Physical Assessment

Integument

● Skin: The client’s skin is uniform in color, unblemished and no

presence of any foul odor. He has a good skin turgor and skin’s

temperature is within normal limit.

● Hair: The hair of the client is thick, silky hair is evenly distributed

and has a variable amount of body hair. There are also no signs of

infection and infestation observed.

● Nails: The client has a light brown nails and has the shape of

convex curve. It is smooth and is intact with the epidermis. When

nails pressed between the fingers (Blanch Test), the nails return to

usual color in less than 4 seconds.

Head

● Head: The head of the client is rounded; normocephalic and

symmetrical.

● Skull: There are no nodules or masses and depressions when

palpated.

● Face: The face of the client appeared smooth and has uniform

consistency and with no presence of nodules or masses.

Eyes and Vision

● Eyebrows: Hair is evenly distributed. The client’s eyebrows are

symmetrically aligned and showed equal movement when asked to

raise and lower eyebrows.

 ● Eyelashes: Eyelashes appeared to be equally distributed and curled

slightly outward.

● Eyelids: There were no presence of discharges, no discoloration

and lids close symmetrically with involuntary blinks approximately

15-20 times per minute.

● Eyes

○ The Bulbar conjunctiva appeared transparent with few

capillaries evident.

○ The sclera appeared white.

○ The palpebral conjunctiva appeared shiny, smooth and

pink.

○ There is no edema or tearing of the lacrimal gland.

○ Cornea is transparent, smooth and shiny and the details of

the iris are visible. The client blinks when the cornea was

touched.

○ The pupils of the eyes are black and equal in size. The iris

is flat and round. PERRLA (pupils equally round respond to

light accommodation), illuminated and non-illuminated

pupils constricts. Pupils constrict when looking at near

object and dilate at far object. Pupils converge when object

is moved towards the nose.

○ When assessing the peripheral visual field, the client can

see objects in the periphery when looking straight ahead.

○ When testing for the Extraocular Muscle, both eyes of the

client coordinately moved in unison with parallel alignment.

○ The client was able to read the newsprint held at a distance

of 14 inches.

Ears and Hearing

 ● Ears: The Auricles are symmetrical and has the same color with his

facial skin. The auricles are aligned with the outer canthus of eye.

When palpating for the texture, the auricles are mobile, firm and not

tender. The pinna recoils when folded. During the assessment of

Watch tick test, the client was able to hear ticking in both ears.

Nose and Sinus

● Nose: The nose appeared symmetric, straight and uniform in color.

There was no presence of discharge or flaring. When lightly

palpated, there were no tenderness and lesions

● Mouth:

○ The lips of the client are uniformly pink; moist, symmetric

and have a smooth texture. The client was able to purse

his lips when asked to whistle.

○ Teeth and Gums: There are no discoloration of the

enamels, no retraction of gums, pinkish in color of gums

○ The buccal mucosa of the client appeared as uniformly

pink; moist, soft, glistening and with elastic texture.

○ The tongue of the client is centrally positioned. It is pink in

color, moist and slightly rough. There is a presence of thin

whitish coating.

○ The smooth palates are light pink and smooth while the

hard palate has a more irregular texture.

○ The uvula of the client is positioned in the midline of the

soft palate.

● Neck:

○ The neck muscles are equal in size. The client showed

coordinated, smooth head movement with no discomfort.

○ The lymph nodes of the client are not palpable.

 ○ The trachea is placed in the midline of the neck.

○ The thyroid gland is not visible on inspection and the

glands ascend during swallowing but are not visible.

Thorax, Lungs, and Abdomen

● Lungs / Chest: The chest wall is intact with no tenderness and

masses. There’s a full and symmetric expansion and the thumbs

separate 2-3 cm during deep inspiration when assessing for the

respiratory excursion. The client manifested quiet, rhythmic and

effortless respirations.

● The spine is vertically aligned. The right and left shoulders and hips

are of the same height.

● Heart: There were no visible pulsations on the aortic and pulmonic

areas. There is no presence of heaves or lifts.

● Abdomen: The abdomen of the client has an unblemished skin and

is uniform in color. The abdomen has a symmetric contour. There

were symmetric movements caused associated with client’s

respiration.

○ The jugular veins are not visible.

○ When nails pressed between the fingers (Blanch Test), the

nails return to usual color in less than 4 seconds.

Extremities

● The extremities are symmetrical in size and length.

● Muscles: The muscles are not palpable with the absence of

tremors. They are normally firm and showed smooth, coordinated

movements.
 ● Bones: There were no presence of bone deformities, tenderness

and swelling.

● Joints: There were no swelling, tenderness and joints move

smoothly.

Nursing Assessment in Tabular Form

Assessment Findings

Integumentary

● Skin When skin is pinched it goes to

previous state immediately (2
seconds).

With fair complexion.

With dry skin

● Hair Evenly distributed hair.

With short, black and shiny hair.

With presence of pediculosis Capitis.

● Nails Smooth and has intact epidermis

With short and clean fingernails and

toenails.

Convex and with good capillary refill

time of 2 seconds.

Skull Rounded, normocephalic and

symmetrical, smooth and has
uniform consistency.Absence of
nodules or masses.
Face Symmetrical facial movement,
palpebral fissures equal in size,
symmetric nasolabial folds.

