PHYSICAL ASSESSMENT FINDINGS

FEU - INSTITUTE OF NURSING 2ND SEMESTER AY 2020-2021

Name of Client: C. H. C Date Conducted: March 24, 2022

Age: 19 Gender: Male

Assessing Head and Face

BODY INTERPRETATION
PART/AREA TO NORMAL FINDINGS ACTUAL FINDINGS and ANALYSIS
BE ASSESSED
Head size and shape vary, As per inspection, the client’s head
especially in accord with ethnicity. is appropriate with its ethnicity.
Usually the head is symmetric, Also, the head is properly aligned in
round, erect, and in midline the midline of the body. Moreover,
Inspect the head. and appropriately related to body the client’s head is normocephalic in
size (normocephalic). other words the client’s head size is NORMAL
No lesions are visible. appropriate with the client’s body
size. Lastly, no lesions are visible.

Head should be held still and The client’s head is upright and
Inspect for involuntary upright. erect. NORMAL
movement.

The face is symmetric with a Upon inspection, the client’s face is

round, oval, or elongated
appearance. No abnormal
Inspect the face. movements noted.
seen to have an oval appearance.
Also, no sudden or uncontrolled
movements were seen which can be NORMAL
an indicator for any neurological
disorders.

The head is normally hard and After palpating, the client’s head is
Palpate the head. smooth, without lesions. hard and smooth. Furthermore, no
Note consistency. lesions, infestations and excess NORMAL
amount of sebum were noted.
The temporal artery is elastic and Upon palpating, the client’s
Palpate the temporal not tender. temporal artery is elastic, and no NORMAL
artery. tenderness were felt.
Normally there is no swelling, After palpating, the
tenderness, or crepitation with temporomandibular joint is within
Palpate the movement. Mouth opens and normal range. no swelling,
temporomandibular closes fully (3 to 6 cm between tenderness and crepitation were NORMAL
joint (TMJ upper and lower teeth). Lower jaw recorded. The client was able to
moves laterally 1to 2 cm in each open his mouth fully for 3 to 6 cm
direction. and the lower jaw to move side to
side for 1 to 2 cm on both sides.

Assessing Neck
 BODY INTERPRETATION
PART/AREA TO NORMAL FINDINGS ACTUAL FINDINGS and ANALYSIS
BE ASSESSED
Neck is symmetric, with head Upon inspection, the neck is seen
centered and without bulging to be in the midline of the body
Inspect the neck. masses. and symmetric. Also, no swelling, NORMAL
lumps and bumps were seen.

The thyroid cartilage, cricoid After swallowing, the client’s neck

Inspect movement of the cartilage move upward structures such as thyroid cartilage
neck structures. symmetrically as the client and cricoid cartilage both move in NORMAL
swallows. sync or symmetrically going up.
C7 (vertebrae prominent) is Upon observation, the client’s
Inspect the cervical usually visible and palpable. cervical vertebrae (C7) is visible NORMAL
vertebrae. and palpable.
Normally neck movements should The client was able to move their
be smooth and controlled with 45- neck without any difficulty and
degree flexion, 55-degree stiffness. The movement was
extension, 40-degree lateral smooth and controlled. Furthermore,
abduction, and 70-degree rotation. the client was able to extend the
Inspect range of motion. movement of their neck in different NORMAL
degree angles: Flexion (45 degrees),
Extension (55 degree), Lateral
Abduction (40 degree) and
Rotation (70 degree).
Trachea is midline. The client’s trachea is seen and felt
Palpate trachea. in the midline of the body. NORMAL

