Physical Assessment

Mr. Ronald Romero

Area To Be Assessed Actual Findings Analysis
I. General Survey
Height & weight in relation
to clients age, lifestyle and
behavior
Posture and gait, j Q
standing, sitting and
Hygiene and grooming Q
Body and breath odor Q
Signs of distress, in Q
posture or facial
expression
Obvious signs of illness Q
Clients attitude . Q
Mood Q
Quantity of speech and Q
quality
Relevance and
organization of thoughts
- proportionate; varies
with lifestyle
- nervousness, increased
irritability, muscle
weakness, extreme
fatigue
- clean, neat
- no body and breath odor
- no distress noted
- Healthy appearance
- cooperative
- appropriate to situation
- understandable;
moderate pace; exhibits
thought association
- logical sequence; makes
sense
- normal
- normal
- normal
- normal
- normal
- normal
- normal
- normal
- normal
- normal
II. Measurements
Height
Weight j Q
Vital signs Q
- Temperature

- 5 7
- 65 kg
- 35.0
o
C
- normal
- normal
- normal
- Pulse Rate

- Respiratory Rate
- Blood Pressure
- 78 beats per minute
- 18 breaths per minute
- 110/80 mmHg
- normal
- normal
- normal
III. Integumentary
A. Skin
Color and uniformity
Presence of edema j Q
Skin moisture Q
Skin temperature Q
Skin turgor Q
- generally uniform
except in areas exposed
to the sun
- no edema
- skin of the client is
moist and is not dry
- uniform; within normal
range
- when pinched, skin
springs back to its
previous state
- normal
- normal
- normal
- normal
- normal
B. Nails
Fingernail plate shape . Q
Fingernail and toenail Q
color
Palpate fingernail and Q
toenail texture
Inspect tissue surrounding
nails
Perform blanch test of
capillary refill
- convex curvature; angle
of name plate about 160
degrees
- highly vascular and pink
- smooth texture
-intact epidermis
- prompt return of pink
color within 2 sec.
- normal
- normal
- normal
- normal
- normal
IV. Head-to-toe examination
A. Head
1. Skull
Size, shape or
symmetry
Nodules, masses and j Q
depressions
- rounded; smooth skull
contour
- no masses, nodules and
depressions present and
is smooth
- normal
- normal
2. Scalp
Color, appearance j - lighter than the exposed
skin, no dandruff
- normal
Tenderness - no tenderness - normal
3. Hair
Evenness of growth,
thickness or thinness
Texture and oiliness of
scalp
- Hair short, black, thick
and is evenly distributed
- hair is resilient and silky
- normal
- normal
4. Face
Facial features, symmetry
of facial movements
- facial features are
asymmetrical, he can
raise his eye brows at the
same time, puff his
cheeks, smile and frown
- normal
B. Eyes
1. Eyebrows
Hair distribution, .
