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Client͛s posture and gait, standing, Relaxed, erect posture; Slightly slouched,
sitting, and walking. Coordinated movement movement not well Deviation from
coordinated normal

Client͛s overall hygiene and Clean, neat Clean and neat normal
grooming
Signs of distress, in posture of facial No distress noted Has signs of distress Deviation from
expression normal
Signs of health or illness Healthy appearance Appears weak at the left Deviation from
side of his body normal
Client͛s attitude Cooperative Not cooperative Deviation from
normal
Client͛s affect/mood; Appropriate to situation The client acted slightly slow Deviation from
Appropriateness of client͛s response to the situation normal
Quantity and quality of speech Understandable, moderate pace; Slurred speech Deviation from
exhibits thought association normal



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Skin color; uniformity of color Varies to light to deep brown; Skin is light brown; uniform
from ruddy pink to light pink; from except in areas exposed to sun normal
yellow over tones to olive.
Generally uniform except in areas
exposed to the sun; areas of
lighter pigmentations(palms, lips,
nail beds) in dark skinned people
Presence of edema No edema No presence of edema normal
Lesions according to location, Freckles, some birthmarks, some No lesions/abrasions Normal
distribution, color, configuration, flat and raised nevi; no abrasions
size, shape, type or structure or other lesions
Skin moisture Moisture is skin folds and the Skin is dry Deviation
axillae from normal
Skin temperature Uniform, within normal range Warm when palpated normal
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Fingernail plate shape to determine Convex curvature; angle of nail The shape of her nails is
its curvature and angle plate about 160° convex curvature normal
Fingernail and toenail bed color Highly vascular and pink in light Pale in color but short and
skinned and clean dirty Deviation
clients; dark skinned client may from normal
have brown or black pigmentation
in longitudinal streaks
Fingernail and toenail texture Smooth texture Smooth texture Normal
Tissues surrounding nails Intact epidermis Intact epidermis
Normal
Blanch test of capillary refill Prompt return of pink or usual Not returning to it usual Deviation
color (generally less than 4 color͙. from normal
seconds)


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Skull size, shape or symmetry Rounded (normocephalic and Round in shape; smooth skull Normal
symmetrical, with frontal, parietal, contour
occipital prominences); smooth
skull contour
Nodules, masses and depressions Smooth, uniform consistency; Absence of nodules, absence normal
Absence of nodules or masses of masses, absence of
depressions
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Color and appearance White in color Normal
Areas of tenderness No tenderness No tenderness normal
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Evenness of growth, thickness or Evenly distributed hair; Has thin hair and not evenly Normal for
thinness thick hair distributed her age
Texture and oiliness over the scalp Silky, resilient hair Dry hair Normal for
her age

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Facial features, symmetry of facial Symmetrical or slightly Has left hemiplegia Deviation
movements asymmetric facial features; from normal
palpebral fissures equal in size.
Symmetric facial movements
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Hair distribution, alignment, skin Hair evenly distributed; skin intact; Hair not evenly distributed, dry Deviati
and quality movement symmetrically aligned; equal eyebrows on
movement from
normal



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Hair distribution and direction of Equally distributed; curled slightly Equally distributed and curled Normal
curl outward outward


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Surface characteristics, position in Skin intact; no discharge; no Skin is intact, no discharge or Normal
relation to the cornea, ability to blink discoloration; lids close discoloration, 15 blinks per
and frequency of blinking symmetrically; Approximately 15 to minute, no visible sclera above
20 blinks per minute; bilateral corneas, upper lower borders of
blinking; when lids are open, no cornea are slightly covered, lids
visible sclera above corneas, and close symmetrically
upper and lower borders of corneas
areas are slightly covered
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Color, texture, and presence of Transparent; capillaries sometimes No lesions. It is transparent , Normal
lesion in bulbar conjunctiva evident; sclera appears and her capillaries are
white(yellowish in dark skinned sometimes evident, no lesions
clients)
Color, texture, and presence of Shiny, smooth, and pink or red Pink in color, shiny and smooth normal
lesions in palpebral conjunctiva

