Physical assessment Guide to collect objective client data

Question Findings
Overall impression of the client
1.Observe physical development (appears to be Wide variety of body types fall within a normal range:
chronologic age) and sexual development (appropriate for from small amounts of fat and muscle. Body proportions
gender & age) are normal.
2.Observe skin ( generalized color, color variation and Color is even without obvious lesions: light to dark beige-
condition) pink in light-skinned client.
3.Observe dress (occasion and weather appropriate) She dress appropriate in weather.

4.Observe hygiene (cleanliness, odor, grooming) There is no indistinct odor, and client is clean

5.Observe posture (erect & comfortable) & gait (rhythmic Posture is erect and comfortable for age
and coordinated)
6.Observe body build (muscle mass & fat distribution) Body is proportions are normal.

7.Observe consciousness level (alertness, Orientation,

appropriateness)
8.Observe comfort level

9.Observe behavior (body movements, affect,

cooperativeness, purposefulness,& appropriateness)
10.Observe facial expression ( culture-appropriate eye
contact & facial expression)
11.Observe speech (pattern & style)

Vital sign
1.Gather equipment ( thermometer, sphygmomanometer,
stethoscope, and watch)
2.Measure temperature (oral, axillary, rectal, tympanic) 37.6%

3.Measure radial pulse ( rate, rhythm, amplitude and The pulse rate is 66, there are regular intervals between
contour, & elasticity) beats
4.Monitor respiration (rate, rhythm, & depth) 16 breath/min is normal

5.Measure blood pressure The client blood pressure is 90/110

Analysis of Data
1. Formulate nursing diagnoses (wellness, risk, actual).

2. Formulate collaborative problems.

3. Make necessary referrals.

Physical assessment Guide to collect objective client data
Question Findings
Nutritional Status
Current symptoms
1. Gather equipment (balance beam scale with height
attachment, metric measuring tape, marking pencil,
and skin calipers.)
2. Measure height. 152cm

3. Measure weight (1kg= 2.205 lb) 46kg

4. Determine BODY MASS INDEX ( BMI= weight in 18

kilograms/ height in meters squared or use the NIH
5. Measure waist circumference and compare findings 14
to table 13-5 on page 230 in the textbook.
6. Measure MID ARM CIRCUMFERENCE (MAC)
and compare.
7. Measure TRICEPS SKINFOLD THICKNESS
(TSF) and Compare to table 13-7 on page 232 in the
textbook.
8. Calculate MID-ARM MUSCLE
CIRCUMFERENCE (MAMC), MAMC (cm)-(0.134 x
TSF)
Analysis of Data
1. Formulate nursing diagnoses (wellness, risk, actual).

2. Formulate collaborative problems.

3. Make necessary referrals.

Physical assessment Guide to collect objective client data
Question Findings
Skin, Hair, & Nails
Current symptoms
1. Gather equipment (gloves, exam light, penlight,
magnifying glass, centimeter ruler, wood lamp if
available)
2. Explain procedure to client I’m going to palpate and inspect your hair, skin and nails

3. Ask client to gown. Maam please wear the gown

Skin
1. Note any distinctive odor. Slightly no odor perspiration.

2. Inspect for generalized color variations (browness, There is no prominent discoloration

yellow, redness, pallor, cyanosis, jaundice, erythema,
vitiligo)
3. inspect for skin breakdown. Skin is intact
4. Inspect for primary, secondary, or vascular lesions.(note Skin is smooth stretch marks, needles scars.
size, shape, location, distribution, and configuration.)
5. Palpate lesions. There is no lesions .
6. Palpate texture (rough, smooth) of skin using Skin is smooth & even
palmar surface of three middle fingers.
7. Palpate temperature (cool, warm, hot) and moisture Skin is normally warm
(dry, sweaty, oily) of skin using dorsal side of hand.
8. Palpate, thickness of skin with fingerpads. Skin is normally thin
9. Palpate mobility and turgor by pitching up skin over The skin is mobile
sternum.
10. Palpate for edema pressing thumbs over feet or
ankles.
Scalp and Hair
1. Inspect color Natural hair color
2. Inspect amount and distribution Hair is evenly distributed
3. Inspect and palpate for thickness, texture, oiliness, The scalp is clean & dry hair is smooth & firm
lesions, and parasites.
Nails
1. Inspect for grooming and cleanliness. Nails are clean

