PHYSICAL ASSESSMENT B.

Arteries and veins (rate and rhythm of

pulse, strength, type and equality of
I. GENERAL SURVEY arterial pulses)
A. General appearance and
behavior VII. BREASTS (symmetry, contour, color,
1. Gender and race lesions, mass, pain, discharges)
2. Signs of distress (Anxiety, pain,
difficulty of breathing)
3. Body type (trim, muscular, obese,
or excessively trim) VIII. ABDOMEN
4. Posture (erect, bent, stoop or A. Inspection
slumped) B. Auscultation
5. Gait C. Percussion
6. Body movement (purposeful, D. Palpation
presence of tremors, immobility)
7. Age IX. GENITALIA (Female / Male)
8. Hygiene and grooming (distribution of hair growth, color of
(appearance of hair, skin, and fingernails)
perineum, presence of discharges,
9. Dress (culture, lifestyle,
socioeconomic level and personal inflammation, edema, ulceration, lesions)
preference affects the type of
clothes worn) X. RECTUM and ANUS (presence of
10. Body odor lesions, ulcers, inflammation, rashes,
11. Affect and mood (feelings) discoloration)
12. Speech (normal tone, rapid, or
slow)qq XII. MUSCULOSKELETAL SYSTEM
B. Taking Height and Weight A. General inspection (gait and
C. Taking Vital Signs posture)
B. Range of joint motion (equality of
II. INTEGUMENT movement, presence of pain,
A. Skin (color, moisture, temp., texture, nodules)
turgor, vascularity, edema, lesions) C. Muscle tone and strength
B. Hair and scalp (distribution, texture, (rigidity, weakness)
scaliness, lesions, dryness, presence of
lice) XIII. NEUROLOGICAL SYSTEM
C. Nails (color, thickness, shape, condition A. Mental and emotional status
of the nail folds) (level of consciousness, behavior
& appearance, language)
III. HEAD and NECK B. Intellectual function (memory,
A. Head knowledge, abstract thinking,
B. Eyes (visual acuity, extraocular association, judgment)
movements, visual fields, external eye C. Cranial nerve function
structure) D. Sensory function (vision, hearing,
C. Ears (auricles, ear canals, eardrums, smell, touch, taste)
hearing acuity) E. Motor function (coordination,
D. Nose and sinuses (color of mucosa, balance)
lesions, discharge, swelling, symmetry) F. Reflexes
E. Mouth and pharynx (color, edema,
bleeding, lesions, smell, swelling or GORDON’S 11 FUNCTIONAL HEALTH
infection) PATTERNS
F. Neck (neck muscles, lymph nodes, size,
shape, tenderness and mobility) PATTERN OF HEALTH PERCEPTION &
IV. THORAX and LUNGS (Posterior, HEALTH MANAGEMENT
Lateral, Anterior) ● How does the person describe her/ his
V. HEART (rate, rhythm, presence of chest current health?
pain) ● What does the person do to improve or
VI. VASCULAR SYSTEM maintain her/ his health?
● What does the person know about links
A. Blood pressure
between lifestyle choices and health?
● How big a problem is financing health
care for this person?
● Can this person report the names of
current medications s/he is taking and
their purpose?
● If this person has allergies, what does
s/he do to prevent problems?
● What does this person know about
medical problems in the family?
● Have there been any important illnesses
or injuries in this person's life?
NUTRITIONAL - METABOLIC PATTERN
● Is the person well nourished?
● How do the person's food choices
compare with recommended food
intake?
● Does the person have any disease that
affects nutritional- metabolic function?
PATTERN OF ELIMINATION
● Are the person's excretory functions
within the normal range?
● Does the person have any disease of
the digestive system, urinary system or
skin?
PATTERN OF ACTIVITY & EXERCISE
● How does the person describe her/ his
weekly pattern of activity and leisure,
exercise and recreation?
● Does the person have any diseases
that affect her/his cardio-respiratory
system or musculoskeletal system?
COGNITIVE - PERCEPTUAL PATTERN
● Does the person have any sensory
deficits? Are they corrected?
● Can this person express her/ himself
clearly and logically?
● How educated is this person?
● Does the person have any disease that
affects mental or sensory functions?
● If this person has pain, describe it and
its causes.
PATTERN OF SLEEP & REST
● Describe this person's sleep-wake
cycle.
● Does this person appear physically
rested and relaxed?
PATTERN OF SELF PERCEPTION &
SELF CONCEPT
● Is there anything unusual about this
person's appearance?
● Does this person seem comfortable
with her/ his appearance?
● Describe this person's feeling state.
ROLE - RELATIONSHIP PATTERN
● How does this person describe her/ his
various roles in life?
● Has, or does this person now have
positive role models for these roles?
● Which relationships are most important
to this person at present?
● Is this person currently going through
any big changes in role or relationship?
What are they?
SEXUALITY - REPRODUCTIVE
PATTERN
● Is this person satisfied with her/ his
situation related to sexuality?
● How have the person's plans and
experience matched regarding having
children?
● Does this person have any disease/
dysfunction of the reproductive
system?
PATTERN OF COPING & STRESS
TOLERANCE
● How does this person usually cope
with problems?
● Do these actions help or make things
worse?
● Has this person had any treatment for
emotional distress?
PATTERN OF VALUES & BELIEFS
● What principles did this person learn as
a child that is still important to her/
him?
● Does this person identify with any
cultural, ethnic, religious, regional, or
other groups?
● What support systems does this
person currently have?