alignment, skin quality and
movement
- hair evenly distributed;
skin intact; eyebrows
symmetrically aligned;
equal movement
- normal
2. Eyelashes
Evenness of distribution
and direction of curl
- equally distributed;
curve slightly outward
- normal
3. Eyelids
Surface characteristics,
position in relation to the
cornea, ability to blink, and
frequency of blinking
- skin intact; no
discharge; no
discoloration; lids close
symmetrically; 15
involuntary blinks per
minute; bilateral blinking;
when lids open, no visible
sclera above cornea; and
upper and lower borders
of cornea are slightly
covered
- normal
4. Conjunctiva
j Q Color, texture, and the
presence of lesions of
bulbar conjunctiva
j Q Color, texture, and the
presence of lesions of
palpebral conjunctiva
- transparent capillaries
no presence of lesions in
the bulbar conjunctiva
-shiny, smooth and pink
- normal
- normal
5. Sclera
Color and clarity jj Q - white in color; has
presence of capillaries
- normal
6. Cornea
Clarity and texture j Q - transparent; shiny and
smooth
- normal
7. Iris
Shape and color j Q - flat and round; black - normal
8. Pupils
Color, shape, and j Q
symmetry of size
Light reaction and j Q
accommodation
- black in color; equal in
size; round; smooth
border
- pupils constrict when
looking at near objects;
pupils dilate when looking
at far objects; pupils
converge when near
object is moved towards
the nose
- normal
- normal
9. Extraocular muscles
Alignment and j. Q
coordination
- both eyes coordinated;
move in unison with
parallel alignment
- normal
10. Visual Fields
Visual fields j Q
Snellen chart j Q
- when looking straight
ahead, the client can see
the object in the
periphery
- 20/20
- normal
- normal
C. Ears
1. Auricles
Color, symmetry of size j Q
and position
Q Texture, elasticity and
areas of tenderness
-same color as skin;
symmetrical; aligned with
the outer canthus of the
eye, about 10 degrees
vertical
- mobile, firm and not
tender, pinna recoils after
it is folded
- normal
- normal
2. External Ear Canal
Q Cerumen, skin lesion, pus
and blood
- contains hair follicle and
glands; (cerumen-grayish
tan in color)
- normal
3. Hearing Acuity Test
Clients response to j Q
normal voice tones
Weber test Q
Rinne test Q
- normal voice tones
audible, positive
- able to hear sounds in
both ears
- air conduction is greater
than bone conduction
(AC>BC)
- normal
- normal
- normal
D. Nose
Shape, size or color and Q
flaring or discharge from
the nerves
Nasal cavities for the Q
presence of redness,
swelling, growths, and
discharge
Nasal septum between Q
the nasal chambers
Patency of both the nasal . Q
cavities
Tenderness, masses, and Q
displacements of cone and
cartilage
- symmetric; no discharge
and flaring; uniform color
-mucosa pink; clear;
watery discharge; no
lesions
- nasal septum intact and
in midline
- air moves freely as the
client breathes through
the nares
- no tenderness; no
lesions
- normal
- normal
- normal
- normal
- normal
E. Sinuses
Tenderness Q - not tender - normal
F. Mouth
1. Lips
QColor and texture - uniform pink color; soft;
moist; smooth texture;
symmetry of contour;
ability to purse lips
- normal
2. Buccal Mucosa
QColor, moisture, texture
and presence of lesions
- uniform pink color; soft;
moist; glistening and
elastic texture
- normal
3. Teeth
Color, number and j Q
condition and presence
of dentures
-the total no. of teeth
is 32 on both upper
and lower.31 teeth at
the upper part and 30
at the lower part, no
dentures
- abnormal
4. Gums
Color and condition Q - pink gums; moist; firm
texture to gums
- normal
5. Tongue/Floor of the Mouth
Color and texture of the Q
mouth floor and frenulum
Position, color and texture, Q
movement and base of the
tongue
- smooth tongue base
with prominent veins
- smooth; moves freely;
no tenderness
- normal
- normal
Nodules, lumps or Q
excoriated areas
- smooth with no palpable
nodules
- normal
6. Palates and Uvula
Color, shape, texture and . Q
presence of bony
prominences
Position of the uvula and Q
mobility & palates
- light; pink hard palate,
more irregular texture
- positioned in midline of
soft palate
- normal
- normal
G. Neck and Lymph Nodes
1. Lymph Nodes
Locate/palpate/identify Q
lymph nodes and note for
tenderness
- not palpable - normal
2. Trachea
Q Placement - central placement in
midline of neck are equal
on both sides
- normal
3. Thyroid Gland
Q Symmetry and visible
masses
Smoothness and areas of j Q
enlargement, masses and
nodules
- not visible on inspection

- no tenderness and
