`

St. Paul University Philippines

Tuguegarao City, Cagayan 3500
School of Nursing and Allied Health Sciences
COLLEGE OF NURSING
Bachelor of Science in Nursing – Level IV
Second Semester: A.Y. 2021–2022

Head-to-toe Physical Assessment

A. Skin and Integument

AREA ASSESSED TECHNIQUE NORMAL FINDING ACTUAL FINDING INTERPRETATION

Evenly colored skin tones
Evenly colored
without any
Inspect without lesions and Normal
Color discolorations.
rashes
Without any rash and
tanned area
No to slight odor of
Odor Inspection No odor Normal
perspiration
Skin integrity Inspection/ loss of intergrity/turgor, Loss of intergrity, Normal
Skin Palpation skin gradually thins and skin gradually thins
loses density and loses density
Skin is smooth, without No lesions and
Lesions Inspection Normal
lesions smooth skin
Texture Inspection/Pal Wrinkled skin, Wrinkled skin Normal
pation
Smooth
Moisture Palpation Skin smooth Normal
Temperature Palpation Normal warm temperature Skin is warm Normal
Skin is mobile, loss of
Mobility and Loss of
Palpation integrity and turgor Normal
turgor intergrity and
turgor. Mobile
Skin
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St. Paul University Philippines
Tuguegarao City, Cagayan 3500
School of Nursing and Allied Health Sciences
COLLEGE OF NURSING
Bachelor of Science in Nursing – Level IV
Second Semester: A.Y. 2021–2022
No scaliness and it is
Scalp and Scalp and Scalp is clean and dry.
Inspect clean and dry. Normal
Hair condition Without dandruff
Without dandruff
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graying and smooth hair, Hair is gray, smooth,

Hair Inspection Normal
less vibrant in color, thin less vibrant and thin
hair hair.
Cleanliness and Clean and
Inspect Clean and Manicured Normal
grooming manicured

.Pink tones and some

Color and Pink tones and longitudinal ridging
Inspect Normal
markings some longitudinal
ridging
Nails
160-degree angle
Shape Palpate/ Inspect 160-degree angle Normal
with no clubbing
Nails are hard and It is hard and
Texture Palpation Normal
immobile immobile
Pink tone returns
Pink tones return
Nail bed Inspect and palpation immediately when nail bed Normal
after 1-3 seconds
pressure is released
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B. Head, Neck, and Eyes

AREA ASSESSED TECHNIQUE NORMAL FINDING ACTUAL FINDING INTERPRETATION

Rounded and no
Inspection/Palpation Rounded, no lumps, etc. Normal
Shape lumps were
found
Varies according to age.
Usually the head is Size of the head is
symmetric, round, normal and
Size Inspection Normal
erect, and in midline, appropriate to age
appropriately related to and body size
body size
Involuntary Head should be still and Head is still and
Head Inspection Normal
Movement upright. uptight
The head is normally hard
Head is hard, smooth,
Consistency Palpation and smooth, without Normal
and without lesions
lesions
The face is symmetric with
a round, oval, elongated, or The face is
Face Inspection square appearance. No symmetric, and no Normal
abnormal movements abnormal movement
noted. are seen
The temporal artery Temporal artery is
Temporal Artery Palpation Normal
is elastic and not palpated and has
tender. no
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elastic or tender
sensation.
Normally there is no
No swelling,
Temporomandi- swelling, tenderness
Palpation tenderness or Normal
b ular Joint or crepitation with
crepitation.
movement.
Neck is symmetric,
Neck is symmetric, with
with head centered
Symmetry Inspection head centered and Normal
and no masses were
without bulging masses.
found.
The thyroid cartilage, The thyroid, cricoid
Movement of
Inspection cricoid cartilage move upward Normal
Neck Structures
moves symmetrically.
upward symmetrically.
Neck C7 (vertebral
Cervical C7 is prominent
Inspection prominence is usually Normal
Vertebrae and palpable
visible and
palpable)
Normally neck movement The range of motion
Range of Motion Inspection should be smooth and of the neck is Normal
controlled. smooth
and controlled
Palpation and Trachea should be midline. Trachea is located on
Trachea Normal
Auscultation No bruits auscultated. the midline
Thyroid Gland Landmarks are positioned Landmarks are
Palpation Normal
(Hyoid bone, midline. positioned midline
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Thyroid Bone,
Cricoid Bone)
Lymph Nodes:
Preauricular
Postauricular
Occipital
Tonsillar
There is no swelling,
Submandibular There is no swelling,
enlargement,
Submental Palpation enlargement, tenderness Normal
tenderness and
Superficial and hardness present
hardness present
Cervical
Posterior
Cervical
Deep Cervical
Supraclavicular

