PERFORMING PHYSICAL ASSESSMENT

PART 1

ASSIGNMENT

PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

1. Explain the purpose and procedure Patient is listening and Patient is unwilling to
paying attention listen
2. Close the doors and/or place screen covering Nurse was able to Providing privacy to the
examination table/bed. provide privacy for the client was unsuccessful
client
3. Encourage the client to empty bladder. Patient successfully Patient was unable to
urinated urinate
4. Perform physical examination. Physical examination Physical examination was
was performed performed but inaccurate
successfully, and data was found
accurate data was
found
A. GENERAL EXAMINATION Response of the client Client is confused and
Assess overall body appearance and mental is appropriate to unable to follow the
status. commands commands
Observe the client’s ability to respond to verbal
commands.
5. Observe the client’s level of consciousness (LOC) Client is aware of their Client is unable to answer
and orientation. Ask the client to state his/her identity and location simple questions
own name, current location, and approximate
day, month, or year.
6. Observe the client’s ability to think, remember, Client can follow Client is disoriented
process information, and communicate. commands and
Inspect articulation on speech style and contents remember information
of speaking.
Client speaks clearly Client is mumbling words
and uses appropriate
language
7. Observe client’s ability to see, hear, smell, and Client can hear even Client must look directly
distinguish tactile sensations. though the speaker at the speaker to hear
turns away, and can clearly
distinguish between Client has impaired sense
soft and sharp objects of
sight/hearing/smell/tactile
sensations
8. Observe signs of distress. Client is not in distress Client shows shortness in
breath and is anxious
9. Observe facial expression and mood. Client is relaxed and Client is anxious and
alert limited responses
10. Observe general appearance: posture, gait, and Client has appropriate Client’s posture is twisted
movement. appearance, gait, and
posture Presents abnormal gait
11. Observe grooming, personal hygiene, and dress. Clothing is appropriate Client is poorly groomed
for age
12. Measurement: Height and weight are Height and weight are not
 Height appropriate for age appropriate for age

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 1) Ask the client to remove shoes and
stand with his/her back and heels
touching the wall
2) Place a pencil flat on his/her head so
that it makes a mark on the wall.
3) This shows his/her height measured
with tape measure from the floor to
the mark on the wall (or if available,
measure the height with measuring
scale).
4) Record height.
 Weight
1) Weigh the client without shoes and
much clothing
2) Record weight.
13. Take the vital signs Temperature: 36℃ to hypothermia < 35 ℃,
 Temperature 37.3℃ pyrexia 38-40 ℃,
 Pulse rate hyperpyrexia > 40.1 ℃
 Respiration Pulse rate: 60-100
 Blood pressure bpm bradypnea <10/ min.,
tachypnea >20/min Pulse
Respiration: 12-20 rate: less than 60- more
cpm than 100 beats per
minute.
Blood pressure: 90/60
mmHg to 120/80 Hypotension: In normal
mmHg for adults adults < 95/60
Hypertension
14. SKIN ASSESSMENT Even skin tone without Skin tone appears blue-ish
*Note for color, moisture, temperature, texture, mobility unusual or prominent and pale
and turgor, edema, and lesions. discoloration
1) Inspect the back and palms of the
client’s hands for skin color. Compare Skin is smooth and
the right and left sides. Make a similar even Flaky and dry skin
inspection of the feet and toes,
comparing the right and left sides. Skin is normally warm
2) Palpate the skin on the back and palms Skin is cool and minimal
of the client’s hands for moisture and The skin’s recoil is sweating is present
texture. immediate Decreased mobility
3) Palpate the skin’s temperature with the
back of your hand. Skin rebounds and is
4) Pinch and release the skin on the back of not indented when Slight indentation on the
the client’s hand. pressure is released skin all over the body
5) Press suspected edematous areas with
the edge of your fingers for 10 seconds Skin is smooth. Moles
and observe for the depression and healed scars are Circular, elevated, and
6) Inspect the skin for lesions. Note the present but in no solid lesions are present
appearance, size, location, presence, particular pattern less than 1 cm
and appearance of drainage.
15. HAIR ASSESSMENT Long, black, thick, and Copper-red color and dry
*Note: Color of hair, texture, amount of hair, flaking, smooth hair hair, and scalp is flaking
parasites,

