Body Parts/ System & Actual Findings Normal Findings Interpretation

Method of Assessment
Used

VITAL SIGNS Temp: Temp: 36.5–37.5ºC The Client’s blood

PR: PR: 60 – 100 bpm pressure is slightly
RR: RR: 12-20cpm elevated due to work at
BP: BP: 120/80 mmHg his age the normal
range of blood
pressure is 120/80.

SKIN
 Inspect skin  Color varies All findings are normal
 Observe and based on race for the age of the
palpate skin and environment client.
moisture effect. Irregular pigmentation
 Assess skin if  Fine hair is seen due to prolonged sun
edema is present over most of the exposure while
skin working

HAIR
 Assess the color,   Equal Whitening of the hair
texture and distribution of is due to aging.
distribution hair and color Dryness of hair and
 Inspect the scalp  No lesions and scalp due to aging also
for color, dryness, tenderness on long sun exposure
lumps, lesions due to his work.

NAILS
 Perform Blanche   Normal nails are The longitudinal
test of capilliary translucent, ridging is normal for
refill shiny and firm in older age also the time
texture. of capillary refill.
 Fingernail  Nails must be
plate,shape,and its kept short and
curvature and angle clean

HEAD
  Rounded All findings are
 Skull size and  The eye brows normal.
shape are aligned
 Eyebrows are
 Inspect the evenly
alignment of distributed
eyebrows  Absence of
 Palpate the skull nodules
for nodules
 EYES
 Inspect the eye   Blinks 16 times All findings occur due
blinks per minute per minute to aging
 Cornea is
 Inspect the cornea transparent and
for clarity and smooth
texture  No edema or
tenderness
 Inspect and palpate
the lacrimal gland

EARS
  Symmetrical All findings are normal
 Inspect auricles for auricles position
color symmetry of  The pina recoils
size and position after it is folded
 Ears are same
 Inspect tympanic color to the face
membranes for  Tympanic
color and gloss membrane is
gray, semi
transparent

NOSE & SINUSES   Air moves freely All findings are normal
 Inspect the external from the nares
nose for any  Symmetric and
deviations in shape, straight
size and color  No discharge or
 Inspect the nasal flaring
septum between the  No lesions
nasal chamber

MOUTH & THROAT

 Inspect the teeth   Smooth, white, Irregular cleaning of
and gums shiny tooth teeth can cause plaque,
 Inspect the surface enamel yellowing of teeth,
of the tongue for  Pink, moist, and dryness of gums and
position, color, and firm texture of white patches on
texture gums tongue.
 Pink in color
 NECK
  Coordinated, All findings are normal
 Head movements smooth
movements with
no discomfort

RESPIRATORY
  Chest symmetric All findings are normal
 Assessing Pt  No tenderness;
posterior thorax for no masses
shape and  Vocal fremitus
symmetry are symmetric
 Spine vertically
 Palpate the chest aligned
for vocal fremitus

 Inspect the spinal

alignment for
deformities

CARDIAC
  No arterial All findings are
 Inspect and palpate the insufficiency normal
aortic and pulmonic  Aortic and pulmonic
area areas has no
pulsations
 Inspect and palpate the  Apical area pulse is
epigastric are at the visible
base of the sternum for
abdominal pulse

ABDOMEN
 Palpate the liver   Liver is not palpate
 Uniform skin color All findings are
 Abdoment for skin  Unblemished skin in normal
integrity the abdomen
 No tenderness
 Inspect and Palpate  Audible bowel
abdomen for tenderness sounds
 GENITALS
 Inspect the perineal area   No inflammation,  All findings are
swelling, and lesions normal

MUSCULOSKELETAL
 Inspect muscle and   Muscles size are All findings are
tendon for contractures equal normal
 Test muscle strength  No contractures
 Inspect the skeleton for  Smooth movements
normal structure and  Muscle strength are
deformities equal
 No deformities

NEUROLOGIC
1. MENTAL STATUS
a. Orientation   Responded All findings are
 Determine the clients immediately and normal
orientation by asking correctly
questions  Easily recalls Due to aging
b. Memory without
* Immediate recall stammering

