Physical Assessment

BODY PART
Integumentary
Skin

ACTUAL FINDINGS

NORMAL FINDINGS

Hair

Nails

Skull

Face

Uniformly tan-pink in
color, warm, dry,
intact, turgor good
No lesions,
birthmarks, edema
No mass, no
swelling, ocular
structures not
involved
Hair normal
distribution and
texture, no pest
inhabitants, with
dandruf
Nails no clubbing,
biting or
discolorations
Nail beds pink and
firm with prompt
capillary refill
Rounded,
normocephalic and
symmetrical, smooth
and has uniform
consistency.
Absence of nodules
or masses
Symmetrical facial
movement,

Uniformly tan-pink in
color, warm, dry,
intact, turgor good
No lesions,
birthmarks, edema
No mass, no
swelling, ocular
structures not
involved
Hair normal
distribution and
texture, no pest
inhabitants
Nails no clubbing,
biting or
discolorations
Nail beds pink and
firm with prompt
capillary refill
Rounded,
normocephalic and
symmetrical, smooth
and has uniform
consistency.
Absence of nodules
or masses
Symmetrical facial
movement,

INTERPRETATION

palpebral fissures
equal in size,
symmetric
nasolabial folds
Eyes and Vision
Eyebrows

Hair evenly
distributed with skin
intact. Eyebrows are
symmetrically
aligned and have
equal movement
Equally distributed
and curled slightly
outward.
Skin intact with no
discharges and no
discoloration.
Lids close
symmetrically and
blinks involuntary.
Transparent with
capillaries slightly
visible
Shiny, smooth, pink

Appears white.
No edema or
tenderness over the
lacrimal gland and
no tearing.

Appears white.
No edema or
tenderness over the
lacrimal gland and
no tearing.

Transparent, smooth
and shiny upon

Transparent, smooth
and shiny upon

Eyelashes

Eyelids

Bulbar conjunctiva

Palpebral
conjunctiva
Sclera
Lacrimal gland,
lacrimal sac,
nasolacrimal duct

Cornea
Clarity and texture

palpebral fissures
equal in size,
symmetric
nasolabial folds

Hair evenly
distributed with skin
intact. Eyebrows are
symmetrically
aligned and have
equal movement
Equally distributed
and curled slightly
outward.
Skin intact with no
discharges and no
discoloration.
Lids close
symmetrically and
blinks involuntary.
Transparent with
capillaries slightly
visible
Shiny, smooth, pink

 Corneal sensitivity

Pupils

Visual fields

inspection by the
use of a penlight
which is held in an
oblique angle of the
eye and moving the
light slowly across
the eye.
Has brown eyes.
Blinks when the
cornea is touched
through a cotton
wisp from the back
of the client.
Black, equal in size
with consensual and
direct reaction,
pupils equally
rounded and
reactive to light and
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

inspection by the
use of a penlight
which is held in an
oblique angle of the
eye and moving the
light slowly across
the eye.
Has [color] eyes.
Blinks when the
cornea is touched
through a cotton
wisp from the back
of the client.
Black, equal in size
with consensual and
direct reaction,
pupils equally
rounded and
reactive to light and
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

Visual acuity

Ear And Hearing

Auricles

External ear canal

Hearing acuity test

Watch tick test

Nose And Sinuses

External nose

facing the nurse at a

distance of 2-3 feet
Able to identify
letter/read in the
newsprints at a
distance of fourteen
inches.
Patient was able to
read the newsprint
at a distance of 8
inches.

Color of the auricles

is same as facial
skin, symmetrical,
auricle is aligned
with the outer
canthus of the eye,
mobile, firm, nontender, and pinna
recoils after it is
being folded.
Without impacted
cerumen.
Voice sound audible.
Able to hear ticking
on right ear at a
distance of one inch
and was able to hear
the ticking on the
left ear at the same
distance

Symmetric and
straight, no flaring,

facing the nurse at a

distance of 2-3 feet.
Able to identify
letter/read in the
newsprints at a
distance of fourteen
inches.
Patient was able to
read the newsprint
at a distance of 8
inches.
Color of the auricles
is same as facial
skin, symmetrical,
auricle is aligned
with the outer
canthus of the eye,
mobile, firm, nontender, and pinna
recoils after it is
being folded.
Without impacted
cerumen.
Voice sound audible.
Able to hear ticking
on right ear at a
distance of one inch
and was able to hear
the ticking on the
left ear at the same
distance
Symmetric and
straight, no flaring,

