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Confidential Page 1 11/11/2009

ARELLANO UNIVERSITY
COLLEGE OF NURSING

Physical Assessment
NAME OF CLIENT: ABCD EFG AGE: 86 Y/O GENDER: MALE MARITAL STATUS: WIDOW

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: partially even Evenly distributed hair Deviation from normal
 Thickness or thinness: Thick hair Deviation from normal
thin
 Texture or oiliness: silky Silky, resilient hair Normal
 presence of infection or No infection or infestation Deviation from normal
infestation: with dandruff
Nails
 Fingernail plate shape, Convex, 160º Normal
curvature and angle:
convex, 160º
 Texture: smooth Smooth texture Normal
 Bed color: pale white Highly vascular and pink Deviation from normal
 Tissue surrounding Intact epidermis Deviation from normal
nails: fairly intact
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 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
 With minor presence of No edema or hollowness Deviation from normal
edema or hollowness
 Symmetry of facial Symmetric facial movement Deviation from normal
movements: asymmetric
Eye
 Distribution and Hair evenly distributed; Deviation from normal
alignment of eyebrows: eyebrows symmetrically
unequally aligned aligned
 Distribution and direction Equally distributed; curled Deviation from normal
of curl of the eyelashes: slightly outward
unequally distributed
 Bulbar conjunctiva: Transparent; sclera appears Normal
transparent; smooth white
 Palpebral conjunctiva: Shiny, smooth and pink or red Deviation from normal
pale white
 Lacrimal gland: No edema or tenderness Deviation from normal
presence of edema
 Lacrimal sac and No edema or tearing Deviation from normal
nasolacrimal duct: with
tenderness
 Cornea: transparent Transparent, shiny and Normal
smooth
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 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 Deviation from normal
normal voice tones: no
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
middle
 No presence of redness, Pink mucosa; clear watery Normal
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swelling, growths and discharge; no lesions
discharge
 Maxillary and frontal Not tender Normal
sinuses: not tender

Mouth and
Oropharynx
• Color, Moisture, Texture Uniform pink color, moist, Deviation from normal
Lesions of inner lips: smooth, soft glistening and
pale, with lesions, dry elastic texture.
• Color and Number of 32 adult teeth’s ,smooth white Deviation from normal
teeth’s and color and shining, pink gums, moist,
texture of gum: white, no firm texture, no retraction of
teeth. gums
• Textures and condition Smooth, intact dentures. Normal
of dentures: No
Dentures
• Position, color, texture of Central Position, Pink Color, Deviation from normal
the tongue: slightly moist, Slightly Rough, thin
deviated to right, pink whitish coating, smooth,
color, most slightly smooth lateral margins no
rough, smooth. lesions raised papillae.
• Tongue Movement: not Move Freely, No tenderness Deviation from normal
able to move.
• Tongue and nodules in Smooth with no palpable Normal
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
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• Muscle Size and Muscle equal in size, Head Normal
symmetry of the neck: centered
equal in size,
symmetrical.
• Muscle Strength: no Equal strength Deviation from normal
strength.
• Enlargements of lymph Not Palpable. Deviation from normal
nodes: 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:
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
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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 strong
effortl
• 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 Deviation from normal
chest: thumb normally 3 to 5cm, Full Symmetric
separated to 5 to 7cm
• 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. Deviation from normal
Distension: Veins are
partially visible.