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Color and clarity White white Normal
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Clarity and texture Transparent, shiny and smooth; Blinked when his cornea is Normal
details of the iris are visible. In touched, smooth, details of the
older people, a thin, grayish white iris are visible, transparent and
ring around the margin, called shiny
arcus senilis, may be evident
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Shape and color Round and flat Flat and round, transparent Normal
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Color, shape and symmetry of size Black in color; equal in size; Black in color, in equal size, Normal
normally 3 to 7 mm in diameter; round smooth border
round smooth border
Light reaction and accommodation Illuminated pupil constricts (direct His pupil has a direct response normal
response) Non-illuminated pupil and a consensual response. The
constricts (consensual response) pupil constricts when looking at
Pupil constricts when looking at near objects and dilates when
near object; pupils dilate when looking at far objects.
looking at far object; pupil is
converge when near object is
moved toward nose

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Near vision Able to read newsprint held at Can͛t read newsprint clearly Deviati
distance of 36cm (14in.) on
from
normal
Distance vision 20/20 vision on Snellen chart Not assessed
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Inspect and palpate No edema or tearing; No edema , tenderness or Normal
No tenderness; No masses hearing

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Alignment and coordination of both Both eyes coordinated move in Her both eyes are coordinated Normal
eyes unison, with parallel alignment in movement
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Peripheral fields Client can see the object in the Client can͛t see clearly in the Normal
periphery periphery for her
age

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Color, symmetry and position Color same as facial skin; Symmetrical, color is same in Normal
symmetrical. Auricle aligned with facial skin, auricle aligned with
outer cantus of the eye, about 10° cathus of the eye
from vertical
Texture, elasticity and areas for Mobile, firm and not tender; Mobile, firm pinna recoils normal
tenderness Pinna recoils after it is folded after it is folded, not tender

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Presence of cerumen, skin lesions, Distal third contains hair follicles Dry cerumen; no lesions, pus, normal
pus and blood and glands; dry cerumen, grayish- and blood; with little amount
tan in color, or sticky, wet of hair
cerumen in various shades of
brown

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Response to normal voice tones Audible to normal voice tones Not well heard Deviatio
n from
normal
Watch tick test Able to hear the ticking both ears Can͛t hear the ticking of the Abnorma
watch on both ears l
Weber͛s Test Sound is heard in both ears or Not assessed
localized at the center of the head
(Weber negative)
Rinne Test Air conducted (AC) hearing is Not assessed
greater than bone-conducted (BC)
hearing, (Rinne Positive)

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Deviations in shape, size, or color, Symmetric and straight; no Not symmetric; no discharge; Normal
and flaring or discharge from nares discharge or flaring; uniform color or flaring and uniform in color
Presence of redness, swelling, Mucosa is pink; Mucosa is pink normal
growths and discharge in the nasal Clear watery discharge; Clear watery discharge,
cavities No lesion No lesion
Nasal septum between nasal Nasal septum is intact and in Nasal septum is intact and in Normal
chambers midline midline
Patency of both nasal cavities Air moves freely as the client Air moves freely as the client normal
breathes through the nares breathes through the nares
Tenderness, masses displacements No tenderness; no lesion No tenderness, no lesion Normal
of bone and cartilage
Locate/palpate/identify the sinuses No tenderness in frontal and No tenderness in frontal and normal
and note for tenderness maxillary sinuses maxillary sinuses
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Symmetry of contour, color and Uniform pink color; soft; Symmetric contour uniform Deviation
texture moisturized; Able to purse lips pink in color, dry, soft texture, from
ability to purse lips Normal
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Color, moisture, texture and Uniform pink color (freckled Uniform in pink color. Moist, Normal
presence of lesions brown pigmentation in dark- smooth. soft texture and no
skinned clients); Moist, smooth, presence of lesions
soft, glistening and elastic texture
(drier buccal mucosa in elderly is
due to decreased salivation)

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Color, number and condition; 32 adult teeth; smooth, white, Has no teeth and has no Deviation
presence of dentures shiny tooth enamel; Smooth and dentures; has dental caries from
intact dentures and tooth decay normal
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Color and condition Pink gums(bluish or dark patches Dark pink Normal
in dark skinned clients) No
retraction of gums (pulling away
from the teeth)

