Physical Assessment

Integument
 Skin: The client’s skin is uniform in color, unblemished and no presence of any foul odor. He
has a good skin turgor and skin’s temperature is within normal limit.
 Hair: The hair of the client is thick, silky hair is evenly distributed and has a variable amount
of body hair. There are also no signs of infection and infestation observed.
 Nails: The client has a light brown nails and has the shape of convex curve. It is smooth and
is intact with the epidermis. When nails pressed between the fingers (Blanch Test), the nails
return to usual color in less than 4 seconds.
Head
 Head: The head of the client is rounded; normocephalic and symmetrical.
 Skull: There are no nodules or masses and depressions when palpated.
 Face: The face of the client appeared smooth and has uniform consistency and with no
presence of nodules or masses.
Eyes and Vision
 Eyebrows: Hair is evenly distributed. The client’s eyebrows are symmetrically aligned and
showed equal movement when asked to raise and lower eyebrows.
 Eyelashes: Eyelashes appeared to be equally distributed and curled slightly outward.
 Eyelids: There were no presence of discharges, no discoloration and lids close symmetrically
with involuntary blinks approximately 15-20 times per minute.
 Eyes
o The Bulbar conjunctiva appeared transparent with few capillaries evident.
o The sclera appeared white.
o The palpebral conjunctiva appeared shiny, smooth and pink.
o There is no edema or tearing of the lacrimal gland.
o Cornea is transparent, smooth and shiny and the details of the iris are visible. The
client blinks when the cornea was touched.
o The pupils of the eyes are black and equal in size. The iris is flat and round.
PERRLA (pupils equally round respond to light accommodation), illuminated and
non-illuminated pupils constricts. Pupils constrict when looking at near object and
dilate at far object. Pupils converge when object is moved towards the nose.
o When assessing the peripheral visual field, the client can see objects in the
periphery when looking straight ahead.
o When testing for the Extraocular Muscle, both eyes of the client coordinately
moved in unison with parallel alignment.
o The client was able to read the newsprint held at a distance of 14 inches.
Ears and Hearing
 Ears: The Auricles are symmetrical and has the same color with his facial skin. The auricles
are aligned with the outer canthus of eye. When palpating for the texture, the auricles are
mobile, firm and not tender. The pinna recoils when folded. During the assessment of Watch
tick test, the client was able to hear ticking in both ears.
Nose and Sinus
 Nose: The nose appeared symmetric, straight and uniform in color. There was no presence
of discharge or flaring. When lightly palpated, there were no tenderness and lesions
 Mouth:
o The lips of the client are uniformly pink; moist, symmetric and have a smooth
texture. The client was able to purse his lips when asked to whistle.
o Teeth and Gums: There are no discoloration of the enamels, no retraction of
gums, pinkish in color of gums
o The buccal mucosa of the client appeared as uniformly pink; moist, soft,
glistening and with elastic texture.
o The tongue of the client is centrally positioned. It is pink in color, moist and
slightly rough. There is a presence of thin whitish coating.
o The smooth palates are light pink and smooth while the hard palate has a more
irregular texture.
o The uvula of the client is positioned in the midline of the soft palate.
 Neck:
o The neck muscles are equal in size. The client showed coordinated, smooth head
movement with no discomfort.
o The lymph nodes of the client are not palpable.
o The trachea is placed in the midline of the neck.
o The thyroid gland is not visible on inspection and the glands ascend during
swallowing but are not visible.
Thorax, Lungs, and Abdomen
 Lungs / Chest: The chest wall is intact with no tenderness and masses. There’s a full and
symmetric expansion and the thumbs separate 2-3 cm during deep inspirationwhen assessing
for the respiratory excursion. The client manifested quiet, rhythmic and effortless respirations.
 The spine is vertically aligned. The right and left shoulders and hips are of the same height.
 Heart: There were no visible pulsations on the aortic and pulmonic areas. There is no
presence of heaves or lifts.
 Abdomen: The abdomen of the client has an unblemished skin and is uniform in color. The
abdomen has a symmetric contour. There were symmetric movements caused associated
with client’s respiration.
o The jugular veins are not visible.
o When nails pressed between the fingers (Blanch Test), the nails return to usual
color in less than 4 seconds.
Extremities
 The extremities are symmetrical in size and length.
 Muscles: The muscles are not palpable with the absence of tremors. They are normally firm
and showed smooth, coordinated movements.
 Bones: There were no presence of bone deformities, tenderness and swelling.
 Joints: There were no swelling, tenderness and joints move smoothly.