1) Inspect and palpate the hair for color,

texture, growth, and distribution of hair.
2) Inspect the scaly, lumps, nevi, or other

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 lesions.
3) Inspect the body, axillae, and pubic hair for
amount and distribution as well as parasites.
4) Inspect the scalp for lesions, flaking, and
parasites by separating the hair at 1- to 2-
inch intervals.
16. NAIL ASSESSMENT Longitudinal bands of Cyanosis and marker
*Note: Color, texture, shape, firm attachment to the nail pigment may be seen. pallor
bed, and longitudinal bands of pigment.
1) Inspect and palpate the fingernails and Capillary refill is <2
toenails. seconds
2) Check the capillary refill by pressing the nail
edge to blanch and then release pressure Nails presents no
quickly, noting the return of color. discoloration, ridges,
pitting, thickening or
separation from edge.

17. HEAD ASSESSMENT Normal skull size and Asymmetric face features
1) Inspect the skull for size, shape, and shape, symmetrical
symmetry. face features
2) Inspect the scalp for tenderness, lesions, and
bumps. Absence of nodules
3) Assess central neurologic function, vision, and masses Sebaceous cyst is present
hearing and mouth structures.
18. NECK ASSESSMENT Head positions Rigid head and neck occur
*Note: Lymph node for size, shape, delimitation, centered in the with arthritis
(discrete or matted together), mobility, consistency, any midline and Pain at any particular
tenderness; difference between lymph node and muscle the head should be movement, limited
or artery. held erect movement due to cervical
1) Inspect anteriorly for symmetry, masses, Lymph nodes are arthritis or inflammation
enlarged lymph nodes, or deviation. neither visible nor on
2) Begin palpation – pads of the 2nd and 3rd redness of the neck muscles
fingers and palpate the preauricular nodes
with a gentle rotary motion. Palpate head,
neck and subclavicular lymph nodes.
3) Inspect trachea position.
4) Test sternomastoid and upper trapezius
muscle strength.
5) Test head and neck range of motion (flexion,
extension, rotation, and lateral bends).
6) Inspect thyroid.
7) Palpate thyroid. (May be from front or back
of patient)
8) The nurse will assess the following from the
back of the patient:
 Assess the cervical spine (inspection,
palpation)
 Assess for pain at the costovertebral
angle (CVA tenderness)

19. EYES ASSESSMENT  Symmetrical  Asymmetrical

 Position and Alignment: eyes & eyes and
1) Eyes. eyebrows eyebrows
 Stand in front of the patient and  No scaling  Presence of scales
survey the eyes for position and of eyebrows around eyebrows,
alignment. If one or both eyes periorbital edema,

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 seem to protrude, assess them  No and excessive
from above. periorbital tearing
2) Eyebrows. edema  Pale bulbar and
 Inspect the eyebrows, noting  No palpebral
their quantity and distribution excessive conjunctivae
and any scaliness of the tearing  Icteric sclerae
underlying skin.  Pink bulbar  Pupils are
3) Eyelids. unequal.
and
 Note the position of the lids in  Pupils are fixed
palpebral
relation to the eyeballs. and dilated
conjunctivae
 Inspect for the width of the  Limited
 Anicteric
palpebral fissures—open area extraocular
between the upper and lower sclerae movement
eyelids  Pupils  Poor convergence
4) Lacrimal Apparatus. equally  Myopia(near-
 Inspect the region of the round and sightedness)
lacrimal gland and lacrimal sac reactive to  Hyperopia(far-
for swelling. light sightedness)
 Look for excessive tearing or  Good
dryness of the eye. convergence
5) Conjunctiva and Sclera.
 Ask the patient to look up as you
depress both lower lids with
your thumbs.
 Inspect the sclera and palpebral
conjunctiva for color and note
the vascular pattern against the
white sclera background.
 Ask the patient to look to each
side and down.
6) Cornea and Lens.
 With oblique lighting, inspect
the cornea of each eye for
opacities and note any opacities
in the lens.
7) Iris.
 At the same time, inspect each
iris. The markings should be
clearly defined.
 With the light shining directly
from the temporal side, look for
a crescentic shadow on the
medial side of the iris.
8) Pupils.
 In dim light, inspect the size,
shape, and symmetry of each
pupil.
 Measure the pupils with a guide
such as a card or a flashlight
with black circles of various sizes
to facilitate measurement.
9) Pupillary Response to Light.
 Ask the patient to look into the
distance, and shine a bright light
or penlight obliquely (from the
side of the eye) into each pupil*

