Bulacan State University

COLLEGE OF NURSING
City of Malolos, Bulacan

PHYSICAL ASSESSMENT TABLE

Patient’s Initial: ___________ Age: ________ Gender: ________ Date performed: _________________
Medical Diagnosis: _______________________________ Chief Complaint: _____________________
Clinical Area: __________________
Height: _____ (m) Vital Signs:
Weight: _____ (kg) Temp: _____ (°C) PR: _____ (bpm)
BMI: _____ BP: _____ (mm Hg) RR: _____ (rpm)

BODY PARTS NORMAL FINDINGS ACTUAL FINDINGS

ASSESSED
GENERAL
SURVEY:
Body built Proportionate (Ectomorph, Mesomorph,
Height & weight Endomorph);

The height appears within normal range for age,

genetic heritage;

The weight appears within normal range for height

and body build; body fat distribution is even
Posture, Stands comfortably erect, normal posture, walk is
symmetry & gait smooth, even, and well balanced; with symmetric
arm swing;

Body parts look equal bilaterally and are relative in

proportion to each other
Physical No physical deformities, no signs of illness
deformities &
signs of health or
illness
Level of Alert and oriented, attends to questions and responds
consciousness to verbal and non-verbal stimulation appropriately

Behavioral Comfortable and cooperative;

(Mood and affect/
Speech/ Dress & Appropriate to the climate, culture and age groups;
Hygiene) Status
Looks clean and well-groomed
Mental Status The person maintains eye contact; expressions are
appropriate to situation
Language & Understandable; exhibits relevance and organization
communication of thoughts
SKIN:
Skin color, Color varies from light to dark brown, uniform in
uniformity, color, unblemished skin, no signs of edema
presence of
edema
Skin lesions No lesions or abrasions. Freckles, birthmarks &
moles are normal
Skin moisture & Moist where the skin folds and in axillae
temperature
Skin turgor Skin springs back when pinched; < 3 seconds is
normal
NAILS:
Fingernail plate No clubbing or spooned; convex curvature, about
shape 160 degrees
 Fingernail color Pinkish in color, highly vascular,
& texture smooth texture
Tissues Intact epidermis
surrounding the
nails
Capillary refill Prompt return of usual color when blanch test is
performed
HEAD and
FACE:
Evenness of hair Normal hair growth, thick hair, evenly distributed,
growth silky
Scalp Pinkish scalp; no dandruff, lesions, nodules or
tenderness
Presence of Infection or infestations not present
infection or
infestations
Skull size, shape Symmetric, round, erect and in midline and
& symmetry appropriately related to body size
Facial movements No involuntary facial movements, facial movements
are symmetrical
EYES:
Eye condition Straight, normal and non-protruding

Eyebrows Symmetrically aligned, hair evenly distributed, no

scaling
Eyelids & Intact skin, no discharge, eyelids close
Eyelashes symmetrically
Ability to blink Approximately 15-20 involuntary blinks per minute

Bulbar Bulbar conjunctiva is clear, moist, and smooth.

conjunctiva Underlying structures are clearly visible.
Palpebral The lower and upper palpebral conjunctivae are
Conjuctiva clear and free of swelling or lesions
Sclera Sclera appears white

Cornea & Lens Cornea: transparent, shiny & with no opacities

Lens: free of opacities
Iris and Pupils Iris: typically round, flat and evenly colored.
Pupils: Black in color, equal in size, round, reactive
to light and accommodation reaction to light
Extraocular Both eyes coordinated, move in unison and with
muscles parallel alignment
Peripheral visual The client can see the object in the periphery.
fields
Visual Acuity Near vision: able to read newsprint (or visual acuity
of 14/14 – This means that the client can read what
the normal eye can read from a distance of 14in)
Distant vision: 20/20 Snellen Chart
EARS:
Auricles Color same as facial skin; Symmetrical; aligned with
Color the outer cantus of the eye; Recoils back when its
Symmetry & folded, mobile and firm
Position
Texture &
Elasticity
Ear canal walls pink and smooth, without nodules;
External Canal distal part has hair follicle; presence of small amount
Tympanic of waxes but no redness or discharge;
membrane Eardrums pearly grey in color, shiny and
(eardrum) translucent, with no bulging or retractions
Hearing Acuity Normal voice tones audible
 Watch tick Test Audible; 1-2 inches from uncovered ear

NOSE:
External Symmetrical and straight; no discharge or flaring;
uniform in color
Nasal Septum Intact and in midline

Patency Air moves freely in and out of the nasal cavities

Nasal cavities No obstruction, pinkish; clear watery discharge; no

lesion
Sinuses Frontal and maxillary sinuses: no tenderness, masses
or crepitus noted
MOUTH:
Lips Uniform in color, soft; moist, smooth texture,
symmetrical; without lesions or swelling
Buccal Mucosa Pink in color; moist smooth soft and elastic texture;
without lesions or swelling
Central position of tongue and frenulum, pink color;
Tongue moves freely; no tenderness; prominent veins at the
base and no nodules

