PHYSICAL ASSESSMENT EVALUATION TOOL

(HEAD TO TOE ASSESSMENT)

NAME OF THE CLIENT: Jenileen Carlette T. Peronilla

BODY PART ACTUAL NORMAL INTERPRETATI

EXAMINED FINDINGS FINDINGS ON/
ANALYSIS
ANTHROPOMETRIC MEASUREMENT
1. Measurement in height 154 cm
2. Measurement in weight 42 kg
3. BMI 17
= W in kg / H² in m
GENERAL SURVEY
3. Body built, proportionate Proportionate, NORMAL
height and weight height and weight, varies with lifestyle
in relation to the has a healthy and
client’s age, active lifestyle.
lifestyle, and health

4. Posture, gait, Relaxed, has an Relaxed, erect in NORMAL

standing, sitting, erect in posture posture,
and walking and coordinated coordinated
body movement. movement
5. Overall hygiene Clean and neat. Clear and neat NORMAL
and grooming
6. Body and breath Has no body odor No body odor or NORMAL
odor as well as bad minor body odor,
breath. no breath odor
7. Signs of distress Shows no signs of No distress noted NORMAL
distress.
8. Signs of health Has a health Healthy NORMAL
and distress appearance. appearance
9. Attitude cooperative Cooperative NORMAL

10. Mood and affect Appropriate. Appropriate to NORMAL

situation, should
have appropriate
response
11. Quantity and Has a fast pacing Understandable, NORMAL
quality of speech moderate in pace
SKIN
13. Uniformity of Has a uniform Uniform in color NORMAL
color white skin color. except in areas
expose to the sun

14. Presence of Has no presence of No edema NORMAL

edema edema on her skin.
15. Lesions Has no lesions in No lesions or NORMAL
according to the skin. abrasions
location
distribution, color,
configuration, size,
shape, type of
structure
16. Skin moisture Are not moist Moisture in the NORMAL
because the air skin folds and the
conditioned axilla varies with
environment. environmental
situation
17. Skin Has a uniform Uniform in NORMAL
temperature temperature. temperature and
within normal
range

18. Skin The skin springs When pinched skin NORMAL

back to previous springs back to
state. previous state

NAILS NORMAL
19. Fingernail plate Has a convex Convex curvature: NORMAL
shape curvature of angel of nail plate
fingernail plate, about 160º
160º.
20. Fingernail and Fingernail and Pinkish in color NORMAL
toenail bed color toenail bed color
are pinkish in
color.
21. Fingernail and Fingernail and Smooth in texture NORMAL
toenail texture toenail texture are
smooth.

22. Tissue The tissues Intact epidermis NORMAL

surrounding nails surrounding the
nails of the client
are intact.
23. Presence of When blanched Highly vascular, NORMAL
capillaries test is performed, prompt return of
color of the nail pink color
bed of the client (generally less than
returns into pink 4 seconds)
in less than 4
seconds.
HEAD
SKULL
24. Size, shape, Symmetric, round Rounded, smooth NORMAL
symmetry and proportional skull contour,
to her weight.
25. Presence of Has no presence of Absence of nodules NORMAL
nodules, masses, nodules, masses, or masses
and depressions and depressions.
SCALP
26. Color and Lighter than the Lighter than the NORMAL
appearance color of her skin skin color