2. Inspect for color and markings. Pink tones visible

3. Inspect shape. The nails is round & no clubbing

4. Palpate texture and consistency Nails are smooth and firm

5. test for capillary refill Pink tones returns immediately to blanched

Analysis of Data
1. Formulate nursing diagnoses (wellness, risk, actual).
2. Formulate collaborative problems.
3. Make necessary referrals.
Physical assessment Guide to collect objective client data
Question Findings
Head & Neck
Current symptoms
1. Gather equipment (gloves, penlight or flashlight,
small glass of water, stethoscope).
2. Explain procedure to the client. I’m going to palpate and inspect your Head and Neck
Head & Face
1. Inspect head for size, shape and configuration. Head size and shape vary, especially in accord with
ethnicity. Usually the head is symmetric round, erect and
in midline.
2. Palpate head for consistency while wearing gloves. The head is normally hard and smooth without lesions.

3. Inspect face for symmetry, feature, movement, The face is symmetric with a round, oval elongated, or
expression and skin condition. square appearance.
4. Palpate temporal artery for tenderness and elasticity. The temporal artery is elastic and not tender.

5. Palpate temporomandibular joint for range of Normally there is no swelling, tenderness, or crepitation
motion, swelling, tenderness, or crepitation by placing with movement. Mouth opens and closes fully.
index finger over the front of each and asking client to
open mouth. Ask if client has story of frequent
headaches.
Neck
1. Inspect neck while it is in a slightly extended Neck is symmetric, with head centered and without
position (and using a light) for position, symmetry, bulging masses.
and presence of lumps and messes.
2. Inspect movement of thyroid and cricoid cartilage The thyroid cartilage and cricoid cartilage move upward
and thyroid gland by having client swallow a small sip symmetrically as the client swallows.
of water.
3. Inspect cervical vertebrae by having client flex C7 (vertebrae prominens) is usually visible and palpable.
neck.
4. Inspect neck range of motion by having client turn Neck is move smooth and controlled with 45-degree
chin to right and left shoulder, touch each ear to the flexion, 55 degree extension, 40-degree lateral abduction,
shoulder, touch chin to chest and lift chin to ceiling. and 70- degree rotation.
5. Palpate trachea by placing your finger in the sternal Trachea is in midline
notch, feeling to each side, and palpating the tracheal
rings.
6. Palpate the thyroid gland. Landmarks are positioned midline.
7. Auscultate thyroid gland for bruits if the glands is No bruits are auscultated.
enlarged (use bell of stethoscope)
Question
8. Palpate lymph nodes for size/shape, delimitation,
mobility, consistency, and tenderness (refer to display
on characteristic of lymph nodes)
A. Preauricular nodes (front of ears) There is no swelling or enlargement and no tenderness.

B. Postauricular nodes (behind the ears) There is no swelling or enlargement and no tenderness.

C. Occipital nodes (posterior base of skull) There is no swelling or enlargement and no tenderness.
D. Tonsillar nodes (angle of the mandible, on the No swelling no tenderness no hardness is present.
anterior edge of the sternocleidomastoid muscle)
E. Submandibular nodes (medial border of the No enlargement or tenderness is present.
mandible); do not confuse with the lobulated
submandibular gland
F. Submental nodes (a few centimeter behind the tip of NO enlargement or tenderness is present.
the mandible); use one hand
G. Superficial servical nodes(superficial to the NO enlargement or tenderness is present.
sternomastoid muscle)
H. Posterior cervical nodes (posterior to the NO enlargement or tenderness is present.
sternocleidomastoid and anterior to the trapezius in the
posterior triangle)
I. Deep cervical chain nodes (deep within and around NO enlargement or tenderness is present.
the sternomastoid muscle
J. Supraclavicular nodes (hook fingers over clavicles NO enlargement or tenderness is present.
and feel deeply between the clavicles and the
sternomastoid muscles)
Analysis of Data
1. Formulate nursing diagnoses (wellness, risk, actual).
2. Formulate collaborative problems.
3. Make necessary referrals.
Physical assessment Guide to collect objective client data
Question Findings
Eyes
Current symptoms
1. Gather equipment (Snellen Chart, handheld Snellen
chart, near vision screener, penlight, opaque card, and
opthalmoscope).
2. Explain procedure to client I’m going to test, inspect and palpate your eyes.

