HEAD TO TOE PHYSICAL ASSESMENT

AREA TO BE ASSESSED NORMAL FINDINGS ACUTAL FINDINGS ANALYSIS

I. APPEARANCE AND MENTAL STATUS
Proportinate, varies with lifestyle

A. Body built, height, and weight (in relation to the client's age, lifestyle, and health) B. Posture and gait, standing, sitting, and walking

Relaxed, erect posture, coordinated movement

C. Overall hygiene and grooming

Clean, neat

D. Body and Breath odor

No body odor or minor body odor relative to work or exercise; no breath odor

E. Signs of distress (in posture or facial expression)

No distress noted

F. Obvious signs of health or illness

Healthy appearance

G. Attitude

Cooperative

H. Afect/mood (appropriateness of client's responses)

Appropriate to situation

I. Quantity and quality of speech

Understandable, moderate pace; exhibits thought association

J. Relevance and organization of thoughts

Logical sequence; makes sense of reality

II. INTEGUMENTARY
A. SKIN
1. Skin color Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive

dark sknned clients may have brown or black pigmentation in longitudinal streaks Smooth texture 2. nail beds) in dark-skinned people No edema ACUTAL FINDINGS ANALYSIS 3. Existence of lesions Freckles. areas of llighter pgmentation (palms. Uniformity of skin color NORMAL FINDINGS Generally uniform except in areas exposed to the sun.HEAD TO TOE PHYSICAL ASSESMENT AREA TO BE ASSESSED 2. Presence of edema 4. Fingernail plate shape (its curvature and angle) Convex curvature. Skin temperature 7. SKULL . Skin turgor When pinched. lips. some birthmarks. some flat and raised nevi. Fingernail and toenail bed color 3. Skin Moisture 6. within normal range 5. Fingernail and toenail texture 4. Presence of tissues Intact epidermis surrounding nails 5. NAILS 1. angle of nail plate about 160° Highly vascular and pink in lightskinned clients. body temperature. no abrasions or other lesions Moisture in skin folds and the axillae (varies with environmental temperature and humidity. skin springs back to previous state B. and activity) Uniform. Blanch test result of capillary refill Prompt return of pink or usual color (generally less than 4 seconds) III. HEAD A.

HEAD TO TOE PHYSICAL ASSESMENT AREA TO BE ASSESSED 1. Smooth skull contour Smooth. EYELIDS Upper eyelids cover the small portion Surface characteristics and position (in relation of the iris. evenly distributed B. shpae and symmetry of the skull NORMAL FINDINGS Rounded (normecephalic and symmetrical. no ulcers Pinkish or red in color. with frontal. FACE Symmetric or slightly asymmetric facial Facial features. ability to blink. and the presence of lesions in the palbebral conjunctiva E. alignment. symmetric nasolabial folds IV. Color. masses. uniform consistence. CONJUNCTIVA 1. EYELASHES Evenness of distribution and direction of curl Evenly distributed. cornea. moist. brown or blond depending on race. no foreigh bodies. and depressions B. and frequency of are open. absence of nodules or masses ACUTAL FINDINGS ANALYSIS 2. EYES A. HAIR 1. with presence of small capillaries. and tine presence of lesions in the bulbar conjunctiva Pinkish or red in color. Color. and occipital prominences). EYEBROWS Hair distribution. texture. palpebral fissures equal in size. thickness or thinness of hair Evenly distributed and covers the whole scalp: Maybe thick or thin C. skin quality and movement Symmetrical and in line with each other. parietal. moist. maybe black. Size. symmetry of facial movements features. texture. no ulcers 2. SCLERA . turned outward C. symmetrical D. and sclera when eyes to the cornea. eyelids meet completely blinking) when the eyes are closed. Evenness of growth. with presence of small capillaries. Presence of nodules. no foreigh bodies.