masses
- normal
- normal
H. Thorax
1. Posterior Thorax
Shape, symmetry and
compare the diameter and
antero posterior thorax to
transverse diameter
j Q Spinal alignment
Q Temperature,
tenderness and masses
Q Vocal fremitus
Q Posterior thorax
- chest symmetrical
- spine vertically aligned
- within normal range; no
tenderness and masses
- bilateral symmetry of
vocal fremitus
- percussion notes
resonate, except over
scapula; vesicular and
bronchovesicular sounds
- normal
- normal
- normal
- normal
- normal
2. Anterior Thorax
Breathing patterns Q
Temperature, tenderness, Q
- quiet, rhythmic and
effortless respiration
- normal
masses
Respiratory excursion Q
Palpate vocal fremitus Q
Anterior thorax . Q
Trachea Q
Anterior thorax Q
- within normal range; no
tenderness and masses
- full symmetric excursion
- fremitus decreased over
heart and breast tissue
- percussion notes
resonate down to the
sixth rib at the level of
diaphragm but are flat
over areas of heavy
muscles, dull over heart,
liver, stomach
- bronchial and tubular
breath sounds
- bronchovesicular and
vesicular breath sounds
- normal
- normal
- normal
- normal
- normal
- normal
K. Jugular Veins
Q Jugular veins
Q Aortic, pulmonic, tricuspid,
apical and epigastric areas
Q Carotid artery
- veins not visible
- S1 & S2 usually heard
at all sites
- Symmetric pulse
volumes; full pulsations
- normal
- normal
- normal
L. Abdomen
Skin integrity Q
Abdominal contour Q
Enlarged liver or spleen Q
Symmetry of contour Q
Bowel sounds, peritoneal . Q
friction rubs
- unblemished skin;
uniform color
- round
- no evidence of
enlargement of liver &
spleen
- symmetric contour
- audible bowel sound
- normal
- normal
- normal
- normal
- normal
M. Musculoskeletal System
1. Muscles
Muscle size Q
- equal size on both sides
of body
- normal
Contractures (shortening) Q
of muscle and tendons
. Q Fasciculation and tremors
. Q Muscle tonicity
Muscle strength .j Q
- no contractures
- no fasciculation and
tremors
- normally firm
- equal strength on each
body side
- normal
- normal
- normal
- normal
2. Bones
Normal structure
and deformities
Edema or tenderness . Q
- no deformities
- no tenderness or
swelling
- normal
- normal
3. Joints
Swelling . Q
Tenderness, smoothness, . Q
swelling, crepitation, and
presence of nodule
- no swelling
- no tenderness, swelling
and presence of nodules;
smooth coordinate
movements
- normal
- normal
N. Assess Joint Range of
Motion
Upper extremities
Lower extremities . Q
- coordinated movements
- coordinated movements
- normal
- normal
(Reference: Weber & Kelley Health Assessment in Nursing, 3
rd
Edition)
Mrs. Ernestina Romero
Area To Be Assessed Actual Findings Analysis
I. General Survey
Height & weight in
relation to clients age,
lifestyle and behavior
Posture and gait, j Q
standing, sitting and
walking
Hygiene and grooming Q
Body and breath odor Q
Signs of distress, in Q
posture or facial
expression
Obvious signs of illness Q
Clients attitude . Q
Mood Q
Quantity of speech and Q
quality
Relevance and
organization of thoughts
- the clients weight and
height is above the
normal range
- nervousness, increased
irritability, muscle
weakness, extreme
fatigue
- clean, neat
- no body and breath odor
- no distress noted
- Healthy appearance
- cooperative
- appropriate to situation
- understandable;
moderate pace; exhibits
thought association
- logical sequence; makes
sense
-abnormal
- normal
- normal
- normal
- normal
- normal
- normal
- normal
- normal
- normal
II. Measurements
Height
Weight j Q
Vital signs Q
- Temperature

- Pulse Rate

- Respiratory Rate
- 5 4
- 67 kg
- 36.4
o
C
- 86 beats per minute
- 20 breaths per minute
- normal
- BMI is equal to
25.35 (obese I)
- normal
- normal
- normal
- Blood Pressure - 110/80 mmHg - normal
III. Integumentary
A. Skin
Color and uniformity
Presence of edema j Q
Skin moisture Q
Skin temperature Q
Skin turgor Q
-Skin is brown generally
uniform except in areas
exposed to the sun
- no presence of edema
- skin of the client is
moist and is not dry
- uniform; within normal
range
- when pinched, skin
springs back to its
previous state
- normal
- normal
- normal
- normal
- normal
B. Nails
Fingernail plate shape . Q
Fingernail and toenail Q
color
Palpate fingernail and Q
toenail texture
Inspect tissue surrounding
nails
Perform blanch test of
capillary refill
- convex curvature; angle
of name plate about 160
degrees
- highly vascular, pink
and clean
- smooth texture
-intact epidermis
- prompt return of pink
color within 2 sec.