Not performed but

Vision Test (Snellen’s client does wear
Visual Acuity Visual Acuity is 20/20 Normal
Chart) eyewear due to
Eyes blurring of vision

With normal peripheral

Peripheral Client sees the
Visual Field Test vision, client sees the Normal
Vision examiner’s finger at
examiner’s finger at the
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same time the examiner the same time the

sees it examiner sees it

A. The reflection of A. The eye has

light on the corneas parallel alignment
should be in exact
same spot on each
eye, which
A. Corneal Light indicates parallel
Reflex Test alignment
Extraocular B. The uncovered
Normal
Muscle Function B. Cover Test B. The uncovered eye remains
eye remains fixed fixed and
C. Positions Test straight ahead
and straight
ahead.
C. Eye movement is
smooth and
C. Eye movement
symmetric
should be smooth
and symmetric
throughout the
test.
 The lids should be on
Eyelids and Inspection and Eyelids are on the
the right margins. Normal
Eyelashes Palpation right margin
No white sclera is
seen
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above or below the iris No sclera is seen

above or below
 No turnings, color, the iris
swelling, lesions No turnings, color
and discharge swelling lesions and
present. discharge present
The eyelids can close
 The eyelids can close normally and
without
difficulty
Position and
Alignment of Inspection and Eyeballs are symmetrically Eyeballs are
Normal
the eyeball in Palpation aligned. symmetrically aligned
the eye socket
Bulbar and The conjunctivae are
Inspection and The conjunctivae are clear,
Palpebral clear, and free of Normal
Palpation and free of swelling
Conjunctiva swelling lesions
lesions
No swelling, or redness
should appear over the
No swelling or
Lacrimal Inspection and nares of the lacrimal
redness found on Normal
Apparatus Palpation gland
the lacrimal
apparatus
No drainage should be
found.
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No opacities were
The cornea is transparent,
Cornea and Lens Inspection seen on the Normal
with no opacities.
client’s
cornea.
The iris is typically round,
flat, and evenly colored.
The iris is of the client
The pupil, round with a
is round, flat, and
regular border, is
evenly colored. The
Iris and Pupil Inspection centered in the iris. Normal
pupil, round with a
regular border, is
Normal pupil size – 3-5
centered in the iris
mm

Pupillary
Normal direct pupillary Pupils constricted in
Reaction to Test Normal
response is constriction the exposure to light.
Light
Red reflex should be easily
Internal Eye visible. The red area shuld
Use Opthalmoscope Not Performed
Structure appear round, with
regular
borders
The optic disc should be
Optic Disc Use Opthalmoscope round to oval with sharp, Not Performed
well defined boarders.
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C. Ear

ACTUAL
AREA ASSESSED TECHNIQUE NORMAL FINDING INTERPRETATION
FINDING
Auricle aligns with the
corner of each eye and
Auricle’s position
within a 10-degree angle Normal
Auricle Inspection is appropriate
of the vertical position
and it is not tender
Not swelling and free of Not swelling and
Tragus Inspection Normal
lesions free of lesions
It is either free lobes or
No lesions or
Lobule Inspection attached lobes without any Normal
swelling present
External Ear lesions or swelling
The skin is free of
The skin is free of lesions, lesions, lumps, or
Lesions,
lumps, or nodules. Color nodules. Color is
Discolorations or Inspection Normal
is consistent with facial consistent with
Discharge
color with no discharges facial color with
no discharges
Mastoid process is not Mastoid process
Mastoid process Inspection Normal
tender is not tender
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External Auditory
Inspection It is not bulging It is not bulging Normal
canal
It may have a small
odorless cerumen. It can
Discharge, Color be color yellow, orange, Yellow cerumen
Inspection Normal
and Consistency red, brown, gray, or is found
black. Consistency may
be soft,
moist, dry, flaky, or hard.
Internal Ear:
Color and
Otoscopic Canal walls are pink and
Consistency of Inspection Not Performed
Examination free of nodules
ear
canal walls
Tympanic It is not bulging and no
Inspection Not Performed
Membrane bleeding
Tympanic Membrane
should be pearly, gray,
Color Inspection shiny, and translucent. Not Performed
Without any bulging or
retraction
Slightly concave, smooth, Ear’s shape is
Shape Inspection Normal
and intact appropriate
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Malleus and Umbo are

