PHYSICAL ASSESSMENT NAME:_________________________________________ AGE: __________________ VITAL SIGNS: PR= RR= TEMPERATURE= BLOOD PRESSURE=

PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS General Survey

ACTUAL FINDINGS

REMARKS

1. Body built, height & weight in relation to clients age, lifestyle & health 2. Clients posture & gait, standing, sitting & walking 3. Clients overall hygiene & grooming 4. Body & breath odor 5. Signs of distress in posture or facial expression 6. Obvious signs of health or illness 7. Clients attitude 8. Clients affect/mood; appropriateness of the clients response 9. Quantity of speech, quality & organization

Inspection

Proportionate and varies with lifestyle. Relax, erect posture, coordinated body movements. Clean, neat No body odor or minor body odor relative to work or exercise, no breath odor. No distress noted. Healthy appearance. Cooperative Appropriate to the situation. Understandable, moderate pace; exhibits thought

Inspection Inspection Inspection

Inspection Inspection Inspection Inspection Inspection

PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS association. Logical sequence; makes sense; has sense of reality. Color- varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive. Uniformity- generally uniform except in areas exposed to sunlight; areas of lighter pigmentation (palms, lips, nail beds) in dark skinned people. No edema. Freckles, some birthmarks, some flat and raised nevi; no abrasions or other lesions. Moisture in skin folds and axillae (varies with environmental temperature and humidity, body temperature and activity.) Uniform; within normal range When pinched, skin springs back to previous state. Convex curvature, angle of nail plate about 160

ACTUAL FINDINGS

REMARKS

10. Relevance & organization of thoughts

Inspection

1. Skin color & uniformity

Inspection and Palpation

2. Presence of edema 3. Skin lesions

Inspection Inspection

4. Skin moisture

Palpation

5. Skin temperature 6. Skin turgor 1. Fingernails plate shape to determine its curvature

Palpation Palpation Inspection

PARTS TO BE ASSESSED & angle 2. Fingernail & toenail bed color 3. Tissues surroundings nails 4. Fingernail & toenail texture 5. Blanch test of capillary refill 1. Evenness of growth over the scalp 2. Hair thickness & thinness 3. Presence of infections or infestations 4. Texture & oiliness over the scalp

TECHNIQUE

NORMAL FINDINGS degrees. Highly vascular and pink in light skinned clients; darkskinned clients may have brown or black pigmentation in longitudinal streaks. Intact epidermis. Smooth texture. Prompt return of pink or usual color (generally less than 4 seconds.) Evenly distributed hair. Thick/thin hair. Not present. Silky, resilient hair.

ACTUAL FINDINGS

REMARKS

Inspection

Inspection Palpation Palpation

Inspection Palpation Inspection Palpation

PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS

1. Size, shape & symmetry

Palpation

2. Nodules or masses & depressions

Palpation

1. Facial features

Inspection

2. Symmetry of the facial movements

Inspection

1. Evenness of distribution & direction of curl

Inspection

SKULL Rounded (normocephalic and symmetrical, with Head is symmetrically frontal, parietal, and round. occipital prominences); smooth skull contour. Smooth, uniform consistency; absence of No mass or nodules noted; nodules or masses. FACE Symmetric or slightly Symmetrical facial asymmetric facial features; palpebral features; palpebral fissures equal in size; fissures equal in size; nasolabial folds are symmetric nasolabial symmetrical folds. Symmetrical facial Facial movements are all movements. symmetrical EYEBROWS & EYELASHES Hair evenly distributed; Eyebrows and eyelashes skin intact. Eyebrows are both evenly asymmetrically aligned distributed, symmetrical equal movement. aligned. Eyelashes curl Eyelashes curl slightly slightly outward. outward.

NORMAL

NORMAL

NORMAL

NORMAL

NORMAL

PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS EYELIDS Skin intact, no discharge, no discoloration. Lids close symmetrically approximately 15-20 involuntary blinks per minute; bilateral blinking. When lids open, no open, no visible sclera above corneas, and upper and lower borders of cornea are slightly covered. CONJUNCTIVA Transparent; capillaries sometimes evident. Shiny, smooth, pink or red in color. SCLERA Sclera appears white (yellowish in dark- skinned clients).

ACTUAL FINDINGS

REMARKS

1. Surface characteristics & ability to blink

Inspection and Palpation

Eyelids skin are intact, no noted discharge, and no noted discoloration. Lids close symmetrically. Client exhibited 18 involuntary blinks per minute.

NORMAL

1. Bulbar conjunctivas color, texture & presence of lesions 2. Palpebral conjunctivas color, texture & presence of lesions 1. Color & clarity

Inspection Inspection

Transparent, capillaries evident, no discharge was noted. Shiny, smooth and pink in color

NORMAL

NORMAL

Inspection

Sclera appears white

NORMAL

PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS CORNEA Transparent, shiny and smooth; details of the iris are visible. In older people, a thin grayish white ring around the margin, called arcus senilis, may be evident. IRIS Flat and round PUPILS Black in color; equal in size; normally 3-7 mm in diameter; round, smooth border. Illuminate pupil constricts (direct response) Nonillluminated pupil constricts (consensual response) Pupils constrict when looking at near object; pupil dilate when looking at far object; pupils converge when object is moved towards the nose.

ACTUAL FINDINGS

REMARKS

1.Clarity & color

Inspection

Details of iris are visible. Transparent, shiny and smooth.

NORMAL

1. Shape & color

Inspection

Flat and round and uniform in color. Black, equal in size, about 4 mm in diameter; round, smooth & symmetrical. Illuminated pupil constricts Non-illuminated pupil constricts too. Pupils dilated when ask to look on distant objects, constricts when pen was placed near eyes; when pen is moved towards the nose.

NORMAL

1. Color, shape symmetry of size

&

Inspection Inspection

NORMAL NORMAL

2. Pupil light reaction & accommodation

3. Pupils consensual light

direct reaction

& to

Inspection

NORMAL

PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS

1. Test near vision 2. Test distance vision 1. Presence of edema

1. Test each eye for alignment & coordination

1. Test for visual fields

peripheral

1. Color & symmetry of size & position

VISUAL ACUITY Able to read newsprint Able to read newsprint 20/20 vision on Snellen 20/20 vision on Snellen Inspection chart. chart. LACRIMAL GLAND, LACRIMAL SAC & NASOLACRIMAL DUCT No edema or tenderness Inspection No edema noted over lacrimal gland. EXTRAOCULAR MUSCLES Both eyes moved in Both eyes are coordinated; coordinated manner, in Inspection move in unison, with unison and in parallel parallel alignment. manner VISUAL FIELDS When looking straight Client can see objects in Inspection ahead, the client can see the periphery. objects in the periphery. EARS AURICLE Color same as facial skin, Color is same with facial symmetrical, auricle skin, symmetrical with Inspection aligned with outer canthus each other, auricle aligned of eye, about 10cm from with outer canthus of eye, vertical. about 10 cm vertical Inspection

NORMAL NORMAL NORMAL

NORMAL

NORMAL

NORMAL

1. Color, moisture, texture & presence of lesions PARTS TO BE ASSESSED 2. Texture & elasticity & areas of tenderness 1. Inspect for color, 1. number & condition & Cerumen, skin lesions, presence pus & blood of dentures 1. Color & condition 1. Clients response to normal voice tones 2. Perform watch tick test 1. Color & texture of the mouth floor & frenulum 1. Shape, size color & & 2. Position, or color flaring or discharge base texture, movement & from the naresthe tongue of 2. Presence of redness, swelling, growths & discharge or nares using the flashlight 3. Position of nasal septum 4. Test patency of both nasal septum 5. Tenderness, masses & displacement of bone & cartilage 1. Color & shape, texture 1. Presence of tenderness & presence of bony prominences 1. Symmetry of contour color & texture 2. Position of the uvula &

