Physical Assessment

Integument

 Skin: The client’s skin is uniform in color, unblemished and no presence of

any foul odor. He has a good skin turgor and skin’s temperature is within
normal limit.
 Hair: The hair of the client is thick, silky hair is evenly distributed and has
a variable amount of body hair. There are also no signs of infection and
infestation observed.
 Nails: The client has a light brown nails and has the shape of convex
curve. It is smooth and is intact with the epidermis. When nails pressed
between the fingers (Blanch Test), the nails return to usual color in less
than 4 seconds.

Head

 Head: The head of the client is rounded; normocephalic and symmetrical.

 Skull: There are no nodules or masses and depressions when palpated.
 Face: The face of the client appeared smooth and has uniform consistency
and with no presence of nodules or masses.

Eyes and Vision

 Eyebrows: Hair is evenly distributed. The client’s eyebrows are

symmetrically aligned and showed equal movement when asked to raise
and lower eyebrows.
 Eyelashes: Eyelashes appeared to be equally distributed and curled
slightly outward.
 Eyelids: There were no presence of discharges, no discoloration and lids
close symmetrically with involuntary blinks approximately 15-20 times per
minute.
 Eyes
 o The Bulbar conjunctiva appeared transparent with few capillaries
evident.
o The sclera appeared white.
o The palpebral conjunctiva appeared shiny, smooth and pink.
o There is no edema or tearing of the lacrimal gland.
o Cornea is transparent, smooth and shiny and the details of the
iris are visible. The client blinks when the cornea was touched.
o The pupils of the eyes are black and equal in size. The iris is flat
and round. PERRLA (pupils equally round respond to light
accommodation), illuminated and non-illuminated pupils
constricts. Pupils constrict when looking at near object and dilate
at far object. Pupils converge when object is moved towards the
nose.
o When assessing the peripheral visual field, the client can see
objects in the periphery when looking straight ahead.
o When testing for the Extraocular Muscle, both eyes of the client
coordinately moved in unison with parallel alignment.
o The client was able to read the newsprint held at a distance of 14
inches.

Ears and Hearing

 Ears: The Auricles are symmetrical and has the same color with his facial
skin. The auricles are aligned with the outer canthus of eye. When
palpating for the texture, the auricles are mobile, firm and not tender. The
pinna recoils when folded. During the assessment of Watch tick test, the
client was able to hear ticking in both ears.

Nose and Sinus

 Nose: The nose appeared symmetric, straight and uniform in color. There

was no presence of discharge or flaring. When lightly palpated, there were
no tenderness and lesions
 Mouth:
 o The lips of the client are uniformly pink; moist, symmetric and
have a smooth texture. The client was able to purse his lips when
asked to whistle.
o Teeth and Gums: There are no discoloration of the enamels, no
retraction of gums, pinkish in color of gums
o The buccal mucosa of the client appeared as uniformly pink;
moist, soft, glistening and with elastic texture.
o The tongue of the client is centrally positioned. It is pink in color,
moist and slightly rough. There is a presence of thin whitish
coating.
o The smooth palates are light pink and smooth while the hard
palate has a more irregular texture.
o The uvula of the client is positioned in the midline of the soft
palate.
 Neck:
o The neck muscles are equal in size. The client showed
coordinated, smooth head movement with no discomfort.
o The lymph nodes of the client are not palpable.
o The trachea is placed in the midline of the neck.
o The thyroid gland is not visible on inspection and the glands
ascend during swallowing but are not visible.

Thorax, Lungs, and Abdomen

 Lungs / Chest: The chest wall is intact with no tenderness and masses.

There’s a full and symmetric expansion and the thumbs separate 2-3 cm
during deep inspiration when assessing for the respiratory excursion. The
client manifested quiet, rhythmic and effortless respiration.
 The spine is vertically aligned. The right and left shoulders and hips are of
the same height.
 Heart: There were no visible pulsations on the aortic and pulmonic areas.
There is no presence of heaves or lifts.
  Abdomen: The abdomen of the client has an unblemished skin and is
uniform in color. The abdomen has a symmetric contour. There were
symmetric movements caused associated with client’s respiration.
o The jugular veins are not visible.

o When nails pressed between the fingers (Blanch Test), the nails
return to usual color in less than 4 seconds.

Extremities

 The extremities are symmetrical in size and length.

 Muscles: The muscles are not palpable with the absence of tremors. They
are normally firm and showed smooth, coordinated movements.
 Bones: There were no presence of bone deformities, tenderness and
swelling.
 Joints: There were no swelling, tenderness and joints move smoothly.

Nursing Assessment in Tabular Form

Assessment Findings

Integumentary

 Skin When skin is pinched it goes to previous

 Assessment Findings

state immediately (2 seconds).