Perform vision test

1. Distant visual acuity (with Snellen chart, normal The client has an 20/20 distant visual acuity.
acuity is 20/20 vision with or without corrective lense.
2. Near visual acuity (with a handheld vision chart, The client can read from a distance of 14 inch
normal acuity 14/14 with or without corrective lenses).

3. Visual fields (use procedure discussed in textbook to test IR- 70 Degree

peripheral vision). SR- 50 Degree
TR- 90 Degree
NL- 60 Degree
Perform Extraocular muscle function test

1. Corneal light reflex (using a penlight to observed The reflection of light on corneas is in the same spot on
parallel alignment of light reflection on corneas). each eye.
2. Cover test (using an opaque card to cover an eye to The uncovered eye remain fixed straight ahead. The
observe an eye movement). covered eye remain fixed straight ahead after being
uncovered.
3. Position test (Observing for an eye movement). Eye movement is smooth and symmetric throughout all
six directions.
External eye structure
1. Inspect eyelids and lashes (width and position of The upper lid margin should be between the upper margin
palpebral fissures, ability to close eyelids, direction of of the iris and the upper margin of the pupil.
eyelids in comparison with eyeballs, color, swelling,
lesions, or discharge).
2. Inspect of positioning of eyeballs (alignment in Eyeballs are symmetrically aligned in sockets without
socket protruding or sunken) protruding or sinking.
3. Inspect bulbar conjunctiva and Sclera (clarity, color and Bulbar conjunctiva is clear, moist and smooth.
texture)
4. Inspect palpebral conjunctiva (Eversion of upper eyelids The lower and upper palpebral conjunctiva are clear and
is usually performed only with complaints of eye pain on free of swelling or lesions.
sensation of something in eye)
5. Inspect the lacrimal apparatus over the lacrimal glands No swelling or redness appear over areas of lacrimal gland
(lateral aspect of upper eyelid) and the puncta (medial
aspect of lower eyelids) observe for swelling, redness, or
drainage.
6. Palpate lacrimal apparatus noting drainage from the No drainage noted from the puncta when palpating the
puncta when palpating the nasolacrimal duct. nasolacrimal duct.
7. Inspect the cornea and lens by shining a light to The cornea is transparent, with no opacities.
determine transparency.
8. Inspect the iris and pupil for shape and color of the The iris is typically round, flat, and evenly colored. The
iris and size and shape of the pupil. pupil, round with a regular border, is centered in the iris.
9. Test pupillary reaction to light (in a darkened room, The normal direct pupillary response is constriction.
have client focus on a distant object, shine a light
obliquely into the pupil, and observe the pupil’s
reaction to light-normally, pupil constrict)
10. Test accommodation of pupils by shifting gaze The normal pupillary response is constriction of the pupils
from far to near (normally, pupils constrict) and convergence of the eyes when focusing on a near
object.
Internal Eye Structure
1. Inspect the red reflex by using of opthalmoscope to The red reflex is easily visible through the ophtalmoscope.
shine the light beam toward the client’s pupil.
2. Inspect the optic disc by using the opthalmoscope The optic disc is round to oval with sharp, well-defined
focused on the pupil and moving every close of the borders.
eye.
3. Inspect the retinal vessels using the above Four sets of arterioles and venules pass thorugh the optic
technique. disc.
4. Inspect retinal background for color and the General background appears consistent in texture . the red
presence of lesions. orange color of the background is lighter near the optic
disc.
5. Inspect the fovea and macula for lesions. The macula is the darker area, one disc diameter in size,
located to the temporal side of the optic disc.
6. Inspect the anterior chamber for transparency. The anterior chamber is transparent.

Analysis of Data
1. Formulate nursing diagnoses (wellness, risk, actual).
2. Formulate collaborative problems.
3. Make necessary referrals.
Physical assessment Guide to collect objective client data
Question Findings
Ears
External ear structure
1. Inspect the auricle, tragus, and lobule for size and Ears are equal in size bilaterally (normally 4—10cm) the
shape, position, lesion/discoloration, and discharge. auricle aligns with the corner of each eye and within a 10
degree angle of the vertical position.
2. Palpate the auricle and mastoid process for Normally the auricle, tragus, and mastoid process are not
tenderness. tender.
Otoscopi Examination
1. Inspect the external auditory canal with the A small amount of odorless cerumen (earwax) is the only
otoscope for discharge, color and consistency of discharge normally present.
cerumen, color and consistency of canal walls, and
nodules.
2. Inspect the tympanic membrane, using the otoscope, Tympanic membrane is pearly gray, shiny, and translucent,
for color and shape, consistency, and landmarks. with no bulging or retraction.