Landmarks are positioned midline. The landmarks of the thyroid gland

Palpate thyroid gland. of the client were position in the NORMAL
midline of the body.
Glandular thyroid tissue may be Upon observation the client’s
felt rising underneath your fingers. thyroid gland has no enlargement
Ask the client to Lobes should feel smooth, rubbery, and the lobes of his thyroid gland is NORMAL
swallow. and free of nodules. smooth, rubbery, and free from any
noticeable nodules.
Auscultate the thyroid No bruits are auscultated. Since no abnormalities or
only if there’s an enlargement were felt in the client’s NORMAL
enlarged thyroid gland. thyroid gland, there is no need to
auscultate and listen for bruits.
There is no swelling or After palpation, there is no seen and
enlargement and no tenderness. felt swelling, enlargement or
Palpate the lymph tenderness.
nodes. NORMAL
 Assessing Eyes
BODY INTERPRETATION
PART/AREA TO NORMAL FINDINGS ACTUAL FINDINGS and ANALYSIS
BE ASSESSED
Normal distant visual acuity is The result of the client’s distant
20/20 with or without corrective visual acuity is both 20/20 for the
lenses this means that the client left and right eye. The client can NORMAL
Test distant visual can distinguish what the person distinguish the letters in the chart
acuity. with normal vision can even from 20 feet away.
distinguish from 20 feet away.
Normal near visual is 14/14 (with The result of the client’s near acuity
or without corrective lenses). This is both 14/14 for the left and the
means that the client can read what right eye. The client can read small
Test near visual acuity. the normal eye can read from 14 letters without difficulty from 14 NORMAL
inches. inches.
With normal peripheral vision, the The peripheral vision of the client is
client should see the examiner’s within normal range and can see the
finger at the same time the examiner’s finger at the same time
examiner sees it. Normal visual in four different field degrees:
Test visual fields for field degrees are approximately as Inferior (70 degrees), Superior (50 NORMAL
gross peripheral vision. follows: degrees), Temporal (90 degrees)
• Inferior: 70 degrees and Nasal (60 degrees).
• Superior: 50 degrees
• Temporal: 90 degrees
• Nasal: 60 degrees
The reflection of light on the On both corneas of the client, the
Perform Corneal Light corneas should be in the exact reflection is in the same spot which
Reflex Test. same spot on each eye, which explains and indicates that the NORMAL
indicates parallel alignment. alignment of the client’s eye is
parallel with each other.
The uncovered eye should remain The client’s covered eye remained
fixed straight ahead. The covered fixed and no need for time to adjust
eye should remain fixed straight and remained focus on the object NORMAL
Perform Cover Test. ahead after being uncovered. after taking off the cover.

Eye movement should be smooth The client’s eye movement is

Perform the Position and symmetric throughout all six smooth and controlled. Both eye are
Test. directions. symmetric and in synch in following NORMAL
an object in all six directions.

The upper lid margin should be The client’s upper lid margin and
between the upper margin of the lower lid margin are both within
iris and the upper margin of the normal levels. The upper lid margin
pupil. The lower lid margin rests or the client is appropriately in
Inspect the eyelids and on the lower border of the iris no between the upper margin of the iris
eyelashes. white sclera are seen above or and the upper margin of the pupil. NORMAL
below the iris palpebral fissures The lower lid margin rests on the
may be horizontal. lower margin of the iris and no
sclera is seen above and below the
iris.
The upper and lower lids close The client had no difficulty in
easily and meet completely when controlling and moving his eyelids.
Assess ability of eyelids closed. No problem has occurred in closing NORMAL
to close. and opening of the eyes. The upper
and lower lids closed easily and can
completely close with no difficulty.
Note the position of the The lower eyelid is upright with no The client’s lower eyelids are
eyelids in comparison inward or outward turning. neither inward nor outward in terms
with the eyeballs. Eyelashes are evenly distributed of turning. Eyelashes are also NORMAL
(Also note any unusual and curve outward along the lead observed that it was evenly
turnings, color, swelling, margins distributed and curved outwards.
lesions, and discharge.)
Skin on both eyelids is without The skin on the client’s eyelids has
Observe for redness, redness, swelling, or lesions. no redness, swelling and lesions.
swelling, discharge, or NORMAL
lesions.

Eyeballs are symmetrically aligned The client’s eyeball are seen to have
Observe the position in sockets without protruding or a structure that are symmetrically
and alignment of the sinking. aligned without protruding and NORMAL
eyeball in the eye socket. sinking.

Bulbar conjunctiva is clear, moist, The client’s Bulbar conjunctiva is

Inspect the bulbar and smooth. Underlying structures clear, moist, and smooth. Also, the
conjunctiva and sclera. are clearly visible. Sclera is white. client’s sclera is white. NORMAL

The lower and upper palpebral The client’s upper and lower
conjunctivae are clear and free of conjunctiva are clear, moist and no
Inspect the palpebral swelling or lesions. swelling and lesions were seen. NORMAL
conjunctiva.

