PHYSICAL ASSESSMENT EVALUATION TOOL

(HEAD TO TOE ASSESSMENT)

NAME OF THE CLIENT: Art Steven D. Donato

Body part examined Normal Findings Actual Findings Analysis

ANTHROPOMETRIC MEASUREMENT
Measurement in
Height
Measurement in
Weight
BMI
= W in kg / H² in m
GENERAL SURVEY
Body built, Proportionate,
height and weight varies with lifestyle
in relation to the
client’s age,
lifestyle, and health
Posture, gait, Relaxed, erect in
standing, sitting, posture,
and walking coordinated
movement
Overall hygiene Clear and neat
and grooming
Body and breath No body odor or
odor minor body odor,
no breath odor
Signs of distress No distress noted
Signs of health Healthy
and distress appearance
Attitude Cooperative
Mood and affect Appropriate to
situation, should
have appropriate
response
Quantity and Understandable,
quality of speech moderate in pace
SKIN
Uniformity of Uniform in color
color except in areas
expose to the sun
Presence of No edema
edema
Lesions No lesions or
according to abrasions
location
distribution, color,
configuration, size,
shape, type of
structure
Skin moisture Moisture in the
skin folds and the
axilla varies with
environmental
situation
Skin Uniform in
temperature temperature and
within normal
range
Skin When pinched skin
springs back to
previous state

