PHYSICAL ASSESSMENT (HEAD-TO-TOE) SKULL AND FACE TECHNIQUE USED ACTUAL FINDINGS The face is rounded normocephal ic and

symmetrical with frontal, parietal, and occipital prominences , smooth skull contour. It has absence of nodules or masses. His hair is evenly distributed has asymmetric facial features. The palpebral fissures are equal in size and symmetric nasolabial fold. He has symmetric facial movements and can easily do the instruction without any difficulties.

AREAS ASSESSED

NORMAL FINDINGS

ANALYSIS

A. Skull Size Shape symmetry

Inspection

Rounded (normocephalic and symmetric, w/ frontal, parietal, and occipital prominences)

NORMAL

B. Skull Nodules Masses Depressions

Palpation

Smooth, uniform consistency ; absence of nodules or masses Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds.

NORMAL

C. Facial Features Symmetry of structures Hair distribution Palpebral fissure Nasolabial folds

Inspection

NORMAL

D. Facial movements Elevate eyebrows close the eyes tightly Puff the cheeks Smile Show the teeth HAIR AND SCALP

symmetric facial movements

Inspection

NORMAL

AREAS ASSESSED

TECHNIQUE USED

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

Evenness of growth over the scalp Hair thickness/thinn ess Hair texture and oiliness Presence of infections

Inspection and Palpation

Evenly distributed hair; thick hair silky, resilient hair; no infector infestation; variable

He has evenly distributed hair, it is thin and silky, has no lesions in scalp.

NORMAL

EYE STRUCTURE AND VISUAL ACUITY AREAS ASSESSED TECHNIQUE USED ACTUAL FINDINGS His hair is evenly Hair evenly distributed the distributed; skin skin is intact; intact; eyebrows eyebrows symmetrically symmetrically aligned equal aligned and has movement. equal movements. The hair of his Hair equally eyelashes is distributed; evenly curled slightly distributed and outward curled slightly outward. Skin intact no His skin is discharge no intact, discoloration eyebrows lids close symmetrically symmetrically aligned, has approximately ability to blink in 15-20 equal involuntary movements. blinks per When the minute; bilateral clients lids blinking when open, theres lids open no no visible visible sclera sclera above NORMAL FINDINGS ANALYSIS

A. Eyebrows Hair distribution Movement

Inspection

NORMAL

B. Eyelashes Hair distribution Direction of curl

Inspection

NORMAL

C. Eyelids Surface characteristic Position in relation to cornea Frequency and ability to blink

Inspection

NORMAL

above corneas and upper and lower borders of cornea are slightly covered.

cornea.

D. Bulbar Conjunctiva Color Texture Presence of lesions

Inspection

Transaparent; capillaries sometimes evident; sclera appears white

E. Palpebral Conjunctiva Color Texture Lesions

Inspection

Shiny, smooth and pink or red.

The bulbar conjunctiva is transparent, theres no lesion; capillaries sometimes evident, sclera appears white. The color of the palpebral conjunctiva is red, it is shiny and smooth. Doesnt feel tenderness when being palpate over lacrimal gland and has no edema. Theres no edema or tearing in the lacrimal sac and nasolacrimal duct. The cornea is transparent, shiny and smooth. Details of the iris are visible. The anterior chamber is transparent, no shadows of light on iris. The color of the pupils are

NORMAL

NORMAL

F. Lacrimal Gland

Palpation

No edema or tenderness over lacrimal gland

NORMAL

G. Lacrimal sac and Nasolacrimal duct

Inspection and Palpation

No edema or tearing

NORMAL

H. Cornea Clarity Texture

Inspection

Transparent, shiny, and smooth; details of the iris are visible Transparent No shadows of light on iris Depth of about 3 mm Black in color; equal in size

NORMAL

I. Anterior Chamber Transparency Depth J. Pupils Color

Inspection

NORMAL

Inspection

NORMAL

Shape Symmetry of size.

normally 3-7 mm in diameter; round, smooth border, iris flat and round Pupils constrict when looking at near object; pupils dilate when looking at far object; pupil converge when near object is move toward nose. When looking straight ahead, client can see objects in the periphery. Both eyes coordinated, moved in unison, with parallel alignment 20/20 vision on snellen-type chart

black, equal in size, round, and iris is flat and round. The pupil constricts when looking at near object, dilates when looking at far object and converges when object is moved towards nose. He can see object in the periphery while looking straight ahead. Both eyes are coordinated; move equally and in parallel alignment. He has 20/20 vision on Snellen Chart.

