Adult Physical Assessment

ADULT
PHYSICAL
ASSESSMENT
Mrs. Melba Sahaya Sweety.D
MSc. Nursing
Pediatric Department
GIMSAR
Chinna Chadayan & Melba

PHYSICAL EXAMINATION
 1, PATIENT PROFILE:-
1. Name :_____________
2. Age :_____________
3. Gender :_____________
4. Diagnosis :______________
5. Name of the surgery(if any):________
6. Ward/ Bed no :___________
7. Name of the physician :_____________
2, GENERAL APPEARANCE
A, Consciousness - Conscious/Semiconscious/
Unconscious
B, Orientation - Oriented to time/place
person
C, Nourishment - Well nourished/moderate
nourished/ Malnourished
D, Health - Healthy/unhealthy
E, Body built - Thin/ moderate/ obese
F, Activity - Active/ Dull
 2, GENERAL APPEARANCE
G, Hygiene - Good/Bad
H, Speech - Clear/slurring/stammering/
maintains eye contact/not
clear
I, Look - Pleasant/Happy/ alert
Depressed/ Fearful/
Anxious/Tired/ Drowsy
2, GENERAL
APPEARANCE
A, Consciousness
Conscious/
Semiconscious/
Unconscious

2, GENERAL
APPEARANCE
B, Orientation
- Oriented
to
time/place/
person

2, GENERAL
APPEARANCE
C, Nourishment –
Well
nourished/
Moderate
nourished/
Malnourished

2, GENERAL
APPEARANCE
D, Health
- Healthy/
unhealthy

2, GENERAL
APPEARANCE
E, Body
built -
Thin/
moderate/
obese

2, GENERAL
APPEARANCE
F, Activity
- Active/
Dull

2, GENERAL
APPEARANCE
G, Hygiene
- Good/Bad

2, GENERAL
APPEARANCE
I, Look -
Pleasant/Happy/
alert/
Depressed/
Fearful/
Anxious/Tired/
Drowsy

2, GENERAL
APPEARANCE
H, Speech -
Clear/slurring/
stammering /
maintains
eye contact/
not clear

PHYSICAL ASSESSMENT
 3, ANTHROPOMETRIC
MEASUREMENT
A, Height - _______ cms/not able to
stand
B, Weight - _________ kgs/not able to
stand

3, ANTHROPOMETRIC
MEASUREMENT
A, Height -
_______ cms/not
able to stand

3, ANTHROPOMETRIC
MEASUREMENT
B, Weight -
_________
kgs/not able to
stand

PHYSICAL ASSESSMENT
 4, VITAL SIGNS
A. Temperature - ______Degree C/F
B. Pulse - _______Beats/min
C. Respiration - _______Breath/min
D. Blood pressure - _____ mm of Hg

4, VITAL
SIGNS
A, Temperature
- ______Degree
C/F

4, VITAL
SIGNS
Pulse -
_______Beats/
min

4, VITAL
SIGNS
Respiration -
_______Breath
/min

4, VITAL
SIGNS
Blood
pressure -
_____ mm of
Hg

5, SKIN
A, Complexion – Fair/ brown/ dark
in complexion
B, Temperature – Warm/Cold/Hyperthermia
C, Texture – Smooth/soft/dry/indurated
D, Skin turgor – normal/tenting/sluggish
E,Discoloration-Absent/yellowish/cyanosis/
vitiligo/pallor/ erythema
F, Hydration – Good/moderate/dehydrated
5, SKIN
G, Vascularity – Absent/
petechiae/purpura/ecchymoses
H, Lesions – Absent/Macule/papule/ulcer/
nodules/scar
I, Edema – Absent/pitting edema/pedal
edema

5, SKIN
A, Complexion –
Fair/ brown/
dark in
complexion

5, SKIN
B, Temperature
– Warm/Cold/
Hyperthermia

5, SKIN
C, Texture –
Smooth/soft/
dry/indurated

5, SKIN
D, Skin
turgor –
normal/
tenting/
sluggish

5, SKIN Cyanosis
E,Discoloration-
Absent/
yellowish/
cyanosis/
vitiligo/pallor/
erythema

