PHYSICAL ASSESSMENT FINDINGS

IHSN-Nursing Program 2ND SEMESTER AY 2022-2023

Name of Client: Date Conducted:

Age: Gender:
BODY PART/AREA NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION and ANALYSIS
TO BE ASSESSED
Inspect the muscles -Equal size on both Interpretation: Normal
for size. Compare sides of body
each muscle on one
side of the body to
the same muscle on
the other side.

-inspect the muscles and -No contractures Interpretation: Normal

tendons for contractures.

Inspect the muscle for No fasciculation or Interpretation: Normal

tremors tremors

Palpate muscles at rest Normally firm Interpretation: Normal

to determine muscle
tonicity.

Palpate muscles while Smooth coordinated Interpretation: Normal

the client is active and movements
passive for
flaccidity, spasticity, and
smoothness of
movement.
 Test muscle strength of Sternocleidomastoid Interpretation: Normal
the head & shoulders Client turns the head to
one side against the
resistance of your hand.

Trapezius
Client shrugs the
shoulders against the
resistance of your
hands.

Deltoid
Client holds arm up and
resists while you try to
push it down.

Test muscle strength of Biceps Interpretation: Normal

upper extremities Client fully extends each
arm and tries to flex it
while you attempt to hold
arm in extension.

Triceps
Client flexes each arm and
then tries to extends it
against your attempt to
keep in flexion

Wrist and Finger Muscles

Client spreads the fingers
and resists as you attempt
to push the fingers
together.

Grip strength
Client grasps your index
finger and middle fingers
while you try to pull the
fingers out.

Hip Muscles
Client is supine, both legs
extended; client raises one
leg at a time while you
attempt to hold it down
Test muscle strength of Hip abduction Interpretation: Normal
lowerr extremities Client is supine, both legs
extended.; client spreads
the legs
apart against your
resistance.

Hip adduction
Client is in same position
as in hip abduction. ;
client brings the legs
together against your
resistance.
 Hamstrings
Client is supine, both
knees bent. Client resists
while you attempt to
straighten the legs.

Quadriceps
Client is supine, knee
partially extended; client
resists while you attempt
to flex the knee.

Muscles of the ankle and

feet
Client resists while you
attempt to dorsiflex the
foot and resists while you
attempt to flex the foot.

Inspect the skeleton for No deformities Interpretation: Normal

normal structure and
deformities.

Palpate the bones to No tenderness, swelling Interpretation: Normal

locate any areas of edema or any signs of edema
or tenderness.

Inspect the joint for No swelling Interpretation: Normal

swelling

Palpate each joint for No tenderness, swelling, Interpretation: Normal

tenderness, smoothness crepitation or presence of
of movement, nodules
swelling, crepitation, and
presence of nodules.
 Assess joint range of Varies to some degree Interpretation: Normal
motion of the head in accordance with
person’s genetic
makeup and degree of
physical activity.
Full range of motion

Assess joint range of Offers full range of Interpretation: Normal

motion of body trunk motion

Assess joint range of Offers full range of Interpretation: Normal

motion of upper motion
extremities

Assess joint range of Offers full range of Interpretation: Normal

motion of lower motion
extremities

*There may be clients who may NOT provide consent to expose or assess certain body parts/area because of
cultural , personal and/or health reasons. You may just indicate N/A or Not Assessed.

FEU – INSTITUTE OF NURSING NCM101 HEALTH ASSESSMENT