Focused Assessment

Focused Assessment
Body Part Examined Actual Finding Normal Finding Clinical Significance

INTEGUMENT (SKIN)
I: Color,

>No discoloration and
her skin color is natural
brown

*colored skin tones
without unusual or
prominent
discolorations

According to Weber and
Kelly- Health
Assessment in Nursing;
3rd ed. That the finding
in client is normal that
Skin color ranges from
pale white with pink,
yellow, or olive tones to
dark brown or black.
Normal with the age of
the patient
uniformity,

>Equal distributed

*equal distributed

Kelly- Health
in client is normal that
distribution of hair
depends on normal
gender distribution.
lesions

>no lesions

* Smooth, without
lesion,
Kelley, normal lesions
may be moles, freckles
and birthmarks. Normal
with the age of the
patient
Integrity

>skin intact
>no reddened areas
>smooth

*Skin is intact, and
there are no reddened
areas.

Kelly- Health
in the patient in skin
integrity is normal with
the age of the patient.
P: moisture, >moist skin

*Moisture in skin folds
and the axillae

Kelly- Health
3rd ed. That skin
surfaces vary from
moist to dry depending
on the area assessed.
the patient.
Temperature

>warm to touch

*Skin is normally warm
temperature.

Kelley, very warm skin
may indicate a febrile
state or
hyperthyroidism.
the patient.
turgor

> Good skin turgor

*Skin pinches easily and
immediately returns to
its original position

According to Webber &
Kelley Health
Assessment in Nursing
3
rd
edition that skin is
quickly a return to
original shape after
being pinched. Normal
with the age of the
patient
edema,

>No edema
>rebounds quickly
* Skin rebounds and
does not remain
indented when
pressure is released.

Kelley Health
3
rd
edition that the
finding is Normal with
HAIR
I: Evenness of growth,
thickness, texture,

>black in color
>semi-long straight hair
>thick
>no presence of
parasites
>evenly distributed

*natural hair color as
opposed to chemically
colored hair, varies
among client from pale
blurred to black to gray
or white, the color is
determined by the
amount of melanin
present
*evenly distributed
covers the whole scalp
(no evidence of
Alopecia), no parasites,
and the amount is
variable.
*tend to increase in
growth; softening and
thinning are common.
According to Daniel the
hair varies from dark
black to pale blonde
and should be shiny and
resilient due to absence
of dandruff and
parasites.
Kelley varying amounts
of terminal hair cover
the scalp, axillaries,
body and pubic areas
according to normal
gender distribution.
the patient
oiliness, infection or
infestation

>No oiliness and
infection or infestation
present
>no dandruff
*Sparse dandruff may
be visible and small
amount oiliness.

Kelley Health
3th edition that
Infested hair may
indicate a need for
client teaching about
poor hygiene or
assistance with
activities of daily living.
the patient
body hair

>Normal growth of
body hair.
>fine distribute

* Varying amounts of
terminal hair cover the
body areas according to
normal gender
distribution.

Kelley Health
3
rd
edition that hair
covers entire body
except for the soles,
palms, lips, and nipples.
the patient
P: Smoothness

>smooth and soft
>Properly distributed
>elastic

*hair is smooth and
firm, somewhat elastic.
However, as people
age.

Kelley Health
3
rd
edition that hair
feels coarser and drier.
the patient
NAILS
I: plate shape,

>round nail with 160
degree nail base

*there is normally 160
degree angle between
the nail base and the
skin
Kelley Health
3
rd
edition that the
texture,

>it is hard and fine in
texture
>medium length
>well cut
>neat

*nails are hard and
basically immobile

According to Kozier,
smooth nail texture,
and pinkish finger nails
may indicate good
arterial circulation.
the patient
bed color

>pink nail bed color

*pink tones should be
seen. Some longitudinal
ridging is normal
immediate return of
color of nails may
indicate good
hydration.
the patient
P: Blanch Test

> color returns
immediately into
normal color

*pink tone returns
immediately to
blanched nail beds
when pressure is
released.

