UNIVERSITY OF CEBU - BANILAD

College of Nursing
Cebu City

ADULT PHYSICAL ASSESSMENT FINDINGS

Date of Birth : ____________________________ Place of Birth : _______________________________

STEPS FINDINGS
SKIN
1. Odor
2. Color
3. Lesions
4. Texture
5. Temperature
6. Thickness
7. Mobility
8. Turgor
9. Edema
HEAD AND FACE
1. Inspect and palpate the head for size,
shape, and configuration
2. Note consistency, distribution, and color
of hair
3. Observe face of symmetry, facial features,
expressions, and skin condition.
4. Check function of CN VII : have the client
smile, from, show teeth, blow out cheeks,
raise eyebrows, and tightly close eyes.
5. Evaluate function of CN V : using the
sharp and dull sides of a paper clip, rest
sensation of forehead, cheeks and chin.
6. Palpate the temporal arteries for elasticity
and tenderness.
7. As the client opens and close her mouth,
palpate the temporomandibular joint for
tenderness, swelling, and crepitation.
EYES
1. Determine Function :
Test vision using Snellen Chart
Test visual Fields
Assess corneal light reflex
Perform cover and position tests
2. Inspection external Eye:
Position and alignment of the eyeball in
the eye socket
Bulbar conjunctiva
Lacrimal apparatus
Cornea, Lens, Iris, and Pupil
3. Test pupillary reaction to light
4. Test accommodation of pupils
5.
Retinal background for color and lesion
Fovea centralis (sharpest area of vision)
and macula
Anterior chamber for clarity
EARS
1. Inspect the auricle, tragus, and lobule for
shape, position, lesions discolorations, and
discharge.
2. Palpate the auricle and mastoid process
for tenderness.
3. Use the otoscope to inspect :
External auditory canal for color and
cerumen (ear wax)
Tympanic membrane for color, shape,
consistency, and landmarks.
4. Test hearing :
Whisper Test
Weber’s Test
Rinnes’ Test
NOSE AND SINUSES
1. Inspect the external nose for color, shape,
and consistency. Palpate the external nose
of tenderness
2. Check patency of airflow through nostrils
(occlude one nostril at a time and ask
client of sniff)
3. Test CN I : ask the client to close his eyes
and smell for soap, coffee, or vanilla
(occlude each nostril).
4. Use an otoscope with a short while tip to
inspect internal nose for color and
integrity of nasal mucosa, nasal septum,
and inferior and middle turbinate.
5. Transilluminate maxillary sinuses with a
penlight to check for fluid or pus.
MOUTH AND THROAT
1. Inspect lips for consistency, color lesions.
2. Inspect the teeth for number and
conditions.
3. Check the gums and buccal mucosa for
color, consistency, lesions.
4. Inspect the hard (anterior) and soft
(posterior) palates for color and integrity.
5. Ask the client to say “ahh” and observe
the rise of the vulva.
6. Test CN X: touch the soft palate to assess
for gag reflex.
7. Inspect the tonsils for color, size, lesions,
and exudates.
8. Inspect the tongue for color, moisture,
size, and texture.
9. Inspect the ventral surface of tongue for
frenulum, color, lesions, and Wharton’s
ducts.
10. Palpate the tongue for lesions.
11. Test CN IX and CN X : assess tongue
strength by asking client to press tongue
against tongue blade.
12. Assess CN VII and CN IX : have the
patient close her eyes. Check taste by
placing salt, sugar, and lemon on tongue.
NECK
1. Inspect neck for appearance of lesions,
masses, swelling and symmetry.
2. Test range of motion (ROM).
3. Palpate the pre-auricular, occipital,
tonsillar, submandibular, and submental
nodes.
4. Palpate the trachea.
5. Palpate the thyroid gland for size,
irregularity, or masses.
6. Auscultate and enlarge thyroid for bruits.
7. Palpate carotid arteries and auscultate for
bruits.
 ARMS, HANDS, AND FINGERS
1. Inspect the upper extremities for overall
skin coloration, texture, moisture, masses,
and lesions.
2. Test function of CN XI – spinal by
shoulder shrug and turning head against
resistance.
3. Palpitate shoulders and arm for
tenderness, swelling and temperature.
4. Assess epitrochlear lymph nodes.
5. Assess ROM of the elbows/
6. Palpate the brachial pulse.
7. Palpate ulnar and radial pulse.
8. Test ROM of the wrist.
9. Inspect palms of hands and palpate the
temperature.
10. Test ROM of the wrist.
11. Use a reflex hammer to test biceps,
triceps, and brachioradial reflexes.
12. Ask the patient to close her eyes; test
sensation.

Remarks :

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Student’s Signature over Printed Name Year and Section

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Clinical Instructor Date

CRITERIA:

 Accuracy (50) : ____________________________

Total (100) : ____________________________