Palpebral conjunctiva is free of After everting the upper eyelids. it is

swelling, foreign bodies, or observed that no swelling, stye or
Evert the upper eyelid. trauma. any foreign object are present. NORMAL

No swelling or redness should Upon observation, the lacrimal

appear over areas of the lacrimal apparatus and the areas surrounding
Inspect lacrimal gland. The puncta are visible it has no swelling or redness. Also,
apparatus. without swelling or redness and is the puncta are visible without any NORMAL
turned slightly toward the eye. swelling or redness.
No drainage should be noted from After palpating, the lacrimal
Palpate lacrimal the puncta when palpating the apparatus of the client has no
apparatus. nasolacrimal duct. drainage from the puncta or the NORMAL
nasolacrimal duct.
The cornea is transparent, with no After inspection, the cornea of the
opacities. The oblique view shows client is transparent, and no
Inspect the cornea and a smooth and overall moist opacities were noted and seen. NORMAL
lens. surface; the lens is free of Overall, the surface is smooth and
opacities. moist. Also, the lens is free from
any opacities.
The iris is typically round, flat, and After inspection, the client’s iris is
evenly colored. The pupil, round round, and the color is evenly
 with a regular border, is centered distributed. The pupil is round as
in the iris pupils are normally well as centered. The pupils are
equal in size (3 to 5 mm). and equal in size for about 3 to 5 mm. A
Inspect the iris and equality in pupil size of lens than condition call anisocoria which is NORMAL
pupil. 0.5 mm of course in 20% of 0.55 mm of deviation for the
clients. This condition called equality of the pupil size is normal.
anisocoria, is normal.
The normal direct pupillary The client’s eye constricted when
Test pupillary reaction response is constriction. light was directly shined at it and
to light. the pupillary response was normal. NORMAL

The normal consensual pupillary The client’s eye constricted when

Assess consensual response is constriction. light was indirectly shined at it and
response. the pupillary response was normal. NORMAL

The normal pupillary response is The client’s eye has no difficulty in

constriction of the pupils and
Test accommodation of convergence of the eyes when
pupils. focusing on a near object
(accommodation and
convergence).
focusing on a moving object (near
or far). Furthermore, the pupillary
response of the pupils are NORMAL
constriction and convergence which
were both observed during the test.

Assessing Ear
BODY INTERPRETATION
PART/AREA TO NORMAL FINDINGS ACTUAL FINDINGS and ANALYSIS
BE ASSESSED
Ears are equal in size bilaterally Upon inspection, the client’s ears
(normally 4 - 10 cm). The are both bilaterally equal in size
auricle aligns with the corner of and the auricle of the client is
each eye and within a 10-degree aligned with the corner of each
Inspect the auricle, angle of the vertical position. eye. Lastly, the client’s earlobes
tragus, and lobule. Earlobes may be free, attached, are attached to the adjacent skin NORMAL
or soldered (tightly attached to
adjacent skin with no apparent
lobe).
Continue inspecting the The skin is smooth, with no Overall view, the skin of the
auricle, tragus, and lesions, lumps, or nodules. Color is external ear is free from lesions,
lobule. consistent with facial color. lumps, and nodules. The color of the NORMAL
Observe for lesions Darwin’s tubercle, which is a ear is even throughout the skin of
discolorations, and clinically insignificant projection, the ear. Also, no discharge was
discharge. may be seen on the auricle. No noted.
discharge should be present.
Palpate the auricle and Normally the auricle, tragus, and After palpation, the auricle and the
mastoid process. mastoid process are not tender. mastoid process of the client are not NORMAL
tender to the touch.
A small amount of odorless The client has little to no cerumen
cerumen (earwax) is the only (earwax) which are odorless. There
discharge normally is a normal amount of discharge of
present. Cerumen cerumen seen. The color of the
 Inspect the external color may be yellow,
auditory canal. orange, red, brown, gray,
or black. Consistency may
be soft, moist, dry, flaky,
or even hard.
cerumen is yellowish, orange, red.
The consistency was also soft moist NORMAL
on some parts and dry flaky on
some.