Consistency Inspection Not Performed
visible

Flutters when bulb is

Inspection (Pneumatic inflated and return back to
Mobility Not Performed
Otoscopy) its resting position once
air is released

Client was able to

Can repeat two-syllable
Whisper Test repeat two- Normal
word
syllable
word
Hearing and Vibrations are heard
Weber’s test Not Performed
Equilibrium equally in both ears
Test Air Conduction is longer
Rinne’s Test Not Performed
than bone conduction
Client
Can maintain stable experienced
Romberg Test Normal
position without slightly swaying
swaying but no
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exaggerated
motions are seen

D. Mouth, Throat, Nose, Sinuses

ACTUAL
AREA ASSESSED TECHNIQUE NORMAL FINDING INTERPRETATION
FINDING

Smooth and
Smooth and Moist,
Lips Inspection Moist, without Normal
without any lesions
any lesions

Teeth is slightly
32 or 28 pearly whitish
yellow, have
Teeth Inspection teeth with no decayed Normal
missing teeth and
Mouth areas.
using dentures.
No decay seen.

Buccal Mucosa is
Inspection with Smooth and moist
Buccal Mucosa moist and Normal
penlight and tongue without any
smooth
depressor lesions
without lesions
No redness,
Color and Inspection with No redness, swelling,
swelling, pain, or Normal
Consistency penlight and tongue pain, or moistness
moistness
depressor
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Pink, Moist, and Medium Pink, Moist, and

Tongue Inspection size with no lesions Medium size with Normal
present no lesions present
Smooth, Shiny,
Inspect, Touch tongue to Smooth, Shiny, Pink or Pink or slightly
Ventral surface
the roof, and use of slightly pale, with pale, with visible Normal
of tongue
penlight visible pains, and free of pains, and free
lesions of
lesions
Visible with
Wharton’s Duct Inspection Visible with salivary flow appropriate Normal
salivary flow
Inspect and use gauze No lesions are
Sides of Tongue No Lesions Normal
pad to hold present
Strength of the Client’s tongue has
Palpate Strong resistance Normal
tongue Strong resistance
Place drops on the top
Ability to taste Can distinguish the taste Not Performed
and sides of tongue
Hard palate is
Hard palate is pale and
pale and
Hard and Soft whitish
Inspect using penlight whitish Soft Normal
palate Soft palate is pinkish,
palate is
spongy, and smooth
pinkish, spongy,
and smooth
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Uvula is normally
Uvula Inspect using penlight Hanging in the midline hanging on the Normal
midline
No unusual foul
Odor Inspection No odor or foul odor Normal
odor present
Present or absent, pinkish Tonsils are pinkish
Inspect using tongue
Tonsils and symmetric with no and symmetric Normal
depressor
lesions with no
lesions
Posterior Inspection using Throat is pink Throat is pink
Normal
Pharyngeal wall tongue depressor and without without lesions
penlight lesions
Nose color is the
Nose color is the same as
same as the face
the face color. It is
External nose Inspection and palpation color. It is smooth, Normal
smooth, symmetric and
symmetric and
free of lesions
free of lesions
Nose
Able to sniff even if one Able to sniff even
Patency of air Inspection and palpation the other nostril is if one the other Normal
occluded nostril is
occluded
Nasal Mucosa is dark pink,
Internal Nose Inspection with otoscope Not Performed
moist, and free of lesions
Non tender and no Non tender and no
Frontal Sinuses Palpation Normal
crepitus crepitus
Sinuses
Non tender and Non tender and
Maxillary Sinuses Palpation Normal
no crepitus no crepitus
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Sinuses Percussion Non tender Non tender Normal