- normal
- normal
- normal
- normal
- normal
IV. Head-to-toe examination
A. Head
1. Skull
Size, shape or
symmetry
Nodules, masses and j Q
depressions
- rounded; smooth skull
contour
- no masses, nodules and
depressions present and
is smooth
- normal
- normal
2. Scalp
Color, appearance j
Tenderness
- lighter than the
exposed skin, with
dandruff and presence
of nits
- no tenderness
- abnormal
- normal
3. Hair
Evenness of growth,
thickness or thinness
Texture and oiliness of
scalp
- Hair long, black, thick
and is evenly distributed
- her hair is oily
- normal
- abnormal
4. Face
Facial features, symmetry
of facial movements
- facial features are
asymmetrical, she can
raise her eye brows at the
same time, puff her
cheeks, smile and frown
- normal
B. Eyes
1. Eyebrows
Hair distribution, .
alignment, skin quality and
movement
- hair evenly distributed;
skin intact; eyebrows
symmetrically aligned;
equal movement
- normal
2. Eyelashes
Evenness of distribution
and direction of curl
- equally distributed;
curve slightly outward
- normal
3. Eyelids
Surface characteristics,
position in relation to the
cornea, ability to blink, and
frequency of blinking
- skin intact; no
discharge; no
discoloration; lids close
symmetrically; 16
involuntary blinks per
minute; bilateral blinking;
when lids open, no visible
sclera above cornea; and
upper and lower borders
of cornea are slightly
covered
- normal
4. Conjunctiva
j Q Color, texture, and the
presence of lesions of
bulbar conjunctiva
j Q Color, texture, and the
presence of lesions of
palpebral conjunctiva
- transparent capillaries
no presence of lesions in
the bulbar conjunctiva
-shiny, smooth and pink
- normal
- normal
5. Sclera
Color and clarity jj Q - white in color; has
presence of capillaries
- normal
6. Cornea
Clarity and texture j Q - transparent; shiny and
smooth
- normal
7. Iris
Shape and color j Q - flat and round; black - normal
8. Pupils
Color, shape, and j Q
symmetry of size
Light reaction and j Q
accommodation
- brown in color; equal in
size; round; smooth
border
- pupils constrict when
looking at near objects;
pupils dilate when looking
at far objects; pupils
converge when near
object is moved towards
the nose
- normal
- normal
9. Extraocular muscles
Alignment and j. Q
coordination
- both eyes coordinated;
move in unison with
parallel alignment
- normal
10. Visual Fields
Visual fields j Q
Snellen chart j Q
- when looking straight
ahead, the client can see
the object in the
periphery
- 20/20
- normal
- normal
C. Ears
1. Auricles
Color, symmetry of size j Q
and position
Q Texture, elasticity and
areas of tenderness
-same color as skin;
symmetrical; aligned with
the outer canthus of the
eye, about 10 degrees
vertical
- mobile, firm and not
tender, pinna recoils after
it is folded
- normal
- normal
2. External Ear Canal
Q Cerumen, skin lesion, pus
and blood
- contains hair follicle and
glands; (cerumen-grayish
tan in color)
- normal
3. Hearing Acuity Test
Clients response to j Q
normal voice tones
Weber test Q
Rinne test Q
- normal voice tones
audible, positive
- able to hear sounds in
both ears
- air conduction is greater
than bone conduction
(AC>BC)
- normal
- normal
- normal
D. Nose
Shape, size or color and Q - symmetric; no discharge - normal
flaring or discharge from
the nerves
Nasal cavities for the Q
presence of redness,