 Nasal cavity

Mouth And Oropharynx

Teeth

Tongue floor of the

mouth

Tongue movement

Uvula

Gag reflex

uniform in color, air

moves freely as the
clients breathes
through the nares.
Mucosa is pink, no
lesions and nasal
septum intact and in
middle with no
tenderness.
Symmetrical, pale
lips, brown gums
and able to purse
lips.
With dental caries
and decaying teeth
in the second lower
left molar and the
right upper molar
Central position, pink
but with whitish
coating which is
normal, with veins
prominent in the
floor of the mouth.
Moves when asked
to move without
difficultyand without
tenderness upon
palpation.
Positioned midline of
soft palate.
Present which is
elicited through the
use of a tongue
depressor

uniform in color, air

moves freely as the
clients breathes
through the nares.
Mucosa is pink, no
lesions and nasal
septum intact and in
middle with no
tenderness.
Symmetrical, pale
lips, brown gums
and able to purse
lips.
With no dental caries
and no decaying
teeth
Central position, pink
but with whitish
coating which is
normal, with veins
prominent in the
floor of the mouth.
Moves when asked
to move without
difficulty and without
tenderness upon
palpation.
Positioned midline of
soft palate.
Present which is
elicited through the
use of a tongue
depressor

Neck

Head movement

Muscle strength
Lymph nodes

Thyroid gland

Thorax And Lungs

Posterior thorax
Spinal alignment

Breadth sounds

Anterior thorax

Positioned at the
midline without
tenderness and
flexes easily. No
masses palpated.
Coordinated, smooth
movement with no
discomfort, head
laterally flexes, head
laterally rotates and
hyperextends.
With equal strength
Non-palpable, nontender
Not visible on
inspection, glands
ascend but not
visible in female
during swallowing
and visible in males.

Chest symmetrical
Spine vertically
aligned, spinal
column is straight,
left and right
shoulders and hips
are at the same
height.
With normal breath
sounds without
dyspnea.
Quiet, rhythmic and
efortless respiration

Positioned at the
midline without
tenderness and
flexes easily. No
masses palpated.
Coordinated, smooth
movement with no
discomfort, head
laterally flexes, head
laterally rotates and
hyperextends.
With equal strength
Non-palpable, nontender
Not visible on
inspection, glands
ascend but not
visible in female
during swallowing
and visible in males.
Chest symmetrical
Spine vertically
aligned, spinal
column is straight,
left and right
shoulders and hips
are at the same
height.
With normal breath
sounds without
dyspnea.
Quiet, rhythmic and
efortless respiration

Abdomen

Abdominal movement

Auscultation of
bowel sounds

Upper extremities

Lower extremities

Muscles

Bone and joints

Mental Status
Language

Orientation

Attention span

Unblemished skin,
uniform in color,
symmetric contour,
slightly tender,
distended and
tympanic.
Symmetrical
movements cause
by respirations.
With audible sounds
of 16 bowel
sounds/minute.
Without scars and
lesions on both
extremities.
With minimal scars
on lower extremities
Equal in size both
sides of the body,
smooth coordinated
movements, 100%
of normal full
movement against
gravity and full
resistance.
No deformities or
swelling, joints move
smoothly.

Unblemished skin,
uniform in color,
symmetric contour,
not distended.

Symmetrical
movements cause
by respirations.
With audible sounds
of 23 bowel
sounds/minute.
Without scars and
lesions on both
extremities.
With minimal scars
on lower extremities
Equal in size both
sides of the body,
smooth coordinated
movements, 100%
of normal full
movement against
gravity and full
resistance.
No deformities or
swelling, joints move
smoothly.

Can express oneself

by speech or sign.
Oriented to a person,
place, date or time.
Able to concentrate

Can express oneself

by speech or sign.
Oriented to a person,
place, date or time.
Able to concentrate

A known distinguishing feature of

the ileus
(http://emedicine.medscape.com)
A known distinguishing feature of
the ileus
(http://emedicine.medscape.com)

as evidence by
answering the
questions
appropriately.
A total of 15 points
indicative of
complete orientation
and alertness.

Level of consciousness

Motor function
Gross Motor And
Balance
Walking gait

Having trouble with

standing up

Standing on one foot with

eyes closed

Having trouble with

standing up

Heel toe walking

Having trouble with

standing up

Toe or heel walking

Having trouble with

standing up

Fine Motor Test For

Upper Extremities
Finger to nose test

Repeatedly and
rhythmically touches
the nose.
Can alternately
supinate and
pronate hands at
moderate pace.
Perform with

Alternating supination and

pronation of hands on
knees

Finger to nose and to the

as evidence by
answering the
questions
appropriately.
A total of 15 points
indicative of
complete orientation
and alertness.

Has upright posture

and steady gait with
opposing arm swing
unaided and
maintaining balance.
Maintained stance
for at least five (5)
seconds.
Maintains a heel toe
walking along a
straight line
Maintains a heel toe
walking along a
straight line

Repeatedly and
rhythmically touches
the nose.
Can alternately
supinate and
pronate hands at
rapid pace.
Perform with

nurses finger
Fingers to fingers

Fingers to thumb

Fine Motor Test For

Lower Extremities
Pain sensation

coordinating and
rapidity.
Perform with
accuracy and
rapidity.
Rapidly touches
each finger to thumb
with each hand.

Able to discriminate
between sharp and
dull sensation when
touched with needle
and cotton

coordinating and
rapidity.
Perform with
accuracy and
rapidity.
Rapidly touches
each finger to thumb
with each hand.

Able to discriminate
between sharp and
dull sensation when
touched with needle
and cotton