Eyes and Vision

● Eyebrows Hair evenly distributed with skin

intact.

Eyebrows are symmetrically aligned

and have equal movement.

● Eyelashes Equally distributed and curled

slightly outward.

● Eyelids Skin intact with no discharges and

no discoloration.

Lids close symmetrically and blinks

involuntary.

● Bulbar conjunctiva Transparent with capillaries slightly

visible

● Palpebral Conjunctiva Shiny, smooth, pink

● Sclera Appears white.

● Lacrimal gland, Lacrimal No edema or tenderness over the

lacrimal gland and no tearing.
sac, Nasolacrimal duct

Cornea

● Clarity and texture Transparent, smooth and shiny

upon inspection by the use of a
penlight which is held in an oblique
angle of the eye and moving the
 light slowly across the eye.

Has [brown] eyes.

● Corneal sensitivity Blinks when the cornea is touched

through a cotton wisp from the back
of the client.

Pupils Black, equal in size with consensual

and direct reaction, pupils equally
rounded and reactive to light and
accommodation, pupils constrict
when looking at near objects, dilates
at far objects, converge when object
is moved toward the nose at four
inches distance and by using
penlight.

Visual Fields When looking straight ahead, the

client can see objects at the
periphery which is done by having
the client sit directly facing the
nurse at a distance of 2-3 feet.

The right eye is covered with a card

and asked to look directly at the
student nurse’s nose. Hold penlight
in the periphery and ask the client
when the moving object is spotted.

Visual Acuity Able to identify letter/read in the

newsprints at a distance of fourteen
inches.

Patient was able to read the

newsprint at a distance of 8 inches.

Ear and Hearing

 ● Auricles Color of the auricles is same as
facial skin, symmetrical, auricle is
aligned with the outer canthus of
the eye, mobile, firm, non-tender,
and pinna recoils after it is being
folded.

● External Ear Canal Without impacted cerumen.

● Hearing Acuity Test Voice sound audible.

● Watch Tick Test Able to hear ticking on right ear at a

distance of one inch and was able to
hear the ticking on the left ear at
the same distance

Nose and sinuses

● External Nose Symmetric and straight, no flaring,

uniform in color, air moves freely as
the clients breathes through the
nares.

● Nasal Cavity Mucosa is pink, no lesions and nasal

septum intact and in middle with no
tenderness.

Mouth and Oropharynx Symmetrical, pale lips, brown gums

and able to purse lips.

● Teeth With dental caries and decayed

lower molars

● Tongue and floor of the Central position, pink but with

whitish coating which is normal,
mouth
with veins prominent in the floor of
the mouth.
 ● Tongue movement Moves when asked to move without
difficulty and without tenderness
upon palpation.

Uvula Positioned midline of soft palate.

Gag Reflex Present which is elicited through the

use of a tongue depressor.

Neck Positioned at the midline without

tenderness and flexes easily. No
masses palpated.

Head movement Coordinated, smooth movement

with no discomfort, head laterally
flexes, head laterally rotates and
hyperextends.

Muscle strength With equal strength

Lymph Nodes Non-palpable, non tender

● Thyroid Gland Not visible on inspection, glands

ascend but not visible in female
during swallowing and visible in
males.

Thorax and lungs

Posterior thorax Chest symmetrical

● Spinal alignment Spine vertically aligned, spinal

column is straight, left and right
shoulders and hips are at the same
height.

Breath Sounds With normal breath sounds without

dyspnea.
 ● Anterior Thorax Quiet, rhythmic and effortless
respiration

Abdomen Unblemished skin, uniform in color,

symmetric contour, not distended.

Abdominal movements Symmetrical movements cause by

respirations.

● Auscultation of bowel With audible sounds of 23 bowel

sounds/minute.
sounds

Upper Extremities Without scars and lesions on both

extremities.

Lower Extremities With minimal scars on lower

extremities

Muscles Equal in size both sides of the body,

smooth coordinated movements,
100% of normal full movement
against gravity and full resistance.

Bones and Joints No deformities or swelling, joints

move smoothly.

Mental Status

Language Can express oneself by speech or

sign.

Orientation Oriented to a person, place, date or

time.

Attention span Able to concentrate as evidence by

answering the questions
appropriately.
Level of Consciousness A total of 15 points indicative of
complete orientation and alertness.

Motor Function

Gross Motor and Balance

● Walking gait Has upright posture and steady gait

with opposing arm swing unaided
and maintaining balance.

Standing on one foot with eyes Maintained stance for at least five
closed (5) seconds.

Heel toe walking Maintains a heel toe walking along a

straight line

Toe or heel walking Able to walk several steps in

toes/heels.

Fine motor test for Upper

Extremities

Finger to nose test Repeatedly and rhythmically

touches the nose.

Alternating supination and pronation Can alternately supinate and

of hands on knees pronate hands at rapid pace.

Finger to nose and to the nurse’s Perform with coordinating and

finger rapidity.

Fingers to fingers Perform with accuracy and rapidity.

Fingers to thumb Rapidly touches each finger to

thumb with each hand.

Fine motor test for the Lower

Extremities

Pain sensation Able to discriminate between sharp

and dull sensation when touched
with needle and cotton.