PHYSICAL ASSESSMENT

Patient: Marvi Fabila August 31, 2008

Student Nurse: Eden D. Dimailig D31- Ms. Aileen Rocha
A06A22

Part I
Behavior
MEASUREMENTS NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS
Height
Weight
Proportionality of BMI=weight(kg)t
height to weight (height in m)2

BMI 18.5-25 kg/m2

Temperature 36.5-37.5 C
Pulse rate 60-100 beats/min
Respiratory Rate 12-20 breaths/min
Blood Pressure 120/80 mmHg
General Survey
AREAS TO BE NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS
ASSESSED
GENERAL
APPEARANCE

Body Build, height, Proportionate, varies with

and weight in relation lifestyle
to the client’s age,
lifestyle, and health
 Relaxed; erect posture;
Posture and Gait coordinated movement

Overall hygiene and Clean, and neat Neat and clean

grooming

Body odor No body odor or minor No body odor. The client uses
body odor relative to work perfume to have pleasant smell and
or exercise. as part of her hygiene
Breath odor No breath odor The client has no breath odor

Signs of distress No signs of distress Presence of eye bags and presence

of pimples in the face

Signs of Healthy appearance The client is healthy and no signs of

health/illness illness

Client’s attitude Cooperative The client is cooperative

Affect/ mood; Appropriate to situation The client’s mood is ecstatic and his
Appropriateness of responses are appropriate
the client’s
responses

Speech(quantity, Understandable, moderate The client’s speech is

quality, and pace, exhibits thought understandable and exhibits thought
organization association association.

Thoughts(relevance Logical sequence; makes The client has a logical sequence of

and organization) sense; has sense of reality thoughts and makes sense.
 HEAD TO TOE PHYSICAL ASSESSMENT

BODY PART NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS

SKIN

Color, uniformity of Light to deep brown; uniform The client’s skin color is dark
Color color except the areas exposed brown
to the sun

Edema No edema No edema

Lesions Freckles, birthmarks, flats and No lesions, no birthmarks

raised nevi; no other lesions

Moisture Moisture in skin folds and axillae There is moisture in skin folds
and axillae.

Temperature Uniform; with normal range The skin temperature is

uniform, and with normal
range. Both feet and hands
are uniform.

Turgor When pinched, skin springs When pinched, skin springs

back to previous back to previous state within 3
state(Fundamentals of Nursing, seconds
8thed., by Kozier, pp 579-580)
NAILS

Shape and angle Convex curvature; angle of nail The shape is convex curvature
plate is 160 degrees and angle is 160 degrees.

Texture Smooth in texture Smooth texture

Color Color is highly vascular and pink Pink in color

in light skinned clients; dark
skinned clients may have brown
or black pigmentation in
longitudinal steaks

Surrounding tissue Intact epidermis Intact epidermis

Blanch test Blanch test, prompt return of Returns to usual color for
usual color(Fundamentals of about 2 seconds.
Nursing, 8thed., by Kozier, pp
583-584)
HEAD

SKULL

Size, shape, Rounded(normocephalic and Rounded(normocephalic and

Symmetry symmetric with frontal, parietal, symmetric with frontal,
temporal, and occipital parietal, temporal, and
prominences); smooth skull occipital prominences) and
contour smooth skull contour

Nodules, masses Absence of nodules or No nodules or masses

And depressions masses(Fundamentals of
Nursing, 8thed. by Kozier, p 585)
SCALP

Color and Lighter than complexion

Appearance

Areas of tenderness No lesions, lies, dandruff, and

bruises or lumps found. Free
from split ends(Manual of
Nursing, 7th., by Lippincott, p.54

HAIR

Evenness of Evenly distributed, thick, The client’s hair is evenly

Growth, distributed, and it is thick. The
Thickness/ hair cut is long.
Thinness

Texture and Silky, and Silky, and resilient hair

Oiliness resilient(Fundamentals of
Nursing, 8thed. by Kozier, p 582)

FACE

Facial features Symmetric or slightly The facial features are

asymmetric facial features. symmetric. Pimples are
present.

