PHYSICAL EXAMINATION

VITAL NORMAL FINDINGS ASSESSMENT

SIGNS
BP <120 / <80
PR 60-100
RR 16-20
Temp 36.5-37.5

AREA TECHNIQUE NORMS FINDINGS

body built, height and
weight in relation to clients
age
Posture while sitting
Inspection Proportionate, varies with lifestyle Small body built, height a
weight was not taken
Inspection Relaxed, erect, posture, coordinated The patient cant sit
movement

.body and breath odor Inspection (talking No body odor or minor odor relative No body odor and breath
with the patient) to work, or exercise; no breath odor
signs of distress in posture Inspection No distress noted The patient looks weak
or facial expression

signs of health and illness Inspection Healthy appearance The client appears weak

clients attitude
clients affect/ mood;
appropriateness of clients
responses
quantity of speech, quality
and organization
Inspection Cooperative, able to follow The patient was cooperati
instructions
Inspection Appropriate to the situation The patient answers quest
coherently without assista
Inspection Understandable, moderate pace, clear Understandable, moderate
tone, exhibits thought association clear

relevance and organization Inspection Logical sequence, makes sense, has Makes sense and has sens
of thoughts sense of reality reality

I. SKIN
AREA TECHNIQUE NORMS FINDINGS

skin color Inspection Varies from light to deep brown; Uniform skin color
from yellow overtones to olive
. uniformity of skin Inspection Generally uniform except in Uniform in skin color
color areas exposed to the sun; areas
lighter pigmentation (palms, lips,
nailbeds) in dark skinned
assess edema Inspection No edema No edema
skin lesions Inspection Freckles, some birthmarks, no No lesions
 abrasions or other lesions
skin moisture Inspection Moisture in skin folds and Skin is dry
axillae

II. HAIR
AREA TECHNIQUE NORMS FINDINGS

evenness of the growth, Inspection Evenly distributed and covers Evenly distributed and co
thickness or thinness of the whole scalp the whole scalp
hair
texture and oiliness over Inspection Silky, resilient hair Silky resilient hair
the scalp
presence of infection Inspection No infection and infestation No Infection and Infestati
and infestation
amount of body hair Inspection Variable Variable. No abnormal
hairiness

III. NAILS
AREA TECHNIQUE NORMS FINDINGS

fingernail plate shape Inspection Convex, curvature; angle of nail Convex

plate
fingernail and toenail Inspection Smooth texture Smooth texture
texture
fingernail and toenail Inspection Highly vascular and pink in light Pale in color
bed color skinned clients; dark skinned
clients may have brown or black
pigmentation in longitudinal
streaks
tissues surrounding nails Inspection Intact epidermis Intact epidermis
blanch test of capillary Inspection, Promptly return of pink or usual Less than 4 seconds
refill palpation color (generally less than 4
seconds)

IV. HEAD
AREA TECHNIQUE NORMS FINDINGS

size, shape and Inspection Round (normocephalic with The clients head is round
symmetry of the skull symmetrical frontal, parietal, and normocephalic with
occipital prominences) smooth symmetrical frontal, parie
skull contour and occipital prominences
presence of nodules, Inspection and Smooth uniform consistence; Smooth, absence of nodul
masses and depressions palpation absence of nodules, or masses masses
presence of edema and Inspection and No edema and hollowness No edema or hollowness
hollowness in the eye palpation

V. EYES
AREA TECHNIQUE NORMS FINDINGS
color, texture and Inspection Pinkish in color with presence of Pale in color
presence of lesions in small capillaries; moist, no
the palpebral foreign bodies
conjunctiva
sclera: color and clarity Inspection White in color; clear, no Yellowish in color
yellowish discoloration, some
capillaries may be visible
iris: shape and color Inspection Anterior chamber is transparent; Anterior chamber is
no noted visible materials, color transparent; no noted visib
depends on the persons race materials, black in color
cornea: clarity and Inspection No irregularities on the surface, No irregularities on the
texture looks smooth, clear or surface; clear
transparent
pupils: color, shape and Inspection Color depends on persons race; Black, equal in size; equa
symmetry of size size ranges from 3- 7 mm; and round; 4mm in size
are equal in size; equally round
light reaction and Inspection Constrict briskly/ sluggish Constricts briskly
accommodation
visual acuity: near vision Inspection Can detect light and dark Can detect light and dark
lacrimal gland: Palpation No edema or tenderness over No edema or tenderness
palpability and lacrimal gland
tenderness of lacrimal
gland
extraocular muscles eye Inspection Both eyes coordinated, moved in Both eyes are coordinated
alignment unison with parallel alignment movement; parallel alignm
visual fields: peripheral Inspection When looking straight ahead the Patient sees objects in
visual fields client can see objects in the periphery
periphery

VI. EARS
AREA TECHNIQUE NORMS FINDINGS

auricles: color, Inspection Color same as facial skin; Aligned with outer canthu
symmetry of size and symmetric; auricle aligned with the eye, same color as fac
position outer canthus of the eye; about skin, both auricle are
10 degrees from vertical symmetrical
texture, elasticity and Inspection and Mobile, firm and not tender, Mobile firm and not tende
areas of tenderness palpation pinna recoils after it is folded pinna recoils after folded
hearing acuity test: Inspection/ rinne Normal voice tones audible The client can hear whisp
client response to test voices
normal voice tones