* Recent memory  Able to answer

the questions

* Remote memory  Able to state what

happened last
year/s Christmas
2. LEVEL OF
CONSCIOUSNESS
-using GCS  15 points, the `
client is alert and
completely All findings are
3. 12 CRANIAL NERVES oriented normal
* Olfactory

 Assess the patients

sense of smell
 Pt. identified sense
correctly with each
* Optic nosetrils
 Assess vision using
reading materials

 Have no difficulty
* Oculomotor reading
 Assess the. 6 ocular
movement.
 Both eyes
coordinated, move in
unison with parallel
alignment

* Trochlear

 Assess Pt. 6 ocular  Both eyes

movement. coordinated, move in
unison with parallel
alignment

* Trigeminal 
 Inspect for blink reflex.
 Pt. eyelids blink
bilaterally
* Facial All findings are
 Assess Pt sense of taste normal
 Test the Pt facial
movements  Pt was able to
identifies taste
* Abducens correctly
 Pt facial movements
 Assess each pupils are symmetrical
reactions to
accommodation
 Pupils equally round
and reacts to light
* Glossopharyngeal accommodation
 Test the Pt taste
and gag reflex
 Pt identified taste and
gag reflex present
* Auditory
 Weber’s Test

 Rinne Test  Pt heard sound in both

ears
 Air- conducted
* Vagus hearing is greater than
bone- conducted
 Ask the Pt to open
mouth and say “ All findings are
ah” normal
 Bilateral, symmetrical
rise of soft palate and
* Accessories uvula

 Test the Neck

muscles strength
( sternocleidomasto
id and trapezius)  Equal strength

* Hypoglossal

 Ask Pt to protrude  Symmetrical tongue

and move it to each with smooth outward
side against tongue movement and
blades bilateral strength

4. REFLEXES
* Biceps  Pt biceps contract
 Biceps reflex test ( 1+,2+, 3+ biceps
the spinal cord level reflex)
C-5, C-6

* Triceps

 Triceps reflex test  Elbow extends

the spinal cord level (1+, 2+, 3+
C-7,C-8 triceps reflex)

* Brachioradialis

 Brachioradialis  Elbow flexes with

reflex test the pronation of
forearm ( 1+, 2+, All findings are
spinal cord level C-
3+ brachioradialis normal
3,C-6
reflex)

* Patellar

 Pattelar reflex test  Extension of knee

the spinal cord level ( 1+, 2+, 3+
L-2,L-3,L-4 patellar reflex

* Achilles

 Achilles reflex tests  Plantar flexion of

the spinal cord level foot (1+, 2+, 3+
S-1,S-2 Achilles reflex)
 * Plantar/Babinski  Flexion of all toes

 Plantar/ Babinski,
reflex is

 Negative
5. MOTOR FUNCTION Romberg, Pt sway
Gross: slightly but he
* Romberg’s Test was able to
maintain upward
posture and foot All findings are
stance normal
* Walking Gait Test
 Pt has upright
posture and
steady gait with
opposing arm
* Stand on One Foot swing. He was
with Eyes close able to walk
Heel to toe walking unaided and
maintained
balance.
*Heal to toe walking  Pt maintained
stance for at least
5 seconds
*Toe to heal walking

Fine:  Pt was able to

*Finger to nose Test maintained heel
to toe walking
All findings are
along a straight
normal
*Finger to nose line.
Nurse’s finger
 Able to walk
several steps on
toes or heels

*Finger to thumb  Repeatedly and

and rhythmically
touches the nose
 Perform with
coordination and
rapidity
*Alternate supination
and pronation
 Rapidly touches
each finger to
thumb with each
 hand
6. SENSATION
* Pain
 Can alternate
*Light Touch supinate and
pronate hands at
rapid face.

*Temperature  Able to
discriminate
“sharp“ and
7. TACTILE “dull“
DISCRIMINATION
*One to two point
discrimination
 Light ticking or
touch sensation.

*Stereognosis
 Able to
discriminate
between “ hot “
*Extinction Phenomenon
and cold “
sensation

 Pt was able to
sense whether 1
or 2 areas of the
skin are being
stimulatedby
pressure

 Pt recognized
common object

 Pt both points of
stimulus are felt