K. Pupils reaction accommodation

Inspection

NORMAL

L. Peripheral visual fields

inspection

NORMAL

M. 6 Ocular movements Eye alignment and movement

Inspection

NORMAL

N. Distance vision

Inspection

NORMAL

EARS AND HEARING

AREAS ASSESSED

TECHNIQUE USED

A. Auricles Color Symmetry of size Position B. Auricles Texture, Elasticity Areas of tenderness C. Normal Voice Tone

Inspection

Palpation

NORMAL FINDINGS Color same as facial skin; symmetrical; auricle aligned w/ outer canthus of eye, about 10o from vertical Mobile, firm, and not tender; pinna recoils after its folded

ACTUAL FINDINGS The color of the auricle is same as facial skin it is symmetrical and aligned with the outer canthus of the eye. The auricle is mobile, firm and not tender. Pinna recoils after it is folded. The normal voice tones audible only on the right side of the ear He heard the sound in both ears and localized at the center of the head. The clients air conducted is greater than bone conducted.

ANALYSIS

NORMAL

NORMAL

Inspection

Normal voice tones audible.

Unable to hear the normal voice on one or both ears

D. Webers Test Inspection

E. Rinne Test Inspection

Sound is heard in both ears is localized at the center of the head. Air conduction hearing is greater than bone conduction.

NORMAL

NORMAL

NOSE AND SINUSES AREAS ASSESSED A. External Nose Shape Size Color Flaring Discharge from the nares TECHNIQUE USED NORMAL FINDINGS Symmetric and straight no discharge or flaring; uniform color ACTUAL FINDINGS He doesnt have any discharge or flaring. The clients nose is symmetric and straight, uniform in color. ANALYSIS

Inspection

NORMAL

B. External Nose Tenderness Masses Displacements of bone and cartilage

No tenderness; no lesions Palpation

His external nose doesnt have any lesions and tenderness. Air moves freely as the client breathes through the nares. His mucosa is pink, clear, has watery discharge and no lesions. The nasal septum is intact and in the middle. There is no tenderness in his maxillary and frontal sinuses.

NORMAL

C. Patency of both nasal cavities D. Nasal cavities Redness Swelling Growths Discharge E. Nasal septum

Inspection

Inspection

Air moves freely as the client breathes through the nares. Mucosa pink Clear, watery discharge No lesions Nasal septum intact and in the middle Not tender

NORMAL

NORMAL

Inspection

NORMAL

F. Maxillary and frontal sinuses

Palpation

NORMAL

MOUTH AND OROPHARYNX AREAS ASSESSED TECHNIQUE USED NORMAL FINDINGS ACTUAL FINDINGS The outer lips is uniform pink in color, soft, moist, symmetry of contour and has the ability to purse lips. ANALYSIS

A. Outer lips symmetry of contour color texture

Inspection

Uniform pink color Soft, moist ,smooth texture Symmetry of contour Ability to purse lips

NORMAL

B. Inner lips and Buccal mucosa color moisture texture presence of lesions

Inspection

Uniform pink color Moist, smooth, soft, glistening, elastic texture

The inner lips are uniform pink in color, moist, smooth, soft, glistening and elastic texture. His teeth is 28, it is shiny white tooth and has pink gums. The surface of the tongue is in a central position, pink color. The tongue moves freely. He has a smooth tongue base with prominent veins. The tongue is smooth with no palpable nodules. The soft palate is smooth and light pink in color. The clients has hard palate and lighter pink in color with more irregular in texture.

