I.

Physical Assessment-
GENERAL SURVEY
(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 572)
AREA TO BE ACTUAL FINDINGS NORMS AND INTERPRETATION ANALYSIS
ASSESSED STANDARDS
Observe body built, Weight 8kg, Height Body built is Normal Normally body
height, and weight in 18 inches, proportionate to built is
relation to age the height and proportionate to
weight. the height and
weight.
Observe posture, Can stand straight Straight and Normal Normally the child
gait, standing, sitting and well balanced Well-balanced are tall, straight,
and walking posture. posture. and well-balanced
posture.
Observe hygiene Unclean and Untidy Clean, neat. Deviation from The infants and
and grooming Normal young children
should be clean
and well groomed.
Observe body and Mild body and breath No body odor or Deviation from Proper hygiene
breath odor odor. minor body odor Normal must have no
relative to work body odors or
or exercise; no breathe odors.
breath odor.
Observe the signs of Signs of distress is No distress. Deviation from The infants or
distress in posture present, irritation is Normal young children
and facial present and fear is must be
expression present when we are cooperative, not in
near to the client ill and feel
relaxed.
Obvious signs of No presence of No signs of Normal The infants or
illness illness. illness. young children
must be
cooperative, not in
ill and feel
relaxed.
Observe clients Uncooperative Cooperative, Deviation from The infants or
attitude able to follow normal young children
instructions. must be
cooperative, not in
ill and feel
relaxed.
Observe clients Not Appropriate Appropriate to Deviation from Normally the
mood, describe the situation. Normal mood of the
appropriateness of infants or young
clients response child may or may
not appropriate to
he situation.
Observe quantity Verbalized the word Understandable Normal The infants or
and quality of mama, , moderate young children
speech pace, clear must be
tone; exhibits cooperative, not in
thought ill and feel
association. relaxed.
Observe relevance Logical
and organization of sequence,
thoughts makes sense,
has sense of
reality.

SKIN and NAILS

(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 579-580, 583-584)

AREA TO BE ACTUAL FINDINGS NORMS AND INTERPRETATION ANALYSIS

ASSESSED STANDARDS

Inspect for color, Skin is light brown in Light to deep Normal Asian persons
uniformity of color color brown, generally have skin that is
uniform except in normally of a
areas exposed to yellow tone.
the sun.
Inspect for No presence of No edema. Normal Normally the
presence of edema edema skin texture of
young children
is smooth,
slightly dry,
and not oily or
clammy.
Inspect, palpate, No presence of Some birthmarks, Normal Normally the
and describe lesions or abrasions. some flat and skin texture of
lesions. raised nevi; no young children
abrasions or
is smooth,
other lesions.
slightly dry,
and not oily or
clammy.

Observe and Some parts of the Moisture in skin Normal Normally the
palpate skin skin are slightly dry folds skin texture of
moisture mostly at the legs young children
is smooth,
slightly dry,
and not oily or
clammy.
Palpate skin Warm to touch Uniform and Normal Normally the
Temperature within normal skin texture of
range. young children
is smooth,
slightly dry,
and not oily or
clammy.
Palpate skin turgor The skin returned When pinched, Normal Elastic tissue
within less than 1-2 skin springs back immediately
seconds. to previous state. assumes its
normal position
without residuals
marks or creases.
Inspect fingernail Convex Convex, angle of Normal Normally the nails
plate shape to nail plate about are pink, convex,
determine its 160 degrees. smooth, and hard
curvature and but flexible.
angle
Inspect fingernail Pink n coor Highly vascular, Normal Normally the nails
and toe nail bed pink. are pink, convex,
color smooth, and hard
but flexible.
Palpate fingernail Smooth to touch, no Smooth texture. Normal Normally the nails
and toenail texture mass. are pink, convex,
smooth, and hard
but flexible.
Inspect tissues No presence of dry Intact epidermis. Deviation from Normally the nails
surrounding nails skin surrounding Normal are pink, convex,
nails, Dirty nails (dark smooth, and hard
brown in color) but flexible and
edges should be
white and should
extend over the
fingers.
Perform blanch test Capillary refill Capillary refill Normal Normally capillary
of capillary refill returned immediately goes back refill returned
immediately or immediately after
less than 2 pinching or
seconds. grasping the
sakin.