Frontal Sinuses Transluminate Red glow Red glow Normal
Maxillary Sinuses Transluminate Red glow Red glow Normal

E. Thorax

ACTUAL
AREA ASSESSED TECHNIQUE NORMAL FINDING INTERPRETATION
FINDING

Nasal flaring and Inspection No nasal flaring is The client’s Normal

pursed lip observed. diaphragm and
breathing intercostal
muscles move
and work during
breathing.
Thorax Color of face, Inspection Client’s skin is fair The client’s skin Normal
lips, and and even. does not have
chest discolorations,
lesions, injury
Color and shape of Inspection Pink tones should observe When checked
nails in nail bed for oxygen Normal
perfusion, the
student nurse
press down the
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nails and
immediately, the
color of nails
appears from
whitish to its
normal nail
color
[pinkish].
The client was
Configuration Inspection Shoulders and scapula are positioned and Normal
symmetric observed that
there is no sign
of any deviated
areas.
Accessory muscles Inspection Diaphragm is at work than The chest of client Normal
Posterior the accessory muscles expands when he
thorax is breathing.
Position of Client Inspection Client is seated with There is no Normal
hands on his lap and complaint of
relaxed. pain
while seated.
Tenderness and Palpation Client does not report There are no Normal
Sensation pain, tenderness, or muscle complaints
swelling. or any local
infection.
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Crepitus Palpation There is no crackling No palpable Normal

sensation. crepitus
Surface Palpation Skin is free from lesion No presence of Normal
characteristic and masses masses and
lesions upon
palpating
the client
Fremitus Palpation Fremitus is Fremitus that is Normal
heard asymmetrical
symmetrically indicates air
trapping.
Expansion Palpation The thumbs should The thumbs Normal
move apart moved when
symmetrically hands are
placed
to test chest
Percuss for Tone Percussion Resonance is the tone Upon percussing Normal
the client, it was
found to be
resonant over
areas to be
percussed
Diaphragmatic Percussion It must be equal bilaterally There is no Normal
excursion dullness during
percussion
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Breath sounds Auscultation Sound is heard to areas to The sound of the Normal
be auscultate breathing pattern
of client is normal
and does not show
difficulty of
breathing
Adventitious Auscultation There should be no No crackles heard Normal
sound adventitious sound
Bronchophony Auscultation Sound is indistinct Sound is muffled Normal
Egophony Auscultation Sound is indistinguishable Sound is not clear Normal
Pectoriloquy Auscultation Sound is inaudible Sound is faint Normal
The client is
Configuration Inspection Shoulders and scapula are positioned and Normal
symmetric observed that
there is no sign
of any deviated
Anterior areas.
Thorax Position of Inspection Located in the middle and Sternum is not Normal
sternum straight deviated.
Sternal retractions Inspection No retractions observed No bulging Normal
Slope of ribs Inspection Ribs are downwardly Ribs are in a Normal
positioned downward
position
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Quality and Inspection Respiration is relaxed, Breathing pattern Normal

pattern of effortless and quiet. of client is
respiration regular
Intercostal space Inspection No retractions observed The client Normal
breathes normally
without any sign
of bulging or
retraction
Accessory muscles Inspection Diaphragm is at work than The chest of client Normal
the accessory muscles expands when
she
is breathing.
Tenderness and Palpation Client does not report There are no Normal
Sensation pain, tenderness, or muscle complaints
swelling. or any local
infection.
Crepitus Palpation There is no crackling No palpable Normal
sensation. crepitus
Surface Palpation Skin is free from lesion No presence of Normal
characteristic and masses masses and
lesions upon
palpating
the client
Fremitus that Normal
Fremitus Palpation Fremitus is is
heard symmetrical
symmetrically
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The thumbs should The thumbs Normal

Expansion Palpation move apart moved when
symmetrically hands are
placed
to test chest
Upon percussing Normal
Percuss for Tone Percussion Resonance is the tone the client, it was
found to be
resonant over
areas to be
percussed
Diaphragmatic Percussion It must be equal bilaterally There is no Normal
excursion dullness during
percussion
Breath sounds The sound of the Normal
Auscultation Sound is heard to areas to breathing pattern
be auscultate of client is normal
and does not show
difficulty of
breathing
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F. Breast and Axillae

