Republic of the Philippines

Bulacan State University

City of Malolos, Bulacan

COLLEGE OF NURSING

PHYSICAL ASSESSMENT TABLE

Patient’s Initial: _M.C.N_ Age: _84__ Gender: __F__ Date Performed: February 09,2021
Medical Diagnosis: _Physical immobility________________ Chief Complaint: _________________________ Clinical Area: _________
Height: __1.4_ (m) Vital Signs:
Weight: __43__ (kg) Temp: _36.1____ (°C) PR: _84___ (bpm)
BMI: __19.0__ BP: _110/80__ (mm Hg) RR: _16_ (rpm)
BODY PARTS TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS REMARKS
ASSESSED
GENERAL SURVEY:
Body built Inspection Proportionate (Ectomorph, Ectomorph Normal Height
Height & weight Mesomorph, Endomorph); Client’s height is 5’1 ft. Weight
appropriate for her age and 43 kg. BMI 19.
The height appears within normal Normal
genetic heritage. Her
range for age, genetic heritage;
weight appears normal and
The weight appears within normal has minimal amount of fat
range for height and body build; in her body.
body fat distribution is even
Posture, symmetry & gait Inspection Stands comfortably erect, normal Stands comfortably erect, Age-Related changes
posture, walk is smooth, even, and normal posture, walk is
well balanced; with symmetric arm slight smooth, not even,
swing; and slightly well
balanced; with
Body parts look equal bilaterally symmetric arm swing;
and are relative in proportion to Body parts look equal
each other bilaterally and are
relative in proportion to
each other
 Physical deformities & Inspection No physical deformities, no signs
signs of health or illness of illness
Level of consciousness Inspection Alert and oriented, attends to
Palpation questions and responds to verbal
Percussion and non-verbal stimulation
appropriately
Behavioral (Mood and Inspection Comfortable and cooperative;
affect/ Speech/ Dress &
Hygiene)Status Appropriate to the climate, culture
and age groups;
Looks clean and well-groomed
Mental Status Inspection The person maintains eye contact;
expressions are appropriate to
situation
Language & Inspection Understandable; exhibits relevance
communication and organization of thoughts
SKIN:
Skin color, uniformity, Inspection Color varies from light to dark
presence of edema brown, uniform in color,
unblemished skin, no signs of
edema
Skin lesions Inspection No lesions or abrasions. Freckles,
birthmarks & moles are normal
No physical deformities, Normal
no signs of illness
Alert and oriented, attends Normal
to questions and responds
to verbal and non-verbal
stimulation appropriately
Comfortable and Normal
cooperative;
Appropriate to the climate,
culture and age groups;
Looks clean and well-
groomed
The person maintains eye Normal
contact; expressions are
appropriate to situation
Understandable;
exhibits relevance and Normal
organization of thoughts
Color varies from light to dark, Normal
uniform in color, blemished skin,
has a no sign of edema
No lesions, no freckles and Normal
birthmarks, presence of mole
and liver spots

Skin moisture & Palpation Moist where the skin folds and in Excessively moist where Normal
temperature axillae the skin folds and axillae
Skin turgor Inspection Skin springs back when pinched; < Skin springs back when Normal
3 seconds is normal pinched; < 3 seconds is
normal
NAILS:
Fingernail plate shape Inspection No clubbing or spooned; convex No clubbing or spooned; Normal
curvature, about 160 degrees convex curvature, about
 160 degrees
Fingernail color & texture Inspection & Pinkish in color, Fingernails are pale in color Normal
Palpation highly vascular, and has smooth texture
smooth texture
Tissues surrounding the Inspection Intact epidermis Intact epidermis Normal
nails
Capillary refill Inspection & Prompt return of usual color when Prompt return of usual color Normal
Palpation blanch test is performed when blanch test in performed
HEAD and FACE:
Evenness of hair growth Inspection Normal hair growth, thick hair, Normal hair growth, thick Normal
evenly distributed, silky hair, evenly distributed, silky
Scalp Inspection Pinkish scalp; no dandruff, lesions, Pinkish scalp; no dandruff, Normal
nodules or tenderness lesions, nodules or tenderness
Presence of infection or Inspection & Infection or infestations not present Infection or infestations not Normal
infestations Palpation present
Skull size, shape & Inspection Symmetric, round, erect and in Normal
symmetry midline and appropriately related to Symmetric, round, erect and
body size in midline and appropriately
related to body size