NORMAL

C. Teeth and Gums

Inspection

D. Surface of the tongue position color texture E. Tongue movement

Inspection

32 adult teeth Smooth shiny white tooth Enamel Pink gums Moist, firm gum texture (-) retraction of gums Central position Pink color Smooth lateral margins (-) lesions Raised papillae (taste buds) Moves freely (-) tenderness

NORMAL

NORMAL

Inspection

NORMAL

F. Base of the tongue, frenulum

Inspection

Smooth tongue base with prominent veins

NORMAL

G. Tongue and Floor of the mouth nodules lumps

Palpation

Smooth with no palpable nodules

NORMAL

H. Hard and Soft Palate

Inspection

Light pink, smooth palate Lighter pink hard palate, more irregular in texture

NORMAL

I.Uvula position mobility

Inspection

Uvula in midline of soft palate

The uvula is in midline of soft palate. The oropharynx is color pink and has a smooth posterior wall. The tonsil has no discharge, pink in color, it is smooth, not visible and in a normal size. Has a Grade of 1. The gag reflex is present.

NORMAL

J. Oropharynx color texture

Inspection

Pink and smooth posterior wall

NORMAL

K. Tonsils color discharge size

Inspection

Pink, smooth, no discharge Normal size Not visible

NORMAL

L. Gag Reflex

Inspection

Present

NORMAL

NECK AND LYMPH NODES AREAS ASSESSED TECHNIQUE USED NORMAL FINDINGS ACTUAL FINDINGS The muscles equal in size and head is centered. Theres no abnormal swelling and masses. The head movement is coordinated, smooth movements with no discomfort. The muscle strength is equal. The lymph nodes are not palpable. ANALYSIS

A. Neck Muscles Abnormal swelling Masses

Inspection

Muscles equal in size; head centered

NORMAL

B. Head Movement

Inspection

Coordinated, smooth movements with no discomfort

NORMAL

C. Muscle Strength

Inspection

Equal strength

NORMAL

D. Lymph Nodes

Palpation

Not palpable

NORMAL

E. Trachea

Palpation

Central placement in midline; spaces are equal in both sides Not visible on inspection Glands ascends during swallowing but is not visible. Lobes may not be palpated. If palpated, lobes are small, smooth, centrally located, painless and rise freely with swallowing.

F. Thyroid Gland

Inspection

The trachea is in midline and spaces are equal in both sides. The thyroid gland is not visible in inspection. A gland ascends during swallowing but is not visible.

NORMAL

NORMAL

G. Thyroid Gland Smoothness Areas of enlargement Masses Nodules

Palpation

The lobes are not palpated.

NORMAL

POSTERIOR THORAX AREAS ASSESSED A. Thorax Shape Symmetry TECHNIQUE USED NORMAL FINDINGS Anteroposterior to transverse diameter is 1:2 ratio Chest symmetric Spine vertically aligned. Spinal column straight, R and L shoulders and hips at same height Uniform temperature Skin intact Chest wall intact No lumps, masses of tenderness ACTUAL FINDINGS They are symmetrical and the anteroposterior diameter is 1:2 ANALYSIS

Inspection

NORMAL

B. Spinal Alignment Deformities

Inspection

The spine is aligned at the center

NORMAL

C. Posterior Thorax Temperature Integrity of all chest skin

Palpation

The temperature is equal, skin is intact and there is no tenderness

NORMAL

D. Respiratory Excursion

Palpation

Symmetrical chest expansion 3-5 cm Thumb separation at inspiration

The chest expands during inspiration

NORMAL

E. Vocal Fremitus

Palpation

Bilateral symmetry of vocal fremitus Fremitus is heard most clearly at the apex of the lungs Resonance except over scapula Lowest resonance at (consolidation of 8-10th posterior rib) Dullness over ribs Vesicular : soft intensity, low pitched, gentle sighing Bronchovesicular: moderate intensity, moderate pitched blowing sounds Bronchial: high pitch, loud, harsh sounds

There is a vibration when he says blue moon

NORMAL

F. Thorax To determine: Underlying lung tissue is filled with air, water, or solid material. Position ang boundaries of certain organs.

