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

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2. Uniformity of skin color

NORMAL FINDINGS
Generally uniform except in areas exposed to the sun; areas of llighter pgmentation (palms, lips, nail beds) in dark-skinned people No edema

ACUTAL FINDINGS

ANALYSIS

3. Presence of edema

4. Existence of lesions

Freckles, some birthmarks, some flat and raised nevi, no abrasions or other lesions Moisture in skin folds and the axillae (varies with environmental temperature and humidity, body temperature, and activity) Uniform; within normal range

5. Skin Moisture

6. Skin temperature

7. Skin turgor

When pinched, skin springs back to previous state

B. NAILS
1. Fingernail plate shape (its curvature and angle) Convex curvature; angle of nail plate about 160 Highly vascular and pink in lightskinned clients; dark sknned clients may have brown or black pigmentation in longitudinal streaks Smooth texture

2. Fingernail and toenail bed color

3. Fingernail and toenail texture 4. Presence of tissues

Intact epidermis surrounding nails 5. Blanch test result of capillary refill Prompt return of pink or usual color (generally less than 4 seconds)

III. HEAD
A. SKULL

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AREA TO BE ASSESSED
1. Size, shpae and symmetry of the skull

NORMAL FINDINGS
Rounded (normecephalic and symmetrical, with frontal, parietal, and occipital prominences); Smooth skull contour Smooth, uniform consistence; absence of nodules or masses

ACUTAL FINDINGS

ANALYSIS

2. Presence of nodules, masses, and depressions

B. HAIR
1. Evenness of growth, thickness or thinness of hair Evenly distributed and covers the whole scalp: Maybe thick or thin

C. FACE
Symmetric or slightly asymmetric facial Facial features, symmetry of facial movements features; palpebral fissures equal in size; symmetric nasolabial folds

IV. EYES
A. EYEBROWS
Hair distribution, alignment, skin quality and movement Symmetrical and in line with each other, maybe black, brown or blond depending on race; evenly distributed

B. EYELASHES
Evenness of distribution and direction of curl Evenly distributed; turned outward

C. EYELIDS
Upper eyelids cover the small portion Surface characteristics and position (in relation of the iris, cornea, and sclera when eyes to the cornea, ability to blink, and frequency of are open; eyelids meet completely blinking) when the eyes are closed; symmetrical

D. CONJUNCTIVA
1. Color, texture, and tine presence of lesions in the bulbar conjunctiva Pinkish or red in color, with presence of small capillaries; moist; no foreigh bodies; no ulcers Pinkish or red in color, with presence of small capillaries; moist; no foreigh bodies; no ulcers

2. Color, texture, and the presence of lesions in the palbebral conjunctiva

E. SCLERA

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AREA TO BE ASSESSED
Color and clarity

NORMAL FINDINGS
White in color, clear, no yellowish discoloration; some capillaries maybe visible

ACUTAL FINDINGS

ANALYSIS

F. CORNEA
Clarity and texture No irregularities on the surface; looks smooth; clear or transarent

G. IRIS
Shape and color Anterior chamber is transparent; no noted visible materials; color depends on the person's race

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H. PUPILS
1. Color, shape, and symmetry of size Color depends on the person's race; size ranges from 3-7 mm, and are equal in size; equally round Constrict briskly/sluggishly when light is directed to the eye, both directly and consensual

NORMAL FINDINGS

ACUTAL FINDINGS

ANALYSIS

2. Light reaction and accommodation

I. VISUAL ACUITY
1. Near vision Able to read newsprint

2. Distance vision

20' 20' vision on Snellen chart

J. 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, move in unison, with parallel alignment

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L. VISUAL FIELDS
Peripheral visual fields When looking straight ahead, client can see objects in the periphery

NORMAL FINDINGS

ACUTAL FINDINGS

ANALYSIS

V. EARS
A. AURICLES
1. Color, symmetry of size, and position Color same as facial skin; symmetrical; auricle aligned with outer canthus of eye, about 10 degrees from vertical Mobile, firm, and not tender, pinna recoils after it is folded

2. Texture, elasticity and areas of tenderness

B. HEARING ACUITY TESTS

1. Client's response to normal voise tones Normal voice tones audible

2. Watch tick test result

Able to hear ticking in both ears

3. Weber's test result

Sound is heard in both ears or is localized at the center of the head

4. Rinne test result

Air-conducted (AC) hearing is greater than bone-conducted (BC) hearing

VI. NOSE
1. Any deviations in shape, size, or color and flaring or discharge from the nares Symmetric and straight; no discharge or flaring; Uniform color

