CENTRO ESCOLAR UNIVERSITY

Nursing Department
Malolos City, Bulacan

PHYSICAL ASSESSMENT TOOL

(ADULT)

Name of Student:
Yr./Sec./Grp. No:

A. GENERAL APPEARANCE
a. Body Built Small frame [] Medium frame [✓] Large frame
b. Posture [ ✓ ] Upright [] Stooped [] Others_________
c. Gait [✓ ] Smooth [] Staggering [] Shuffling
rhythmic [] Others: ___________
Uncertain
d. Dress, Grooming Hygiene
[✓ ] Appropriately [] Well Groomed []
dressed [] Unkempt [] Others
Inappropriately dressed [] Alcohol [] Acetone
e. Odor (Body/Breath) [ ✓ ] None [] Others []
Cigarette Smoke

f. Obvious Physical Deformity NONE

g. Clinical Measurements
Health 165.50cm Weight 65kg

h. Vital Signs
Temperature 36.5°C BP 130/80 RR 20 PR 82 bmp
Remarks ____________________________

B. MENTAL STATUS
a. Level of Consciousness
Conscious [✓ ] Lethargic [ ] Stuporous [ ] Semi-comatose [ ] Deep Coma [ ]
b. Orientation Time [ ] Place [✓ ] Person [ ] Remarks
__________
c. Emotional Status
Peasant [ ] Cooperative [✓ ] Anxious [ ] Angry irritable [ ] Withdrawn [ ]
Fearful [ ] Resistive [] Euphoric [ ] Others ____________________________________
d. Language and Communication Use of simple words [✓ ] Use of technical words [ ]

Others ________________ Remarks _________________

Copy to: Student

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C. SKIN
a. Color Normal skin color [ ✓ ] Pallor [ ] Cyanotic [ ] Jaundice [ ] Erythema [ ]
Others _____________________
b. Temperature Warm [ ✓ ] Cold [ ]
c. Moisture Dry [ ✓ ] Clammy [] Sweaty [] Oily [ ]
d. Texture Smooth [ ✓ ] Rough [] Scaly [] Others _________________
e. Turgor Elastic and mobile [ ✓ ] Wrinkle loss of elasticity [ ]
Remarks ____________________
f. Lesions Type ___________________ Location _________________________
Size _______________ Distribution ___________ Remarks THERE IS NO LESSION
g. Hair distribution EVENLY DISTRIBUTED

D. NAILS
a. Nail plate shape Convex 160 [✓ ] Clubbing [ ] Others ________________________
Remarks ___________________
b. Nail condition Smooth [ ✓ ] Rough [ ] Ridged [ ] Brittle [ ] Thick [ ] Thin [ ]
Others ________________________________
c. Nail bed Color Pink [ ✓ ] Pale [ ] Blue [ ] Others ____________________________
d. Capillary Refill Within 3 seconds [ ✓ ] Exceeds 3 seconds [ ]
Remarks _______________________________

E. HEAD AND FACE

a. Skull Proportionate to body size [✓] Smooth contour []
Disproportionate to body size [] Irregular contour [ ]
b. Scalp Tenderness [ ] Lesions [ ] White [✓] Scaly [ ]
Others THERE ARE NO LESSION
c. Hair condition Evenly distributed [ ✓ ] Unevenly distributed [ ] Thick [ ]
Fine [ ] Brittle [ ] Dull [ ] Shiny [ ] Infestation [ ]
Others __________________________
d. Face
Symmetry Symmetrical [ ✓ ] Asymmetrical [ ]
Facial movement Symmetrical [ ✓ ] Easy movement [ ] Difficult movement [ ]
Asymmetrical [ ] No movement [ ] Remarks _____________________

