Physical assessment evaluation tool - Nursing Crib

PHYSICAL ASSESSMENT EVALUATION TOOL
(HEAD TO TOE ASSESSMENT)
NAME OF THE CLIENT: Jenileen Carlette T. Peronilla
BODY PART
EXAMINED
ACTUAL
FINDINGS
NORMAL
FINDINGS
ANTHROPOMETRIC MEASUREMENT
1. Measurement in height 154 cm
2. Measurement in weight 42 kg
3. BMI
17
= W in kg / H² in m
3. Body built,
height and weight
in relation to the
client’s age,
lifestyle, and health
4. Posture, gait,
standing, sitting,
and walking
5. Overall hygiene
and grooming
6. Body and breath
odor
GENERAL SURVEY
proportionate
height and weight,
has a healthy and
active lifestyle.
Relaxed, has an
erect in posture
and coordinated
body movement.
Proportionate,
varies with lifestyle
Relaxed, erect in
posture,
coordinated
movement
NORMAL
NORMAL
Clean and neat. Clear and neat NORMAL
Has no body odor
as well as bad
breath.
7. Signs of distress Shows no signs of
distress.
8. Signs of health
and distress
Has a health
appearance.
No body odor or
minor body odor,
no breath odor
No distress noted
Healthy
appearance
NORMAL
NORMAL
NORMAL
9. Attitude cooperative Cooperative NORMAL
INTERPRETATI
ON/
ANALYSIS
10. Mood and affect Appropriate. Appropriate to
situation, should
have appropriate
response
NORMAL
11. Quantity and
quality of speech
Has a fast pacing
Understandable,
moderate in pace
NORMAL
SKIN

13. Uniformity of
color
Has a uniform
white skin color.
Uniform in color
except in areas
expose to the sun
NORMAL
14. Presence of
edema
15. Lesions
according to
location
distribution, color,
configuration, size,
shape, type of
structure
Has no presence of
edema on her skin.
Has no lesions in
the skin.
16. Skin moisture Are not moist
because the air
conditioned
environment.
17. Skin
temperature
Has a uniform
temperature.
18. Skin The skin springs
back to previous
state.
No edema
No lesions or
abrasions
Moisture in the
skin folds and the
axilla varies with
environmental
situation
Uniform in
temperature and
within normal
range
When pinched skin
springs back to
previous state
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NAILS
19. Fingernail plate
shape
20. Fingernail and
toenail bed color
21. Fingernail and
toenail texture
Has a convex
curvature of
fingernail plate,
160º.
Fingernail and
toenail bed color
are pinkish in
color.
Fingernail and
toenail texture are
smooth.
Convex curvature:
angel of nail plate
about 160º
Pinkish in color
Smooth in texture
NORMAL
NORMAL
NORMAL
NORMAL
22. Tissue
surrounding nails
The tissues
surrounding the
nails of the client
are intact.
Intact epidermis
NORMAL

23. Presence of
capillaries
SKULL
24. Size, shape,
symmetry
When blanched
test is performed,
color of the nail
bed of the client
returns into pink
in less than 4
seconds.
Symmetric, round
and proportional
to her weight.
Highly vascular,
prompt return of
pink color
(generally less than
4 seconds)
HEAD
Rounded, smooth
skull contour,
NORMAL
NORMAL
25. Presence of
nodules, masses,
and depressions
SCALP
26. Color and
appearance
Has no presence of
nodules, masses,
and depressions.
Lighter than the
color of her skin
Absence of nodules
or masses
Lighter than the
skin color
NORMAL
NORMAL
27. Areas of
tenderness
HAIR
28. Evenness of
growth, thickness
or thinness
29. Texture, and
oiliness over the
scalp
FACE
30. Facial features,
symmetry of facial
movements
EYEBROWS
31. Hair
distribution,
alignment, skin,
quality, and
movement
EYELASHES
32. Hair
distribution and
No areas of
tenderness.
Evenly distributed,
thick hair
Silky, smooth,
resilient
Symmetric facial
movements
Evenly distributed
hair, intact skin,
symmetrically
aligned, equal
movement
Evenly distributed
hair, curled
outward
No signs of
tenderness
Evenly distributed,
thick hair
Silky, smooth,
resilient
Symmetric facial
movements
EYES
Evenly distributed
hair, intact skin,
symmetrically
aligned, equal
movement
Evenly distributed
hair, curled
outward
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
direction of curl
EYELIDS
33. Surface Skin intact, no Skin intact, no NORMAL

