PHYSICAL ASSESSMENT

DATE ASSESSED
INITIAL VITAL SIGNS

December 12, 2014 @ 9:20 am

Temperature
Pulse Rate
Respiratory Rate

GENERAL APPEARANCE

38.7C
130 bpm
39 cpm

The patient is awake, cuddled by the S.O.

with an ongoing IVF #3 D5IMB 500cc x
20gtts/min @70cc level at left metacarpal
vein patent and infusing well.

SKIN
AREA
ASSESSED

TECHNIQUE
USED

NORMAL FINDINGS

ACTUAL
FINDINGS

ANALYSIS

Color

Inspection

Fair

Normal

Color
Uniformity
Edema

Inspection

According to race (Varies

from light to deep
brown/tan; ruddy pink to
light pink)
Generally uniform

Normal

No edema

Generally
uniform
No edema

Smooth

Smooth

Normal

Snaps back immediately

Snaps back in <2

second

Normal

Moist specially in skin folds

Moist at skin
folds
Hot to touch,
38.7C

Normal

Texture
Turgor
Moisture
Temperatur
e

Inspection
Palpation
Inspection
Palpation
Inspection
and Palpation
Inspection
and Palpation
Palpation

AREA ASSESSED

TECHNIQUE
USED

Nail bed

Inspection

Capillary refill

Warm to touch

NAILS
NORMAL FINDINGS

Normal

due to increased
pyrogens circulating
in the body

ACTUAL
FINDINGS

ANALYSIS

Pinkish

Pinkish

Normal

Returns within 2-3 seconds

Finger nails:
Returns in a 3
seconds
Firm

Normal

Nail base

Inspection and
Palpation (Blanch
Test)
Palpation

Nail plate shape

Inspection

Convex in
curvature

Normal

Nail texture

Inspection

Convex curvature; angle

between nail and nail bed
is about 160o
Smooth

Tissue
surrounding nails

Inspection

Intact epidermis

Intact epidermis

AREA ASSESSED

TECHNIQU

Firm

HAIR
NORMAL FINDINGS

Normal

Smooth

ACTUAL

Normal
Normal

ANALYSIS

E USED

FINDINGS

Hair color

Inspection

Varies from races, usually

black among Filipinos
Evenly distributed

Distribution

Inspection

Texture

Inspection
Palpation

Silky, resilient hair

Hair Strands

Inspection

Thick hair strands

Presence of
infestation

Inspection

No infestation

AREA ASSESSED

TECHNIQUE
USED

Scalp

Inspection

Symmetry
Shape
Masses or Nodules

Inspection
Inspection
Palpation

AREA ASSESSED

TECHNIQUE
USED

Texture

Inspection
and
Palpation
Inspection

Facial features

Edema and
Hollowness in
eyes
Symmetry of facial
movements

Inspection
Palpation

AREA ASSESSED

TECHNIQ
UE USED

Symmetry

Inspection

Pupils

Inspection

Inspection

Eyebrows

Inspection

Eyelashes

Inspection

Upper and Lower

Eyelids

Inspection

Black

Normal

Evenly
distributed
coarse

Normal
Due to lack of
natural oil

Thick Hair
Strands
No
infestation
noted

Normal
Normal

HEAD
NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

No infestation or
infection
Symmetrical
Round
Absence of masses or
nodules

No infestation or
infection
Symmetrical
Round
Masses or Nodules
absent

Normal

FACE
NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

Smooth

Smooth

Normal

Symmetric or slightly
asymmetric facial features,
palpebral fissures equal in
size
No edema and hollowness
in eyes

Symmetric facial
features, palpebral
fissures equal in size

Normal

No edema and
hollowness in eyes
noted
Symmetric facial
movements

Normal

Symmetric facial
movements

Normal
Normal
Normal

Normal

EYES
NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

Symmetrical to each
other
Black

Symmetrical to each
other
Black

Normal

PERRLA- Pupils equally

round react to light
and accommodation
Symmetrical in size,
extension, hair texture
and movement
Distributed evenly and
curved outward
Skin Intact, No lesions,
Same color as the skin

PERRLA- Pupils equally

round react to light
and accommodation
Symmetrical in size,
extension, hair texture
and movement
Distributed evenly and
curved outward
Skin Intact, No lesions,
Same color as the skin

Normal

Normal
Normal
Normal

Conjunctiva

Inspection

Sclera
Cornea
Lacrimal gland for
presence of edema
or tenderness
Lacrimal sac &
nasolacrimal duct
for presence of
edema or tearing
Six ocular
movements

Inspection
Inspection
Inspection
Palpation

Blinks involuntarily
and bilaterally up to
20 times per minute

Blinks involuntarily
and bilaterally 18
times per minute

No visible sclera above

corneas, and upper
and lower borders of
cornea are slightly
covered lids normally
close symmetrically
Pinkish

No visible sclera above

corneas, and upper
and lower borders of
cornea are slightly
covered lids normally
close symmetrically
Pale

