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NORMS and STANDARDS

BODY PART ACTUAL FINDINGS ANALYSIS


INTEGUMENTARY
SKIN
Varies from light brown
1. Inspect for color; to deep brown; from ruddy pink
uniformity of color to light pink; from yellow
overtones to olive. Generally
uniform except on areas of
lighter pigmentation (palms,
Light brown; generally uniform lips, nail beds) in dark-skinned
except for areas exposed to sun Normal people.
Skin pinches easily and
2. Inspect for immediately returns to its
presence of edema original position.
No edema Normal
3. Inspect for lesions Stretch marks, healed scars,
according to location, freckles, moles are common in
distribution, color, findings. Freckles, some
configuration, size, birthmarks, some flat and raised
shape, type, or structure No lesions; no abrasion; some nevi; no abrasion or other
freckles; some flat nevi Normal lesions.
4. Palpate or skin Moisture in skin folds and the
moisture axillae (varies with
environmental temperature’
body temperature and humidity,
Moisture in skin folds and the body temperature, and activity)
axillae
Normal
Uniform; skin is normally a
warm temperature; within
5. Palpate for skin normal range.
temperature Uniform with normal range Normal
When pinched, skin springs
When pinched, skin springs back to previous state. Maybe
6. Note skin turgor back to previous state Normal slower in elders.
NAILS
1. Inspect fingernail Convex curvature; angle of nail
plate shape uniform; plate about 160 degrees
Within the normal range Convex curvature;angle of nail between the nail base and the
angle. plate about 160 degrees Normal skin.
Highly vascular and pink in
3. Inspect fingernail light-skinned clients; dark-
and toenail bed skinned clients may have brown
color o black pigmentation in
Highly vascular and pink Normal longitudinal streaks.
Smooth texture and firm; nail
3. Palpate fingernail plate should be firmly attached
and toenail texture Smoothe texture Normal to nail bed.
4. Inspect tissue Intact epidermis
surrounding nails
Intact epidermis Normal
5. Perform blanch test Return of pink in less than 4 Prompt return pink or usual
of capillary refill seconda color (generally less than 4
Normal seconds)
Eyebrows
1. Inspect for hair
distribution,
alignment, skin Evenly distributed hair, skin Hair evenly distributed; skin
quality and intact, eyebrows intact. Eyebrows symmetrically
movement. symmetrically aligned, equal aligned; equal movement.
movement Normal
Eyelashes
1. Inspect the eyelashes
for evenness of
distribution and direction
of curl. Equally distributed; curled Equally distributed; curled
slightly outward slightly outward
Normal
EYELIDS
Skin intact; no discharge; no Skin intact; no discharge; no
discoloration; Lids close discoloration.
1. Inspect for the symmetrically; approximately
surface 15 to 20 involuntary blinks Lids close symmetrically.
characteristics, per minute; When lids open,
position in relation no visible sclera above Approximately 15 to 20
to the cornea, ability corneas, and upper and involuntary blinks per minute;
to blink, and lower borders of cornea are bilateral blinking. When lids
frequency of slightly covered. open, no visible sclera above
blinking. corneas, and upper and lower
borders of cornea are slightly
Normal covered.
CONJUNCTIVA
1. Inspect the bulbar Transparent; capillaries
conjunctiva (lying over sometimes evident; sclera
the cornea) for color, appears white (darker or
texture, and presence of Transparent; capillaries yellowish and it small brown
lesions. evident; sclera appears white Normal macules in dark-skinned clients).
2. Inspect the palpebral The lower and upper
conjunctiva (lining the palpebral conjunctivae are The lower and upper palpebral
eyelids) for color, clear and free of swelling or conjunctivae are clear and free
texture and presence of lesions; shiny; smooth; pink of swelling or lesions. Shiny
lesions. Normal smooth, and pink or red.
SCLERA
White. Dar-skinned clients may
1. Inspect the color have sclera with yellow or
and clarity. White pigmented freckles.
Normal
Lacrimal Gland
No swelling or redness should
appear over areas of the
1. Inspect and lacrimal gland. The puncta is
palpate the visible without swelling or
lacrimal gland redness and is turned slightly
toward the eye.
Nasolacrimal Gland

