Physical Assessment
Body Part Skin
Normal Findings
Inspection
Palpation
Actual Findings
Interpretation & Analysis Skin is uniform Skin is brown Skin may be whit whitis ish h pink pink or dry dry beca becaus usee of brown color insufficient fluid intake No Bleeding Nor Norm mal fluid uid area of No bleeding No No increased area of intake should be 2500 ml per day vasc vascul ular arit ity y and and increased ecchymosis vascularity and No skin lesions ecchymosis pre prese sent nt exce except pt No lesions for freckles, birthma hmarks or moles which may (pp.283-304, be flat or Health elevated Asses ssesssment ment & Skin is dry Physical with a minimum Exam Examin inat atio ion n – of perspiration. Skin is dry Zator Estes) Warm and equal bilaterall bilaterally. y. Hands and skin Warm and equal slig slight htly ly cool cooler er bilaterally than than the the rest rest of the body Skin Skin surf surface acess non-tender Texture: Smoo Smooth th,, even even and and firm firm exce except pt wher here there is signi signifi fica cant nt hair hair growth Skin sprung back Skin turgor: when When When rele releas ased, ed, rapidly should should return return to pinched origin original al contou contour r rapidly edema Edema not No present present
Scalp and Hair
Inspection
Palpation
Nails
Inspection
Dark
black to Hair appears pale blonde; may black turn gray or white; may be chemically changed hair Even distribution Terminal found in the of hair eyebrows,, eyelashes, and scalp, and in axilla and pubic areas after puberty. No infestation or No signs of lesions infestation or lesions. Seborrhea/ dandruff may be present Hair is thick and Hair may feel shiny thin, straight, coarse, thick or curly. Shiny and resilient Have a pink- Brown-cast nails cast in lightskinned and brown in darkskinned. Capillary refill of Capillary refill 1.5 seconds present (should return to normal 2-3 sec) Surface smooth is and slightly Surface smooth, and rounded slightly rounded or flat. Curved nails are normal. Uniform nail No splinters or thickness brittle edges throughout; no splintering or brittle edges.
No significant findings
(pp.305-308, Health Assessment Physical Examination Zator Estes)
& –
No significant findings
(pp.308-311, Health Assessment Physical Examination Zator Estes)
& –
Angle
Palpation Eyes
Inspection
Ears
Inspection
Palpation
Nose
Inspection
approx.
Angle
approx.
160° 160° Firm nail base Firm nail base significant Symmetrical Eyes No with no symmetrical findings drooping, infection, tumors or other abnormalities Visual Acuity: Visual acuity of 20/20 20/20 Sclera: Sclera appears White in light- white (pp.350-362, skinned w/o Health exudates, lesions Assessment & or foreign Physical bodies. In darkExamination – skinned, may Zator Estes) have brown patches Pupils: equally round, reactive to Pupils equally light and round, reactive to accommodation; light and 2-6 mm accommodation; No tearing, approx. 4 mm swelling or No tearing, discharge swelling or descharge Match flesh Same color as No significant color of the rest face findings of the skin. Central Central position position. Proportional Proportional. No redness,(pp.386-389, No redness, swelling, or Health Assessment & lesions, swelling, tenderness Physical tenderness not No pain assessed Examination – Should Zator Estes) complain of pain or tenderness Symmetrical,
midline face.
of
Symmetrical
the in midline
and
No significant findings
Without
Palpation
Mouth
Inspection
No swelling, swelling, bleeding, lesions, (pp.394-397, Health bleeding, lesions, or masses Assessment or masses. Physical Each nostril Patent nostrils Examination patent. No pain or No pain or Zator Estes) discomfort during palpation Breath
Neck
Inspection
Palpation
Chest
Inspection
–
discomfort noted
smells
fresh. Lips and membranes pink and moist with no lesions or inflammation. Tongue is midline. Pink, moist, rough without lesions. Symmetrical; moves freely. have Gums pale-red strippled surface. No swelling or bleeding.
&
No significant findings Lips
and membranes are moist, dark flesh colored; no lesions or inflammation Tongue in midline and moves (pp.398-405, Health freely Assessment Physical Examination Zator Estes)
& –
No swelling or bleeding
Symmetrical
Symmetrical
with head in central position. Able to move head without discomfort or noticeable limits Muscles should be symmetrical without palpable masses or spasm Without lesions; skin intact. Quiet,
with head central position to move Able Health head w/o (p.331, Assessment & discomfort Physical No palpableExamination – Zator Estes) masses
Without Quiet
and
No significant in findings
lesions rhythmic effortless
No significant findings
Palpation
Auscultation
Abdomen
Inspection
Auscultation
Percussion
Palpation
Suprapubic Area
rhythmic and breathing effortless breathing No masses or No pulsations, tenderness (pp.451-469, masses, thoracic Health tenderness Bronchovesicula Assessment present. r breath sounds Physical Normal lung Examination tissue produces Zator Estes) resonant sound, diaphragm has dull sounds. Bronchial, bronchovesicular or vesicular breath sounds Abdominal
Abdominal
contour flat or contour rounded. rounded. Symmetrical. Symmetrical. Uniform in Uniform in color or color. pigmentation. No abdominal scars. No striae No scars; striae Intermittent gurgling sounds Gurgling sounds in abdomen throughout abdominal quadrants. Tympany, No friction rubs/ predominant audible bruits sound heard No organ enlargement palpable, or any masses, bulges, or swelling
Inspection
Without
Without
Palpation
lesions Urinary bladder
Urinary
Lesions
& –
No significant findings
(pp.552-562, Health Assessment Physical Examination Zator Estes)
& –
No significant findings
bladder (p.638, notnot palpable
palpable and not tender Genitalia
Inspection Palpation
Rectum
Inspection
Palpation
Upper Extremities
Inspection
Lower Extremities
Inspection Palpation
Fundamentals of Nursing Kozier) Pubic hair Pubic hair evenly No significant distributed in distributed findings triangular form. More coarse (pp.746-753, than scalp hair. Health No nits or lice No nits or lice. & lesions or Assessment Penis skin free No Physical of lesions and inflammation Examination – inflammation. Zator Estes)
No lesions, In midline redness Redundant mass Sphincter noted, reddish intact Non-tender
A
Without
Without
lesions, scars No edema
scars No edema
dilated vein seen as swollen, reddish-blue mass signifies hemorrhoids (pp. 55-56, Medical Surgical Nursing, Harkness and Dincher) Without Without lesions, No significant lesions, scars or scars or findings inflammation inflammation (p.579, Fundamentals of Nursing, Kozier) lesions,
No significant findings (p.579, Fundamentals of Nursing, Kozier)