General note for The color is consistent The client’s Normal

Color and texture INSPECTION and even to the skin breast color is
Under this, this was not even and the
thoroughly performed by same with the
the student nurse color of his skin
because of the exposure
of breasts to be checked
but the participant was
asked
about it.
Breasts
Areolas Inspection Areolas vary from The client’s Normal
dark pink to dark areolas are
brown normally
color
dark brown
Nipples Inspection Nipples are equally The client’s Normal
bilateral and same nipples are
in equal
location. and the same
Retraction and Inspection Client’s breast must The client Normal
Dimpling rise symmetrically reported that his
breast has no
signs of dimpling
and
retraction
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Texture and Palpation Palpation should be The client’s Normal

Elasticity smooth, firm and elastic breast is smooth,
firm
and elastic
Tenderness and Palpation No tenderness and The client’s breast Normal
Temperature breasts temperature are in are not tender and
normal body temperature breasts
temperature are
in
normal body
temperature
Masses Palpation No masses should The client’s Normal
be palpated breast does not
have
masses
Nipples Palpation Nipples should erect The client’s Normal
nipples are erected
The client’s breast Normal
Axillae Inspection and Palpation No rash or infection and does not have
Axillae
no palpable nodes rash, infection or
nodes
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G. Abdomen

ACTUAL
AREA ASSESSED TECHNIQUE NORMAL FINDING INTERPRETATION
FINDING

Abdominal skin may be The skin is a little

Coloration of the
Inspection paler than the general lighter than the
skin
skin tone. general skin Normal

Pale smooth, minimally

Inspect for scars, raised old scars may be There are small
Inspection Normal
lesions and seen. Free from rashes and old scars
rashes and lesions
Abdomen The umbilical skin tones
are similar to surrounding The umbilicus is
abdominal skin tones or protruded and
even pinkish. The the color is
Umbilicus Inspection and palpation umbilicus is midline at similar to the Normal
lateral line. It is recessed abdominal skin
or protruding no more and located in
than the
0.5 cm, and is round or midline.
conical
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The surrounding are free

of swellings, bulges, or
masses
Abdominal Abdomen is flat, rounded,
The abdomen
contour Inspection or scaphoid and it Normal
is flat and
should be evenly
round
rounded
Symmetry Inspection Abdomen is symmetry It is symmetrical Normal
There were some
Abdominal respiratory
Abdominal abdominal
Inspection movement maybe seen, Normal
movement respiratory
especially in male
movement seen
Slight pulsation of the
abdominal aorta, which
Observe aortic There was
Palpation is visible in the Normal
pulsations slight
epigastrium extends full
pulsation
length in thin
people
Peristaltic waves are not
seen, although they may
Observe peristatic There was no
Inspection be visible in very thin Normal
waves peristaltic wave
people as a slight ripple on
the
abdominal wall
A series of intermittent, There was
Bowel sounds Auscultation Normal
soft clicks and gurgles are stomach growling
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head at a rate of 5-10 per

minute.
Auscultation Bruits are not normally
heard over abdominal No
Vascular sounds Normal
aorta or renal, iliac, or Bruits were heard
femoral arteries
Venous hum Auscultation Venous hum is not
There was no
normally heard over
venous hum Normal
the epigastric and
that was heard
umbilical
areas
Friction rub over Auscultation
No friction rub over No friction rub
the liver and Normal
liver or spleen is was present
spleen
present

Generalized tympany Dullness was

predominates over the heard over
Tone Percussion Normal
abdomen because of air in the liver and
the stomach and at spleen
intestines
The lower border of liver The liver size is 9
dullness is located at the cm and dullness
Liver height Percussion Normal
costal margin to 1-2 cm were heard at the
below lower border
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The aorta has

Aorta if approximately 2-5-
regular pulse
Aorta Palpation 3.0 cm wide with moderate Normal
and
strong and regular pulse.
there’s not
tenderness