With fair complexion.
With dry skin
Evenly distributed hair.
 Hair With short, black and shiny hair.
With no presence of pediculosis Capitis.
Smooth and has intact epidermis
With short and clean fingernails and
 Nails toenails.
Convex and with good capillary refill time of
2 seconds.
Rounded, normocephalic and symmetrical,
Skull smooth and has uniform
consistency.Absence of nodules or masses.
Symmetrical facial movement, palpebral
Face fissures equal in size, symmetric nasolabial
folds.
Eyes and Vision
Hair evenly distributed with skin intact.
 Eyebrows Eyebrows are symmetrically aligned and
have equal movement.
Equally distributed and curled slightly
 Eyelashes
outward.
Skin intact with no discharges and no
discoloration.
 Eyelids
Lids close symmetrically and blinks
involuntary.
 Bulbar conjunctiva Transparent with capillaries slightly visible
 Palpebral Conjunctiva Shiny, smooth, pink
 Sclera Appears white.
 Lacrimal gland, Lacrimal sac, No edema or tenderness over the lacrimal
Nasolacrimal duct gland and no tearing.
Cornea
 Assessment Findings

Transparent, smooth and shiny upon

inspection by the use of a penlight which is
 Clarity and texture held in an oblique angle of the eye and
moving the light slowly across the eye.
Has [brown] eyes.
Blinks when the cornea is touched through
 Corneal sensitivity
a cotton wisp from the back of the client.
Black, equal in size with consensual and
direct reaction, pupils equally rounded and
reactive to light and accommodation, pupils
Pupils constrict when looking at near objects,
dilates at far objects, converge when object
is moved toward the nose at four inches
distance and by using penlight.
When looking straight ahead, the client can
see objects at the periphery which is done
by having the client sit directly facing
the nurse at a distance of 2-3 feet.
Visual Fields The right eye is covered with a card and
asked to look directly at the student nurse’s
nose. Hold penlight in the periphery and ask
the client when the moving object is
spotted.
Able to identify letter/read in the newsprints
at a distance of fourteen inches.
Visual Acuity
Patient was able to read the newsprint at a
distance of 8 inches.
Ear and Hearing
Color of the auricles is same as facial skin,
symmetrical, auricle is aligned with the
 Auricles outer canthus of the eye, mobile, firm, non-
tender, and pinna recoils after it is being
folded.
 External Ear Canal Without impacted cerumen.
 Assessment Findings

 Hearing Acuity Test Voice sound audible.

Able to hear ticking on right ear at a
distance of one inch and was able to hear
 Watch Tick Test
the ticking on the left ear at the same
distance
Nose and sinuses
Symmetric and straight, no flaring, uniform
 External Nose in color, air moves freely as the clients
breathes through the nares.
Mucosa is pink, no lesions and nasal septum
 Nasal Cavity
intact and in middle with no tenderness.
Symmetrical, pale lips, brown gums and able
Mouth and Oropharynx
to purse lips.
With dental caries and decayed lower
 Teeth
molars
Central position, pink but with whitish
 Tongue and floor of the mouth coating which is normal, with veins
prominent in the floor of the mouth.
Moves when asked to move without
 Tongue movement difficulty and without tenderness upon
palpation.
Uvula Positioned midline of soft palate.
Present which is elicited through the use of
Gag Reflex
a tongue depressor.
Positioned at the midline without
Neck tenderness and flexes easily. No masses
palpated.
Coordinated, smooth movement with no
Head movement discomfort, head laterally flexes, head
laterally rotates and hyperextends.
Muscle strength With equal strength
Lymph Nodes Non-palpable, non tender
 Thyroid Gland Not visible on inspection, glands ascend but
 Assessment Findings

not visible in female during swallowing and

visible in males.
Thorax and lungs
Posterior thorax Chest symmetrical
Spine vertically aligned, spinal column is
 Spinal alignment straight, left and right shoulders and hips
are at the same height.
With  normal breath sounds without
Breath Sounds
dyspnea.
 Anterior Thorax Quiet, rhythmic and effortless respiration
Unblemished skin, uniform in color,
Abdomen
symmetric contour, not distended.
Symmetrical movements cause by
Abdominal movements
respirations.
With audible sounds of 23 bowel
 Auscultation of bowel sounds
sounds/minute.
Without scars and lesions on both
Upper Extremities
extremities.
Lower Extremities With minimal scars on lower extremities
Equal in size both sides of the body, smooth
coordinated movements, 100% of normal
Muscles
full movement against gravity and full
resistance.
No deformities or swelling, joints move
Bones and Joints
smoothly.
Mental Status
Language Can express oneself by speech or sign.
Orientation Oriented to a person, place, date or time.
Able to concentrate as evidence by
Attention span
answering the questions appropriately.
A total of 15 points indicative of complete
Level of Consciousness
orientation and alertness.
 Assessment Findings

Motor Function
Gross Motor and Balance
Has upright posture and steady gait with
 Walking gait opposing arm swing unaided and
maintaining balance.
Maintained stance for at least five (5)
Standing on one foot with eyes closed
seconds.
Maintains a heel toe walking along a straight
Heel toe walking
line
Toe or heel walking Able to walk several steps in toes/heels.
Fine motor test for Upper Extremities
Repeatedly and rhythmically touches the
Finger to nose test
nose.
Alternating supination and pronation of Can alternately supinate and pronate hands
hands on knees at rapid pace.
Finger to nose and to the nurse’s finger Perform with coordinating and rapidity.
Fingers to fingers Perform with accuracy and rapidity.
Rapidly touches each finger to thumb with
Fingers to thumb
each hand.
Fine motor test for the Lower Extremities
Able to discriminate between sharp and dull
Pain sensation sensation when touched with needle and
cotton.