HEAD-TO-TOE PHYSICAL ASSESSSMENT

Head and Neck

AREA ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL FINDING INTERPRETATIO

N
Head Involuntary movement Inspection Head should be held still and upright Head slightly held still and upright NORMAL
The face is symmetric with round, oval, The face is symmetric with round, oval,
Symmetry, movement,
Inspection elongated, or square appearance; No abnormal elongated, or square appearance; NORMAL
expression movements noted No abnormal movements noted
Neck is symmetric, with head centered and
Neck is symmetric, with head centered and without
Neck Neck muscle Inspection without abnormal swelling and NORMAL
abnormal swelling and bulging masses.
bulging masses.

Ears and Mouth

AREA ASSEESED TECHNIQUE NORMAL FINDING ACTUAL FINDING INTERPRETATION

Ears Size Inspection Ears are equal in size bilaterally 4- Ears are equal in size bilaterally 4-10cm
NORMAL
10cm
 St. Paul University Philippines
Tuguegarao City, Cagayan 3500
SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES
COLLEGE OF NURSING
SUMMER SEMESTER, AY 2021-2022
BACHELOR OF SCIENCE IN NURSING – LEVEL
III
Position Inspection The auricle aligns with the corner of The auricle aligns with the corner of each
each eye and within a 10-degree angle of eye and within a 10-degree angle of the vertical NORMAL
the vertical position position

Mouth Color Inspection Pink lips are normal in light-skinned Pale- colored lips ABNORMAL
clients

Moisture Inspection Lips are smooth and moist without Lips are cracked and not moist ABNORMAL
lesions or swelling

Nose Shape Inspection Smooth and symmetric Slightly smooth and symmetric NORMAL
Color Inspection Color is the same as the rest of the face Color is the same as the rest of the face NORMAL
 St. Paul University Philippines
Tuguegarao City, Cagayan 3500
SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES
COLLEGE OF NURSING
Thorax and Lungs SUMMER SEMESTER, AY 2021-2022
BACHELOR OF SCIENCE IN NURSING – LEVEL
Posterior Thorax
III
Shoulder and Symmetry Inspection Scapulae are symmetric; Shoulder and Scapulae are symmetric; Shoulder and scapulae are at NORMAL
Scapulae scapulae are at equal horizontal positions equal horizontal positions
Use of Inspection The patient does not use accessory muscle to assist The patient use accessory muscle to assist breathing ABNORMAL
accessory breathing
muscles
Posture and Inspection Patient should sit up and relaxed, breathing easily Patient is able to sit up but needed to be assisted due to state NORMAL
ability to with arms on sides
support weight
Anterior Thorax Respirations are relaxed, effortless, and quiet; Respirations are deep and with effort, ; They are of a regular ABNORMAL
They are of a regular rhythm and normal depth at rhythm and normal depth at a rate of 10-20 per minute in
Quality and
Inspection a rate of 10-20 per minute in adults; Tachypnea adults; Tachypnea (21bpm) occurred once during the vital sign
pattern
and bradypnea may be monitoring but is Normal for an
normal in some clients unconscious patient.
Use of accessory muscles is not seen with normal ABNORMAL
respiratory effort; after strenuous exercise or
Use of Use of accessory muscles is seen with abnormal respiratory effort
Inspection activity, clients with normal respiratory status
accessory
may use neck muscles for
a short time to enhance breathing