Physical Assessment

Body Part Normal Findings Actual Findings Interpretation &

Analysis
Skin Inspection Skin is uniform Skin is brown Skin may be
whitish pink or dry because of
brown color insufficient fluid
No Bleeding intake
No area of No bleeding Normal fluid
increased No area of intake should be
vascularity and increased 2500 ml per day
ecchymosis vascularity and
No skin lesions ecchymosis
present except No lesions
for freckles,
birthmarks or
moles which may
be flat or (pp.283-304,
elevated Health
Skin is dry Assessment &
with a minimum Physical
Palpation of perspiration. Skin is dry Examination –
Warm and Zator Estes)
equal bilaterally.
Hands and skin Warm and equal
slightly cooler bilaterally
than the rest of
the body
Skin surfaces
non-tender
Texture:
Smooth, even
and firm except
where there is
significant hair
growth
Skin turgor: Skin sprung back
When released, rapidly when
should return to pinched
original contour
rapidly
Edema not No edema
present present
Scalp and Hair Inspection Dark black to Hair appears No significant
pale blonde; may black findings
turn gray or
white; may be
chemically
changed
Terminal hair Even distribution
found in the of hair (pp.305-308,
eyebrows,, Health
eyelashes, and Assessment &
scalp, and in Physical
axilla and pubic Examination –
areas after Zator Estes)
puberty. No infestation or
No signs of lesions
infestation or
lesions.
Seborrhea/
dandruff may be
present Hair is thick and
Palpation Hair may feel shiny
thin, straight,
coarse, thick or
curly. Shiny and
resilient
Nails Inspection Have a pink- Brown-cast nails No significant
cast in light- findings
skinned and
brown in dark-
skinned. Capillary refill of
Capillary refill 1.5 seconds
present (should
return to normal
2-3 sec) Surface smooth
Surface is and slightly (pp.308-311,
smooth, and rounded Health
slightly rounded Assessment &
or flat. Curved Physical
nails are normal. Examination –
Uniform nail No splinters or Zator Estes)
thickness brittle edges
throughout; no
splintering or
brittle edges.
 Angle approx. Angle approx.
160° 160°
Palpation Firm nail base Firm nail base
Eyes Inspection Symmetrical Eyes No significant
with no symmetrical findings
drooping,
infection, tumors
or other
abnormalities
Visual Acuity: Visual acuity of
20/20 20/20
Sclera: Sclera appears
White in light- white
skinned w/o (pp.350-362,
exudates, lesions Health
or foreign Assessment &
bodies. In dark- Physical
skinned, may Examination –
have brown Zator Estes)
patches
Pupils: equally
round, reactive to Pupils equally
light and round, reactive to
accommodation; light and
2-6 mm accommodation;
No tearing, approx. 4 mm
swelling or No tearing,
discharge swelling or
descharge
Ears Inspection Match flesh Same color as No significant
color of the rest face findings
of the skin.
Central Central position
position. Proportional
Proportional. No redness, (pp.386-389,
Palpation No redness, swelling, or Health
lesions, swelling, tenderness Assessment &
tenderness Physical
Should not No pain assessed Examination –
complain of pain Zator Estes)
or tenderness

Nose Inspection Symmetrical, Symmetrical and No significant

midline of the in midline findings
face.
 Without No swelling,
swelling, bleeding, lesions, (pp.394-397,
bleeding, lesions, or masses Health
or masses. Assessment &
Each nostril Patent nostrils Physical
patent. Examination –
No pain or No pain or Zator Estes)
Palpation discomfort discomfort noted
during palpation

Mouth Inspection Breath smells No significant

fresh. findings
Lips and Lips and
membranes pink membranes are
and moist with moist, dark flesh
no lesions or colored; no lesions
inflammation. or inflammation
Tongue is Tongue in
midline. Pink, midline and moves (pp.398-405,
moist, rough freely Health
without lesions. Assessment &
Symmetrical; Physical
moves freely. Examination –
Gums have Zator Estes)
pale-red strippled
surface.
No swelling or No swelling or
bleeding. bleeding

Neck Inspection Symmetrical Symmetrical No significant

with head in with head in findings
central position. central position
Able to move Able to move
head without head w/o(p.331, Health
discomfort or discomfort Assessment &
noticeable limits Physical
Palpation Muscles No palpable Examination –
should be masses Zator Estes)
symmetrical
without palpable
masses or spasm
Chest Inspection Without Without lesions No significant
lesions; skin findings
intact. Quiet rhythmic
Quiet, and effortless
 rhythmic and breathing
Palpation effortless
breathing No masses or
No pulsations, tenderness
masses, thoracic (pp.451-469,
Auscultation tenderness Bronchovesicula Health
present. r breath sounds Assessment &
Normal lung Physical
tissue produces Examination –
resonant sound, Zator Estes)
diaphragm has
dull sounds.
Bronchial,
bronchovesicular
or vesicular
breath sounds

Abdomen Inspection Abdominal Abdominal No significant

contour flat or contour rounded. findings
rounded.
Symmetrical. Symmetrical.
Uniform in Uniform in
color or color.
pigmentation.
No abdominal
scars.
No striae (pp.552-562,
Auscultation No scars; striae Health
Intermittent
gurgling sounds Gurgling sounds Assessment &
throughout in abdomen Physical
abdominal Examination –
quadrants. Zator Estes)
Percussion
Tympany,
predominant No friction rubs/
sound heard audible bruits
Palpation
No organ
enlargement
palpable, or any
masses, bulges,
or swelling

Suprapubic Area Inspection Without Without Lesions No significant

lesions findings
Palpation Urinary Urinary bladder
bladder not not palpable (p.638,
 palpable and not Fundamentals of
tender Nursing -
Kozier)
Genitalia Inspection Pubic hair Pubic hair evenly No significant
distributed in distributed findings
Palpation triangular form.
More coarse
than scalp hair. (pp.746-753,
No nits or lice. No nits or lice Health
Penis skin free No lesions or Assessment &
of lesions and inflammation Physical
inflammation. Examination –
Zator Estes)
Rectum Inspection No lesions,  In midline A dilated vein
redness Redundant mass seen as swollen,
Sphincter noted, reddish reddish-blue
intact mass signifies
Palpation Non-tender hemorrhoids
(pp. 55-56,
Medical Surgical
Nursing,
Harkness and
Dincher)
Upper Inspection Without Without lesions, No significant
Extremities lesions, scars or scars or findings
inflammation inflammation (p.579,
Fundamentals of
Nursing, Kozier)

Lower Inspection Without Without lesions, No significant

Extremities lesions, scars scars findings
Palpation No edema No edema (p.579,
Fundamentals of
Nursing, Kozier)