V.

Physical Assessment

AREA TECHNIQUE NORMS FINDINGS ANALYSIS and INTERPRETATION

A. SKULL

1. Size, shape and Inspection Rounded Rounded(normoceph Normal

symmetry of the skull Palpation (normocephalic alic); smooth skull
and symmetrical, contour
with frontal,
parietal, and
occipital
prominences);
Smooth skull
contour

2. Presence of Palpation Smooth, uniform Has no tenderness; Normal

nodules, masses, and Inspection consistence; no masses nor
depressions absence of nodules nodules
or masses

3. Facial Features Inspection Symmetric or Symmetrical and Normal

Palpation slightly asymmetric palpebral fissure
facial features; equal in size,
palpebral fissure nasolabial folds are
equal in size; symmetrical
symmetric
nasolabial

4. Presence of edema Inspection No edema and Has Hollowness Abnormal, Volume deficiency of fat within
and hollowness in the hollowness the orbit (the space inside of the bony eye
eye. socket). This condition of the patient is
related to his nutritional status, she is
malnourished. Her BMI is 12.5.
 (http://www.drmeronk.com/hollowed/under
-eye-hollows.html)
C. HAIR

1. Evenness of Inspection Evenly distributed Evenly distributed Normal

growth, thickness, or Palpation and covers the with no patches of
thinness of hair whole scalp; Maybe hair loss; thick hair
thick or thin

2. Texture and Inspection Silky; resilient hair Silky, smooth and Normal.
oiliness over the Palpation resilient hair
scalp

3. Presence of Inspection No infection and Presence of lice Abnormal, There is pediculosis, a type of
infection and Palption infestation parasitic infection. Lice may be contracted
infestation from infcetd clothes and direct contact
with an infected person. The idea is that an
oily substance, such as oil, smothers the
lice and they may die. (Kozier,
Fundamentals of Nursing 7th ed. Page 733)

D. FACE

Facial features, Inspection Symmetric or Symmetrical facial Normal

symmetry of facial slightly asymmetric features while talking
movements facial features; or elevating the
palpebral fissures eyebrow. Equal
equal in size; palpebral fissure,
symmetric symmetrical
nasolabial folds nasolabial folds.

IV. EYES
A. EYEBROWS Inspection Hair distribution Hair eventually Normal
and alignment of distributed; skin
skin quality and
movement

B. EYELASHES Inspection For evenness of Equally distributed Turned inward

distribution and
direction of curl

C. EYELIDS

Surface Inspection Upper eyelids Able to close the Normal

characteristics and cover the small eyes and has the
position (in relation to portion of the iris, ability to blink.
the cornea, ability to cornea, and sclera
blink, and frequency when eyes are
of blinking) open; eyelids meet
completely when
the eyes are
closed;
symmetrical

D. CONJUNCTIVA

1. Color, texture, and Inspection Pinkish or red in Pale color; smooth in Abnormal, pale conjunctiva may be related
the presence of Palapation color; with texture to the low RBC level of the patient.
lesions in the bulbar presence of small (Fundamentals of Nursing 5th edition by
conjunctiva capillaries; moist; Taylor, page 642)
no foreign bodies;
 no ulcers

2. Color, texture, and Inspection Pinkish or red in Pale Abnormal, pale conjunctiva may be related
the presence of Palpation color; with to the low RBC level of the patient.
lesions in the presence of small (Fundamentals of Nursing 5th edition by
palpebral conjunctiva capillaries; moist; Taylor, page 642)
no foreign bodies;
no ulcers

E. SCLERA

Color and clarity Inspection White in color; White sclera with Normal
clear; no yellowish some visible
discoloration; some capillaries, anicteric
capillaries maybe sclera.
visible

F. CORNEA

Clarity and texture Inspection No irregularities on Clear and smooth in Normal

the surface; looks texture
smooth; clear or
transparent

G. IRIS

Shape and color Inspection Anterior chamber is Dark brown in color; Normal
transparent; no transparent anterior
noted visible chamber
materials; color
depends on the
person’s race
H. PUPILS

1. Color, shape, and Inspection Color depends on Pupil size is 3mm. Normal
symmetry of size the person’s race;
size ranges from 3-
7 mm, and are
equal in size;
equally round

2. Light reaction and Inspection Constrict Dilates when looking Normal

accommodation briskly/sluggishly at far objects and
when light is constricts when
directed to the eye, looking at near
both directly and objects. Constricts
consensual when there is light.