Kelley Health
3
rd
edition that If there
is slow (greater than 2
sec.) capillary refill w/
respiratory or
cardiovascular diseases
that cause hypoxia
which is indicate as
abnormal finding.
HEAD
I:Skull and Face: size,
shape, symmetry

>head is symmetrical,
round centered position
>normocephalic
>no lesion is visible

*head size and shape
vary especially in accord
with ethnicity.
*Usually the head is
symmetric round, erect,
and midline.
*No lesions are visible.

Kelley the skull is
normocephalic and
symmetry, with frontal,
parietal and occipital
prominences.
the patient

: facial features

> Face is symmetrical
with round appearance
> no abnormal
movements
>with wrinkles

*the face is symmetric
with a round, oval,
elongated or square
appearance.
*No abnormal
movements noted.
presence of wrinkles
may vary on age and
stress level.
the patient
: eyes for edema and
hollowness

>no edema
>no hollowness
>puffy eyes with
periorbital darkening

*absence of edema
and no hollowness
found
Kelley Health
3
rd
edition that there
must be absence of
edema in eye because it
indicates infection.
P: nodules, masses,
depressions

>no nodules
>no masses
>no depression

*no nodules, no lumps
and depression felt
during palpation

Kelley the skull is
smooth and in uniform
consistency with
absence of nodules,
lumps or masses.
the patient

EYES AND VISION
I: eyebrows for
distribution &
alignment, quality &
movement

>evenly distributed
> Symmetrically aligned
>equal-fine movement
>no pimples and
dandruff
>black in color

*Hair in eyebrows is
evenly distributed; skin
intact.
*Eyebrows
symmetrically aligned;
equal movement,
absence of pimples and
dandruff, maybe black
brown or blond
Kelley Health
3
rd
edition that the
function is to protect
the eye from sweat and
rain, and it is also used
as a facial expression.
depending on race. Normal with the age of
the patient
:eyelashes for evenness
of distribution &
direction of curl

>eyelashes are short
>properly distributed
>color in black

*Equally distributed;
curled slightly outward
and black in color
Kelley Health
3
rd
edition that the
normal eyes have
eyelashes turn upward,
with equal alignment
and movements.
the patient
:eyelids for surface,
characteristics,

>color of eyelids is
similar to her color of
the skin
> Has ability to blink

*Eyelids depend on the
color of skin tone,
absence of swelling,
lesions and discharges.

Kelley Health
3
rd
edition that If there
is presence of lesions or
swelling it is caused by
trauma. Normal with
the age of the patient
position in relation to
cornea,

>Eyelids are
symmetrically aligned
with the cornea.

*the upper lid margin
should be between the
upper margin of the iris
and the upper margin of
the pupil.
*The lower lid margin
rests on the lower
border of iris.
Kelley Health
3
rd
edition that the
upper and lower lids
close easily and meet
completely when
closed. Normal with the
age of the patient
ability to blink &
frequency

> Has ability to blink

The upper and lower
lids close easily and
meet completely when
closed.

Kelley Health
3
rd
edition that the
: bulbar conjunctiva for
color, texture, and
lesion

>clear
> moist
> smooth
>sclera is white
>no lesion
*bulbar conjunctiva is
clear, moist and
smooth.
*Sclera is white and
absence of lesion.

Kelley Health
3
rd
edition that
underlying structures
are clearly visible.
Bulbar conjunctiva is
clear, moist and
smooth. Normal with
: palpebral conjunctiva > No swelling or lesions * The lower and upper According to Webber &
for color, texture, and
lesion

palpebral conjunctiva is
clear and free of
swelling or lesions.
Kelley Health
3
rd
edition that A
foreign body or lesion
may cause irritation,
burning, pain and/or
swelling of the upper
eyelid. Normal with the
age of the patient
I/P: Lacrimal gland sac,
nasolacrimal duct for
edema,
tenderness/tearing

>not swelling or
redness
>no drainage

*I: no swelling or
redness should appear
over areas of the
lacrimal gland.
P: no drainage should
be noted when
palpating nasolacrimal
duct.

