PHYSICAL ASSESSMENT

Date of Assessment:
Vital Signs:
Blood Pressure: Heart Rate: 78 bpm Respiratory Rate:
Temperature: Oxygen Saturation: GCS:
AREA ASSESSED TECHNIQUE NORMAL ACTUAL ANALYSIS
USED FINDINGS FINDINGS
SKIN
- Color Inspection Varies with Brown Normal
race
- Temperature Palpation Warm to Warm to touch Normal
touch
- Turgor Palpation Springs back Springs back Normal
to previous to previous
state state
(1-2 (2 seconds)
seconds)
- Moisture Palpation Skin Moist Normal
surfaces
vary from
moist to dry
depending
on the area
assessed
- Texture Palpation Smooth and Smooth and Normal
soft soft

- Presence of Inspection No lesions Scar on right Due to the fighting

lesions and and scars knee incidents encountered as
scars verbalized by the
patient.
HAIR
- Color Inspection Varies with Black Normal
race
- Distribution Inspection Evenly Shaved head As per hospital policy to
distributed avoid harm

- Texture Palpation Smooth, Smooth, firm, Normal

firm, and and Silky
Silky
- Presence of Inspection and No Presence of Possibly due to poor
parasite palpation infestation sores hair hygiene and
scratching of the scalp
HEAD
 - Shape Inspection Normocephali Normocephali Normal
and Symmetry c and c and
Symmetric symmetric

- Consistency Inspection Hard and Scar is present Due to the fighting

Smooth; incidents encountered
without as verbalized by the
lesions and patient.
masses or scars
FACE
- Symmetry Inspection Proportionate Proportionate Normal
and and Symmetric
Symmetric
- Facial Inspection Movements are Movements are Normal
Movement equal equal
bilaterally bilaterally
- Color Inspection Same as body Same as body Normal
color color

- Lesion Inspection Absence of Absence of Normal

lesions lesions

EYES
- Position, size, Inspection Symmetric Symmetric Normal
and shape
- Movement Inspection Symmetrical Symmetrical in Normal
in movement movement
- Eyelids Inspection Without Without Normal
swelling, swelling,
discharge and discharge and
lesions lesions
Conjunctiva Pinkish; free Pinkish; free of Normal
of discharge, discharge,
lesions, lesions,
redness and redness and
lacerations lacerations
- Sclera Inspection White; free of White; free of Normal
discharge, discharge,
lesions, lesions,
redness and redness and
lacerations lacerations
- Pupils Inspection Color varies Black; Normal
with race; PERRLA, 2 to
PERRLA 4 mm in
diameter in
bright light to
 4 to 8 mm in
the dark
- Iris Inspection Round, flat, Round, flat, Normal
and evenly and evenly
colored colored
- Eyebrows Inspection Symmetric in Symmetric in Normal
and eyelashes shape and shape and
movement; movement; hair
hair evenly evenly
distributed distributed
EARS
- Position Inspection Symmetric Symmetric Normal
- Shape and size Inspection Symmetric on Symmetric on Normal
both sides both sides
- Color Inspection Consistent Consistent with Normal
with facial facial color
color
- Texture Palpation Smooth Smooth Normal
without without
lesions, lumps lesions, lumps
or nodules and nodules
- Discharges Inspection No discharges No discharges Normal
-Hearing Inspection Responds to Responds to Normal
acuity sound sound
MOUTH
- Lip Inspection Smooth and Smooth and Normal
Consistency moist without moist without
lesions and lesions and
swelling swelling
- Lip Color Inspection Varies with Dark Possibly due to reduced
race pigmentation blood flow and
of the lips exposure to tar and
nicotine which cause
the melanin in the lips
to darken leading to
uneven pigmentation.
- Teeth and Inspection White, no Teeth are Tartars and dental
Gums tartars, no yellow, with carries are possibly due
dental carries, tartars and to plaque buildup in the
complete set dental carries; teeth.
of teeth; 4 extracted Tooth extraction due to
teeth (left toothache as verbalized
molars) from by the patient.
the inferior lip
Pink and Dark gums are possibly
 Moist Gums Dark due to the smoker’s
pigmentationmelanosis or increased
of gums tissue pigmentation due
to irritation from
nicotine that occurs on
the gingiva.
- Buccal Inspection Pink and Pink and moist This is possibly due to
Mucosa moist without with white and the consumption of
lesions red lesions tobacco and alcohol
that renders oral
mucosa epithelium
susceptible to the
colonization of
pathogens which might
lead to microbial
infections and
irritation.
- Tongue Inspection Pink, moist, a Pink, moist, a Normal
moderate size moderate size
with papillae with papillae
present present
NOSE
- Position and Inspection Midline in Midline in Normal
Size face; face;
Symmetric Symmetric