I. VISUAL ACUITY

1. Near vision Inspection Able to read Nearsightedness Abnormal, it is a refractive defect of the
newsprint (Myopia) eye in which collimated light produces
image focus in front of the retina when
accommodation is relaxed. It is caused by
an eyeball that is longer than normal,
which may be a familial trait. Transient
mayopia occurs due to influenza, steroids,
sever dehydration and large intake of
antacids. (Black, Medical Surgical
Nursing7th edition, page 1963).
J. LACRIMAL GLAND

Palpability and Palpation No edema or No tenderness and Normal

tenderness of the tenderness over edema noted.
lacrimal gland lacrimal gland
K. EXTRAOCULAR
MUSCLES

Eye alignment and Inspection Both eyes Moves in Unison Normal

coordination coordinated, move
in unison, with
parallel alignment

L. VISUAL FIELDS

Peripheral visual Inspection When looking Can see objects in The right eye of the patient has a cataract
fields straight ahead, the periphery.
client can see
objects in the
periphery

V. EARS

A. AURICLES

1. Color, symmetry of Inspection Color same as Same color as the Normal

size, and position facial skin; facial skin; tip of
symmetrical; auricle aligned at the
auricle aligned with outer canthus of the
outer canthus of eye.
eye, about 10
degrees from
vertical

2. Texture, elasticity Palpation Mobile, firm, and Smooth in texture, Normal

and areas of not tender; pinna flexible and elastic
tenderness recoils after it is pinna; no tenderness
folded
C. HEARING ACUITY
TESTS

1. Client’s response Inspection Normal voice tones Can hear normal Normal
to normal voice tones audible volume tones or
words.

VI. NOSE

1.Any deviations in Inspection Symmetric and Symmetric and Abnormal, Nasal flaring suggests airway
shape, size, or color straight; no straight; Uniform obstruction. Nasal discharge shows the
and flaring or discharge or color with nasal presence of mucus secretions in the air
discharge from the flaring; Uniform flaring. tract.
nares color

2. Nasal septum Inspection Nasal septum Nasal septum intact Normal

(between the nasal Palpation intact and in and in midline
chambers) midline

3. Patency of both Inspection Air moves freely as Only left nares is Abnormal, not patent right nares show the
nasal cavities the client breathes patent. Right nares is presence of mucus secretions and would
through the nares with secretion. suggest there is an infection in the
respiratory system.

4. Tenderness, Palpation Not tender; no Nor tenderness nor Normal

masses, and lesions lesions.
displacements of
bone and cartilage

VII. SINUSES

Identification of the Inspection Not tender Not painful when Normal

sinuses and for
tenderness palpated

VIII. MOUTH

A. LIPS

Symmetry of contour, Inspection Uniform pink color; Pink in color, dry and Abnormal, May suggest cellular
color and texture Palpation soft, moist, smooth cracked lips dehydration. (Black, Medical Surgical
texture; symmetry Nursing7th edition, page 208).
of contour; ability
to purse lips

B. BUCCAL
MUCOSA

Color, moisture, Inspection Uniform pink color; Pink color and dry. Abnormal, May suggests dehydration.
texture, and the moist, smooth, (Black, Medical Surgical Nursing7th
presence of lesions soft, glistening, and edition, page 208).
elastic texture

C. TEETH

Color, number and Inspection 32 adult teeth; Has 31 adult teeth. Abnormal, most unpleasant odor are
condition and smooth, white, The patient has known to arise from proteins trapped in
presence of dentures shiny tooth yellowish teeth. Have the mouth which are processed by oral
enamel; smooth, bad breath. Have bacteria. The most common location for
intact dentures tooth decay in the mouth-related halitosis is the tongue. It is
lower right second also related to dental carries and
molars. frequency of tooth brushing.

