HEALTH ASSESSMENT RETURN a.

Symmetric with movement

DEMONSTRATION b. Immobile, masklike,
asymmetric, drooping
c. Bell’s palsy – half face
General Survey (drooping eye)
Normal findings vs. abnormal findings 6. Overall
a. No signs of acute distress
Physical Appearance b. Respiratory signs: shortness
1. Age of breath, wheezing
a. Appears his/her stated age 7. Pain 
b. Appears older that stated age a. Indicate by grimace,
i. Chromosomal holding/guarding body part,
differences knees drawn up over the
ii. Premature sterility abdomen
2. Gender Body Structure
a. Sexual development is  It appears within normal range for
appropriate for gender and age, genetic heritage
age  Excessively short or tall
b. Delayed or advanced puberty  body structure
3. LOC  endomorph -pear-shaped
a. Client is alert, oriented, body, rounded head, wide
attends to queries and hips, shoulders, a lot of fat on
responds appropriately the body, upper arms and
b. Confused, disoriented, thighs wider, front to back
lethargic, obtruded, than side to side
stuporous, comatose  mesomorph – high forehead,
c. Lethargic – drowsy, open eyes receding chin, narrow
& look at you, respond to shoulders, chest and abdomen
questions then falls asleep thin arms and legs/slender
d. Obtruded – open eyes, look at little muscle or fat
you but responds slowly and  ectomorph – normal, lean
is somewhat confused 1. Height – assess standing straight
e. Stupurous – aroused from without shoes
sleep only after a painful a. Note growth of children and
stimulus, verbal responds low diminished height in older
or absent. adults
f. Comatose – remains b. Wheelchairs or scoliosis – use
unarousable, no evident of wingspan
response to stimuli c. Marfan syndrome
4. Skin color d. Gigantism – pituitary (growth
a. Color tone is even, skin is hormone)
intact with no obvious lesions e. Dwarfism – hypopituitarism
b. Pallor – pale f. Male = 5”4 Female = 4”11
c. Cyanosis – bluish skin 2. Nutrition
d. Jaundice – yellow a. Weight appears within normal
e. Erythema – redness, any range for height and body
lesions build, body fat distribution is
f. Ecchymosis – bluish even
discoloration
5. Facial features
 b. Emaciated, cachetic (tissue table, arms relaxed at the
wasting) obviously obese with sides, head turned to the
even fat examiner
c. Distribution: fat coordinated b. Curled up with fetal position,
in face, neck, trunk with thin leaning forward
arms and legs 8. Body odor
3. BMI 9. ROM
a. A practical marker of optimal a. Full mobility of each joint,
nutrition for height and an movement is deliberate,
indicator for obesity or accurate, smooth and
protein calorie malnutrition coordinated, no involuntary,
i. Wt in kg/ ht in m2 no un-purposeful movement
ii. Wt in lbs/ ht in in2 X b. Paralysis (absence of
704 movement), movement jerky,
iii. Underweight ≤ 18.6 uncoordinated tremors,
iv. Normal 18.5-24.9 seizure
v. Overweight 25-29.9 c. LSC paraplegia – lower
vi. Obesity class 1 30- extremities
34.99 d. Hemiplegia – left and right
vii. Obesity class 2 35-35.9 body
viii. Obesity class 3 ≥ 40 e. Quadriplegia – all body
4. Symmetry  10. Behavior
a. Body parts look equally a. Facial expression – client eye
bilaterally and are in relatively to eye contact, expression are
proportion to each other appropriate to the
b. Unilateral atrophy (loss of environment, flat, depressed,
muscle volume) or angry, sad, anxious
hypertrophy (increase in b. Mood and affect – client is
muscle volume) comfortable, cooperative with
5. Posture the examiner, pleasantly
a. body erect, sway back hostile, distrustful, suspicious,
b. lumbar lordosis crying
c. thoracic lordosis c. Speech – speaks clearly, stern
d. kyphosis of talking fluent with an even
