Student Nurse: Good Morning Maam, Good Morning Baby. Im Marie Nelle E.

Limpoco and im your nurse today. So I will be having first a physical

assessment to your child. PA is an inevitable procedure not just for nurses but
also for doctors. Establishing a good assessment will later-on provide us more
accurate diagnosis, planning, better interventions and evaluation for your
child. Dont worry maam I will be fast as I could so that your child will have
enough rest. So now, I will be performing a head to toe physical assessment.
Let us start with head.
HEAD
1. Observe the size, shape, and contour of the skull.
2. Observe scalp in several areas by separating the hair at various locations.
Note the presence of lice, nits, dandruff or lesion.
3. Palpate the head by running the pads of the fingers over the entire surface of
the skull; inquire about tenderness upon doing so. (wear gloves if necessary)
4. Observe and feel the hair condition.

NORMAL FINDINGS:
SKULL

Generally round, with prominences in the frontal and occipital area.

(normocephalic)
No tenderness noted upon palpation.

SCALP

Lighter in color than the complexion

Moist
No scars noted.
Free from lice, nits and dandruff.
No lesion should be noted.
No tenderness or masses on palpation.

HAIR

Black
Evenly distributed that covers the whole scalp
No evidence of alopecia
Thick and smooth

FACE

Observe the face for shape

Inspect for symmetry
- Inspect for palpebral fissure (distance between the eyelids); should be
equal in both eyes.

Ask the patient to smile, there should be bilateral nasolabial fold.

If both are met, then the face is symmetrical

NORMAL FINDINGS

Round
Face is symmetrical
No involuntary muscle movements
Can move facial muscle
Intact cranial nerve V and VII

MOUTH AND OROPHARYNX

1. Inspect for symmetry and surface abnormalities.
2. Inspect the color.
3. Inspect the edema.
NORMAL FINDINGS:

With visible margin

Symmetrical in appearance and movement
Pinkish in color
No edema

LIPS
1. Inspect for color and texture.
NORMAL FINDINGS:

Pinkish
Moist

ABNORMAL FINDINGS:
- Dry, cracked and pale lips

TEMPOROMANDIBULAR
1. Palpate while the mouth is opened wide and then closed for:

Crepitus
Deviations
Tenderness

NORMAL FINDINGS:

Moves smoothly no crepitus

No deviations noted
No pain or tenderness on palpation and jaw movement

GUMS
1. Inspect for color, bleeding and retraction of gums.
NORMAL FINDINGS:

Pinkish in color

No gum bleeding
No receding gums

TEETH
1. Inspect for number, color, dental carries, dental fillings, alignment and
malocclusions (2 teeth in the space for 1, or overlapping teeth), tooth loss, and
breath sound should also be assessed during the process.
NORMAL FINDINGS:

28 for children and 32 for adults

White in color
With dental carries
No halitosis

TONGUE
1. Palpate for texture
NORMAL FINDINGS:

Pinkish with white taste buds on the surface

No lesion noted
No varicosities on ventral surface
Gag reflex is reflex
Able to move the tongue freely and with strength
Surface of the tongue is rough

UVULA
1. Inspected for position, color and cranial nerve X. ( Tested by saying the
client to say ah note that uvula will move upward and forward.
NORMAL FINDINGS:

Positioned in the mid line.

Pinkish to red in color.
No swelling and lesion noted.
Moves upward and backwards when asked to say Ah