D. GUMS
Color and condition Inspection Pink gums; no Pink gums; has no Normal
retraction visible retractions

E. TONGUE/FLOOR
OF THE MOUTH

1. Color and texture Inspection pink color; moist; Pink and moist. Normal
of the mouth floor slightly rough; thin Tongue moves freely
and frenulum. whitish coating; and no pain felt.
moves freely; no
tenderness

2. Position, color and Inspection Central position; Located and Normal

texture, movement pink color; smooth positioned in the
and base of the tongue base with center.
tongue prominent veins

3. Any nodules, Palpation Smooth with no No tenderness nor Normal

lumps, or excoriated Inspection palpable nodules, masses
areas lumps, or
excoriated areas

F. PALATES and
UVULA

1. Color, shape, Inspection Light pink, smooth, The hard palate has Normal
texture and the Palpation soft palate; lighter a lighter color than
presence of bony pink hard palate , the soft palate; has
prominences more irregular quite rough texture
texture

2. Position of the Inspection Positioned in Positioned at the Normal

uvula and mobility midline of soft center of the
(while examining the
palates) palate oropharynx

G. OROPHARYNX
and TONSILS

1. Color and texture Inspection Pink and smooth Dry, pinkish in color. Abnormal, May suggests dehydration.
posterior wall (Black, Medical Surgical Nursing7th
edition, page 208).

2. Size, color, and Inspection Pink and smooth; Has no discharge; Normal
discharge of the no discharge; of pinkish
tonsils normal size

3. Gag reflex Inspection Present Present Normal

X. THORAX

A. ANTERIOR
THORAX

1. Breathing patterns Inspection Quiet, rhythmic, Difficulty of Abnormal, labored breathing is a common
and effortless breathing manifestation affecting clients with cardiac
respirations and pulmonary disorders. It is related to
obstructed airway. It also related to the
decreased size of the lungs due to PTB.
(Black, Medical Surgical Nursing7th
edition, page 1566).

2. Temperature, Palpation Skin intact; uniform Has an intact skin; Normal

tenderness, masses temperature; chest has equal warmth on
wall intact; no both sides. No
tenderness; no masses.
masses
3. Anterior thorax Auscultation Bronchovesicular Has crackles sounds Abnormal, crackles or rales are audible
auscultation and vesicular on the upper thorax when there is a sudden opening of small
breath sounds & lower thorax airways that contain fluid. It is usually
heard during inspiration. (Black, Medical
Surgical Nursing7th edition, page 1756).

B. POSTERIOR
THORAX

1. Shape, symmetry, Inspection Anteroposterior to Has a Normal

and comparison of Palpation transverse anteroposterior to
anteroposterior diameter in ratio transverse diameter
thorax to transverse 1:2; Chest ratio of 1:2, elliptical
diameter symmetric in shape and
symmetrical chest

2. Spinal alignment Inspection Spine vertically Has a vertical Normal

aligned alignment

3. Temperature, Palpation Skin intact; uniform No masses nor Normal

tenderness, and temperature; chest tenderness; has
masses wall intact; no equal warmth on
tenderness; no each side
masses

7. Posterior thorax Auscultation Vesicular and Has crackles heard Abnormal, the condition is related to the
auscultation bronchovesicular on the anterior and decreased size of the right lung and poor
breath sounds middle part of right inspiratory effort due to pain.
and left lungs. (http://www.nurse411.com/Heart_Lung_So
Diminished lung unds.asp)
sound on the
posterior right
 lung.

