Skin

Area/Region Findings Normal Findings Interpretation/Analysis

Color Brown Complexion Color varies from light to ruddy No area of increased
pink or dark brown. vascularity and
ecchymosis

Temperature Warmth to touch Temperature is within normal Temperature is

and her range. normal.
temperature is
36.4°C
Texture Smooth and even Texture is not uniform like the No abnormal findings
palms and soles are thicker than
any areas. Wrinkled and
leathery skin in the elderly
results from the normal aging.
Process with decreased collagen
subcutaneous fats, and sweat
glands.
Mobility And Turgor Skin recoils Absence of indention is No presence of edema.
immediately dependent areas and the Normal findings
resilience of the skin spring back
to its previous state after being
pinched.

Hair

Area/Region Findings Normal Findings Interpretation/Analysis

Color And Black colored hair Color varies from black to pale No abnormal findings
Distribution with artificial hair blonde based on the amount of
coloring, and melanin present
evenly distributed
Texture And Oiliness Soft and not oil hair Thin, straight, coarse. Normal findings
Infestation Absence of lice Free from any infestation No signs of infestation
or lesion.

Scalp

Area/ Region Findings Normal Findings Interpretation/Analysis

Tenderness No lesion, redness, Absence of redness and No presence of any
and scaliness scalines. lesion
Nail

Area/Region Findings Normal Findings Interpretation/ Analysis

Color, Shape and Pink color, convex Nail beds are highly vascular Normal color, shape and
Texture shaped, and firmly with a pink color in light skin texture of nails
intact to the skin and longitudinal streaks of
brown or black pigmentation in
dark skin.
Capillary Refill Immediately return When pressure is released Capillary refill of 1.5
to its normal color form the nail, it promptly seconds
return to its normal color. No abnormal findings
Lesion No lesions Tissue surrounding the nail is No presence of lesions
intact.

Skull

Area/ Region Findings Normal/ Findings Interpretation/ Analysis

Shape and Round and Rounded, symmetrical, No abnormal findings
Symmetry symmetrical normocephalic, and upright.
Contour, Masses, Smooth and not Smooth, non-tender, free of No presence of any
Depression and tenderness and no masses and depressions lesions
Tenderness lesions or no
masses

Face

Area/ Region Findings Normal Findings

Facial features Rounded face, May be oval or round. No abnormal and
symmetrical and no Symmetrical features and significant findings
involuntary movement.
movement
Edema And Masses No presence of No edema and masses No presence of lesions
edema and masses and edema

Eyes

Area/ Region Findings Normal Findings

Visuals Acuity 20/20 vision Normal vision based on the
Snellen chart is 20/20 at the
distance of 20 feet the normal
eye can read the chart.
Extraocular muscular Normal movement Eye movements is
movement and no History of symmetrical as both eyes
visual disturbance follow the direction of the
gaze and converge on the held
object as it moves toward the
Normal visual acuity
Sclera appears white
Pupils is equally round,
reactive to light, and
accomodation
approximately 4 mm.
Normal findings
 nose
External Anatomical No inflammation, Eyelid overlap iris. No tearing, swelling or
Structure edema and masses Eyes and eyelids are free of discharge.
edema, lumps, crusting, or
irritation.

Ears

Area/ Region Findings Normal Findings Interpretation/ analysis

External Ear Auricles are Upper attachment is Same color as face
symmetrical, same symmetrical and positioned at Central position
in color to the skin eye corner level. It is fleshed No redness, swelling or
on the face, aligned colored. tenderness
with the eye’s No abnormal findings
outer canthus, and
there is no
discharged and
swelling present
Auditory acuity Normal hearing Able to repeat the whispered Clear hearing
word

Nose and Sinuses

Area/Region Findings Normal Findings Interpretation / analysis

Nose No presence of Located symmetrically, mid- Symmetrical and in
discharge, swelling line of the face and is without midline of the face
or lesions. Nose swelling, bleeding, lesions or No abnormal findings
appeared masses
symmetrical.
Nasal Cavities There is only a Mucosa is pink or dull with- No swelling, bleeding,
small amount of out swelling or polyps lesions or masses
watery discharge
and no presence of Septum is midline and intact
swelling
A small amount of clear
watery discharge is normal
Sinuses No tenderness None tender air filled cavities No significant findings
Resonant sound upon
percussion
Mouth

Area/ Region Findings Normal Findings Interpretation/analysis

Breath No bad breath Breath slightly smell fresh Breathe smells fresh
Normal findings
Lips Moist with no Lips and mucosa is pink, firm Lips and membranes
lesion. and moist without pink and moist with no
inflammation or lesions. lesions or inflammation.
Gums Pinkish gums, Gums are pink, smooth and Gums has pink color,
moist and firm. moist. moist and firm.
Normal findings
Gums are firm.
Teeth No discoloration Teeth are properly aligned, Properly aligned and
and enamels. white and shiny white in color.
Normal findings
Tongue The center of the When protrude, tongue lays Tongue is midline, pink,
tongue is centrally midline, medium red, or pink moist, rough and
positioned, pink in color, moist and smooth without lesion.
and moist. along literal margins, with free
mobility. The dorsal sur- face
is slightly rough and free from
lesions.

