CENTRO ESCOLAR UNIVERSITY

Nursing Department
Malolos City, Bulacan

PHYSICAL ASSESSMENT TOOL

(ADULT)

Name of Student: _____________________________

Yr./Sec./Grp. No: _____________________________

A. GENERAL APPEARANCE
a. Body Built Small frame [] Medium frame [] Large frame
b. Posture Upright [] Stooped [] Others_________
c. Gait Smooth rhythmic [] Staggering [] Shuffling
Uncertain [] Others: ___________
d. Dress, Grooming Hygiene
Appropriately dressed [] Well Groomed []
Inappropriately dressed [] Unkempt [] Others
e. Odor (Body/Breath) None [] Alcohol [] Acetone
Cigarette Smoke [] Others []
f. Obvious Physical Deformity __________________________________________________________

g. Clinical Measurements
Health _______________ Weight _________________

h. Vital Signs
Temperature __________ BP __________ RR ___________ PR ___________
Remarks ____________________________

B. MENTAL STATUS
a. Level of Consciousness
Conscious [ ] Lethargic [ ] Stuporous [ ] Semi-comatose [ ] Deep Coma [ ]
b. Orientation Time [ ] Place [ ] Person [ ] Remarks __________
c. Emotional Status
Peasant [ ] Cooperative [ ] Anxious [ ] Angry irritable [ ] Withdrawn [ ]
Fearful [ ] Resistive [ ] Euphoric [ ] Others ____________________________________
d. Language and Communication Use of simple words [ ] Use of technical words [ ]

Others ________________ Remarks _________________

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C. SKIN
a. Color Normal skin color [ ] Pallor [ ] Cyanotic [ ] Jaundice [ ] Erythema [ ]
Others _____________________
b. Temperature Warm [ ] Cold [ ]
c. Moisture Dry [] Clammy [] Sweaty [] Oily [ ]
d. Texture Smooth [ ] Rough [] Scaly [] Others _________________
e. Turgor Elastic and mobile [ ] Wrinkle loss of elasticity [ ]
Remarks ____________________
f. Lesions Type ___________________ Location _________________________
Size _______________ Distribution ________________ Remarks ________________
g. Hair distribution ___________________________________________________________________

D. NAILS
a. Nail plate shape Convex 160 [ ] Clubbing [ ] Others _____________________________
Remarks ___________________
b. Nail condition Smooth [ ] Rough [ ] Ridged [ ] Brittle [ ] Thick [ ] Thin [ ]
Others ________________________________
c. Nail bed Color Pink [ ] Pale [ ] Blue [ ] Others ____________________________
d. Capillary Refill Within 3 seconds [ ] Exceeds 3 seconds [ ]
Remarks _______________________________

E. HEAD AND FACE

a. Skull Proportionate to body size [] Smooth contour []
Disproportionate to body size [] Irregular contour [ ]
b. Scalp Tenderness [ ] Lesions [ ] White [ ] Scaly [ ]
Others __________________________
c. Hair condition Evenly distributed [ ] Unevenly distributed [ ] Thick [ ]
Fine [ ] Brittle [ ] Dull [ ] Shiny [ ] Infestation [ ]
Others __________________________
d. Face
Symmetry Symmetrical [ ] Asymmetrical [ ]
Facial movement Symmetrical [ ] Easy movement [ ] Difficult movement [ ]
Asymmetrical [ ] No movement [ ] Remarks _____________________

F. EYES
a. Eye condition Straight normal [ ] Strabismus [ ] Others ____________________
b. Eyebrows Hair distribution Thick [ ] Thin [ ] None/artificial [ ]
Others _________________________
c. Eyelid and lashes
Palpebral fissure Size
Effective closure [ ] Lesions [ ] Fallen Eyelashes [ ] Others ______________________
d. Blink Response Bilateral Frequent [ ] Infrequent [ ] Unilateral [ ]
Others ________________________
e. Eyeballs Symmetric [ ] Firm [ ] Asymmetric [ ] Hard [ ] Soft [ ] Sunken [ ]
Protruding [ ] Others: _________________________________
f. Conjunctiva: Bulbar Clear [ ] Palpebral Pink [ ]
Others: __________________________
g. Sclera White [ ] Icteric [ ] Reddish [ ] Others: _________________________