SKULL and FACE, EYE STRUCTURES and VISUAL ACUITY, EARS and HEARING,
NOSE and SINUSES, MOUTH and OROPHARYNX, NECK
(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 585, 587-593, 595-598, 599-
600, 602-604, 607-610)

AREA TO BE ACTUAL FINDINGS NORMS AND INTERPRETATION ANALYIS

ASSESSED STANDARD
Inspect the skull for Rounded and
size, shape, and symmetric, with
symmetry frontal, parietal,
occipital
prominences;
smooth skull
contour.
Palpate the skull for Smooth, uniform
nodules or masses consistency;
and depressions absence of
nodules or
masses.
Inspect the hair for Hair evenly Hair evenly Normal
color, texture, and distributed,resilient distributed,
evenness resilient.
Inspect the scalp No dandruff, no lice. No dandruff, no Normal
lice.
Palpate the scalp Presence of prickly No tenderness, Deviation from
for lesions, heat rashes red in no lesions. normal
tenderness, color evenly
bruises, masses, or distributed on scalp
nodules
Inspect the facial Symmetric or
features slightly
asymmetric
facial features;
palpebral
features equal in
size.
Note symmetry of Symmetric facial --
facial movements. movements.
Inspect the Hair evenly
eyebrows for hair distributed; skin
distribution and intact; eyebrows
alignment and skin symmetrically
quality and aligned; equal
movement movement.
Inspect the Equally
eyelashes for distributed;
evenness of curled slightly
distribution and outward.
direction of curl
Inspect the eyelids Skin intact; no
for surface discharge; no
characteristics discoloration.
Lids close
symmetrically.
Involuntary and
ability to blink.
Inspect the bulbar Transparent;
conjunctiva for capillaries
color, texture, and sometimes
the presence of evident; sclera
lesions. appears white
(darker or
yellowish and
with small brown
macules in dark-
skinned clients).
Inspect the Shiny, smooth,
palpebral moist, and pink
conjunctiva in color.
Inspect and palpate No edema or
the lacrimal gland tenderness over
lacrimal gland.
Inspect and palpate No edema or
the lacrimal sac tearing.
and nasolacrimal
duct
Inspect the cornea Transparent,
for clarity and shiny, and
texture smooth; details
of iris are visible.
Perform corneal Client will blink
sensitivity test when the cornea
is touch,
indicating that
the trigeminal
nerve is intact.
Inspect the anterior Transparent; no
chamber for shadow of light
transparency and on iris; depth of
depth about 3 mm.
Inspect the pupils Black in color;
for color, shape, equal size;
and symmetry of normally 2-4
size mm in diameter
in bright light;
round, smooth
border
Assess each pupils Illuminated pupil
direct and constrict; non-
consensual illuminated
reaction to light constrict
Assess each pupil Constriction of
reaction to the pupil when
accommodation looking at near
object, dilation of
pupil when
looking far
 object;
convergence of
the pupils.
Assess peripheral When looking -
visual fields straight ahead,
the clients can
see objects in
periphery.
Assess six ocular Both eyes
movements coordinated,
move in unison,
with parallel
alignment.
Assess distance Not assessed 20/20 vision on --
vision Snellen-type
chart.
Inspect the auricles Auricles has same Color same as Normal
for color, symmetry, color as the face; facial skin;
position symmetrical; auricle symmetry.
is aligned with the
outer canthus of the
eye about 10 degree
from vertical.
Palpate the auricles Firm, mobile, no Mobile, firm, and Normal
for texture, tenderness; pinna not tender; pinna
elasticity, and areas recoils immediately recoils after it is
of tenderness after folding. folded.
Inspect the external Few dry yellowish Distal third Normal
ear canal for cerumen is present in contains hair