Facial movements Inspection No involuntary facial movements, No involuntary facial Normal

facial movements are symmetrical movements, facial movements
are symmetrical
EYES:
Eye condition Inspection Straight, normal and non- Straight, normal and non- Normal
protruding protruding
Eyebrows Inspection Symmetrically aligned, hair evenly Normal
distributed, no scaling Symmetrically aligned, hair
evenly distributed, no scaling
Eyelids & Eyelashes Inspection Intact skin, no discharge, eyelids Normal
close symmetrically Intact skin, no discharge,
eyelids close symmetrically

Ability to blink Inspection Approximately 15-20 involuntary Normal

blinks per minute Approximately 15-20
involuntary blinks per minute
 Bulbar conjunctiva Inspection Bulbar conjunctiva is clear, moist, Normal
and smooth. Underlying structures Bulbar conjunctiva is clear,
are clearly visible. moist, and smooth.
Underlying structures are
clearly visible.

Palpebral conjunctiva Inspection The lower and upper palpebral Normal

conjunctivae are clear and free of The lower and upper palpebral
swelling or lesions conjunctivae are clear and free
of swelling or lesions

Sclera Inspection Sclera appears white Sclera appears white

Normal

Cornea & Lens Inspection Cornea: transparent, shiny with no

opacities Cornea: transparent, shiny Normal
Lens: free of opacities with no opacities
Lens: free of opacities

Iris and Pupils Inspection Iris: typically round, flat and evenly
colored.
Pupils: Black in color, equal in size,
round, reactive to light and
accommodation reaction to light
Iris: typically round, flat and Normal
evenly colored.
Pupils: Black in color, equal
in size, round, reactive to light
and accommodation reaction
to light

Extraocular muscles Inspection Both eyes coordinated, move in Both eyes coordinated, move in Normal
unison and with parallel alignment unison and with parallel
alignment

Peripheral visual fields Inspection The client can see the object in the
periphery.
Visual Acuity Inspection Near vision: able to read
newsprint(or visual acuity of 14/14 Age related changes
– This means that the client can
 read what the normal eye can read
from a distance of 14in)
Distant vision: 20/20 Snellen Chart
EARS:
Auricles Color same as facial skin; Color same as facial skin; Normal
Color Inspection Symmetrical; aligned with the outer Symmetrical; aligned with the
Symmetry & Position canthus of the eye; Recoils back outer canthus of the eye; Recoils
Texture & Elasticity when its folded, mobile and firm
back when its folded, mobile and
firm

Ear canal walls pink and smooth,
External Canal Inspection without nodules; distal part has
Tympanic membrane hair follicle; presence of small
(eardrum) amount of waxes but no redness or
discharge;
Eardrums pearly grey in color,
shiny and translucent, with no
bulging or retractions
Ear canal walls pink and smooth,
without nodules; distal part has Normal
hair follicle; presence of small
amount of waxes but no redness
or discharge;
Eardrums pearly grey in color,
shiny and translucent, with no
bulging or retractions

Hearing Acuity Inspection Normal voice tones audible Audible; 1 inches from uncovered Age related changes
ear

Watch tick Test Inspection Audible; 1-2 inches from Audible; 1 inches from uncovered
uncovered ear ear
Age related changes

NOSE:
External Inspection Symmetrical and straight; no Symmetrical and straight; no normal
discharge or flaring; uniform in discharge or flaring; uniform in
color color