27. Areas of No areas of No signs of NORMAL

tenderness tenderness. tenderness
HAIR
28. Evenness of Evenly distributed, Evenly distributed, NORMAL
growth, thickness thick hair thick hair
or thinness
29. Texture, and Silky, smooth, Silky, smooth, NORMAL
oiliness over the resilient resilient
scalp
FACE
30. Facial features, Symmetric facial Symmetric facial NORMAL
symmetry of facial movements movements
movements
EYES
EYEBROWS
31. Hair Evenly distributed Evenly distributed NORMAL
distribution, hair, intact skin, hair, intact skin,
alignment, skin, symmetrically symmetrically
quality, and aligned, equal aligned, equal
movement movement movement
EYELASHES
32. Hair Evenly distributed Evenly distributed NORMAL
distribution and hair, curled hair, curled
direction of curl outward outward
EYELIDS
33. Surface Skin intact, no Skin intact, no NORMAL
characteristics, discharge, no discharge, no
position in relation discolorization, discolorization,
to the cornea, approximately 15 approximately 15
ability to blink, to 20 involuntary to 20 involuntary
frequency of blinks per minute, blinks per minute,
blinking bilateral blinking bilateral blinking
CONJUNCTIVA
34. Bulbar Transparent, Transparent, NORMAL
conjunctiva for capillaries capillaries
color, texture, and sometimes evident, sometimes evident,
presence of lesions sclera appears sclera appears
white white
35. Palpebral Shiny smooth, pink Shiny smooth, pink NORMAL
conjunctiva for in color in color
color, texture, and
presence of lesions
SCLERA
36. Color and Appears white and Appears white and NORMAL
clarity clear clear
CORNEA
37. Clarity and Transparent, shiny Transparent, shiny NORMAL
texture and smooth, details and smooth, details
of iris are visible of iris are visible
IRIS
38. Shape and color Brown, flat and Brown, flat and NORMAL
round round
PUPILS
39. Color, shape, Equal in size Equal in size NORMAL
and symmetry of usually, 3 – 7 mm, usually, 3 – 7 mm,
size equally round equally round
VISUAL ACUITY
40. Near vision Able to read Able to read NORMAL
newsprint newsprint
41. Distance vision 20/40 vision on 20/20 vision on NOT NORMAL
Snellen chart Snellen chart Because the client wasn’t
without eyeglasses able to see the letters on
the Snelle chart at 20/40
vision
PUPILS
42. Light reaction Constrict when Constrict when NORMAL
and looking at near looking at near
accommodation object, dilate when object, dilate when
looking at far looking at far
object, converge object, converge
when near object is when near object is
moved tenderness moved tenderness
 over lacrimal over lacrimal
gland and lacimal gland and lacimal
sac, no discharges sac, no discharges
in nasolacrimal in nasolacrimal
duct duct
EXTRAOCULAR MUSCLES
44. Alignment and Both eyes Both eyes NORMAL
coordination coordinated move coordinated move
in unison with in unison with
parallel alignment parallel alignment
VISUAL FIELDS
45. Peripheral Able to see objects Able to see objects NORMAL
fields in the periphery in the periphery
EARS
AURICLES
46. Color, Color same as Color same as NORMAL
symmetry, and facial skin, facial skin,
position symmetrical, symmetrical,
aligned with outer aligned with outer
canthus of eye canthus of eye
about 10º from about 10º from
vertical vertical
47. Texture, Mobile, firm and Mobile, firm and NORMAL
elasticity, and areas not tender, pinna not tender, pinna
of tenderness recoils after it is recoils after it is
folded folded
EXTERNAL EAR CANAL
48. Cerumen, kin Dry cerumen, has Dry cerumen, has NORMAL
lesions, pus, blood presence of hair presence of hair
follicles, no pus or follicles, no pus or
blood blood
HEARING ACUITY
49. Response to Normal voice tones Normal voice tones NORMAL
normal voice tones 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
both or is localized
at the center of the
at the center of the
head head
52. Rinne’s test Air-conducted Air-conducted NORMAL
hearing is greater hearing is greater
than bone- than bone-
conducted hearing conducted hearing
NOSE
53. Deviations in Normal voice tones Color is the same NORMAL
shape, size, color, audible as the facial skin,
and flaring or uniform in color,
discharge from symmetric and
nares straight, no nasal
discharges or
flaring
54. Nasal cavities Able to hear Absence of NORMAL
for presence of ticking in both ears redness, swelling,
redness, swelling, and discharge
growths and
discharge
55. Nasal septum Sound is heard in Intact in midline NORMAL
between nasal both or is localized
chambers at the center of the
head
56. Patency of both Air-conducted Air moves freely NORMAL
nasal cavities hearing is greater through the nares
than bone-
conducted hearing
57. Tenderness, No tenderness or No tenderness or NORMAL
masses, and masses masses
displacements of
bone and cartilage
SINUSES
58. Tenderness No tenderness on No tenderness on NORMAL
sinuses sinuses
MOUTH
LIPS
59. Symmetry of Uniform pink Uniform pink NORMAL
contour, color, and color, soft, moist, color, soft, moist,