cerumen, skin both ear canals. follicles and
lesions, pus, and glands; dry
blood cerumen,
grayish-tan
color; or sticky,
wet cerumen in
various shades
of brown.
Perform Webers Not assessed Sound is heard --
test to assess the in both ears or is
bone conduction by localized at the
examining the center of the
lateralization of head (Weber
sounds Negative).
Conduct the Not assessed Air-conducted --
Rinnes test to (AC) hearing is
compare air greater than
conduction to bone bone-conducted
conduction (BC).
Inspect the external Symmetric with Symmetric and Normal
nose for any lesions. Septum is in straight; no
deviations in the midline; pinkish in discharge or
shape, size, color, color; patent and has flaring; uniform
flaring, discharge no discharges color.
from the nares
Lightly palpate the No tenderness and Not tenderness, Normal
external nose lesions. no lesions.
Determine the As the clients Air moves freely Normal
patency of both breathes the air as the clients
nasal cavities moves freely breathes through
the nares.
Observe for the No presence of Mucosa pink,
presence of discharge clear watery
redness, swelling, discharge, no
growths, and lesions.
discharge
Inspect the nasal Nasal septum intact Nasal septum Normal
septum between and is in midline. located at the
the nasal chambers center.
Inspect the outer Not dry and pink in Uniform pink Normal
lips for symmetry of color color, moist,
contour, color, and smooth, soft,
texture glistening, and
elastic.
Inspect the teeth Not assessed 32 adult teeth, --
and gums smooth, white,
shiny tooth
enamel, pink
gums.
Inspect the surface Central position, --
of the tongue for pink color, moist,
position, color, and slightly rough,
texture thin whitish
coating, no
lesions, raised
papillae.
Inspect the tongue Not assessed Moves freely. --
movement
Inspect the base of Not assessed Smooth tongue --
the tongue, the base with
mouth floor, and prominent veins.
the frenulum
Palpate the tongue Not assessed Smooth with no --
and floor of the palpable
mouth for any nodules.
nodules, lumps, or
excoriated area
Inspect the salivary Not assessed Same as color of --
duct opening for buccal mucosa
any swelling or and floor of the
redness mouth.
Inspect the hard Not assessed Light pink, --
and soft palate for smooth, soft
color, shape, palate; lighter
texture, and pink hard palate,
presence of bony more irregular
prominences texture.
Inspect the uvula Not assessed Positioned in --
for position and midline of soft
mobility while palate.
examining the
palates
Inspect the Not assessed Pink and smooth --
oropharynx for posterior wall.
color and texture
Inspect the tonsils Not assessed Pink and --
for color, discharge, smooth; no
and size discharge.
Elicit the gag reflex Not assessed Present --
by pressing the
posterior tongue
with a tongue
depressor
Inspect the neck Head is centered; Muscles equal in Normal
muscles muscles are equal in size; head
(sternocleidomastoi size. centered.
d and trapezius)
Observe head No involuntary Coordinated, Normal
movement movements smooth
movements.
Palpate the entire No enlargements, Not palpable Normal
neck for enlarged lymph nodes are not
lymph nodes palpable, no
tenderness
Palpate the trachea Not assessed Central --
for lateral deviation placement in
midline of neck;
spaces are
equal on both
sides
Inspect the thyroid Not assessed Not visible on --
gland inspection
Palpate the thyroid Not assessed Lobes mat not --
gland for be palpated, if
smoothness palpated, lobes
are small,
smooth, centrally
located,
painless, and
rise freely with
swallowing
 THORAX and LUNGS, HEART
(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 614-618)