The canal walls should be pink and The client’s canal wall is pinkish
Observe the color and smooth, without nodules. and smooth. Also, it was observed
consistency of the ear that the canal wall is free of nodules.
canal walls and inspect NORMAL
the character of any
nodules.
The tympanic membrane Upon inspection, the tympanic
should be pearly, gray, membrane of the client is
shiny, and translucent, translucent, gray, shiny and pearly.
with no bulging or No bulging and retraction were
retraction. It is slightly concave, noticed. It is slightly concave,
smooth, and intact. A cone-shaped smooth, and intact. Furthermore, the
Inspect the tympanic reflection of the otoscope light is short process and handle of the
membrane (eardrum). normally seen at 5 malleus and the umbo are visible NORMAL
o’clock in the right ear and 7
o’clock in the left
ear. The short process and handle
of the malleus and the umbo are
clearly visible.
Able to correctly repeat the two- The client was able to repeat the
Perform the whisper syllable word as whispered. two-syllable word correctly which
test. was whispered for 2 feet away. NORMAL

Perform Weber’s test if Vibrations are heard equally well The client was able to hear the
the client reports in both ears. No lateralization of vibrations and sound of the tuning
diminished or lost sound to either ear. fork equally on both ears. NORMAL
hearing in one ear.
Air conduction sound is normally The client was able to hear the air
Perform Rinne’s test. heard longer than bone conduction conduction longer than the bone NORMAL
sound (AC > BC). conduction.

Client maintains position for 20 The client was able to stand up

seconds without swaying or with straight with minimal swaying for
Perform the Romberg minimal swaying. 20 seconds. NORMAL
test.

Assessing Nose
BODY INTERPRETATION
PART/AREA TO NORMAL FINDINGS ACTUAL FINDINGS and ANALYSIS
 BE ASSESSED
Color is the same as the rest of The client’s external nose is
the face; the nasal structure is unified in color with the rest of
Inspect and palpate the smooth and symmetric; the the face. Also, the nasal structure NORMAL
external nose. client reports no tenderness. of the client is smooth and
symmetric, no tenderness was
reported by the client and
seen/felt by the examiner.
Check patency of air Client can sniff through each The client had no difficulty in
flow through the nostrils nostril while other is occluded. sniffing on one nostril when the
by occluding one nostril other is covered or occluded. NORMAL
at a time and asking
client to sniff.
Inspect Internal nose. The nasal mucosa is dark The nasal mucosa of the client is
pink, moist, and free of observed to be dark pink, moist and NORMAL
exudate. The nasal septum is intact free from any exudate. The nasal
and free of ulcers or perforations. septum of the client was also seen to
Turbinates be intact and free from ulcers and
are dark pink (redder than oral other perforations. Lastly, the
mucosa), moist, and free of Turbinate of the client are dark pink
lesions. which is darker and redder than the
nasal mucosa. As well as moist and
no lesions were seen.
Frontal and maxillary sinuses are After palpating the frontal and
Palpate sinuses. nontender to palpation, and no maxillary sinuses, no tenderness and NORMAL
crepitus is evident. no crepitus were seen and heard.
The sinuses are not tender on The sinuses of the client has no
percussion. tenderness felt upon percussion.
Percuss the sinuses. NORMAL

Assessing Mouth
BODY INTERPRETATION
 PART/AREA TO NORMAL FINDINGS ACTUAL FINDINGS and ANALYSIS
BE ASSESSED
Lips are smooth moist without The client’s lips were seen to be
lesions or swelling. smooth and moist. Also, there is
Inspect the lips. no lesions and swelling were NORMAL
seen.
Thirty-two pearly whitish The client was seen to have 30
teeth with smooth surfaces and pearly white teeth with smooth
edges. Upper molars should rest surfaces and edges/ The client has
directly on the lower molars and the 28 teeth present on his gum with
front soft surfaces and edges. The upper
Inspect the teeth and upper incisors should slightly molars rest on the lower molars. NORMAL
gums. override the lower incisors. Some As well as the upper incisors is
clients normally have only 28 teeth slightly in front of the lower
if the four wisdom teeth do incisors.
not erupt.

