Physical / Health Assessment

Body Part Examined Normal Findings Actual Findings Interpretation

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

 Facial features Symmetric or slightly Slightly symmetric Normal

symmetric facial features

 Hair Evenly distributed, thick; Evenly distributed, thick, Normal

silky, resilient dry, no presence of lesion

 Scalp Color is lighter than the Color is lighter than the Normal
skin, no tenderness skin, no tenderness
Nails Convex curvature; angle Convex curvature; hard Normal
of nail plate about 160°; and immobile; pink;
smooth texture; highly intact epidermis
vascular and pink in
light-skinned
clients; intact epidermis

 Blanch test Prompt return of pink or Capillary refill <2 Normal

usual color seconds
(generally less than 2
seconds)

Skin Varies from light to deep Light brown Normal

brown; from ruddy pink
to light pink; from yellow
overtones to olive

No edema No edama noted Normal

Freckles, some Presence of moles Normal

birthmarks that have not
changed since childhood

Moisture in skin folds Skin folds not moist Normal

and the axillae

Skin temperature within Axillary temperature at Normal

normal range 36.7°

When pinched, skin Poor skin turgor Not normal.

 springs back to previous Poor blood
state circulation due to
increased blood
viscosity.
Indicative of
dehydration.

Eyes

 Eyebrows Hair evenly distributed; Hair evenly distributed; Normal

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

Approximately 15 to 20 16 involuntary blinks Normal

involuntary blinks

 Sclera Sclera appears white White Normal

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

Equal in size, illuminate Equally round and Normal

pupil constricts reactive to light and
accommodation
 Cornea
Transparent, shiny, and Transparent and shiny Normal
smooth; details of the iris
are visible
 Bulbar Conjunctiva
Transparent; capillaries Transparent Normal
sometimes evident;
 Palpebral
Shiny, smooth, and pink Shiny Normal
Conjunctiva
or red
 Extraocular Both eyes coordinated, Both yes are coordinated; Normal
movement move in unison with unison in movement with
parallel alignment parallel alignment

 Visual Acuity Able to read newspaper Able to read newspaper Normal

 20/20 vision on snellen Not assessed Normal
chart
Ears

 Auricles Same color to his facial Same color to his/her Normal

skin; symmetrical; facial skin; symmetrical;
mobile, firm and not mobile, firm and not
tender; pinna recoils after tender; pinna recoils after
it is folded it is folded

 External Ear Canal Distal third contains hair No skins and lesions, has Normal
follicles and glands slight presence of
Dry cerumen; no skin cerumen, no skin lesions
lesions, pus and blood

 Gross hearing acuity Normal voice tones Normal voice tones Normal
test 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 color Normal

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

 Nasal Septum Intact and in midline Intact and in midline Normal

 Facial sinuses Not tender Not tender Normal

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 lateral indicates improper
tooth enamel incisor hygiene.

 Gums Pink gums Pinkish and no retraction Normal

No retraction of gums

 Tongue Central position Central position Normal

Pink in color Pink in color
Moves freely Moves freely

 Uvula Positioned midline of Position midline of soft Normal

soft palate, rises during palate
vocalization
Soft palate- Pinkish and
 smooth and located
posteriorly;
 Palates Hard palate- slightly Not assessed
rough and dome shape
and located anteriorly

Pink and smooth

 Oropharynx posterior wall Not assessed

Pink and smooth

 Tonsils No discharge Not assessed
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 asymmetric Not normal.
Spinal column is straight, expansion. Asymmetrical chest
right, and left shoulders, expansion may
and hips are at same indicate conditions
height such as
Full and symmetric pneumothorax, rib
expansion 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 excursion Full symmetric excursion

Tactile fremitus is
normally decresed over Not assessed
heart and breast
Breast and axillae

 Breast Rounded shape; slightly Rounded shape and Normal

unequal in size; generally generally symmetric
symmetric
 Round or oval and Round and brown areola Normal
bilaterally the same
areola, color varies
widely, from light to dark
brown

 Axillary, No tenderness, masses or No tenderness, masses or Normal

subclavicular and nodules nodules
supraclavicular
lymph nodes
Heart and Central vessels
 Apical
Pulsation visible in 50% Palpable in PMI Normal
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 underlying
Symmetric in contour inflammatory
conditions.

Musculoskeletal system Equal in size on both No deformity Normal

(muscles, bones & joints) sides of body

No swelling Absence of swell

Neurologic system Oriented and Not normal.

coordinated, responds Poor coordination. Poor May indicate total
appropriately, no muscle tone and strength. body dehydration.
neurologic dysfunctions
Male genitals and Inguinal Pubic skin intact, no Not assessed
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