Color white
Transparent, shiny
No edema or
tenderness over
lacrimal gland
No edema or tearing

White
Transparent, shiny
No edema or
tenderness over
lacrimal gland noted
No edema or tearing
noted

Both eyes coordinated

with parallel alignment

Both eyes coordinated

with parallel alignment

Normal

EARS
NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

Color the same as

facial skin; symmetric
position
Firm; mobile and not
tender; pinna and
tragus recoils after it is
folded
No canal discharge
noted

Normal

Inspection
Palpation
Inspection
;
Extraocula
r muscle
test

AREA ASSESSED

TECHNIQ
UE USED

Auricles for color,

symmetry of size
and position
Auricles for
texture, elasticity
and areas of
tenderness
Canal discharges

Inspection

AREA ASSESSED

TECHNIQUE
USED

Position

Inspection

External nose

Inspection
Palpation
Inspection
Inspection
Palpation

Nasal Septum
Patency of Nasal
Cavities
Maxillary and
Frontal sinuses

Inspection
Palpation
Inspection

Palpation

Color the same as

facial skin; symmetric
position
Firm; mobile and not
tender; pinna and
tragus recoils after it is
folded
No canal discharge

NOSE
NORMAL FINDINGS
Symmetric and
straight
No tenderness
No lesions
Intact and in midline
Air moves freely as
the client breaths
through the nares
No tenderness
MOUTH

Due to decrease
hemoglobin in
the blood
Normal
Normal
Normal
Normal

Normal

Normal

ACTUAL FINDINGS

ANALYSIS

Symmetric and straight

Normal

No tenderness
No lesions
Intact and in midline
Air moves freely as the
client breaths through
the nares
No tenderness

Normal
Normal
Normal
Normal

AREA ASSESSED

TECHNIQUE
USED

NORMAL
FINDINGS

ACTUAL FINDINGS

ANALYSIS

Lips

Inspection
Palpation

Pink in color,
Soft,
Moist

Normal

Gums

Inspection
Palpation
Inspection
Palpation

Tongue

Inspection

Tongue movement

Inspections

Tongue Texture
Base of the
tongue, mouth
floor and frenulum
Salivary glands

Palpation
Inspection

Pink gums
Moist
Firm
No retraction
6 temporary teeth,
White in color no
cavities
Central position
Pink in color
Moist
Slightly rough
With thin whitish
coating
Smooth
No lesions
Raised taste buds
Moves freely without
pain or discomfort
No tenderness noted
Smooth tongue base
with prominent veins

Normal

Teeth

Pink in color,
Soft,
Moist,
Smooth in texture,
Symmetrical contour
Pink gums
Moist
Firm
No retraction
Smooth
White in color with
no cavities
Central position
Pink in color
Moist
Slightly rough
With thin whitish
coating
Smooth
No lesions
Raised taste buds
Moves freely without
pain or discomfort
No tenderness
Smooth tongue base
with prominent veins

Inspection
Palpation

Uvula

Inspection

Tonsils

Inspection

No redness and
swelling noted
Light pink
Smooth
Soft palate
Lighter pink than
hard palate
Positioned in midline
of soft palate
Pink
No redness and
swelling
No discharge

Normal

Palates

No redness and
swelling
Light pink
Smooth
Soft palate
Lighter pink than
hard palate
Positioned in midline
of soft palate
Pink
No redness and
swelling
No discharge

Palpation
Inspection

Normal
Normal

Normal
Normal
Normal

Normal

Normal
Normal

NECK
NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

Inspection

Equal in size
Head centered

Equal in size
Head centered

Normal

Head
movement

Inspection
Inspection

Coordinated, smooth
movement with no
discomforts noted
Equal strength

Normal

Muscle
strength
Lymph Nodes
Trachea

Coordinated, smooth
movement with no
discomforts
Equal strength
Not palpable
Central placement on
the center of the neck
Spaces are equal on
both sides

Not palpable
Central placement on the
center of the neck
Spaces are equal on both
sides

Normal
Normal

AREA
ASSESSED

TECHNIQUE
USED

Neck muscles

Palpation
Palpation

Normal

Thyroid Gland

Inspection

AREA
ASSESSED

TECHNIQUE
USED

Symmetry
Shape and
symmetry of
thorax
Alignment
Temperature
Respiratory
Excursion
Vocal Fremitus

Inspection
Inspection
Inspection
Palpation
Inspection

Lung Tissues

Palpation
Inspection
Percussion

Breath Sounds

Auscultation

AREA ASSESSED

TECHNIQU
E USED

Breathing Pattern

Inspection

Respiratory
Excursion

Inspection
Palpation

Lung Tissues

Percussion

Anterior Chest for

breath sounds

Auscultatio
n

AREA
ASSESSED

TECHNIQUE
USED

Heart sounds

Auscultation

Not visible
POSTERIOR THORAX
NORMAL FINDINGS

Not visible

Normal

ACTUAL FINDINGS

ANALYSIS

Chest symmetrical
1:2
Anteroposterior to
Transverse diameter
Spine vertically aligned
Uniform temperature
Full and symmetric
chest excursion
Bilateral symmetry of
vocal fremitus
Resonate except on
scapula
Lowest point of
resonance is at the
diaphragm
No adventitious breath
sounds

