Physical Assessment

Body Part Normal Findings Actual Findings Interpretation & Analysis

Skin Inspection

Palpation

Skin is uniform whitish pink or brown color No BleedingNo area of increased vascularity and ecchymosisNo skin lesions present except for freckles, birthmarks or moles which may be flat or elevatedSkin is dry with a minimum of perspiration. Warm and equal bilaterally. Hands and skin slightly cooler than the rest of the bodySkin surfaces non-tenderTexture:Smooth, even and firm except where there is significant hair growthSkin turgor:When released, should return to original contour rapidlyEdema not present

Skin is brown

No bleedingNo area of increased vascularity and ecchymosisNo lesions

Skin is dry

Warm and equal bilaterally

Skin sprung back rapidly when pinched

No edema present

Skin may be dry because of insufficient fluid intakeNormal fluid intake should be 2500 ml per day

(pp.283-304, Health Assessment & Physical Examination – Zator Estes)

Scalp and Hair Inspection Dark black to pale blonde; may turn gray or white; may be chemically changedTerminal hair found in the eyebrows,, eyelashes, and scalp, and in axilla and pubic areas after puberty. No signs of infestation or

Hair appears black

Even distribution of hair

No infestation or lesions

No significant findings

(pp.305-308, Health Assessment & Physical Examination – Zator Estes)

Palpation

lesions. Seborrhea/ dandruff may be presentHair may feel thin, straight, coarse, thick or curly. Shiny and resilient

Hair is thick and shiny

Nails Inspection

Palpation

Have a pink-cast in light- skinned and brown in dark-skinned.Capillary refill present (should return to normal 2-3 sec)Surface is smooth, and slightly rounded or flat. Curved nails are normal. Uniform nail thickness throughout; no splintering or brittle edges. Angle approx. 160°Firm nail base

Brown-cast nails

Capillary refill of 1.5 seconds

Surface smooth and slightly rounded

No splinters or brittle edges

Angle approx. 160°Firm nail base

No significant findings

(pp.308-311, Health Assessment & Physical Examination – Zator Estes)

Eyes Inspection Symmetrical with no drooping, infection, tumors or other abnormalities Visual Acuity:20/20Sclera:White in light-skinned w/o exudates, lesions or foreign bodies. In dark-skinned, may have brown patchesPupils: equally round, reactive to light and accommodation; 2-6 mmNo tearing, swelling or discharge

Eyes symmetrical

Visual acuity of 20/20Sclera appears white

Pupils equally round, reactive to light and accommodation; approx. 4 mmNo tearing, swelling or descharge

No significant findings

(pp.350-362, Health Assessment & Physical Examination – Zator Estes)

Ears Inspection Match flesh color of the rest of the skin.Central

Same color as face

Central position

No significant findings

Palpation

position.Proportional.No redness, lesions, swelling, tendernessShould not complain of pain or tenderness

ProportionalNo redness, swelling, or tenderness

No pain assessed

(pp.386-389, Health Assessment & Physical Examination – Zator Estes)

Nose Inspection

Palpation

Symmetrical, midline of the face.Without swelling, bleeding, lesions, or masses.Each nostril patent.No pain or discomfort during palpation

Symmetrical and in midline

No swelling, bleeding, lesions, or masses

Patent nostrils

No pain or discomfort noted

No significant findings

(pp.394-397, Health Assessment & Physical Examination – Zator Estes)

Mouth Inspection Breath smells fresh.Lips and membranes pink and moist with no lesions or inflammation.Tongue is midline. Pink, moist, rough without lesions. Symmetrical; moves freely.Gums have pale-red strippled surface.No swelling or bleeding.

Lips and membranes are moist, dark flesh colored; no lesions or inflammationTongue in midline and moves freely 

No swelling or bleeding

No significant findings

(pp.398-405, Health Assessment & Physical Examination – Zator Estes)

Neck Inspection

Palpation

Symmetrical with head in central position. Able to move head without discomfort or noticeable limitsMuscles should be symmetrical without palpable masses or spasm

Symmetrical with head in central positionAble to move head w/o discomfort

No palpable masses

No significant findings

(p.331, Health Assessment & Physical Examination – Zator Estes)

Chest Inspection

Palpation

Without lesions; skin intact.Quiet, rhythmic and effortless breathingNo pulsations, masses, thoracic

Without lesions

Quiet rhythmic and effortless breathing

No masses or tenderness

No significant findings

(pp.451-469,

Auscultationtenderness present.Normal lung tissue produces resonant sound, diaphragm has dull sounds. Bronchial, bronchovesicular or vesicular breath sounds

Bronchovesicular breath sounds

Health Assessment & Physical Examination – Zator Estes)

Abdomen Inspection

Auscultation

Percussion

Palpation

Abdominal contour flat or rounded. Symmetrical. Uniform in color or pigmentation. No abdominal scars.No striaeIntermittent gurgling sounds throughout abdominal quadrants.Tympany, predominant sound heardNo organ enlargement palpable, or any masses, bulges, or swelling

Abdominal contour rounded.

Symmetrical.Uniform in color.

No scars; striaeGurgling sounds in abdomen  

No friction rubs/ audible bruits

No significant findings

(pp.552-562, Health Assessment & Physical Examination – Zator Estes)

Suprapubic Area Inspection

Palpation

Without lesionsUrinary bladder not palpable and not tender

Without Lesions

Urinary bladder not palpable

No significant findings

(p.638, Fundamentals of Nursing - Kozier)

Genitalia Inspection

Palpation

Pubic hair distributed in triangular form. More coarse than scalp hair. No nits or lice.Penis skin free of lesions and inflammation.

Pubic hair evenly distributed

No nits or liceNo lesions or inflammation

No significant findings

(pp.746-753, Health Assessment & Physical Examination – Zator Estes)

Rectum Inspection

Palpation

No lesions, rednessSphincter intactNon-tender

In midlineRedundant mass noted, reddish

A dilated vein seen as swollen, reddish-blue mass signifies hemorrhoids(pp. 55-56, Medical Surgical Nursing, Harkness and

Dincher)Upper

ExtremitiesInspection Without

lesions, scars or inflammation

Without lesions, scars or inflammation

No significant findings(p.579, Fundamentals of Nursing, Kozier)

Lower Extremities

Inspection

Palpation

Without lesions, scarsNo edema

Without lesions, scarsNo edema

No significant findings(p.579, Fundamentals of Nursing, Kozier)