A.

Focused Assessment
Body Part Examined Actual Finding Normal Finding Clinical Significance
INTEGUMENT
Skin
I: color, uniformity,
edema, lesions
P: moisture, temp.
turgor
Hair
I: evenness of growth
thickness, texture,
oiliness, infection
or infestation, body
hair
P: smoothness
Nail
I: plate shape, texture,
bed color,
surrounding tissues
P: Blanch test
HEAD
Skull and Face
I: size, shape ,
symmetry
: facial features
: eyes for edema
and hollowness
P: nodules, masses,
depressions
Eyes and Vision
I: eyebrows for
distribution &
alignment, quality &
movement
: eyelashes for
evenness of
distribution &
direction of curl
: eyelids for surface
characteristics, position in
relation to cornea, ability
to blink & frequency
: bulbar & palpebral
conjunctiva for color,
texture, and lesion
I/P: lacrimal gland sac,
nasolacrimal duct for
edema, tenderness /
tearing
I: cornea for clarity, texture
& sensitivity
I: pupils for color, shape,
symmetry of size, direct
and consensual reaction
to light, &
accommodation
* Visual Acuity (near & far
vision test)
* Visual Field Test
* EOM Test
Ears and Hearing
I: auricles for color,
 symmetry and position
: external canal for
cerumen, lesions, pus or
blood
P: auricles for texture,
elasticity and areas of
tenderness
* Gross Hearing Acuity
Tests: normal voice tone
and whispered voice
* Watch Tick Test
* Tunning Fork Tests:
- Weber for bone
conduction
- Rinne’s to compare air
and bone conductions
Nose and Sinuses
I: nose deviation in shape
size, color, flaring,
discharge;
: nasal mucosa for
redness, swelling, growth
or discharge
Pa: tenderness, masses,
displacements;
: nasal patency
: maxillary and frontal
sinuses for tenderness
Pe: the above sinuses for
tenderness
Transillumination Test
Mouth / Oropharynx
I: lips for symmetry of
contour, color, texture,
moisture, lesion
: teeth for alignment, loss,
dental filings and caries;
: gums for bleeding, color,
retraction, lesions,
swelling
: tongue for position, color
& texture; movement, as
well as the base of the
tongue, mouth floor and
frenulum
: salivary gland ducts for
swelling, redness
: palates for color, shape,
texture, presence of bony
prominences
: uvula for position &
mobility
: oropharynx for color &
texture
: tonsils for color,
discharge, and size
Test for Gag Reflex
P: nodules, lump and
excoriated areas
NECK
Neck Muscles
I: abnormal swelling or
 masses, head movement,
and muscle strength
Lymph Nodes
P: enlargement
Trachea
P: lateral deviation
Thyroid Gland
I: symmetry and visible
masses, rise during
swallowing
P: smoothness
A: bruit
THORAX & LUNGS
Posterior Thorax
I: shape & symmetry from
posterior-lateral views;
spinal alignment for
deformities
Pa: temperature, bulges,
tenderness, abnormal
movements, respiratory
excursion, vocal
fremitus
Pe: for symmetry of
resonance;
diaphragmatic
excursion
A: breath sounds

Anterior Thorax
I: breathing pattern, coastal
and costovertebral angle
Pa: respiratory excursion,
tactile fremitus
Pe: symmetry of resonance
A: breath sounds
Heart
I: precordium for
pulsations & lifts or
heaves
A: heart sounds (S1, S2,
etc.)
Central Vessels:
Carotid Arteries
P: volume, quality
A: bruit
Jugular Veins
I: distention
Peripheral Vessels
I: presence or appearance
of superficial veins, signs
of phlebitis
*Buerger’s Test
*Capillary Refill
Breast & Axillae
I: breast for size,
symmetry, contour or
shape, discoloration,
retraction,
hypervascularity,
swelling, edema
: areaola for size, shape,
 symmetry, color, surface
characteristics, masses,
lesions
: nipples for size, shape,
position, color, discharge,
lesion
P: lymph nodes, breast,
areola & nipples for
tenderness, masses,
nodules, discharge
ABDOMEN
I: skin integrity, contour &
symmetry, hernia,
distention (girth),
movements associated
w/ respiration, peristalsis
& aortic pulsations
A: bowel, vascular, &
peritoneal friction rub
sounds
Pe: all quadrants / regions
for tympany and
deviations
Pa: light to deep palpations If necessary / applicable
ALL quadrants from least / significant
painful to most painful for
masses, tenderness,
muscle guarding; liver
(bimanual) and bladder
palpation
* Leopold’s Maneuver for
OB clients for
presentation, lie,
engagement, attitude,
position
MUSCULOSKELETAL
Muscles
I: size, contractures,
fasciculations, tremors
P: tonicity, flaccidity,
spasticity, smoothness of
movement, strength If necessary / applicable
Bones / significant
I: structure, deformity
P: edema, tenderness
Joints
I: swelling
P: tenderness, smoothness
of movement, swelling,
crepitation, nodules
NEUROLOGIC
Mental Status
- Language
- Orientation
- Memory
- Attention Span /
Calculation
Consciousness Level
Glassgow Coma Scale
Cranial Nerves
- I to XII
Reflexes
- Deep, superficial &
pathologic
Gross Motor/Balance
* Walking Gait
* Romberg
* Standing on 1 foot w/
eyes closed
* Heel-toe walking
Fine Motor
- Upper Extremities:
* Finger-Nose Test
* Alternate Supination &
Pronation of hands on
knees
* Finger to Nose & to RN
finger
* Fingers-to-fingers
* Fingers-to-thumb
- Lower Extremities:
* Heel down opposite skin
* Toe / Ball of Foot to RN’s
finger If necessary / applicable
Sensory Function / significant
* Light/Deep Touch
* Pain Sensation
* Temperature
* Position / Kinesthetic
* Tactile Discrimination
GENITALS
*For males:
I: pubic hair for distribution,
amount, characteristics
: penis shaft and glans for
lesions, nodules,
swelling, inflammation
: urethral meatus for
swelling, inflammation,
discharge
: inguinal areas for bulges
or swelling
P: penis for tenderness,
thickening, nodules
: scrotum for appearance,
size and symmetry, and
underlying testes,
epididymis and spermatic
cord
: inguinal areas for If necessary / applicable
palpable bulge / significant
* For females:
I: pubic hair distribution,
amount, characteristics;
its areas for parasites,
inflammation, swelling,
lesions
: clitoris, urethral and
vaginal orifices for
inflammation or discharge
P: bartholin’s glands,
lymph nodes for
enlargement, tenderness,
swelling
* Internal Exam for OB
clients for cervical
dilation, effacement and
AP pelvic diameter
RECTUM & ANUS If necessary / applicable
I: anus and surrounding / significant
tissue for color, integrity,
lesions
P: anal spinchter tonicity,
nodules, masses and
tenderness
: if male, prostate gland
for tenderness
: if female, cervix through
the anterior rectal wall for
tenderness