CORNEA Clarity and texture No irregularities on the surface.HEAD TO TOE PHYSICAL ASSESMENT AREA TO BE ASSESSED Color and clarity NORMAL FINDINGS White in color. some capillaries maybe visible ACUTAL FINDINGS ANALYSIS F. no noted visible materials. no yellowish discoloration. IRIS Shape and color Anterior chamber is transparent. color depends on the person's race . clear or transarent G. looks smooth. clear.

both directly and consensual NORMAL FINDINGS ACUTAL FINDINGS ANALYSIS 2. with parallel alignment . Light reaction and accommodation I. move in unison. Distance vision 20' 20' vision on Snellen chart J. PUPILS 1. and are equal in size. VISUAL ACUITY 1. LACRIMAL GLAND Palpability and tenderness of the lacrimal gland No edema or tenderness over lacrimal gland K. EXTRAOCULAR MUSCLES Eye alignment and coordination Both eyes coordinated. Near vision Able to read newsprint 2. size ranges from 3-7 mm. shape. Color. and symmetry of size Color depends on the person's race. equally round Constrict briskly/sluggishly when light is directed to the eye.HEAD TO TOE PHYSICAL ASSESMENT AREA TO BE ASSESSED H.

Client's response to normal voise tones Normal voice tones audible 2. no discharge or flaring. about 10 degrees from vertical Mobile. Watch tick test result Able to hear ticking in both ears 3. Uniform color 2. Any deviations in shape. no lesions 3. NOSE 1. client can see objects in the periphery NORMAL FINDINGS ACUTAL FINDINGS ANALYSIS V. size. AURICLES 1. or color and flaring or discharge from the nares Symmetric and straight. Presence of redness. growths and discharge in the nasal cavities Mucosa pink. Color. symmetrical. pinna recoils after it is folded 2. auricle aligned with outer canthus of eye. Texture. and position Color same as facial skin. and not tender. clear. elasticity and areas of tenderness B. firm. swelling. EARS A. HEARING ACUITY TESTS 1. symmetry of size. Rinne test result Air-conducted (AC) hearing is greater than bone-conducted (BC) hearing VI. Nasal septum (between the nasal chambers) Nasal septum intact and in midline . Weber's test result Sound is heard in both ears or is localized at the center of the head 4.HEAD TO TOE PHYSICAL ASSESMENT AREA TO BE ASSESSED L. VISUAL FIELDS Peripheral visual fields When looking straight ahead. watery discharge.

masses. SINUSES Identification of the sinuses and for tenderness Not tender .HEAD TO TOE PHYSICAL ASSESMENT AREA TO BE ASSESSED 4. Patency of both nasal cavities NORMAL FINDINGS Air moves freely as the client breathes through the nares ACUTAL FINDINGS ANALYSIS 5. and displacements of bone and cartilage Not tender. no lesions VII. Tenderness.

slightly rough. glistening. no retraction E. or excoriated areas F. smooth white. or excoriated areas Smooth with no palbable nodules. and elastic texture C. movement and base of the tongue 3. lumps. LIPS Symmetry of contour color and texture Uniform pink color. smooth. TEETH Color. moist. MOUTH A. Color. more irregular texture 2. smooth texture. lighter pink hard palate. texture and the presence of bony prominences Light pink. BUCCAL MUCOSA Color. shape. lumps. ability to purse lips NORMAL FINDINGS ACUTAL FINDINGS ANALYSIS B. moist smooth. soft. OROPHARYNX and TONSILS . Color and texture of the mouth floor and frenulum Pink color. soft palate. shiny tooth enamel. smooth tongue base with prominent veins 2. Position. thin whitish coating. no tenderness Central position. Any nodules. number and condition and presence of dentures 32 adult teeth. pink color. symmetry of contour. moist. TONGUE/FLOOR OF THE MOUTH 1. intact dentures D.HEAD TO TOE PHYSICAL ASSESMENT AREA TO BE ASSESSED VIII. PALATES and UVULA 1. Position of the uvula and mobility (while examining the palates) Positioned in midline of soft palate G. texture and the presence of lesions Uniform pink color. smooth. soft. color and texture. GUMS Color and condition Pink gums. moves freely. moisture.

