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Part Being Assessment Method of Assessment Normal Findings Actual Findings Inhibition Clinical Finding
HEAD Inspection Configuration – normocephalic, Configuration – NORMAL
masses normocephalic, masses
Hair – normal, evenly distributed Hair – normal, evenly
Scalp – clean distributed
Face – symmetry Scalp – clean
Face – symmetry
SKIN Inspection Smooth skin turgor Smooth skin turgor NORMAL

EYES Inspection Pupils – normally black, equal in Pupils – equal in size, NORMAL
size, round and smooth boarders reactive to light and
Lids – symmetrical accommodation
Conjunctiva – pinkish Lids – symmetrical
Cornea and lens – smooth, clear Conjunctiva – pinkish
Sclera – white Cornea and lens – smooth,
Sclera – white
EARS Inspection and Auditory acuity Auditory acuity ABNORMAL May be related to self-care deficit
Palpation Ear canal – smooth and pinkish Ear canal – smooth and
pinkish; dirty
NOSE Inspection Patency – both are patent Patency – both are patent NORMAL
MOUTH AND Inspection Lips – pink, moist and smooth Lips – pink, moist and NORMAL
PHARYNX Gums – pinkish smooth
Mucosa – pinkish Gums – pinkish
Speech – intact Mucosa – pinkish
Uvula – midline Speech – intact
Tonsils – not inflamed Uvula – midline
Tonsils – not inflamed
NECK Inspection and Trachea – midline Trachea – midline NORMAL
Palpation Cervical lymph nodes – not Cervical lymph nodes –
palpable not palpable
Thyroids – non-palpable Thyroids – non-palpable

BACK Palpation Spine – midline Spine – midline NORMAL

MUSCULOSKELETAL Inspection and ROM Limited ROM on the left ABNORMAL May be related to weakness and effect of
SYSTEM Palpation arm seizure attack.
ANTERIOR THORAX Inspection, Palpation, Inspiration/respiration ratio: 1:2 Inspiration/respiration NORMAL
AND LUNGS Percussion, and Breathing pattern – eupnea ratio: 1:2
Auscultation Shape of chest Breathing pattern –
Percussion – resonant eupnea
Breath sound – vesicular Shape of chest
Percussion – resonant
Breath sound – vesicular
ABDOMEN Inspection, Skin – clear Skin – clear NORMAL
Auscultation, Umbilicus – sunken Umbilicus – sunken
Percussion, and Configuration – symmetrical Configuration –
Palpation masses symmetrical masses
Bowel sound – normoactive Bowel sound –
Percussion – tympanic normoactive
Palpation – muscles guarding Percussion – tympanic
Palpation – muscles
LOWER Inspection and Skin – clear Skin – clear NORMAL
EXTREMITIES Palpation Size - symmetry Size - symmetry