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Color and texture of the mouth floor Smooth tongue base with Smooth tongue base with Normal
and frenulum prominent veins prominent veins
Position, color, texture, movement Central position; pink in color Moves freely, no tenderness, Normal
and base of the tongue (some brown pigmentation on pink in color and slightly rough
tongue borders in dark skinned
clients); moist; slightly rough; thin
whitish coating; smooth, lateral
margins; no lesions; Raised
papillae; moves freely; no
tenderness
Nodules, lumps or any excoriated Smooth with no palpable nodules Smooth with no palpable Normal
areas nodules
Color, shape, texture and the Light pink, smooth soft palate; Light pink, smooth soft palate; normal
presence of bony prominences lighter pink, hard palate; more lighter pink, hard palate; more
regular texture regular texture
Position of the uvula and mobility Positioned in the midline of the Positioned in the midline of Normal
while examining the palate soft palate the soft palate
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Color and texture Pink in color and smooth posterior Smooth and pink in color Normal
wall
Size of the tonsil, color and Pink and smooth; No discharge; No discharge, pink and normal
discharge No deviation from normal size smooth, no discharge
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Locate/palpate/identify lymph No tenderness Not assessed
nodes and note for tenderness

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Placement Central placement in midline of Central placement in the normal
the neck; spaces are equal on both midline of the neck
spaces
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Symmetry and visible masses Not visible on inspection; Not visible in inspection Normal
Thyroid ascends upon swallowing
Smoothness and areas of Lobes may not be palpated; Lobes may not be palpated, normal
enlargement, masses or nodules If palpated, lobes are small, centrally located gland
smooth, centrally located, ascends during swallowing but
painless, and rise freely with is not visible, smooth lobes
swallowing may not be enlarged
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Aortic and Pulmonic areas No pulsation No pulsation Normal
Tricuspid areas No pulsation No pulsation normal
Apical Area Pulsation visible in 50% of adults Pulsation visible in 50% of normal
and palpable in most PMI in 5th adults and palpable in most
th
LICS at or medial to MCL PMI in 5 LICS at or medial to
Diameter of 1 to 2 cm; MCL
No lift or heave Diameter of 1 to 2 cm;
No lift or heave
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Auscultate the aortic, pulmonic, S1: usually heard at all site, usually usually heard at all sites, Normal
tricuspid and apical valves louder at apical area usually louder at the base of
S2: usually heard at all sites, the heart
usually louder at the base of the Systole: silent interval; slightly
heart shorter duration than diastole
Systole: silent interval; slightly at o deviation from normal
shorter duration than diastole at o heart rate(60 to 90 bpm)
deviation from normal heart Diastole: silent interval;
rate(60 to 90 bpm) slightly longer interval than
Diastole: silent interval; slightly systole at no deviation from
longer interval than systole at no normal heart rates
deviation from normal heart rates S4: in many other adult
S3: in children and young adult
S4: in many other adult
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Palpate carotid artery with extreme Symmetric pulse volumes; Symmetric pulse volumes, full Normal
caution Full pulsations, thrusting quality; pulsations quality remains the
Quality remains same when client same when client breathes,
breathes; turns head, and changes elastic arterial wall
from sitting to supine position;
elastic arterial wall

Auscultate the carotid arteries No sound heard on auscultation No sound heard in auscultation normal
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Jugular veins Veins not visible (indicating right normal
side of the heart is functioning Veins not visible
normally)

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Size, symmetry, contour or shape Females: rounded shape; slightly Rounded shape, slightly Normal
unequal in size; generally unequal in size, generally
symmetric symmetric
Males: breast even in chest wall; If
obese, may be similar in shape to
female breast
Skin of breast for localized Uniform skin color(same Uniform skin color, skin is normal
discoloration or hyper pigmentation, appearance as skin of abdomen or intact and smooth, diffuse
retraction, dimpling, localized hyper back) Skin smooth intact; Diffuse symmetric horizontal or
vascular areas, swelling or edema symmetric horizontal or vertical vertical
vascular pattern in light skinned
people; striae (stretch marks);
moles and nevi
Areola area for size, shape, Round or oval and bilaterally the Round or oval and bilaterally Normal
symmetry, color, surface same; colors varies widely; from the same, o masses and no
characteristics, and any mass or light pink to dark brown; irregular lesions
lesions placement of sebaceous glands on
the surface of the areola
(Montgomery͛s tubercles)


