PHYSICAL ASSESSMENT

Temperature: 37.8 o C Pulse Rate: 69

bpm
Blood Pressure: 110/70 mmHg Respiratory rate:
17 cpm
Height: 5’1’’ Weight: 57 kgs.
BMI: 24

AREA TO BE NORMAL ACTUAL ANALYSIS

ASSESSED FINDINGS FINDINGS
I. APPEARANCE AND MENTAL STATUS
1. Body built, Proportionate His body built, height NORMAL
height, and varies with lifestyle and weight is
weight(in relation to proportional to his
the clients age, lifestyle, age and
health.
lifestyle, and health)
2. Posture and gait, Relax, erect NOT ASSESSED Client was
standing and posture: bedridden.
walking coordinated
movement
3. Body and breath No body odor or Mild body odor Because of lack of
odor minor body odor along with mild proper hygiene the
relative to work or breath odor noted body and breath
exercise: no breath odor was affected
odor
4. Sign of distress(in No distress noted Looks weak and Because of
posture or facial pale difficulty of
expressions) breathing
5. Obvious sign of Healthy Weak appearance Because of
health or illness appearance difficulty of
breathing
6. Attitude Cooperative Cooperative NORMAL
7. affect/mood Appropriate to Appropriate to NORMAL
( appropriateness of situation situation
clients responses)
8. Quantity and Understandable, Difficulty in NORMAL
Quality of Speech moderate, pace; understanding
Exhibits thought speech, However,
association thought
association is
present
9. Relevance and Logical sequence; Logical sequence; NORMAL
organization of makes sense; has makes sense; has
thoughts sense of reality sense of reality
II. Head
A.Skull
1. Size, shape and Rounded Rounded NORMAL
symmetry of the (normocephalic (normocephalic
skull and symmetrical, and symmetrical,
with frontal, with frontal,
parietal, and parietal, and
occipital occipital
prominences); prominences);
smooth skull smooth skull
contour contour
2. Presence of Smooth, uniform Smooth, uniform NORMAL
nodules, masses consistence; consistence;
and depressions absence of nodules absence of nodules

B. Hair
1. Evenness of Evenly distributed Evenly distributed NORMAL
growth, thickness or and covers the and covers the
thinness of hair scalp; maybe thick scalp; maybe thick
or thin or thin
2. Texture and Silky; resilient hair Silky; resilient hair NORMAL
oiliness of scalp
D. Face
1. Facial features, Symmetric or slightly NORMAL
symmetry of facial slightly asymmetrical
movements asymmetrical facial features;
facial features; palpebral fissures
palpebral fissures equal in size;
equal in size; symmetrical
symmetrical nasolabial folds
nasolabial folds
III. Eyes
A. Eyebrows
1. Hair distribution, Symmetrical and in Symmetrical and NORMAL
alignment, skin line with each in line with each
quality and other; maybe other, Partially
movement black, brown or Gray Client is
blond depending or Elderly
race; evenly
distributed
B. Eyelashes
1. Evenness of Equally distributed; Equally distributed NORMAL
distribution and curled slightly
direction of curl outward

C. Eyelids
Surface Skin intact; no Skin intact; no NORMAL
characteristics, discharge; no discharge; no
position in relation discoloration; Lids discoloration; Lids
to the cornea, close close
ability to blink, and symmetrically; symmetrically;
frequency of When lids open, no When lids open, no
blinking visible sclera visible sclera
above corneas,& above corneas,&
upper & lower upper & lower
borders of cornea borders of cornea
are slightly are slightly
covered; covered;
Approximately 15- Approximately 15-
20 involuntary 20 involuntary
blinks per minute; blinks per minute;
bilateral blinking bilateral blinking
D. Conjunctiva
1. Color, texture, Transparent; Transparent, No NORMAL
and presence of capillaries Lesions
lesions in the bulbar sometimes
conjuctiva evident;