Color and texture NORMAL FINDINGS Pink and smooth posterior wall ACUTAL FINDINGS ANALYSIS 2. no discharge.HEAD TO TOE PHYSICAL ASSESMENT AREA TO BE ASSESSED 1. color. Size. and discharge of the tonsils Pink and smooth. of normal size 3. Gag reflex Present .

Vocal fremitus palpation Bilateral symmetry of vocal fremitus. Chest symmetric 2. no tenderness. POSTERIOR THORAX 1. THYROID GLAND 1. NECK MUSCLES Inspection of neck muscle and head movement. Shape. Respiratory excursion assessment Full and symmetric chest expansion 5. no masses 4. THORAX A. coordinated head movement without discomfort NORMAL FINDINGS ACUTAL FINDINGS ANALYSIS A. tenderness. TRACHEA Placement of the Trachea Central placement in midline of neck. NECK and LYMPH NODES A. and masses Skin intact. and comparison of anteroposterior thorax to transverse diamter Anteroposterior to transverse diameter in ratio 1:2. symmetry. uniform temperature. Smoothness and areas of enlargement. Fremitus is heard most clearly at the apex of the lungs . Symmetry and visible masses Not visible on inspection 2. Temperature. spaces are equal on both sides C. Muscles equal in size. chest wall intact.HEAD TO TOE PHYSICAL ASSESMENT AREA TO BE ASSESSED IX. Spinal alignment Spine vertically aligned 3. masses or nodules Lobes may not be palpated X. LYMPH NODES Identification of Lymph nodes and for tenderness Not palpable B.

Fremitus is normally decreased over heart and breast tissue. Lowest point of resonance is at the diaphragm. dull on areas over heart and the liver. and effortless respirations 2. tenderness. Temperature. Posterior thorax auscultation B.HEAD TO TOE PHYSICAL ASSESMENT AREA TO BE ASSESSED NORMAL FINDINGS Percussion notes resonate except over scapula. Anterior thorax auscultation Bronchovesicular and vesicular breath sound . Respiratory excursion assessment Full symmetric excursion. no tenderness. Anterior thorax percussion 6. Posterior thorax percussion 7. masses Skin intact. percussion on a rib normally elicits dullness Vesicular and bronchovesicular breath sounds ACUTAL FINDINGS ANALYSIS 6. and tympanic over the underlying stomach 4. rhytmic. thumbs normally separate 3 to 5 cm Bilateral symmetry of vocal fremitus. Breathing patterns Quiet. Vocal Fremitus palpation 5. uniform temperature. Trachea auscultation Bronchial and tubular breath sounds 7. Percussion notes resonate down to the sixth rib at the level of the diaphragm but are flat over areas of heavy muscle and bone. ANTERIOR THORAX 1. no masses 3. chest wall intact.

slightly shorter duration than diastole at normal heart rate (60 to 90 beats/min) Diastole: silent interval. TRICUSPID AREA No pulsations. AORTIC and PULMONIC AREAS No pulsations NORMAL FINDINGS ACUTAL FINDINGS ANALYSIS B. CARDIOVASCULAR AREAS AUSCULTATION S1: Usually heard at all sites Usually louder at the apical area S2: usually heard at all sites Usually louder at the base of heart Systole: silent interval. slightly longer duration than systole at normal heart rates S3: in children and young adults S4: in many older adults . EPIGASTRIC AREA Aortic pulsations E. APICAL AREA Pulsations visible in 50% of adults and palpable in most PMI in fifth LICS at or medial to MCL D. CARDIOVASCULAR A. no lift or heave C.HEAD TO TOE PHYSICAL ASSESMENT AREA TO BE ASSESSED XI.