AREA TO BE ACTUAL FINDINGS NORMS AND INTERPRETATION ANALYSIS

ASSESSED STANDARDS
Posterior thorax
Inspect the shape . Anteroposterior
and symmetry of to transverse
the thorax from diameter in ratio
posterior and lateral of 1:2.
views. Chest
Compare the symmetric.
anteroposterior
diameter to the
transverse
diameter.
Inspect the spinal Spine vertically --
alignment for aligned.
deformities.
Palpate the Skin intact;
posterior thorax. uniform
temperature;
chest wall
intact; no
tenderness; no
masses
Palpate the . Full and
posterior chest for symmetric
respiratory chest
excursion. expansion. 3 to
5cm.
Palpate the chest Bilateral
for vocal fremitus. symmetry of
vocal fremitus.
Fremitus is
heard most
clearly at the
apex of the
lungs.
Percuss the thorax Percussion
notes resonate,
except over
scapula.
Lowest point of
resonance is at
the diaphragm.
Auscultate the Vesicular and
chest using the flat- bronchiovesicul
disc diaphragm of arbreath
the stethoscope sounds.
Anterior Thorax
Inspect breathing Quiet, rhythmic,
patterns and effortless
respirations.
Inspect the costal Costal angle is --
angle and the angle less than 90
at which ribs enter degrees, and
the spine the ribs insert
into the spine at
approximately
at 45 degrees
angle.
Palpate the anterior Skin intact; --
chest uniform
temperature;
chest wall is
intact; there is
no tenderness,
bulges, and
 abnormal
movements
Palpate the anterior Full symmetric --
chest for respiratory excursion;
excursion thumbs
normally
separate 3 to
5cm

Palpate tactile Same as --

fremitus posterior vocal
fremitus;
fremitus is
normally
decreased over
heart and
breast tissue
Percuss the Percussion --
anterior chest notes resonate
systematically down to the
sixth rib at the
level of the
diaphragm but
are flat over
areas of heavy
muscle and
bone, dull on
areas over the
heart and the
liver, and
tympanic over
the underlying
stomach
Auscultate the Bronchial and --
trachea tubular breath
sounds
Auscultate the Bronchiovesicul --
anterior chest ar and vesicular
breath sounds
 HEART and CENTRAL VESSELS
(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 621-623)

AREA TO BE ACTUAL FINDINGS NORMS AND INTERPRETATION ANALYSIS

ASSESSED STANDARDS
Inspect and
palpate the
precordium for the
presence of
abnormal
pulsations, lifts, or
heaves: No pulsations
Inspect and
palpate the
aortic and
No pulsations
 pulmonic areas, No lift or heave
observing them
at an angle and
to the side Palpable in 5th
Inspect and ICS and medial
palpate the MCL.
tricuspid area Diameter of 1 to
for pulsations 2 cm.
and heaves or
lifts
Inspect and No lift or heave.
palpate the
apical area for
pulsation

Inspect and
palpate the
epigastric area
at the base of
the sternum for
abdominal
aortic pulsations
Auscultate the
heart in all four
anatomic sites:
aortic, pulmonic,
tricuspid, and
apical (mitral)
Palpate the carotid
artery.
Auscultate the
carotid artery.
Inspect the jugular
veins for
distention.
 BREAST and AXILLAE
(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 628-630)

