PHYSICAL ASSESSMENT

BODY PART NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION AND ANALYSIS

SKIN
 Inspect general Inspection reveals evenly NORMAL
skin coloration colored skin tones without According to (Health Assessment in
unusual or prominent Nursing, Janet R. Weber and Jane H.
discolorations. Kelley, fifth edition) Inspection reveals
evenly colored skin tones without unusual
or prominent discolorations.
 Note any odors No odor of perspirations, NORMAL
emanating from depending on activity. According to (Health Assessment in
the skin Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) No odor of
perspirations, depending on activity.
 Inspect the color Common variations NORMAL
variations include suntanned areas, According to (Health Assessment in
freckles, or white patches Nursing, Janet R. Weber and Jane H.
known as vitiligo. Dark Kelley, fifth edition) Common variations
skinned clients have include suntanned areas, freckles, or
lighter- colored palms, white patches known as vitiligo. Dark
soles, nail beds, and lips. skinned clients have lighter- colored
Freckle-like or dark streaks palms, soles, nail beds, and lips. Freckle-
of pigmentation are also like or dark streaks of pigmentation are
common in the sclera and also common in the sclera and nail beds of
nail beds of dark-skinned dark-skinned clients.
clients.
 Check skin integrity Skin is intact, and there NORMAL
are no reddened areas According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Skin is intact, and
there are no reddened areas.
 Inspect the lesions Skin is smooth, without NORMAL
If you observe a lesions. Stretch According to (Health Assessment in
lesion: marks(striae), healed Nursing, Janet R. Weber and Jane H.
-Note color, shape, scars, freckles, moles or Kelley, fifth edition) Skin is smooth,
and size of lesion. birthmarks are common without lesions. Stretch marks (striae),
For very small findings. Freckles or moles healed scars, freckles, moles or birthmarks
lesions, use a may be scattered over the are common findings. Freckles or moles
magnifying glass skin in no particular may be scattered over the skin in no
note this pattern. particular pattern.
characteristics.
-Note its locations,
distribution and
configuration.
-Measure the
lesions with a
centimeter ruler.
 Palpate the skin to Skin is smooth and even. NORMAL
assess texture According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Skin is smooth and
even.
 Palpate to assess Skin is normally thin but NORMAL
thickness calluses(rough, thick According to (Health Assessment in
sections of epidermis) are Nursing, Janet R. Weber and Jane H.
common on areas of the Kelley, fifth edition) Skin is normally thin
body that are exposed to but calluses (rough, thick sections of
 constant pressure.
 Palpate to assess Skin surfaces vary from
moisture moist to dry depending on
the area assessed.
 Palpate to assess Skin is normally a warm
temperature temperature.
 Palpate to assess Palpate to assess mobility
mobility and turgor and turgor
 Palpate to detect Skin rebounds and does
edema not remain indented when
pressure is released.
HAIR on the head
 Inspect the scalp Nature hair color, as
and hair for opposed to chemically
general color and colored hair, varies among
condition clients from pale blond to
black to gray or white. The
color is determined by the
amount of melanin
present.
Scalp is skin and dry.
Sparse dandruff may be
visible. Hair is smooth and
firm, somewhat elastic.
 Inspect amount Varying amount of
and distribution of terminal hair cover the
scalp, body, axillae scalp, axillary, body, and
and pubic hair pubic areas according to
normal gender
distribution. Fine vellus
hair covers the entire body
except for the soles,
palms, lips, and nipples.
Normal male pattern
balding is symmetric.
NAIL
 Inspect nail Nails are clean and
grooming and manicured.
cleanliness
epidermis) are common on areas of the
body that are exposed to constant
pressure.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Skin surfaces vary
from moist to dry depending on the area
assessed.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Skin is normally a
warm
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The skin is mobile,
with elasticity and returns to original
shape quickly.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Skin rebounds and
does not remain indented when pressure
is released.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Nature hair color, as
opposed to chemically colored hair, varies
among clients from pale blond to black to
gray or white. The color is determined by
the amount of melanin present.
Scalp is skin and dry. Sparse dandruff may
be visible. Hair is smooth and firm,
somewhat elastic.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Varying amount of
terminal hair cover the scalp, axillary,
body, and pubic areas according to normal
gender distribution. Fine vellus hair covers
the entire body except for the soles,
palms, lips, and nipples. Normal male
pattern balding is symmetric.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Nails are clean and
manicured.
  Inspect nail color Pink tones should be seen.
and markings and Some longitudinal ridging
markings is normal.
Dark-skinned clients may
be have freckles or
pigmented streaks in the
nails.
 Inspect shape of There is normally 160-
the nails degree angle between the
nail base and the skin.
 Palpate nail to Nails are hard and
assess texture basically immobile
 Palpate to assess Nails are smooth and firm;
texture and nail palate should be firmly
consistency, noting attached to nail bed.
whether nail plate
is attached to nail Pink tones returns
bed. immediately to blanched
nail beds when pressure is
released
HEAD AND FACE
 Inspect the head Head size and shape vary,
especially in accord with
ethnicity. Usually the head
is symmetric, round, erect
and in midline and
approximately related to
the body size. No lesions
are visible.
 Inspect for Head should be held still
involuntary and upright.
movement
 Palpate the head The head is normally hard
and smooth, without
lesions.
 Inspect the face The face is symmetric with
round, oval, elongated or
square appearance. No
abnormal movements
noted.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Pink tones should be
seen. Some longitudinal ridging is normal.
Dark-skinned clients may be have freckles
or pigmented streaks in the nails.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) There is normally 160-
degree angle between the nail base and
the skin.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Nails are hard and
basically immobile
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Nails are smooth and
firm; nail palate should be firmly attached
to nail bed.
Pink tones returns immediately to
blanched nail beds when pressure is
released.
Circled shaped head and NORMAL
no lesions are visible. According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Head size and shape
vary, especially in accord with ethnicity.
Usually the head is symmetric, round,
erect and in midline and approximately
related to the body size. No lesions are
visible.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Head should be held
still and upright.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The head is normally
hard and smooth, without lesions.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The face is symmetric
with round, oval, elongated or square
appearance. No abnormal movements
noted.
  Palpate the The temporal artery is
temporal artery elastic and not tender
 Palpate the Normally, there is no
temporomandibula swelling, tenderness, or
r joint crepitation with
NECK
 Inspect the neck Neck is symmetric, with
head centered and
without bulging masses.
 Inspect movement The thyroid cartilage,
of the neck cricoid cartilage move
structure upward symmetrically as
the client swallows.
 Inspect the cervical C7 is usually visible and
vertebrae palpable.
 Inspect the range Normally neck movement
of motion should be smooth and
controlled with 45-degree
flexion, 55-degree
extension, 40-degree
lateral abduction and 70-
degree rotation.
 Palpate the trachea Trachea is midline
 Palpate the thyroid Landmarks are positioned
gland midline. Unless, the client
is extremely thin with a
long neck, the thyroid
gland is usually not
palpable. However, the
isthmus may be palpated
in midline. If the thyroid
can be palpated, the lobes
are smooth, firm and
nontender. The right lobe
is often 25% larger than
the left lobe.
 Palpate the lymph No enlargement, no
nodes swelling and no
tenderness is palpated.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The temporal artery is
elastic and not tender
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Normally, there is no
swelling, tenderness, or crepitation with
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Neck is symmetric,
with head centered and without bulging
masses.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The thyroid cartilage,
cricoid cartilage move upward
symmetrically as the client swallows.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) C7 is usually visible
and palpable.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Normally neck
movement should be smooth and
controlled with 45-degree flexion, 55-
degree extension, 40-degree lateral
abduction and 70-degree rotation.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Trachea is midline.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Landmarks are
positioned midline. Unless, the client is
extremely thin with a long neck, the
thyroid gland is usually not palpable.
However, the isthmus may be palpated in
midline. If the thyroid can be palpated,
the lobes are smooth, firm and nontender.
The right lobe is often 25% larger than the
left lobe.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) No enlargement, no
swelling and no tenderness is palpated.
EYES
 Test distant visual Normal distant visual
acuity acuity is 20/20 with or
without corrective lenses
 Test near visual Normal near visual acuity
acuity is 14/14 with or without
corrective lenses.
 Test visual fields for With normal peripheral
gross peripheral vision the client should see
vision the examiner’s finger at
the same time the
examiner sees it. Normal
visual field degrees are
approximately as follows:
Inferior: 70 degrees
Superior: 50 degrees
Temporal: 90 degrees
Nasal: 60 degrees
 Perform Corneal The reflection of light on
Light reflex test the corneas should be in
the exact same spot on
each eye, which indicates
parallel alignment.
 Perform cover test The uncovered eye should
remain fixed straight
ahead. The covered eye
should remain fixed
straight ahead after being
uncovered.
 Perform positions Eye movement should be
test smooth and symmetric
throughout all six
directions.
 Inspect the eyelids The upper lid margin
and eyelashes should be between the
upper margin of the iris
and the upper margin of
the pupil. The lower lid
margin rests on the lower
border of the iris. No white
sclera is seen above or
below the iris. Palpebral
fissures may be horizontal.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Normal distant visual
acuity is 20/20 with or without corrective
lenses.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Normal near visual
acuity is 14/14 with or without corrective
lenses.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) With normal
peripheral vision the client should see the
examiner’s finger at the same time the
examiner sees it. Normal visual field
degrees are approximately as follows:
Inferior: 70 degrees
Superior: 50 degrees
Temporal: 90 degrees
Nasal: 60 degrees
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The reflection of light
on the corneas should be in the exact
same spot on each eye, which indicates
parallel alignment.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The uncovered eye
should remain fixed straight ahead. The
covered eye should remain fixed straight
ahead after being uncovered
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Eye movement should
be smooth and symmetric throughout all
six directions.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The upper lid margin
should be between the upper margin of
the iris and the upper margin of the pupil.
The lower lid margin rests on the lower
border of the iris. No white sclera is seen
above or below the iris. Palpebral fissures
may be horizontal.
 Assess the ability The upper and lower lids
of eyelids to close close easily and meets
when closed.
 Note the position The lower eyelid is upright
of the eyelids in with no inward or outward
comparison with turning. Eyelashes are
the eyeballs evenly distributed and
curve outward along the
lid margins.
 Observe eyelids Skin on both eyelids is
swelling, redness without redness, swelling
and discharge of or lesions.
lesions
 Observe the Eyeballs are symmetrically
position and aligned in sockets without
alignment of the protruding or sinking.
eyeball in the eye
socket
 Inspect the bulbar Bulbar conjunctiva is clear,
conjunctiva and moist and smooth.
sclera Underlying structures are
clearly visible. Sclera is
white.
 Inspect the The lower and upper
palpebral palpebral conjunctivae are
conjunctiva clear and free of swelling
or lesions.
 Evert the eyelid Palpebral conjunctiva is
free of swelling, foreign
bodies, or trauma.
 Inspect the No swelling or redness
lacrimal apparatus should appear over areas
of the lacrimal gland. The
puncta is visible without
swelling or redness, and is
turned slightly toward the
eye.
 Palpate the No drainage should be
lacrimal apparatus noted from the puncta
when palpating the
nasolacrimal duct.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The upper and lower
lids close easily and meets when closed.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The lower eyelid is
upright with no inward or outward
turning. Eyelashes are evenly distributed
and curve outward along the lid margins.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Skin on both eyelids is