The ventral surface is highly

vascular, smooth, moist and
free of lesions.
Palate Pink color and hard Palates are concave and pink. No abnormal findings
palate. Hard palate has ridge, Soft
palate is smooth.
Pharynx Soft palate and With phonation, the soft No presence of lesions
uvula are palate and uvula rise symmet-
symmetrical, has a rically. The pharynx is pink.
pink tint, and are vascular, lesion free.
free of lesions. Tonsil size is evaluated using
the grading scale.

Neck

Area /Region Findings Normal findings Interpretation/ analysis

Symmetry and Symmetrical and Muscles are symmetrically Symmetrical with head
musculature comfortably moved with head in central position. and in central position
from side to side. Movement though full range Normal findings
of motion without compliant
of discomfort or limitation.
Lymph nodes It is not palpable Lymph nodes is not palpable. Able to move neck
 Small, movable nodes are
insignificant.
Trachea It placed in the Middle position above the
middle of the neck. suprasternal notch.
Thyroid Unable to assess Thyroid cannot be visualized.
It may or may not be felt.
without discomfort
No palpable masses
No significant findings
Normal findings in
thyroid

If felt, it should be smooth,

soft, non-tender, and not
enlarged

Thorax and Lungs

Area / regions Findings Normal findings Interpretation/ analysis

A full symmetric Respiratory are quite, effort- Symmetrical thorax and

thorax and a less, and regular, with 12-20 no presence of abnormal
breathing rate of breaths per minute. Thorax breathing
19 cpm that is rises and falls in uni- son with Quiet, rhythmic, and
quiet, rhythmic, respiratory cycle. Ribs slope effortless breathing
and effortless across down, without No abnormal findings
movement or bulging in the
intercostal space.
Lesion When inhaling, the Thumb should separate an No presence of any
thumb separates equal distance of 3-5 cm and lesion
by 3 cm and the in the same direction during
pain and lesion thoracic expansion and meet
free. in the midline on expiration.

Posterior thorax is free from

tenderness, lesion and
pulsation.

Fremitus is equal on both

sides of thorax, strongest at
the level of tracheal
bifurcation.
Sound Unable to assess Air filled lungs create a Normal lung tissue
resonant sound. produces resonant
sound, diaphragm has
Identify collateral sound; dull sounds
bones create flat sound.
Thorax is more resonant in
children than adults.
Breath sound Unable to assess Posterior sounds: vesicular Normal bronchial,
and bronchovesicular. bronchovesicular, or
Lateral sound: vesicular vesicular breath sounds
 A large chest will produce
decreased breath sound.

Anterior thorax

Area/region Findings Normal findings Interpretation/analysis

Symmetry, Rhythm, Normal symmetry Thorax rises and falls in unison Normal symmetry,
and Slope with respiratory cycle, ribs as 45 rhythm, and slope
degree angle with sternum. In-
of spiratory breath sounds are
not audible at a distance or more
than 2 to 3 cm from mouth
Tenderness, No pain temperature No significant or
Pulsation, Masses, warm to touch, abnormal findings
and Crepitance equal bilateral, no
moisture, swelling, Same normal findings with
masses, or posterior palpation.
Respiratory deformities equal
excursion tactile fremitus.

Tactile fremitus
Symmetry and The bronchia, Good air entry, equal bilaterally, No significant findings
Sound bronchovesicular, no adventitious sounds
vesticular are throughout all lobes on anterior
present and equally thorax. Bronchovesicular sounds
thoughout. heard in upper lobes close to
sternum. Vesicular sounds heard
throughout peripheral lung field.

Cardiovascular

Area / region Findings Normal findings Interpretation/analysis

Arterial Pulse Has arterial pulse of Regular pulse Normal arterial pulse
80 bpm
Heart Unable to assess Note for location, size ang No significant findings
because of the quality of impulse
client’s right Palpate for PMI
Aortic area
Pulmonic area
Tricuspid area
 Mitral area (PMI)

Abdomen

Area / region Findings Normal findings Interpretation/analysis

Generalized Abdomen flat, Contour is flat or rounded and Abdominal contour
appearance of symmetrical with no bilaterally symmetrical. rounded
abdomen bulging, swelling, Symmetrical
discoloration. Uniform in color
Umbilicus is depressed and
Skin intact. Normal findings
beneath the abdominal
surface.

Visible peristalsis is slowly of

transverses the abdomen in
slanting downward
movements as observed in
thin client. Pulsation of the
abdominal aorta are visible in
the epigastric area in thin 1-
clients.

Bowel sounds Bowel sounds is High pitched sounds heared No friction rubs or
normal every 5-15 seconds as audible bruits
intermittent gurgling sounds in
all 4 quadrants. As a result of
fluid and air movement in GIT.

Bowel sounds should always be

heard at the eliocecal valve
Abdominal All quadrants are Tympany is heard because of air Intermittent gurgling
Quadrants normal in the stomach and intestines. sounds throughout
Dullness is heard over organs abdominal quadrants
Normal findings

Vascular system

Area/ Region Findings Normal Findings Interpretation/analysis

Tissue perfusion The palm Palms turned pink promptly No significant findings
immediately
become pinky.