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Nipples for size, shape, position, Round, everted, and equal in size; Round, everted, and equal in normal
color, discharge, and lesion similar in color; soft and smooth; size; similar in color; soft and
both nipples point same direction smooth; both nipples point
same direction
Axillary, subclavicular and No tenderness, masses, or nodules No tenderness, masses, or Normal
supraclavicular lymph nodes nodules
Breast for masses and tenderness No tenderness, masses, nodules, No tenderness, masses, normal
or nipple discharge nodules, or nipple discharge
Nipple for tenderness and discharge No tenderness, masses, nodules, No tenderness, masses, normal
or nipple discharge nodules, or nipple discharge
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Skin integrity Unblemished skin; uniform skin Unblemished skin; uniform in Normal
color; silver-white striae or skin color, silver ʹ white striae
surgical scars or surgical scars
Abdominal contour Flat, rounded(convex), or scaphoid Flat, rounded normal
Enlarge liver or spleen No evidence of enlargement of No evidence of enlargement Normal
liver or spleen of liver or spleen
Symmetry of contour Symmetric contour symmetrical normal
Abdominal contour associated with Symmetric movement cause by Symmetric movement cause Normal
respiration, peristalsis, or aortic respiration; visible peristalsis in by respiration; visible
pulsations very lean people; aortic pulsation peristalsis in very lean people;
in thin persons on epigastric area aortic pulsation in thin
persons on epigastric area
Vascular pattern No visible vascular pattern No visible vascular pattern normal
Ausculatate abdomen for bowel Audible bowel sounds; absence of Audible bowel sounds;
sounds, vascular sounds, and arterial bruits; absence of arterial bruits;
peritoneal friction rubs Absence of friction rubs Absence of friction rubs
Percuss several areas in each of four Tympanic over the stomach and Tympanic over the stomach Normal
quadrants gas-filled bowels; dullness, and gas-filled bowels;
especially over the liver and dullness, especially over the
spleen, or a full bladder. liver and spleen, or a full
bladder.
Light palpation followed by deep No tenderness; relaxed abdomen No tenderness, relaxed normal
palpation of all four quadrant with smooth, consistent tension;
tenderness maybe present near
xiphoid process; over cecum and
other sigmoid colon
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Inspect the muscle for size Equal on both sides of the body Equal on both sides of the Normal
body
Muscle and tendons for No contractures No contractures normal
contractures

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Fasciculation and tremors Has some tremors Deviation
from ormal
Muscle tonicity Normally firm Normally firm normal
Strength (neck) Smooth coordinated movement Not well coordinated Deviation
movement from
normal
Strength (upper extremities) Equal strength on each of the Weak on the right side of the Deviation
body part body from
normal
Strength (lower extremities) Equal strength on each of the Weak on the right side of the Deviation
body part body from
normal
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Skeleton for normal structure and No deformities No deformities Normal
deformities
Areas of edema or tenderness No tenderness; no swelling No tenderness, no swelling normal
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Inspect joint for swelling No swelling No swelling Normal
Tenderness, smoothness of No tenderness; no crepitation; no No tenderness, no nodules normal
movement, swelling, crepitation and nodules; joints move smoothly
presence of nodule
 
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Upper extremities (shoulder and Flexion, extension, abduction, Has some problems in the left Deviation
scapula) adduction, hyperextension side of the upper extermeties from
normal
Upper extremities (elbows) Flexion, extension Has some problems in the left Deviation
side of the upper extermeties from
normal
Upper extremities (hands) Flexion, extension, abduction, Has some problems in the left Deviation
adduction, hyperextension side of the upper extermeties from
normal
Lower extremities (acetabulum/ Flexion, extension, abduction, Has some problems in the left Deviation
inguinal area) adduction side of the lower extermeties from
normal
Lower extremities (popliteal) Flexion, extension Has some problems in the left Deviation
side of the lower extermeties from
normal
Lower extremities (ankles) Plantar flexion, dorsal flexion Has some problems in the left Deviation
side of the lower extermeties from
normal
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