without redness, swelling or lesions.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Eyeballs are
symmetrically aligned in sockets without
protruding or sinking.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Bulbar conjunctiva is
clear, moist and smooth. Underlying
structures are clearly visible. Sclera is
white.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The lower and upper
palpebral conjunctivae are clear and free
of swelling or lesions.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Palpebral conjunctiva
is free of swelling, foreign bodies, or
trauma.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) No swelling or redness
should appear over areas of the lacrimal
gland. The puncta is visible without
swelling or redness, and is turned slightly
toward the eye.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) No drainage should be
noted from the puncta when palpating the
nasolacrimal duct.
  Inspect the cornea The cornea is transparent,
and lens with no opacities. The
oblique view shows a
smooth and overall moist
surface; the lens is free of
opacities.
 Inspect the iris and The iris is typically round,
pupil flat and evenly colored.
The pupil, round with a
regular border, is centered
in the iris. Pupils are
normally equal in size (3-5
mm). An inequality in pupil
size of less than 0.5 mm
occurs in 20% of clients.
This condition, called
anisocoria, is normal.
 Test pupillary The normal direct pupil
reaction to light response is constriction.
(Pupillary Light
Reflex)
 Assess Consensual Assess Consensual
Response Response
 Test The normal pupillary
accommodation of response is constriction of
pupils the pupils and
convergence of the eyes
when focusing on a near
object.
EARS
 Inspect the auricle, Ears are equal in size
tragus and lobule bilaterally (normally 4-10
cm). The auricle aligns
with the corner of each
eye and within a 10-
degree angle of the
vertical position. Earlobes
may be free, attached or
soldered ( tightly attached
to adjacent skin with no
apparent lobe). The skin is
smooth, with no lesions,
lumps, or nodules. Color is
consistent with facial color.
Darwin’s tubercle, which is
a clinically insignificant
projection, may be seen
on the auricle. No
discharge should be
present.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The cornea is
transparent, with no opacities. The
oblique view shows a smooth and overall
moist surface; the lens is free of opacities.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The iris is typically
round, flat and evenly colored. The pupil,
round with a regular border, is centered in
the iris. Pupils are normally equal in size
(3-5 mm). An inequality in pupil size of
less than 0.5 mm occurs in 20% of clients.
This condition, called anisocoria, is
normal.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The normal direct
pupil response is constriction.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The normal
consensual pupillary response is
constriction.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The normal pupillary
response is constriction of the pupils and
convergence of the eyes when focusing on
a near object.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Ears are equal in size
bilaterally (normally 4-10 cm). The auricle
aligns with the corner of each eye and
within a 10-degree angle of the vertical
position. Earlobes may be free, attached
or soldered ( tightly attached to adjacent
skin with no apparent lobe). The skin is
smooth, with no lesions, lumps, or
nodules. Color is consistent with facial
color. Darwin’s tubercle, which is a
clinically insignificant projection, may be
seen on the auricle. No discharge should
be present.
  Palpate the auricle Normally, the auricle,
and mastoid tragus and mastoid
process process are not tender.
GROSS HEARING ACQUITY TESTS
 Perform the Able to correctly repeat
Whisper test the two-syllable words as
whispered.
 Perform the Client maintains position
Romberg Test for 20 seconds without
swaying or with minimal
swaying.
 Perform the Weber Vibrations are heard
test equally well in both ears.
No lateralization of sound
to either ear.
 Rinne test Air-conducted hearing is
greater than bone-
conducted;
Positive Rinne
NOSE
 Inspect and Color is the same as the
palpate the rest of the face; the nasal
external nose structure is smooth and
symmetric; the client
reports no tenderness.
 Check patency of Client is able to sniff
airflow through the through each nostril while
nostrils other is occluded.
 Inspect the internal The nasal mucosa is dark
nose pink, moist and free of
exudate. The nasal septum
is intact and free of ulcers
or perforations. Turbinates
are dark pink moist and
free of lesions. The
superior turbinate will not
be visible from this point
of view. A deviated septum
nay appear to be an
overgrowth of tissue. This
is a normal finding as long
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Normally, the auricle,
tragus and mastoid process are not
tender.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Able to correctly
repeat the two-syllable words as
whispered.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Client maintains
position for 20 seconds without swaying
or with minimal swaying.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Vibrations are heard
equally well in both ears. No lateralization
of sound to either ear.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Air conduction is
normally heard longer than bone
conduction sound (AC > BC).
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Color is the same as
the rest of the face; the nasal structure is
smooth and symmetric; the client reports
no tenderness.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Client is able to sniff
through each nostril while other is
occluded.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The nasal mucosa is
dark pink, moist and free of exudate. The
nasal septum is intact and free of ulcers or
perforations. Turbinates are dark pink
moist and free of lesions. The superior
turbinate will not be visible from this
point of view. A deviated septum nay
appear to be an overgrowth of tissue. This
is a normal finding as long as breathing is
not obstructed.
 as breathing is not
obstructed.
FACIAL SINUSES
 Palpate the sinuses Frontal and maxillary
sinuses are nontender to
palpation and no crepitus
is evident.
 Percuss the sinuses The sinuses are not tender
on percussion.
MOUTH
 Inspect the lips Lips are smooth and moist
without lesions or
swelling.
 Inspect the teeth Thirty-two pearly white
and gums teeth with smooth surface
edges. Upper molars
should rest directly on the
lower molars and the front
upper inscisors should
slightly override the lower
inscisors. Some clients
normally have only 28
teeth if the four wisdom
teeth do not erupt. No
decayed areas; no missing
teeth. Client may have
appliances on teeth. Client
may have evidence of
repair work done on teeth.
Gums are pink, moist and
firm with tight margins to
the tooth. No lesions or
masses.
 Inspect the Buccal In all clients, tissue is
mucosa smooth and moist without
lesions. Stenson’s ducts
are visible with flow of
saliva and with no
redness, swelling, pain, or
moistness in area. Fordyce
spots or granules,
yellowish-whitish raised
spots, are normal ectopic
sebaceous glands.
 Inspect and Tongue should be pink,
palpate the tongue moist a moderate size with
papillae (little
protuberances) present. A
common variation is a
fissured, topographic-map-
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Frontal and maxillary
sinuses are nontender to palpation and no
crepitus is evident.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The sinuses are not
tender on percussion.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Lips are smooth and
moist without lesions or swelling.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Child client normally
have only 28 teeth if the four wisdom
teeth do not erupt. No decayed areas; no
missing teeth. Client may have appliances
on teeth. Client may have evidence of
repair work done on teeth. Gums are pink,
moist and firm with tight margins to the
tooth. No lesions or masses.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) In all clients, tissue is
smooth and moist without lesions.
Stenson’s ducts are visible with flow of
saliva and with no redness, swelling, pain,
or moistness in area. Fordyce spots or
granules, yellowish-whitish raised spots,
are normal ectopic sebaceous glands.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Tongue should be
pink, moist a moderate size with papillae
(little protuberances) present. A common
 like tongue which is not
unusual in older clients.
No lesions are present.
 Assess the ventral The tongue’s ventral
surface of the surface is smooth, shiny,
tongue pink, or slightly pale, with
visible veins and no
lesions.
 Inspect the The frenulum is midline;
Wharton’s duct Wharton’s ducts are
visible, with salivary flow
or moistness in the area.
The client has no swelling,
redness or pain.
 Observe the sides No lesions, ulcers, or
of the tongue nodules are apparent.
 Check the strength The tongue offers strong
of the tongue resistance.
 Inspect the hard The hard palate is pale or
(anterior) and soft whitish with firm,
(posterior) palates transverse rugae ( wrinkle-
and uvula like folds). Palatine tissues
are intact; the soft palate
should be pinkish,
movable, spongy and
smooth.
 Note odor while No unusual or foul odor is
the mouth is wide noted.
open
 Assess the uvula No redness of or exudate
from uvula or soft palate.
Midline elevation of uvula
and symmetric elevation
of the soft palate.
 Inspect the tonsils Tonsils may be present or
absent. They are normally
pink and symmetric and
may be enlarged to 1 + in
healthy clients. No
exudate, swelling or
lesions should be present.
 Inspect the Throat is normally pink,
variation is a fissured, topographic-map-
like tongue which is not unusual in older
clients. No lesions are present.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The tongue’s ventral
surface is smooth, shiny, pink, or slightly
pale, with visible veins and no lesions.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The frenulum is
midline; Wharton’s ducts are visible, with
salivary flow or moistness in the area. The
client has no swelling, redness or pain.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) No lesions, ulcers, or
nodules are apparent.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The tongue offers
strong resistance.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The hard palate is pale
or whitish with firm, transverse rugae
( wrinkle-like folds). Palatine tissues are
intact; the soft palate should be pinkish,
movable, spongy and smooth.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) No unusual or foul
odor is noted.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) No redness of or
exudate from uvula or soft palate. Midline
elevation of uvula and symmetric
elevation of the soft palate.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Tonsils may be present
or absent. They are normally pink and
symmetric and may be enlarged to 1 + in
healthy clients. No exudate, swelling or
lesions should be present.
NORMAL
 posterior without exudate or
pharyngeal wall lesions.
POSTERIOR THORAX
 Inspect A Scapulae are symmetric
Configuration and nonprotruding.
Shoulders and scapulae
are at equal horizontal
positions. The ratio of
anteroposterior to
transverse diametes is 1:2.
 Observe use of The client does not use
accessory muscles accessory muscle to assist
breathing.
 Inspect for client’s The client should be sitting
positioning up and relaxed, breathing
easily with arms at sides or
in lap.
 Palpate for Client reports no
tenderness, tenderness, pain or
sensation and sensual sensations.
crepitus Temperature should be
equal bilaterally. The
examiner finds no palpable
crepitus.
 Palpate for Fremitus is symmetric and
fremitus easily identified in the
upper regions of the lungs.
A decrease in the intensity
of fremitus is normal as
the examiner moves
toward the base of the
lungs. However, fremitus
should remain symmetric
for bilateral positions.
 Assess chest When the client takes a
expansion deep breath, the
examiner’s thumbs should
move 5-10 cm apart
symmetrically.
 Observe use of The client does not use
accessory muscles accessory muscle when
breathing.
 Percuss the tone Resonance is the
percussion tone elicited
over normal lung tissue.
Percussion elicits a flat
tones over the scapula.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Throat is normally
pink, without exudate or lesions.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Scapulae are
symmetric and nonprotruding. Shoulders
and scapulae are at equal horizontal
positions. The ratio of anteroposterior to
transverse diametes is 1:2.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The client does not
use accessory muscle to assist breathing.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The client should be
sitting up and relaxed, breathing easily
with arms at sides or in lap.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Client reports no
tenderness, pain or sensual sensations.
Temperature should be equal bilaterally.
The examiner finds no palpable crepitus.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Fremitus is symmetric
and easily identified in the upper regions
of the lungs. A decrease in the intensity of
fremitus is normal as the examiner moves
toward the base of the lungs. However,
fremitus should remain symmetric for
bilateral positions.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) When the client takes
a deep breath, the examiner’s thumbs
should move 5-10 cm apart symmetrically.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The client does not
use accessory muscle when breathing.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Resonance is the
percussion tone elicited over normal lung
tissue. Percussion elicits a flat tones over