Kelley Health
3
rd
edition that
the patient
:cornea for clarity
texture & sensitivity
>clear
>smooth
> Sensitive to light

The cornea is
transparent w/ no
opacities. The oblique
shows a smooth and
overall moist surface
Kelley Health
3
rd
edition that
the patient

I: pupils for color shape,
symmetry of size,

>equal round
>symmetric
>constrict

.*The iris is typically
round, flat, and evenly
colored. The pupil,
round with a regular
border, is centered on
the iris.

Kelley the normal
papillary response is
constriction of the
pupils and convergence
of the eyes when
focusing on near object.
the patient
direct and consensual
reaction to light &

>normal direct and
consensual pupillary
response is constricting

*The normal direct
pupillary response is
constricting.

Kelley Health
3
rd
edition that It is
considered abnormal, if
pupils do not react at all
to direct and
consensual papillary
testing. Normal with the
age of the patient
accommodation

>response constriction
of pupils

*The normal pupillary
response is constriction
of the pupils and
convergence of the eyes
when focusing on a
Kelley Health
3
rd
edition that It is
near object. considered abnormal,
pupils do not constrict;
eyes do not converge.
the patient
EARS AND HEARING
I: auricles for color,
symmetry and position

>it is equal in size and
has similar appearance
>Symmetrically aligned
>Brown Color

*ears are equal in size
bilaterally
*tympanic membranes
clear: landmarks visible.
* The auricle aligns with
the corner of each.

Kelley Health
3
rd
edition that auricle
aligns with the corner of
each eye. Earlobes may
be free, attached, or
soldered (tightly
attached to adjacent
skin with no apparent
lobe). Normal with the
age of the patient
: external canal for
cerumen,

>no odor and ear is
clean
> minimal amount of
cerumen
>slightly moist
*a small amount of
odorless cerumen
(earwax) is the only
discharge normally
present, cerumen may
be yellow, orange, red,
brown, gray, or black
and soft, moist dry,
flanky or even hard.
According to Daniels-
Fundamentals of
Nursing that ears
should be symmetrical
but the cerumen must
be in normal moist
because its dryness may
cause temporary
hearing loss.
the patient
lesions, pus or blood >no lesion and no blood
found

>The canal walls should
be pink and smooth and
without nodules.

Kelley Health
3
rd
edition that the
findings is normal with
as seen with the use of
penlight.
P: auricles for texture
elasticity and areas of
tenderness

>not tender
>soft

*normally the auricle,
tragus and mastoid
process are not tender.

Kelley Health
3
rd
edition that a painful
auricle is associated
with otitis externa or a
post auricular cyst.
the patient
NOSE AND SINUSES
I: nose deviation in
shape, size, color,
flaring, discharge

>color is same with the
face
> symmetric
appearance
>no tenderness

*color is the same as
the rest of the face ; the
nasal structure is
smooth and symmetric;
the client repots no
tenderness

According to Pilliteri-
Maternal and Child
Health Nursing that
there must be no
excessive discharge and
nasal flaring. Normal
with the age of the
patient
:nasal mucosa for
redness, swelling
growth or discharge

>no redness in nasal
mucosa
>no discharge or
swelling
>pink in color

*swelling and redness
may result from
increased estrogen
production.
*Normally pink
Kelley Health
3
rd
edition that the
nasal mucosa is dark
pink and free of
exudates. Normal with
Pa: tenderness, masses,
displacements

>no masses
>no tenderness

*no tender and masses,

Kelley Health
3
rd
edition that if Nasal
tenderness on palpation
accompanies a local
infection. Normal with
:maxillary and frontal
sinuses for tenderness

>no tenderness in
palpating and crepitus

*frontal and maxillary
sinuses are no tender to
palpation, and no
crepitus is evident

Kelley Health
3
rd
edition that negative
pain in sinuses during
percussion indicates
absence of discomforts.
the patient
MOUTH AND OROPHAYNX
I: lips for symmetry of
contour, color, texture,
moisture, lesion

>Symmetric in contour
>Moist
>no lesion
>smooth
>pink in color

*lips are smooth and
moist without lesions or
swelling. Pink lips are
normal in light-skinned
clients as are bluish or
freckled lips some dark-
skinned.
Kelley Health
3
rd
edition that the
findings of Symmetric of
contour, moist ,no
lesion, smooth and pink
in color is Normal with
: teeth for alignment >slight well aligned *32 pearly whitish teeth According to Weber and
loss, dental filings,
caries

>13 dental caries in
upper and lower teeth

with smooth surfaces
and edges. *Upper
molars should rest
directly on lower molars
and front upper
incisions should slightly
over ride the lower
incisors.
*Some clients normally
have 28 teeth if 4
wisdom teeth do not
erupt.