Percussion

Resonance except on the scapula and there is dullness over the ribs

NORMAL

G. Posterior Thorax

Auscultation

It has a bronchovesicular breath sounds

NORMAL

ANTERIOR THORAX AREAS ASSESSED A. Breathing Patterns B. Costal Angle Angle at which the ribs enter the spine TECHNIQUE USED Inspection NORMAL FINDINGS Quiet rhythmic and effortless respiration Costal and is <90 degree Ribs insert into spine at 45 degree angle ACTUAL FINDINGS It is effortless and quiet ANALYSIS NORMAL

Inspection

The costal angle is less than 90o

NORMAL

C. Anterior Thorax

Palpation

Uniform temperature Skin intact Chest wall intact No lumps, masses areas of tenderness Full and symmetric 3-5 inches bilateral thumb separation Bilateral symmetry of vocal fremitus Fremitus is heard most clearly at the apex of the lungs Decrease fremitus over heart and breast tissue Resonance down to 6th rib at diaphragm level Flat over heavy muscles and bone Dull over the heart and the liver Tympanic over underlying stomach Bronchial/tubular breath sounds Bronchovesicular and vesicular breath sounds.

The temperature is equal and there is no masses

NORMAL

D. Anterior Thorax Respiratory excursion

Palpation

The chest expands during respiration

NORMAL

F. Tactile Fremitus

Palpation

There is vibration

NORMAL

G. Anterior Thorax

Percussion

There is resonance at the ribs and flat on muscles and tympanic on the stomach

NORMAL

H. Trachea

Auscultation

The sound is bronchial The sound is bronchovesicular

NORMAL

I. Anterior Chest

Auscultation

NORMAL

HEART AND CENTRAL VESSELS AREAS ASSESSED A. Aortic and Pulmonic Areas B. Tricuspid Area TECHNIQUE USED Inspection and Palpation Inspection and Palpation NORMAL FINDINGS No pulsations No pulsations No lifts or heaves Pulsations visible in 50% of adults Palpable in most PMI in 5th LICS MCL Diameter of 1-2 cm No lifts or heaves Aortic pulsations S1- all sites, especially at apical S2- all sites, especially base of the heart S3- in children/young adults S4- older adults Symmetric pulse volumes Full pulsation, thrusting quality Quality remains same when client breathes, turns head, changes from sitting to supine Elastic arterial wall Veins not visible (R side of heart is functioning properly) ACTUAL FINDINGS There are no pulsations There are no pulsations ANALYSIS NORMAL NORMAL

C. Apical Area

Inspection and Palpation

There is no pulsations and no heaves

NORMAL

D. Epigastric Area

Inspection and Palpation

Aortic pulsations are present

NORMAL

E. Four Anatomical sites Aortic Pulmonic Tricuspid Apical

Auscultation

S1 and S2 are barely audible using the bell of the stethoscope

NORMAL

F. Carotid Artery

Palpation

Both sides have pulsations

NORMAL

G. Jugular Vein

Inspection

No veins present

NORMAL

BREAST AND AXILLAE AREAS ASSESSED TECHNIQUE USED NORMAL FINDINGS Females: rounded shape slightly unequal in size, generally symmetric Males: even with chest wall. If obese, may be similar in shape to females Skin uniform in color Skin smooth and intact Diffuse symmetric horizontal or vertical vascular pattern in light skinned people Striae, moles and nevi Rounded or oval bilaterally the same Color varies widely, from light pink to dark brown Irregular placement of sebaceous glands Round, everted, equal in size Similar in color, soft and smooth Point in same direction No discharge, except pregnant or breast feeding Inversion of one or both nipples that is present from puberty (-) tenderness/masses /nodules ACTUAL FINDINGS ANALYSIS