 Percuss for Excursion should be equal
diaphragmatic bilaterally and measure 3-
excursion 5 cm in adults. The level of
the diaphragm may be
higher on the right
because of the position of
the liver. In well-
conditioned clients,
excursion cam measure up
to 7 or 8 cm.
 Auscultate for Voice transmission is soft,
voice sounds muffled, and indistinct.
The sound of the voice
may be heard but the
actual phrase cannot be
distinguished. Voice
transmission will be soft
and muffled but the letter
E should be
distinguishable.
Transmission of sound is
very faint and muffled. It
may be inaudible.
ANTERIOR THORAX
 Inspect for shape The anteroposterior
and configuration diameter is less than the
transverse diameter. The
ratio should be
approximately 1:2.
 Inspect position of Sternum is positioned at
the sternum midline and straight.
 Watch for sternal Retractions are not
retractions observed.
 Inspect slope of Ribs slope downward with
the ribs symmetric intercostal
spaces. Costal angle is
within 90 degrees.
 Observe quality Respirations are relaxed,
and pattern of effortless and quiet. They
respirations are of regular rythm and
normal depth at a rate of
10-20 per minute in
adults. Tachypnea and
bradypnea may be normal
in some clients.
the scapula.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Excursion should be
equal bilaterally and measure 3-5 cm in
adults. The level of the diaphragm may be
higher on the right because of the position
of the liver. In well-conditioned clients,
excursion cam measure up to 7 or 8 cm.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Voice transmission is
soft, muffled, and indistinct. The sound of
the voice may be heard but the actual
phrase cannot be distinguished. Voice
transmission will be soft and muffled but
the letter E should be distinguishable.
Transmission of sound is very faint and
muffled. It may be inaudible.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The anteroposterior
diameter is less than the transverse
diameter. The ratio should be
approximately 1:2.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Sternum is positioned
at midline and straight.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Retractions are not
observed.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Ribs slope downward
with symmetric intercostal spaces. Costal
angle is within 90 degrees.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Respirations are
relaxed, effortless and quiet. They are of
regular rythm and normal depth at a rate
of 10-20 per minute in adults. Tachypnea
and bradypnea may be normal in some

