Areas examined Subjective

Physical Assessment Objective

“Cephalocaudal Assessment” Problems identified
INTEGUMENTARY:
Skin Good turgor, no rash, No problems identified.
unusual bruising or
prominent lesions

Hair Normal texture and No problems identified.

distribution.
Absence of lice
Nails Pink color, convex No problems identified.
shaped, and firmly
intact to the skin

Neurology Sensation to pain,

touch, and No problems identified.
proprioception
normal.
Head:
Head & Skull Round and No problems identified
symmetrical.
Smooth and not No problems identified
tender, and no
lesions or masses
Face Rounded face, No problems identified
symmetrical and no
involuntary
movements.
Eyes and Vision:
Eyebrows Eyebrows are No problems identified
symmetrically
aligned
Eyelashes Eyelashes appeared No problems identified
to be equally
distributed and
curled slightly
outward

Eyelids There was no No problems identified.

presence of
discharges, no
discoloration and lids
close symmetrically
with involuntary
blinks approximately
15-20 times per
minute.

Eyes 20/20 vision. The No problems identified.

sclera appeared
white. The palpebral
conjunctiva appeared
shiny, smooth and
 pink. There is no
edema or tearing of
the lacrimal gland.
Ears and Hearing Firm, smooth, free
from lesions and No problems identified.
pain.
Nose & Sinuses Located
symmetrically, mid- No problems identified.
line of the face and is
without swelling,
bleeding.

Mouth The lips of the client No problems identified.

are uniformly pink;
moist, symmetric
and have a smooth
texture. The client
was able to purse his
lips when asked to
whistle.

Neck Movement though No problems identified.

full range of motion
without compliant of
discomfort or
limitation.

Thorax & Lungs

Lungs  Palpation:  Ineffective airway
Increased tactile clearance related to
fremitus copious
tracheobronchial
 Percussion: secretions.
Dullness on
percussion  Activity intolerance
related to impaired
 Auscultation: respiratory function.
Decreased breath
sounds  Risk for deficient
Bronchial breath fluid volume related
sounds to fever and a rapid
Rhonchi respiratory rate.
Crackles, Rales
Increased vocal
fremitus
Heart  The patient’s
heart has no No problems identified.
palpable
pulsation over
the aortic,
pulmonic, and
mitral valves, no
noted abnormal
heaves, and
thrills.
 No abnormal
heart sounds are
heard like
murmurs.

GI System Bowel sounds No problems identified.

present on
auscultation.
Abdomen soft on
palpation with no
pain or tenderness.
Tolerates prescribed
diet without nausea
and/or vomiting.
Having bowel
movements within
normal pattern

Extremities No amputations or No problems identified.

deformities,
cyanosis, edema or
varicosities,
peripheral pulses
intact

Muscles There was no No problems identified.

presence of bone
deformities,
tenderness and
swelling.

Bones No deformities No problems identified.

Joints No swelling or No problems identified.

tenderness in joints.
ROM without
limitations. No
muscular weakness
or pain.

Lymphatic System No lumps detected No problems identified.

Hematology No problems identified.
RBC, WBC,
Platelets are normal.

Hanilou H. Carballo
BSN4-C