PHYSICAL ASSESSMENT OF THE FAMILY

A. Physical Assessment of _____________

Body Parts/ System Actual Findings Normal Findings Interpretation

& Method of
Assessment Used

SKIN  Light to deep

 Inspect skin brown colour
colour  Generally,
 Inspect uniform in
uniformity of colour except in
skin colour areas exposed to
 Pinch skin to sun
note the skin  When pinched,
turgor skin spring back
to previous state

NAILS
 Inspect  Convex
fingernail curvature
plate shape  Angle 160°
 Inspect  Intact epidermis
fingernail
texture
 Perform
blanch test of
capillary
refill

HEAD
 Inspect the  Rounded
skull for size, (normocephalic)
shape, and  No masses and
symmetry nodules
 Palpate the  Uniform
skull for consistency
nodule or  Smooth skin
masses and
depressions
  Note
symmetry of
facial
movement

EARS  Able to hear

 Inspect the both ears
auricles for  Symmetrical
colour, 10°
symmetry of  Dry cerumen
size, and Mobile and firm
positions
 Inspect the
external ear
canal for
cerumen,
skin lesions,
and blood
 Perform
webers test
using tuning
fork

NOSE &
SINUSES  Air moves
 Inspect freely as the
external client breaths
nose for through nares
flaring,  No discharge
shape, or  Mucosa pink
colour  Symmetric
 Inspect the
nasal
septum
between the
nasal
chambers
 Palpate the
maxillary
and frontal
sinuses for
 tenderness

MOUTH &
THROAT  32 adult teeth
 Inspect the  Smooth shiny
outer lips for tooth
symmetry of  Smooth intact
contour, dentures
colour, and  Smooth tongue
texture base with
 Inspect the prominent veins
teeth and  No palpable
gums while nodules
examining
the inner lips
and buccal
mucosa
 Inspect
tongue
movement
 Palpate the
tongue and
floor of the
mouth for
any nodules,
lumps, and
excoriated
areas.

EYES
 Inspect the  Pupils size is 3
eyebrows for to 7 mm in
hair diameter
distribution  Pupils equally
 Inspect and round and react
palpate the to light
lacrimal sac accommodation
and (PERRLA)
nasolacrimal  Both eyes are
duct coordinated
 Perform  No edema or
 corneal tearing
sensitivity  Cornea is
 Assess six transparent
ocular
movement to
determine
eye
alignment
and
coordination
 Assess
distance
vision

NECK
 inspect the  Equal strength
neck muscles  Equal size of
for abnormal muscle
swelling or  Absence of
masses bruits
 observe head  Coordinated,
movement smooth
 assess movement with
muscle no discomfort
strength  No spasm and
 palpate the stiffness
entire neck
for
enlargement
lymph nodes
 palpate the
trachea for
lateral
deviation
Body Parts/ Actual Findings Normal Findings Interpretation
System & Method
of Assessment
Used

RESPIRATORY  No evidence of
 inspect enlargement of
posterior liver
thorax for  Flat, rounded,
shape and convex
symmetry  No tenderness
 Inspect the
spinal
alignment
for
deformities

 Inspect
breathing
pattern

CARDIAC
 Palpate the  Symmetric
peripheral heart volume
pulse  Normal heart
sound
 Inspect the
 Limbs not
skin of the
tender
hand and
 Veins are not
feet for
visible
colour,
temp, and
edema

 Assess the
adequate of
arterial
blood flow
using
capillary
 refill test

ABDOMEN  Flat, rounded,

 Inspect convex
Abdomen
for skin  No tenderness
integrity in abdomen
 Inspect the
abdomen for
contour and
symmetry
 Percuss the
abdomen

 Percuss the
liver

Body Parts/ Method of Actual Findings Normal Findings

Assessment Used Interpretation
MUSCULOSKELETAL
 Inspect the Muscle
 No deformities
size
 No tenderness
and swelling
 Inspect the Muscle  Equal strength
and tendons for in each body
contractures side

 Test muscle strength

 Inspect the joints for

 swelling

NEUROLOGIC
1. MENTAL STATUS
a. Orientation
 Memory is
 Ask the Patient the
intact patient
city and state of
don’t have any
residence
difficulty in
remembering

 Ask the patient for

time of day, day of
the week

 Ask the patient to

names the family
members

 Immediate
b. Memory
* Immediate recall recall is intact
 Ask patient to repeat patient don’t
a series of digits “9- have any
4-6-2-1-5” difficulty in
remembering
 Ask patient to state
the same digits but
in reverse

 Recent Memory
* Recent memory is intact patient
 Ask the Patient how don’t have any
she got to the school difficulty in
remembering

 Provide the client

with three facts to
recall
 Remote
 Memory is
intact patient
don’t have any
* Remote memory
difficulty in
 Ask patient to recall
remembering
what happened
during her vacation

 15 score
2. LEVEL OF
CONSCIOUSNESS
-using GCS
 Glasgow coma scale
test