SKIN

BODY PART

NORMAL FINDINGS

Skin color

Varies from light to

deep brown; from ruddy
pink to light pink; from
yellow overtones to
olive
Uniform except in areas
exposed to the sun
No edema
Freckles;
some
birthmarks; some flat
and raised nevi; no
abrasions
or
other
lesions
Moisture in skin folds
and axillae
Uniform; within normal
range
When pinched, skin
springs back to previous
state, may be slower in
elders.

Uniformity of skin
color
Edema
Skin lesions

Skin moisture

Skin temperature

Skin turgor

HAIR on the head

Evenness of growth
Hair thickness or
Thinness
Hair texture and
oiliness
Presence of infection/
infestation
Amount of body hair
NAIL
Fingernail plate shape

Fingernail and toenail

texture
Finger
nail
and
toenail bed color

Inspect
tissues
surrounding nails
Perform blanch test of
capillary refill

SKULL AND FACE

Skulls size, shape
and symmetry

Skull for nodules or

Evenly distributed
Thick hair
Silky, resilient hair
No infection/ infestation
Variable
Convex curvature; 160
angle
Smooth texture
Highly vascular and
pink in light skinned
clients; dark skinned
clients may have brown
or black pigmentation in
longitudinal streaks
Intact dermis
Prompt return of pink or
usual color less than 4
seconds
Rounded (norm cephalic
and
symmetric
w/
frontal, parietal and
occipital prominences);
Smooth skull contour
Smooth
uniform

ACTUAL FINDINGs

DATA GAPS/ INCONSISTENCIES

masses
depression
Facial features

and

Inspect
eyes
for
edema
and
hallowness
Symmetry of facial
movements
EYE STRUCTURE AND
VISUAL ACUITY
EXTERNAL
EYE
STUCTURE
Inspect the eyebrows
for hair distribution
and alignment and
skin
quality
and
movement
Inspect eyelashes for
evenness
of
distribution of curl
Inspect the eyelids for
surface characteristics

Inspect
Conjunctiva

Inspect
palpebral
conjunctiva
Inspect and palpate
lacriminal gland
Inspect and palpate
the lacriminal sac and
nasocriminal duct
Inspect cornea

Inspect the pupils

bulbar

consistency; absence of
nodules or masses
Symmetric or slightly
asymmetric
facial
features
palpebral
fissures equal in size;
symmetric
nasolabial
folds
No edema

Symmetric
movements

facial

Hair evenly distributed;

skin intact; eyebrows
symmetrically aligned;
equal
movement
(Kozier,2008)
Equally
distributed;
curled slightly outward
Skin
intact;
no
discharge;
no
discoloration;
Lids
close
symmetrically;
approximately
15-20
involuntary blinks per
minute;
bilateral
blinking
When lids open , no
visible sclera above
corneas, and upper and
lower borders of cornea
are slightly covered
Transparent; capillaries
sometimes
evident,
sclera appears white
Shiny, smooth, pink or
red
No edema or tenderness
over lacrimal gland
No edema or tearing

Transparent, shiny and

smooth; details of iris
are visible
Black in color; equal in
size;
3-7mm
in
diameter; round, smooth

border, iris is flat and

round

Pupils direct and

consensual reaction to
light

Pupils reaction
accommodation

VISUAL FIELDS
Peripheral
fields

to

visual

EXTRAOCULAR MUSCLE
TEST
Six
ocular
movements
VISUAL ACQUITY
Near vision

Snellens chart

EARS AND HEARING

Inspect the auricles
for color, symmetry
of size and position

Illuminated
pupil
constricts
(direct
response)
Non illuminated pupil
constricts (consensual
response)
Pupils constricts while
looking at near object;
Pupils dilate while
looking at far object;
Pupils converge when
near object is moved
toward the nose
When looking straight
ahead, client can see
objects in the periphery

Both eyes coordinated.

