PHYSICAL ASSESSMENT
BODY PARTS NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS
Skin
-light to dark brown & feels warm -no swelling,
-light to dark brown & feels warm -mild skin rashes -smooth and soft
Due to disease process
-smooth and soft Hair and Scalp -color black -properly distributed - smooth and soft normal
Nails
no presence of parasites (lice) -fine texture -no masses -round nail with 160degrees nail base
round nail with 160degrees nail base -pink nail bed -normal
-pink nail bed Head -face is symmetrical, centeredhead position -face is symmetrical, centered-head position -normal
Neck
-smooth and controlled -smooth and controlled movements movements
-normal
Eyes
Eye brows
-blinking symmetrical, involuntary & approximately 15 blinks/min -evenly distributed -eye lashes are short -eye lid margins moist & pink -pupil is equally round and reactivated to light accommodati on
-blinking symmetrical, involuntary & approximately 15 blinks/min -evenly distributed -eye lashes are short -eye lid margins moist & pink -pupil is equally round and reactivated to light accommodation -normal
Eye lashes
Eye lids
Pupil
-uniform in color
-transparent, smooth, moist
-uniform in color
Ears
-Ears of equal size & similar appearance -Skin in the external ear is smooth and color pink
-Ears of equal size & similar appearance -Skin in the external ear is smooth and color pink
-normal
Nose
-color is same as face -symmetrical appearance -no redness in the nasal mucosa
-color is same as face -symmetrical appearance -no redness in the nasal mucosa
-normal
Mouth -pink in color -dry -smooth, moist with no lesions -moist with no lesions -pink and
-pink in color -moist -normal
Lips
-smooth, moist with no lesions -moist with no lesions -pink and moist -no dental carries -32 total no. of teeth
Buccal mucosa
Tongue
Gums
moist -no dental carries -normal
Teeth
-32 complete no. of teeth
-normal
Thoracic & Lungs
-position of sternum is level with ribs -no masses -lungs clear upon auscultation
-position of sternum is level with ribs -no masses - lungs clear upon auscultation
-normal
-normal -smooth skin surface -flat areola -no masses -PMI is felt upon pulsation -Rhythm: regular -normal -normal
Breast
-smooth skin surface -flat areola -no masses
Heart
-PMI is felt upon pulsation -Rhythm: regular
Upper Extremities (right and
-bilateral -bilateral pulses strong & pulses strong equal (radial pulse) & equal
-normal
left)
(radial pulse) -mobile -intact condition of the skin in arms -no lesions, no swelling
-mobile - intact condition of the skin in arms -no lesions, no swelling
-normal -normal
Abdomen
-no rashes or lesions -umbilicus is centrally located -rounded abdomen -symmetrical -high pitched, irregular gurgles 535times/min -abdomen rises with inspiration in synchrony with chest
-presence of rashes -umbilicus is centrally located -rounded abdomen Due to the disease process
-symmetrical -high pitched, irregular gurgles 5-35times/min -abdomen rises with inspiration in synchrony with chest
Lower Extremities (right and
-bilaterally symmetrical and equal
-bilaterally symmetrical and equal -right foot has no lesions,
-normal
left)
-right foot has no lesions, no swelling -left foot has no lesions, no swelling -skin color is the same as the other part of the body
no swelling -left foot has no abrasions
- normal
- skin color is the same as the other part of the body
-normal