e. forward toe pace, word choice is
f. hollow back appropriate, difficulty of
6. Mobility – manner of walking – base is kicking, abnormal pitch or
as wide as shoulder with, front volume
placement, accurate, walks smooth, 11. Dress
even and well balanced a. Appropriate to climate, looks
a. exceptionally wide base, clean and fits the body and is
staggered. Stumbling, shifting appropriate to age group. 
gait b. Trousers too large, held up by
b. gait cycle – stance, swing belt, looks unclean,
c. abnormal – spastic gait inappropriate to the climate
(stroke), scissors (lower 12. Personal hygiene – clean, groomed
extremities) appropriate for age, occupation, socio-
7. Position economic group, hair groomed,
a. Client sits comfortably in a brushed
chair or in bed or examination
Integumentary system  Temperature: warm or cold (face and
Skin hands)
 Color: fair, light brown, white, brown,  Moisture: fairly dry with
pinkish, jaundice, cyanosis perspirations or flaking
 Vascularity: there are no areas of  Texture: rough/smooth, firm/soft
increased vascularity, no ecchymosis  Mobility and turgor: good skin turgor,
and lesion count if not returned immediately (1-
 Moisture: fairly dry/moist 2 sec)
Lesions
 Type
Primary lesions Hair
a. Vesicles, bullae & pustules – fluid,  Color
elevated  Texture: smooth/rough,
 Vesicles – fluid within straight/curly, shiny/brittle
the skin, elevated, serous  Moisture: moist/dry
</= 0.5 (chicken pox)  Distribution: thinly/thickly
i. Senus – clear (chicken distributed
pox, blisters)  Scalp lesions: there is a lesion/none
ii. Sanguinous – red  Infestation: lice infestation/none
iii. Serosanginous - pink Nails
iv. Pustule – yellow  Shape: convex, 160 degrees
 Bullae - > 0.5 (burns)  Color
 Pustules – yellow/green  Capillary refill: comes back in 1-3 sec
(acne) (white when pressed, pinkish when
b. Nodules, tumor & papules – palpable, not pressed)
elevated, mass (solid) – moles,  Texture: firm/spongy
birthmarks
 Papules – firm <0.5 Head and Face 
(warts)
 Nodules - < 0.5 more Skull
firmer than papules  Shape: circular/round
i. Fibromas  Size:
 Tumor – larger nodules normocephalic/macrocephalic/micro
>0.5 (malignant/benign) cephalic
 Wheals – edematous,  Symmetry: skull is at the midline/
elevated (insect bites) deviates In the right or left
c. Macules & patches – flat, non-palpable
(scar) Face
 Macules - <0.5  Symmetry: symmetrical/drooping
 Patches - > 0.5 (can be  Shape: oval, round, heart, square
irregular in shape  Abnormal features: space between
 Color: reddish, blueish, etc. eyes are widen
 Shape: circular/irregular  Swelling: periorbital swelling (edema
 Size: (use of ruler) on eyes – fluid filled)
 Location: part of the body  Unusual movement: abnormal
 Pattern: localized, regionalized or twitching
generalized
 Distribution: linear, group/clustered, Palpation
discrete
Palpate (dorsum)
  Head: use pads of the fingers, check if
smooth, even and no presence of
lesions
 Temporal artery: are there abnormal
palpations or not

Auscultation
 Temporal artery for bruit: use bell,
should not hear anything “there is no
presence of bruit” (bruit is narrowing
of artery)

Palpation
 Frontal sinus: use thumb
 Maxillary sinus: use thumb
 PAINFUL or tender?

Percuss
 Frontal sinus: resonance
 Maxillary sinus: resonance

Test motor function of CN V (Trigeminal

Nerve): “clench teeth, mandibular should be
hard, able to resist” FINDINGS: INTACT AND
HARD

Test sensory function CN V (Trigeminal

Nerve): ask patient to close their eyes, then
asses the forehead, left and right jaw, left and
right cheek. FINDINGS: patient is able and
identify my hand” “intact”

Test motor function of CN VII: Close lids,

raised eyebrows “intact”