PHYSICAL ASSESSMENT

A. General Survey

The patient is 4 years old of age male. He has evenly distributed thin hair. He has
symmetrical face structure. He can move freely, His nails are concave; He has intact memory
and is oriented with regards to where he is, his condition, and who he is with.

B. Head to toe assessment

Body Parts Normal/Standard Actual Findings Analysis
V. PHYSICAL
ASSESSMENT
a. hair Inspection and palpation: Patient’s hair is evenly Normal
Evenly distributed hair, distributed, thin with
thick, silky, resilient hair; black hair
no infection or
manifestations; coarse or
texture fine.
(fundamentals of Nursing
Kozier, pp541)
b. cranium Inspection and palpation: Patient’s head is round Normal
Rounded (normocephalic and symmetrical
and symmetrical; smooth
skull contour, uniform, With wound on the Due to gunshot
consistent. frontal area wound
(fundamentals of Nursing
Kozier, pp.544)
Face Inspection: Patient has symmetrical Normal
Oval round or square, face structure.
symmetrical and
distribution of hair, (-)
edema on eyes; (-)
hollowness.
(fundamentals of Nursing
Kozier, pp.545)
Facial movement Inspection: He has symmetrical facial Normal
Symmetrical facial movement
movement.
(fundamentals of Nursing
Kozier, pp.545)
2. EYES and
VISION
a. external eye
structure
a.1 eyebrows Inspection: Upon inspection, Normal
Hair evenly distributed; eyebrows are evenly
skin intact; eyebrows distributed with white
symmetrically aligned; hairs, symmetrically
equal movements. aligned and has equal
(fundamentals of Nursing movement.
Kozier, pp.548)
a.2 eyelids Inspection: Lids close symmetrically; Normal
Skin intact; no discharge; no discharge; upper and
no discoloration; lids close lower border of cornea is
symmetrically; bilateral slightly covered.
blinking when the lids
open; no visible sclera
above corneas. Upper and
lower borders of cornea
are slightly covered.
(fundamentals of Nursing
Kozier, pp.548)

a.3 eyelashes Inspection: Eyelashes are equally Normal

Equally distributed curled distributed curled slightly
slightly outward. outward.
(fundamentals of Nursing
Kozier, pp.548)
a.4 conjunctiva Inspection: Transparent ; capillaries Normal
Transparent; capillaries sometimes evident
sometimes evident.
(fundamentals of Nursing
Kozier, pp.548)
a.5 cornea Inspection: Patient has transparent Normal
Transparent; shiny; details cornea.
of the iris are available
(fundamentals of Nursing
Kozier, pp.550)
a.6 pupils Inspection: Black in color with equal Normal
Black in color, equal in size, constricted
size; normally 3-7 mm in
diameter; round with
smooth border.
(fundamentals of Nursing
Kozier, pp.550)
b. visual acuity
b.1 near vision Inspection: Patient can read at the Normal
Able to read newsprint level of his age
held at a distance of 14
inches.
(fundamentals of Nursing
Kozier, pp.552)
b.2 color vision Able to perceive purple Able to perceive and Normal
colors and discriminate discriminate color.
pastel colors.
(fundamentals of Nursing
Kozier, pp.552)
c. extra-ocular Inspection: Both of patient’s eyes Normal
motor function Both eyes are coordinated; were observed to move
move in unison with with coordination.
parallel alignment.
(fundamentals of Nursing
Kozier, pp.552)

3. EARS and
HEARING
a. External Ear No drainage; color match Symmetrically aligned. Normal
Canal with the face; no redness;
nodules; swelling or
lesions.
b. hearing Inspection: Able to hear loud and Normal
Normal voice tones modulated sounds.
audible; when watch thick
test performed; able to
head ticking in both ears
(fundamentals of Nursing,
Kozier, pp 558)
4. NOSE
a. structure Inspection: Symmetrical and straight Normal
Symmetric and straight; with no obvious
no discharge or flaring; deformity.
uniform color, no
tenderness, no lesions.
(fundamentals of Nursing,
Kozier, pp 560)
b. obstruction Inspection: Air moves freely as the Normal
Air moves freely as client client breathes
breathes through the
nurse; no visible
obstruction.
(Fundamentals of Nursing,
Kozier, pp. 560)
c. sense of smell Able to identify common The patient is able to Normal
odors. identify common odors.
(fundamentals of Nursing,
Kozier, pp 559)