characteristics,
position in relation
to the cornea,
ability to blink,
frequency of
blinking
CONJUNCTIVA
34. Bulbar
conjunctiva for
color, texture, and
presence of lesions
35. Palpebral
conjunctiva for
color, texture, and
presence of lesions
SCLERA
36. Color and
clarity
CORNEA
37. Clarity and
texture
discharge, no
discolorization,
approximately 15
to 20 involuntary
blinks per minute,
bilateral blinking
Transparent,
capillaries
sometimes evident,
sclera appears
white
Shiny smooth, pink
in color
Appears white and
clear
Transparent, shiny
and smooth, details
of iris are visible
IRIS
38. Shape and color Brown, flat and
round
PUPILS
39. Color, shape,
and symmetry of
size
Equal in size
usually, 3 – 7 mm,
equally round
VISUAL ACUITY
40. Near vision Able to read
newsprint
41. Distance vision 20/40 vision on
Snellen chart
without eyeglasses
PUPILS
42. Light reaction
and
accommodation
Constrict when
looking at near
object, dilate when
looking at far
object, converge
when near object is
moved tenderness
discharge, no
discolorization,
approximately 15
to 20 involuntary
blinks per minute,
bilateral blinking
Transparent,
capillaries
sometimes evident,
sclera appears
white
Shiny smooth, pink
in color
Appears white and
clear
Transparent, shiny
and smooth, details
of iris are visible
Brown, flat and
round
Equal in size
usually, 3 – 7 mm,
equally round
Able to read
newsprint
20/20 vision on
Snellen chart
Constrict when
looking at near
object, dilate when
looking at far
object, converge
when near object is
moved tenderness
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NOT NORMAL
Because the client wasn’t
able to see the letters on
the Snelle chart at 20/40
vision
NORMAL

EXTRAOCULAR MUSCLES
44. Alignment and
coordination
VISUAL FIELDS
45. Peripheral
fields
AURICLES
46. Color,
symmetry, and
position
47. Texture,
elasticity, and areas
of tenderness
EXTERNAL EAR CANAL
48. Cerumen, kin
lesions, pus, blood
HEARING ACUITY
49. Response to
normal voice tones
over lacrimal
gland and lacimal
sac, no discharges
in nasolacrimal
duct
Both eyes
coordinated move
in unison with
parallel alignment
Able to see objects
in the periphery
Color same as
facial skin,
symmetrical,
aligned with outer
canthus of eye
about 10º from
vertical
Mobile, firm and
not tender, pinna
recoils after it is
folded
Dry cerumen, has
presence of hair
follicles, no pus or
blood
over lacrimal
gland and lacimal
sac, no discharges
in nasolacrimal
duct
Both eyes
coordinated move
in unison with
parallel alignment
Able to see objects
in the periphery
EARS
Color same as
facial skin,
symmetrical,
aligned with outer
canthus of eye
about 10º from
vertical
Mobile, firm and
not tender, pinna
recoils after it is
folded
Dry cerumen, has
presence of hair
follicles, no pus or
blood
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
Normal voice tones Normal voice tones NORMAL
audible
audible
50. Watch tick test Able to hear Able to hear NORMAL
ticking in both ears ticking in both ears
51. Weber’s test Sound is heard in Sound is heard in NORMAL
both or is localized
at the center of the
head
both or is localized
at the center of the
head
52. Rinne’s test Air-conducted Air-conducted NORMAL
hearing is greater
than boneconducted
hearing
hearing is greater
than boneconducted
hearing
NOSE
53. Deviations in Normal voice tones Color is the same NORMAL