A. Breast Size Symmetry Contour/Shape

Inspection

He has a flat chest wall, the breast are symmetrical

NORMAL

B. Skin of the breast Discoloration Retraction Dimpling Swelling Edema

Inspection

There is no discoloration, dimpling, and edema, the skin is uniform in color

NORMAL

C. Areola Size Shape Symmetry Color Surface Characteristic Masses or Lesions

Inspection

The shape is rounded it is symmetrical the color is dark brown and there is no masses or lesions

NORMAL

D. Nipples Size Shape Position Color Discharge Lesions

Inspection

Size is equal and there are no discharges

NORMAL

E. Axillary and Supraclavicular lymph nodes F. Breast

Palpation

No tenderness, masses, or nodules No tenderness, masses, nodules or nipples discharge No tenderness, masses, nodules or nipples discharge

There is no tenderness There is no tenderness

NORMAL

Palpation

NORMAL

G. Areola and Nipples

Palpation

There is no tenderness

NORMAL

ABDOMEN AREAS ASSESSED A. Abdomen Skin integrity Pigmentation Lesions Striae Scars Veins Umbilicus TECHNIQUE USED NORMAL FINDINGS Unblemished skin, uniform color (no lesion) Silver-white striae (stretch marks) or surgical scars Flat, rounded (convex) or scaphoid (concave) No evidence of liver/spleen enlargement Symmetric contour Symmetric movements caused by respiration Visible peristalsis in very lean clients Aortic pulsations in thin persons at epigastric area No visible pattern ACTUAL FINDINGS ANALYSIS

Inspection

Has a pinkish colostomy/stoma

DEVIATION FROM NORMAL

B. Abdomen Contour Symmetry

Inspection

Abdomen has a convex contour and symmetric; no evidence of liver/spleen enlargement

NORMAL

C. Abdominal movements

Auscultation

Symmetric abdominal movement

NORMAL

D. Vascular pattern

Auscultation

No visible pattern

NORMAL

E. Bowel sounds

Auscultation

F. Vascular sound G. Friction rub

Auscultation Auscultation

H. Abdomen

Percussion

Audible bowel sounds (heard every 5 to 20 seconds) 3 - 20 BS/min. Absence of arterial bruits Absence of friction rub Tympany over the stomach and gasfilled bowels; Dullness over the liver and spleen or a full bladder No tenderness, relaxed abdomen with smooth, consistent tension May not be palpable Border feels smooth

Audible bowel sounds

NORMAL

No bruit present No friction rub Tympany over the stomach; Dullness over the liver and spleen

NORMAL NORMAL

NORMAL

I. Abdomen Areas of tenderness Muscle guarding J. Liver Enlargement Muscle guarding

Palpation

No tenderness

NORMAL

Palpation

Liver not palpable

NORMAL

UPPER AND LOWER EXTREMITIES

AREAS ASSESSED A. Muscles Size TECHNIQUE USED Inspection NORMAL FINDINGS Equal in size on both sides ACTUAL FINDINGS NOT DONE ANALYSIS

NOT DONE

B. Muscle Fasciculation and Tremors C. Muscles Tonicity Flaccidity Spasticity Smoothness of movements D. Muscle Strength

Inspection

No fasciculations/tremors

NOT DONE

NOT DONE

Palpation

Normally firm Smooth, coordinated movement

NOT DONE

NOT DONE

Inspection

Equal strength in both sides

NOT DONE

NOT DONE

E. Joint Swelling

Inspection

(-) swelling/tenderness (-) crepitation/nodules Joints move smoothly Varies to some degree in accordance with clients genetic makeup and degree of physical activity

NOT DONE

NOT DONE

F. Range of Motion

Inspection

NOT DONE

NOT DONE

*All normal findings and analysis are based on (Fundamentals of Nursing by Kozier 8th edition vol. 1)