1. Inspect and
palpate the No drainage should be noted
nasolacrimal from the puncta when palpating
gland the nasocrimal duct.
CORNEA
Transparent, shiny, and smooth
and the iris are visible.
1. Inspect for clarity Transparent, shiny, and In older people, a thin, grayish
and texture. smooth and the iris are white ring around the margin,
visible. called arcus senilis, may be
Normal evident.
1. Perform cornea
sensitivity test

IRIS
1. Inspect for color Strongly pigmented, with colors
and shape. Strongly pigmented; dark ranging from brown to green,
brown Normal blue, grey, and hazel
Pupils
Transparent. No shadows of
light on iris. Depth of about 3
mm. Black in color; equal in Transparent. No shadows of
1. Inspect for color, size; normally, round, light on iris. Depth of about 3
shape and smooth border, iris flat and mm. Black in color; equal in size;
symmetry of size round. normally, round, smooth border,
iris flat and round.
Normal
The illuminated pupil constrict)
direct response) the non-
2. Test each pupil illuminated. Pupil dilates
for light reaction (consensual response). Pupils
and constrict when looking at near
accommodation. object; pupils dilate when
looking at far pupils object;
converge when near object is
moved toward the nose.
EXTRAOCULAR
MUSCLES
1. Test each eye for Both eyes coordinated, move Both eyes coordinated, move in
alignment and in unison with parallel unison, with parallel alignment
coordination. alignment Normal
VISUAL FIELDS
When looking straight ahead,
1. Test peripheral Client can see object in Client can see object in the
fields. periphery Normal periphery
Visual Acuity

1. Test near vision The client is able to read the


Able to read newsprint newsprint.
Normal

2. Test Far vision 20/20 vision on Snellen-type


chart
20/20
Normal
EARS
AURICLES
1. Inspect for color, Color is same as facial skin,
symmetry and Color is same as facial skin, symmetrical, auricle aligned
position. symmetrical, auricle aligned with with outer degrees canthus of
outer degrees canthus of eye eye about 10 degrees from
about 10 degrees from vertical. Normal vertical.
2. Palpate for texture, Mobile, firm, and not tender;
elasticity and areas for Mobile, firm, and not tender; pinna pinna recoils after is folded.
tenderness. recoils after is folded. Normal
EXTERNAL EAR
CANAL
1. Inspect ear canal for Dry-cerumen, grayish-tan
cerumen, skin lesions, color; or sticky, wet cerumen in
pus and blood. various shades of brown.

HEARING ACUITY
1. Assess client's Normal voice tones audible
response to normal
voice tones. Nomal voice tones audible Normal
2. Perform watch tick Able to hear ticking in both
test Able to hear ticking in both ears Normal ears.
Sound is heard in both ears or
3. Perform Weber's test is localized at the center of the
head (Weber negative)
4. Perform Rinne’s Air conducted hearing is
test greater than bone conducted
(Rinne positive
NOSE ACTUAL FINDINGS ANALYSIS NORMS and STANDARDS
1. Inspect for any Symmetric and straight, no
deviations in shape, discharge or flaring, uniform
size, or color and flaring color. No tenderness or
or discharge from nares. lesions.
2. Inspect the nasal
cavities for the presence No discharge, no redness, no
of redness, swelling, swelling, no lesions
growth and discharge,
using the flashlight.
3. Inspect the nasal
septum between nasal Nasal septum intact and in
chambers. midline.
4. Test potency both Air moves freely as the client
nasal cavities breathes through nares. No
tender, no lesions
5. Palpate for any
tenderness, masses
displacements of bone No tenderness
and cartilage.
SINUSES

1.Locate/palpate/identif Frontal and maxillary sinuses


y the sinuses and note are non tender to palpation,
for tenderness. and no crepitus is evident.
MOUTH
LIPS
1. Inspect for
symmetry of Uniform pink color (darker, e.g.
contour, color, and bluish hue, in Mediterranean
texture. groups and dark-skinned
clients). Soft, moist, smooth
texture. Symmetry of contour,
Ability to purse lips.
BUCCAL MUCOSA
Uniform pink color (freckled
1. Inspect for color, brown pigmentation in dark-
moisture, texture, skinned clients). Moist smooth,
and presence of soft, glistering and elastic
lesions. texture (drier oral mucosa in
elderly due to decreased
salivation)

TEETH
1. Inspect for color,
number and 32 adult teeth. Smooth, white,
condition and shiny tooth enamel. No
presence of repaired or decayed areas; no
dentures. missing teeth or appliances.