 Inspect intercostal Use of accessory muscles
spaces is not seen with normal
respiratory effort.
 Observe for use of Use of accessory muscles
accessory muscles is not seen with normal
respiratory effort.
 Palpate for No tenderness or pain is
tenderness palpated over the lung
sensation and area with respirations.
surface masses
 Palpate for Palpation does not elicit
tenderness at tenderness.
costochondral
junctions of ribs
 Palpate for crepitus No crepitus is palpated.
 Palpate for Fremitus is symmetric and
fremitus easily identified in the
upper regions of the lungs.
A decreased intensity of
fremitus is expected
toward the base of the
lungs. However, fremitus
should be symmetric
bilaterally.
 Palpate for anterior Thumbs move outward in
chest expansion a symmetric fashion from
the midline.
 Percuss for tone Resonance is the
percussion tone elicited
over the normal lung
tissue. Percussion elicits
dullness over breast tissue,
the heart and the liver.
Tympany is detected over
the stomach and flatness
is detected over the
muscles and bones.
 Auscultate for Three types of normal
breath sounds breath sounds may be
auscultated-bronchial,
bronchovesicular and
vesicular.
clients.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) No retractions or
bulging of intercostal spaces are noted.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Use of accessory
muscles is not seen with normal
respiratory effort.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) No tenderness or pain
is palpated over the lung area with
respirations.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Palpation does not
elicit tenderness.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) No crepitus is
palpated
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Fremitus is symmetric
and easily identified in the upper regions
of the lungs. A decreased intensity of
fremitus is expected toward the base of
the lungs. However, fremitus should be
symmetric bilaterally.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Thumbs move
outward in a symmetric fashion from the
midline.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Resonance is the
percussion tone elicited over the normal
lung tissue. Percussion elicits dullness over
breast tissue, the heart and the liver.
Tympany is detected over the stomach
and flatness is detected over the muscles
and bones.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Three types of normal
breath sounds may be auscultated-

