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a Physical Assessment Procedures
l
Assessing Appearance and Mental Status (General Survey)
s Normal Findings Deviation from Findings
u Normal
r 1.Observe body build, height, Proportionate, Excessively thin or Normal
v and weight in relation to the varies with obese
e client’s age, lifestyle, and lifestyle
y health.
R 2.Observe the client’s posture Relaxed, sits Tense, slouched, bent Normal
and gait, standing, sitting, properly, posture,
e
and walking. coordinated uncoordinated
c movement movement, tremors,
e dirty, unkempt
i 3.Observe the client’s overall
v hygiene and grooming.
e Relate these to the person’s Clean, neat Dirty, unkempt Normal
activities prior to the
p assessment.
a 4.Note body and breath odor No body/breath Foul body odor, Normal
t in relation to activity level. odor or minor body ammonia odor,
i odor relative to acetone breath odor,
work or exercise foul breath
e
5.Observe for signs of distress Smiling patient Facial grimace Normal
n
in posture or facial
t expression.
6.Note obvious signs of health Healthy Pallor, weakness, Normal
a or illness. appearance obvious illness
l 7.Assess the client’s attitude. Cooperative Negative, hostile, Normal
e withdrawn
r 8.Note the client’s Appropriate to Inappropriate to Normal
t affect/mood; assess the situation situation
, appropriateness of the
client’s responses.
c 9.Listen for quantity, quality, Understandable, Rapid or slow pace, Normal
o and organization of speech. moderate pace, overly loud or soft,
exhibits thought uses generalizations,
n
association lacks association
s
10.Listen for relevance and Logical sequence, Illogical sequence, Normal
c organization of thoughts. makes sense, has flight of ideas,
i sense of reality confusion
o
u
s
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 Assessing the Skin
Normal Findings Deviation from Findings
Normal
1.Inspect skin color. Varies from light Pallor Normal
to deep
brown, from Cyanosis
ruddy pink to
light pink Jaundice

Erythema
2.Inspect uniformity of skin Generally uniform Areas of either Normal
color. except in Hyperpigmentation or
areas exposed
to sun; areas Hypopigmentation
of lighter
pigmentation
in dark
skinned
3.Assess edema, if present. No edema Edema Normal
4.Inspect, palpate, and Freckles, some Various interruption in Normal
describe skin lesions. Apply birth skin integrity;
gloves if lesions are open or marks, irregular,
draining. some flat multicolored,
and raised or raised nevi
Describe lesions according nevi, no
to location, distribution, abrasion
color, configuration, size, or other
shape, type, or structure. lesion
5.Observe and palpate skin Moisture in skin Excessive moisture or Normal
moisture. folds and the dryness
axillae, affected
by different
factors
6.Palpate skin temperature. Uniform; within Generalized/ Localized Normal
normal hyperthermia/
Compare the two feet and range hypothermia
the two hands, using the
backs of your fingers.
7.Note skin turgor by lifting When pinched, Skins stays pinched or Normal
and pinching the skin on skin tented or
an extremity. springs moves back
back to slowly
previous
state

Assessing the Hair

 Normal Findings Deviation from Findings
Normal
1.Inspect the evenness of growth Evenly distributed Patches of hair loss Normal
over the scalp. hair (alopecia)
2.Inspect hair thickness or Thick hair Very thin hair Normal
thinness.
3.Inspect hair texture and Silky, resilient hair Brittle hair; Normal
oiliness. excessively oily or
dry hair
4.Note presence of infections or No infection or Flaking, sores, lice, Normal
infestations by parting the infestation nits, and ringworms
hair in several areas and
checking behind the ears and
along the hairline at the neck.
5.Inspect the amount of body Variable Hirsutism in women; Normal
hair. naturally absent or
sparse leg hair (poor
circulation)

Assessing the Nails

Normal Findings Deviation from Findings
Normal
1.Inspect fingernail plate Convex curvature; Less: spoon shaped Normal
shape to determine its
curvature and angle. angle between nail More: clubbing
and nail bed usually
160°
2.Inspect fingernail and Smooth texture Excessive thickness Normal
toenail texture. or thinness or
presence of grooves
or furrows; Beau’s
line
3.Inspect fingernail and Highly vascular and Bluish or purplish Normal
toenail bed color. pink in light tint; pallor
skinned; dark
skinned may be
brown or black
4.Inspect tissues surrounding Intact epidermis Hangnails; Normal
nails. paronychia;
koilonychia
5.Perform blanch test of Prompt return or Delayed return of Normal
capillary refill. pink or usual color, pink or usual color
less than four
Press two or more nails seconds
between your thumb and index
finger; look for blanching and
return of pink color to nail
bed.