Chest symmetrical
1:2
Anteroposterior to
Transverse diameter
Spine vertically aligned
Uniform temperature
Full and symmetric
chest excursion noted
Bilateral symmetry of
vocal fremitus
Resonate except on
scapula
Lowest point of
resonance is at the
diaphragm
No adventitious sounds
noted

Normal
Normal

ANTERIOR THORAX
NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

Quiet, rhythmic and

effortless
Full symmetric
excursion
Thumbs normally
separate 4 cm
Resonate down to the
sixth rib at the level of
the diaphragm
Flat over areas of
heavy muscle and
bone
Dull on areas over the
heart and the liver.
Tympany over the
stomach.

Normal

No adventitious breath
sounds

Normal

Quiet, rhythmic and

effortless
Full symmetric excursion
Thumbs normally
separate 3-5 cm
Resonance is heard down
to the sixth rib at the
level of the diaphragm
Flatness is heard over
areas of heavy muscle
and bone
Dullness is heard on
areas over the heart and
the liver.
Tympany is heard over
the stomach.
No adventitious breath
sounds

HEART AND CENTRAL VESSELS

NORMAL FINDINGS
ACTUAL FINDINGS
Systole: silent interval;
slightly shorter duration
than diastole

Systole: silent interval;

slightly shorter duration
than diastole

Diastole: silent interval;

slightly longer duration
than systole

Diastole: silent interval;

slightly longer duration

Normal
Normal
Normal
Normal
Normal

Normal

Normal

Normal

ANALYSIS
Normal

S1 and s2 heard at all

sites
Carotid Arteries
Jugular Veins for
distention
AREA
ASSESSED
Peripheral
Pulses
Peripheral
Perfusion

Palpation
Inspection

S1 and s2 heard at all

sites
Full pulsations noted
Veins not visible

Full pulsations
Veins not visible

PERIPHERAL VASCULAR SYSTEM

TECHNIQUE
NORMAL FINDINGS
ACTUAL FINDINGS
USED

Normal
Normal

ANALYSIS

Palpation

Full pulsations

Full pulsations

Normal

Inspection,palpatio
n

Skin color= Pink

Skin color= Pink

Normal

AREA
ASSESSED

TECHNI
QUE
USED

Color

Inspectio
n
Inspectio
n

Areola

than systole

Nipples

Inspectio
n
Palpation

Lymph nodes

Palpation

BREAST & AXILLAE

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

Skin uniform in color

Skin uniform in color

Normal

Round; bilaterally the same.

Dark brown to Pink in color.

Round; bilaterally the

same.
Dark brown in color.
Round
Everted
Equal in size
Similar in color
Smooth
Soft
Both nipples point in
same direction.
No tenderness, No
masses
No nodules

Normal

Round
Everted
Equal in size
Similar in color
Smooth
Soft
Both nipples point in same
direction.
No tenderness, No masses
No nodules

AREA ASSESSED

TECHNIQU
E USED

Skin Integrity

Inspection

Contour

Inspection

Symmetry

Inspection

Abdominal
movements

Inspection

Abdomen for
areas of
tenderness

Palpation
and
percussion

ABDOMEN
NORMAL
FINDINGS
Unblemished,
Uniform color
Flat,
rounded(convex), or
scaphoid(concave)
Symmetrical
contour
Symmetric
movements caused
by respiration
No tenderness

Normal

Normal

ACTUAL FINDINGS

ANALYSIS

Unblemished,
Uniform color
Rounded

Normal

Contour is symmetric

Normal

Symmetric movements
caused by respiration

Normal

No tenderness

Normal

UPPER EXTREMETIES

Normal

AREA
ASSESSED

TECHNIQUE
USED

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

Symmetry
Skin color

Inspection
Inspection
Palpation

Symmetrical
Same with the color of
other parts of the body
Warm to touch

Normal
Normal

Skin
temperature
Presence of
lesion
ROM

Symmetrical
Same with the color of
other parts of the body
Warm to touch

Inspection

No lesions

No lesions noted

Normal

Inspection

Moves freely without

discomfort

Moves freely without

discomfort

Normal

AREA
ASSESSED

TECHNIQUE
USED

Symmetry
Skin Color

Inspection
Inspection

Skin
Temperature
Presence of
Lesion/ edema
ROM

Palpation
Inspection
Inspection

LOWER EXTREMETIES
NORMAL FINDINGS
ACTUAL FINDINGS

Normal

ANALYSIS

Symmetrical
Same with the color of
other parts of the
body
Warm to touch

Symmetrical
Same with the color of
other parts of the body

Normal
Normal

Warm to touch

Normal

No lesions
No edema
Moves freely without
discomfort

No lesions
No edema
Moves freely without
discomfort

Normal
Normal