2. Color, texture, Shiny, smooth, Shiny, smooth, NORMAL

and presence of pink or red pink or red
lesions in the
palpebral conjuctiva
E. Sclera
1. Color and clarity White and clear White and clear NORMAL
F. Cornea
1. Clarity and No irregularities in No irregularities in NORMAL
texture surface, looks surface, looks
smooth, clear and smooth, clear and
transparent transparent
G. Iris
1. Shape and color Anterior chamber Anterior chamber NORMAL
is transparent, no is transparent, no
noted visible noted visible
materials, color materials,Brown
depends on the
person’s race.
H. PUPILS
1. Color, shape and Color depends on Black Color, NORMAL
symmetry of size the person’s race, depends on the
size ranges from 3- person’s race, size
7 mm and are ranges from 3-7
equal in size; mm and are equal
equally rounded in size; equally
rounded
2. Light reaction Illuminated pupil Illuminated pupil NORMAL
and accommodation constricts non- constricts non-
illuminated pupil illuminated pupil
dilates; pupils dilates; pupils
constrict when constrict when
looking at near looking at near
object; pupils object; pupils
 dilate when dilate when
looking at far looking at far
objects; pupils objects; pupils
converge when converge when
near object is near object is
moved towards moved towards
nose nose
I. VISUAL ACUITY
1. Near vision Able to read NOT ASSESSED NOT ASSESSED
newsprint
2. Distance vision 20/20 vision on NOT ASSESSED NOT ASSESSED
Snellen’s chart
J. LACRIMAL GLAND
1. Palpability and No edema or No edema or NORMAL
tenderness tenderness over tenderness over
lacrimal gland lacrimal gland
K. EXTRAOCULAR MUSCLE
1. Eye alignment Both eyes Loss of movement Because of the
and coordination coordinated, move in the Right Eye cerebrovascular
in unison, with noted disease that
parallel alignment happen the
cerebrum of the
patient affect the
sensory input from
the receptors in
the eyes.

L. VISUAL FIELDS
Peripheral visual When looking NOT ASSESSED NOT ASSESSED
fields straight ahead,
client can see
objects in the
periphery
IV. EARS
A. AURICLES
1. Color, symmetry Color same as Fair skin color, NORMAL
of size and position facial skin; same as facial skin
symmetrical; about ; symmetrical;
10 degrees from about 10 degrees
vertical auricle from vertical
aligned with the auricle aligned
outer canthus of with the outer
the eye; canthus of the eye;
2. Texture, Mobile, firm, and Mobile, firm, and NORMAL
elasticity, and areas not tender; pinna not tender; pinna
of tenderness recoils after it is recoils after it is
folded folded
B. External Ear Canal
1. Ear canal No cerumen, no No cerumen, no NORMAL
 lesions, no pus and lesions, no pus and
no blood no blood
C. Hearing Acuity Tests
1. Client’s response Normal voice tones Normal voices can NORMAL
to normal voice audible hear
tones
2. Watch tick test Able to hear NOT ASSESSED NOT ASSESSED
ticking in both ears
VII. Nose
1. Any deviations in Symmetric and Symmetric and NORMAL
shape, size, color straight; no straight; no
and flaring or discharge or discharge or
discharge from the flaring; uniform flaring; uniform
nares color color

2. Presence of Mucosa is pink, Mucosa is pink, NORMAL

redness, swelling, clear with watery clear with watery
growths and discharge; no discharge; no
discharge in the lesions lesions
nasal cavities
3. Nasal septum Nasal septum Nasal septum NORMAL
(between the nasal intact and in intact and in
chambers midline midline

4. Patency of both Air moves freely as Air moves freely as NORMAL

nasal cavities the client breathes the client breathes
through the nares through the nares
5. Tenderness, No tenderness, no No tenderness, no NORMAL
masses, lesions lesions
displacement of
bone and cartilage