swelling, growths, and
discharge
Nasal septum between Q
the nasal chambers
Patency of both the nasal . Q
cavities
Tenderness, masses, and Q
displacements of cone and
cartilage
and flaring; uniform color
-mucosa pink; clear;
watery discharge; no
lesions
- nasal septum intact and
in midline
- air moves freely as the
client breathes through
the nares
- no tenderness; no
lesions
- normal
- normal
- normal
- normal
E. Sinuses
Tenderness Q - not tender - normal
F. Mouth
1. Lips
QColor and texture - uniform pink color;
choppy lips symmetry
of contour; ability to
purse lips
- abnormal
2. Buccal Mucosa
QColor, moisture, texture
and presence of lesions
- uniform pink color; soft;
moist; glistening and
elastic texture
- normal
3. Teeth
Color, number and j Q
condition and presence of
dentures
-the upper and lower
teeth are composed of 32
teeth. No cavities
- normal
4. Gums
Color and condition Q - pink gums; moist; firm
texture to gums
- normal
5. Tongue/Floor of the Mouth
Color and texture of the Q
mouth floor and frenulum
Position, color and texture, Q
movement and base of the
tongue
Nodules, lumps or Q
excoriated areas
- smooth tongue base
with prominent veins
- smooth; moves freely;
no tenderness
- smooth with no palpable
nodules
- normal
- normal
- normal
6. Palates and Uvula
Color, shape, texture and . Q
- light; pink hard palate,
more irregular texture
- normal
presence of bony
prominences
Position of the uvula and Q
mobility & palates
- positioned in midline of
soft palate
- normal
G. Neck and Lymph Nodes
1. Lymph Nodes
Locate/palpate/identify Q
lymph nodes and note for
tenderness
- not palpable - normal
2. Trachea
Q Placement - central placement in
midline of neck are equal
on both sides
- normal
3. Thyroid Gland
Q Symmetry and visible
masses
Smoothness and areas of j Q
enlargement, masses and
nodules
- not visible on inspection

- no tenderness and
masses
- normal
- normal
H. Thorax
1. Posterior Thorax
Shape, symmetry and
compare the diameter and
antero posterior thorax to
transverse diameter
j Q Spinal alignment
Q Temperature,
tenderness and masses
Q Vocal fremitus
Q Posterior thorax
- chest symmetrical
- spine vertically aligned
- within normal range; no
tenderness and masses
- bilateral symmetry of
vocal fremitus
- percussion notes
resonate, except over
scapula; vesicular and
bronchovesicular sounds
- normal
- normal
- normal
- normal
- normal
I. Jugular Veins
Q Jugular veins
Q Aortic, pulmonic, tricuspid,
apical and epigastric areas
Q Carotid artery
- veins not visible
- S1 & S2 usually heard
at all sites
- Symmetric pulse
volumes; full pulsations
- normal
- normal
- normal
J. Breast and Axillae
Q Size symmetry, and
contour or shape
Masses, and tenderness j Q
- breast even with the
chest wall
- no tenderness, masses,
nodules
- normal
- normal
K. Abdomen
Skin integrity Q
Abdominal contour Q
Enlarged liver or spleen Q
Symmetry of contour Q
Bowel sounds, peritoneal . Q
friction rubs
- unblemished skin;
uniform color
- round
- no evidence of
enlargement of liver &
spleen
- symmetric contour
- audible bowel sound
- normal
- normal
- normal
- normal
- normal
L. Musculoskeletal System
1. Muscles
Muscle size Q
Contractures (shortening) Q
of muscle and tendons
. Q Fasciculation and tremors
. Q Muscle tonicity
Muscle strength .j Q
- equal size on both sides
of body
- no contractures