Nursing Assessment in Tabular Form

Assessment Findings

Integumentary
When skin is pinched it goes to previous state
immediately (2 seconds).
 Skin
With fair complexion.
With dry skin
Evenly distributed hair.
 Hair With short, black and shiny hair.
With presence of pediculosis Capitis.
Smooth and has intact epidermis
 Nails With short and clean fingernails and toenails.
Convex and with good capillary refill time of 2 seconds.
Rounded, normocephalic and symmetrical, smooth and
Skull
has uniform consistency.Absence of nodules or masses.
Symmetrical facial movement, palpebral fissures equal
Face
in size, symmetric nasolabial folds.
Eyes and Vision
Hair evenly distributed with skin intact.
 Eyebrows Eyebrows are symmetrically aligned and have equal
movement.
 Eyelashes Equally distributed and curled slightly outward.
Skin intact with no discharges and no discoloration.
 Eyelids
Lids close symmetrically and blinks involuntary.
 Bulbar conjunctiva Transparent with capillaries slightly visible
 Palpebral Conjunctiva Shiny, smooth, pink
 Sclera Appears white.
 Lacrimal gland, Lacrimal sac, No edema or tenderness over the lacrimal gland and no
Nasolacrimal duct tearing.
Cornea
Transparent, smooth and shiny upon inspection by the
use of a penlight which is held in an oblique angle of
 Clarity and texture
the eye and moving the light slowly across the eye.
Has [brown] eyes.
Blinks when the cornea is touched through a cotton
 Corneal sensitivity
wisp from the back of the client.
Black, equal in size with consensual and direct reaction,
Pupils
pupils equally rounded and reactive to light and
 Assessment Findings

accommodation, pupils constrict when looking at near

objects, dilates at far objects, converge when object is
moved toward the nose at four inches distance and by
using penlight.
When looking straight ahead, the client can see objects
at the periphery which is done by having the client sit
directly facing the nurse at a distance of 2-3 feet.
Visual Fields The right eye is covered with a card and asked to look
directly at the student nurse’s nose. Hold penlight in the
periphery and ask the client when the moving object is
spotted.
Able to identify letter/read in the newsprints at a
distance of fourteen inches.
Visual Acuity
Patient was able to read the newsprint at a distance of
8 inches.
Ear and Hearing
Color of the auricles is same as facial skin, symmetrical,
auricle is aligned with the outer canthus of the eye,
 Auricles
mobile, firm, non-tender, and pinna recoils after it is
being folded.
 External Ear Canal Without impacted cerumen.
 Hearing Acuity Test Voice sound audible.
Able to hear ticking on right ear at a distance of one
 Watch Tick Test inch and was able to hear the ticking on the left ear at
the same distance
Nose and sinuses
Symmetric and straight, no flaring, uniform in color, air
 External Nose
moves freely as the clients breathes through the nares.
Mucosa is pink, no lesions and nasal septum intact and
 Nasal Cavity
in middle with no tenderness.
Symmetrical, pale lips, brown gums and able to purse
Mouth and Oropharynx
lips.
 Teeth With dental caries and decayed lower molars
Central position, pink but with whitish coating which is
 Tongue and floor of the mouth
normal, with veins prominent in the floor of the mouth.
Moves when asked to move without difficulty and
 Tongue movement
without tenderness upon palpation.
Uvula Positioned midline of soft palate.
Present which is elicited through the use of a tongue
Gag Reflex
depressor.
Positioned at the midline without tenderness and flexes
Neck
easily. No masses palpated.
Coordinated, smooth movement with no discomfort,
Head movement head laterally flexes, head laterally rotates and
hyperextends.
Muscle strength With equal strength
Lymph Nodes Non-palpable, non tender
Not visible on inspection, glands ascend but not visible
 Thyroid Gland
in female during swallowing and visible in males.
Thorax and lungs
Posterior thorax Chest symmetrical
Spine vertically aligned, spinal column is straight, left
 Spinal alignment
and right shoulders and hips are at the same height.
Breath Sounds With normal breath sounds without dyspnea.
 Anterior Thorax Quiet, rhythmic and effortless respiration
 Assessment Findings

Unblemished skin, uniform in color, symmetric contour,

Abdomen
not distended.
Abdominal movements Symmetrical movements cause by respirations.
 Auscultation of bowel sounds With audible sounds of 23 bowel sounds/minute.
Upper Extremities Without scars and lesions on both extremities.
Lower Extremities With minimal scars on lower extremities
Equal in size both sides of the body, smooth
Muscles coordinated movements, 100% of normal full
movement against gravity and full resistance.
Bones and Joints No deformities or swelling, joints move smoothly.
Mental Status
Language Can express oneself by speech or sign.
Orientation Oriented to a person, place, date or time.
Able to concentrate as evidence by answering the
Attention span
questions appropriately.
A total of 15 points indicative of complete orientation
Level of Consciousness
and alertness.
Motor Function
Gross Motor and Balance
Has upright posture and steady gait with opposing arm
 Walking gait
swing unaided and maintaining balance.
Standing on one foot with eyes closed Maintained stance for at least five (5) seconds.
Heel toe walking Maintains a heel toe walking along a straight line
Toe or heel walking Able to walk several steps in toes/heels.
Fine motor test for Upper Extremities
Finger to nose test Repeatedly and rhythmically touches the nose.
Alternating supination and pronation of Can alternately supinate and pronate hands at rapid
hands on knees pace.
Finger to nose and to the nurse’s finger Perform with coordinating and rapidity.
Fingers to fingers Perform with accuracy and rapidity.
Fingers to thumb Rapidly touches each finger to thumb with each hand.
Fine motor test for the Lower Extremities
Able to discriminate between sharp and dull sensation
Pain sensation
when touched with needle and cotton.