The liver is usually not

The liver is
Liver Palpation palpable, although it may Normal
not
be felt in some thin
palpable
clients
Spleen is seldom palpable The spleen is not
Spleen Palpation Normal
at the left costal margin. palpable
The kidneys
were not
Kidneys Palpation Kidneys are not palpable Normal
palpable and it is
slightly
tender
There is no
An empty bladder is
Urinary bladder Palpation tenderness and Normal
neither palpable nor
it
tender
is not palpable
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H. Musculoskeletal

AREA ASSESSED TECHNIQUE NORMAL FINDING ACTUAL FINDING INTERPRETATION

Head As him
Mouth opens 1-2 in
temporomandibular
(distance between upper
joint was palpated,
and lower teeth). The
there is no swelling
Temporomandibular Inspection client’s mouth opens and
and tenderness Normal
Joint Palpation closes smoothly. Jaw
found He is able to
moves laterally 1-2 cm. Jaw
open Protrude and
protrudes and retracts
retract his mouth
easily
smoothly with no
pain
As the client’s
Neck sternoclavicular joint
is inspected, no
There is no visible bon
Sternoclavicular Inspection visible bone, swelling
overgrowth, swelling or Normal
Joint Palpation nor redness found.
redness: joint is non
His sternoclavicular
tender
joint was palpated
with no
tenderness
His spine curves are
Cervical and lumbar
Cervical, Thoracic Inspection normal. No
spines are concave; Normal
Spine and Lumbar Palpation tenderness found in
thoracic spine
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is convex. Spine is straight his spinous Process.

(when observed behind) His paravertebral
Nontender spinous muscles are firm and
Process; well-developed, smooth. No muscle
firm and smooth, spasms and
nontender paravertebral deformities are
muscles. No muscle spasm found.
He is able to reach his
toes and bend side to
side with no pain
Shoulders are
symmetrically round; no
redness, swelling, or
deformity or heat.
Clavicles and
Shoulders Muscles are fully
scapulae are
developed.
symmetrical. There
Clavicles and scapulae are
Shoulders, arms and Inspection are no redness,
even symmetric. The client Normal
elbows Palpation swelling or
reports no tenderness
deformities found
Arms external and internal
He was able to move
rotation should be about
his hands freely and
90 degrees, respectively
no pain is felt
The client can flex,
extend, adduct, abduct,
rotate and shrug
shoulders against
resistance
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Elbows are in
symmetry and there
Arms
are no abnormal
Elbows are symmetric,
formations of muscles
without deformities,
or bones. There are no
redness or swelling
nodules and
Inspection Olecranon process and
Elbows tenderness recognized Normal
Palpation epicondyles are
as his elbows are
nontender and without
palpated
nodules Client should
The client can flex
have full ROM against
and extend his
resistance
elbows without the
need of
support

Wrists are symmetric,

without redness, or The client’s wrists
swelling. They are are free of nodules,
Inspection nontender and free of redness and
Wrists Normal
Palpation nodules swelling.
Client tolerates test without He can move his arms
extreme pain upward, downward
and sideward easily
Inspection Hands and fingers are The client’s hands are
Hands and fingers
Palpation symmetric, nontender and symmetrical. There Normal
`

without nodules. Fingers lie are no deformities

in strength line. No and swelling.
swelling or deformities.
The thumb should easily
move away from other
fingers.

Hips Buttocks are equally sized;

The client’s hips
iliac crests are symmetric
structure is in
Inspection in height. Hips are stable,
Hips symmetry Normal
Palpation nontender and without
He can perform the
crepitus
range of motion
normally
Knees symmetric, hollows
The client’s patella
present on both sides of
has no swelling or
the patella, no swelling or
tenderness. He has an
deformities. Lower leg in
Legs Inspection aligned formation of
Knees alignment with the upper Normal
Palpation knees. He is able to do
leg
squat and stand
Non tender and cool.
movements without
Muscles firm and no
feeling any pain
nodules
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With the client sitting,

standing, walking, toe
usually point forward and
The client’s ankle
lie flat; toes and feet are in
joints are free from
alignment with the lower
nodules and
Inspection leg. Skin is free of corns
tenderness. He can Normal
Ankles and feet Palpation and calluses
rotate his feet at the
No pain, heat, swelling or
same time.
nodules are noted
Client tolerates squeeze
test without felling extreme
pain
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