3. Have the client perform the valsalva maneuver, and

observe the center of tympanic membrane for a flutter.
Hearing and equilibrium Test
1. Perform the whisper test by having the client place a Able to correctly repeat the two-syllable word as
finger on the tragus of one ear. Whisper a two syllable whispered.
word 30.4-60.9cm (1-2ft) behind the client. Repeat on
the other ear.
2. Perform the weber test by using a tuning fork placed Vibrations are heard equally well in both ears. No
on the centered of the head or forehead and asking lateralization of sound to either ear.
whether the client hears the sound better in one ear or
the same in both ear.
3. Perform rinne test by using a tuning fork and Air conduction sound is normally heard longer than bone
placing the base on the client’s mastoid process. When conduction sound(AC>BC)
the client no longer hears the sound. Note the time
interval and move it in front of external ear when the
client no longer hears a sound note the time interval.
4. Perform the Romberg test to evaluate equilibrium Client maintains position for 20 second without swaying or
with feet together and arms at the side, close eyes for with minimal swaying.
20 seconds. Observe for swaying.
Analysis of Data
1. Formulate nursing diagnoses (wellness, risk, actual).
2. Formulate collaborative problems.
3. Make necessary referrals.
Physical assessment Guide to collect objective client data
Question Findings
Mouth
1. note any distinctive odors. There is no indistinctive odor.
2. Inspect lips, gums and buccal mucosa Lips are smooth and moist without lesions. Buccal mucosa
is pink in light- skinned client.
3. Inspect gums for hyperplasia, blue-black line. Color and consistency of tissues along cheeks and gums
are even.
4. Inspect teeth Thirty pearly whitish teeth with smooth surfaces and
edges.
5. Inspect ad palpate tongue. The tounge is pink, moist, moderate size with papillae. No
lesions are present.
Throat
1. Inspect the throat for color Throat is normally pink, without exudate or lesions.
2. Inspect tonsils Tonsils may be present or absent. They are normally pink
and symmetric and may be enlarged to 1+ healthy client.
Nose
1. Inspect and Palpate external nose for color, shape, Color is the same as the rest of the face. The nasal
consistency . structure is smooth and symmetric .
2. Inspect and Palpate internal nose for color swelling, The nasal mucosa is dark pink, moist, and free of exudate.
exudate, bleeding.
Sinuses
1. Palpate for sinuses for tenderness. Frontal and maxillary sinuses are not tender to palpation,
and no crepitus is evident.
2. Percuss and transilluminate the sinuses for air The sinuses are not tender on percussion.
versus fluid or pus.
Analysis of Data
1. Formulate nursing diagnoses (wellness, risk, actual).
2. Formulate collaborative problems.
3. Make necessary referrals.
Physical assessment Guide to collect objective client data
Question Findings
Lungs and thorax
Posterior
1. Ask the client to continue sitting with arms at sides and Client sitting up and relaxed, breathing easily with arms at
stand behind the client. Untie gown to expose posterior sides or lap.
chest
2. Inspect scapulae and chest wall. The ratio of anteroposterior to transverse diameter is 1:2.