- no fasciculation and
tremors
- normally firm
- equal strength on each
body side
- normal
- normal
- normal
- normal
- normal
2. Bones
Normal structure
and deformities
Edema or tenderness . Q
- no deformities
- no tenderness or
swelling
- normal
- normal
3. Joints
Swelling . Q
Tenderness, smoothness, . Q
swelling, crepitation, and
presence of nodule
- no swelling
- no tenderness, swelling
and presence of nodules;
smooth coordinate
movements
- normal
- normal
M. Assess Joint Range of
Motion
Upper extremities
Lower extremities . Q
- coordinated movements
- coordinated movements
- normal
- normal
(Reference: Weber & Kelley Health Assessment in Nursing, 3
rd
Edition)
Physical Assessment
Ronald Romero Jr.
Area To Be Assessed Actual Findings Analysis
I. General Survey
Height & weight in relation
to clients age, lifestyle and
behavior
Posture and gait, j Q
standing, sitting and
walking
Hygiene and grooming Q
Body and breath odor Q
Signs of distress, in Q
posture or facial
expression
Obvious signs of illness Q
Clients attitude . Q
Mood Q
Quantity of speech and Q
quality
Relevance and
organization of thoughts
- proportionate; varies
with lifestyle
- nervousness, increased
irritability, muscle
weakness, extreme
fatigue
- clean, neat
- no body and breath odor
- no distress noted
- Healthy appearance
- cooperative
- appropriate to situation
- understandable;
moderate pace; exhibits
thought association
- logical sequence; makes
sense
- normal
- normal
- normal
- normal
- normal
- normal
- normal
- normal
- normal
- normal
II. Measurements
Height
Weight j Q
Vital signs Q
- Temperature

- Pulse Rate

- Respiratory Rate
- 5 3
- 71 kg
- 36.0
o
C
- 80 beats per minute
- 20 breaths per minute
- normal
- BMI is 27.73
- normal
- normal
- normal
- Blood Pressure - 110/70 mmHg - normal
III. Integumentary
A. Skin
Color and uniformity
Presence of edema j Q
Skin moisture Q
Skin temperature Q
Skin turgor Q
- hes skin is brown
generally uniform except
in areas exposed to the
sun
- no edema
- skin of the client is
moist and is not dry
- uniform; within normal
range
- when pinched, skin
springs back to its
previous state
- normal
- normal
- normal
- normal
- normal
B. Nails
Fingernail plate shape . Q
Fingernail and toenail Q
color
Palpate fingernail and Q
toenail texture
Inspect tissue
surrounding nails
Perform blanch test of
capillary refill
- convex curvature; angle
of name plate about 160
degrees
- highly vascular and pink
- smooth texture, long
and dirty nails
-intact epidermis. Nails
is long and dirty
- prompt return of pink
color within 2 sec.
- normal
- normal
- normal
- normal
- normal
IV. Head-to-toe examination
A. Head
1. Skull
Size, shape or
symmetry
Nodules, masses and j Q
depressions
- rounded; smooth skull
contour
- no masses, nodules and
depressions present and
is smooth
- normal
- normal
2. Scalp
Color, appearance j
Tenderness
- lighter than the exposed
skin, no dandruff
- no tenderness
- normal
- normal
3. Hair
Evenness of growth, - Hair short, black, thick - normal
thickness or thinness
Texture and oiliness of
scalp
and is evenly distributed
- hair is resilient and silky - normal
4. Face
Facial features, symmetry
of facial movements
- facial features are
asymmetrical, he can
raise his eye brows at the
same time, puff his
cheeks, smile and frown
- normal
B. Eyes
1. Eyebrows
Hair distribution, .
