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1. Inspect and
palpate the No drainage should be noted
nasolacrimal from the puncta when palpating
gland the nasocrimal duct.
CORNEA
Transparent, shiny, and smooth
and the iris are visible.
1. Inspect for clarity Transparent, shiny, and In older people, a thin, grayish
and texture. smooth and the iris are white ring around the margin,
visible. called arcus senilis, may be
Normal evident.
1. Perform cornea
sensitivity test
IRIS
1. Inspect for color Strongly pigmented, with colors
and shape. Strongly pigmented; dark ranging from brown to green,
brown Normal blue, grey, and hazel
Pupils
Transparent. No shadows of
light on iris. Depth of about 3
mm. Black in color; equal in Transparent. No shadows of
1. Inspect for color, size; normally, round, light on iris. Depth of about 3
shape and smooth border, iris flat and mm. Black in color; equal in size;
symmetry of size round. normally, round, smooth border,
iris flat and round.
Normal
The illuminated pupil constrict)
direct response) the non-
2. Test each pupil illuminated. Pupil dilates
for light reaction (consensual response). Pupils
and constrict when looking at near
accommodation. object; pupils dilate when
looking at far pupils object;
converge when near object is
moved toward the nose.
EXTRAOCULAR
MUSCLES
1. Test each eye for Both eyes coordinated, move Both eyes coordinated, move in
alignment and in unison with parallel unison, with parallel alignment
coordination. alignment Normal
VISUAL FIELDS
When looking straight ahead,
1. Test peripheral Client can see object in Client can see object in the
fields. periphery Normal periphery
Visual Acuity
HEARING ACUITY
1. Assess client's Normal voice tones audible
response to normal
voice tones. Nomal voice tones audible Normal
2. Perform watch tick Able to hear ticking in both
test Able to hear ticking in both ears Normal ears.
Sound is heard in both ears or
3. Perform Weber's test is localized at the center of the
head (Weber negative)
4. Perform Rinne’s Air conducted hearing is
test greater than bone conducted
(Rinne positive
NOSE ACTUAL FINDINGS ANALYSIS NORMS and STANDARDS
1. Inspect for any Symmetric and straight, no
deviations in shape, discharge or flaring, uniform
size, or color and flaring color. No tenderness or
or discharge from nares. lesions.
2. Inspect the nasal
cavities for the presence No discharge, no redness, no
of redness, swelling, swelling, no lesions
growth and discharge,
using the flashlight.
3. Inspect the nasal
septum between nasal Nasal septum intact and in
chambers. midline.
4. Test potency both Air moves freely as the client
nasal cavities breathes through nares. No
tender, no lesions
5. Palpate for any
tenderness, masses
displacements of bone No tenderness
and cartilage.
SINUSES
TEETH
1. Inspect for color,
number and 32 adult teeth. Smooth, white,
condition and shiny tooth enamel. No
presence of repaired or decayed areas; no
dentures. missing teeth or appliances.
GUMS
NECK AND
LYMPNODES
LYMP NODES
Not palpable. There is no swelling
1.Locate/palpate/identif or enlargement and no
y lymph nodes and note tenderness.
for tenderness.
TRACHEA
Central placement in midline of
1. Inspect and palpate neck; spaces are equal on both
for color, placement. sides.
THYROID GLAND
1. Inspect symmetry
and visible masses. Not visible on inspection.
Observe arm size and Arms are bilaterally symmetric with minimal
venous pattern, also look variation in size and shape
for edema No edema or prominent venous patterning
Observe coloration of the Color varies depending on the client’s skin
hands and arms tone, although the color should be the same
bilaterally
Palpation
Legs
Observe skin color while Pink color for lighter-skinned clients and pink
inspecting both legs from or red tones visible under darker-pigmeneted
the toes to the groin. skin
No changes in pigmentation
Inspect distribution of Hair covers the skin on the legs and appears
hair on the dorsal surface of the toes
Inspect for the lesions or Legs are free from lesions and ulcerations
ulcers
Inspect for edema Identical size and shape bilaterally
no swelling or atrophy
Palpate edema No edema present in the legs
Palpate bilaterally for Toes, feet, and legs are equally warm
temperature of the feet bilaterally
and legs
General Survey
Body Assessment Actual Findings Normal Analysis
Findings
Body built, height, weight, in Proportionate,
relation to the client’s age, varies with
health and lifestyle lifestyle.
Client’s posture, gait, Relaxed, erect
standing, walking, and sitting posture;
coordinated
movement.
Client’s overall hygiene and Clean and neat.
grooming
Body and breath odor No body odor or
minor body odor
relative to work
or exercise; no
breath odor.
Signs of distress in posture No distress
or facial expression noted.
Signs of health and illness Healthy
appearance.
Client’s attitude Cooperative.
Client’s affect/mood; Appropriate to
appropriate of the client situation.
responses
Quantity and quality of Understandable,
speech moderate pace;
exhibits thoughts.
Relevance and organization of Logical sequence;
thoughts makes sense; has
sense of reality.