Symmetry of facial Symmetric facial The facial movements are

movements movements(Fundamentals of symmetric.
Nursing, 8thed. by Kozier, p 585)
EYES

VISUAL ACUITY

Near vision Able to read The client is able to read

Distance vision 20/20 vision on snellen chart The client is able to read
She has a 20/20 vision in her
both eyes

EYEBROWS

Distribution, Hair is evenly distributed; skin The hair is distributed evenly,

Alignment, skin intact, eyebrows symmetrically alignment is symmetrical, and
Quality and aligned; equal movement. skin is intact and equal
movement (Fundamentals of Nursing, movement.
8thed., by Kozier, p 588)

EYELASHES

Evenness of Equally distributed and curled Equally distributed and curled

Distribution and slightly outward(Fundamentals slightly outward
Direction of curl of Nursing, 8thed., by Kozier, p
544)

LACRIMAL No edema/ tenderness No edema/ tenderness

APPARATUS
EYELIDS
Surface Skin intact, no discharges and
characteristics, no discoloration
position in relation to
the cornea, able to Lids close symmetrically
blink; frequency of
blinking 15-20 blinks/min.
Bilateral blinking
When lids open, no visible
sclera above corneas, upper
and lower borders of cornea are
slightly covered(Fundamentals
of Nursing, 8thed., by Kozier, p
588)
CONJUNTIVA
Bulbar conjunctiva Transparent, capillaries
Color, texture, sometimes evident, sclera
Presence of appears white (yellowish in
Lesions dark-skinned clients)
Palpebral Shiny, smooth, and pink or
Conjunctiva color, red(Fundamentals of Nursing,
Texture, lesions 8thed., by Kozier, p 588)
SCLERA
Color and clarity White in color
Skin is intact, no discharges
and no discoloration
Lids close symmetrically
19 blinks per minute
There is no visible sclera
above corneas when lids
open, upper and lower borders
of cornea are slightly covered.
Capillaries are seen and it is
transparent. Sclera appears
white
The client’s palpebral
conjunctiva is pink in color.
The texture is smooth and
shinny.
The client’s sclera is white.
CORNEA
Transparent, shiny and smooth
Clarity and texture details of the iris are
visible(Fundamentals of
Nursing, 8thed., by Kozier, p
590)
IRIS
Shape and color Flat and round(Fundamentals of
Nursing, 8thed., by Kozier, p590)
PUPILS
Color, shape, and Black in color, equal in size, 3 -
Size 7 mm in diameter; round,
smooth border.
Light reaction and Illuminated pupil
Accommodation constricts(direct response)
Nonilluminated pupil
constricts(consensual response)
Pupils constrict when looking at
near object; pupils dilate when
looking at far object; pupils
converge when near object is
moved toward
nose(Fundamentals of Nursing,
8thed., by Kozier, p 590)
It has a transparent, shiny and
smooth. Details of the iris are
visible
Color is brown. And it is flat
and rounded.
Pupils are black in color; the
size is 3 – 7 mm in diameter.
Round and smooth.
Illuminated pupil
constricts(direct response)
Nonilluminated pupil
constricts(consensual
response)
The client’s pupils constrict
when looking at near object;
pupils dilate when looking at
far object; pupils converge
when near object is moved
toward nose.
EXTRAOCULAR
MUSCLES
Alignment; Both eyes coordinated, move in
coordination unison with parallel
alignment(Fundamentals of
Nursing, 8thed., by Kozier, p
592)
VISUAL FIELDS
Peripheral visual When looking straight ahead,
fields the client can see objects in the
periphery(Fundamentals of
Nursing, 8thed., by Kozier, p
591)
EARS
AURICLES
Color, symmetry, Color same as facial skin,
Position symmetrical, auricle aligned with
outer canthus of eye, about 10
degrees from vertical
Texture, elasticity Texture, elasticity and
And tenderness tenderness:
Mobile, firm and tender; pinna
recoils after it is folded
(Fundamentals of Nursing,
8thed., by Kozier, p 596)
The both eyes of the client
moved in unison with parallel
alignment and both
coordinated.
The object the client is looking
is a pen. The client can see
objects in the periphery when
looking straight ahead.
Color of the client’s auricle is
same as the facial skin,
symmetrically in size. Aligned
with outer canthus of the eye.
Texture is smooth, elastic and
tenderness.
It is firm and mobile Pinna
recoils after it is foded
EXTERNAL EAR
CANALS

Cerumen, skin Distal third contains hair follicles Distal third contains hair
Lesions Pus and and glands dry cerumen, follicles and glands, and the
blood grayish tan color/sticky/ wet external ear canals has
cerumen in various shades of cerumen
brown(Fundamentals of
Nursing, 8thed., by Kozier, p
596)

HEARING ACUITY
TEST

In normal voice Audible The client verbalized that she

Ones can hear clearly what the
health care provider says, like
ears check twice and twice
awesome.

