Physical – Head-to-Toe Physical Assessment

Vital Signs

Normal Findings Actual Findings Analysis

Vital signs
-Interpretat
ion

Blood Pressure
120/80 130/80 Within Normal
(Averages and Range
Ranges)

90 bpm
Pulse Rate
80 bpm (60-100) Within Normal
(Averages and Range
Ranges)
Temperature 36.5 oC – 37.5 oC 37.3 Within Normal
Range
(Averages and
Ranges)

Deviation From
Respiratory Rate
16 cpm (15-20) 28 Normal
(Averages and
Ranges)

Parts Normal Findings Actual Findings Analysis –

Interpretation
Skin o Varies from light to -The client has
deep brown; from light brown skin
ruddy pink to light
pink; from yellow -Skin exposed to
overtones to olive. sun is darker in Normal
Generally uniform color
except in areas
exposed to the sun; -Areas not
areas lighter exposed to the
pigmentation in dark- sun has lighter
skinned people skin pigmentation
• No edema Negative Edema Normal
or swelling
 • Freckles, some Presence of
birthmarks, some flat bedsores on the
and raised nevi; no gluteal area Deviation From
abrasions or other Normal
lesions
• Moisture in skin fold There is moisture
and the axillae in the skin folds Normal
and axilla.
• When pinched, skin The client’s skin
springs back to when pinched on
previous state scapula, sternum Normal
and at his back
moves back.
Nails • Convex curvature; The client’s
angle of nail plate fingernails plate
about 160 degrees shape has a
smooth convex Normal
curvature, but the
angle is greater
than 160 degrees.

• Highly vascular and The fingernail Normal

pink in light skinned and toenail beds
clients; dark skinned color of the client
clients mat have is highly vascular Normal
brown or black and pinkish in
pigmentation in light brown skin
longitudinal streaks in color and no
discoloration.

• Smooth texture It has a smooth Deviation From

texture and flat Normal
except for the
right point finger
that is in irregular
shape, rough and
brown in color.
• Intact epidermis The client has
intact epidermis Normal
on both fingernail
and toenail
because there are
no breaks or any
cuts present.
• Prompt return of pink When the blanch
or usual color in less test performed to
 than 4 seconds the client’s Normal
fingernail and
toenail, the color
returned into its
usual color after 2
seconds.
Skull • Rounded The client’s size,
(normocephalic and shape and
symmetrical, with symmetry of the Normal
frontal, parietal and skull is rounded
occipital and with smooth
prominences); skull contour. It is
smooth skull contour appropriate for
the shape of his
body.
• Smooth, uniform -The skull of the
consistency; absence client has smooth
of nodules or mass and uniform Normal
consistency.
-(-) nodules or
masses or any
depressions.
• Facial features (e.g., The client’s facial
symmetry of features are Normal
structures and of symmetric,
distribution of hair) palpebral fissures
with equal in both
side of face of the
client
• Symmetry of facial The facial
movements. movements of the Normal
client are
symmetrical.

Scalp • Lighter than the The color of the

exposed skin(white) scalp of the client
No scales and lesions is lighter than the Normal
exposed skin.
(-) lesions
(-) scales
• No masses and (-) Masses and Normal
tenderness tenderness