shape, size, color,
and flaring or
discharge from
nares
54. Nasal cavities
for presence of
redness, swelling,
growths and
discharge
55. Nasal septum
between nasal
chambers
56. Patency of both
nasal cavities
57. Tenderness,
masses, and
displacements of
bone and cartilage
audible
Able to hear
ticking in both ears
Sound is heard in
both or is localized
at the center of the
head
Air-conducted
hearing is greater
than boneconducted
hearing
No tenderness or
masses
SINUSES
58. Tenderness No tenderness on
sinuses
LIPS
59. Symmetry of
contour, color, and
texture
BUCCAL MUCOSA
60. Color,
moisture, texture,
presence of lesions
TEETH
61. Color, number
and condition, and
presence of
dentures
Uniform pink
color, soft, moist,
smooth texture,
symmetry of
contour, ability to
purse lips
Uniform pink
color, moist,
smooth, soft,
glistening, and
elastic in texture,
no lesions
31 adult teeth,
white to yellowish
in color, shiny
tooth enamel, no
intact dentures
as the facial skin,
uniform in color,
symmetric and
straight, no nasal
discharges or
flaring
Absence of
redness, swelling,
and discharge
Intact in midline
Air moves freely
through the nares
No tenderness or
masses
No tenderness on
sinuses
MOUTH
Uniform pink
color, soft, moist,
smooth texture,
symmetry of
contour, ability to
purse lips
Uniform pink
color, moist,
smooth, soft,
glistening, and
elastic in texture,
no lesions
32 adult teeth,
white to yellowish
in color, shiny
tooth enamel, no
intact dentures
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL

GUMS
62. Color and
condition
Pink, moist, firm,
no retraction and
bleeding of gums
TONGUE/FLOOR OF THE MOUTH
63. Color and Pink, moist,
texture of the slightly rough, has
mouth floor and thin whitish color
frenulum
64. Texture,
movement and
base of the tongue
65. Presence of
nodules, lumps, or
excoriated areas
PALATES AND UVULA
66. Color, shape,
texture, presence of
bony prominences
67. Position of the
uvula and mobility
Moves freely, the
base is smooth with
prominent veins
No palpable
nodules or lumps
Soft palate is light
pin in color, hard
palate is much
lighter and more
irregular in texture
Positioned in
midline of soft
palate
OROPHARYNX AND TONSILS
68. Color and Pink and smooth
texture
posterior wall
69. Size of the Pink in color, no
tonsils, color, and discharges
discharge
LYMPH NODES
70. Tenderness Absence of
tenderness
TRACHEA
71. Placement Central placement
in midline of neck,
spaces are equal on
THYROID GLAND
72. Symmetry and
visible masses
both sides
Pink, moist, firm,
no retraction and
bleeding of gums
Pink, moist,
slightly rough, has
thin whitish color
Moves freely, the
base is smooth with
prominent veins
No palpable
nodules or lumps
Soft palate is light
pin in color, hard
palate is much
lighter and more
irregular in texture
Positioned in
midline of soft
palate
Pink and smooth
posterior wall
Pink in color, no
discharges
NECK AND LYMPH NODES
Not visible in
inspection, gland
ascends during
swallowing, no
masses
Absence of
tenderness
Central placement
in midline of neck,
spaces are equal on
both sides
Not visible in
inspection, gland
ascends during
swallowing, no
masses
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
73. Smoothness and Smooth, no areas Smooth, no areas NORMAL

areas of
enlargement,
masses, or nodules
of enlargement, or
nodules
POSTERIOR THORAX
74. Size, shape, Symmetric, ribs
symmetry, are sloped
compare the downward at 45º
diameter of the relative to the
anteroposterior spine, muscle
thorax to the development is
transverse thorax equal,
anteroposterior to
transverse
diameter in ratio of
1:2
75. Spinal
alignment
76. Temperature,
tenderness, masses
77. Respiratory
excursion
of enlargement, or
nodules
THORAX
Symmetric, ribs
are sloped
downward at 45º
relative to the
spine, muscle
development is
equal,
anteroposterior to
transverse
diameter in ratio of
1:2
NORMAL
Slightly Vertically aligned NOT NORMAL because
the client has scoliosis.
Uniform in Uniform in NORMAL
temperature, no temperature, no
tenderness and tenderness and
masses
masses
Full and
symmetric chest
expansion
78. Vocal fremitus Bilaterally equal,
heard mostly at the
apex of the lungs
79. Sounds Percussion notes
resonant except
over the scapula,
bronchovesicular
and vesicular
ANTERIOR THORAX
80. Breathing Quiet, rhythmic,
patterns
effortless
81. Temperature, Warm, no
tenderness, masses tenderness or
82. Respiratory
excursion
masses
Full and
symmetric chest
expansion
83. Vocal fremitus Bilaterally equal,
mostly heard at the
apex of the lungs
84. Sounds Flat sound on the
part with heavy
Full and
symmetric chest
expansion
Bilaterally equal,
heard mostly at the
apex of the lungs
Percussion notes
resonant except
over the scapula,
bronchovesicular
and vesicular
Quiet, rhythmic,
effortless
Warm, no
tenderness or
masses
Full and
symmetric chest
expansion
Bilaterally equal,
mostly heard at the
apex of the lungs
Flat sound on the
part with heavy
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL

muscles and bony
prominences,
tympani on the
stomach, dullness
on the liver and
spleen,
bronchovesicular,
vesicular
muscles and bony
prominences,
tympani on the
stomach, dullness
on the liver and
spleen,
bronchovesicular,
vesicular
85. Trachea Bronchial sound Bronchial sound NORMAL
CARDIOVASCULAR
PRECORDIUM
86. Aortic,
pulmonic, tricuspid
area
87. Apical area With palpable
pulsation (point of
maximal impulse)
88. Sounds of
tricuspid and
apical
89. Sounds of
Tricuspid and
apical area
CAROTID ARTERIES
90. Pulsations and
sounds
No pulsation No pulsation NORMAL
S2 is louder than
S1
S1 is lauder than
S2
Symmetric pulse
volumes, full
pulsation, no sound
With palpable
pulsation (point of
maximal impulse)
S2 is louder than
S1
S1 is lauder than
S2
Symmetric pulse
volumes, full
pulsation, no sound
NORMAL
NORMAL
NORMAL
NORMAL
91. Visibility Not visible NORMAL
BREAST AND AXILLA
BREAST
92. Size, symmetry,
contour, shape
93. Skin color,
hyperpigmentation,
retraction, swelling
or edema, lumps
AREOLA
94. Size, shape,
symmetry, color,
surface
characteristics,
mass or lesions
Slightly unequal,
symmetric, convex,
round
Lighter color
because of less
exposure, evenly
pigmented, no
swelling, edema, or
lumps
Equal, round,
symmetric, dark
brown, smooth,
has no lesions
Slightly unequal,
symmetric, convex,
round
Lighter color
because of less
exposure, evenly
pigmented, no
swelling, edema, or
lumps
Equal, round,
symmetric, dark
brown, smooth,
has no lesions
NORMAL
NORMAL
NORMAL

NIPPLES
95. Size, shape,
position, color,
discharges, lesions,
tenderness
Equal, round,
everted in the same
direction, brown,
has no discharges,
lesions, or
tenderness
Equal, round,
everted in the same
direction, brown,
has no discharges,
lesions, or
tenderness
NORMAL
AXILLARY, SUBCLAVICULAR AND SUPRACVICALAR LYMPH NODES
96. Masses or Absence of masses Absence of masses NORMAL
lumps
or lumps
or lumps
ABDOMEN
97. Skin integrity,
contour,
enlargement of
liver or spleen,
symmetry of
contour
Unblemished skin,
uniform in color,
no signs of
enlargement of the
liver and spleen,
symmetrical
Unblemished skin,
uniform in color,
no signs of
enlargement of the
liver and spleen,
symmetrical
NORMAL
98. Visibility of
peristalsis
movement
99. Visibility of
vascular patterns
100. Bowel sounds,
vascular and
peritoneal friction
rubs
MUSCLES
101. Size,
contractures,
tremors
102. Tonicity,
strength (neck,
upper, lower
extremities)
BONES
103. Structure,
deformities,
tenderness, edema
contour
Not visible, slightly
visible on thin
persons
contour
Not visible, slightly
visible on thin
persons
NORMAL
Not visible Not visible NORMAL
Audible bowel
sounds, not audible
vascular and
peritoneal friction
rubs
Audible bowel
sounds, not audible
vascular and
peritoneal friction
rubs
MUSCULOSKELETAL SYSTEM
Bilaterally
symmetric, no
contractures and
tremors
Normal muscle
tension, adequate
strength of the
muscles
Uniform in
structure, no
deformities,
tenderness or
edema
Bilaterally
symmetric, no
contractures and
tremors
Normal muscle
tension, adequate
strength of the
muscles
Uniform in
structure, no
deformities,
tenderness or
edema
NORMAL
NORMAL
NORMAL
NORMAL
JOINTS
104. Swelling, Absence of Absence of NORMAL

tenderness,
smoothness of
movement,
crepitation,
presence of nodule
105. Range of
motion (shoulder
and scapula,
elbows, hands,
acetabulum,
popliteal, ankles)
tenderness and
swelling, has
smooth movement,
no nodules
Able to perform
the exercises in full
range of motion,
no tenderness,
moves smoothly
tenderness and
swelling, has
smooth movement,
no nodules
Able to perform
the exercises in full
range of motion,
no tenderness,
moves smoothly
NORMAL