HEART AND NECK VESSELS
 Observe for jugular Jugular vein is normally
venous phase not visible when the client
is sitting upright. This
position fully distends the
vein, and pulsations may
or may not be discernible.
 Evaluate for jugular The jugular vein should
venous phase not be distended, bulging
or protruding at 45 degree
or greater.
 Auscultate the Pulses are equally strong;
carotid arteries normal with no variation in
strength from beat to
beat.
Arteries are elastic and no
thrills are noted.
 Inspect pulsations The apical impulse may or
may not be visible. If
apparent, it would be in
the mitral area.
 Palpate the apical The apical impulse is
impulse palpated in the mitral area
and may be in the size of a
nickel.
 Palpate for No pulsations or vibrations
abnormal are palpated in the areas
pulsations of the apex, left sternal
border, or base.
 Auscultate the Rate should be 60-100
heart rate and beats per min., with
rhythm regular rhythm.
 Auscultate to S1 corresponds with the
identify S1 and S2 carotid pulsations and is
loudest at the apex of the
heart. S2 immediately
follows after s1 and is
loudest at the base of the
heart.
 Auscultate for Normally no sounds are
extra heart sounds heard.
bronchial, bronchovesicular and vesicular.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Jugular vein is
normally not visible when the client is
sitting upright. This position fully distends
the vein, and pulsations may or may not
be discernible.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The jugular vein
should not be distended, bulging or
protruding at 45 degree or greater.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Pulses are equally
strong; normal with no variation in
strength from beat to beat.
Arteries are elastic and no thrills are
noted.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The apical impulse
may or may not be visible. If apparent, it
would be in the mitral area.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The apical impulse is
palpated in the mitral area and may be in
the size of a nickel.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) No pulsations or
vibrations are palpated in the areas of the
apex, left sternal border, or base.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Rate should be 60-100
beats per min., with regular rhythm.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) S1 corresponds with
the carotid pulsations and is loudest at the
apex of the heart. S2 immediately follows
after s1 and is loudest at the base of the
heart.
NORMAL
According to (Health Assessment in