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h. Pupils
Size Equal [ ] Unequal []
_____ R _______ L
Reaction to light and accommodation R Brisk [ ] Sluggish [ ] No reaction [ ]
L Brisk [ ] Sluggish [ ] No reaction [ ]

Visual Acuity near vision 12-14 inches away

Able to recognize object [ ] Unable to recognize object [ ] Score ___________
i. Lacrimal Apparatus: Moist [ ] Excess tearing [ ] Absent tears [ ]
Remarks _______________________________

G. EARS
a. Auricle:
1. Color Normal racial tone [ ] Cyanosis [ ] Redness [ ]
Others: ____________________________
2. Symmetry and size position Symmetric [ ] Asymmetric [ ]
Deformity [ ]
3. Texture and elasticity Elastic [ ] Non tender [ ] Tender [ ] Firm [ ]
Others __________________________
b. Pinna Recoils when folded [ ] Tenderness [ ] Flaky [ ] Scaly [ ]
Lesions [ ] Inflammations [ ]
Others ______________________
c. External Canal Some cerumen [ ] Foreign body [ ] Discharges [ ] Masses [ ]
Impacted Cerumen [ ] Swelling [ ] Redness [ ] Others
____________________
d. Hearing Acuity Responds to normal voice [ ] Respond to whispered voice (2 ft away) [ ]
AD Difficulty [ ] AS Difficulty AU Difficulty [ ]
Remarks: ________________________________

H. NOSE
a. External Normal racial tone [ ] Flaring [ ] Discharge [ ]
Others: _____________________________
b. Septum Midline [ ] Deviated [ ] Perforated [ ]

Remarks: ___________________________
c. Mucosa Pink [ ] Pale [ ] Discharges [ ]
Remarks: ___________________________
d. Patency Both Patent [ ] Mass Lesion [ ] Obstruction [ ] Others ____________
Remarks _________________________________
e. Nasal Cavity Moist [ ] Dry [ ] Discharges [ ]
Remarks: _____________________
f. Sinuses Tender [ ] Non-tender [ ] Remarks: ___________________________________

I. MOUTH
a. Lips Pink [ ] Pallor [ ] Cyanosis [ ] Lesions [ ] Dryness [ ]
Symmetrical [ ] Asymmetrical [ ]
Remarks: _____________________________
b. Mucosa Pink [ ] Pallor [ ] Cyanosis [ ] Lesions [ ] Moist [ ]
Remarks: _____________________________
c. Tongue Midline [ ] Deviation [ ] R[] L[]
Texture [ ] Rough [ ] Smooth [ ]
Color [ ] Pink [ ] Red [ ] Movable [ ] Atrophy [ ]
Others: ___________________________

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d. Teeth Complete [ ] Incomplete [ ] Carries [ ] Dentures [ ]

Remarks ____________________________
e. Gums Pink [ ] Pallor [ ] Reddish [ ] Tender [ ] Mouth Sores [ ]
Remarks ____________________________

J. PHARYNX
a. Uvula Midline [ ] Deviation [ ] R[] L[]
Remarks ________________________
b. Mucosa Pink [ ] Pallor [ ] Reddish [ ] Others _______________
c. Tonsils Inflamed [ ] Not inflamed [ ] R[] L[]
Remarks ________________________
d. Posterior Pharynx Inflamed [ ] Congested [ ]
Remarks ________________________
e. Gag Reflex Present [ ] Absent [ ]
Remarks ________________________

K. NECK
a. Neck Muscles Equal in size [ ] Swelling [ ] ROM [ ]
Remarks _________________________
b. Muscle Strength (refer to neuro assessment)
c. Lymph Nodes Palpable [ ] Not palpable [ ] Tender [ ] Not tender [ ]
Remarks _________________________
d. Trachea Midline [ ] Deviation [ ] R[] L[]
Remarks _________________________
e. Thyroid Gland Palpable [ ] Not palpable [ ] Remarks ________________

L. BREAST AND AXILLA

a. Symmetry Symmetrical [ ] Asymmetrical [ ]
b. Contour Flat [ ] Round [ ] Sagging [ ] Others ___________________
c. Skin Characteristics Smooth [ ] Orange Peel Appearance [ ] masses [ ]
edema [ ] Retractions [ ] Nipples inverted [ ] Dimpling [ ] Tender [ ]
Others __________________________