AREA TO BE ACTUAL FINDINGS NORMS AND INTERPRETATION ANALYSIS

ASSESSED STANDARDS
Inspect the breasts Females:
for size, symmetry, Rounded shape;
and contour or slightly unequal
shape while the in size; generally
client is in a sitting symmetric
position.
Inspect the skin of Skin uniform in color. Skin uniform in Normal
the breast for color (same in
localized appearance as
discolorations or skin of abdomen
hyperpigmentation, or back).
retraction or Skin smooth and
dimpling, localized intact.
hypervascular Diffuse
areas, swelling or symmetric
edema horizontal or
vertical vascular
pattern in light-
skinned people.
Striae (stretch
marks); moles
and nevi
Inspect the areola Round or oval
area for size, and bilaterally
shape, symmetry, the same.
color, surface Color varies
characteristics, and widely, from light
any masses or pink to dark
lesions brown.
Irregular
placement of
sebaceous
glands on the
surface of the
areola.
Inspect the nipples Round, everted and Round, everted, Normal
for size, shape, equal in size; similar in and equal in
position, color, color; soft and smooth; size; similar in
discharge, and both nipple point in color; soft and
lesions same direction smooth; both
nipples point in
same direction.
No discharge,
except from
pregnant or
breast-feeding
females.
Inversion of one
or both nipples
that is present
from puberty.
Palpate the axillary, No presence of No tenderness, Normal
subclavicular, and tenderness, masses or masses, or
supraclavicular nodules nodules
lymph nodes.
Palpate the breast No tenderness,
for masses, masses,
tenderness, and nodules, or
any discharge from nipple discharge
the nipples.
Palpate the areola No tenderness,
and the nipples for masses,
masses. nodules, or
nipple
discharge.
 Veronica A. Guarin
ABDOMEN
(Ref: Nursing Care of Infants and Children 8th edition, Wongs Vol.1, page 193-195)

AREA TO BE ACTUAL FINDINGS NORMS AND INTERPRETATION ANALYSIS

ASSESSED STANDARDS
Inspect the abdomen Skin is intact; uniform Uniformly taut, Normal The skin
for skin integrity. in color without wrinkles covering the
or creses. abdomen shoul
Silver-white be uniformly
striae (stretch taut, without
marks) or wrinkles or
surgical scars. creases.
Sometimes
silvery, whitish
striae are seen
especially in
obesity.
Inspect the abdomen Rounded and no Cylindric, erect Normal Normally the
for contour and enlargement of liver or position. abdomen of
symmetry. spleen. infants and
young children i
cylindric and
erect position,
fairly prominent
because of the
physiologic
lordosis of the
spine.
Observe abdominal Symmetry movement Chest and Normal Normally the
movements caused by respiration. Abdominal chest and
associated with movements are abdominal
respiration, synchronous. movements are
peristalsis, or aortic synchronous. In
pulsations. infants and thin
children
peristaltic wave
may be visible
through the
abdominal wall.
Observe the vascular No presence of No visible Normal Normally the
pattern. vascular pattern. vascular abdominal wall
 pattern. n visible vascula
pattern and skin
intact. Umbilicus
should be flat or
slightly
protruding.
Auscultate abdomen. Hyperactive bowel Audible bowel Deviation from Normal Sounds like
sounds mostly heard at sounds. metallic clicks
the LLQ and RUQ. Absence of and gurgles. (3
arterial bruits. to 5 per minute)
Absence of
friction rubs.
Percuss abdomen. Not Applicable Not Applicable Not Applicable
Percuss liver to Not Applicable Not Applicable Not Applicable
determine its size.
Palpate abdomen. No presence of No tenderness,
tenderness, superficial muscle tone,
lesions such as cysts. and superficial
lesions such as
cysts.
Deep palpation over No presence of mass. Tenderness Normal Normally
all four quadrants. may be present tenderness may
near xiphoid be present at th
process, over xiphoid process
cecum, and and part of the
over sigmoid colon.
colon.
Palpate liver. Not palpable May not be Normal Normally the
palpable.(1-2 liver descends
cm) below the during
right costal inspirations the
margin diaphragm
moves
downward.
 MUSCULOSKELETAL
(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 640-641)