Move in unison with
parallel alignment
Able to read newsprint
OD 20/20, without
corrective lenses;
OS 20/20, c-c, without
corrective lenses

Color same as facial

skin;
Symmetrical;
Auricle aligned with
outer canthus of eye,
about 10 from vertical
Palpate auricles for Mobile, firm and not
texture, elasticity and tender; Pinna recoils
after it is folded
areas of tenderness
GROSS HEARING ACQUITY TESTS
voice tone
Clients response to Normal
audible
normal voice tones
Able to hear ticking in
Watch tick test
both ears;
Sound is heard in both
Tuning fork test
ears or is localized at the
center of the head
Air-conducted hearing is
Rinne test
greater
than
boneconducted;
Positive Rinne
NOSE AND SINUSES

Inspect the external

nose
for
any
deviations in shape,
size or color and
discharge from the
nares
Palpate external nose
to determine any
areas of tenderness,
masses
and
displacements
of
bone and cartilage

Symmetric and straight;

No discharge or flaring;
Uniform color;

Patency of both nasal

cavities

Air moves freely as the

client breathes through
the nares
Mucosa pink;
Clear, water discharge;
No lesions

Observe
for
the
presence of redness,
swelling, growths and
discharge
Inspect nasal septum
between the nasal
chambers
FACIAL SINUSES
Palpate the maxillary
and frontal sinuses for
tenderness
MOUTH
AND
OROPHARYNX
LIPS
AND
BUCCAL
MUCOSA
Inspect outer lips for
symmetry of contour,
color and texture

Inspect and palpate

the inner lips and
buccal mucosa for
color,
moisture,
texture
and
the
presence of lesions
TEETH AND GUMS

Inspect
gums

teeth

and

TONGUE/ FLOOR OF THE

MOUTH
Inspect the surface of
the
tongue
for
position, color and

Not tender; no lesions

Nasal septum intact and

in midline

Not tender

Uniform pink color

Soft, moist, smooth
texture;
Symmetry of contour
Ability to purse lips
Uniform Pink color;
Moist, smooth, soft,
glistening and elastic
texture

32 Adult teeth
Smooth, white, shiny
tooth enamel;
Pink gums;
Moist, firm texture to
gums;
No retraction of gums

Central position;
Pink color;
Smooth, lateral margins;

texture

Inspect
tongue
movement
Inspect the base of
the tongue, the mouth
floor
and
the
frenulum
Palpate the tongue
and floor of the
mouth
for
any
nodules, lumps or
excoriated areas
Inspect the hard and
soft palate for color,
shape, texture and the
presence of bony
prominences
Inspect uvula for
position and mobility

OROPHARYNX
AND
TONSIL
Inspect
the
oropharynx for color
and texture
Inspect the tonsils for
color, discharge and
size
Elicit gag reflex
NECK
Inspect the neck
muscles
Observe
head
movement

Assess
strength

muscle

LYMPH NODES
Palpate the entire
neck for enlarged
lymph nodes
TRACHAE
Palpate the trachea
for lateral deviations
THYROID GLAND
Inspect the thyroid
gland
Palpate the thyroid
gland for smoothness

no lesions;
Raised papillae
Moves
freely;
no
tenderness
Smooth tongue base
with prominent veins

Smooth with palpable

nodules

Light pink, smooth soft

palate;
Lighter pink hard palate,
more irregular texture
Positioned
midline of
palate

in
the

Pink
and
posterior wall

the
soft

smooth

Pink and smooth;

No discharge
Grade 1
Present
Muscles in equal size;
head centered
Coordinated,
smooth
movement with no
discomfort
Equal strength

Not palpable

Central placement in the

midline of neck; spaces
are equal in both sides
Not
visible
on
inspection
Lobes may not be
palpated
If palpated, lobes are
small, smooth, centrally

located, painless and

rise
freely
with
swallowing
THORAX AND LUNGS
Inspect the shape and
symmetry of the
thorax from posterior
and lateral views
Inspect the spinal
alignment
for
deformities

Palpate
thorax

Palpate the posterior

chest for respiratory
excursion
Palpate the chest for
vocal fremitus

posterior

Percuss the thorax

Percuss
diaphragmatic
excursion

Auscultate the chest

the

ANTERIOR THORAX
Inspect
breathing
patterns
Inspect the costal
angle

Palpate the anterior

chest

Palpate
tactile
fremitus
Percuss the anterior
chest symmetrically

Anteroposterior
to
transverse in diameter in
ratio of 1:2
Chest symmetric
Spine vertically aligned;
Spinal
column
is
straight, right and left
shoulders and hips are at
same height
Skin intact; uniform
temperature;
Chest wall intact; no
tenderness; no masses
Full and symmetric
chest expansion
Bilateral symmetry of
vocal fremitus;
Fremitus is heard most
clearly at the apex of the
lungs
Percussion
notes
resonate, except over
scapula;
Lowest
point
of
resonance is at the
diaphragm
Excursion is 3 to 5 cm
bilaterally;
Diaphragm is usually
slightly higher on the
right side
Vesicular
and
bronchovesicular breath
sounds
Quiet, rhythmic and
effortless respirations
Costal angle is less than
90, and the ribs insert
into the spine at
approximately a 45
angle
Full
symmetric
excursion
-thumbs
normally
separate at 3-5 cm
Same as posterior vocal
fremitus;
Percussion
notes
resonate down to the