- Configuration Inspection With nose With nose Normal

of the nose bridge; located bridge; located
bridge at the midline at the midline
- Color Same as the Same as the Normal
rest of the rest of the
body body
- Tenderness, Palpation No tenderness No tenderness Normal
masses and and masses and masses
lesions
- Discharges Inspection No discharges No discharges Normal
- Nasal Flaring Inspection No nasal No nasal Normal
flaring flaring
NECK
- Length Inspection Short and Short and thick, Normal
thick, surrounded by
surrounded by skin folds
skin folds
- Position Inspection Centrally Centrally Normal
located located
between the between the
 shoulders shoulders
- Trachea Inspection Central Central Normal
placement in placement in
midline of midline of
neck; spaces neck; spaces
are equal on are equal on
both sides both sides
- Mobility Inspection Can move Can move Normal
spontaneously spontaneously
in all in all directions
directions
- Appearance Inspection No lesions and No lesions and Normal
scars scars
- Jugular veins Inspection Veins not Veins not Normal
visible visible
THORAX
- Shape Inspection Smooth, Rounded and Normal
Rounded and Symmetric
Symmetric
- Respiratory Inspection Respirations RR = 19 cpm Normal
Effort should be
unlabored and
regular;

- Tenderness Palpation No tenderness No tenderness Normal

and Masses and masses and masses
noted noted
- Breath Auscultation Clear breath Clear breath Normal
Sounds sounds can be sounds can be
heard; no heard; no
adventitious adventitious
sounds sounds
HEART
- Apical Pulse Auscultation Regular and 78 BPM Normal
rapid; 60-100
BPM
- Heart Sounds Auscultation Louder, higher Louder, higher Normal
pitched, and pitched, and
of shorter of shorter
duration; duration;
innocent innocent
murmurs are murmurs are
normal normal

ABDOMEN
 - Size and contour Inspection Rounded and Rounded; Normal
prominent in prominent in
supine supine position
position
Color Same color as Brown Normal
the rest of the
body
- Movement Inspection Diaphragmatic, Diaphragmatic, Normal
with abdominal and abdominal and
respirations chest chest movement
movement synchronize
synchronize
- Bowel Sounds Auscultation Normal bowel Gurgles can be Normal
sounds heard
occur every
10 to 30s;
clicks,
gurgles or
growls can be
heard
- Presence of Inspection No lesions and No lesions and Normal
lesions and scars scars
scars
- Masses and Soft to
Palpation Soft; globular Normal
Tenderness palpation; nontender
without
masses and
tenderness
UPPER AND LOWER EXTREMITIES
- Color Inspection Reddish to Brown Normal
light brown

- Lesions and Inspection No lesions and Scars on both Due to a slip and fall
scars scars knees accident as verbalized by
the patient.

- Shape and size Inspection Mobile Mobile Normal

extremities; extremities;
symmetric in symmetric in
size size
-Temperature Palpation Warm to touch Warm to touch Normal

-Nails Inspection Nails have a Fingernails and With age, nails become
and palpation smooth texture, toenails are rough, or ridges may
convex rough or have become more prominent
 curvature in ridges because of changes in
shape cell turnover within the
nail.

Nail beds Nail beds are Possibly due to fungal

slightly pinkish yellow in an or bacterial infection.
in appearance, appearance on
with intact both hands and
epidermis, feet
capillary refill
in two sec
-Muscle strength, Inspection No contractures No contractures Normal
tone, and limb and tremors and tremors
movement Muscle has Muscle has
equal strength equal strength
Freely moves Freely moves
the arm and the the arm and the
hands hands
- Joints Inspection No swelling, No swelling, Normal
tenderness, tenderness,
crepitation, or crepitation, or
nodules nodules
- Edema Palpation No edema No edema Normal