Kelly- Health
3rd ed. that the clients
finding is abnormal
because the client has
tooth decay (caries)
may appear as brown
dots or cover more
extensive areas of
chewing surface.
: gums for bleeding,
color, retraction,
lesions, swelling

>not bleeding
>no retraction
>no swelling
>pink, moist, and
smooth

*The gums should be
pink, moist, smooth
texture with no
evidence of lesions or
inflammation.
* Not crack and
symmetrical
Kelley Health
3
rd
edition that it is
normal with the age of
the patient.
: tongue for position,
color, texture;

>Located in the middle
>no lesions
>Good movement
>Pink in color

*tongue should be pink,
moist, a moderate size
with papillae present

Kelley Health
3
rd
edition that the
tongue must be in the
midline with no
discharges found.
the patient
movement

>was able to move *The tongue offer
strong resistance.

Kelley Health
3
rd
edition that
decreased tongue
strength may occur with
a defect of the XII
cranial nerve
(hypoglossal) or with a
short frenulum that
limits motion. Normal
with the age of the
patient
the base of the tongue,
mouth floor and
frenulum

>pink in color
>no lesion
>visible veins-presence
>frenulum is in the
midline
*The tongues ventral
surface is smooth,
shiny, pink or slightly
pale with visible veins
and no lesions.
* The frenulum is
Kelley Health
3
rd
edition that the
findings are Normal
midline.

with the age of the
patient.
:palates for color,
shape, texture,
presence of bony
prominences

>no presence of bony
prominence
>lighter pink color
>moist
>no lesion

*hard palate-is concave
and lighter in pink in
color, it has many ridges
and it is moist, without
any lesion or
malformation
*Soft palate-is also
concave and light pink
in color, it is smooth
and no lesions or
malformation noted

Kelley Health
3
rd
edition that the hard
(anterior) palates are
pale or pale or whitish
with firm, tranverse
rugae.
the patient.
:uvula for position &
mobility

>hang in the midline
>fleshly solid

*uvula is fleshly, solid,
structure that hangs
freely in midline.

Kelley Health
3
rd
edition that no
redness of exudates
from uvula or soft
palate. Midline
elevation of uvula and
symmetric elevation of
the soft palate. Normal
with the age of the
patient.
:oropharynx for color &
Texture

>color in pink
>no lesions

*throat is normally pink
without exudates or
lesions.

Kelley Health
3
rd
edition that Any
deviation in color is
considered abnormal.
the patient
: tonsils for color,
discharge, and size

>no discharge
>color in pink
>no edema
>not exudates, swelling
and lesions

*tonsils maybe present
or absent.
* They are normally
pink and symmetric and
may be enlarged. *No
exudates, swelling or
lesions should be
presented.

Kelley Health
3
rd
edition that tonsil
are behind the pillars.
the patient.
P: nodules, lump and
excoriated areas

>no nodules palpated
>no lump

*there should no lumps,
nodule to palpate, also
in excoriated areas

Kelley Health
3
rd
edition that no
nodules, lump and
excoriated is Normal
with the age of the
patient.
NECK
Neck Muscles
I: abnormal swelling or
masses, head
movement and muscle
strength

>not swelling
>no masses
>Good head movement
>symmetric

*The muscles of the
neck are symmetrical
with the head at the
central position.
*The patient is able to
move head through a
full range of motion
without complaint of
discomfort or
noticeable limitation.

Kelley Health
3
rd
edition that the neck
is symmetric with head
centered and without
bulging masses. Normal
with the age of the
patient.
P:presence of masses
and tenderness

>no masses
>no tenderness
>symmetrical

*smooth, non-tender,
small cervical odes may
be palpable.
Kelley Health
3
rd
edition that the neck
is normally smooth
without edema and
lesions. Normal with the
age of the patient.
Lymph nodes
P: enlargement

>no lymph nodes
palpated
>no enlargement

*normally, lymph nodes
should not be palpable
in the health adult
patient.