texture smooth texture, smooth texture,
symmetry of symmetry of
contour, ability to contour, ability to
purse lips purse lips
BUCCAL MUCOSA
60. Color, Uniform pink Uniform pink NORMAL
moisture, texture, color, moist, color, moist,
presence of lesions smooth, soft, smooth, soft,
glistening, and glistening, and
elastic in texture, elastic in texture,
no lesions no lesions
TEETH
61. Color, number 31 adult teeth, 32 adult teeth, NORMAL
and condition, and white to yellowish white to yellowish
presence of in color, shiny in color, shiny
dentures tooth enamel, no tooth enamel, no
intact dentures intact dentures
GUMS
62. Color and Pink, moist, firm, Pink, moist, firm, NORMAL
condition no retraction and no retraction and
bleeding of gums bleeding of gums
TONGUE/FLOOR OF THE MOUTH
63. Color and Pink, moist, Pink, moist, NORMAL
texture of the slightly rough, has slightly rough, has
mouth floor and thin whitish color thin whitish color
frenulum
64. Texture, Moves freely, the Moves freely, the NORMAL
movement and base is smooth with base is smooth with
base of the tongue prominent veins prominent veins
65. Presence of No palpable No palpable NORMAL
nodules, lumps, or nodules or lumps nodules or lumps
excoriated areas
PALATES AND UVULA
66. Color, shape, Soft palate is light Soft palate is light NORMAL
texture, presence of pin in color, hard pin in color, hard
bony prominences palate is much palate is much
lighter and more lighter and more
irregular in texture irregular in texture
67. Position of the Positioned in Positioned in NORMAL
uvula and mobility midline of soft midline of soft
palate palate
OROPHARYNX AND TONSILS
68. Color and Pink and smooth Pink and smooth NORMAL
texture posterior wall posterior wall
69. Size of the Pink in color, no Pink in color, no NORMAL
tonsils, color, and discharges discharges
discharge
NECK AND LYMPH NODES
LYMPH NODES
70. Tenderness Absence of Absence of NORMAL
tenderness tenderness
TRACHEA
71. Placement Central placement Central placement NORMAL
in midline of neck, in midline of neck,
spaces are equal on spaces are equal on
both sides both sides
THYROID GLAND
72. Symmetry and Not visible in Not visible in NORMAL
visible masses inspection, gland inspection, gland
ascends during ascends during
swallowing, no swallowing, no
masses masses
73. Smoothness and Smooth, no areas Smooth, no areas NORMAL
areas of of enlargement, or of enlargement, or
enlargement, nodules nodules
masses, or nodules
THORAX
POSTERIOR THORAX
74. Size, shape, Symmetric, ribs Symmetric, ribs NORMAL
symmetry, are sloped are sloped
compare the downward at 45º downward at 45º
diameter of the relative to the relative to the
anteroposterior spine, muscle spine, muscle
thorax to the development is development is
transverse thorax equal, equal,
anteroposterior to anteroposterior to
transverse transverse
diameter in ratio of diameter in ratio of
1:2 1:2
75. Spinal Slightly Vertically aligned NOT NORMAL because
alignment the client has scoliosis.
76. Temperature, Uniform in Uniform in NORMAL
tenderness, masses temperature, no temperature, no
tenderness and tenderness and
masses masses
77. Respiratory Full and Full and NORMAL
excursion symmetric chest symmetric chest
expansion expansion
78. Vocal fremitus Bilaterally equal, Bilaterally equal, NORMAL
heard mostly at the heard mostly at the
apex of the lungs apex of the lungs
79. Sounds Percussion notes Percussion notes NORMAL
resonant except resonant except
over the scapula, over the scapula,
bronchovesicular bronchovesicular
and vesicular and vesicular
ANTERIOR THORAX
80. Breathing Quiet, rhythmic, Quiet, rhythmic, NORMAL
patterns effortless effortless
81. Temperature, Warm, no Warm, no NORMAL
tenderness, masses tenderness or tenderness or
masses masses
82. Respiratory Full and Full and NORMAL
excursion symmetric chest symmetric chest
expansion expansion
83. Vocal fremitus Bilaterally equal, Bilaterally equal, NORMAL
mostly heard at the mostly heard at the
apex of the lungs apex of the lungs
84. Sounds Flat sound on the Flat sound on the NORMAL
part with heavy part with heavy
 muscles and bony muscles and bony
prominences, prominences,
tympani on the tympani on the
stomach, dullness stomach, dullness
on the liver and on the liver and
spleen, spleen,
bronchovesicular, bronchovesicular,
vesicular vesicular
85. Trachea Bronchial sound Bronchial sound NORMAL
CARDIOVASCULAR
PRECORDIUM
86. Aortic, No pulsation No pulsation NORMAL
pulmonic, tricuspid
area
87. Apical area With palpable With palpable NORMAL
pulsation (point of pulsation (point of
maximal impulse) maximal impulse)
88. Sounds of S2 is louder than S2 is louder than NORMAL
tricuspid and S1 S1
apical
89. Sounds of S1 is lauder than S1 is lauder than NORMAL
Tricuspid and S2 S2
apical area
CAROTID ARTERIES
90. Pulsations and Symmetric pulse Symmetric pulse NORMAL
sounds volumes, full volumes, full
pulsation, no sound pulsation, no sound