Localized discolorations or hyperpigmentation. and changes from sitting to supine position. skin smooth and intact. swelling or edema in the skin of the breast Rounded Shape. localized hypervascular areas. generally symmetric Skin uniform in color. turns head. JUGULAR VEINS Jugular veins inspection No sound heard on auscultation XIV. thrusting quality. and contour or shape 2. full pulsations. Carotid artery palpation 2. retraction or dimpling. Breast's size symmetry.HEAD TO TOE PHYSICAL ASSESMENT AREA TO BE ASSESSED XII. no major discolorations . BREAST and AXILLAE 1. quality remains same when the client breathes. Carotid arteries auscultation XIII. slightly unequal in size. elastic arterial wall No sound heard on auscultation NORMAL FINDINGS ACUTAL FINDINGS ANALYSIS 1. CAROTID ARTERIES Symmetric pulse volumes.

Axillary. visible peristalsis in very lean people. and supraclavicular lymph nodes No tenderness. aortic pulsations in thin persons at epigastric area 5. Nipple's size. no discharge. irregular placement of sebaceous glands on the surface of the areola irregular placement of sebaceous glands on the surface of the areola Round. or nodules 6. and lesions 4. inversion of one or both nipples that is present from puberty ACUTAL FINDINGS ANALYSIS 3. color varies widely. soft and smooth. Masses. Symmetry of contour Symmetric Contour Symmetric movements caused by respiration. similar in color. everted. or nodules. and any discharge from No tenderness.HEAD TO TOE PHYSICAL ASSESMENT AREA TO BE ASSESSED NORMAL FINDINGS Round or oval and bilaterally the same. Skin Integrity Unblemished skin. shape. peristalsis or aortic pulsations . position. shape. Areola's size. color. except from pregnant or breast-feeding females. from light pink to dark brown. symmetry color. ABDOMEN 1. masses. Abdominal movements associated with respirations. discharge. Enlargement of liver of spleen No evidence of enlargement of liver or spleen 4. or scaphoid (concave) 3. and equal in size. and lesions 5. uniform color 2. both nipples point in the same direction. or the nipples nipple discharge XV. Abdominal contour Flat rounded (convex). tenderness. subclavicular. masses. discharge.

Muscle size and comparison on the other side Proportionable to the body even in both sides 2.HEAD TO TOE PHYSICAL ASSESMENT AREA TO BE ASSESSED 6. dullness. vascular sounds. absence of friction rub Tympany over the stomach and gasfilled bowels. Muscle strength 100% muscle strength . Light palpation in the four quadrants XVI. Bowel sounds. Muscle tonicity Even and firm muscle tone 5. Absence of arterial bruits. or a full bladder No tenderness. and peritoneal friction rubs Audible bowel sounds. Vascular pattern NORMAL FINDINGS No visible vascular pattern ACUTAL FINDINGS ANALYSIS 7. Fasciculations and tremors in the muscles No fasciculation and tremors 4. consistent tension 8. Contractures in the muscles and tendons No contractures 3. relaxed abdomen with smooth. Several abdominal areas of the four quadrants 9. especially over the liver and spleen. MUSCLES 1. MUSCULOSKELETAL SYSTEM A.

Joint swelling No joint swelling. no warmth. Areas of edema or tenderness in the bones Absence of edema or tenderness in bones C. BONES 1. swelling. crepitation and presence of nodules . Tenderness. Normal structures and deformities in the skeleton No deformities NORMAL FINDINGS ACUTAL FINDINGS ANALYSIS 2. redness No tenderness. smoothness of movement. JOINTS 1.HEAD TO TOE PHYSICAL ASSESMENT AREA TO BE ASSESSED B. swelling and nodules: smooth movements: minimal crepitus may be present but there should be no pronounced crepitation 2.

Sign up to vote on this title
UsefulNot useful