Nasal Septum Inspection Intact and in midline Intact and in midline Normal

Patency Palpation Air moves freely in and out of the Air moves freely in and out of the Normal
nasal cavities nasal cavities
Nasal cavities Inspection No obstruction, pinkish; clear No obstruction, pinkish; clear Normal
watery discharge; no lesion watery discharge; no lesion
Sinuses Palpation Frontal and maxillary sinuses: no Frontal and maxillary sinuses: no Normal
tenderness, masses or crepitus tenderness, masses or crepitus
noted noted
MOUTH:
Lips Inspection & Uniform in color, soft; moist, Uniform in color, soft; moist, Normal
Palpation smooth texture, symmetrical; smooth texture, symmetrical;
without lesions or swelling without lesions or swelling
Buccal Mucosa Inspection Pink in color; moist smooth soft Pink in color; moist smooth soft Normal
and elastic texture; without lesions and elastic texture; without
or swelling lesions or swelling
Inspection & Central position of tongue and Central position of tongue and Normal
Tongue Palpation frenulum, pink color; moves freely; frenulum, pink color; moves
no tenderness; prominent veins at freely; no tenderness; prominent
the base and no nodules veins at the base and no nodules
Teeth Inspection 32 permanent teeth, smooth and all teeth are Dentures
white enamel; no decayed areas or Age-Related Changes
missing teeth
Gums Inspection & Pink gums, moist firm texture, no Pink gums, moist firm texture, no Age-Related Changes
Palpation lesions, no discharge lesions, no discharge

Palates Inspection Soft: light pink, smooth Soft: light pink, smooth Normal
Hard: lighter pink, irregular texture Hard: lighter pink, irregular
texture

Uvula Inspection Positioned midline of the soft Normal

palate; no redness or exudates Positioned midline of the soft
palate; no redness or exudates

May be present or absent;

May be present or absent; pink,
pink, symmetric and smooth; Normal
Tonsils Inspection symmetric and smooth; no
no discharge or swelling
discharge or swelling present
present
Gag reflex Inspection Gag reflex is present Gag reflex is present
Normal
 NECK:
Neck movements Inspection Coordinated, smooth movement Coordinated, smooth movement
with no discomfort with no discomfort Normal

Neck muscles Inspection Equal strength, muscles equal in Equal strength, muscles equal in
size and head is centered and size and head is centered and Normal
without bulging masses without bulging masses
Lymph Nodes Inspection & Not seen nor palpable; no swelling Not seen nor palpable; no
Palpation or tenderness swelling or tenderness Normal

Trachea
Inspection and Central placement, midline of the Central placement, midline of the
Normal
palpation neck neck
Thyroid Gland Inspection
Not visible and glands ascends Not visible and glands ascends Normal
during swallowing during swallowing

THORAX & LUNGS:

Posterior Thorax: Inspection Anteroposterior to transverse Anteroposterior to transverse
Shape & Symmetry diameter in ratio of 1:2; diameter in ratio of 1:2; Normal
symmetrical in size symmetrical in size
Inspection Spine is vertically aligned, spinal Spine is vertically aligned, spinal
Spinal Alignment column is straight, right and left column is straight, right and left Normal
shoulders are straight and hips are shoulders are straight and hips are
at the same level at the same level Normal

Color, Temperature, Inspection & Skin intact, uniform temperature, Skin intact, uniform temperature,
Tenderness & Masses Palpation no tenderness and no masses, full no tenderness and no masses, full Normal
and symmetric chest expansion and symmetric chest expansion
Respiratory Excursion Inspection Thumbs separates during Thumbs separates during
respiration respiration Normal

Vocal Fremitus Palpation Bilateral symmetry of vocal Bilateral symmetry of vocal

fremitus when “99” was repeated fremitus when “99” was repeated Normal
Diaphragmatic Excursion Percussion Resonate lowest point of resonance Resonate lowest point of
on the diaphragm resonance on the diaphragm Normal

