth enamel. presence of dental caries.
Inspect gums for the color and Pink gums; moist, firm texture to Pink gums; moist, firm texture to normal
condition. gums. gums.
Inspect the tongue for position, Central position; pink color; moist, Central position; pink color; moist, Normal
color, and texture. slightly rough; thin whitish coating. slightly rough; thin whitish coating.

NECK AND LYMPH NODES


Palpate lymph nodes and note for Not palpable. Not palpable Normal
tenderness.
Inspect and palpate trachea for Central placement in midline of Central placement in midline of normal
placement. the neck; spaces are equal on the neck; spaces are equal on
both sides. both sides.
CARDIOVASCULAR
Auscultate the heart in all four S1 and S2 are usually heard at all S1 and S2 are usually heard at all Normal
anatomic sites: aortic, pulmonic, sites. sites.
tricuspid, and apical (mitral.)
MUSCULOSKELETAL SYSTEM
Inspect muscles for size. Equal size on both sides of the Equal size on both sides of the normal
body. body.
Inspect the muscles and tendons No contractures; no tremors. No contractures; no tremors. normal
for contractures (shortening) and
tremors.
Palpate muscles at rest to Normally firm. firm normal
determine muscle tonicity.
Test for strength (neck, upper and Equal strength on each body side. Equal strength on each body side. normal
lower extremities.)
Inspect the skeleton for structure. No deformities. No deformities. normal
Palpate the bones to locate any No tenderness or swelling. No tenderness or swelling. normal
areas of edema or tenderness.
Inspect the joint for swelling, No swelling, tenderness or No swelling, tenderness or normal
tenderness, smoothness, and nodules; joints move smoothly. nodules; joints move smoothly.
presence of nodules.
REFLEXES
Assess upper extremity reflexes +2 normal response. +2 normal response normal
(biceps/ triceps/ supinator.)
Assess lower exterimity reflexes +2 normal response. +2 normal response. normal
(patellar, ankle, plantar.)

Measurement Normal Findings Actual Findings Interpretation


Weight 18-25kg
Height 115-125cm
BMI
Vital signs

Temperature 34.7-37.3 normal


Cardiac rate 60-100 normal
Respiratory rate 20bpm normal