Download as doc, pdf, or txt
Download as doc, pdf, or txt
You are on page 1of 3

PHYSICAL ASSESSMENT

Date assessed: September 2011 General assessment: Initial vital signs: T= , RR=, BP= , PR=

Area Assessed Skin Color Lips, nail beds, soles and palms Moisture Temperature Texture

Technique Inspection

Inspection

Inspection/ Palpation Palpation Palpation

Normal Findings Actual Findings Light brown, tanned skin (vary according to race) Lighter colored palms, soles, lips and nail beds Skin normally dry Normally warm Smooth, soft and flexible palms and soles (thicker) Skin snaps back immediately

Evaluation

Turgor

Palpation

Skin appendages a. Nails Nail beds Nail base Capillary refill

Inspection Inspection Inspection Inspection/ Palpation

Transparent, smooth and convex Pinkish Firm White color of nail bed under pressure should return to pink within 2-3 seconds Evenly distributed Black Smooth Parallel to each other PERRLA- Pupils equally round react to light and accommodation Symmetrical in size, extension, hair texture and movement Distributed evenly and curved outward Transparent with light pink color Color is white Transparent, shiny Black, constrict briskly Clearly visible Free of lesions, discharge of inflammation Canal walls pink Client normally hears words when whispered Smooth, symmetric with same color as the face Close to midline, thicker anteriorly than posteriorly Pink, moist symmetric Slightly pink color, moist and tightly fit against each tooth

b. Hair Distribution Color Texture c. Eyes Eyes Visual Acuity

Inspection Inspection Inspection/ Palpation Inspection Inspection (penlight) Inspection

Eyebrows

Eyelashes Conjunctiva Sclera Cornea Pupils Iris Ears Ear canal opening Hearing Acuity Nose Nasal septum

Inspection Inspection Inspection Inspection Inspection Inspection Inspection

Inspection Inspection Inspection

Mouth and Pharynx Inspection Lips Gums Inspection

You might also like