No decayed areas; no missing teeth. The client’s selection of teeth has

Client may have appliances on the
teeth (e.g., braces). Client may
have evidence of repair work done
Put on gloves and on teeth (e.g., fillings, crowns, or
retract the client’s lips cosmetics such as veneers). Gums
and cheeks to check are pink, moist, and firm with tight
gums for color and margins to the tooth. No lesions or
consistency. masses.
no decayed areas and no missing
teeth on the client’s gums. Also,
the gums of the clients are pink,
moist, and firm with tight margins.
Lastly, there are no lesions or
masses. NORMAL

The buccal mucosa should appear The client’s buccal mucosa is

pink in light-skinned clients; tissue pinking and red.
Inspect buccal mucosa. pigmentation typically increases in NORMAL
dark skinned clients.
Tongue should be pink, moist, a The client’s tongue is pink and
moderate size with papillae (little moist. The size of it is appropriate
protuberances) present. A common and moderate in size and slight
Inspect and palpate variation is a fissured, topographic- papillae were present. Also, No
tongue. map-like tongue, which is not lesions are seen on the surface of NORMAL
unusual in older clients. No lesions the tongue.
are present.
The tongue’s ventral surface is After assessing the ventral surface
Assess the ventral smooth, shiny, pink, or slightly pale, of the client’s tongue. It is seen to
surface of the tongue. with visible veins and no lesions. be smooth, shiny, and pink with NORMAL
visible veins and no lesions.
The older client may have varicose Since the client is still young adult
Palpate the area if you veins on the ventral surface of the with no vices in using cigarettes
see lesions, if the client is tongue. there is no presence of varicose
over age 50, or if the veins on the client’s ventral surface
client uses tobacco or of the tongue. The size of the
alcohol. Note any client’s frenulum is appropriate NORMAL
induration. Check also without limiting the movements of
for a short the client’s tongue.
frenulum that limits
 tongue motion (the
origin of “tongue-
tied”).

The frenulum is in the midline; The client’s frenulum is in midline

Wharton’s ducts are visible, with then the client’s Wharton’s ducts is
Inspect for Wharton’s salivary flow or moistness in the visible, with salivary flow or NORMAL
ducts. area, The client has no swelling, moistness in the area. There is no
redness, or pain. swelling redness, or pain upon
inspecting the ventral surface of
the tongue of client.
No lesions, ulcers, or nodules are Upon observing the sides of the
Observe the sides of the apparent. tongue, no lesions, ulcers, and
tongue. nodules are seen and present at the NORMAL
client’s tongue.

The tongue offers strong resistance. The client’s tongue gives out a
Check the strength of strong resistance when the tongue NORMAL
the tongue. is given slight pressure.

The hard palate is pale or

whitish with firm, transverse rugae The hard palate of the client is
Inspect the hard (wrinkle-like folds). Palatine tissues slightly white with firm and
(anterior) and soft are intact; the soft palate transverse rugae or the wrinkle like NORMAL
(posterior) palates and should be pinkish, movable, spongy, folds. Furthermore, the client’s soft
uvula. and palate is pinkish, spongy, smooth,
smooth. and movable.

No unusual or foul odor is noted. During the whole mouth

Note odor.
The uvula is a fleshy, solid
structure that hangs freely in the
midline. No redness of or exudate
from uvula or soft palate. Midline
elevation of uvula and symmetric
elevation of the soft palate. A bifid
Assess uvula uvula, common in Native
Americans, looks like it is split in
two or partially severed.
assessment, no unusual or foul NORMAL
odor was noticed.
The client’s uvula has no redness
or exudate seen. The uvula of the
client hangs freely in the midline
of the mouth and has symmetric
elevations.
NORMAL

Tonsils may be present or absent. The client’s tonsils are present and
They are normally pink and pinkish in color. No swelling and
symmetric and may be enlarged to lesions are noticed.
1+ in healthy clients. No exudate,
Inspect the tonsils. swelling, or lesions should be NORMAL
present.
 Throat is normally pink, without After the inspection, the throat or
Inspect the posterior exudate or lesions. the posterior pharyngeal wall is
pharyngeal wall. pinkish and no lesions and NORMAL
exudates are seen.

*There may be clients who may NOT provide consent to expose or assess certain body parts/area because of
cultural, personal and/or health reasons. You may just indicate N/A or Not Assessed.

FEU – INSTITUTE OF NURSING NCM101 HEALTH

ASSESSMENT