 Auscultate for Normally no murmurs are
murmurs heard.
BREAST AND AXILLAE
 Inspect the size Female: Rounded shape;
and symmetry slightly unequal, generally
symmetric
Male: Breast even with
chest wall, if obese, maybe
similar in shape to female
breasts
 Inspect color and Normally, the texture of
texture breasts are smooth and its
tone is paler than the
general skin tone.
 Inspect superficial Veins radiate horizontally
venous pattern and toward the axilla or
vertically with a lateral
flare.
 Inspect for areolas Areola vary from dark pink
to dark brown, depending
on the client’s skin tones.
They are round and may
vary in size.
 Inspect for nipples Nipples are nearly equal
bilaterally in size and are in
the same location on each
breast. Nipples are usually
everted, but they may be
inverted or flat
 Inspect for Breasts rise and fall
retraction and symmetrically, with no sign
dimpling of retraction and dimpling.
 Palpate for texture Palpations reveal smooth,
and elasticity firm and elastic tissue.
 Palpate for Tenderness may be
tenderness and normally reported
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Normally no sounds
are heard.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Normally no murmurs
are heard.
NORMAL
There is milk in the left breast of the
mother. According to (Health Assessment
in Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Breast can be a variety
of sizes and are somewhat round and
pendulous. One breast may normally be
larger than the other.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Normally, the texture
of breasts are smooth and its tone is paler
than the general skin tone.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Veins radiate
horizontally and toward the axilla or
vertically with a lateral flare.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Areola vary from dark
pink to dark brown, depending on the
client’s skin tones. They are ro
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Nipples are nearly
equal bilaterally in size and are in the
same location on each breast. Nipples are
usually everted, but they may be inverted
or flat.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Breasts rise and fall
symmetrically, with no sign of retraction
and dimpling.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Palpations reveal
smooth, firm and elastic tissue.
NORMAL
According to (Health Assessment in
 temperature associated with the
menstrual cycle and
breasts should be in a
normal temperature.
 Palpate for masses No masses should be
palpated.
 Palpate of nipples Palpate of nipples
 Inspect and No rashes or infections
palpate for axillae should be noted.
No palpable nodes or one
to two small, discrete,
nontender, movable nodes
in the central area.
 Demonstrate how Client may request
to perform Breast instructions on how to
Self-Exam perform the exam or
choose not to learn how to
perform the exam.
ABDOMEN
 Observe the Abdominal skin is paler
coloration of the than the general skin tone
skin because thus skin is so
seldom exposed to the
natural elements.
 Note the Scattered fine veins may
vascularity of the normally or may not be
abdominal skin visible.
 Note any striae New striae are pink or
bluish in color; old striae
are silvery, white, linear,
and uneven stretch marks
from weight gain.
 Inspect for scars Pale, smooth, minimally
raised old scars may be
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Tenderness may be
normally reported associated with the
menstrual cycle and breasts should be in a
normal temperature.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) No masses should be
palpated.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The nipples may have
erect and areolas may pucker in response
to stimulation.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) No rashes or
infections should be noted.
No palpable nodes or one to two small,
discrete, nontender, movable nodes in the
central area.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Client may request
instructions on how to perform the exam
or choose not to learn how to perform the
exam.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Abdominal skin is
paler than the general skin tone because
thus skin is so seldom exposed to the
natural elements.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Scattered fine veins
may normally or may not be visible.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) New striae are pink or
bluish in color; old striae are silvery, white,
linear, and uneven stretch marks from
weight gain.
NORMAL
According to (Health Assessment in
 seen.
 Assess for lesions Abdomen is free of lesions
and rashes or rashes. Flat or raised
brown moles; however,
are normal and may be
apparent.
 Inspect the Umbilicus skin tone is
umbilicus similar with the abdominal
skin tone.
Umbilicus is midline at
lateral line.
 Inspect the Abdomen is flat, rounded
abdominal contour or scaphoid. Abdomen
should be evenly rounded.
 Assess abdominal Abdomen is symmetric.
symmetry
 Inspect abdominal Abdominal respiratory
movement when movement may be seen.
the client breaths
 Observe aortic A slight pulsations of the
pulsations abdominal aorta, which is
visible in the epigastrium,
extends full length in thin
people.
 Observe for Normally, peristaltic waves
peristaltic waves are not seen but may be
seen in thin people.
AUSCULTATION OF THE ABDOMEN
 Auscultate for A series of intermittent on
bowel sounds and off click and soft
gurgles in every 5-30 per
min.
 Auscultate for Bruits are not normally
vascular sounds heard over abdominal
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Pale, smooth,
minimally raised old scars may be seen.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Abdomen is free of
lesions or rashes. Flat or raised brown
moles; however, are normal and may be
apparent.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Umbilicus skin tone is
similar with the abdominal skin tone.
Umbilicus is midline at lateral line.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Abdomen is flat,
rounded or scaphoid. Abdomen should be
evenly rounded.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Abdomen is
symmetric.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Abdominal respiratory
movement may be seen.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) A slight pulsations of
the abdominal aorta, which is visible in
the epigastrium, extends full length in thin
people.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Normally, peristaltic
waves are not seen but may be seen in
thin people.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) A series of
intermittent on and off click and soft
gurgles in every 5-30 per min.
NORMAL
According to (Health Assessment in
 aorta or renal, iliac, or
femoral arteries.
 Listen for venous Venous hum is not
hum normally heard over the
epigastric and umbilical
areas.
 Auscultate for a No friction rub over the
friction rub over liver or spleen is present.
the liver and
spleen
PERCUSSION OF THE ABDOMEN
 Percuss the tone Generalized tympany
predominates over the
abdomen because of air in
the stomach and
intestines. Dullness is
heard over the liver and
spleen.
 Percuss the span or The lower border of liver
height of the liver dullness is located at the
by determining its costal margin to 11 to 2 cm
lower and upper below.
boarders
On deep palpation, the
lower border of liver
dullness may descend
from 1 to 3 cm below the
costal margin.
The upper border of liver
dullness is located bet. Left
fifth and seventh
intercostal spaces.
 Perform blunt Normally, no tenderness is
percussion on the elicited.
liver and the
kidneys
PALPATION OF THE ABDOMEN
 Perform light Abdomen is non tender
palpation and soft. There is no
guarding.
 Deeply palpate all Normal (mild) tenderness
quadrants to is possible over the
delineate xiphoid, aorta, cecum,
abdominal organs sigmoid colon, and ovaries
and detect subtle with deep palpation.
masses
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Bruits are not
normally heard over abdominal aorta or
renal, iliac, or femoral arteries.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Venous hum is not
normally heard over the epigastric and
umbilical areas.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) No friction rub over
the liver or spleen is present.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Generalized tympany
predominates over the abdomen because
of air in the stomach and intestines.
Dullness is heard over the liver and
spleen.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The lower border of
liver dullness is located at the costal
margin to 11 to 2 cm below.
On deep palpation, the lower border of
liver dullness may descend from 1 to 3 cm
below the costal margin.
The upper border of liver dullness is
located bet. Left fifth and seventh
intercostal spaces.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Normally, no
tenderness is elicited.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Abdomen is
nontender and soft. There is no guarding.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Normal (mild)
tenderness is possible over the xiphoid,
aorta, cecum, sigmoid colon, and ovaries
 with deep palpation.
 Palpate the liver The liver is usually not NORMAL
palpable, although it may According to (Health Assessment in
be felt in some thin clients Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The liver is usually not
palpable, although it may be felt in some
thin clients.
 Palpate the urinary An empty bladder is NORMAL
bladder neither palpable nor According to (Health Assessment in
tender. Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) An empty bladder is
neither palpable nor tender.
 Assess for rebound No rebound tenderness is NORMAL
tenderness present. According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) No rebound
tenderness is present.
MUSCULOSKELETAL SYSTEM
 Inspect the Equal in size in both sides NORMAL
muscles for size. of the body According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Compare each Kelley, fifth edition) Equal size on both
muscle on one side sides of body
of the body to the
same muscle on
the other side for
size
 Inspect the No contractures NORMAL
muscles and According to (Health Assessment in
tendons for Nursing, Janet R. Weber and Jane H.
contractures. Kelley, fifth edition) No contractures.

