Physical Assessment Body Part Skin Inspection Normal Findings Skin is uniform whitish pink or brown color No Bleeding

No area of increased vascularity and ecchymosis No skin lesions present except for freckles, birthmarks or moles which may be flat or elevated Skin is dry with a minimum of perspiration. Warm and equal bilaterally. Hands and skin slightly cooler than the rest of the body Skin surfaces non-tender Texture: Smooth, even and firm except where there is significant hair growth Skin turgor: When released, should return to original contour rapidly Edema not present Actual Findings Skin is brown Interpretation & Analysis Skin may be dry because of insufficient fluid intake and on his age.

No bleeding has NO area of fluid at the leg Normal intake should be vascularity 2500 ml per day No lesions

Palpation

Skin is dry Warm and equal bilaterally

Skin sprung back rapidly when pinched edema

No present

Scalp and Hair

Inspection

Palpation

Nails

Inspection

Dark black to pale blonde; may turn gray or white; may be chemically changed Terminal hair found in the eyebrows,, eyelashes, and scalp, and in axilla and pubic areas after puberty. has a signs of infestation or lesions. Seborrhea/ dandruff may be present Hair may feel thin, straight, coarse, thick or curly. Shiny and resilient Have a pinkcast in lightskinned and brown in darkskinned. Capillary refill present (should return to normal 2-3 sec) Surface is smooth, and slightly rounded or flat. Curved nails are normal. Uniform nail thickness throughout; no splintering or brittle edges.

Hair appears greysih black

No significant findings

Even distribution hair

of

has a infestation of lesions and has a dandruff

Hair is thick yellowish -cast No significant nails findings

Capillary refill of 3 seconds Surface rough and slightly rounded

No splinters or brittle edges

Eyes

Palpation Inspection

Angle approx. 160 Firm nail base Symmetrical with no drooping, infection, tumors or other abnormalities Sclera: White in lightskinned w/o exudates, lesions or foreign bodies. In darkskinned, may have brown patches Pupils: equally round, reactive to light and accommodation; 2-6 mm No tearing, swelling or discharge Match flesh color of the rest of the skin. Central position. Proportional. No redness, lesions, swelling, tenderness Should not complain of pain or tenderness Symmetrical, midline of the face. Without swelling,

Angle approx. 160 Firm nail base Eyes symmetrical

No significant findings

Sclera appears white

Pupils equally round, reactive to light and accommodation; approx. 4 mm has no tearing. Same color as No significant face findings Central position Proportional No redness, swelling, or tenderness No assessed

Ears

Inspection

Palpation

(pp.386-389, Health Assessment Physical Examination pain Zator Estes)

&

Nose

Inspection

Symmetrical and in midline No swelling, bleeding, lesions,

No significant findings

Palpation

bleeding, lesions, or masses. Each nostril patent. No pain or discomfort during palpation Breath smells fresh. Lips and membranes pink and moist with no lesions or inflammation. Tongue is midline. Pink, moist, rough without lesions. Symmetrical; moves freely. Gums have pale-red strippled surface. No swelling or bleeding. Symmetrical with head in central position. Able to move head without discomfort or noticeable limits Muscles should be symmetrical without palpable masses or spasm Without lesions; skin intact. Quiet, rhythmic and effortless

or masses Patent nostrils No pain or discomfort noted No significant findings Lips and membranes are moist, dark flesh colored; no lesions or inflammation Tongue in (pp.398-405, midline and Health Assessment moves freely Physical Examination Zator Estes)

Mouth

Inspection

&

No swelling or bleeding Symmetrical with head in central position Able to move head w/o discomfort No significant findings

Neck

Inspection

Palpation

(p.331, Health Assessment & Physical No palpable Examination Zator Estes) masses No significant findings

Chest

Inspection

Without lesions Quiet rhythmic and effortless breathing

Palpation

Auscultation

breathing No pulsations, No masses or (pp.451-469, Health masses, thoracic tenderness Assessment tenderness Physical present. breath sounds Examination Normal lung Zator Estes) tissue produces resonant sound, diaphragm has dull sounds. Bronchial, bronchovesicular or vesicular breath sounds Abdominal contour flat or rounded. Symmetrical. Uniform in color or pigmentation. No abdominal scars. No striae Intermittent gurgling sounds throughout abdominal quadrants. Tympany, predominant sound heard No organ enlargement palpable, or any masses, bulges, or swelling Abdominal contour rounded. Symmetrical. Uniform in color.

&

Abdomen

Inspection

No significant findings

Auscultation

Percussion Palpation

(pp.552-562, No scars; striae Health Assessment Gurgling sounds in Physical Examination abdomen Zator Estes)

&

No rubs/ bruits

friction audible

Suprapubic Area

Inspection Palpation

Without Without lesions Lesions Urinary bladder not Urinary palpable and not bladder tender palpable

No significant findings (p.638, not Fundamentals of Nursing - Kozier)

Genitalia

Inspection Palpation

Pubic hair distributed in triangular form. More coarse than scalp hair. No nits or lice. Penis skin free of lesions and inflammation. No lesions, redness Sphincter intact Non-tender

Pubic evenly distributed

hair No significant findings

(pp.746-753, Health No nits or lice Assessment No lesions or Physical Examination inflammation Zator Estes) In midline Redundant mass noted, reddish

&

Rectum

Inspection

Palpation

Upper Extremities

Inspection

Without with scars lesions, scars or inflammation

A dilated vein seen as swollen, reddish-blue mass signifies hemorrhoids (pp. 55-56, Medical Surgical Nursing, Harkness and Dincher) No significant findings (p.579, Fundamentals of Nursing, Kozier) No significant findings (p.579, Fundamentals of Nursing, Kozier)

Lower Extremities

Inspection Palpation

Without lesions, scars No edema

Without lesions, scars No edema