XI.
CARDIOVASCULAR

A. AORTIC and Auscultation No pulsations No pulsations felt Normal

PULMONIC AREAS

B. TRICUSPID AREA Auscultation No pulsations; no No pulsations of lifts Normal

lift or heave

C. APICAL AREA Auscultation Pulsations visible in Has full pulsation Normal

50% of adults and
palpable in most
PMI in fifth LICS at
or medial to MCL

D. EPIGASTRIC Auscultation Aortic pulsations Has pulsation Normal

AREA

E. Auscultation S1: Usually heard Has full and rapid Normal

CARDIOVASCULAR at all sites pulsation. 84
AREAS bpm/minute.
AUSCULTATION Usually louder at
the apical area Sounds on the aortic Normal
and pulmonic areas;
S2: Usually heard has a lub sound on
at all sites the apex and dub
sounds on the
Usually louder at
tricuspid area. Normal
the base of heart
Blood pressure is
Systole: silent
90/70 mm Hg.
interval; slightly
shorter duration
 than diastole at
normal heart rate
(60 to 90
beats/min)

Diastole: silent
interval; slightly
longer duration
than systole at
normal heart rates

S3: in children and

young adults

S4: in many older

adults

XII. CAROTID
ARTERIES

1. Carotid artery Palpation Symmetric pulse Has weak pulsation. Abnormal, decreased amount of blood
palpation volumes; full Symmetrical pulse. volume passing the artery. (Black, Medical
pulsations, Surgical Nursing7th edition, page 1574).
thrusting quality;
quality remains
same when the
client breathes,
turns head, and
changes from
sitting to supine
position; elastic
arterial wall
XIV. AXILLAE

1. Axillary, Inspection No tenderness, Have no masses and Abnormal, The appocrine glands located in
subclavicular, and masses, or nodules nodules. Presence of the axillae produces sweat. The secretion
supraclavicular lymph a foul smelling odor. of these glands is odorless, but when
nodes decomposed or acted upon by bacteria in
the skin, it takes on a musky, unpleasant
odor. (Kozier et.al, Fundamentals of
Nursing 7th ed. Page 699)

XV. ABDOMEN

1. Skin integrity Inspection Unblemished skin; Uniform color and Normal

uniform color has no blemishes

2. Abdominal contour Inspection Flat, Has a concave Normal

rounded(convex), abdomen.
or
scaphoid(concave)

3. Enlargement of Inspection No evidence of No enlargement of Normal

liver or spleen enlargement of the spleen and liver
liver or spleen seen

4.Symmetry of Inspection Symmetric contour Has a symmetrical Normal

contour abdominal contour

5. Abdominal Inspection Symmetric Abdominal Normal

movements movements caused movements noted
associated with by respiration; when inhaling.
respirations, visible peristalsis in
peristalsis or aortic very lean people;
pulsations aortic pulsations in
thin persons at
 epigastric area

6. Vascular pattern Inspection No visible vascular Has no blood vessels Normal

pattern visible

XVI.
MUSCULOSKELETA
L SYSTEM

A. MUSCLES

1. Muscle size and Inspection Proportionate to Proportionate to the Normal

comparison on the the body; even in body; even in both
other side both sides sides

2. Fasciculation and Inspection No fasciculation Has no fasciculation Normal

tremors in the and tremors and tremors
muscles

3. Muscle tonicity Palpation Even and firm Weak muscle tone Abnormal, possibly related to the amount
muscle tone of food that patient is eating. Possible
exhaustion experienced by the patient
when she coughs.
(http://en.wikipedia.org/wiki/Muscle_weakn
ess)
4. Muscle strength Palpation Has equal muscular Weak muscle Abnormal, possibly related to the amount
strength on both strength of food that patient is eating. Possible
sides exhaustion experienced by the patient
when she coughs.
(http://en.wikipedia.org/wiki/Muscle_weakn
ess)
C. JOINTS

1. Joint swelling Inspection No swelling, no No swelling, no Normal

 warmth, no warmth, no redness,
redness, no pain, no pain, no crepitus
no crepitus

EXTREMETIES Inspection, No swelling, no No edema, no pain Normal

Palpation warmth, no when moved.
redness, no pain.