PHYSICAL ASSESSMENT

BODY PART EXAMINE ACTUAL FINDINGS NORMAL INTERPRETATION

FINDINGS
SKIN
Uniformity of color Has a uniform Uniform in color NORMAL
white skin color. except in areas
expose to the sun
Presence of edema Has no presence No edema NORMAL
of edema on her
skin
Lesions according to Has no lesions in No lesions or NORMAL
location distribution, the skin. abrasions.
color
configuration,size,shap
e,type of structure
Skin moisture Are not moist Moisture in the NORMAL
because the air skin folds and the
condition axilla varies with
environment. environmental
situation.
Skin temperature Has a uniform in Uniform in NORMAL
temperature temperature and
within normal
range.
NAILS
Fingernail plate shape Has a convex Convex curvature: NORMAL
curvature of Angel of nail plate
fingernail plate , about 160
160
Fingernail and toenail Finger nail and Pinkish in color NORMAL
bed color toenail bed color
are pinkish in
color
Fingernail and toenail Fingernail and Smooth in texture NORMAL
texture toenail texture are
smooth
Tissue surrounding The tissues Intact epidermis NORMAL
nails surrounding the
nails of the client
are intact
Presence of capillaries When blanced Highly vascular , NORMAL
test is performed, prompt return of
color of the nail pink in color
bed of the client ( generally <
returns into pink 4secs)
in less than 4
secs.
HEAD
SKULL
 PHYSICAL ASSESSMENT
Size, shape, symmetry Symmetric, round Rounded, smooth NORMAL
and proportional skull contour
to her weight

Presence of Has no Presence Absence of NORMAL

nodules,masses and of nodules,masses nodules and
depressions and depressions masses
SCALP
Color and appearance Lighter than the Lighter than the NORMAL
color of her skin color of her skin
Areas of tenderness No areas of No signs of NORMAL
tenderness tenderness
HAIR
Evenness of growth, Evenly distributed, Evenly NORMAL
thickness or thinness thick hair distributed ,thick
hair
Texture,and oiliness Silky,smooth,resill Silky,smooth,resill NORMAL
over the scalp ent ent
FACE
Facial features, Symmetric facial Symmetric facial NORMAL
symmetry of facial movements movements
movements
EYES Eyebrows are Eyebrows are NORMAL
evenly distributed, evenly distributed,
intact intact
skin,symmetrically skin,symmetrically
align, equal align, equal
movement. movement.
Eyelashes are Eyelashes are
evenly distributed evenly distributed
hair, curled hair, curled
outward outward
Eyelids has intact, Eyelids has intact,
no discharge, no no discharge, no
discoloration discoloration
Conjunctiva is Conjunctiva is
transparent and , transparent and ,
shiny smooth in shiny smooth in
color sclera is color sclera is
white and clear white and clear
Pupil is equal in Pupil is equal in
size, equally size, equally
rounded, reacted rounded, reacted
to light and to light and
accommodation . accommodation .

EARS Color same as Color same as NORMAL

facial facial
skin,symmetric skin,symmetric
position,mobile,fir position,mobile,fir
m and not m and not
 PHYSICAL ASSESSMENT
tender,pinna tender,pinna
recoils after it is recoils after it is
folded,dry folded,dry
cerumen ,has cerumen ,has
presence of hair presence of hair
follicles no pus or follicles no pus or
blood, able to blood, able to
hear ticking in hear ticking in
both ears, air both ears, air
conducted hearing conducted hearing
is greater than is greater than
bone conducted bone conducted
hearing hearing
NOSE AND SINUSES Symmetric and Symmetric and NORMAL
straight, no straight, no
discharge or discharge or
flaring, uniform in flaring, uniform in
color, not tender color, not tender
no no
lesions,patent,air lesions,patent,air
moves freely as moves freely as
the client breaths the client breaths
through the through the
nares , mucosa nares , mucosa
pink,clear,watery pink,clear,watery
discharge, no discharge, no
lesions, nasal lesions, nasal
septum intact and septum intact and
in midline in midline
MOUTH AND Lips are Uniform Lips are Uniform NORMAL
OROPHARYNX pink in color , pink in color ,
buccal mucosa is buccal mucosa is
moist, smooth moist, smooth
soft, glistering and soft, glistering and
elastic texture, elastic texture,
gums are pink in gums are pink in
color no bleeding, color no bleeding,
tongue are intact , tongue are intact ,
hardand soft hardand soft
palate are light palate are light
pink in color and pink in color and
smoth soft palate, smoth soft palate,
lighter pink hard lighter pink hard
palate more palate more
irregular texture, irregular texture,
uvula is in midline, uvula is in midline,
tonsils are pink tonsils are pink
and smooth, of and smooth, of
normal size no normal size no
discharge. discharge.
NECK Muscles equal in Muscles equal in NORMAL
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size, head size, head
centered, centered,
coordinated,smoot coordinated,smoot
h movements with h movements with
no discomfort, no discomfort,
equal equal
strength,head strength,head
hyper extended, hyper extended,
laterally flexes laterally flexes
and rotates, large and rotates, large
lymph node ar not lymph node ar not
palpaple. palpaple.
THORAX AND LUNGS Shape is Shape is NORMAL
anteroposterior to anteroposterior to
lateral, diameter lateral, diameter
in ration of 1:2, in ration of 1:2,
chest symmetric, chest symmetric,
spine vertically spine vertically
aligned aligned
,skin intact, ,skin intact,
uniform uniform
temperature,chest temperature,chest
wall intact,no wall intact,no
tenderness, no tenderness, no
masses, full and masses, full and
symmetric chest symmetric chest
ecpansion, ecpansion,
percussion notes percussion notes
resonate. And resonate. And
have vesicular have vesicular
and and
brochiovesicular brochiovesicular
breath sounds breath sounds
Breast is rounded Breast is round in ABNORMAL
and equally shape,asymmetric
unequal, slightly , uniform in color
discoloration of smooth and
the skin smooth intact, color varies
and intact but (+) to light pink to
masses, dark brown, no
tenderness and nodules,
nodules. Brown tenderness and
nipple masses.
ABDOMEN Unblemished skin, Unblemished skin, NORMAL
uniform in color, uniform in color,
flat, rounded, not flat, rounded, not
distended, distended,
symmetric symmetric
movements movements
caused by caused by
respiration, respiration,
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audible bowel audible bowel
sounds, no sounds, no
tenderness,relaxe tenderness,relaxe
d, not palpaple d, not palpaple
MUSCULOSKELETAL Equal in size on Equal in size on NORMAL
both sides of the both sides of the
body, no body, no
contractures and contractures and
tremors,firm when tremors,firm when
palpation has a palpation has a
normal muscle normal muscle
strength, no strength, no
swelling and swelling and
tenderness on tenderness on
joints areas, freely joints areas, freely
movable with no movable with no
pain and pain and
discomfort. discomfort.