91. Visibility Not visible NORMAL

BREAST AND AXILLA
BREAST
92. Size, symmetry, Slightly unequal, Slightly unequal, NORMAL
contour, shape symmetric, convex, symmetric, convex,
round round
93. Skin color, Lighter color Lighter color NORMAL
hyperpigmentation, because of less because of less
retraction, swelling exposure, evenly exposure, evenly
or edema, lumps pigmented, no pigmented, no
swelling, edema, or swelling, edema, or
lumps lumps
AREOLA
94. Size, shape, Equal, round, Equal, round, NORMAL
symmetry, color, symmetric, dark symmetric, dark
surface brown, smooth, brown, smooth,
characteristics, has no lesions has no lesions
mass or lesions
NIPPLES
95. Size, shape, Equal, round, Equal, round, NORMAL
position, color, everted in the same everted in the same
discharges, lesions,direction, brown, direction, brown,
tenderness has no discharges, has no discharges,
lesions, or lesions, or
tenderness tenderness
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, Unblemished skin, Unblemished skin, NORMAL
contour, uniform in color, uniform in color,
enlargement of no signs of no signs of
liver or spleen, enlargement of the enlargement of the
symmetry of liver and spleen, liver and spleen,
contour symmetrical symmetrical
contour contour
98. Visibility of Not visible, slightly Not visible, slightly NORMAL
peristalsis visible on thin visible on thin
movement persons persons
99. Visibility of Not visible Not visible NORMAL
vascular patterns
100. Bowel sounds, Audible bowel Audible bowel NORMAL
vascular and sounds, not audible sounds, not audible
peritoneal friction vascular and vascular and
rubs peritoneal friction peritoneal friction
rubs rubs
MUSCULOSKELETAL SYSTEM
MUSCLES
101. Size, Bilaterally Bilaterally NORMAL
contractures, symmetric, no symmetric, no
tremors contractures and contractures and
tremors tremors
102. Tonicity, Normal muscle Normal muscle NORMAL
strength (neck, tension, adequate tension, adequate
upper, lower strength of the strength of the
extremities) muscles muscles
BONES
103. Structure, Uniform in Uniform in NORMAL
deformities, structure, no structure, no
tenderness, edema deformities, deformities,
tenderness or tenderness or
edema edema
JOINTS
104. Swelling, Absence of Absence of NORMAL
tenderness, tenderness and tenderness and
smoothness of swelling, has swelling, has
movement, smooth movement, smooth movement,
crepitation, no nodules no nodules
presence of nodule
105. Range of Able to perform Able to perform NORMAL
motion (shoulder the exercises in full the exercises in full
and scapula, range of motion, range of motion,
elbows, hands, no tenderness, no tenderness,
acetabulum, moves smoothly moves smoothly
popliteal, ankles)