5, SKIN (E,Discoloration)
Pallor Erythema

5, SKIN (E,Discoloration)
Vitiligo Yellowish

5, SKIN
F, Hydration
– Good/
moderate/
dehydrated

5, SKIN
Petechiae
G, Vascularity
– Absent/
petechiae/
purpura/
ecchymosis

5, SKIN (G, Vascularity)
Purpura Ecchymosis

5, SKIN
Macule
H, Lesions –
Absent/Macule/
papule/ulcer/
nodules/scar

5, SKIN (H, Lesions )
Papule Ulcer

5, SKIN (H, Lesions )
Nodules Scar

5, SKIN
I, Edema –
Absent/
pitting edema/
pedal edema

6, NAILS
On Observation - Intact/Onycholysis/Peeling
or Cracking(Onychoschizia)/
Paronchyia
Shape - Rounded/flat/spoon shape
Nail beds – Pink / Cyanosed/Pale
Nail Plate – Flat/Clubbing/Whitening
(Leukonychia)
Schamroth’s window test
Chinna Chadayan – normal/Abnormal
& Melba
6, NAILS
Intact
On Observation -
Intact/
Onycholysis/
Peeling or
Cracking/
Paronchyia

6, NAILS (On Observation)
Onycholysis Peeling or Cracking

6, NAILS (On
Observation)
Paronchyia

6, NAILS
Nail beds
– Pink/
Cyanosed/
Pale

6, NAILS
Nail Plate
– Flat/
Clubbing/
Whitening

6, NAILS
Schamroth’s
window test –
normal/
Abnormal

6, NAILS
Shape -
Rounded/flat/spo
on shape

7, HAIR
Color – Black/Brown/Red/Grey/flag
sign
Texture – Normal/Dry
Grooming – Not grommed/Well
grommed
Distribution - Normal/Scanty/
Bald/Alopecia
7, HAIR (Color)
Black Brown

7, HAIR (Color)
Red Grey

7, HAIR
(Color)
Flag sign

7, HAIR
Texture
–
Normal/
Dry
7, HAIR
Grooming –
Not
grommed/
Well
grommed
7, HAIR
Distribution -
Normal/Scanty/
Bald/Alopecia

8, HEAD
Shape - Normocephalic/micro/macro/
hydrocephalic
Scalp - Clean/ Pediculosis/ dandruff/
any scar
Face - Puffiness/ moon face/ bell’s
palsy/ no complaints
8, HEAD
Shape -
Normocephalic/m
icro/macro/
hydrocephalic

8, HEAD
Scalp - Clean/
Pediculosis/
dandruff/
any scar

8, HEAD
Puffiness
Face -
Puffiness/
moon face/
bell’s palsy/
no
complaints

8, HEAD (Face )
Bell’s palsy Moon face

9, EYES
Eye Brows - Symmetrical/ equally
distributed/Assymetrical/
Scanty
Eye Lashes - Absent/equally
distributed/presences of
dandruff
Eye Lid - Normal/ edematous/
stye/ptosis
9, EYES
Eye position – Normal/ expothalmus/
strabismus
Extraoccular movement –
Parallel/nystagmus
Sclera – White/ reddish/yellowish/
greenish
Conjunctiva - Normal/pale/yellowish/
erythemia/edema/
lesion
9, EYES
Cornea - Smooth, shiny&transperent
Pupil
Size - Equal in size/pin pointed/ dilated/
Constricted
Shape – Round/oval/irregular/pin pointed
Pupillary reaction – Equally reacted to
light (PERRLA)
Iris
Color – Black / blue/ brown/ grey/cloudy
9, EYES
Visual acuity – Normal visual
acuity / myopia/
hyperopia/astigmatism

Eye Brows - Symmetrical/equallydistributed/
Assymetrical/ Scanty

Eye Lashes - Absent/equally
distributed/presences of
dandruff

Eye Lid - Normal/ edematous/
stye/ptosis

Eye position – Normal/ expothalmus/
strabismus

Extraoccular movement –
Parallel/nystagmus

Sclera – White/ reddish/yellowish

Conjunctiva - Normal/pale/yellowish/
erythemia/

Cornea - Smooth, shiny&transperent

Pupil
Size - Equal in size/pin pointed/
dilated/ Constricted

Shape – Round/oval/irregular/pin
pointed

Iris
Color – Black / blue/ brown/ grey/cloudy

Pupillary reaction – Equally reacted to
light (PERRLA)