3. Note the use of accessory muscles when breathing. The diaphragm is the major muscle at work.

4. Palpate chest. No tenderness, pain, or unusual sensations. Temperature

is equal bilaterally.
5. Evaluate chest expansion at T9 or T10. The thumbs move 5 to 10 cm apart symmetrically
6. Percuss at posterior intercostal spaces. Resonance is the percussion tone elicited over normal lung
tissue.
7. Determine diaphragmatic excursion. Excursion is equal bilaterally and measure 3-5 cm in adults.
8.Auscultate posterior chest.
9. Test for two-point discrimination on back.
10. Auscultate apex and left sternal boarder of heart No adventitious sounds such as crackles or wheezes.
during exhalation.
Anterior Chest
1. Inspect chest The ratio of anteroposterior diameter to the transverse
diameter is 1:2.
2.Note quality and pattern of respirations Respirations are relaxed, effortless, and quiet.
3. Observe intercostal spaces. No retractions or bulging of intercostal spaces are noted
4. Palpate anterior chest. No tenderness or pain in palpated over the lung area with
respiration.
5. Percuss anterior chest. Resonance is the percussion tone elicited over normal lung
tissue.
6. Auscultate anterior chest. Refer to text in the posterior thorax section for normal
voice sounds.
7. Test skin mobility and turgor
8. Ask client to fold gown to waist and sit with arms
hanging freely.
Analysis of Data
1. Formulate nursing diagnoses (wellness, risk, actual).
2. Formulate collaborative problems.
3. Make necessary referrals.
Physical assessment Guide to collect objective client data
Question Findings
Abdomen
Current symptoms
1. Gather equipment (pillow/towel, centimeter ruler
stethoscope, marking pen ).
2. Explain the procedure to client I’m going to palpate, inspect, percuss your abdomen
3. Ask the client to put on a gown Please wear the gown.
Head & Face
1. Inspect the skin, noting color, vascularity, striae, Abdominal skin may be paler than the general skin tone
scars and lesions (wear glove to inspect lesions) because this skin is so seldom exposed to the natural
elements.
2. Inspect the umbilicus, noting color, location, and Umbilical skin tones are similar to surrounding abdominal
contour. skin tones or even pinkish.
3. Inspect the contour of the abdomen. Abdomen is flat , rounded or scaphoid.
4. Inspect the symmetry of the abdomen. Abdomen is symmetric.

5. Inspect abdominal movement, noting respiratory Abdominal respiratory movement may be seen, especially
movement, aortic pulsation, and/or peristaltic waves. in male clients.
6. Auscultate for bowel sounds, noting intensity, pitch, A series of intermittent, soft clicks and gurgles are heard at
and frequency.
7. Auscultate for vascular sounds and friction rubs. Bruits are not normally heard over abdominal aorta or
renal, iliac, or femoral arteries.
8. Percuss the abdomen for tone. Generalized tympany predominates over the abdomen
because of air in the stomach and intestine.
9. Percuss the liver The lower border of liver dullness is located at the costal
margin to 1-2cm below.
10. Percuss the spleen. The spleen is an oval area of dullness approximately 7cm
wide near the left tenth rib and slightly posterior to the
mal.
11. perform blunt percussion on the liver on the Normally , no tenderness is elicited.
kidney.
12. Perform light palpation, noting tenderness or Abdomen is nontender and soft. There is no guarding
guarding in all quadrants.
13. Perform deep palpation, noting tenderness or Normal tenderness is possible over the xiphoid, aorta,
masses in all quadrants. cecum, sigmoidcolon, and
14. Palpate the umbilicus. It is recessed (inverted) or protruding no more than 0.5
cm and is round or conical.
15. Palpate the aorta. The aorta is approximately 2.5-3.0 cm wide with a
moderately strong and regular pulse.
16. Palpate the liver, noting consistency and The liver is usually not palpable, although it may be felt in
tenderness. some thin clients.
17. Palpate spleen, noting consistency and tenderness. The spleen is seldom palpable at the left costal margin.
18. Palpate the kidneys. The kidney are not usually not palpable sometimes the
lower pole of the right kidney may be palpable.
19. Palpate the urinary bladder. An empty bladder is neither palpable nor tender.
20. Perform the test for shifting dullness. The borders between tympany and dullness remain
relatively constant throughout position changes.
21. Perform the fluid wave test. No fluid wave is transmitted.
22. Perform the ballottement test.
23. Perform the tests for appendicitis
Rebound tenderness No rebound tenderness is present
Rovsing sign
Referred rebound tenderness
Psoas sign No abdominal pain is present
Obturator sign No abdominal pain is present
Hypersensitivity test The client feels no pain and no exaggerated sensation

24. Perform the test for cholecystitis ( murphy sign) No increase in pain is present
Analysis of Data
1. Formulate nursing diagnoses (wellness, risk, actual).
2. Formulate collaborative problems.
3. Make necessary referrals.
 Head
To
Toe
ASSESSMENT

Submitted by: Gabriel Villegas

Submitted to: Mrs: Carmela Perez
BSN 1A2-1