Assessing the Skull & Face

 Normal Findings Deviation from Findings
Normal
1.Inspect the skull for size, Rounded Lack of symmetry; Normal
shape, and symmetry. (normocephalic and increased skull size
symmetrical, with with more prominent
frontal, parietal and nose and forehead;
occipital longer mandible
prominences);
smooth skull contour
2.Palpate the skull for Smooth, uniform Sebaceous cysts; Normal
nodules or masses and consistency; absence local deformities
depressions. of nodules or masses from trauma

Use a gentle rotating motion

with the fingertips. Begin at
the front and palpate down
the midline, then palpate each
side of the head.
3.Inspect the facial features. Symmetric or Increased facial hair; Normal
slightly assymetric thinning of eyebrows;
facial features exophthalmos;
myxedema facies;
moonfacies
4.Inspect the eyes for edema No edema Periorbital edema; Normal
and hollowness. sunken eyes
5.Note symmetry of facial Symmetric facial Asymmetric facial Normal
movements. movements movements, drooping
of lower eyelid and
Ask the client to elevate the mouth, involuntary
eyebrows, frown, or lower facial movement
the eyebrows, close the eyes
tightly, puff the cheeks, and
smile and show teeth.

Assessing the Eye Stuctures & Visual Acuity

External Eye Structures Normal Findings Deviation from Findings
Normal
1.Inspect the eyebrows for Hair evenly Loss of hair; scaling Normal
hair distribution and distributed; skin and flakiness of skin
alignment, and for skin intact
quality and movement. Unequal alignment
Symmetrically and movement of
aligned; equal eyebrow
movement
2.Inspect the eyelashes for Equally distributed; Turned inward Normal
evenness of distribution curled slightly
and direction of curl. outward

3.Inspect the eyelids for Skin intact; no Redness, swelling, Normal

 surface characteristics, discharge; no flaking, crusting,
position in relation to the discoloration plaques, discharge,
cornea, ability to blink, nodules, lesions;Lids
and frequency of blinking. Lids close close asymmetrically,
Inspect the lower eyelids symmetrically incompletely, or
while the client’s eyes are painfully;
closed. 15-20 blinks/min,
involuntarily, Rapid, monocular,
bilateral absent or infrequent
blinking
4.Inspect the bulbar Transparent, Jaundiced sclera, Normal
conjunctiva for color, capillaries excessively pale
texture, and the presence sometimes evident sclera, reddened
of lesions. sclera; lesions or
nodules
5.Inspect the palpebral Shiny, smooth, and Extremely pale, Normal
conjunctiva by everting thepink or red extremely red,
lids. nodules or other
lesions
7.Inspect and palpate the No edema or Swelling or Normal
lacrimal gland. tenderness over tenderness over
lacrimal gland. lacrimal gland
Using the tip of your index
finger,

palpate the lacrimal gland.

Observe for edema between

the lower lid and the nose.
8.Inspect and palpate the No edema or tearing Evidence of Normal
lacrimal sac and increased tearing,
nasolacrimal duct. regurgitation of fluid
on palpation of
Observe for evidence of lacrimal sac
increased tearing.

Using the tip of your index

finger, palpate inside the
lower orbital rim near the
inner canthus.
9.Inspect the cornea for Transparent, shiny, Opaque, surface not Normal
clarity and texture. Ask and smooth; details smooth
the client to look straight of iris are visible
ahead. Hold a penlight at
an oblique angle to the eye,
and move the light slowly
across the corneal surface.

10.Perform the corneal Client blinks when One or both eyelids Normal
 sensitivity (reflex) test to the cornea is fail to respond
determine the function of touched, indicating
the fifth (trigeminal) that the trigeminal
cranial nerve. Ask the nerve is intact.
client to keep both eyes
open and look straight
ahead. Approach from
behind and beside the
client, and lightly touch
the cornea with a corner of
the gauze.
11.Inspect the anterior Transparent Cloudy Normal
chamber for transparency
and depth. Use the same No shadows of light Crescent-shaped
oblique lighting used when on iris shadows on far side
testing the cornea. of iris
Depth of about 3
mm Shallow chamber
(possible glaucoma)
12.Inspect the pupils for Black in color, equal Cloudiness, Normal
color, shape, and in size; normally 3 mydriasis, miosis,
symmetry of size. to 7 mm in diameter;anisocoria
smooth border
13.Assess each pupil’s direct Illuminated pupil Neither pupil Normal
and consensual reaction to constricts; non- constricts
light. illuminated
constricts Unequal responses
Partially darken a room.
Absent responses
Ask the client to look
straight ahead.

Using a penlight and

approaching from the side,
shine a light on the pupil.

Observe the response. The

pupil should constrict (direct
response).