Hair • Evenly distributed The hair growth Normal

hair; thick hair over the scalp of
 the client is
evenly distributed
and he has a thick
hair.
• Silky, resilient hair; The hair of the Normal
client is color
black, silky and
resilient and
smooth in texture.
• Presence of infection (-) Presence of Normal
or infestation any infection or
infestation on the
client’s hair.
• Amount of body hair The amount of Normal
the client’s body
hair varies from
his facial hair,
axillary, hair and
pubic hair.
Face • Symmetric facial The client’s facial Normal
movements and features and
features movements are
symmetrical.
Eyebrows • Hair evenly The hair Normal
distributed; eyebrows distribution and
symmetrically alignment on the
aligned; equal eyebrows of the
movement client is evenly
distributed. It has
equal movement
and was able to
raise his
eyebrows equally.
Eyelashes • Equally distributed; The eyelashes of Normal
curled slightly the client are
outward equally
distributed and its
direction is curled
slightly outward.
Eyelids • Skin intact; -The client’s Normal
• No discharge; eyelids has skin
• No discoloration; intact, there no
• Lids close presence of any
symmetrically; discharge.
• Approximately 15 to
20 involuntary blinks -The lids close
 per minute; symmetrically; it
• Bilateral blinking; blinks regularly,
• When lids open, no involuntary and
visible sclera above bilaterally blinks.
corneas, and upper
and lower borders of -When lids open
cornea are slightly there no visible
covered. sclera above
corneas and upper
and lower borders
of cornea are
slightly covered.
Bulbar • Transparent; The bulbar Normal
capillaries sometimes conjunctivas of
evident; sclera the client is pale
appears white and with some
yellowish in dark- evidence of
skinned clients capillaries..
Sclera appears
white.
Palpebral • Shiny, smooth and The palpebral Normal
pink or red conjunctivas of
the client are
shiny and smooth
and pale and with
some evidence of
capillaries.
Sclera • Appears white and The sclera of the Normal
sometimes capillaries client appears
are present white and
capillaries are
present.
Cornea • Transparent, shiny The cornea of the Normal
and smooth; details client are
of iris are visible. transparent, shiny
and smooth,
details of the iris
are visible
Iris • The color depends on The color of the Normal
the race and iris flat iris depends on
and round the race. The
client’s iris is flat
and round.
Pupil • Black in color; equal - The pupils of Normal
in size; normally 3 to the client are
7 mm in diameter; black in color,
 round, smooth with smooth
border, border and equal
in size. Normally
5 mm in diameter.
- Pupil is Equally
Round and
Restricted to
Light and
Accommodation
• Pupil constrict when The client’s Normal
looking at near pupil’s direct
object; pupils dilate response when
when looking at far illuminated
object; pupils constricts, and
converge when near consensual
object is moved response when
toward nose. non-illuminated.
And when
looking at near
object pupil dilate
and when looking
at near object
pupil converge.
Extra Ocular Muscles • Both eyes The eye Normal
coordinated; move in movement of the
unison, with parallel client is
alignment coordinated with
parallel
alignment.
Visual Fields • When looking The peripheral Normal
straight ahead, client visual fields of
can see objects in the the client when
periphery looking straight
ahead can see the
object in the
periphery.
Lacrimal Gland, • No edema or There is no Normal
Lacrimal sac and tenderness over edema or
Nasolacrimal Duct lacrimal gland or tenderness and
tearing tearing on the
client’s lacrimal
sac and
nasolacrimal duct.
Auricles • Color same as facial The auricles of Normal
skin; symmetrical; the client has
auricle aligned with color same as
 the outer canthus of facial skin, it is
eye, about 10 degrees symmetrical, and
from vertical the auricles
aligned with outer
canthus of eye
about 10˚ from
vertical.
• Mobile, firm and not The texture of the Normal
tender; pinna recoils client’s auricle is
after it is folded mobile, firm and
not tender; pinna
recoils after it is
folded.
External Ear Canal • Distal third contains The external ear Normal
hair follicles and canal of the client
glands; dry cerumen, when examined
grayish-tan color; or the distal third
sticky, wet cerumen contains hair
in various shades of follicles and
brown glands with
moisture in the
cerumen and
varies from
grayish-tan color
Nose • Symmetric and -The external Normal
straight; no discharge nose of the client
or flaring; uniform is symmetrical,
color straight and it is
uniform in color.
No discharge and
flaring
• Mucosa pink; clear, The mucosa of Normal
watery discharge; no the client is color
lesions pink and clear

• Nasal septum intact The nasal septum Normal

and in midline of the client is
intact and in
midline.
• Air moves freely as The client’s Normal
the client breathes patency on both
through the nares nasal cavities is
that air moves
freely as the
client breathes
through the nares.
 • Not tender; no The external nose Normal
lesions of the client has
no any lesions
and non tender.
Sinuses • Not tender The sinuses of the Normal
client are non
tender.
Lips • Uniform pink color The lips of the Normal
soft, smooth texture, client are uniform
moist, symmetry of pink in color,
contour with symmetry of
contour, and able
to purse lips.
Teeth
Color, number and 32 adult teeth All teeth were NORMAL
condition and presence Smooth, white, shiny, removed. Part of aging process.
of dentures smooth enamel Wearing dentures.
Smooth and intact
dentures
Tongue/Floor of the • Surface of the tongue The client’s Normal
Mouth for position, color, surface of the
and texture tongue is in the
central position,
pink in color,
moist, slightly
rough, and with
thin whitish
coating. There are
no lesions found.
And it has raised
papillae.

