Confidential Page 1 11/11/2009

ARELLANO UNIVERSITY
COLLEGE OF NURSING

Physical Assessment
NAME OF CLIENT: ABCD EFG AGE: 4 Y/O GENDER: FEMALE

Area of assessment  Assessment Findings Norms and Standards Analysis

Skin
 Skin color: pale white Varies form light to deep Deviation from normal
brown
 Uniformity of skin color: Generally uniform except in Normal
uniform areas exposed to the sun
 Skin moisture: dry Moisture in skin folds and the Normal
axillae
 Skin temperature: warm Within normal range Deviation from Normal
 Skin turgor: goes back Skin goes back to previous Deviation from normal
slowly to usual form state
Hair 
 Growth: evenly Evenly distributed hair Normal
distributed
 Thickness or thinness: Thick hair Normal
thick hair
 Texture or oiliness: silky Silky, resilient hair Normal
 presence of infection or No infection or infestation Normal
infestation: without
dandruff
Nails
 Fingernail plate shape, Convex, 160º Normal
curvature and angle:
convex, 160º
 Texture: smooth Smooth texture Normal
 Bed color: pale pink Highly vascular and pink Normal
 Tissue surrounding Intact epidermis Deviation from normal
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nails: fairly intact
 Blanch test: goes back Prompt return of pink or usual Deviation from normal
slowly to its original color
color in less than 7
seconds
Skull and Face
 Size, shape and Rounded; smooth skull Normal
symmetry: round, contour
symmetric
 With some presence of Absence of nodules or Deviation from normal
nodules or masses and masses
depressions
 Facial features: slightly Symmetric or slightly Normal
asymmetric asymmetric
 Without presence of No edema or hollowness Normal
edema or hollowness
 Symmetry of facial Symmetric facial movement Normal
movements: symmetric
Eye
 Distribution and Hair evenly distributed; Normal
alignment of eyebrows: eyebrows symmetrically
equally aligned aligned
 Distribution and direction Equally distributed; curled Normal
of curl of the eyelashes: slightly outward
equally distributed
 Bulbar conjunctiva: Transparent; sclera appears Normal
transparent; smooth white
 Palpebral conjunctiva: Shiny, smooth and pink or red Normal
pale pink
 Lacrimal gland: no No edema or tenderness Normal
presence of edema or
tenderness
 Lacrimal sac and No edema or tearing Normal
nasolacrimal duct: no
tenderness
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 Cornea: transparent Transparent, shiny and Normal
smooth
 Anterior chamber: Transparent Normal
transparent
 Pupil: black, equal in Black in color, equal in size, Normal
size, round 3-7 mm in diameter, round,
smooth
Ears and hearing
 Color, symmetry of size same as facial skin; Normal
and position of auricle: symmetrical; aligned with
same as facial skin; outer cantus of the eye
symmetrical; aligned
with outer cantus of the
eye
 Auricle’s texture , Smooth, firm, not tender; Normal
elasticity and areas of pinna recoils after it is folded
tenderness: no
tenderness, smooth
 Client’s response to Audible Normal
normal voice tones: with
audible response

Nose and Sinuses

 Shape, size, color or symmetric and straight; Normal
flaring of external nose: uniform in color
symmetric and straight;
uniform in color
 No tenderness, masses Not tender; no lesions Normal
and displacements of
bone and cartilage
 Pathway of both Air moves freely as the client Normal
cavities: air passes breath through the nares
through freely
 Nasal septum between Nasal septum intact and in Normal
nasal chambers: in the midline
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middle
 No presence of redness,
swelling, growths and
discharge
 Maxillary and frontal
sinuses: not tender
Mouth and
Oropharynx
• Color, Moisture, Texture
Lesions of inner lips:
pale pink, without
lesions, partially dry
• Color and Number of
teeth’s and color and
texture of gum: pink
gums, incomplete
number of teeth for
children
• Textures and condition
of dentures: No
Dentures
• Position, color, texture of
the tongue: slightly
deviated to right, pink
color, most slightly
rough, smooth.
• Tongue Movement: able
to move freely.
• Tongue and nodules in
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Pink mucosa; clear watery Normal
discharge; no lesions
Not tender Normal
Uniform pink color, moist, Normal
smooth, soft glistening and
elastic texture.
32 adult teeth’s ,smooth white Deviation from normal
shining, pink gums, moist,
firm texture, no retraction of
gums
Smooth, intact dentures. Normal
Central Position, Pink Color, Normal
moist, Slightly Rough, thin
whitish coating, smooth,
smooth lateral margins no
lesions raised papillae.
Move Freely, No tenderness Normal
Smooth with no palpable Normal
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the tongue: none nodules.
• Swelling and redness of Same as color of bucal Normal
salivary duct: no redness mucosa and floor of the
and swelling mouth
Neck
• Muscle Size and Muscle equal in size, Head Normal
symmetry of the neck: centered
equal in size,
symmetrical.
• Muscle Strength: with Equal strength Normal
equal strength.
• Enlargements of lymph Not Palpable. Normal
nodes: not palpable
• Symmetry of the thyroid Not visible in inspection Normal
gland: Symmetrical
• Enlargement of masses: Lobes may not be palpated; Normal
None lobes are small, smooth,
centrally located.
• Enlargement of the Absence of Bruit Normal
gland: none
Thorax and lungs
• Shape and symmetry of Anterior Posterior Transverse Normal
the thorax: symmetrical diameter in ratio of 1:2 chest
symmetric
• Alignment of Spinal: Spine Vertically Aligned Normal
Vertically Aligned
• Presence of scoliosis: Spinal column is straight, right Normal
none left shoulders hips are same
height.
• Temperature of the Skin Intact, Uniform Normal
thorax: Uniform Temperature.
temperature
• Presence of bulges, Chest was intact, no Deviation from normal
tenderness and tenderness, no masses
abnormal movement:
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with tenderness, warm
• Movement of hand in Full and symmetric chest Normal
deep breathing expansion thumb separate in
separates 3 to 5 cm. 3 to 5cm.
• Vocal Fremitus: There is Bi lateral symmetry of vocal Normal
Vibration. fremitus
• Movement of diaphragm: for men excursion between 5 Normal
excursion 5 to 6cm. to 6cm
• Breathing pattern: quiet Quiet rhythm, effortless Deviation from normal
rhythm, with some effort
• Angle of ribs and spine: Coastal angle is less than Normal
coastal angle is less 90degrees ribs and spinal
than 90degrees ribs and 45degrees
spinal 45degrees
• Excursion of anterior thumb normally separated to Normal
chest: thumb normally 3 to 5cm, Full Symmetric
separated to 3 to 5cm
• Heart in 4 anatomic there is sound of S1 and S2 Normal
sites: there is sound of
S1 and S2
• Carotid Artery using Symmetric Pulse Normal
extreme Caution:
Symmetric Pulse
• Jugular Veins in Veins are not visible. Normal
Distension: Veins are
not visible.