GUMS

Pink gums (bluish or brown


1. Inspect for color patches in dark-skinned
and condition. clients). Moist, firm texture to
gums. No retraction of gums
(pulling away from the teeth)
TOUNGE/FLOOR OF
THE
MOUTH
Central position. Pink color
(some brown pigmentation on
1. Inspect for color tongue borders in dark-
and texture of the skinned clients); moist; slightly
mouth floor and rough; thin whitish coating.
frenulum. Smooth, lateral margins; no
lesions. Raised papillae (taste
buds)

2. Inspect and palpate Moves freely, no tenderness.


the position, color, and Smooth tongue base with
texture, movement and prominent veins.
base of the tongue.
3. Palpate for any
nodules, lumps, or Smooth with no palpable
excoriated areas. nodules.
PALATES AND
UVULA
1. Inspect and
palpate for color, Light pink, smooth, soft palate.
shape, texture and Lighter pink hard palate, more
the presence of bone irregular texture.
prominences.

2. Inspect for position


of the uvula and Positioned in midline of soft
mobility while palate. The hard palate is pale
examining the or whitish with firm.
palates.
OROPHARYNX
AND TONSILS
1. Inspect and
palpate for color, and
texture (one side at a
time to avoid eliciting Pink and smooth posterior wall.
gag reflex)
Pink and smooth. No
2. Inspect the size discharge. Grade one or
of the tonsils normal size. The tonsils are
color, and behind the tonsillar pillars( the
discharge. soft structure supporting the
soft palate).

NECK AND
LYMPNODES
LYMP NODES
Not palpable. There is no swelling
1.Locate/palpate/identif or enlargement and no
y lymph nodes and note tenderness.
for tenderness.
TRACHEA
Central placement in midline of
1. Inspect and palpate neck; spaces are equal on both
for color, placement. sides.
THYROID GLAND

1. Inspect symmetry
and visible masses. Not visible on inspection.

Lobes may not be palpated, if


2. Palpate for palpated; lobes are small, smooth
smoothness and areas and rise freely with swallowing.
of enlargement, masses
or nodules.
THORAX and LUNGS
Procedure and Technique Anteroposterior to lateral diameter in ratio
for Assessing Posterior 1:2, chest symmetric,spine vertically aligned
Thorax
1. Inspect for shape,
symmetry, spinal
alignment and
deformities
2. Palpate for Skin intact,uniform temperature, chest wall
bulges, tenderness intact, no tenderness, no masses
abnormal Full and symmetric chest expansion, bilateral
movement, symmetry of vocal fremitus
respiratory
excursion and
vocal (tactile)
fremitus
(vibration felt
through the chest
wall when client
speaks)
3. Percuss for Percussion notes resonates, except over the
resonance and scapula
diaphragmatic
excursion
4. Auscultate Vesicular and bronchovesicular breath sounds
a. Vesicular – soft,
low-pitch, normal
sounds of air
moving through
small airways
b. Bronchovesicular
– moderate
intensity
“blowing” sounds
of air moving
through larger
airways
c. Adventitious –
abnormal sounds
c.1 Rhonchi – low
pitch gurgling as the
large airways fill with
fluid
c.2 Crackles/rales – a
fine to coarse
popping as air passes
through fluid in the
small airways
c.3 Wheezes – high
pitched whistling as
air passes through
narrowed airways
c.4 Friction rubs –
grating or scratching as
the inflamed pleura rubs

Procedure and technique


for assessing Anterior
Thorax (same as the
posterior)
Breast and Axillae
1. Inspect for size Females: rounded shape, slightly unequal in
symmetry and size, generally symmetric
contour or shape Males: Breast even with the chest wall
2. Inspect the skin Skin uniform color, smooth and intact
for localized
discoloration or hyper
pigmentation, retraction
or dimpling, localized
hyper vascular areas,
swelling or edema
3. inspect the areola for Round or oval and bilaterally the same color
size, shape, symmetry, varies to light pink to dark brown
color, surface
characteristics and any
masses or lesions
4. Inspect the nipples for Round everted, equal in size, similar in color,
size, shape, position, soft and smooth, both pointing in same
color, discharge lesions direction

