UNIVERSITY OF PERPETUAL HELP

DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

Sto. Niño, Biñan City, Laguna

COLLEGE OF NURSING

V. PHYSICAL ASSESSMENT

Body Parts Technique Normal Findings Actual Findings Analysis

& Rationale
Skin Inspection  Light to Dark  Yellow skin color Abnormal
Palpation Brown  No swelling
 No swelling  No lesions Yellow
 No lesions  Slightly poor skin discoloration
 Good skin turgor turgor (jaundice) of
 Warm to touch  Warm to touch the skin may
 No noticeable  No noticeable indicate a
body odor body odor serious
problem with
the function
of your
RBC’s, liver,
gallbladder,
or pancreas.
Hair and Scalp Inspection  Evenly  Evenly Normal
Palpation distributed distributed
 Neither brittle nor  Neither brittle nor
dry dry
 No scars  No scars
 No lesions  No lesions
 No masses  No masses
 Free from lice  Free from lice
and nits and nits
Head Inspection  Face is  Face is Normal
symmetrical symmetrical
 Erect and in  Head is erect
midline and in midline
 Proportion to  Proportion to
body size body size
Neck Inspection  Symmetric with  Neck is Normal
Palpation head symmetric with
 Midline head
 No lesions  Midline
 No swelling  No lesions
 No tenderness or  No swelling
masses  No tenderness or
masses

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 UNIVERSITY OF PERPETUAL HELP
DR. JOSE G. TAMAYO MEDICAL UNIVERSITY
Sto. Niño, Biñan City, Laguna

COLLEGE OF NURSING

Eyes Inspection  Blinking  Blinking Abnormal

 Eyebrow  Symmetrically  Symmetrically
 Eyelashes align align Yellow
 Eyelids  Good extra  Good extra discoloration
 Sclera ocular movement ocular movement of the eyes
 Conjunctiva  Hair evenly  Hair evenly may indicate
 Pupil distributed distributed problems
 Without redness  Without redness with
and lesions and lesions gallbladder,
 White in color  Yellowish in liver, or
 Moist color pancreas.
 Pinkish in color  Moist
 Moist  Yellowish in
 Equally round color
and reactivate to  Moist
light and  Equally round
accommodation and reactivate to
light and
accommodation
Ears Inspection  No lesions  No lesions Normal
Palpation  No swelling  No swelling
 No discharge  No discharge
 Equal in size  Equal in size and
 Symmetrically symmetrically
align align
Nose Inspection  Uniform in color  Uniform in color Normal
Palpation  Symmetric and  Symmetric and
straight/midline straight/midline
 Dry or no  Dry or no
discharge discharge
 No swelling & No  No swelling & No
tenderness tenderness
 No redness on  No redness on
the nasal the nasal
mucosa mucosa
Lips Inspection  Soft, moist  Dry Abnormal
 Pinkish in color  Pale in color

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 UNIVERSITY OF PERPETUAL HELP
DR. JOSE G. TAMAYO MEDICAL UNIVERSITY
Sto. Niño, Biñan City, Laguna

COLLEGE OF NURSING

 Smooth texture  Dry texture Dry, chapped

 Ability to purse (chapped) and pale lips
lips  Ability to purse may indicate
lips decrease
fluid intake,
dehydration,
poor diet and
lack of
vitamins.
Teeth Inspection  Complete  Complete Normal
number of teeth number of teeth

Buccal Mucosa Inspection  Pink in color  Pink in color Normal

 Tonsillar pillars  Tonsillar pillars
symmetrical symmetrical
 Impalpable  Impalpable
Lymph nodes Lymph nodes
 Soft  Soft
 Moist  Moist
 Smooth  Smooth
 Glistening  Glistening
 Elastic texture
 Elastic texture
Throat Inspection  Pinkish in Color Pinkish in Color Normal
Tongue Inspection  No lesions  No lesions Normal
 No swelling  No swelling

Gums Inspection  Pinkish in color  Pinkish in Color Normal

 Moist  Moist
Chest and Lung Auscultation  No abnormal  No abnormal Normal
breath sound breath sounds
 Symmetric chest
 Symmetric chest expansion
expansion
Upper extremities Inspection  No lesions  No swelling Normal
Palpation  No swelling  No lesions
 No mumps  No mumps
 Light to dark  Light to dark in
brown in color color
 Symmetrically  Symmetrically
align align
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 UNIVERSITY OF PERPETUAL HELP
DR. JOSE G. TAMAYO MEDICAL UNIVERSITY
Sto. Niño, Biñan City, Laguna

COLLEGE OF NURSING

Nails Inspection  Capillary beds Normal

refill and color  Good capillary
returns in 1 to 2 refill
seconds

Abdomen Inspection  No lesions  (+) surgical Abnormal

Palpation  No tenderness lesions
 No tenderness JP Drain is
 (+) Jackson-Pratt for collecting
Drain bodily fluids
from surgical
site.
Lower Extremities Inspection  Right to left foot  Right to left foot Normal
Palpation has complete has complete
fingers fingers
 Skin color same  Skin color same
as the part of the as the part of the
body body
 Bilaterally  Bilaterally
symmetrical and symmetrical and
equal equal
 Should have no  Should have no
lesions lesions
 Edema Edema

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