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  Remove it on the other side and
observe how the pupil reacts
 Repeat other side with same
procedure
 Look for:
 Direct reaction (pupillary
constriction in the same eye)
 Consensual reaction (pupillary
constriction in the opposite eye)
10) Coordination of Eye Movement (6
Extraocular Eye Movements /EOMs).
 Hold an object at a distance
from the client
 Ask him/her to keep his/head
still and follow the object with
eyes only
 Making a wide “H” in the air,
lead the patient’s gaze:
 To the patient’s extreme right
 To the right and upward
 Down on the right
 Without pausing in the middle,
to the extreme left
 To the left and upward
 Down on the left
11) Convergence Test.
 Ask the client to follow your
finger or pencil as you move it in
toward the bridge of the nose.
The converging eyes normally
follow the object to within 5-8
cm of the nose.
12) Snellen Eye Chart Test.
 Use the Snellen Eye Chart, which includes
objects, letters, or numbers of different sizes
in rows, under well-light.
 Position the client 20 feet from the chart and
ask him/her to identify the items
 Compare visual acuity of the client with
normal vision
20. EAR ASSESSMENT  Symmetric  Asymmetric
1) Using an otoscope, hold the helix, gently pull auricles, the pinna auricles, pinna is
the pinna upward and backward toward the is at the level of not at the level of
occiput. the inner and the inner and
2) Gently insert the otoscope and examine the outer canthus of outer canthus of
ear. the eyes the eyes
3) Inspect the pinna, external canal, tympanic  Minimal  Atresia
membrane, landmarks. hen inspecting the cerumen on
 Impacted
ear canal, note any discharge, foreign ears
cerumen
bodies, redness of the skin, or swelling.
 The client is
Cerumen/ear wax varies in color and  No masses and
unable to hear
consistency from yellow to flaky to brown lesions on
and sticky or even to dark and hard, may auricles,  High tone loss
wholly or partly obscure your view. mastoid region  Sound will be
4) Palpate pinna for tenderness, consistency of heard best in
the cartilage, and swelling.  Client repeats abnormal ear or

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*Hearing/Auditory Acuity Tests each word normal ear
a) Voice/Whisper Test: correctly after  Bone conduction
1) Test one ear at a time. hearing it. is heard longer
2) Stay 30-60 cm away from the client’s ear. than air
3) Whisper slowly some two-syllable words  Equal sound in conduction sound
(e.g. black shirt, blue wall). both ears
b) Weber Test (512 Hz on top of head):
1) Hold the tuning fork at its base.  Normal
2) Activate it by tapping the fork gently against hearing
the back of your hand near the knuckles or presents
by stroking the fork between the thumb and when: air
the index finger (soft ringing). conduction is
3) Place the base of the lightly vibrating fork on longer than
top of the client’s head or midforehead. bone
4) Ask where the patient hears it: on one or conduction in
both sides? Normally the sound is heard in both ears.
the midline or equally in both ears.
5) If nothing is heard, try again, pressing the
fork more firmly on the head. Because
patients with normal hearing may lateralize,
this test should be restricted to those with
hearing loss.
c) Rinne Test (512 Hz on mastoid bone)
1) Hold the handle of the activated tuning fork
in the mastoid process of one ear until the
client states that the vibration can no longer
be heard.
2) When the patient can no longer hear the
sound, quickly place the fork close to the ear
canal and ascertain whether the sound can
be heard again. Here the “U” of the fork
should face forward, thus maximizing its
sound for the patient.
3) Immediately hold the still vibrating fork
prongs in front of the client’s ear canal
4) Ask whether the client now hears the sound.

A (92-100) Student’s Signature: _____________________________

A- (84-91.99) Clinical Instructor’s Signature: _____________________

B (76-83.99)

B- (68-75.99)

C (60-67.99)

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F (<60)