alignment, skin quality and
movement
- hair evenly distributed;
skin intact; eyebrows
symmetrically aligned;
equal movement
- normal
2. Eyelashes
Evenness of distribution
and direction of curl
- equally distributed;
curve slightly outward
- normal
3. Eyelids
Surface characteristics,
position in relation to the
cornea, ability to blink, and
frequency of blinking
- skin intact; no
discharge; no
discoloration; lids close
symmetrically; 15
involuntary blinks per
minute; bilateral blinking;
when lids open, no visible
sclera above cornea; and
upper and lower borders
of cornea are slightly
covered
- normal
4. Conjunctiva
j Q Color, texture, and the
presence of lesions of
bulbar conjunctiva
j Q Color, texture, and the
presence of lesions of
palpebral conjunctiva
- transparent capillaries
no presence of lesions in
the bulbar conjunctiva
-shiny, smooth and pink
- normal
- normal
5. Sclera
Color and clarity jj Q - white in color; has
presence of capillaries
- normal
6. Cornea
Clarity and texture j Q - transparent; shiny and
smooth
- normal
7. Iris
Shape and color j Q - flat and round; black - normal
8. Pupils
Color, shape, and j Q - black in color; equal in - normal
symmetry of size
Light reaction and j Q
accommodation
size; round; smooth
border
- pupils constrict when
looking at near objects;
pupils dilate when looking
at far objects; pupils
converge when near
object is moved towards
the nose
- normal
9. Extraocular muscles
Alignment and j. Q
coordination
- both eyes coordinated;
move in unison with
parallel alignment
- normal
10. Visual Fields
Visual fields j Q
Snellen chart j Q
- when looking straight
ahead, the client can see
the object in the
periphery
- 20/20
- normal
- normal
C. Ears
1. Auricles
Color, symmetry of size j Q
and position
Q Texture, elasticity and
areas of tenderness
-same color as skin;
symmetrical; aligned with
the outer canthus of the
eye, about 10 degrees
vertical
- mobile, firm and not
tender, pinna recoils after
it is folded
- normal
- normal
2. External Ear Canal
Q Cerumen, skin lesion, pus
and blood
- contains hair follicle and
glands; (cerumen-grayish
tan in color)
- normal
3. Hearing Acuity Test
Clients response to j Q
normal voice tones
Weber test Q
Rinne test Q
- normal voice tones
audible, positive
- able to hear sounds in
both ears
- air conduction is greater
than bone conduction
(AC>BC)
- normal
- normal
- normal
D. Nose
Shape, size or color and Q
flaring or discharge from
the nerves
- symmetric; no discharge
and flaring; uniform color
- normal
Nasal cavities for the Q
presence of redness,
swelling, growths, and
discharge
Nasal septum between Q
the nasal chambers
Patency of both the nasal . Q
cavities
Tenderness, masses, and Q
displacements of cone and
cartilage
-mucosa pink; clear;
watery discharge; no
lesions
- nasal septum intact and
in midline
- air moves freely as the
client breathes through
the nares
- no tenderness; no
lesions
- normal
- normal
- normal
- normal
E. Sinuses
Tenderness Q - not tender - normal
F. Mouth
1. Lips
QColor and texture - uniform pink color; soft;
moist; smooth texture;
symmetry of contour;
ability to purse lips
- normal
2. Buccal Mucosa
QColor, moisture, texture
and presence of lesions
- uniform pink color; soft;
moist; glistening and
elastic texture
- normal
3. Teeth
Color, number and j Q
condition and presence of
dentures
-the upper and lower
teeth are composed of 28
teeth. No cavities
- normal
4. Gums
Color and condition Q - pink gums; moist; firm
texture to gums
- normal
5. Tongue/Floor of the Mouth