Visual acuity – Normal visual
acuity / myopia/
hyperopia/astigmatism

 10, EARS
Position - Symmetrical / Asymmetrical
Pinna – Normally placed / Anotia /
Microtia / Melotia
Cerumen – Absent / packed with
Ottorhoea – Absent / Purulent / serous/
bloody / sangiunous
Hearing – Normal / decreased (specify)
Subjective Symptoms – No complaints /
Otalgia/ tinnitus/
Vertigo
Chinna Chadayan / Autophony
& Melba
10, EARS
Position - Symmetrical /
Asymmetrical

Pinna – Normally placed / Anotia /
Microtia / Melotia

Cerumen – Absent / packed with

Ottorhoea – Absent / Purulent /
serous/
bloody or sangiunous

Hearing – Normal / decreased
(specify)

 11, NOSE
Nasal septum – Midline / Deviated
Nasal pathway – Patent / Obstructed /
Nasal polyp
Smell – Normal / absent
Rhinorrhoea – Absent/ watery/ purulent/
Mucoid/ Epistaxis
Subjective symptoms – No complaints /
Nasal flarings

11, NOSE
Nasal septum – Midline / Deviated

Nasal pathway – Patent / Obstructed
/Nasal polyp

Smell – Normal / absent

Rhinorrhoea – Absent/ watery/ purulent/
Mucoid/ Epistaxis

Subjective symptoms – No complaints /
Nasal flarings

 12, MOUTH
Lips – Dry/ Cracks /Symmetrical
/Asymmetrical
Lips Color – Pink / Pale / blue
Gums – Color – Pink / pale / dark ;
Bleeding / Gingivitis
Tongue – Moist / Dry / Coating /
/ Ankyloglossia/ Glositis
Tongue Colour – Pink / Pale / reddish
Blue
12, MOUTH
Taste – Normal/ Absent
Teeth – Normal / Dental caries /
Discolouration / stains / denture
Mucus membrane – Normal / Moist / Dry
/ Stomatitis
Breath odour – Absent / Halitosis /
Fruity odor
Pharynx – Sore throat / infection

Gag reflex – Present / absent

Tonsils – Normal / Enlarged / infection
Speech – Clear / Stuttering /
stammering/ aphonia /
dysphonia
Subjective symptoms – No complaint/
Toothache/ Dysphagia/
Odynophagia

12, MOUTH
Lips – Dry/ Cracks /Symmetrical
/Asymmetrical

Lips Color – Pink / Pale / blue

Gums – Color – Pink / pale / dark ;
Bleeding / Gingivitis

Tongue – Moist / Dry / Coating /
/ Ankyloglossia/ Glossitis

Tongue Colour – Pink / Pale / reddish
Blue

Taste – Normal/ Absent

Teeth – Normal / Dental caries /
Discoloration / stains / denture

Mucus membrane – Normal / Moist / Dry
/ Stomatitis

Breath odor – Absent / Halitosis /
Fruity odor

Pharynx – Sore throat / infection

Gag reflex – Present / absent

Tonsils – Normal / Enlarged /
infection

Speech Speech – Clear / Stuttering /
stammering/ aphonia /
dysphonia

Subjective symptoms – No complaint/
Toothache/ Dysphagia/
Odynophagia

 13, NECK
Range of motion exercise – Possible/
painful / absent / limited
Lymph Node – Not enlarged / enlarged /
Painful
Trachea – midline / deviated
Thyroid gland – Not enlarged / enlarged /
Removed
Jugular Veins – Distended / not distended
Subjective symptoms – If any

12, NECK
Range of motion exercise – Possible/
painful / absent / limited

Lymph Node – Not enlarged / enlarged /
Painful

Trachea – midline / deviated

Thyroid gland – Not enlarged / enlarged
Removed

Jugular Veins – Distended / not
distended

14, CHEST
INSPECTION :-
Scar - absent
Thorax shape – Symmetrical / Barrel chest /
pectus excavatum (Funnel chest),
pectus Carinatum ( Pigeon chest )
Thorax Expansion - Symmetrical / Shallow
Asymmetrical / delayed
Respiratory rate – _____________ breath per mts
Use of Assessory muscle – absent / Intercostal
Chinna Chadayan retraction
& Melba
14, CHEST
PALPATION :-
Tactile fremitus – Bilateral symmetry /
Increased fremitus/
Decreased Fremitus
Lump or masses – Absent / present
Aortic thrill - Absent / present