Kelley Health
3
rd
edition that no
swelling, no tenderness,
no hardness is present.
the patient.
Trachea
P: lateral deviation

>midline

*Trachea is midline

Kelley Health
3th edition that trachea
is pulled to one side in
case of a tumor. Normal
with the age of the
patient.
Thyroid Gland
I: symmetry and visible
masses, rise during
swallowing

>no visible masses
>smooth
>enlargement

*thyroid tissue moves
up with swallowing but
often the movement is
so small it is not visible
on inspection.

Kelley Health
3th edition that
landmarks deviate from
midline or are obscured
because of masses or
abnormal growth are
indicate as a abnormal
finding.
A: bruit

>no bruits auscultated

*no bruit are
auscultated

Kelley Health
3th edition that no bruit
finding is a normal with
THORAX AND LUNGS
Posterior Thorax
I: shape & symmetry
from posterior- lateral
views; spinal alignment
for deformities

>Symmetrically aligned
>no deformities
>no patches
>no abnormal
inspiration

*anteroposterior to
transverse diameter in
ratio 1.2; chest
symmetric; spine
column vertically
aligned.
*No patches, no
abnormal inspiratory
retraction of
interspaces.
Kelley Health
3
rd
edition that the
findings is Normal with

Pa: temperature,
bulges, tenderness,
abnormal movements,
respiratory excursion,
vocal fremitus

>no tenderness
>no abnormal
movement
> Bilateral symmetry of
vocal fremitus
> intact
>uniform temperature
*The chest wall intact;
uniform temperature.
*Full and symmetric
chest expansion.
*Bilateral symmetry of
vocal fremitus.
*Fermitus is heard most
clearly at the apex of
the lungs.
Kelley Health
3
rd
edition that
Posterior thorax is free
from tenderness,
lesions and pulsations.
the patient
Pe: for symmetry of
resonance;
diaphragmatic
excursion

>resonant sound
>symmetry

*normal lung tissue-
resonant sound, rib flat
sound except over
scapula.
*And the lowest point
of resonance is at the
diaphragm.

Kelley Health
3
rd
edition that air-filled
lungs create a resonant
sound. Normal with the
age of the patient
A: breath sounds

>vesticular and
bronchovesticular are
the breath sounds
noted.

*excursion is bilaterally
in women *Diaphragm
is usually slight higher
on the right side.
*Vesicular and
bronchovesticular
breathe sound.

Kelley Health
3
rd
edition that the
finding in breath sound
is Normal with the age
of the patient.
Anterior Thorax
I: breathing pattern,
coastal and
costoverterbral angle

> Symmetrical
movement of the chest
>effortless respiration
>smooth

*Breathing pattern
should be smooth.
*Normal rate of
breathing in adult is
46/16 per min.
*Red patches present,
ribs sloping downward
with symmetric
interspaces.

Kelley Health
3
rd
edition that quite,
rhythmic, and effortless
respiration. Normal
with the age of the
patient.
Pa: respiratory
excursion, tactile
fremitus

>Symmetric excursion
>equal expand
>not tender
>no masses
>no pulsation
>skin warm and dry

*it should be full
symmetric excursion;
thumbs normally
separate to 3-5 cm.
equal expansion.

Kelley Health
3
rd
edition that Fremitus
is normally decreased
over heart and breast
tissue. Normal with the
age of the patient
Pe: symmetry of
resonance

>symmetry-resonant
sound noted

>symmetry-resonant
sound

Kelley Health
3
rd
edition that
resonant sound is
normal finding
with the age of the
patient
A: breath sounds

> generates
different sound during
inspiration and
expiration

*air brushing through
the respiratory tract
during inspiration
expiration generates
different breath sounds.

Kelley Health
3
rd
edition that the
HEART
I: pericordium for
pulsations & lifts or
heaves

> Normal respiratory
>no tenderness
> apical impulses

*apical impulses may or
may not be visible, it be
would in mitral area.

