Physical / Health Assessment

Body Part Examined Normal Findings Actual Findings Interpretation

Head
 Skull Rounded Normocephalic, Normal
(normocephalic and symmetric
symmetric, with frontal, prominences
parietal, and occipital
prominences); smooth
skull contour

 Facial features Normal

Symmetric or slightly Slightly symmetric
symmetric facial
features
 Hair Normal
Evenly distributed,
Evenly distributed, thick, dry, no presence
thick; silky, resilient of lesion
 Scalp Normal

Color is lighter than Color is lighter than

the skin, no the skin, no tenderness
tenderness
Nails Convex curvature; Convex curvature; Normal
angle of nail plate hard and immobile;
about 160°; smooth pink; intact epidermis
texture; highly vascular
and pink in light-
skinned
clients; intact
 Blanch test epidermis Capillary refill <2 Normal
seconds
Prompt return of pink
or usual color
(generally less than 2
seconds)
Skin Varies from light to Light brown Normal
deep brown; from
ruddy pink to light pink;
from yellow overtones
to olive

No edema No edema noted Normal

Freckles, some
birthmarks that have Presence of moles Normal
not changed since
childhood

Moisture in skin folds Skin folds not moist Normal

and the axillae
 Skin temperature Axillary temperature at Not noral.
within normal range 36.7° Poor blood
circulation due to
When pinched, skin increased blood
springs back to Poor skin turgor. viscosity.
previous state >2seconds Indicative of
dehydration.

Eyes

 Eyebrows Hair evenly distributed; Hair evenly distributed; Normal

skin intact; eyebrows skin intact; eyebrows
symmetrically aligned; symmetrically aligned;
equal movement equal movement
 Eyelashes
Equally distributed; Equally distributed; Normal
curled outward curled outward
 Eyelids
Skin intact; no Sunken Eyeball, visible Not normal. It may
discharge, no dark shadow below the indicate
discoloration eyelids. dehydration.
Normal
Lids close Lids close
symmetrically symmetrically Normal

Approximately 15 to 20 16 involuntary blinks

 Sclera involuntary blinks Normal

Sclera appears white White

(darker or yellowish
and with small brown
 Pupils macules or dark-
skinned clients) Normal

Black in color Black in color Normal

Equal in size, Equally round and

 Cornea illuminate pupil reactive to light and
constricts accommodation Normal

Transparent, shiny, Transparent and shiny

 Bulbar Conjunctiva
and smooth; details of Normal
the iris are visible
 Palpebral
Transparent; Transparent Normal
Conjunctiva
capillaries sometimes
evident;
 Extraocular
movement Shiny, smooth, and Shiny Normal
pink or red
Both eyes are Normal
coordinated; unison in
movement with parallel
 Visual Acuity alignment
 Able to read Able to read Not normal. It may
newspaper newspaper but indicate certain
sometimes have blurry disease that left
vision uncontrolled.

20/20 vision on snellen Not assessed

chart
Ears

 Auricles Color same with facial Color same with facial Normal
skin; symmetrical; skin; symmetrical;
mobile, firm and not mobile, firm and not
tender; pinna recoils tender; pinna recoils
after it is folded after it is folded

 External Ear Canal Distal third contains No skins and lesions, Normal
hair follicles and has slight presence of
glands cerumen, no skin
Dry cerumen; no skin lesions
lesions, pus and blood
 Gross hearing Normal
acuity test Normal voice tones Normal voice tones
audible audible
 Tuning fork test
Sound is heard in both Not assessed
ears or is localized at
the center of the head
Nose

 External nose Symmetric and straight Symmetrical; same Normal

No discharge or flaring color with face; nasal
Uniform color discharge and flaring,
Not tender; no lesions localized areas of
Air moves freely redness; not tender; air
moves freely

 Nasal Septum Intact and in midline Normal

Intact and in midline

 Facial sinuses Not tender Normal

Not tender
Mouth

 Lips Uniform pink color Uniform pink color Normal

Symmetry in contour Symmetry in contour
Ability to purse lip Ability to purse lip

 Teeth and Gums 32 adult teeth 28 adult teeth; tartar Not normal. Tartar
Smooth, white, shiny noted in upper left indicates improper
tooth enamel lateral incisor hygiene.

Pink gums Pinkish and no

 Gums No retraction of gums retraction Normal

Central position
  Tongue Pink in color Central position Normal
Moves freely Pink in color
Moves freely
Positioned midline of
 Uvula soft palate, rises Position midline of soft Normal
during vocalization palate
Soft palate- Pinkish
and smooth and
located posteriorly;
 Palates Hard palate- slightly
rough and dome shape Not assessed
and located anteriorly

Pink and smooth Not assessed

posterior wall
 Oropharynx
Pink and smooth Not assessed
No discharge
 Tonsils Grade 1 (tonsils
behind the tonsillar
pillar
Neck
 Neck muscles Muscles equal in size, Muscles equal in size, Normal
head centered; head centered; smooth
coordinated movements with a little
discomfort

 Lymph nodes Not palpable No enlarge lymph node Normal

noted

 Trachea Central placement in Not assessed

midline of neck;
spaces are equal on
both sides
Thorax and Lungs

 Posterior thorax Spine vertically aligned Thorax has Not normal.

Spinal column is asymmetric expansion. Asymmetrical
straight, right, and left chest expansion
shoulders, and hips may indicate
are at same height conditions such
Full and symmetric as
expansion pneumothorax, rib
fracture, severe
pneumonia, or
atelectasis.
Bilateral symmetry of Not assessed
vocal fremitus.
Fremitus is heard
mostly at the apex of
the lungs.

 Anterior thorax Quiet, rhythmic and Quiet, rhythmic and Normal

effortless respirations effortless respirations
Full symmetric Full symmetric
excursion excursion
 Tactile fremitus is
normally decresed Not assessed
over heart and breast
Breast and axillae

 Breast Rounded shape; Rounded shape and Normal

slightly unequal in size; generally symmetric
generally symmetric

Round or oval and Round and brown Normal

bilaterally the same areola
areola, color varies
widely, from light to
dark brown

 Axillary,
subclavicular and No tenderness, Normal
supraclavicular masses or nodules No tenderness,
lymph nodes masses or nodules

Heart and Central

vessels
 Apical Pulsation visible in Palpable in PMI Normal
50% of adults and
palpable in most PMI
in fifth LICS at or
medial to MCL.
Diameter is 1 – 2 cm
No lift and heaves
Abdomen Flat Abdominal tenderness Not normal.
Tenderness may
indicate
Symmetric in contour underlying
inflammatory
conditions.

Musculoskeletal system Equal in size on both Presence of 1 cm Not normal.

(muscles, bones & sides of body epidermal ulcer at the Due to high blood
joints) left tarsal and 30mm at glucose, prevents
the metatarsal. the immune
system to function
well. Thus,
vulnerability to
inflammation is
highly possible.
Neurologic system Oriented and Not normal.
coordinated, responds Poor coordination. May indicate total
appropriately, no Poor muscle tone and body dehydration.
neurologic strength.
dysfunctions
Male genitals and Pubic skin intact, no Not assessed
Inguinal Area lesions; skin of vulva
slightly darker than the
rest of the body

No enlargement or No enlargement or Normal

tenderness of inguinal tenderness
lymph nodes