Shine the light on the pupil

again, and observe the
response of the other pupil.
It should also constrict
(consensual response).
14.Move the penlight or Pupils converge One or both pupils Normal
pencil toward the client’s when near object is fail to converge
nose. The pupils should moved towards the
converge. nose
 15.Assess peripheral visual
fields.
16.Assess six ocular
movements to determine
eye alignment and
coordination.
17.Assess near vision by
providing adequate
lighting and asking the
client to read from a
magazine or newspaper.
18.Assess distance vision by 20/20 vision on
asking the client to wear Snellen Chart
corrective lenses unless
they are used for reading
only.
When looking Visual field smaller Normal
straight ahead, client than normal; one half
can see objects in vision in one or both
periphery eyes
Both eyes Eye movements not Normal
coordinated, move coordinated or
in unison, with parallel; one or both
parallel alignment eyes fail to follow a
penlight in specific
directions; nystagmus
Able to read Difficulty reading Normal
newsprint newsprint unless due
to aging process
Denominator of 40 or Normal
more on Snellen
Chart with corrective
lenses

• Ask the client to sit or

stand 6 meters (20 ft)
from Snellen’s chart,
cover the eye not being
tested, and identify the
letters or characters.

• Take three readings:

right eye, left eye, and
both eyes.

Assessing the Musculoskeletal System

Normal Findings Deviation from Normal
1.Inspect the muscles for size. Equal size on both sides Atrophy (a decrease in size)
of body or hypertrophy
• Compare each muscle on one
side of the body to the same (an increased in size)
muscle on the other side. For any
apparent discrepancies, measure
the muscles with a tape.
2.Inspect the muscles and tendons for No contractures Malposition of body part
contractures. (foot drop or foot flexed
forward)
3.Inspect the muscles for tremors. No fasciculation or Presence of fasciculation or
tremors tremors
• Inspect any tremors of the hands
and arms by having the client
hold arms out in front of body.
 4.Palpate muscles at rest to determine Normally firm Atonic ( lacking tone)
muscle tonicity.
5.Palpate muscles while the client is Smooth coordinated Flaccidity (weakness or
active and passive for flaccidity, movements laxness) or spasticity
spasticity, and smoothness of (sudden involuntary muscle
movement. contraction)
6.Test muscle strength. Compare the Equal strength on each 25% or less muscle strength
right side with left side. body side

Grading Muscle Strength

GRADE DESCRIPTION
5 100% of normal muscle strength; normal full movement against gravity and against full resistance.
4 75% of normal strength; normal full movement against gravity and against minimal resistance.
3 50% of normal strength; normal movement against gravity.
2 25% of normal strength; full muscle movement against gravity, with support.
1 10% of normal strength; no movement, contraction of muscle is palpable or visible.
0 0% of normal strength; complete paralysis

Sternocleidomastoid
Client turns the head to one side against the resistance of your hand. Repeat with the
other side.
Trapezius
Client shrugs the shoulders against the resistance of your hands.
Deltoid
Client holds arm up and resists while you try to push it down.
Biceps
Client fully extends each arm and tries to flex it while you attempt to hold arm in
extension.
Triceps
Client flexes each arm and then tries to extends it against your attempt to keep in flexion
Wrist and Finger Muscles
Client spreads the fingers and resists as you attempt to push the fingers together.
Grip strength
Client grasps your index finger and middle fingers while you try to pull the fingers out.
Hip Muscles
Client is supine, both legs extended; client raises one leg at a time while you attempt to
hold it down.
Hip abduction
Client is supine, both legs extended. Place your hands on the lateral surface of each knee;
client spreads the legs apart against your resistance.
Hip adduction
Client is in same position as in hip abduction. Place your hands between the knees; client
brings the legs together against your resistance.
Hamstrings
Client is supine, both knees bent. Client resists while you attempt to straighten the legs.
Quadriceps
 Client is supine, knee partially extended; client resists while you attempt to flex the knee.
Muscles of the ankle and feet
Client resists while you attempt to dorsiflex the foot and and again resists while you
attempt to flex the foot.

Bones & Joints DEVIATION FROM

NORMAL FINDINGS
NORMAL
7.Inspect the skeleton for normal No deformities Bones misaligned
structure and deformities.
8.Palpate the bones to locate any No tenderness of swelling Presence tenderness of
areas of edema or tenderness. swelling
9.Inspect the joint for swelling. No swelling One or more swollen joints

• Palpate each joint for No tenderness, swelling, Presence of tenderness,

tenderness, smoothness of crepitation, or nodules sweeling, crepitation, or
movement, swelling, crepitation, nodules
and presence of nodules.
10.Assess joint range of motion. Varies to some degree in Limited range of motion in
accordance with person’s one or more joints
• Ask the client to move selected genetic makeup and
body parts. If available, use a degree of physical activity
goniometer to measure the angle
of the joint in degrees.
Cranial Nerves
Cranial Nerve Major Function
I. Olfactory sensory smell
II. Optic sensory vision
III. Oculomotor motor eyelid and eyeball movement
IV. Trochlear motor innervates superior oblique
turns eye downward and laterally
V. Trigeminal motor chewing
sensory face & mouth touch & pain
VI. Abducens motor turns eye laterally
VII. Facial motor controls most facial expressions
secretion of tears & saliva
sensory taste
VIII. Vestibulocochlear(auditory) sensory hearing
equillibrium sensation
IX. Glossopharyngeal motor swallowing
sensory senses carotid blood pressure & taste buds
X. Vagus sensory senses aortic blood pressure
slows heart rate
motor stimulates digestive organs
taste
XI. Accessory motor controls trapezius & sternocleidomastoid
XII. Hypoglossal motor controls tongue movements