PHYSICAL
EXAMINATION
14, CHEST
PERCUSSION : -
Fluid Collection – Absent /present
Air Collection – Absent /present

14, CHEST
AUSCULTATION :-
Breath Sounds – Normal (Vesicular,
Bronchovesicular, Bronchial)/
Wheezing / Crackle/Rhonchi/
Stridor
Heart Sounds – Normal (s1, s2)/
Murmur/gallop sounds/Thrill
Heart Rate - _____________ beats per mts
14, CHEST
INSPECTION :-
Scar - absent

Thorax shape – Symmetrical / Barrel chest
pectus excavatum (Funnel chest),
pectus Carinatum ( Pigeon chest )

Use of Assessory muscle – absent / Intercostal
retraction / Supraclavicular
retraction /Substernal retraction

Respiratory rate – _____________ breath
per mts

14, CHEST
PALPATION :-
Tactile fremitus – Bilateral symmetry/Increased
fremitus/
Decreased Fremitus

Thorax Expansion - Symmetrical / Shallow
Asymmetrical / delayed

Lump or masses – Absent / present

Aortic thrill - Absent / present

14, CHEST
PERCUSSION : -
Fluid Collection – Absent /present
Air Collection – Absent /present

14, CHEST
AUSCULTATION :-Breath Sounds –
Normal(Vesicular,Bronchovesicular, Bronchial)/
Wheezing / Crackle/Rhonchi/ Stridor

Heart Sounds – Normal (s1, s2)/
Murmur/gallop
sounds/Thrill

Heart Rate - _____________ beats
per mts

15, BREAST AND AXILLA :-
Position – Symmetrical / Asymmetrical
Areola & Nipple – Retracted / Inverted /
Dimpling
Discharge – Absent / Milky / Yellowish
Purulent
Lesions / Masses – Absent / Ulceration /
nodes / Swelling /
moving / Painful / tender
Axillary Nodes – Not palpable / Palpable
Moving / Painful / tender
Hair distribution – Well Distributed /
Scanty/ Absent
Subjective Symptoms – If any___________

Position – Symmetrical / Asymmetrical

Areola & Nipple – Retracted / Inverted /
Dimpling

Discharge – Absent / Milky / Yellowish
Purulent /Bleeding

Lesions / Masses – Absent / Ulceration /
nodes / Swelling /
moving / Painful / tender

Axillary Nodes – Not palpable / Palpable
Moving / Painful / tender

Hair distribution – Well Distributed /
Scanty/ Absent

16, ABDOMEN :-
INSPECTION :-
Skin Color - Redness / Lesions / Bruises/
Cyanosis / Rashes / linea nigra/ striae
Skin Surface & Movement – Flat /
protrution/ Visible Peristalsis
Skin Contour – Smooth
Umbilicus – Clean / infected / everted
PHYSICAL
EXAMINATION
16, ABDOMEN :-
AUSCULTATION :-
Bowel Sound - Normal / Increased /
Decreased/ no_______ Per min
Bruit – Absent / Present

PHYSICAL
EXAMINATION
16, ABDOMEN :-
PERCUSSION :-
Fluid Collection – Absent / Present
Air Collection – Absent / Present

16, ABDOMEN :-
PALPATION :-
Liver – Normal / Hepatomegaly / Tenderness
Spleen – Normal / Spleenomgaly /
Tenderness
Inguinal Lymph nodes – Enlarged /
not enlarged / Movable / painful

INSPECTION :-
Skin Color - Redness / Lesions / Bruises/
Cyanosis / Rashes / linea nigra/ striae

Skin Surface & Movement – Flat /
Distended /protrusion/ Visible Peristalsis

Skin Contour – Smooth
Umbilicus – Clean / infected / everted

16, ABDOMEN :-
AUSCULTATION :-
Bowel Sound - Normal / Increased /
Decreased/ no_______ Per min
Bruit – Absent / Present

16, ABDOMEN :-
PERCUSSION :-
Fluid Collection – Absent / Present
Air Collection – Absent / Present

16, ABDOMEN :-
PALPATION :-
Liver – Normal / Hepatomegaly / Tenderness

Spleen – Normal / Spleenomgaly /
Tenderness

Inguinal Lymph nodes – Enlarged /
not enlarged / Movable / painful

17, MUSCULOSKLETAL :-
Postural Curves – Normal / Kyphosis /
Lordosis/ Scoliosis
Muscle Tone – Normal / Hypertonia /
Hypotonia / Flaccid/
Spastic/ Rigid
Muscle strength – Normal / Weaker than
normal / Hyperactive