2. Presence of redness, swelling, growths and discharge in the nasal cavities

Mucosa pink; clear, watery discharge; no lesions

3. Nasal septum (between the nasal chambers)

Nasal septum intact and in midline

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4. Patency of both nasal cavities

NORMAL FINDINGS
Air moves freely as the client breathes through the nares

ACUTAL FINDINGS

ANALYSIS

5. Tenderness, masses, and displacements of bone and cartilage

Not tender; no lesions

VII. SINUSES
Identification of the sinuses and for tenderness Not tender

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VIII. MOUTH
A. LIPS
Symmetry of contour color and texture Uniform pink color, soft, moist, smooth texture; symmetry of contour, ability to purse lips

NORMAL FINDINGS

ACUTAL FINDINGS

ANALYSIS

B. BUCCAL MUCOSA
Color, moisture, texture and the presence of lesions Uniform pink color, moist smooth, soft, glistening, and elastic texture

C. TEETH
Color, number and condition and presence of dentures 32 adult teeth; smooth white, shiny tooth enamel, smooth, intact dentures

D. GUMS
Color and condition Pink gums; no retraction

E. TONGUE/FLOOR OF THE MOUTH

1. Color and texture of the mouth floor and frenulum Pink color; moist; slightly rough; thin whitish coating; moves freely; no tenderness Central position; pink color; smooth tongue base with prominent veins

2. Position, color and texture, movement and base of the tongue

3. Any nodules, lumps, or excoriated areas

Smooth with no palbable nodules, lumps, or excoriated areas

F. PALATES and UVULA

1. Color, shape, texture and the presence of bony prominences Light pink, smooth, soft palate; lighter pink hard palate, more irregular texture

2. Position of the uvula and mobility (while examining the palates)

Positioned in midline of soft palate

G. OROPHARYNX and TONSILS

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1. Color and texture

NORMAL FINDINGS
Pink and smooth posterior wall

ACUTAL FINDINGS

ANALYSIS

2. Size, color, and discharge of the tonsils

Pink and smooth; no discharge; of normal size

3. Gag reflex

Present

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IX. NECK and LYMPH NODES
A. NECK MUSCLES
Inspection of neck muscle and head movement. Muscles equal in size, coordinated head movement without discomfort

NORMAL FINDINGS

ACUTAL FINDINGS

ANALYSIS

A. LYMPH NODES
Identification of Lymph nodes and for tenderness Not palpable

B. TRACHEA
Placement of the Trachea Central placement in midline of neck; spaces are equal on both sides

C. THYROID GLAND
1. Symmetry and visible masses Not visible on inspection

2. Smoothness and areas of enlargement, masses or nodules

Lobes may not be palpated

X. THORAX
A. POSTERIOR THORAX
1. Shape, symmetry, and comparison of anteroposterior thorax to transverse diamter Anteroposterior to transverse diameter in ratio 1:2; Chest symmetric

2. Spinal alignment

Spine vertically aligned

3. Temperature, tenderness, and masses

Skin intact; uniform temperature; chest wall intact; no tenderness; no masses

4. Respiratory excursion assessment

Full and symmetric chest expansion

5. Vocal fremitus palpation

Bilateral symmetry of vocal fremitus; Fremitus is heard most clearly at the apex of the lungs

HEAD TO TOE PHYSICAL ASSESMENT

AREA TO BE ASSESSED NORMAL FINDINGS
Percussion notes resonate except over scapula; Lowest point of resonance is at the diaphragm; percussion on a rib normally elicits dullness Vesicular and bronchovesicular breath sounds

ACUTAL FINDINGS

ANALYSIS

6. Posterior thorax percussion

7. Posterior thorax auscultation

B. ANTERIOR THORAX
1. Breathing patterns Quiet, rhytmic, and effortless respirations

2. Temperature, tenderness, masses

Skin intact; uniform temperature; chest wall intact; no tenderness; no masses

3. Respiratory excursion assessment

Full symmetric excursion; thumbs normally separate 3 to 5 cm Bilateral symmetry of vocal fremitus; Fremitus is normally decreased over heart and breast tissue. Percussion notes resonate 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 heart and the liver, and tympanic over the underlying stomach