NAILS
Fingernail plate Convex curvature:
shape angel of nail plate
about 160º
Fingernail and Pinkish in color
toenail bed color
Fingernail and Smooth in texture
toenail texture
Tissue Intact epidermis
surrounding nails
Presence of Highly vascular,
capillaries prompt return of
pink color
(generally less than
4 seconds)
 HEAD
SKULL
Size, shape, Rounded, smooth
symmetry skull contour
Presence of Absence of nodules
nodules, masses, or masses
and depressions
SCALP
Color and Lighter than the
appearance skin color
Areas of No signs of
tenderness tenderness
HAIR
Evenness of Evenly distributed,
growth, thickness thick hair
or thinness
Texture, and Silky, smooth,
oiliness over the resilient
scalp
FACE
Facial features, Symmetric facial
symmetry of facial movements
movements
EYES
EYEBROWS
Hair Evenly distributed
distribution, hair, intact skin,
alignment, skin, symmetrically
quality, and aligned, equal
movement movement
EYELASHES
Hair Evenly distributed
distribution and hair, curled
direction of curl outward
EYELIDS
Surface Skin intact, no
characteristics, discharge, no
position in relation discolorization,
to the cornea, approximately 15
ability to blink, to 20 involuntary
frequency of blinks per minute,
blinking bilateral blinking
CONJUNCTIVA
Bulbar Transparent,
conjunctiva for capillaries
color, texture, and sometimes evident,
presence of lesions sclera appears
white
Palpebral Shiny smooth, pink
conjunctiva for in color
color, texture, and
presence of lesions
SCLERA
Color and Appears white and
clarity clear
CORNEA
Clarity and Transparent, shiny
texture and smooth, details
of iris are visible
IRIS
Shape and color Brown, flat and
round
PUPILS
Color, shape, Equal in size
and symmetry of usually, 3 – 7 mm,
size equally round
VISUAL ACUITY
Near vision Able to read
newsprint
Distance vision 20/20 vision on
Snellen chart
PUPILS
Light reaction Constrict when
and looking at near
accommodation object, dilate when
looking at far
object, converge
when near object is
moved tenderness
over lacrimal
gland and lacrimal
sac, no discharges
in nasolacrimal
duct
EXTRAOCULAR MUSCLES
Alignment and Both eyes
coordination coordinated move
in unison with
parallel alignment
VISUAL FIELDS
Peripheral Able to see objects
fields in the periphery
EARS
AURICLES
Color, Color same as
symmetry, and facial skin,
position symmetrical,
aligned with outer
canthus of eye
about 10º from
vertical
Texture, Mobile, firm and
elasticity, and areas not tender, pinna
of tenderness recoils after it is
folded
EXTERNAL EAR CANAL
Cerumen, kin Dry cerumen, has
lesions, pus, blood presence of hair
follicles, no pus or
blood
HEARING ACUITY
Response to Normal voice tones
normal voice tones audible
Watch tick test Able to hear
ticking in both ears
Weber’s test Sound is heard in
both or is localized
at the center of the
head
Rinne’s test Air-conducted
hearing is greater
than boneconducted
hearing
 NOSE
Deviations in shape, Color is the same as
size, color, the facial skin,
and flaring or uniform in color,
discharge from symmetric and
nares straight, no nasal
discharges or
flaring
Nasal cavities Absence of
for presence of redness, swelling,
redness, swelling, and discharge
growths and
discharge
Nasal septum Intact in midline
between nasal
chambers
Patency of both Air moves freely
nasal cavities through the nares
Tenderness, No tenderness or
masses, and masses
displacements of
bone and cartilage
SINUSES
Tenderness No tenderness on
sinuses
MOUTH
LIPS
Symmetry of Uniform pink
contour, color, and color, soft, moist,
texture smooth texture,
symmetry of
contour, ability to
purse lips
BUCCAL MUCOSA
Color, Uniform pink
moisture, texture, color, moist,
presence of lesions smooth, soft,
glistening, and
elastic in texture,
no lesions
TEETH
Color, number 32 adult teeth,
and condition, and white to yellowish
presence of in color, shiny
dentures tooth enamel, no
intact dentures
GUMS
Color and Pink, moist, firm,
condition no retraction and
bleeding of gums
TONGUE/FLOOR OF THE MOUTH
Color and Pink, moist,
texture of the slightly rough, has
mouth floor and thin whitish color
frenulum
Texture, Moves freely, the
movement and base is smooth with
base of the tongue prominent veins
Presence of No palpable
nodules, lumps, or nodules or lumps
excoriated areas
PALATES AND UVULA
Color, shape, Soft palate is light
texture, presence of pin in color, hard
bony prominences palate is much
lighter and more
irregular in texture
Position of the Positioned in
uvula and mobility midline of soft
palate
OROPHARYNX AND TONSILS
Color and Pink and smooth
texture posterior wall
Size of the Pink in color, no
tonsils, color, and discharges
discharge
NECK AND LYMPH NODES
LYMPH NODES
Tenderness Absence of
tenderness
TRACHEA
Placement Central placement
in midline of neck,
spaces are equal on
both side
THYROID GLAND
Symmetry and Not visible in
visible masses inspection, gland
ascends during
swallowing, no
masses
Smoothness and Smooth, no areas of
areas of enlargement, or
enlargement, nodules
masses, or nodules
THORAX
POSTERIOR THORAX
Size, shape, Symmetric, ribs
symmetry, are sloped
compare the downward at 45º
diameter of the relative to the
anteroposterior spine, muscle
thorax to the development is
transverse thorax equal,
anteroposterior to
transverse
diameter in ratio of
1:2
Spinal Vertically aligned
alignment
Temperature, Uniform in
tenderness, masses temperature, no
tenderness and
masses
Respiratory Full and
excursion symmetric chest
expansion
Vocal fremitus Bilaterally equal,
heard mostly at the
apex of the lungs
Sound Percussion notes
resonant except
over the scapula,
bronchovesicular
and vesicular
ANTERIOR THORAX
Breathing Quiet, rhythmic,
patterns effortless
Temperature, Warm, no
tenderness, masses tenderness or
masses
Respiratory Full and
excursion symmetric chest
expansion
Vocal fremitus Bilaterally equal,
mostly heard at the
apex of the lungs
Sound Flat sound on the
 part with heavy
muscles and bony
prominences,
tympani on the
stomach, dullness
on the liver and
spleen,
bronchovesicular,
vesicular
Trachea Bronchial sound
CARDIOVASCULAR
PRECORDIUM
Aortic, No pulsation
pulmonic, tricuspid
area
Apical area With palpable
pulsation (point of
maximal impulse)
Sounds of S2 is louder than
tricuspid and S1
apical
Sounds of S1 is lauder than
Tricuspid and S2
apical area
CAROTID ARTERIES
Pulsations and Symmetric pulse
sounds volumes, full
pulsation, no sound
Visibility Not visible
BREAST AND AXILLA
BREAST
Size, symmetry, Slightly unequal,
contour, shape symmetric, convex,
round
Skin color, Lighter color
hyperpigmentation, because of less
retraction, swelling exposure, evenly
or edema, lumps pigmented, no
swelling, edema, or
lumps
AREOLA
Size, shape, Equal, round,
symmetry, color, symmetric, dark
surface brown, smooth,
characteristics, has no lesions
mass or lesions
NIPPLES
Size, shape, Equal, round,
position, color, everted in the same
discharges, lesions,direction, brown,
tenderness has no discharges,
lesions, or
tenderness
AXILLARY, SUBCLAVICULAR AND SUPRACVICALAR LYMPH NODES
Masses or Absence of masses
lumps or lumps
ABDOMEN
Skin integrity, Unblemished skin,
contour, uniform in color,
enlargement of no signs of
liver or spleen, enlargement of the
symmetry of liver and spleen,
contour symmetrical
contour
Visibility of Not visible, slightly
peristalsis visible on thin
movement persons
Visibility of Not visible
vascular patterns
Bowel sounds, Audible bowel
vascular and sounds, not audible
peritoneal friction vascular and
rubs peritoneal friction
rubs
MUSCULOSKELETAL SYSTEM
MUSCLES
Size, Bilaterally
contractures, symmetric, no
tremors contractures and
tremors
Tonicity, Normal muscle
strength (neck, tension, adequate
upper, lower strength of the
extremities) muscles
BONES
Structure, Uniform in
deformities, structure, no
tenderness, edema deformities,
tenderness or
edema
JOINTS
Swelling, Absence of
tenderness, tenderness and
smoothness of swelling, has
movement, smooth movement,
crepitation, no nodules
presence of nodule
Range of Able to perform
motion (shoulder the exercises in full
and scapula, range of motion,
elbows, hands, no tenderness,
acetabulum, moves smoothly
popliteal, ankles)