 Inspect the No fasciculation or NORMAL

muscles for tremors According to (Health Assessment in
tremors. Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) No fasciculation or
Inspect any tremors
tremors of the
hands and arms by
having the client
hold arms out in
front of body.
 Palpate muscles at Normally firm NORMAL
rest to determine According to (Health Assessment in
muscle tonicity. Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Normally firm.

 Palpate muscles Smooth coordinated NORMAL

while the client is movements According to (Health Assessment in
active and passive Nursing, Janet R. Weber and Jane H.
for flaccidity, Kelley, fifth edition) Smooth coordinated
spasticity, and movements
smoothness of
movement.

 Test muscle Equal strength on each NORMAL

strength of the body side According to (Health Assessment in
 head & shoulders. Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Equal strength on
each body side.

 Test muscle Equal strength on each NORMAL

strength of upper body side According to (Health Assessment in
extremities. Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Equal strength on
each body side.
 Test muscle Equal strength on each NORMAL
strength of lower body side According to (Health Assessment in
extremities Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Equal strength on
each body side
BONES
 Inspect the No deformities NORMAL
skeleton for normal According to (Health Assessment in
structure and Nursing, Janet R. Weber and Jane H.
deformities. Kelley, fifth edition) No deformities
 Palpate the bones No swelling and NORMAL
to locate any areas tenderness According to (Health Assessment in
of edema or Nursing, Janet R. Weber and Jane H.
tenderness. Kelley, fifth edition) No tenderness or
swelling
JOINTS
 Inspect the joint No swelling No NORMAL
for swelling. tenderness, crepitation, or According to (Health Assessment in
nodules Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) No swelling No
tenderness, crepitation, or nodules
 Palpate each joint No swelling , No NORMAL
for tenderness, tenderness, crepitation, or According to (Health Assessment in
smoothness of nodules Nursing, Janet R. Weber and Jane H.
movement, Kelley, fifth edition) No swelling
swelling,
crepitation, and No tenderness, crepitation, or nodules
presence of
nodules.
 Assess joint range Varies to some degree in NORMAL
of motion of the accordance with person’s According to (Health Assessment in
head. genetic makeup and Nursing, Janet R. Weber and Jane H.
degree of physical activity. Kelley, fifth edition) Varies to some degree
Full range of motion. in accordance with person’s genetic
makeup and degree of physical activity.
Full range of motion.
 Assess joint range Varies to some degree in NORMAL
of motion of body accordance with person’s According to (Health Assessment in
trunk genetic makeup and Nursing, Janet R. Weber and Jane H.
degree of physical activity. Kelley, fifth edition) Varies to some degree
Full range of motion. in accordance with person’s genetic
makeup and degree of physical activity.
Full range of motion.
 Assess joint range Varies to some degree in NORMAL
of motion of upper accordance with person’s According to (Health Assessment in
extremities genetic makeup and Nursing, Janet R. Weber and Jane H.
degree of physical activity. Kelley, fifth edition) Varies to some degree
Full range of motion. in accordance with person’s genetic
makeup and degree of physical activity.