Kelley Health
3
rd
edition that no
pulsation is palpated, it
is because of social her
threats. Normal with
A: heart sounds(S1, S2)

>S1 is loud heard at
apex while S2 is loader
heard at base.
>normal heart sound
*s1 corresponds with
each carotid pulsation
and its loudest at apex
of the heart. S2
Kelley Health
>no heart murmurs
heard

immediately follows
after s1 and is loudest
at base of the heart.
S1 and s2 heart sound
are normally present.
*no heart murmur
3
rd
edition that normally
that no heart murmur
be heard. Normal with
Breast
I:breast

>The patient refused to
inspect her breast.
*texture is smooth with
no edema. Color varies
depending on the
clients skin tone.
Kelley Health
3
rd
edition that Breast
can be a variety of sizes
and somewhat round
and pendulous. One
breast may normally be
larger than the other.
-Areola

inspect her areola.

*vary from dark pink to
dark brown.
*round and may vary in
size
*Small Montgomery
tubercles are present.

Kelley Health
3
rd
edition that
pigmentation on the
areola varies to the race
and health state
condition.
-Nipple

inspect her nipples.

*nearby equal
bilaterally in size and
are in the same and in
the same location on
each breast.
*no discharges should
be present.

Kelley Health
3
rd
edition that Nipples
are usually everted, but
they may inverted or
flat. Supplementary
nipples may appear
along the embryonic
milk line.
P: masses, tenderness,
temperature, texture,
and elasticity.

palpate her breast,
areola and nipples.
*no masses should be
palpated.
*smooth, firm, elastic
tissue.
*generalize increase in
nodularity and
tenderness may be a
normal finding
associated with the
menstrual cycle or
hormonal medication.
*breast should be
Kelley Health
3
rd
edition that no
discharge should be
present. It should be
smooth, firm and
elastic.
normal body
temperature.

Abdomen
I: skin integrity,
contour & symmetry,
hernia, distention
(girth), movements
associated with
respiration, peristalsis
& aortic pulsations
>Smooth skin
Round shape
>no lesions
>with straight incision
*Round shape and
smooth with no
discharge present.
Kelley Health
3
rd
edition that the
certain finding is
abnormal due to CS
surgery procedure.
Extremities
lower
I: size, contour, and
movements

>no lesions
>Symmetric
> no involuntary
movements.
>No edema.
>skin color is even.

*equal in size
*same contour with
prominence of joints.
*no involuntary
movements.
*No edema.
*Color is even.

Kelley Health
3
rd
edition that the
findings is Normal with
P: temperature,
contraction, motion
>no masses
>no tenderness
>equal contracting
>warm and even
>perform range of
motion

*temperature is warm
and even
*has equal contraction.
*can perform complete
range of motion.

Kelley Health
3
rd
edition that no
abnormalities found in
palpating the
extremities. Normal
with the age of the
patient
MUSCULOSKELETAL
INSPECTION

*no difficulty in moving -No difficulty in moving According to Webber &
Kelley Health
3
rd
edition that the
findings are determines
that there are no signs
of inflammation and
disproportion. Normal
with the age of the
patient.
NEUROLOGIC
INSPECTION

*the client is not tense
and cooperates actively
during the examination
-cooperative actively

Kelley Health
3
rd
edition that patient

is no neurological
problem. Normal with
SENSORY FUNCTION
INSPECTION

*all extremities can feel
and touch

*can distinguish 6 given
colors
-all extremities can feel
and touch

-can distinguish 6 given
colors
Kelley Health
3
rd
edition that it is
normal with the age of
the patient.

ANTHROPOMETRIC DATA:

Client J.F HEIGHT(cm) WEIGHT(kg) BMI WHO
Classification
ASIA-
PACIFIC
Classification
Pre- pregnant
state
160.02 54.2 20.77 Normal Normal
Pregnant State:
First Trimester
160.02 55.3 21.9 Normal Normal
Second
Trimester
160.02 57.6 22.07 Normal Normal
Third Trimester 160.02 59.0 22.61 Normal Normal
Post Partum 160.02 54.5 21.28 Normal Normal

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Body Part Examined Actual Finding Normal Finding Clinical Significance

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