VIII. Sinuses
1. Identification of No tenderness No tenderness NORMAL
the sinuses and for
tenderness
IX. Mouth
A. Lips
1. Symmetry of Uniform pink color Slightly darker NORMAL
contour, color and (darker in shade of pink due
texture Mediterranean to client’s
groups and dark- complexion. Able
skinned clients); to purse lips soft,
able to purse lips; moist, smooth
soft, moist, smooth texture, symmetry
texture, symmetry of contour.
of contour
B. Buccal Mucosa
1. Color, moisture, Uniform pink color, Uniform pink color, NORMAL
texture and moist, smooth, moist, smooth,
presence of lesions soft, glistening, soft, glistening,
and elastic texture and elastic texture
C. Teeth
Color, number, 32 adult teeth; 32 adult teeth; NORMAL
condition and smooth, white, smooth, white,
presence of shiny tooth shiny tooth
dentures enamel; smooth enamel; smooth
intact dentures intact dentures
D. Gums
Color and condition Pink gums (bluish Pink gums (bluish NORMAL
or dark patches in or dark patches in
dark-skinned dark-skinned
clients), moist, firm clients), moist, firm
texture, no texture, no
retraction of gums retraction of gums,
retraction cannot
be determined due
to absence of
client’s teeth.
E. Tongue/Floor of the Mouth
Color and texture of Pink in color, Pink in color,
the mouth floor and moist, slightly moist, slightly NORMAL
frenulum rough; thin whitish rough; thin whitish
coating; moves coating; moves
Any nodules, lumps freely; no freely; no
or excoriated areas tenderness tenderness
Smooth with no Smooth with no
palpable nodules, palpable nodules,
lumps or lumps or
excoriated areas excoriated areas
Position, color, Central position; Central position; NORMAL
texture, movement Pink color (some Pink color (some
and the base of the brown brown
tongue pigmentation in pigmentation in
dark-skinned dark-skinned
clients); moist; clients); moist;
slightly rough; thin slightly rough; thin
whitish coating whitish coating
smooth, lateral smooth, lateral
margins; no margins; no
lesions; raised lesions; raised
papillae; moves papillae; moves
freely freely
F. Palates and Uvula
Color, shape, Light pink, smooth Light pink, smooth NORMAL
texture and (soft palate) (soft palate)
presence of bony Lighter pink, more Lighter pink, more
prominences irregular texture irregular texture
(hard palate) (hard palate)
Position and Positioned in the Light Pink in colour NORMAL
mobility of the midline of the soft smooth and soft
uvula palate palate

G. Oropharynx and Tonsils

Color and texture Pink and smooth Pink in colour and NORMAL
posterior wall soft when palpated
Size, color and Pink and smooth, Normal size, pink NORMAL
discharge of the no discharge; in in colour.
tons normal size; gag
reflex present
VIII. NECK MUSCLE
1. Inspection of No jugular venous No Jugular venous NORMAL
neck muscle and distension distension, head
head movement. movement
unhindered.
XI. TRACHEA
1. placement of Central placement Central placement NORMAL
trachea in midline of neck; in midline of neck;
spaces are equal in spaces are equal in
both side both side
X. THYROID GLAND
1. Symmetry and It is symmetrical
visible masses
2. Smoothness and No nodules No nodules, nor NORMAL
areas of areas of
enlargement, enlargement
masses or nodules
Thorax
A. Posterior thorax
1. shape and Anteroposterior to NOT ASSESSED NOT ASSESSED
symmetry of the transverse
thorax from diameter in ratio
posterior and lateral 1:2; chest
views symmetric
2. spinal alignment Spine vertically Spine vertically NORMAL
for deviation aligned aligned
3. Palpate posterior Skin intact; Skin intact; NORMAL
thorax uniform uniform
temperature temperature
4. Posterior chest Full and symmetric Full and symmetric NORMAL
for respiratory chest expansion chest expansion
excursion
5. chest for vocal Bilateral symmetry Bilateral symmetry NORMAL
(tactile) fremitus, of vocal fremitus; of vocal fremitus;
the faintly fremitus is hard fremitus is hard
perceptible most clearly apex most clearly apex
vibration felt of the lungs of the lungs
through the chest
wall
6. Percussion of the Percussion notes NOT ASSESSED NOT ASSESSED
thorax resonate, except
over scapula
7. Percussion of Excursion is 3-5 cm NOT ASSESSED NOT ASSESSED
diaphragmatic (11/2 to 2 in).
excursion bilaterally in
(movement of women and men
diaphragm during is 5-6 cm (2-3 in)
maximal inspiration
and expiration)
8. Auscultation of Vesicular and Vesicular and NORMAL
the chest using bronchovesicular bronchovesicular
flatdisc diaphragm breath sounds breath sounds, No
of the stethoscope crackles.
B. ANTERIOR THORAX
1. Breathing Quiet, rhythmic Quiet, rhythmic NORMAL
patterns and effortless and effortless
respiration respiration
2. Anterior chest for chest for NOT ASSESSED NOT ASSESSED
respiratory respiratory
excursion excursion
3. chest for vocal Excursion is 3-5 cm NOT ASSESSED NOT ASSESSED
(tactile) frebmitus, (11/2 to 2 in).
the faintly bilaterally in
perceptible women and men
vibration felt is 5-6 cm (2-3 in)
through the chest
wall
4. percussion of the Percussion notes NOT ASSESSED NOT ASSESSED
anterior the resonate down
symmetrically to the sixth rib at
the level of the
diaphragm but are
flat over areas
over the heart and
the liver and
tympanic over the
underlying
stomach
BREAST AND AXILLAE
1. size, symmetry Males: breast even breast even with NORMAL
and contour or with the chest wall; the chest wall
shape if obese maybe
similar in the
females breast
2. skin of the breast Uniform in color Uniform in color NORMAL
3. areola area for Round or oval and Round or oval and NORMAL
size, shape, bilaterally the bilaterally the
symmetry, color, same; color varies same; color varies
surface widely, from light widely, from, Dark
characteristics and pink to dark brown Brown color due to
any masses or client’s complexion
lesions
4. Nipples for size, Round, everted, Round, everted, NORMAL
shape, position, and equal in size; and equal in size;
color, discharge and similar in color; similar in color;
lesions soft and smooth; soft and smooth;
both nipples point both nipples point
in the same in the same
direstion direstion
ABDOMEN
1. skin integrity Uniform in color Uniform in color NORMAL
2. contour and Flat, rounded or Flat, rounded or NORMAL
symmetry scaphoid scaphoid
3. movements Symmetric Symmetric NORMAL
associated with movements; movements;
respiration, visible peristalsis; visible peristalsis;
peristalsis, or aortic aortic pulsation aortic pulsation
pulsation
4. vascular pattern No visible vascular No visible vascular NORMAL
pattern pattern
5. Auscultation of Audible bowel Audible bowel NORMAL
the abdomen sounds; absence of sounds; absence of
arterial bruits; arterial bruits;
absence of friction absence of friction
rub rub
6. Percussion of Tympany over the NOT ASSESSED NOT ASSESSED
several areas in stomach and gas-
each of the four filled bowels;
quadrant to dullness, especially
determine presence over the liver and
of tympanic spleen or a full
bladder
7. light palpation of No tenderness; Tenderness on
the abdomen relaxed abdomen palpation, soft,
with smooth, presence of mass
consistent tension
X. MUSCULOSKELETAL SYSTEM
A. MUSCLES
1. Muscle size and It is proportionate It is proportionate NORMAL
comparison on the
other side
2. Contractures in No contractures No contractures NORMAL
the muscles and
tendons
3. Fasciculations No fasciculation No fasciculation NORMAL
and tremors in the
muscles
4. Muscle tonicity Even and firm Even and firm NORMAL
muscle tone muscle tone