Watch tick test Able to hear ticking in both ears The client is able to hear the
ticking in both ears.

Weber’s test Sound is heard in both ears or is The client heard in both ears.
localized at the center of the
head

Rinne’s test Air-conducted hearing is greater Air conduction is greater than

than bone-conducted bone conduction.
hearing(Fundamentals of
Nursing, 8thed., by Kozier, pp
597-598)
NOSE

Shapes, size, Symmetric and straight; no The client’s nose is symmetric

color, flaring/ discharge or flaring; uniform in and straight. No discharges or
discharge from color. flaring. The color of the nose
nares. ranges from medium to light
brown. Uniform to the color of
the face.

Nasal cavities: Pink mucosa; clear watery Mucosa is pink. And no watery
Redness, swelling discharge; no lesions discharge and lesions.
Growths, and
Discharge

Nasal septum Intact and in the midline Nasal septum is in the midline

Nasal cavity Patency, air moves freely as the Air moves freely as the client
Patency client breathes through the breathes through the nares.
nares.

Tenderness, No tenderness; no No tenderness; no lesions

masses and lesions(Fundamentals of
displacement of Nursing, 8thed., by Kozier, p
bone and cartilage 600)

FACIAL SINUSES

Frontal, Supraobital No tenderness(Fundamentals of No tenderness

ridges ,ethmoid, Nursing, 8thed., by Kozier, p
sphenoid, maxillary 600)
MOUTH

LIPS

Symmetry of Pinkish; symmetrical with lip She has a dark lips, Abnormal
contour, color, margin. Smooth and symmetrical with lip margin.
texture moist(Fundamentals of Nursing, And texture is moist and
8thed., by Kozier, p 602) smooth.

BUCCAL MUCOSA

Color, moisture, Moist, smooth, soft, glistering The client’s buccal mucosa is Normal
Texture and lesions and elastic(Fundamentals of moist, smooth, soft, glistering,
Nursing, 8thed., by Kozier, p and elastic
602)

TEETH

Color, number Smooth, white, shiny tooth

condition enamel; smooth, intact
dentures. 28-32 normal
numbers of teeth(Fundamentals
of Nursing, 8thed., by Kozier, p
602)

GUMS
Pink color, moist, firm texture,
Color condition no retraction(Fundamentals of
Nursing, 8thed., by Kozier, p
591)
TONGUE/ MOUTH
FLOOR

Surface of the Pink color, slightly rough, moist. The client’s tongue is pink in
Tongue for Smooth and no lesions. color, slightly rough and moist.
position, color, Central positioned. Positioned in center. And the
Texture. And Freely movable tongue can freely move.
tongue movement

Base of the tongue Smooth tongue base with

prominent veins

Nodules, lumps or Smooth with no palpable

enlarged lymph nodules(Fundamentals of
nodes Nursing, 8thed., by Kozier, pp
603-604)

PALATES AND
UVULA

Palate color, Hard palate: Lighter pink and Hard palate: Lighter pink and
shape, texture and more irregular texture more irregular texture
body prominence Soft palate: Light pink, smooth Soft palate: Light pink, smooth

Position of uvula, Positioned in midline of soft The uvula is positioned in

and mobility palate(Fundamentals of midline of soft palate
Nursing, 8thed., by Kozier, pp
604)
OROPHARYNX
AND TONSILS

Color, texture Pink in color, smooth posterior Oropharynx is pink in color

wall and has a smooth posterior
wall.

Tonsils, color, Pink and smooth. No discharge Pink and smooth. And no
Discharge discharge. Grade 1 tonsils

Gag reflex Present(Fundamentals of Present

Nursing, 8thed., by Kozier, p
604)

NECK

NECK MUSCLES

Neck muscles for Muscles equal in size; head Head centered and muscles
abnormal swellings centered are equal in size.
or masses

Head movements Coordinated, smooth The client has a coordinated

movements with no head movements and a
discomfort(Fundamentals of smooth movement. No
Nursing, 8thed., by Kozier, p discomfort
607)

LYMPH NODES
 Occipital
Postauriular
Preauricular Not palpable(Fundamentals of
Submandibular Nursing, 8thed., by Kozier, p
Submental 607)
Superficial anterior

TRACHEA

Placement Midline of neck; spaces are The placement of the trachea

equal on both is in the midline of the neck
sides(Fundamentals of Nursing, and the spaces on both sides
8thed., by Kozier, p 608) are equal.