5. MOUTH
a. lips Inspection: Uniform, symmetric Normal
Uniform; pink in color; contour
soft; moist; smooth
texture; symmetric
contour; able to purse lips

b. tongue Inspection: The tongue is on central Normal

Central position; pink; position, with no lesions
moist; slightly rough thick and moves freely
whitish coating smooth
lateral margins; no lesions
c. gums Pink gums (bluish or Pink gums, moist firm Normal
brown patches in dark- texture to gums, no
skinned clients), moist retractions of gums
firm texture to gums, no (pulling away from the
retractions of gums teeth).
(pulling away from the
teeth).
(Fundamentals of Nursing,
Kozier, pp. 602)
d. teeth 32 adult teeth, smooth, smooth, white, shiny Normal
white, shiny tooth enamel. tooth enamel.
(Fundamentals of Nursing,
 Kozier, pp. 602)
e. breath odor No breath odor. no breath odor noted Normal
(Fundamentals of Nursing,
Kozier, pp. 572)
6. NECK
a. musculo- Muscles equal in size; Patient’s neck can rotate Normal
skeletal head centered; movement sideways, up and down
structures coordinated with no
discomfort
Inspection:
Equal strength against
resistance of hands
(fundamentals of Nursing,
Kozier, pp 558)
b. lymph nodes Inspection: Not palpable Normal
Not palpable
(fundamentals of Nursing,
Kozier, pp 558)
c. thyroid gland Inspection and palpation: The thyroid glands was Normal
Not visible on inspection; not visible on inspection;
glands ascends during and the lobes are not
swallowing; lobes may not palpated
be palpated.
(fundamentals of Nursing,
Kozier, pp 568)

7. UPPER
EXTREMITIES
a. musculo- Inspection and palpation: Equal size on both sides Normal
skeletal Equal size on both sides of of the body: color varies.
structures, skin the body; normally firm;
nails no contractures
(shortening); with equal
number of fingers.
Inspection: Brown
Color varies with lifestyle Normal
and genes; skin color
uniform
(-)edema
(-abrasions, lesions
temperature not
excessively warm or cold Convex curvature; 160
Inspection: angle; smooth texture; Normal
Convex curvature; 160 highly vascular and
angle; smooth texture; pinkish; 1-2 sec capillary
highly vascular and refill.
pinkish; 1-2 sec capillary
refill.
(fundamentals of Nursing,
Kozier, pp 600)

b. musculo Equal strength on each

skeletal strength body side

8. ANTERIOR
CHEST
a. breast Palpation and Inspection: Skin uniform in color Normal
Breast even with the chest (some in appearance as
wall; if obese, may be skin of abdomen or back)
similar in shape to female Skin smooth and intact
breast.
Skin uniform in color
(some in appearance as
skin of abdomen or back)
Skin smooth and intact
axillae Palpation: No tenderness or masses. Normal
No tenderness, masses on
nodules
(fundamental of Nursing,
Kozier, pp589)
b. thorax Inspection and Palpation: Skin intact and no Normal
Chest symmetrical; quiet tenderness; chest
and effortless respiration; symmetrical
full symmetric excursions;
skin intact; no tenderness
(fundamentals of Nursing,
Kozier, pp 578)

9. BACK
a. musculo- Inspection and palpation: Chest symmetric Normal
skeletal Chest symmetric; spinal
structures and column is straight, right,
posterior thorax and left shoulders and hips
are at the same height;
skin intact
10. ABDOMEN
a. 4 quadrants Inspection: Unblemished skin; Normal
Unblemished skin; uniform in color, flat
uniform in color, flat round or scaphoid
round or scaphoid (concave); symmetric
(concave); symmetric contour; no visible
contour; no visible vascular pattern
vascular pattern Auscultation:
Auscultation: Audible bowel sounds;
Audible bowel sounds; absence of arterial bruits;
absence of arterial bruits; absence of friction rub.
absence of friction rub.
Palpation:
No tenderness; relaxed
abdomen with smooth,
consistent tension
(Fundamentals of Nursing,
Kozier, pp 596/
597)
11. LOWER
EXTREMITIES
a. musculo Inspection and palpation:
skeletal Equal size on both sides of
structures, skin, body; normally firm; no
nails contractures(shortening)
(Fundamental of Nursing
Kozier, pp.600)
12. GENITALS N/A
and
PELVIS(male)

a. external No inflammation, swelling N/A

genitals or discharge
(Fundamental of Nursing,
Kozier, pp654)
13. RECTUM
a. lesions No presence of lesions N/A
Level of consciousness:
GCS: