PHYSICAL ASSESSMENT

Client: JKL (kaw na sumagot nito jk) saka ung mga box na color red thanks 

MEASUREMENTS:
Height-5’7’’ ½
Weight-72kg( during hospitalization), 54kg (before hospitalization)
Head circumference-
Chest circumference-
Abdominal circumference-
BMI-

VITAL SIGNS:
Temperature- 37.7
Pulse Rate- 84
Respiration- 24
Blood Pressure- 160/ 120

Area of Assessment Normal findings Actual findings Evaluation

Body build, height, Proportionate, varies

weight with lifestyle

Posture and gait, Relaxed, erect posture; Relaxed, erect posture; Normal
standing sitting walking coordinated movement coordinated movement

Overall hygiene and Normal

Clean, neat Clean, neat
grooming

No body odor or minor Normal

body odor relative to No foul body and breath
Body and breath odor
work or exercise; no odor
breath odor

Signs of distress in Deviation from normal

posture and facial No distress noted fatigue, lethargic
expression

Bipedal edema, Deviation from normal

periorbital edema,
ascites, facial
Obvious signs of health
Healthy appearance edema,waxy pallor or
and illness
shiny extremities

Cooperative, able to Irritable and agitated in Deviation from normal

attitude
follow instructions following instruction

Affect/mood Appropriate to situation irritable Normal

Quantity and quality of Understandable, Understandable, clear Normal
speech moderate pace; clear tone and exhibits
tone and inflection;
 exhibits thought
association thought association

Logical sequence; Normal

Relevance and Thoughts make sense
makes sense, has
organization of thoughts and has sense of reality
sense of reality

Area to be Assessed

INTEGUMENTARY
Skin

Color varies from light to Skin is light in color Normal

deep brown

Generally uniform in waxy pallor or shiny Deviation from normal

color extremities
No edema Skin on the lower legs, Abnormal findings
back look stretched and Indicative of peripheral
shiny and sacral edema

Moisture in skin folds Moisture in skin folds Normal

and the axillae and the axillae

Generally uniform in Generally uniform in Normal

temperature and within temperature and within
normal range normal range

Springs back to 8 seconds before going Deviation from normal

previous state when back to previous state
pinched when pinched

Nails

Convex curvature, 160 Convex curvature, 150 Normal

degree angle; degree angle;

smooth texture; highly Smooth texture;, pale in Deviation from normal

vascular, pink in light- color
skinned, brown in dark-
skinned clients;

intact epidermis Intact epidermis Normal

original color returns original color returns in Deviation from normal
generally less than 4 5 secs when pinched
secs when pinched

Short and clean Short and clean Normal

HEAD

Rounded Rounded with smooth Normal

(normocephalic and skull contour
symmetric with frontal,
Skull occipital and parietal
prominence); smooth
skull contour;

Absence of nodules and Absence of nodules and Normal

masses masses

Lighter than facial skin, Lighter than facial skin, Normal

moist, no scar;no moist, no scar;no
Scalp dandruff dandruff

Evenly distributed;thick; Evenly distributed;thick; Normal

silky and resilient; silky and resilient;
Hair
no infection or no infection or
infestation infestation
Symmetric facial Periorbital edema, and Deviation from normal
Face features and facial edema
movements

No lesions and No lesions and Deviation from normal

EYES
inflammations inflammations

 Hair evenly  Hair evenly Normal

distributed; skin distributed; skin
intact intact
Eyebrows
 Symmetrically  Symmetrically
aligned; aligned;

 equal movement equal movement

Equally Equally distributed; Normal

Eyelashes distributed;Curled
slightly outward Curled slightly outward

Eyelids  Skin intact; no  Skin intact; no Normal

discharge, no discharge, no
discoloration discoloration

 Lids close  Lids close

symmetrically symmetrically

 Approx. 15 – 20  Approx 17
involuntary blinks involuntary blinks
per minute; per minute;
bilateral blinking; bilateral blinking;

 When lids are open,  When lids are open,

no visible sclera no visible sclera
 above corneas, above corneas, and
and upper and upper and lower
lower border of border of cornea are
cornea are slightly slightly covered
covered

 Transparent; Deviation from normal

Conjuctiva:  Transparent;
capillaries
capillaries
sometimes evident
sometimes evident
Bulbar Conjuctiva

 Shiny, smooth, and

Palpebral Conjuctiva pink or red  Shiny, smooth, and
pale
Sclera Sclera appears white Sclera appears white Normal
 Transparent, shiny  Transparent, shiny Normal
and smooth and smooth
Cornea  Client blinks when Client blinks when
the cornea is the cornea is
touched touched

Proportional to the size Proportional to the size Normal

of the eye, with of the eye, with
Iris
transparent anterior transparent anterior
chamber chamber

Black; equal in size; Black; equal in size;5 Normal

normally 3-7 inches in inches in diameter;
Pupils diameter; round, smooth round, smooth border,
border, iris flat and iris flat and round
round

 Able to read  Able to read Normal

newsprint 14 newsprint 14
inches away inches away
Visual acuity
 20/20 vision on  20/20 vision on
Snellen-type chart Snellen-type chart

 Pupils constrict when  Pupils constrict when

looking at near looking at near
object; pupils dilate object; pupils dilate
when looking at far when looking at far
Pupils reaction and objects; objects;
Accomodation
 Pupils converge  Pupils converge
when near object is when near object is
moved towards moved towards nose
nose

Lacrimal gland, No edema, no Puffiness on area of the Abnormal findings

lacrimal sac and tenderness or tearing lacrimal gland, sac and Indicative of periorbital
nasolacrimal gland noted nasolacrimal gland edema
Both eyes coordinated, Both eyes coordinated, Normal
Extraocular muscles move in unison, with move in unison, with
parallel alignment parallel alignment

When looking straight When looking straight Normal

Visual fields ahead, the client can ahead, the client can
see objects in perirhery see objects in perirhery

EARS

 Color same as facial  Color same as facial Normal

skin; symmetrical; skin; symmetrical;

 Aligned with outer  Aligned with outer

canthus of eye, canthus of eye,
about 10 degrees about 10 degrees
Auricles
from vertical; from vertical;

 Mobile, firm and not  Mobile, firm and not

tender; pinna tender; pinna
recoils after it is recoils after it is
folded folded

Distal third contains hair Distal third contains hair Normal

follicles and glands, dry follicles and glands, dry
cerumen, grayish-tan cerumen, grayish-tan
color, or sticky, wet color, or sticky, wet
External Ear Canal cerumen on various cerumen on various
shades o brown shades o brown

 Normal voice tones Normal

audible;  Normal voice tones
audible;
 Able to hear ticking in
both ears when  Able to hear ticking in
performing the both ears when
watch thick test performing the
watch thick test
 Sound is heard in
Hearing acuity both ears or is  Sound is heard in
localized at the both ears (Weber
center of the head Negative) when
(Weber Negative) performing the
when performing tuning fork test
the tuning fork test
 AC hearing is greater
 AC hearing is greater than BC hearing
than BC hearing (positive rinne)
(positive rinne)

NOSE  Symmetric and  Symmetric and Normal

straight; No straight; No
discharge or discharge or
flaring; Uniform flaring; Uniform
color color
  Not tender; no lesion  Not tender; no lesion
External  Air moves freely as  Air moves freely as
the client breathes the client breathes
through the snares through the snares

Internal  Mucosa pink; Clear  Mucosa pink; Clear

watery discharge; watery discharge;
no lesions; nasal no lesions; nasal
septum is intact septum is intact
and in midline and in midline
Sinuses
 Maxillary and Maxillary and frontal
frontal sinuses are sinuses are not tender
not tender
MOUTH Normal
 Outer lips: Uniform  Outer lips: Uniform Normal
pink color; soft, pink color; soft,
moist, smooth moist, smooth
texture; symmetry texture; symmetry
Lips of contour; ability to of contour; ability to
purse lips purse lips

 Inner lips: Uniform  Inner lips: Uniform

pink color pink color

moist, smooth, soft, moist, smooth, soft, Normal

Buccal mucosa glistening, and elastic glistening, and elastic
texture texture

32 adult teeth; smooth, 32 adult teeth; smooth, Normal

teeth white, shiny tooth white, shiny tooth
enamel enamel

pink gums; moist and pink gums; moist and Normal

gums firm texture to gums; no firm texture to gums; no
retraction of gums retraction of gums

 central position;  central position; Normal

Tongue or floor of the pink color; moist; pink color; moist;
mouth slightly rough; thin slightly rough; thin
whitish coating; whitish coating;
smooth lateral smooth lateral
margins; no margins; no
lesions; raised lesions; raised
papillae papillae

 moves freely; no  moves freely; no

tenderness tenderness

 smooth tongue  smooth tongue

base with base with
prominent veins prominent veins

 smooth with no  smooth with no

palpable nodules palpable nodules
  salivary duct  salivary duct
openings have openings have
same color of same color of
buccal mucosa and buccal mucosa and
floor of the mouth floor of the mouth

 light pink, smooth  light pink, smooth Normal

soft palate; lighter soft palate; lighter
Palate pink hard palate pink hard palate
with irregular with irregular
texture texture

Ovula  uvula is positioned in  uvula is positioned in

the midline of soft the midline of soft
palate palate

 oropharynx: pink and  oropharynx: pink and Normal

Oropharynx smooth posterior smooth posterior
wall wall
Tonsils
 tonsil: pink and  tonsil: pink and
smooth; no smooth; no
discharge; of discharge; of
normal size or not normal size or not
visible visible

 presence of gag  presence of gag

reflex reflex

 muscles equal in  muscles equal in Normal

size; head centered size; head centered
Neck  coordinated smooth  coordinated smooth
movements with no movements with no
discomfort discomfort

 non palpable and no  non palpable and no Normal

Lymph nodes
tenderness noted tenderness noted

 central placement in  central placement in Normal

midline of neck; midline of neck;
Trachea
spaces are equal in spaces are equal in
both sides both sides

Thyroid gland  not visible ion  not visible ion Normal

inspection inspection

 gland ascends during  gland ascends during

swallow but is not swallow but is not
visible visible

 lobes may not be  lobes are small,

palpated; if smooth, centrally
palpated, lobes are located, painless
small, smooth, and rise freely with
centrally located, swallowing
painless and rise
 freely with
swallowing

THORAX
Normal

 Anteroposterior to
 Anteroposterior to
transverse diameter
transverse diameter
in ratio of 1:2
in ratio of 1:2
 Chest symmetric
 Chest symmetric
 Spine vertically
 Spine vertically
Posterior Thorax aligned
aligned
 Uniform
 Uniform
temperature, skin
temperature, skin
intact; no
intact; no
tenderness, no
tenderness, no
masses
masses
 Full and symmetric
 Full and symmetric
chest expansion;
chest expansion;
thumbs separate 4
thumbs normally
cm.
separate 3-5 cm.
 Bilateral symmetry
 Bilateral symmetry
of vocal fremitus
of vocal fremitus
 Fremitus is heard
 Fremitus is heard
most clearly at the
most clearly at the
apex of the lungs
apex of the lungs
 Low- pitched voices
 Low- pitched voices
are more readily
of males are more
palpated than higher
readily palpated
pitched voice
than higher pitched
voice of female 
 Percussion notes  Percussion notes
resonate, except resonate, except
over scapula over scapula
 Lowest point of  Lowest point of
resonance is a at resonance is a at
the diaphragm the diaphragm
 Vesicular and  Vesicular and
bronchovesicular bronchovesicular
breath sounds breath sounds

 Quiet, rhythmic and  Quiet, rhythmic and Normal

effortless effortless
respirations respirations

Anterior Thorax  Uniform temperature,  Uniform temperature,

 skin intact; no skin intact; no
tenderness, no tenderness, no
masses masses

 Full and symmetric  Full and symmetric

chest expansion; chest expansion;
thumbs normally thumbs normally
separate 3-5 cm separate 3-5 cm

 Same as posterior  Same as posterior

vocal fremitus; vocal fremitus;
normally decreased normally decreased
over heart and over heart and
breast tissue breast tissue

 Percussion notes  Percussion notes

resonate down to resonate down to
the sixth rib at the the sixth rib at the
level of the level of the
diaphragm but are diaphragm but are
flat over areas of flat over areas of
heavy muscle and heavy muscle and
bone, dull on areas bone, dull on areas
over the heart and over the heart and
the liver, and the liver, and
tympanic over the tympanic over the
underlying stomach underlying stomach

 Bronchial and tubular  Bronchial and tubular

breath sounds breath sounds

 Bronchovesicular and  Bronchovesicular and

vesicular breath vesicular breath
sounds sounds

CARDIOVASCULAR

Aortic and pulmonic No pulsations No pulsations Normal

areas
No pulsations No pulsations Normal
Tricuspid areas
No lift or heave No lift or heave
 Pulsations visible in Normal
50% of adults and  Pulsations visible in
Apical area (locate for palpable in most PMI in 5th LICS at or
point of maximal PMI in 5th LICS at or medial to MCL
impulse) medial to MCL  Diameter of 2 cm.
 Diameter of 1-2 cm.  No lift or heave
 No lift or heave
Auscultate aortic,  S1: Usually heard at  S1: heard at all sites Normal
pulmonic, tricuspid and all sites and louder at apical
apical valves  Usually louder at area
apical area
 S2: Usually heard at  S2: heard at all sites
all sites and louder at the
  Usually louder at the
base of the heart
base of the heart
 Systole: silent
 Systole: silent
interval; slightly
interval; slightly
shorter duration
shorter duration
than diastole at
than diastole at
normal heart rate
normal heart rate
(60-90 bpm)
( bpm)
 Diastole: silent
 Diastole: silent
interval; slightly
interval; slightly
longer duration than
longer duration than
systole at normal
systole at normal
heart rates
heart rates
 S3: in children and
 S3: not present
young adults
 S4: not present
 S4: in many older
adults
Carotid Arteries
 Symmetric pulse  Symmetric pulse Normal
volumes volumes
 Full pulsations,  Full pulsations,
thrusting quality thrusting quality
 Quality remains the  Quality remains the
Palpate carotid artery
same when client same when client
with extreme caution
breathes, turns breathes, turns
head and changes head and changes
from sitting to from sitting to
supine position supine position
 Elastic arterial wall  Elastic arterial wall
Auscultate carotid No sound heard on No sound heard on Normal
arteries auscultation auscultation
Jugular Veins
Abnormal finding
Inspect jugular veins Veins not visible Jugular vein visible
Distended jugular vein
BREAST AND
AXILLAE
Males: Breasts even Normal
Size, symmetry, contour
with the chest wall; if Breasts even with the
or shape while the client
obese, may be similar in chest wall
is in the sitting position
shape to female breast
Skin of the breast for Normal
localized discolorations
and hyper  Skin uniform in color  Skin uniform in color
pigmentations,  Skin smooth and  Skin smooth and
retraction, dimpling, intact intact
localized hypervascular  Striae, moles or nevi  Striae, moles or nevi
areas, swelling or
edema
Inspect areola for  Round or oval and  Round or oval and Normal
size, shape, symmetry, bilaterally the same bilaterally the same
color, surface  Color varies widely  Pink in color
characteristics and any from light pink to  Irregular placement
mass or lesions dark brown of sebaceous glands
 Irregular placement on the surface of
of sebaceous areola
 glands on the
surface of areola
Round, everted and Round, everted and Normal
Inspect for nipple size, equal in size; similar in equal in size; similar in
shape, position, color, color; soft and smooth; color; soft and smooth;
discharge and lesions both nipples point in the both nipples point in the
same direction same direction
Palpate for breast No tenderness, masses, No tenderness, masses, Normal
masses, tenderness nodules or discharges nodules or discharges
Palpate nipples for Normal
No tenderness, masses, No tenderness, masses,
tenderness and
nodules or discharges nodules or discharges
discharges
Inspect areola for Normal
Males: Breasts even
size, shape, symmetry,
with the chest wall; if Breasts even with the
color, surface
obese, may be similar in chest wall
characteristics and any
shape to female breast
mass or lesions
ABDOMEN
Inspect the abdomen for  Unblemished skin Skin of the abdomen is Abnormal findings
skin integrity  Uniform color shiny and stretched Indicative of ascites
 Flat, rounded Increased size of the Abnormal findings
(convex), or abdomen Indicative of ascites
scaphoid (concave)
Inspect the abdomen for
 No evidence of
contour and symmetry
enlargement of liver
or spleen
 Symmetric contour
 Symmetric  Symmetric Normal
movements caused movements caused
Observe abdominal
by respiration by respiration
movements associated
 Visible peristalsis in  Visible peristalsis in
with respiration,
very lean people very lean people
peristalsis, or aortic
 Aortic pulsations in  Aortic pulsations in
pulsations
thin persons at thin persons at
epigastric area epigastric area
Observe the vascular No visible vascular No visible vascular Normal
pattern pattern pattern
 Audible bowel  Audible bowel Normal
Auscultate the abdomen sounds sounds
for bowel sounds,  Absence of arterial  Absence of arterial
vascular sounds, and bruits bruits
peritoneal friction rubs  Absence of friction  Absence of friction
rub rub
Tympany over the Tympany over the Normal
Percuss several areas stomach and gas-filled stomach and gas-filled
in each four quadrants bowels; dullness, bowels; dullness,
todetermine presence of especially over the liver especially over the liver
tympany and dullness and spleen, or a full and spleen, or a full
bladder bladder
12 cm in the 6 to 12 cm in the Normal
Percuss the liver to
midclavicular line; 8 cm midclavicular line; 4 to 8
determine its size
at the midsternal line cm at the midsternal line
Perform light palpation No tenderness; relaxed Pain on the left lower Deviation from normal
first to detect areas of abdomen with smooth, quadrant near
tenderness consistent tension
 umbilicus
 Tenderness may be Pain on the left lower Deviation from normal
present near xiphoid quadrant near
Perform deep palpation
process, over
over all four quadrants umbilicus
cecum, and over
sigmoid colon
Palpate the liver to
 May not be palpable
detect enlargement
Palpate for the bladder
on the area above the  Not palpable
pubic symphysis.
MUSCULOSKELETAL
SYSTEM
Muscles
Inspect muscles for Not equal in size Abnormal findings
Equal size on both sides
size. Compare the especially on the lower Indicative of edema
of the body
muscles on one side of
legs
the body to the same
muscle on the other
side.
Inspect the muscles and No contractures Normal
No contractures
tendons for contractures
Inspect the muscles for Normal
No tremors No tremors
tremors
Palpate muscles at rest Normal
to determine muscle Normally firm Normally firm
tonicity
Palpate the muscles Normal
while the client is active
and passive for Smooth coordinated Smooth coordinated
flaccidity, spasticity, and movements movements
smoothness of
movement
Test muscle strength. Weakness noted on
Equal strength on each Weakness noted on
Compare the right side both lower extremities
side of the body both lower extremities
with the left side

Sternocleidomastoid
Trapezius
Deltoid
Biceps
Triceps
Wrists and finger
muscles
Grip strength
Hip muscles
Hip abduction
Hip adduction
Hamstrings
Quadriceps
Muscles of the ankles
and feet
Bones
Inspect the skeleton for No deformities Normal
No deformities
structure
 Swelling on the lower Abnormal findings
legs; Indicative of edema
Pushing in gently on the
Palpate the bones to swollen area with finger
No tenderness or
locate any areas of for about 10 to 15
swelling
edema or tenderness seconds and then
removing finger will
leave a dimple in the
skin.
Joints
 edematous Deviation from normal
Inspect the joints for  Noswelling
 No tenderness,
swelling. Palpate for  No tenderness,
tenderness, swelling,
smoothness of crepitation, or
movement, swelling, nodules
crepitation, and  Joints move
presence of nodules smoothly