VII. NOSE
AREAS TECHNIQUES NORMS FINDINGS

any deviation in shape, Inspection Symmetric and straight; no Symmetric and straight; n
size or color and flaring discharge; uniform in color discharge; uniform in colo
or discharge from nares not flaring and has no
 discharge
nasal septum (between Inspection Nasal septum intact and in Nasal septum is in midlin
the nasal chambers) midline intact
patency of both nasal Inspection Air moves freely as the client Air moves freely in both n
cavities breathes through the nares
tenderness, masses and Palpation Not tender; no lesions No lesions, not tender
displacement of the
bones and cartilage
sinuses: identification of Palpation not tender Not tender
the sinuses for
tenderness

VIII. MOUTH
AREA TECHNIQUE NORMS FINDINGS

lips: symmetry and Inspection Uniform pink color, soft, moist, Pale in Color
contour, control and smooth texture, symmetry of
texture contour, ability to purse lips
buccal mucosa Inspection Pink color, moist, smooth, soft Pale in color
glistening and classic texture

gums: color and Inspection Pink gums; no retraction Pale in color

condition

tongue/ floor of the Inspection Pink color; moist, slightly rough; Pink color; moist, slightly
mouth: color and texture thin; whitish coating; moves rough; thin; whitish coatin
of the mouth and freely; no tenderness moves freely; no tenderne
frenulum
position, color, and Inspection Central position, pink in color, Pink in color; smooth ton
texture, movement and smooth tongue, base with base with prominent veins
base of the tongue prominent veins
any nodules, lymph Inspection Smooth with no palpable Smooth with no palpable
nodes or exocrated areas nodules lumps or excoriated nodules
areas
plates and uvula: color Inspection and Light pink, smooth, soft palate, Soft palate, lighter pink h
shape texture and palpation lighter, pink hard palate, move palate
presence of bony irregular texture
prominences
position of the uvula and Inspection Positioned in midline of soft Positioned in midline
mobility (while examing palates
the palates)
oropharynx and tonsil: Inspection Pink, smooth posterior wall Smooth posterior wall
color and texture
size, color and discharge Inspection Pink and smooth posterior wall Smooth posterior wall
of tonsils
gag reflex Inspection Present Present
 IX. THORAX
AREA
anterior thorax:
breathing patterns
temperature, tenderness
and masses
anterior thorax
auscultation
posterior thorax: shape,
symmetry and
comparison of
anteroposterior thorax to
transverse diameter
spinal alignment
temperature, tenderness
and masses
posterior thorax
auscultation
X. ABDOMEN
AREA
skin integrity
abdominal contour
enlargement of liver or
spleen
symmetry of contour
abdominal movements
associated with
respiration, peristalsis or
aortic pulsations
vascular pattern
XI. MUSCULOSKELETAL SYSTEM
TECHNIQUES NORMS FINDINGS
Inspection Quiet, rhythmic, and effortless Effortless respiration
respiration
Palpation Skin intact, uniform temperature, Uniform temperature; no
chest wall intact; no tenderness; tenderness or masses
no masses
Auscultation Bronchovesicular and vesicular Bronchovesicular
breath sounds
Inspection Anteroposterior to transverse Anteroposterior to transve
diameter in ration 1;2 chest diameter; symmetric
symmetric
Inspection and Spine vertically aligned Spine aligned vertically
palpation
Palpation Skin intact, uniform No tenderness or masses;
temperature; chest wall intact, no intact
tenderness no masses
Auscultation Bronchovesicular and vesicular Bronchovesicular
breath sounds
TECHNIQUE NORMS FINDINGS
Inspection Unblemished skin, uniform color Uniform color, unblemish
skin
Inspection Flat, rounded (convex), scaphoid Presence of abdominal ma
(concave)
palpation No evidence of enlargement of No evidence of enlargeme
liver or spleen spleen or liver
Inspection Symmetric contour Symmetric contour
Auscultation Symmetric movements caused Symmetric movement
by respiration; visible peristalsis
in very lean people; aortic
pulsations in thin persons at
epigastric area
Inspection No visible vascular patter No visible vascular patter
 AREAS TECHNIQUE NORMS FINDINGS

muscle size and Inspection Proportionte to body; even in Proportionate to body, equ
comparison on the other both sides strength on both sides
side
fasciculation and Inspection No fasciculation and tremors No fasciculation and trem
tremors in muscle
muscle tonicity Inspection Even and firm in muscle tone Even and firm in muscle t
muscle strength Inspection Has equal strength on both sides Has equal strengths

XII. JOINTS
AREA TECHNIQUE NORMS FINDINGS

joint swelling Inspection and No swelling; no warmth, no No swelling, redness, pain

palpation redness, no pain, no crepitus crepitus
Extremities Inspection and No swelling, no warmth, no No swelling, warmth or
palpation redness, no pain redness