THYROID GLAND

Symmetry and Not visible, gland ascends During swallowing gland

Masses during swallowing ascends bit not visible.

Smoothness, Lobes may not be palpated. Smoothness and nodules are

Areas of If palpated, lobes are small, not palpable. Tenderness is
Enlargement, smooth, centrally located, located centrally
Masses, painless, and rise freely with
nodules swallowing(Fundamentals of
Nursing, 8thed., by Kozier, p 609
)
 PART II
THORAX
POSTERIOR
THORAX

Shape, symmetry, Anteroposterior to transverse The anteroposterior to

Diameter diameter in ratio of 1:2,.chest transverse diameter in ratio is
symmetrical 1:2 and chest symmetrical

Spinal alignment Vertically aligned Vertically aligned

Temperature, and Skin intact; uniform temperature Skin intact; uniform

The integrity of all temperature
Chest skin

Respiratory Full and symmetric chest During deep inspiration

Excursion expansion thumbs separate 3-5 cm

Vocal fremitus Fremitus is heard most clearly
at the apex of the lungs.
Bilateral symmetry
The client is high pitched
voice. And the fremitus is
heard most clearly at the apex
of the lungs. Bilateral
symmetry.

Percussion Percussion notes resonate, the Resonate, except over the

level of diaphragm but are flat level of diaphragm but are flat
over areas of heavy muscle and over areas of heavy muscle
bone, dull on areas over and bone, dull on areas over
stomach stomach

Auscultation(posterio Vesicular and bronchovesicular Bronchial and tubular breath

r thorax) breath sounds(Fundamentals of sounds
Nursing, 8thed., by Kozier, p615)
ANTERIOR
THORAX

Breathing patterns Quiet, rhythmic, and effortless The client has quiet, rhythmic,
respiration and effortless respiration.

Temperature and Skin intact; uniform temperature Skin intact and uniform
The integrity of temperature.
All chest skin

Respiratory Full symmetric excursion; During deep inspiration

Excursion thumbs normally separate 3 to 5 thumbs separate 3-5 cm
cm

Vocal fremitus Fremitus is normally decreased

over heart and breast tissue

Percussion Percussion notes resonates

down to the sixth rib at the level
of the diaphragm but are flat
over areas of heavy muscle and
bone, dull on areas over the
heart and the liver, and
tympanic over the underlying
stomach

Auscultation(trachea) Bronchial and tubular breath Bronchial and tubular breath

sounds sounds

Auscultation(anterior Bronchovesicular and vesicular Bonchovesicular and vesicular

thorax) breath sounds(Fundamentals of breath sounds
Nursing, 8thed., by Kozier, p617)
CARDIOVASCULAR
PALPATION
Aortic and pulmonic No pulsations No pulsations Normal

Tricuspid area and No pulsation and no heaves or No pulsation and no heaves or Normal
Heaves or lifts lifts lifts

Apical area Pulsation visible in 50% of Pulsation is visible and

adults and palpable in most PMI palpable.
in fifth LISC at or medial to
MCL.
Diameter of 1 to 2 cm. no he
heave or lift

Auscultation
Aortic S1: usually heard at all sites S1: usually heard at all sites Normal
Pulmonic usually louder at apical area usually louder at apical area
Tricuspid
Apical S2: usually heard at all sites S2: usually heard at all sites
usually louder at base of heart usually louder at base of heart

Systole: silent interval; slightly

shorter duration than diastole at
normal heart rate(60-90bpm)

Diastole: silent interval; slightly

longer than systole at normal
heart rates

S3: in children and young adult

S4: in many older adults.
(Fundamentals of Nursing,
8thed., by Kozier, pp620-622)
CAROTID
ARTERIES

Palpation Symmetric pulse volumes. Symmetric pulse volumes. Normal

Full pulsations, thrusting quality. Full pulsations, thrusting
Elastic artery wall quality. Elastic artery wall

Auscultation No sound heard on During auscultation no sound Normal

auscultation(Fundamentals of heard
Nursing, 8thed., by Kozier,
pp622-623)

JUGULAR VEINS

Inspect Veins not visible(Fundamentals Veins are not visible Normal

of Nursing, 8thed., by Kozier, p
623)

BREAST AND
AXILLAE

BREAST

Size, symmetry and Rounded shape; slightly The shape is round and
Shape unequal in size; generally slightly unequal and it is
symmetric generally symmetric.