4. Vocal Fremitus palpation

5. Anterior thorax percussion

6. Trachea auscultation

Bronchial and tubular breath sounds

7. Anterior thorax auscultation

Bronchovesicular and vesicular breath sound

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AREA TO BE ASSESSED
XI. CARDIOVASCULAR
A. AORTIC and PULMONIC AREAS
No pulsations

NORMAL FINDINGS

ACUTAL FINDINGS

ANALYSIS

B. TRICUSPID AREA

No pulsations; no lift or heave

C. APICAL AREA

Pulsations visible in 50% of adults and palpable in most PMI in fifth LICS at or medial to MCL

D. EPIGASTRIC AREA

Aortic pulsations

E. 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 shorter duration than diastole at normal heart rate (60 to 90 beats/min) Diastole: silent interval; slightly longer duration than systole at normal heart rates S3: in children and young adults S4: in many older adults

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XII. CAROTID ARTERIES
Symmetric pulse volumes; full pulsations, thrusting quality; quality remains same when the client breathes, turns head, and changes from sitting to supine position; elastic arterial wall No sound heard on auscultation

NORMAL FINDINGS

ACUTAL FINDINGS

ANALYSIS

1. Carotid artery palpation

2. Carotid arteries auscultation

XIII. JUGULAR VEINS

Jugular veins inspection No sound heard on auscultation

XIV. BREAST and AXILLAE

1. Breast's size symmetry, and contour or shape 2. Localized discolorations or hyperpigmentation, retraction or dimpling, localized hypervascular areas, swelling or edema in the skin of the breast Rounded Shape; slightly unequal in size; generally symmetric

Skin uniform in color; skin smooth and intact; no major discolorations

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AREA TO BE ASSESSED NORMAL FINDINGS
Round or oval and bilaterally the same; color varies widely, from light pink to dark brown; irregular placement of sebaceous glands on the surface of the areola irregular placement of sebaceous glands on the surface of the areola Round, everted, and equal in size; similar in color; soft and smooth; both nipples point in the same direction; no discharge, except from pregnant or breast-feeding females; inversion of one or both nipples that is present from puberty

ACUTAL FINDINGS

ANALYSIS

3. Areola's size, shape, symmetry color, discharge, and lesions

4. Nipple's size, shape, position, color, discharge, and lesions

5. Axillary, subclavicular, and supraclavicular lymph nodes

No tenderness, masses, or nodules

6. Masses, tenderness, and any discharge from No tenderness, masses, or nodules, or the nipples nipple discharge

XV. ABDOMEN
1. Skin Integrity Unblemished skin; uniform color

2. Abdominal contour

Flat rounded (convex), or scaphoid (concave)

3. Enlargement of liver of spleen

No evidence of enlargement of liver or spleen

4. Symmetry of contour

Symmetric Contour Symmetric movements caused by respiration; visible peristalsis in very lean people; aortic pulsations in thin persons at epigastric area

5. Abdominal movements associated with respirations, peristalsis or aortic pulsations

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6. Vascular pattern

NORMAL FINDINGS
No visible vascular pattern

ACUTAL FINDINGS

ANALYSIS

7. Bowel sounds, vascular sounds, and peritoneal friction rubs

Audible bowel sounds; Absence of arterial bruits; absence of friction rub Tympany over the stomach and gasfilled bowels; dullness, especially over the liver and spleen, or a full bladder No tenderness; relaxed abdomen with smooth, consistent tension

8. Several abdominal areas of the four quadrants

9. Light palpation in the four quadrants

XVI. MUSCULOSKELETAL SYSTEM

A. MUSCLES
1. Muscle size and comparison on the other side Proportionable to the body even in both sides

2. Contractures in the muscles and tendons

No contractures

3. Fasciculations and tremors in the muscles

No fasciculation and tremors

4. Muscle tonicity

Even and firm muscle tone

5. Muscle strength

100% muscle strength

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AREA TO BE ASSESSED
B. BONES
1. Normal structures and deformities in the skeleton No deformities

NORMAL FINDINGS

ACUTAL FINDINGS

ANALYSIS

2. Areas of edema or tenderness in the bones

Absence of edema or tenderness in bones

C. JOINTS
1. Joint swelling No joint swelling, no warmth, redness No tenderness, swelling and nodules: smooth movements: minimal crepitus may be present but there should be no pronounced crepitation

2. Tenderness, smoothness of movement, swelling, crepitation and presence of nodules