PHYSICAL ASSESSMENT

BODY PARTS NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS

Skin

-light to dark brown & feels warm -no swelling,

-light to dark brown & feels warm -mild skin rashes -smooth and soft

Due to disease process

-smooth and soft Hair and Scalp -color black -properly distributed - smooth and soft normal

Nails

no presence of parasites (lice) -fine texture -no masses -round nail with 160degrees nail base

round nail with 160degrees nail base -pink nail bed -normal

-pink nail bed Head -face is symmetrical, centeredhead position -face is symmetrical, centered-head position -normal

Neck

-smooth and controlled -smooth and controlled movements movements

-normal

Eyes

Eye brows

-blinking symmetrical, involuntary & approximately 15 blinks/min -evenly distributed -eye lashes are short -eye lid margins moist & pink -pupil is equally round and reactivated to light accommodati on

-blinking symmetrical, involuntary & approximately 15 blinks/min -evenly distributed -eye lashes are short -eye lid margins moist & pink -pupil is equally round and reactivated to light accommodation -normal

Eye lashes

Eye lids

Pupil

-uniform in color

-transparent, smooth, moist

-uniform in color

Ears

-Ears of equal size & similar appearance -Skin in the external ear is smooth and color pink

-Ears of equal size & similar appearance -Skin in the external ear is smooth and color pink

-normal

Nose

-color is same as face -symmetrical appearance -no redness in the nasal mucosa

-color is same as face -symmetrical appearance -no redness in the nasal mucosa

-normal

Mouth -pink in color -dry -smooth, moist with no lesions -moist with no lesions -pink and

-pink in color -moist -normal

Lips

-smooth, moist with no lesions -moist with no lesions -pink and moist -no dental carries -32 total no. of teeth

Buccal mucosa

Tongue

Gums

moist -no dental carries -normal

Teeth

-32 complete no. of teeth

-normal

Thoracic & Lungs

-position of sternum is level with ribs -no masses -lungs clear upon auscultation

-position of sternum is level with ribs -no masses - lungs clear upon auscultation

-normal

-normal -smooth skin surface -flat areola -no masses -PMI is felt upon pulsation -Rhythm: regular -normal -normal

Breast

-smooth skin surface -flat areola -no masses

Heart

-PMI is felt upon pulsation -Rhythm: regular

Upper Extremities (right and

-bilateral -bilateral pulses strong & pulses strong equal (radial pulse) & equal

-normal

left)

(radial pulse) -mobile -intact condition of the skin in arms -no lesions, no swelling

-mobile - intact condition of the skin in arms -no lesions, no swelling

-normal -normal

Abdomen

-no rashes or lesions -umbilicus is centrally located -rounded abdomen -symmetrical -high pitched, irregular gurgles 535times/min -abdomen rises with inspiration in synchrony with chest

-presence of rashes -umbilicus is centrally located -rounded abdomen Due to the disease process

-symmetrical -high pitched, irregular gurgles 5-35times/min -abdomen rises with inspiration in synchrony with chest

Lower Extremities (right and

-bilaterally symmetrical and equal

-bilaterally symmetrical and equal -right foot has no lesions,

-normal

left)

-right foot has no lesions, no swelling -left foot has no lesions, no swelling -skin color is the same as the other part of the body

no swelling -left foot has no abrasions

- normal

- skin color is the same as the other part of the body

-normal