PHYSICAL ASSESSMENT

BODY PARTS TECH-NIQUE Skin Inspection, Palpation NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS

-light to dark -light to dark brown & brown & feels feels warm warm -mild skin rashes -no swelling, -smooth and soft

-abnormal

Hair and Scalp

Inspection,

-smooth and soft -color black -properly distributed -no presence of parasites (lice)

- smooth and soft

-normal

Inspection

-fine texture

-round nail with 160degrees nail base

-abnormal

Nails

-no masses -round nail with 160degrees nail base -pink nail bed

-pail nail bed on toe

Head

Inspection

Neck Eyes

Inspection Inspection

-face is -face is symmetrical, -normal symmetrical, centered-head position centered-smooth and controlled head position movements -smooth and controlled -normal movements -blinking symmetrical, involuntary & approximately 15 blinks/min -evenly distributed -eye lashes are short -blinking symmetrical, involuntary & approximately 15 blinks/min -evenly distributed -eye lashes are short -eye lid margins moist & pink -normal

Eye brows

Eye lashes

-pupil is equally round -eye lid and reactivated to light margins moist

Eye lids

& pink

accommodation

Pupil

-pupil is equally round -uniform in color and reactivated to light accommodati on -transparent, smooth, moist -uniform in color

Iris

-transparent, smooth, moist

Ears

Palpation , Inspection

-Ears of equal -Ears of equal size & -normal size & similar similar appearance appearance -Skin in the external ear

-Skin in the is smooth and color pink external ear is smooth and color pink Nose Inspection -color is same -color is same as face -normal as face -symmetrical appearance -symmetrical -no redness in the nasal appearance mucosa -no redness in the nasal mucosa -pink in color -moist -pink in color -dry -smooth, moist with no lesions -normal

Mouth

Inspection Palpation

Lips

Buccal mucosa Tongue

-moist with no lesions -smooth, moist with no -pink and moist lesions -no dental carries -moist with no -32 total no. of teeth lesions -pink and moist -no dental

Gums

Inspection Teeth

carries -32 complete no. of teeth

-normal

-normal

Thoracic & Lungs

Inspection Palpation, Auscultation

-position of -position of sternum is sternum is level with ribs level with ribs -no masses -no masses - lungs clear upon -lungs clear auscultation upon auscultation -smooth skin surface -flat areola -no masses -smooth skin surface -flat areola -no masses -PMI is felt upon pulsation -Rhythm: regular

-normal

-normal -normal

Breast

Inspection Palpation

Heart

Palpation, Inspection

-PMI is felt upon pulsation -Rhythm: regular

-normal

Upper

Palpation,

-bilateral

-bilateral pulses strong & -normal

Extremities (right and left)

Inspection

pulses strong equal (radial pulse) & equal -mobile (radial pulse) - intact condition of the -mobile skin in arms -intact -no lesions, no swelling condition of the skin in arms -no lesions, no swelling

-normal -normal

Abdomen

Inspection, Auscultation Percussion Palpation

-no rashes or lesions -umbilicus is centrally located -rounded abdomen -symmetrical

-no rashes or lesions -umbilicus is centrally located -rounded abdomen

-normal

-symmetrical -high pitched, irregular gurgles 5-35times/min

-high pitched, irregular -abdomen rises with gurgles 5inspiration in synchrony 35times/min with chest -abdomen rises with

inspiration in synchrony with chest Genitourinary (The patient refused to assess his genitourinary organs.) Inspection -bilaterally symmetrical and equal (The patient refused to assess his genitourinary organs.)

Lower Extremities (right and left)

-bilaterally symmetrical -normal and equal

-right foot has no lesions, -right foot has no swelling no lesions, no -left foot has no swelling abrasions - normal -left foot has no lesions, no swelling - skin color is the same as the other part of the -skin color is -normal body the same as the other part of the body