Cranial Nerve I—Olfactory

Ask client to close eyes and identify different mild aromas, such as coffee and vanilla.
Cranial Nerve II—Optic
Ask the client to read Snellen’s chart; check visual fields by confrontation, and conduct
an ophthalmoscopicexamination.
Cranial Nerve III—Oculomotor
Assess six ocular movements and pupil reaction.
Cranial Nerve IV—Trochlear
Assess six ocular movements.
Cranial Nerve V—Trigeminal
While client looks upward, lightly touch the lateral sclera of the eye to elicit the blink
reflex. To test light sensation, have the client close eyes, and wipe a wisp of cotton over
client’s forehead and paranasal sinuses. To test deep sensation, use alternating blunt and
sharp ends of a safety pin over same area.
Cranial Nerve VI—Abducens
Assess directions of gaze.
Cranial Nerve VII—Facial
Ask the client to smile, raise the eyebrows, frown, puff out cheeks, and close eyes tightly.
Ask the client to identify various tastes placed on the tip and sides of tongue—sugar, salt
—and to identify areas of taste.
Cranial Nerve VIII—Auditory
Assess the client’s ability to hear the spoken word and the vibrations of a tuning fork.
Cranial Nerve IX—Glossopharyngeal
Apply tastes on the posterior tongue for identification. Ask the client to move tongue
from side to side and up and down.
Cranial Nerve X—Vagus
Assessed with CN IX; assess the client’s speech for hoarseness.
Cranial Nerve XI—Accessory
Ask the client to shrug shoulders against resistance from your hands and to turn head to
the side against resistance from your hand. Repeat for the other side.
Cranial Nerve XII—Hypoglossal
Ask the client to protrude tongue at midline, then move it side to side.

Reflexes
Scale for Grading Reflex Response
Grade
0 No reflex response
+1 Minimal activity (hypoactive)
+2 Normal response
+3 More active than normal
+4 Maximal activity (hyperactive)

Biceps Reflex
• Partially flex the client’s arm at the elbow, and rest the forearm over the thighs,
placing the palm of the hand down.
• Place the thumb of your nondominant hand horizontally over the biceps tendon.
• Deliver a blow (slight downward thrust) with the percussion hammer to your thumb.
• Observe the normal slight flexion of the elbow, and feel the biceps’s contraction
through your thumb.

Triceps Reflex
• Flex the client’s arm at the elbow, and support it in the palm of your nondominant
hand.
• Palpate the triceps tendon about 2–5 cm (1–2 inches) above the elbow.
• Deliver a blow with the percussion hammer directly to the tendon
• Observe for the normal slight extension of the elbow.
Brachioradialis Reflex
• Rest the client’s arm in a relaxed position on your forearm or on the client’s own
leg.
• Deliver a blow with the percussion hammer directly on the radius 2–5 cm (1–2
inches) above the wrist or the styloid process, the bony prominence on the thumb side
of the wrist.
• Observe the normal flexion and supination of the forearm. The fingers of the hand
might also extend slightly.

Patellar Reflex
• Ask the client to sit on the edge of the examining table so that legs hang freely.
• Locate the patellar tendon directly below the patella.
• Deliver a blow with the percussion hammer directly to the tendon.
• Observe the normal extension or kicking out of the leg as the quadriceps muscle
contracts
• If no response occurs, and you suspect the client is not relaxed, ask the client to
interlock fingers and pull.
Achilles Reflex
• With the client in the same position as for the patellar reflex test, slightly dorsiflex
the client’s ankle by supporting the foot lightly in your hand.
• Deliver a blow with the percussion hammer directly to the Achilles tendon just above
the heel.
• Observe and feel the normal plantar flexion (downward jerk) of the foot.

Plantar (Babinski’s) Reflex

• Use a moderately sharp object, such as the handle of the percussion hammer, a key,
or the dull end of a pin or applicator stick.
• Stroke the lateral border of the sole of the client’s foot, starting at the heel,
continuing to the ball of the foot, and then proceeding across the ball of the foot
toward the big toe.
• Observe the response. Normally, all five toes bend downward; this reaction is
negative Babinski’s. In an abnormal Babinski response, the toes spread outward and
the big toe moves upward.