BUCCAL MUCOSA Inspection and Palpation Uniform pink color Uniform pink color. Moist, (freckled brown smooth, glistening and pigmentation in darkelastic texture. skinned clients) TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS Moist, smooth, soft, glistening, and elastic texture (drier oral mucosa Mobile, firm and not Both pinna recoils after in pinna due to Palpation tender,elderlyrecoils after being folded. Mobile, firm decreased salivation) it is folded. and not tender. TEETH CANAL EXTERNAL EAR Inspection 32 adult teeth 32 adult blood Distal third contains hair No noted pus, teeth and Smooth, white, shiny tooth Smooth, white, shiny tooth follicles and glands. Dry odor. Minimal cerumen Inspection enamel enamel cerumen in various shades noted. Distal third contains GUMS of brown hair follicles. Inspection Pink gums (bluish or dark Pink gums, moist, firm, no HEARING AUITY TEST patches invoice tones noted lesions and nodules Normal dark-skinned Client responds to normal Inspection clients) audible voice tones Moist, firm texture to Client able to hear ticking Able to hear ticking in both gums Inspection sound of watch in both ears TONGUE/FLOOR OF THE MOUTH ears Inspection and Palpation Smooth tongue base with Smooth tongue base with NOSE prominent veins prominent and/or No dischargeveins Symmetricin position and straight Inspection and Palpation Central Centered; pink in color, flaring noted. Symmetrical Inspection No discharge or flaring Pink in color (some brown moist, both sides. Alsohas on slightly rough, Uniform on tongue pigmentation color thin white coating, uniform in color. borders in darj-skinned smooth, no lesions; moves Mucosa are intact and Mucosa pink clients); moist; slightly pinkish; freely. moist minimal Inspection Clear, watery discharge rough; thin white coating noted inside; no swelling No lesions. Smooth, lateral margins, or nodules found. no lesions and in Nasal septum is intact and Nasal septum intact Inspection Raised papillae (taste midline, intact in midline buds) Air moves freely as the Air moves freely as the Moves freely, no Inspection client breathes through client breathes through tenderness the nares each nares No tenderness, no lesions Palpation Not tender; no lesions noted. No displacement of bone & cartilage. PALATES & UVULA SINUSES Inspection and Palpation Soft palate- light pink, Light pink, smooth and Palpation Not lesions, moist. Not tenderness noted. smooth, no tender moist soft palate. LIPS Hard palate- lighter pink, Light pink, irregular Uniformirregular more pink color textured and moist hard Soft, moist, smooth Reddish, smooth, soft and texture/ridges no lesions palate. Inspection and Palpation texture symmetrical.nodules or No noted Client is able Symmetry of contour to purse lips. masses Ability toin midline of purse lips Inspection Positioned Midline of soft palate

NORMAL

REMARKS

NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL

NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL

NORMAL NORMAL

MUSCOLOSKELETAL SYSTEM 1. Muscle size compare the muscles on one side of the body (arm, thigh, calf) to the same muscle on the other side 2. Constructures (shortening) of the muscles & tendons 3. Muscle fasciculations & tremors. Presence of tremors of the hands & arms when stretched in front of the body 4. Muscle tonicity 5. Muscle strength 1. Normal structure 2. Edema & tenderness 1. Swelling 2. Presence of tenderness, smoothness of movement, swelling, crepitation & presence of nodules Inspection Equal size on both sides of body. Equal on both sides of the body. NORMAL

Inspection

No contractures.

No contractures.

NORMAL

Inspection Inspection Inspection Inspection Inspection Inspection Inspection

No tremors. Normally firm. Equal strength on each body side. BONES No deformities. No tenderness or swelling. JOINTS No swelling. No tenderness, swelling, crepitation or nodules. Joints move smoothly. RANGE OF MOTION Uniform in color, veins are visible in face, neck and dorsum of the hands, average muscles size, fingers are complete No lesions, no edema. Uniform in color, no deformities, complete fingers in both feet.

No tremors. Firm. Equal strength on each body side. No deformities. No tenderness. No swelling. No tenderness, swelling, crepitation or nodules. Joints move smoothly. Uniform in color, veins are visible in face, neck and dorsum of the hands, average muscles size, fingers are complete No lesions, no edema. Uniform in color, no deformities, complete fingers in both feet.

NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL

1. Upper extremities

Inspection

NORMAL

2. Lower extremities

Inspection

NORMAL