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PHYSICAL ASSESSMENT

Area Assessed Technique Actual Findings Normal Findings Interpretation

1. SKIN color Inspection Light to deep brown Light to deep brown Normal

Skin color uniformity Inspection Gen. uniform Uniform in color warm


Normal

Skin temperature Warm Warm

Skin turgor Palpation Returns to previous Skin intact/ Spring Normal


state when pinched Back to previous state
when pinched
Skin moisture Dry Dry Dehydrated

Presence of edema Palpation No signs of edema No sign of edema Normal

Presence of skin Palpation None None Normal


lesion

2. Nails
Fingernail plate Inspection Convex Convex, Curvature Normal
shape

Color Inspection Vascular Highly vascular Normal

3. HAIR
Hair evenness of Inspection Evenly distributed, Evenly distributed, Normal
growth, thickness, moderately thick thick hair
thinness

Hair texture and Inspection Oily Normal


oiliness over the
scalp

Presence of Inspection Presence of dry Silky and resilient hair Due to


inspection/ scalp unhygienic
Infestation practices
4. Head/Skull
Symmetry Inspection None None Normal
Size and Shape

Presence Of Inspection None None Normal


nodules Masses,
Depression

5. SCALP
Color and Inspection Symmetric Symmetric Normal
appearance

Areas of Palpation Normocephalic, Rounded, Normal


tendernerness smooth normocephalic,Smooth

6. EARS
Placement Inspection Symmetric Smooth, uniform in Normal
consistency, absence
of modules and
masses

Color Inspection No visible flakes Yellow overtoned,no Normal


visible flakes
Symmetry Inspection Auricle aligned with Auricle Aligned with Normal
cantus of eye outer cantus of eye

External Ear Canal Inspection No discharge/ No Normal


Discoloration discharge/discoloration

7. FACE Symmetry Inspection symmetrical Same color in the face Normal

8. EYEBROWS
Hair distribution, Inspection Symmetric Symmetrical both sides Normal
alignment, skin and Hair evenly Hair evenly distributed
movement distributed

9. EYELASHES
Hair distribution and Inspection Symmetrical Symmetrical Normal
direction of curl
Hair evenly Hair evenly distributed Normal
distributed
Equally distributed Equally distributed
curled slightly curled slightly outward
outward
10. EYELIDS I
Surface, nspection Skin intact, no Skin intact, no Normal
characteristic, discharge no discharge no
Position in relation to discoloration, lids discoloration, lids close
cornea, ability to close symmetrically symmetrically, bilateral
blink, frequency of blinking
blinking

11. CONJUNCTIVA
Color, texture, and Inspection Shiny, smooth, red Shiny, smooth, red Normal
presence of lesions No lesions No lesions

12. SCLERA
Color and clarity Inspection White and vascular, White and vascular, Normal
clear clear
13. CORNEA
Clarity and texture Inspection Clear and Clear and transparent, Normal
transparent, shiny shiny smooth in texture
smooth in texture

14. IRIS
Shape Inspection Flat = Round Flat = round Normal
Black
15.PUPILS
Light reaction & Inspection With Glasgow Varies from green blue, With Glasgow
accommodation Coma Scale of 1, brown Coma Scale of
Size and color Pupil size 3, Equally round size & 1, eyes never
Lacrimal gland equally round size color open
Lacrimal sac and color

16.NOSE
Any deviation in Inspection Nasal septum intact Nasal septum intact Normal
shape, size, color, & And in midline And in midline
flaring

Nasal cavities for Inspection Air moves clearly Air moves clearly as Normal
redness, swelling, as the client the client breathes thru
growth & discharge breathes thru nose nose

With NGT None For OF

Nasal septum Inspection Symmetric Symmetry of contour Normal


Uniform pink color
Soft, moist smooth

Any tenderness, Inspection/ No tenderness nor No tenderness nor Normal


masses, Palpation displacement of displacement of bones
displacement of bones and cartilage and cartilage
bones & cartilage
17. LIPS
Symmetry of Inspection Moist, plum Uniform pink; moist Poor circulation
contour, color & Glistening; elastic
texture

18. Buccal Mucosa


Color, moisture, Inspection Redish, no lesion Redish, no lesion, Normal
texture, lesions moist

19. TEETH
Color, number, Inspection Yellowish, poor Poor oral
condition and condition hygiene
presence of practice
dentures

20.GUMS
Color and condition Inspection dark, moist Pink gums, moist and Normal
firm. Texture,
No retractions
21. TONGUE
Color,t exture, Inspection While slightly Pink to reddish Normal
position rough, position, moist
Movement Central position, Moves freely
moist
22. PALATES AND
UVULA
Color, shape, texture Inspection Light pink, smooth Light pink, smooth, Normal
and movement moves freely

Position None Midline of soft palate Normal

23. NECK ROM/LOM

Masses, Lesions Palpation None None Normal

Lymph Nodes Palpation None None Normal


Note: for tenderness

24. TRACHEA
Placement Inspection/ Located at median Located at median of Normal
Palpation of neck neck

25. Thyroid gland


Symmetry and Inspection Symmetric, Symmetric, Normal
visible None None
Masses

Tenderness/Nodules Inspection None None Normal


26. CHEST & LUNGS
Contour Symmetry Inspection Symmetric Symmetrical Normal
Chest Cage

LUNGS Ausculatation With crackling Quiet, rhythmic =, Presence of


sound effortless respiration fluid inside the
lungs

27. ABDOMEN
Skin/Integrity Palpation Unblemished skin, Unblemished skin, Normal
uniform color uniform color

Any enlargement of Palpation None None Normal


Spleen/Liver

28. POSTERIOR
THORAX
Size, shape & Inspection/ Symmetric Symmetrical Normal
symmetry Palpation