M. CHEST AND LUNGS

a. Shape AP to lateral ratio 1:2 [ ] Barrel [ ] Funnel [ ] Pigeon [ ]
Remarks: _______________________________
b. Lung Expansion Anterior Symmetrical [ ] Asymmetrical [ ]
Posterior Symmetrical [ ] Asymmetrical [ ]
Chest Excursion 3-5 cm.
Remarks: ____________________________
c. Fremitus Symmetrical [ ] Increase [ ] R[] L[]
Decrease [ ] R[] L[]
d. Breathing pattern Regular [ ] Irregular [ ] Use of accessory Muscle [ ] Dyspnea [ ]
Remarks: _____________________________
e. Breath Sounds Vesicular [ ] Bronchial [ ] Bronchovesicular [ ]
Rales [ ] Wheeze [ ] Bronchi [ ] Others ______________________
Remarks _____________________________
f. Percussion Resonant [ ] Tympany [ ] Dullness [ ] Hyper-resonance [ ] Flatness [ ]
Others ___________________________

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g. Costal Angle 45 degrees [ ] >45 degrees [ ]

Remarks___________________
h. Heart Sounds Rate ____________ Rhythm ______________
Pulmonic [ ] Aortic [ ] Tricuspid [ ] Apical [ ]
Remarks: _______________________________

N. ABDOMEN Normal Racial tone [ ] Blemished [ ] Unblemished [ ]

a. Skin Integrity Lesion [ ] Scarf [ ] Rashes [ ] Tense and glistening [ ]
Remarks ________________________________
b. Contour and Symmetry Flat [ ] Rounded [ ] Scaphoid [ ] Obtunded [ ]
Others _____________________ Remarks __________________________
c. Movement Symmetrical [ ] Asymmetrical [ ] Visible peristalsis [ ]
Limited movement [ ] Others _____________________
Remarks ____________________________
d. Bowel Sounds Normal [ ] Hyperactive [ ] Hypoactive [ ] Bruits [ ]
Friction rub [ ] Other _____________________
Remarks _____________________________________
e. Palpation Muscle guarding [ ] Tender [ ] Masses [ ] Mobile [ ] Fixed [ ]
Remarks _____________________________________
f. Bladder Distended [ ] Not distended [ ]
Remarks _____________________________
g. Liver Palpable [ ] Not palpable [ ]
Others ________________
Remarks _____________________

O. UPPER EXTERMITIES
a. Motor Strength ___________________
b. Muscle Tone ____________________
c. Lesions _________________________
d. Deformity ______________________
e. Peripheral Pulses Normal [ ] Bounding [ ] Weak [ ] Absent [ ]
f. Lymph Nodes Palpable [ ] Not palpable [ ]
Remarks: _________________________

P. LOWER EXTERMITIES
a. Motor Strength ___________________
b. Muscle Tone _____________________
c. Lesions _________________________
d. Deformity _______________________
e. Peripheral Pulses Normal [ ] Bounding [ ] Weak [ ] Absent [ ]
f. Lymph Nodes Palpable [ ] Not palpable [ ]
Remarks ________________________
g. Presence of : Homan’s sign [ ] Varicosities [ ] Phlebities [ ]
Others _____________________ Remarks _______________________

Copy to: Student

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Q. GENITALIA
Male
a. Pubic hair Normal Distribution [ ] Others _________________________

b. Penis Circumcised [ ] Not circumcised [ ] retractable foreskin [ ]

Not retractable foreskin [ ] Others _________________________

c. Urinary Meatus Lateral Opening [ ] Ventral [ ] Dorsal [ ] Swelling [ ]

Others ___________________

d. Scrotum Symmetrical [ ] Asymmetrical [ ] Swelling [ ] Hydrocele [ ]

Spermatocele [ ] Remarks: ___________________________________

e. Testes Descended [ ] Undescended [ ] Unilateral [ ] Bilateral [ ]

f. Inguinal Hernia Presence [ ] Absence [ ]

Remarks __________________________

Female (refer to OB/GYNE tool)

Copy to: Student

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