Teeth 32 permanent teeth, smooth and white enamel; no

decayed areas or missing teeth
Gums Pink gums, moist firm texture, no lesions, no
discharge
Palates Soft: light pink, smooth
Hard: lighter pink, irregular texture
Uvula Positioned midline of the soft palate; no redness or
exudates
May be present or absent; pink, symmetric and
Tonsils
smooth; no discharge or swelling present
Gag reflex Gag reflex is present
NECK:
Neck movements Coordinated, smooth movement with no discomfort

Neck muscles Equal strength, muscles equal in size and head is

centered and without bulging masses
Lymph Nodes Not seen nor palpable; no swelling or tenderness

Trachea
Central placement, midline of the neck
Thyroid Gland
Not visible and glands ascends during swallowing

THORAX &
LUNGS:
Posterior Thorax:
Anteroposterior to transverse diameter in ratio of
Shape &
1:2; symmetrical in size
Symmetry
Spine is vertically aligned, spinal column is straight,
Spinal Alignment right and left shoulders are straight and hips are at
the same level
Color, Skin intact, uniform temperature, no tenderness and
Temperature, no masses, full and symmetric chest expansion
Tenderness &
Masses
Respiratory Thumbs separates during respiration
Excursion
Vocal Fremitus Bilateral symmetry of vocal fremitus when “99” was
repeated
Diaphragmatic Resonate lowest point of resonance on the
Excursion diaphragm
 Vesicular sound is louder on inspiration; Broncho
vesicular sound is equal on inspiration and
Breath Sounds expiration; Bronchial sound is shorter on inspiration

Anterior Thorax: Breathing is effortless; No wheezing. Ronchi,

Breathing Pattern crackles or friction rubs heard
Color, Skin intact, uniform temperature, no tenderness and
Temperature, no masses, full and symmetric chest expansion
Tenderness &
Masses
Respiratory Thumbs separates during respiration
Excursion
Vocal Fremitus Bilateral symmetry of vocal fremitus when “99” was
repeated
Diaphragmatic Dullness over heart and the liver
Excursion
Anterior chest: Broncho vesicular and vesicular
Breath Sounds breath sounds.
The same as posterior thorax
Trachea Bronchial and tubular breath sounds present

BREAST &
AXILLA:
Breast size, shape Breast are round, slightly equal in size and generally
& symmetry symmetric; no tenderness, masses and lesions
Skin is uniform in color, skin is smooth and intact,
Skin no swelling/edema
characteristics
Rounded or oval; light pink to dark brown in color,
Areola irregular placement of sebaceous gland on the
surface
Round, everted (they may be inverted or flat at
Nipple Condition times), equal in size, similar in color, soft & smooth,
both pointed on the same direction, no discharge
Axillary,
Subclavicular and No tenderness, masses or nodules
Supraclavicular
lymph nodes
Breast No areas of tenderness, masses, nodules or nipple
discharge

HEART, NECK
and
PERIPHERAL
VESSELS:
Precordium Aortic and pulmonic areas: No pulsations
(Aortic and Tricuspid area: No pulsation; no lift or heave
Pulmonic areas; Apical area: Pulsations visible in 50% of adults and
tricuspid and palpable in most PMI in fifth LICS at or medial to
apical area; MCL; no lift or heave
epigastric area) Epigastric area: Aortic pulsation

Heart Sounds – S1: Usually heard at all sites (usually louder at apical
aortic, pulmonic, area)
tricuspid and S2: Usually heard at all sites (usually louder at base
apical (mitral) of heart)
S3 in children and young adults
S4 in many older adults
Carotid Arteries Full and symmetric pulse volumes; no sound heard
on auscultation

Jugular veins Veins not visible

Peripheral Veins Veins collapse when limbs are elevated and distend
and Arterial when in dependent position; limbs not tender; pink
Perfusion skin color; skin not excessively warm or cold; no
edema
ABDOMEN:
Skin integrity Unblemished skin; uniform color
Contour and
Flat, rounded or scaphoid, symmetric contour
symmetry
Symmetric movements; peristalsis & aortic
Movements
pulsations ONLY visible on very thin clients
Vascular pattern No visible vascular pattern
Series of intermittent, soft clicks and gurgles are
Bowel Sounds heard over at a rate of 5-30 seconds; borborygmi
may also be heard
Liver: May not be palpable; border feels smooth
Liver and spleen Spleen: Rarely palpable; if can be palpated, it should
be soft and nontender
Abdominal tone Tympany over the stomach and gas-filled bowel;
and tenderness in dullness, especially over liver, spleen and/or a full
all four quadrants bladder
MUSCULO-
SKELETAL
SYSTEM
(Muscles, Bones
and Joints):
Centered, uniform in color, no swelling or masses;
Sternoclavicular No tenderness, no crepitation or nodules
Joint
Cervical, Symmetrical, no tenderness, no nodules, no presence
Thoracic & of pain
Lumbar Spine
Shoulders, Arms Symmetrical, uniform in color, no swelling or
& Elbows masses; uniform in elbow size & shape, no
deformities
Symmetrical, no tenderness, no nodules, no presence
Wrist of pain; no deformities
Symmetrical uniform in color, no swelling or
Hands & Fingers masses; No tenderness, no crepitation or nodules
Symmetrical uniform in color, no swelling or
Knees, Ankles masses; No tenderness, no crepitation
and Feet