• Tongue movement The client’s Normal

tongue moves
freely and there is
no tenderness
found.
• Smooth tongue base The client’s base Normal
with prominent vein of the tongue is
smooth and with
prominent veins.
Palates • Light pink, smooth, The hard and soft Normal
soft palate palate of the
client is light pink
in color, smooth
and soft in texture
 Lymph Nodes • No tenderness, not The lymph nodes Normal
palpable of the client are
not palpable.
Trachea • Central placement in The trachea of the Normal
midline of the neck client is in the
central placement
in midline of the
neck, and spaces
are equal on both
sides.
Thyroid Gland • No visible masses The thyroid gland Normal
of the client is not
visible on
inspection and
has no visible
masses
• Centrally located, The thyroid gland Normal
lobes are small, of the client is
painless, rise freely centrally located,
with swallowing lobes are small,
painless, rise
freely with
swallowing, it
ascends during
swallowing but it
is not visible.
AORTIC AND No pulsations No pulsations are
PULMONIC AREAS present. Normal

TRICUSPID AREA No pulsations No pulsations are

No lift or heave present. There is Normal
no lift or heave.
APICAL AREA Pulsations visible in Pulsations are
50% of adults and palpable in most
palpable in most PMI PMI in 5th LICS.
in 5th LICS at or medial The diameter is
Normal
to MCL approximately 2
Diameter of 1 to 2 cm cm. There are no
(1/3 to ½ inches) lifts or heaves.
No lift or heave
AORTIC, PULMONIC, S1: Usually heard at all S4 is present on Impede blood flow as a
TRICUSPID AND sites the client. result increase in
APICAL VALVES S2: Usually heard at all pressure and
AUSCULTATION sites Usually louder at Findings in tachycardia occurs.
the base of heart Auscultation:
Systole: silent interval; Tachycardia
 slightly shorter than .
diastole at normal hear
rate (60 to 90
beats/minute)
Diastole: silent
interval; slightly longer
duration than systole at
normal heart rates
S3: In children and
young adults
S4: In many older
adults

Carotid artery palpation Symmetric pulse Symmetric pulse

(with extreme caution) volumes volumes are
Full pulsations, noted.
thrusting quality Full pulsations
Quality remains the and thrusting
same when client quality are
breathes, turns head, present.
and changes from Quality remains
Normal
sitting to supine the same when
position client breathes,
Elastic arterial wall turns head, and
changes from
sitting to supine
position. The
arterial wall is
elastic.
Carotid arteries No sound heard at No sound is heard
auscultation auscultation upon auscultation. Normal

Jugular veins inspection Veins not visible Veins are not

(indicating right side of visible.
Normal
the heart is functioning
normally)
Breast and Axillae o Breast even with the The breast of the Normal
chest wall upon client is even with
observation the chest wall.
o No tenderness, Breast area is Normal
masses, or nodules palpated but not
exposed, no
masses and
tenderness.
Abdomen o Unblemished skin; The abdomen of Normal
uniform color; silver- the client when
white striae (stretch being inspect
mark) or surgical there is
scars unblemished skin,
uniform in color.
Bones o No deformities The bones of the Normal
client have no
deformities
found.
o No tenderness or The bones of the Normal
swelling client have no
tenderness or
swelling.
Joints o No swelling When the join of Normal
the client was
inspected there
are no swelling
found.
o No tenderness, The joints of the The arthritis of joints
swelling, crepitation client has known as synovitis is
or nodules tenderness upon inflammation of
palpation the synovial
membrane that lines
joints and tendon
sheaths.
Joints become swollen,
tender and warm, and
stiffness limits their
movement
o Joints range of It varies to some Pain is cause by
motion degrees in arthritis as what
accordance with also the client
person’s genetic verbalized Joints
makeup and become swollen,
degree of physical tender and warm,
activity. and stiffness
limits their
Limited range of movement
motion of the
both knees result
pain.