PHYSICAL ASSESSMENT

Area Assessed

Technique Used

Normal Findings Medium brown

Actual findings

Analysis

SKIN Color Texture Turgor

Inspection

Palpation Palpation

Smooth, soft Skin snaps back immediately when pinched

Hair distribution

Inspection

Evenly distributed

Temperature Moisture

Palpation Palpation

Warm to touch Skin is slightly moist

NAILS Color of Nail bed Texture Shape

Inspection

Pink and clear

Palpation Inspection

Smooth Convex and curvature

Nail base Capillary refill HAIR Color Distribution

Inspection Blanch test Inspection

Firm 2-3 seconds Black ( may vary)

Inspection

Evenly distributed

Moisture Texture

Inspection Inspection

Slightly moist Silky, resilient

HEAD

Scalp Symmetry Skull size Shape

Inspection Inspection Inspection and palpation

Symmetrical Normocephalic Normocephalic

Nodules/Masses

Palpation

Abseces of nodules and masses

FACE Symmetry Facial Movement

Inspection Inspection Inspection

Symmetrical Symmetrical Symmetrical

Skin Color EYE Eyebrows

Inspection Inspection

Medium brown

Symmetrically aligned , equal movement

Eyelashes Eyelids

Inspection Inspection

Curved upward Smooth , brown do not cover pupil as sclera, close symmetrically

Ability to blink

Inspection

Blinks voluntarily and bilaterally

Frequency of blinking Ocular movement Position

Inspection

15-20 blinks per minute

Inspection

Eye moves freely

Inspection

Drawn from

lateral angle

Size Texture

Inspection Palpation

Medium Mobile, firm and non-tender

CONJUNCTIVA Color Texture

Inspection

Transparent with light color

Inspection and palpation

Shiny and smooth No lesions

Presence of lesions APPARATUS Cornea Color Texture

Inspection

Inspection

Black

Inspection

Shiny and smooth

PUPILS Color Inspection Black

Reaction to light

Inspection

Pupils equally round and reactive to light (PERRLA)

Size Shape

Inspection Inspection

Equal Round and constrict briskly

Symmetry Visual Acuity

Inspection Inspection

Equal in size Unable to read news print in

certain distance Visual fields Inspection Can look straight ahead Ocular NOSE Symmetry, Shape , size and color Inspection Inspection Eyes move freely Symmetrical, smooth and brown

Sinuses MOUTH Secretion

Inspection Inspection

Not tender

Without mucus production

Lips Color Symmetry Texture

Inspection

Pinkish to slight brown

Palpation Palpation

Symmetrical Soft and moist

Moisture TONSILS Color TEETH Color Number of teeth NECK Position Movement HEART

Palpation Inspection

Soft and moist Pinkish

Inspection Ivory yellowish Inspection 32

Inspection Inspection Auscultation

Head centered Moves freely 60-100 bpm

Heart Rate Heart sounds Auscultation Clear, without crackles

Lung field THORAX AND LUNGS POSTERIOR THORAX Symmetry Respiratory rate Spinal alignment

Percussion

Resonant

Inspection Inspection Inspection

Symmetrical 12-20 cpm Spine vertically aline

Skin integrity ANTERIOR THORAX Breathing pattern

Inspection Auscultation

Skin is intact Breathing is automatic and effortless regularly even

Lung / breath sounds UPPER EXTREMITY Skin Color Movement

Auscultation

Broncho vesicular sound

Inspection

Medium brown

Inspection

With ROM and sensation

Size ( arm) Symmetry Hair distribution

Inspection Inspection Inspection

Equal Symmetrical Evenly distributed

LOWER EXTREMITY Skin Color Movement Inspection Inspection Medium Brown With ROM and sensation Size ( Legs) Symmetry Hair distribution Inspection Inspection Inspection Equal Symmetrical Evenly distributed NEUROLOGICAL Level of consciousness Interview Can follow instructions and command