F. EYES
a. Eye condition Straight normal [ ✓ ] Strabismus [ ] Others ____________________
b. Eyebrows Hair distribution Thick [ ] Thin [ ✓ ] None/artificial [ ]
Others _________________________
c. Eyelid and lashes
Palpebral fissure Size
Effective closure [ ✓ ] Lesions [ ] Fallen Eyelashes [ ] Others ______________________
d. Blink Response Bilateral Frequent [ ] Infrequent [ ] Unilateral [ ✓ ]
Others ________________________
e. Eyeballs Symmetric [ ✓ ] Firm [ ] Asymmetric [ ] Hard [ ] Soft [ ] Sunken [ ]
Protruding [ ] Others: _________________________________
f. Conjunctiva: Bulbar Clear [ ✓ ] Palpebral Pink [ ]
Others: __________________________
g. Sclera White [ ] Icteric [ ] Reddish [✓ ] Others: _________________________

Copy to: Student

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h. Pupils
Size Equal [✓ Unequal []
_R ____ L
Reaction to light and accommodation R Brisk [✓] Sluggish [ ] No reaction [ ]
L Brisk Sluggish [ ] No reaction [ ]

Visual Acuity near vision 12-14 inches away

Able to recognize object [ ] Unable to recognize object [✓] Score __________
i. Lacrimal Apparatus: Moist [ ✓ ] Excess tearing [ ] Absent tears [ ]
Remarks _______________________________

G. EARS
a. Auricle:
1. Color Normal racial tone [ ✓ ] Cyanosis [ ] Redness [ ]
Others: ____________________________
2. Symmetry and size position Symmetric [ ✓ ] Asymmetric [ ]
Deformity [ ]
3. Texture and elasticity Elastic [ ✓ ] Non tender [ ] Tender [ ] Firm [ ✓ ]
Others __________________________
b. Pinna Recoils when folded [✓ ] Tenderness [ ] Flaky [ ] Scaly [ ]
Lesions [ ] Inflammations [ ]
Others NON-TENDERNESS
c. External Canal Some cerumen [ ✓ ] Foreign body [ ] Discharges [ ] Masses [ ]
Impacted Cerumen [ ] Swelling [ ] Redness [ ] Others
____________________
d. Hearing Acuity Responds to normal voice [ ✓ ] Respond to whispered voice (2 ft away) [ ]
AD Difficulty [ ] AS Difficulty AU Difficulty [ ]
Remarks: ________________________________

H. NOSE
a. External Normal racial tone [ ✓ ] Flaring [ ] Discharge [ ]
Others: _____________________________
b. Septum Midline [ ✓ ] Deviated [ ] Perforated [ ]

Remarks: ___________________________
c. Mucosa Pink [ ✓ ] Pale [ ] Discharges [ ]
Remarks: ___________________________
d. Patency Both Patent [ ✓ ] Mass Lesion [ ] Obstruction [ ] Others
____________
e. Nasal Cavity Remarks _________________________________
Moist [ ✓ ] Dry [ ] Discharges [ ]
f. Sinuses Remarks: _____________________
Tender [ ] Non-tender [ ✓ ] Remarks:
___________________________________

I. MOUTH
a. Lips Pink [ ✓ ] Pallor [ ] Cyanosis [ ] Lesions [ ] Dryness [ ]
Symmetrical [ ✓ ] Asymmetrical [ ]
Remarks: _____________________________
b. Mucosa Pink [ ✓ ] Pallor [ ] Cyanosis [ ] Lesions [ ] Moist [ ]
Remarks: _____________________________
c. Tongue Midline [ ✓ ] Deviation [ ] R[] L[]
Texture [ ] Rough [✓] Smooth [ ]
Color [ ] Pink [✓ ] Red [ ] Movable [ ] Atrophy [ ]
Others: ___________________________

Copy to: Student

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d. Teeth Complete [ ] Incomplete [ ] Carries [ ] Dentures [✓ ]
Remarks ____________________________
e. Gums Pink [ ✓ ] Pallor [ ] Reddish [ ] Tender [ ] Mouth Sores [ ]
Remarks _____________________ _______