Auscultate the trachea

Auscultate
the
anterior chest
HEART AND CENTRAL
VESSELS
Inspect and palpate
the precordium for
the
presence
of
abnormal pulsations

Auscultate the heart

in all four anatomic
sites:
aortic,
pulmonic, tricuspid
and apical

sixth rib at the level of

the diaphragm but are
flat over the areas of
heavy muscle and bone,
dull over the liver and
tympanic
over
the
underlying stomach
Bronchial and tubular
breath sounds
Bronchiovesicular and
vesicular breath sounds

No pulsations, no lifts
and heaves
Pulsation visibile in
50% of adults &
palpable in most PMI in
5thics.
= 1-2 diametes
S1: Louder at apical
area;
S2: Louder at the base
of the heart
Presence of S3 for
children and young
adults
Presence of S4 older
adults

CAROTID ARTERIES
pulse
Palpate the carotid Symmetric
volumes
artery
Auscultate the carotid No sound heard on
auscultation
artery
JUGULAR VEINS
Inspect the jugular Veins not visible
veins
BREAST AND AXILLAE
Rounded
Inspect the breast for Female:
slightly
size, symmetry and shape;
unequal,
generally
contour or shape
symmetric
Male: Breast even
with chest wall, if
obese, maybe similar
in shape to female
breasts

Inspect the skin of the

breast for discoloration

Skin uniform in
color;
Skin smooth and
intact; horizontal or
vertical
vascular
pattern in skinned
people

Striae, moles, nevi

Inspect the areola area

for
size,
shape,
symmetry, color, surface
characteristics and any
masses or lesions

Inspect the nipples for

size, shape, position,
color, discharge and
lesions

Palpate the axillary,

subclavicular,
and
supraclavicular lymph
nodes
Palpate the breast for
masses, tenderness and
any discharge from the
nipples
Palpate the areola and
nipples for masses

ABDOMEN
Inspect the abdomen for
skin integrity

Round or oval and

bilaterally the same;
Colors varies widely,
from light pink to
dark brown
Irregular placement
of sebaceous glands
outer
surface
of
areola
Round, everted and
equal in size;
Similar in color;
Both nipples point at
the same direction;
No discharge; except
for
breastfeeding
females
No
tenderness,
masses or nodules

No
tenderness,
masses, nodules or
nipple discharge
No
tenderness,
masses, nodules or
nipple discharge

Unblemished skin;
Uniform color
Silver white stria or
surgical scars
Inspect the abdomen for Flat, round, concave
or convex
contour and symmetry
No
evidence
of
enlargement of liver
or spleen;
Symmetric contour
Observe
abdominal -Symmetric
movements caused
movements
by respiration
-Visible peristalsis in
--very skinny people
-aortic pulsation in
thin
person
at
epigastric area
Observe vascular pattern No visible vascular
pattern
AUSCULTATION OF THE ABDOMEN
bowel
Auscultate the abdomen Audible
sounds;
for
bowel
sounds,

vascular sounds and

peritoneal friction rubs

Absence of arterial
bruits; absence of
friction rub
PERCUSSION OF THE ABDOMEN
Percuss several areas in Tympanic sound over
each
of
the
four the stomach and gas
filled bowels
quadrants
PALPATION OF THE ABDOMEN
No
tenderness;
Perform light palpation
relaxed with smooth,
consistent tension
maybe
Perform deep palpation Tenderness
present
near
xiphoid
over all four quadrants
process, over cecum
and sigmoid process
MUSCULOSKELETAL SYSTEM

Inspect the muscle for

size
Inspect the muscle and
tendons for contractures
Inspect the muscle for
tremors
Palpate the muscles at
rest
Palpate muscle while the
client is active and
passive
Test muscle strength

BONES
Inspect the skeleton
Palpate the bones to
locate any areas of
edema or tenderness
JOINTS
Inspect the joints for
swelling

Equal in size in both

sides of the body
Absence
of
contractures
No tremors
Normally firm
Smooth coordinated
movements
Equal in strength on
each body side
No deformities
No swelling
tenderness

and

No swelling;
No tenderness;
Joints
moves
smoothly

PERINEUM
Normal looking genitalia
Absence of swelling and inflammation
With Foley catheter inserted