Color and texture of the Q
mouth floor and frenulum
Position, color and texture, Q
movement and base of the
tongue
Nodules, lumps or Q
excoriated areas
- smooth tongue base
with prominent veins
- smooth; moves freely;
no tenderness
- smooth with no palpable
nodules
- normal
- normal
- normal
6. Palates and Uvula
Color, shape, texture and . Q
presence of bony
- light; pink hard palate,
more irregular texture
- normal
prominences
Position of the uvula and Q
mobility & palates
- positioned in midline of
soft palate
- normal
G. Neck and Lymph Nodes
1. Lymph Nodes
Locate/palpate/identify Q
lymph nodes and note for
tenderness
- not palpable - normal
2. Trachea
Q Placement - central placement in
midline of neck are equal
on both sides
- normal
3. Thyroid Gland
Q Symmetry and visible
masses
Smoothness and areas of j Q
enlargement, masses and
nodules
- not visible on inspection

- no tenderness and
masses
- normal
- normal
H. Thorax
1. Posterior Thorax
Shape, symmetry and
compare the diameter and
antero posterior thorax to
transverse diameter
j Q Spinal alignment
Q Temperature,
tenderness and masses
Q Vocal fremitus
Q Posterior thorax
- chest symmetrical
- spine vertically aligned
- within normal range; no
tenderness and masses
- bilateral symmetry of
vocal fremitus
- percussion notes
resonate, except over
scapula; vesicular and
bronchovesicular sounds
- normal
- normal
- normal
- normal
- normal
2. Anterior Thorax
Breathing patterns Q
Temperature, tenderness, Q
masses
Respiratory excursion Q
Palpate vocal fremitus Q
- quiet, rhythmic and
effortless respiration
- within normal range; no
tenderness and masses
- full symmetric excursion
- fremitus decreased over
heart and breast tissue
- normal
- normal
- normal
- normal
Anterior thorax . Q
Trachea Q
Anterior thorax Q
- percussion notes
resonate down to the
sixth rib at the level of
diaphragm but are flat
over areas of heavy
muscles, dull over heart,
liver, stomach
- bronchial and tubular
breath sounds
- bronchovesicular and
vesicular breath sounds
- normal
- normal
- normal
K. Jugular Veins
Q Jugular veins
Q Aortic, pulmonic, tricuspid,
apical and epigastric areas
Q Carotid artery
- veins not visible
- S1 & S2 usually heard
at all sites
- Symmetric pulse
volumes; full pulsations
- normal
- normal
- normal
L. Abdomen
Skin integrity Q
Abdominal contour Q
Enlarged liver or spleen Q
Symmetry of contour Q
Bowel sounds, peritoneal . Q
friction rubs
- unblemished skin;
uniform color
- round
- no evidence of
enlargement of liver &
spleen
- symmetric contour
- audible bowel sound
- normal
- normal
- normal
- normal
- normal
M. Musculoskeletal System
1. Muscles
Muscle size Q
Contractures (shortening) Q
of muscle and tendons
. Q Fasciculation and tremors
. Q Muscle tonicity
- equal size on both sides
of body
- no contractures
- no fasciculation and
tremors
- normal
- normal
- normal
Muscle strength .j Q
- normally firm
- equal strength on each
body side
- normal
- normal
2. Bones
Normal structure
and deformities
Edema or tenderness . Q
- no deformities
- no tenderness or
swelling
- normal
- normal
3. Joints
Swelling . Q
Tenderness, smoothness, . Q
swelling, crepitation, and
presence of nodule
- no swelling
- no tenderness, swelling
and presence of nodules;
smooth coordinate
movements
- normal
- normal
N. Assess Joint Range of
Motion
Upper extremities
Lower extremities . Q
- coordinated movements
- coordinated movements
- normal
- normal
(Reference: Weber & Kelley Health Assessment in Nursing, 3
rd
Edition)