5. Palpate the No tenderness, masses or nodules


axillary’s
subclavicular and
supraclavicular
lymph nodes
6. Palpate the
breast,nipple and No tenderness, masses, nodules or nipple
areola for masses, discharge
tenderness and
any discharge
from the nipples
Head and Face
1. Inspect the head for Head size and shape vary, head is symmetric,
size, shape and round erect, and in midline, no lesions are
configuration visible
2. Inspect for involuntary Head should be held still and upright
movement
3. Palpate the head, The head is normally hard and smooth
palpate for consistency without lesions
4 .Palpate he temporal The temporal artery is elastic and not tender
artery, which is located
between the top of the The strength of the pulsation of the temporal
ear and the eye artery may be decreased in the older adult
5. Palpate the Normally no swellimg, tendernees, or
temporomandibular joitn crepitation with movement.
to assess the Mouth opens and closes fully. (3-6 cm
temporomandibulra joint, between upper and lower teeth) Lower jaw
place your index finger moves laterally 1-2cm in each direction
ovet the front of each ear
as you ask the client to
open her mouth
Arms
Inspection

Observe arm size and Arms are bilaterally symmetric with minimal
venous pattern, also look variation in size and shape
for edema No edema or prominent venous patterning
Observe coloration of the Color varies depending on the client’s skin
hands and arms tone, although the color should be the same
bilaterally
Palpation

Palpate the client’s Skin is warm to touch bilaterally from


fingers, hands, and arms, fingertips to upper arms
and note the temperature
Palpate to assess Capillary beds refill in 1-2 seconds or less
capillary refill time
Palpate the radial pulse Equal strength bilaterally (2+)
Artery walls have a resilient quality
Palpate the ulnar pulses May not be detectable
Palpate brachial pulses Equal strength
Palpate the epitrochlear Normally epitrochlear lymph nodes are not
lymph nodes palpable

Legs
Observe skin color while Pink color for lighter-skinned clients and pink
inspecting both legs from or red tones visible under darker-pigmeneted
the toes to the groin. skin
No changes in pigmentation
Inspect distribution of Hair covers the skin on the legs and appears
hair on the dorsal surface of the toes
Inspect for the lesions or Legs are free from lesions and ulcerations
ulcers
Inspect for edema Identical size and shape bilaterally
no swelling or atrophy
Palpate edema No edema present in the legs
Palpate bilaterally for Toes, feet, and legs are equally warm
temperature of the feet bilaterally
and legs

Abdomen Unblemished skin, uniform in color


Flat rounded or scaphoid, not distended
Symmetric movements caused by respiration
Audible bowel sounds
No tenderness, relaxed, not palpable
Mucoloskeletal Equal size on both sides of the body, no
contractures and tremors
No swelling, no tenderness
Freely movable with no pain and discomfort
Male genitalia Pubic hair Triangular distribution, spreading into the
abdomen
Penis skin intact, slightly wrinkled, smooth
and slightly movable
Pink positioned at the lip of the penis
Scrotum Darker in color and loose, appears
asymmetric, testicles are rubbery smooth and
mass
No palpable bulge

Female genitalia Pubic hair Distributed in the shape of an inverted


triangle, pubic skin intact, no lesions
Vaginal orifice, clitoris,urethral No inflammation, swelling and discharge no
tender or palpabke no enlargement or
tenderness
Intact perianal skin
Rectal wall is smooth and not tender
Heart No pulsations
No distended, veins not visible
Limbs not tender, symmetric in size
Name: Vital Signs
Sex: BP =
Age: PR =
Height: RP =
Weight: Temperature =
BMI:

General Survey
Body Assessment Actual Findings Normal Analysis
Findings
Body built, height, weight, in Proportionate,
relation to the client’s age, varies with
health and lifestyle lifestyle.
Client’s posture, gait, Relaxed, erect
standing, walking, and sitting posture;
coordinated
movement.
Client’s overall hygiene and Clean and neat.
grooming
Body and breath odor No body odor or
minor body odor
relative to work
or exercise; no
breath odor.
Signs of distress in posture No distress
or facial expression noted.
Signs of health and illness Healthy
appearance.
Client’s attitude Cooperative.
Client’s affect/mood; Appropriate to
appropriate of the client situation.
responses
Quantity and quality of Understandable,
speech moderate pace;
exhibits thoughts.
Relevance and organization of Logical sequence;
thoughts makes sense; has
sense of reality.