UPPER EXTRIMITIES :-
Symmetry – Symmetrical / Asymmetrical
Finger Nails – Capillary Refill _________ sec
Range of Motion – Possible / If impossible
( specify)
Reflexes – Biceps,Triceps (Normal /
Abnormal )
Pulses – Radial / Brachial (Normal /
Abnormal )
Oedema / Swelling – Absent/ Present
Cyanosis – Absent/ Present
Joints – No complaints / Swollen / Stiff /
Tender / crepitus
Deformity – Absent / If any specify ____

LOWER EXTRIMITIES :-
Toe Nails - Capillary Refill _________ sec
Gait – Normal / Scissoring / dystonic /
ataxia
( specify)
Tender / crepitus
Varicose Veins – Absent / Present
Pulses – Dorsalis pedis /Tibial /Popliteal
(Normal / Abnormal )
Reflexes – Patellar / Achilles tendon /
Plantar
Deformity – Absent / Chadayan
Chinna If any& Melba
specify ____
Postural Curves – Normal / Kyphosis /
Lordosis/ Scoliosis

Muscle Tone – Normal / Hypertonia /
Hypotonia / Flaccid/
Spastic/ Rigid

Muscle strength – Normal / Weaker than
normal / Hyperactive


Finger Nails – Capillary Refill
_________ sec

( specify)

Reflexes – Biceps,Triceps (Normal /
Abnormal )

Pulses – Radial / Brachial (Normal /
Abnormal )


Tender / crepitus

Deformity – Absent / If any specify
____


Toe Nails - Capillary Refill _________ sec

Gait – Normal / Scissoring /
ataxia

( specify)


Tender / crepitus

Varicose Veins – Absent / Present

Pulses – Dorsalis pedis /Tibial /Popliteal
(Normal / Abnormal )

Reflexes – Patellar / Achilles tendon /
Plantar

Deformity – Absent / If any specify
____

18, GENITO URINARY :-
Male :-
Lesion / Scar – Absent / present
Discharge / Infection – Absent / present
Voiding – Continent / incontinent/
Catheterized
Inguinal hernia – Absent / present
Prostate gland – Normal / Enlarged

Female :-
Lesion – Absent / present
Catheterized
Episiotomy Scar – Absent / present
Vaginal orifice – No complaints /
Inflammation / Edema/ Discoloration
Male :-

Catheterized

Inguinal hernia – Absent / present
Prostate gland – Normal / Enlarged

Female :-
Lesion – Absent / present

Catheterized
Episiotomy Scar – Absent / present

Vaginal orifice – No complaints /
Inflammation / Edema/
Discoloration

19, RECTUM & ANUS :-

Haemorrhoids – Absent / present
Fissure - Absent / present
Subjective Symptoms – No Complaints /
Bleeding / Pain/ Rectal mass

19, RECTUM & ANUS :-

Haemorrhoids – Absent /
present

Fissure - Absent / present

Subjective Symptoms – No Complaints /
Bleeding / Pain/ Rectal mass

THE END

Adult Physical Assessment

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Adult Physical Assessment

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ADULT

Chinna Chadayan & Melba

Chinna Chadayan & Melba

Chinna Chadayan & Melba

Chinna Chadayan & Melba

Chinna Chadayan & Melba

Chinna Chadayan & Melba

Chinna Chadayan & Melba

Chinna Chadayan & Melba

Chinna Chadayan & Melba

Chinna Chadayan & Melba

Chinna Chadayan & Melba

Chinna Chadayan & Melba

Chinna Chadayan & Melba

D. Blood pressure - _____ mm of Hg

Chinna Chadayan & Melba

Chinna Chadayan & Melba

Chinna Chadayan & Melba

Chinna Chadayan & Melba

Chinna Chadayan & Melba

Chinna Chadayan & Melba

Chinna Chadayan & Melba

Chinna Chadayan & Melba

Chinna Chadayan & Melba

Chinna Chadayan & Melba

Chinna Chadayan & Melba

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Chinna Chadayan & Melba

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Chinna Chadayan & Melba

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Chinna Chadayan & Melba

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