J. PHARYNX
a. Uvula Midline [✓] Deviation [ ] R[] L[]
Remarks ________________________
b. Mucosa Pink [✓ ] Pallor [ ] Reddish [ ] Others ______
c. Tonsils Inflamed [ ] Not inflamed [✓ ] R[] L[]
Remarks ________________________
d. Posterior Pharynx Inflamed [ ] Not Inflamed [✓] Congested [ ]
Remarks ________________________
e. Gag Reflex Present [✓ ] Absent [ ]
Remarks ________________________

K. NECK
a. Neck Muscles Equal in size [ ✓ ] Swelling [ ] ROM [ ]
Remarks _________________________
b. Muscle Strength (refer to neuro assessment)
c. Lymph Nodes Palpable [ ✓ ] Not palpable [ ] Tender [ ] Not tender [ ]
Remarks _________________________
d. Trachea Midline [ ✓ ] Deviation [ ] R[] L[]
Remarks _________________________
e. Thyroid Gland Palpable [ ✓ ] Not palpable [ ] Remarks ________________

L. BREAST AND AXILLA

a. Symmetry Symmetrical [✓ ] Asymmetrical [ ]
b. Contour Flat [✓ ] Round [ ] Sagging [ ] Others ___________________
c. Skin Characteristics Smooth [✓] Orange Peel Appearance [ ] masses [ ]
edema [ ] Retractions [ ] Nipples inverted [ ] Dimpling [ ] Tender [ ]

Others __________________________

M. CHEST AND LUNGS

a. Shape AP to lateral ratio 1:2 [ ✓ ] Barrel [ ] Funnel [ ] Pigeon [ ]
Remarks: _______________________________
b. Lung Expansion Anterior Symmetrical [ ✓ ] Asymmetrical [ ]
Posterior Symmetrical [ ] Asymmetrical [ ]
Chest Excursion 3-5 cm.
Remarks: ____________________________
c. Fremitus Symmetrical [ ✓ ] Increase [ ] R[] L[]
Decrease [ ] R[] L[]
d. Breathing pattern Regular [ ✓ ] Irregular [ ] Use of accessory Muscle [ ] Dyspnea [ ]
Remarks: _____________________________
e. Breath Sounds Vesicular [ ✓ ] Bronchial [ ] Bronchovesicular [ ]
Rales [ ] Wheeze [ ] Bronchi [ ] Others ______________________
Remarks _____________________________
f. Percussion Resonant [ ✓ ] Tympany [ ] Dullness [ ] Hyper-resonance [ ] Flatness
[]
Others ___________________________

Copy to: Student

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g. Costal Angle 45 degrees [ ✓ ] >45 degrees [ ]
Remarks___________________
h. Heart Sounds Rate ____________ Rhythm ______________
Pulmonic [ ] Aortic [ ] Tricuspid [ ] Apical [ ✓ ]
Remarks: _______________________________

N. ABDOMEN Normal Racial tone [✓ ] Blemished [ ] Unblemished [ ]

a. Skin Integrity Lesion [ ] Scarf [ ] Rashes [ ] Tense and glistening [ ]
Remarks ________________________________
b. Contour and Symmetry Flat [ ] Rounded [✓ ] Scaphoid [ ] Obtunded [ ]
Others _____________________ Remarks __________________________
c. Movement Symmetrical [✓ ] Asymmetrical [ ] Visible peristalsis [ ]
Limited movement [ ] Others _____________________
Remarks ____________________________
d. Bowel Sounds Normal [✓] Hyperactive [ ] Hypoactive [ ] Bruits [ ]
Friction rub [ ] Other _____________________
Remarks _____________________________________
e. Palpation Muscle guarding [ ] Tender [✓ ] Masses [ ] Mobile [ ] Fixed [ ]
Remarks _____________________________________
f. Bladder Distended [ ] Not distended [✓]
Remarks _____________________________
g. Liver Palpable [ ] Not palpable [✓]
Others ________________
Remarks _____________________