Physical Assessment Body Part Skin Inspection Normal Findings Skin is uniform whitish pink or brown color No Bleeding

No area of increased vascularity and ecchymosis No skin lesions present except for freckles, birthmarks or moles which may be flat or elevated Skin is dry with a minimum of perspiration. Warm and equal bilaterally. Hands and skin slightly cooler than the rest of the body Skin surfaces non-tender Texture: Smooth, even and firm except where there is significant hair growth Skin turgor: When released, should return to original contour rapidly Edema not present Dark black to pale blonde; may turn gray or white; may be chemically changed Terminal hair found in the eyebrows,, eyelashes, and scalp, and in axilla and pubic areas after puberty. No signs of infestation or Interpretation & Analysis Skin is brown Skin may be dry because of insufficient fluid intake No bleeding Normal fluid No area of intake should be 2500 ml per day increased vascularity and ecchymosis No lesions Actual Findings

Palpation

Skin is dry Warm and equal bilaterally

(pp.283-304, Health Assessment Physical Examination Zator Estes)

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Skin sprung back rapidly when pinched edema appears No significant findings

No present Hair black

Scalp and Hair

Inspection

Even distribution (pp.305-308, of hair Health Assessment Physical Examination Zator Estes) No infestation or lesions

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Palpation

Nails

Inspection

Eyes

Palpation Inspection

lesions. Seborrhea/ dandruff may be present Hair may feel thin, straight, coarse, thick or curly. Shiny and resilient Have a pinkcast in lightskinned and brown in darkskinned. Capillary refill present (should return to normal 2-3 sec) Surface is smooth, and slightly rounded or flat. Curved nails are normal. Uniform nail thickness throughout; no splintering or brittle edges. Angle approx. 160 Firm nail base Symmetrical with no drooping, infection, tumors or other abnormalities Visual Acuity: 20/20 Sclera: White in lightskinned w/o exudates, lesions or foreign bodies. In dark-skinned, may have brown patches Pupils: equally round, reactive to light and accommodation; 2-6 mm No tearing, swelling or discharge

Hair is thick and shiny

Brown-cast nails

No significant findings

Capillary refill of 1.5 seconds smooth slightly (pp.308-311, Health Assessment Physical Examination No splinters or Zator Estes) brittle edges Surface and rounded

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Angle approx. 160 Firm nail base Eyes symmetrical No significant findings

Visual acuity of 20/20 Sclera appears white (pp.350-362, Health Assessment Physical Examination Zator Estes)

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Ears

Inspection

Pupils equally round, reactive to light and accommodation; approx. 4 mm No tearing, swelling or descharge Match flesh Same color as No significant color of the rest face findings of the skin. Central Central position

Palpation

position. Proportional. No redness, lesions, swelling, tenderness Should not complain of pain or tenderness Symmetrical, midline of the face. Without swelling, bleeding, lesions, or masses. Each nostril patent. No pain or discomfort during palpation Breath smells fresh. Lips and membranes pink and moist with no lesions or inflammation. Tongue is midline. Pink, moist, rough without lesions. Symmetrical; moves freely. Gums have pale-red strippled surface. No swelling or bleeding. Symmetrical with head in central position. Able to move head without discomfort or noticeable limits Muscles should be symmetrical without palpable masses or spasm Without lesions; skin intact. Quiet, rhythmic and effortless breathing No pulsations, masses, thoracic tenderness

Proportional No redness, (pp.386-389, swelling, or Health Assessment tenderness Physical No pain assessed Examination Zator Estes)

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Nose

Inspection

Symmetrical and No significant in midline findings No swelling, bleeding, lesions, (pp.394-397, Health or masses Assessment Physical Patent nostrils Examination No pain or Zator Estes) discomfort noted

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Palpation

Mouth

Inspection

No significant findings Lips and membranes are moist, dark flesh colored; no lesions or inflammation Tongue in midline and moves (pp.398-405, Health freely Assessment Physical Examination Zator Estes)

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No swelling or bleeding Symmetrical with head in central position Able to move head w/o discomfort No masses No significant findings

Neck

Inspection

Palpation

(p.331, Health Assessment & Physical palpable Examination Zator Estes)

Chest

Inspection

Without lesions Quiet rhythmic and effortless breathing No masses tenderness or

No significant findings

Palpation

(pp.451-469,

Auscultation

present. Bronchovesicular Normal lung breath sounds tissue produces resonant sound, diaphragm has dull sounds. Bronchial, bronchovesicular or vesicular breath sounds Abdominal contour flat or rounded. Symmetrical. Uniform in color or pigmentation. No abdominal scars. No striae Intermittent gurgling sounds throughout abdominal quadrants. Tympany, predominant sound heard No organ enlargement palpable, or any masses, bulges, or swelling Abdominal contour rounded. Symmetrical. Uniform in color.

Health Assessment Physical Examination Zator Estes)

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Abdomen

Inspection

No significant findings

Auscultation

Percussion Palpation

(pp.552-562, No scars; striae Gurgling sounds Health Assessment in abdomen Physical Examination Zator Estes) No friction rubs/ audible bruits

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Suprapubic Area

Inspection Palpation

Genitalia

Inspection Palpation

Without lesions Without Lesions No significant findings Urinary bladder not Urinary bladder (p.638, palpable and not not palpable Fundamentals of tender Nursing Kozier) Pubic hair Pubic hair evenly No significant distributed in distributed findings triangular form. More coarse (pp.746-753, than scalp hair. Health No nits or lice. No nits or lice & Penis skin free No lesions or Assessment Physical of lesions and inflammation Examination inflammation. Zator Estes) No lesions, In midline A dilated vein redness Redundant mass seen as swollen, reddish-blue Sphincter intact noted, reddish mass signifies Non-tender hemorrhoids (pp. 55-56, Medical Surgical Nursing, Harkness and

Rectum

Inspection

Palpation

Upper Extremities

Inspection

Dincher) Without Without lesions, No significant lesions, scars or scars or findings inflammation inflammation (p.579, Fundamentals of Nursing, Kozier) Without lesions, scars No edema Without lesions, No significant scars findings (p.579, No edema Fundamentals of Nursing, Kozier)

Lower Extremities

Inspection Palpation