Vesicular sound is louder on Vesicular sound is louder on

inspiration; Broncho vesicular
Breath Sounds Auscultation sound is equal on inspiration and
expiration; Bronchial sound is
shorter on inspiration
Anterior Thorax: Breathing is effortless; No
Breathing Pattern Inspection wheezing. Ronchi, crackles or
friction rubs heard
inspiration; Broncho vesicular Normal
sound is equal on inspiration and
expiration; Bronchial sound is
shorter on inspiration
Breathing is effortless; No
wheezing. Ronchi, crackles or
friction rubs heard Normal

Color, Temperature, Inspection & Skin intact, uniform temperature, Skin intact, uniform temperature,
Tenderness & Masses Palpation no tenderness and no masses, full no tenderness and no masses, full Normal
and symmetric chest expansion and symmetric chest expansion
Respiratory Excursion Inspection Thumbs separates during Thumbs separates during
respiration respiration Normal

Vocal Fremitus Palpation Bilateral symmetry of vocal Bilateral symmetry of vocal

fremitus when “99” was repeated fremitus when “99” was repeated Normal

Diaphragmatic Excursion Percussion Dullness over heart and the liver Dullness over heart and the liver
Normal

Anterior chest: Broncho vesicular Anterior chest: Broncho vesicular

Breath Sounds Auscultation and vesicular breath sounds. and vesicular breath sounds. Normal
The same as posterior thorax The same as posterior thorax
Trachea Auscultation Bronchial and tubular breath Bronchial and tubular breath
sounds present sounds present Normal

BREAST & AXILLA:

Breast size, shape & Inspection Breast are round, slightly equal in Breast are round, slightly equal in
symmetry size and generally symmetric; no size and generally symmetric; no Normal
 tenderness, masses and lesions
Inspection and Skin is uniform in color, skin is
Skin characteristics palpation smooth and intact, no
swelling/edema
Rounded or oval; light pink to dark
Areola Inspection brown in color, irregular placement
of sebaceous gland on the surface
Round, everted (they may be
Nipple Condition Inspection inverted or flat at times), equal in
size, similar in color, soft &
smooth, both pointed on the same
direction, no discharge
Axillary, Subclavicular
and Supraclavicular lymph Palpation No tenderness, masses or nodules
nodes
Breast Palpation No areas of tenderness, masses,
nodules or nipple discharge
tenderness, masses and lesions
Skin is uniform in color, skin is
smooth and intact, no Normal
swelling/edema
Rounded or oval; light pink to
dark brown in color, irregular Normal
placement of sebaceous gland
on the surface
Round, everted (they may be
inverted or flat at times), equal in Normal
size, similar in color, soft &
smooth, both pointed on the same
direction, no discharge
No tenderness, masses or
nodules Normal
No areas of tenderness, masses,
nodules or nipple discharge Normal

HEART, NECK and

PERIPHERAL
VESSELS:
Precordium (Aortic and
Pulmonic areas; tricuspid
and apical area; epigastric
area)
Heart Sounds – aortic, Auscultation
pulmonic, tricuspid and
apical (mitral)
Inspection Aortic and pulmonic areas: No
Palpation pulsations
Tricuspid area: No pulsation; no
lift or heave
Apical area: Pulsations visible in
50% of adults and palpable in most
PMI in fifth LICS at or medial to
MCL; no lift or heave
Epigastric area: Aortic pulsation
S1: Usually heard at all sites
(usually louder at apical area)
S2: Usually heard at all sites
Aortic and pulmonic areas: No
pulsations Normal
Tricuspid area: No pulsation;
no lift or heave
Apical area: Pulsations visible
in 50% of adults and palpable
in most PMI in fifth LICS at
or medial to MCL; no lift or
heave
Epigastric area: Aortic
pulsation
S1: Usually heard at all sites
(usually louder at apical area) Normal
S2: Usually heard at all sites
 (usually louder at base of heart) (usually louder at base of heart)
S3 in children and young adults S3 in children and young adults
S4 in many older adults S4 in many older adults
Carotid Arteries Palpation Full and symmetric pulse volumes; Full and symmetric pulse
Auscultation no sound heard on auscultation volumes; no sound heard on Normal
auscultation
Jugular veins Inspection Veins not visible Veins not visible
Normal