 Assess joint range Varies to some degree in
of motion of lower accordance with person’s
extremities genetic makeup and
degree of physical activity.
Full range of motion.
PERINEUM
MALE GENITALIA
 Inspect the skin of The skin of the penis is
the shaft wrinkled and hairless and
is normally free of lesion,
or lumps.
 Palpate the shaft The penis in a nonerect
state is usually soft, flaccid,
and nontender.
 Inspect the The foreskin, which covers
foreskin the glans in an
uncircumcised male client,
is intact and uniform in
color with the penis.
 Inspect the glans The glans size and shape
vary, appearing rounded,
broad, or even pointed.
The surface of the glans is
normally smooth, free
from lesions and redness.
 Inspect the size, The scrotum varies in size
shape, and position (according to the
of the scrotum temperature) and shape.
The scrotal sac hangs
below or at the level of the
penis. The left side of the
scrotal sac usually hangs
lower than the rights side.
 Inspect the scrotal Scrotal skin is thin and
skin rugated (crinkled) with
little hair dispersion. Its
color is slightly darker than
the penis. Lesion and
rashes are not normally
present.
 Palpate the scrotal Testes are ovoid, appx 3.5-
content 5 cm wide, and 2.5 cm
deep, and equal bilaterally
Full range of motion.
NORMAL
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Varies to some degree
in accordance with person’s genetic
makeup and degree of physical activity.
Full range of motion.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The skin of the penis
is wrinkled and hairless and is normally
free of lesion, or lumps.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The penis in a
nonerect state is usually soft, flaccid, and
nontender.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The foreskin, which
covers the glans in an uncircumcised male
client, is intact and uniform in color with
the penis.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The glans size and
shape vary, appearing rounded, broad, or
even pointed. The surface of the glans is
normally smooth, free from lesions and
redness.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The scrotum varies in
size (according to the temperature) and
shape. The scrotal sac hangs below or at
the level of the penis. The left side of the
scrotal sac usually hangs lower than the
rights side.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Scrotal skin is thin and
rugated (crinkled) with little hair
dispersion. Its color is slightly darker than
the penis. Lesion and rashes are not
normally present.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Testes are ovoid, appx
 in size and shape. They are
smooth, firm, rubbery,
mobile, free of nodules,
and rather tender to
pressure.
The epididymis is non
tender, smooth, and softer
than the testes.
 Inspect for inguinal The inguinal and femoral
and femoral hernia areas are normally free
from bulges.
 Palpate for inguinal Bulging masses are not
hernia and nodes normally palpated
 Palpate inguinal No enlargement or
lymph nodes tenderness is normal
 Palpate for femoral Bulges or masses are not
hernia normally palpated
 Inspect the The opening should
perianal area appear hairless, moist, and
tightly closed. The skin
around the anal opening is
more darkly pigmented.
The surrounding perianal
area should be free of
redness, lumps, ulcers,
lesions, and rashes.
 Palpate the anus Sphincter relaxes,
permitting entry.
 Palpate the rectum Rectal mucosa is normally
soft, smooth, non-tender,
and free of nodules.
 Palpate the Normally smooth and non-
peritoneal area tender.
 Palpate the Normally non-tender and
prostate gland rebbery. Lobes are
normally smooth, 2.5 cm
long and, heart shaped.
FEMALE GENITALIA
 Inspect the mons Pubic hair is distributed in
pubis an inverted triangular
3.5-5 cm wide, and 2.5 cm deep, and
equal bilaterally in size and shape. They
are smooth, firm, rubbery, mobile, free of
nodules, and rather tender to pressure.
The epididymis is non tender, smooth, and
softer than the testes.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The inguinal and
femoral areas are normally free from
bulges.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Bulging masses are
not normally palpated
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) No enlargement or
tenderness is normal
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Bulges or masses are
not normally palpated.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The opening should
appear hairless, moist, and tightly closed.
The skin around the anal opening is more
darkly pigmented. The surrounding
perianal area should be free of redness,
lumps, ulcers, lesions, and rashes.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Sphincter relaxes,
permitting entry.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Rectal mucosa is
normally soft, smooth, non-tender, and
free of nodules.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Normally smooth and
non-tender.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Normally non-tender
and rebbery. Lobes are normally smooth,
2.5 cm long and, heart shaped.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
 pattern and there are no
signs of infestation.
 Observe and There should be no
palpate inguinal enlargement or swelling of
lymph nodes. the lymph nodes.
 Inspect the labia The labia majora are equal
majora and in size and free of lesions,
perineum swelling, and excoriation.
The perineum shuld be
smooth.
 Inspect the labia The labia minor a appear
minora, clitoris, symmetric, dark pink, and
urethral meatus, moist.
and vaginal The clitoris is a small
opening. mound of erectile tissue,
sensitive to touch.
 Palpate bartholin’s Bartholin’s glands are
glands usually soft, non-tender,
and drainage free.
 Palpate the urethra No drainage should be
noted from the urethral
meatus. The area is
normally soft and non-
tender.
 Inspect the size of The normal vaginal
vaginal opening opening varies in size
and the angle of according to the client’s
the vagina. age, sexual history, and
whether she has given
birth vaginally.
 Inspect the vaginal The client should be able
musculature to squeeze around the
examiner’s finger.
No bulging and no urinary
discharge.
 Inspect the cervix The surface of the cervix is
normally smooth, pink,
and even.
 Inspect the vagina The vagina should appear
pink, moist, smooth, and
free of lesions and
irritation. Free from any
malodorous discharge.
 Palpate the vaginal The vaginal wall should
wall feel smooth, and the client
should not report any
Kelley, fifth edition) Pubic hair is
distributed in an inverted triangular
pattern and there are no signs of
infestation.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) There should be no
enlargement or swelling of the lymph
nodes
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The labia majora are
equal in size and free of lesions, swelling,
and excoriation.
The perineum shuld be smooth.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The labia minor a
appear symmetric, dark pink, and moist.
The clitoris is a small mound of erectile
tissue, sensitive to touch.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Bartholin’s glands are
usually soft, non-tender, and drainage
free.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) No drainage should be
noted from the urethral meatus. The area
is normally soft and non-tender.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The normal vaginal
opening varies in size according to the
client’s age, sexual history, and whether
she has given birth vaginally.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The client should be
able to squeeze around the examiner’s
finger. No bulging and no urinary
discharge.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The surface of the
cervix is normally smooth, pink, and even.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The vagina should
appear pink, moist, smooth, and free of
lesions and irritation. Free from any
malodorous discharge.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The vaginal wall
 tenderness.
 Palpate the cervix The cervix should feel firm
and soft (like tip of your
nose). Rounded and can
be moved from side to
side without eliciting
tenderness.
 Palpate the uterus Normally round, firm, and
smooth.
 Palpate the ovaries Ovaries are appx 3x2x1 cm
(or size of a walnut) and
almond-shaped.
 Inspect the The opening should
perianal area appear hairless, moist, and
tightly closed. The skin
around the anal opening is
more darkly pigmented.
The surrounding perianal
area should be free of
redness, lumps, ulcers,
lesions, and rashes.
 Palpate the anus Sphincter relaxes,
permitting entry.
 Palpate the rectum Rectal mucosa is normally
soft, smooth, non-tender,
and free of nodules.
 Palpate the Normally smooth and non-
peritoneal area tender.
 Palpate the Normally non-tender and
prostate gland rebbery. Lobes are
normally smooth, 2.5 cm
long and, heart shaped.
should feel smooth, and the client should
not report any tenderness.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The cervix should feel
firm and soft (like tip of your nose).
Rounded and can be moved from side to
side without eliciting tenderness.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Uterus is normally
round, firm, and smooth.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Ovaries are appx
3x2x1 cm (or size of a walnut) and
almond-shaped.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) The opening should
appear hairless, moist, and tightly closed.
The skin around the anal opening is more
darkly pigmented. The surrounding
perianal area should be free of redness,
lumps, ulcers, lesions, and rashes.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Sphincter relaxes,
permitting entry.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Rectal mucosa is
normally soft, smooth, non-tender, and
free of nodules.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Normally smooth and
non-tender.
According to (Health Assessment in
Nursing, Janet R. Weber and Jane H.
Kelley, fifth edition) Normally non-tender
and rebbery. Lobes are normally smooth,
2.5 cm long and, heart shaped.