Localized Skin uniform in color; skin The skin is uniform in color

discolorations or smooth and intact. and it is also smooth and
hyperpigmentation, Diffuse symmetric horizontal or intact.
retraaction or vertical vascular pattern in light
dimpling, localized skinned people.
hypervascular areas, Striae; moles and nevi
swelling or edema

AREOLA

Shape,, color, Round/oval; bilaterally the

masses or lesions same; color varies widely from
light pink to dark brown. No
lumps, masses or areas of
tenderness

NIPPLES

Size, shape, color, Round; everted/inverted; equal
Position, discharge in size; similar in color.
And lesions. Soft and smooth; no discharge,
masses or lesions. No lumps
and masses.
Round everted and equal in
size. Similar in color with
areola and texture is smooth
and soft, No discharges and
lesions nor masses.

Axillary, No tenderness, masses, or No tenderness, masses, or

Subclavicular and nodules nodules
supraclavicular
lymph nodes

Breast for Masses, No tenderness, masses, No tenderness, masses,

tenderness nodules, or nipple discharge nodules, or nipple discharge

Nipples for No tenderness, masses, No tenderness, masses,

tenderness and nodules, or nipple nodules, or nipple discharge
discharges discharge(Fundamentals of
Nursing, 8thed., by Kozier, pp
628-630)
ABDOMEN

Inspection Unblemished skin; uniform color The color is light to medium

Abdomen skin brown and it is uniform.
Unblemished skin.

Inspection Flat, rounded; symmetric The abdomen is flat and

Abdomen for contour. rounded and has a symmetric
Contour and contour.
Symmetry

Inspection No enlargement of the There is no enlargement of the

Enlargement of liver/spleen liver/spleen
Liver/spleen

Assess symmetry Symmetric contour The client has a symmetric

Of contour while contour
standing at the foot
of the bed

Abdominal Symmetric movements caused Symmetric movements.

Movements by respiration.
associated w/ Visible peristalsis in very lean
respiration, people.
peristalsis, or aortic Aortic pulsations in thin persons
pulsations at epigastric area.

Vascular patterns No visible vascular pattern Vascular pattern is not visible

Auscultation Audible bowel sounds; absence Absence of arterial bruits and

of arterial bruits; absence of friction rub. The bowel sounds
friction rub are audible
 Tympany over the stomach and
Percussion each gas-filled bowels; dullness,
Of the four especially over the liver and
Quadrants spleen, or a full bladder
Tympany is heard over the
stomach and gas-filled
bowels; dullness, sound is
heard over the liver and
spleen, or a full bladder

Percuss the liver 6 to 12 cm in the midclavicular

To determine its line; 4 to 8 cm at midsternal line
Size

No tenderness; relaxed No tenderness relaxed

Light Palpation abdomen with smooth, abdomen w/ smooth,
consistent tension consistent tension.

Deep palpation Tenderness may be present

near xiphoid process, over
cecum, and over sigmoid colon

Palpate area above

The symphysis Not palpable(Fundamentals of
Pubis to determine Nursing, 8thed., by Kozier, pp
possible urinary 633-638)
retention

MASCULAR
SKELETAL
SYSTEM

MUSCLE

Size Equal on both sides of body Muscle is equal on both sides

of the body
Tendons for
Contractures No contractures No contractures

Fasciculation and No fasciculation and tremors No fasciculation and tremors

Tremors

Palpate muscle Normally firm Muscle is firm

Tonicity

Test for muscle Equal strength on each body Muscle strength is equal on
Strength side. (Fundamentals of Nursing, both sides.
8thed., by Kozier, pp 640-641)

BONES

Inspect skeleton No deformities No deformities

For structure

Palpate bones to
Locate areas of No tenderness or swelling No tenderness or swelling
Edema or
Tenderness

Inspect joint for No swelling; Joints of the client do not have

Swelling swelling.

Palpate each joint No tenderness or nodules.

For tenderness, No tenderness, crepitation, or Joints move smoothly
Smoothness, nodules. Joints move
Swelling, crepitation smoothly(Fundamentals of
& presence of Nursing, 8thed., by Kozier, p
nodule 641)