5. Muscle strength Muscle is strong Muscles are still Normal

strong
B. BONES
1. Normal structures No deformities No deformities NORMAL
and deformities in
the skeleton
2. Areas of edema No edema and No edema and NORMAL
or tenderness in the tenderness in tenderness in
bones bones bones

C. JOINTS
1. Joint swelling No joint swelling No joint swelling NORMAL

2. Tenderness, No tenderness, No tenderness, NORMAL

smoothness of swelling and swelling and
movement, nodules nodules
swelling, crepitation
and presence of
nodules
III. Integumentary
A. Skin
Skin color and Varies from light to Fair skin color, NORMAL
uniformity of color deep brown; from Generally uniform
ruddy pink to light except in areas
pink; from yellow exposed to the
overtones to olive. sun; areas of
Generally uniform lighter
except in areas pigmentation
exposed to the (palms, lips, nail
sun; areas of beds) in dark-
lighter skinned people.
pigmentation
(palms, lips, nail
beds) in dark-
skinned people.
Presence of edema No edema No edema NORMAL
Existence of lesions Freckles, some Unable to NORMAL
birthmarks, some determine
flat and raised existence of
nevi; no abrasion Birthmarks, no
or lesions abrasions,
presence of nevi
 found in the right
knee
Skin moisture Moisture in skin Moisture in skin NORMAL
folds and axillae folds and axillae
(varies with (varies with
environmental environmental
temperature and temperature and
humidity, body humidity, body
temperature,& temperature,&
activity activity
Skin temperature Uniform; within Uniform; within NORMAL
normal range normal range

Skin turgor When pinched, When pinched, NORMAL

skin springs back skin springs back
to previous state to previous state
B. Nails
Fingernail plate Convex curvature, Convex curvature, NORMAL
shape (curvature angle about 160 angle about 160
and angle) degrees degrees

Fingernail and Highly vascular Highly vascular NORMAL

toenail bed color and pink in light- and pink in light-
skinned clients; skinned clients;
dark-skinned dark-skinned
clients may have clients may have
brown or black brown or black
pigmentation in pigmentation in
longitudinal longitudinal
streaks streaks
Presence of tissue Intact epidermis NORMAL NORMAL
surrounding area
Blanch test result of prompt return of prompt return of NORMAL
capillary refill pink or usual color pink or usual color
(less than 4 (less than 4
seconds) seconds)