Peripheral Veins and Inspection Veins collapse when limbs are Veins collapse when limbs are
Arterial Perfusion elevated and distend when in elevated and distend when in Normal
dependent position; limbs not dependent position; limbs not
tender; pink skin color; skin not tender; pink skin color; skin not
excessively warm or cold; no excessively warm or cold; no
edema edema
ABDOMEN:
Unblemished skin; uniform color
Skin integrity Inspection Unblemished skin; uniform color Normal

Flat, rounded or scaphoid, Flat, rounded or scaphoid,

Contour and symmetry Inspection Normal
symmetric contour symmetric contour
Symmetric movements; peristalsis Symmetric movements; peristalsis
Movements Inspection & aortic pulsations ONLY visible & aortic pulsations ONLY visible Normal
on very thin clients on very thin clients
No visible vascular pattern
Vascular pattern Inspection No visible vascular pattern Normal

Series of intermittent, soft clicks Series of intermittent, soft clicks

and gurgles are heard over at a rate and gurgles are heard over at a Normal
Bowel Sounds Auscultation
of 5-30 seconds; borborygmi may rate of 5-30 seconds; borborygmi
also be heard may also be heard
Liver and spleen Palpation Liver: May not be palpable; border Liver: May not be palpable;
feels smooth border feels smooth Normal
Spleen: Rarely palpable; if can be Spleen: Rarely palpable; if can be
palpated, it should be soft and palpated, it should be soft and
 nontender nontender
Tympany over the stomach and Tympany over the stomach and
Abdominal tone and
gas-filled bowel; dullness, gas-filled bowel; dullness, Normal
tenderness in all four Percussion
especially over liver, spleen and/or especially over liver, spleen
quadrants
a full bladder and/or a full bladder
MUSCULO-SKELETAL SYSTEM(Muscles, Bones and Joints):

Inspection & Centered, uniform in color, no Centered, uniform in color, no

Sternoclavicular Joint Palpation swelling or masses; No tenderness, swelling or masses; No Normal
no crepitation or nodules tenderness, no crepitation or
nodules
Cervical, Thoracic & Inspection, Symmetrical, no tenderness, no Symmetrical, no tenderness, no
Lumbar Spine Palpation & nodules, no presence of pain nodules, no presence of pain Normal
ROM
Shoulders, Arms & Inspection, Symmetrical, uniform in color, no Symmetrical, uniform in color, no
Elbows Palpation & swelling or masses; uniform in swelling or masses; uniform in Normal
ROM elbow size & shape, no deformities elbow size & shape, no
deformities
Inspection, Symmetrical, no tenderness, no Symmetrical, no tenderness, no
Wrist Palpation & nodules, no presence of pain; no nodules, no presence of pain; no Normal
ROM deformities deformities
Inspection, Symmetrical uniform in color, no Symmetrical uniform in color, no
Hands & Fingers Palpation & swelling or masses; No tenderness, swelling or masses; No Normal
ROM no crepitation or nodules tenderness, no crepitation or
nodules
Inspection, Symmetrical uniform in color, no Symmetrical uniform in color, no
Knees, Ankles and Feet Palpation & swelling or masses; No tenderness, swelling or masses; No Normal
ROM no crepitation tenderness, no crepitation

Summary of Significant Findings:

⮚ Most of the findings were normal but there are some deviation Age-related changes.