AREA TO BE ACTUAL FINDINGS NORMS AND INTERPRETATION

ASSESSED STANDARDS
Inspect muscles and Symmetric and no Equal size on Normal
tendons. presence of tremors. both sides of
body. No
contractures.
No tremors.
Palpate muscles for Normally firm. --
tonicity, flaccidity, Smooth
spasticity and coordinated
smoothness of movements
movement.
Test muscle strength: --
Sternocleidomastoid Not assessed
Trapezius
Deltoid
Biceps
Triceps
Wrist Equal strength
Grip strength on each body
Hip muscles side.
Hip abduction
Hip adduction
Hamstrings
Quadriceps
Muscles of the ankles
and feet
Inspect skeleton for No deformities. No deformities. Normal
structure.
Palpate bones. No tenderness
or swelling.
Inspect joints. No tenderness
or swelling.
Palpate joints. . No tenderness,
swelling,
crepitation, or
nodules. Joints
move
smoothly.
 CRANIAL NERVES
(Ref: Fundamentals of Nursing 8th Edition by Kozier and Erb, page 653)

AREA TO BE ACTUAL FINDINGS NORMS AND INTERPRETATION

ASSESSED STANDARDS

I. OLFACTORY Able to --
identify
Ask the client to close aromas.
eyes and identify
different mild aromas.

II. OPTIC 20/20 vision --

on Snellen-
Ask the client to read type chart.
Snellen chart; check
visual fields by (Ref:
confrontation. Fundamentals
of Nursing 8th
Edition by
Kozier and
Erb, page
592)

When looking
straight
ahead, the
clients can
see objects in
periphery.

(Ref:
Fundamentals
of Nursing 8th
 Edition by
Kozier and
Erb, page
591)

III. OCULOMOTOR Both eyes normal .

coordinated,
Assess six ocular Both eyes coordinated, move in
movements and pupil move in unison, with unison, with
reaction. parallel alignment. parallel
alignment.

(Ref:
Fundamentals
of Nursing 8th
Edition by
Kozier and
Erb, page
592)

Constriction
of the pupil
when looking
at near object,
dilation of
pupil when
looking far
object;
convergence
of the pupils.

(Ref:
Fundamentals
of Nursing 8th
Edition by
Kozier and
Erb, page
590)

IV. TROCHLEAR Both eyes coordinated, Both eyes Normal

move in unison, with coordinated,
Assess six ocular parallel alignment. move in
movements. unison, with
parallel
alignment.
 (Ref:
Fundamentals
of Nursing 8th
Edition by
Kozier and
Erb, page
592)

V. TRIGEMINAL Client blinks -----

when the
Perform corneal cornea is
sensitivity test. Have touch,
client close eyes; wipe indicating that
a wisp of cotton over the trigeminal
clients forehead and nerve is
sinuses. Use intact.
alternating blunt and
sharp ends of a safety (Ref:
pin to test deep Fundamentals
sensations. of Nursing 8th
Edition by
Kozier and
Erb, page
589)

VI. ABDUCENS Both eyes coordinated, Both eyes Normal

move in unison, with coordinated,
Assess direction of parallel alignment. move in
gaze. unison, with
parallel
alignment.

(Ref:
Fundamentals
of Nursing 8th
Edition by
Kozier and
Erb, page
592)

VII. FACIAL Symmetric

facial
Note symmetry of movements. --
facial movements.
(Ref:
Fundamentals
Ask client to identify of Nursing 8th
various taste Edition by
Kozier and
Erb, page
585)

Able to
identify
various taste

VIII. AUDITORY

Perform Rombergs Can maintain --

test her balance
even her eyes
are close.

Sound is
heard in both
Perform Webers test
ears or is
to assess the bone
localized at
conduction by
the center of
examining the
the head
lateralization of
(Weber
sounds
Negative).

(Ref:
Fundamentals
of Nursing 8th
Edition by
Kozier and
Erb, page
597)

Conduct the Rinnes Air-conducted --

test to compare air (AC) hearing
conduction to bone is greater
conduction than bone-
conducted
(BC).

(Ref:
Fundamentals
of Nursing 8th
Edition by
 Kozier and
Erb, page
598)

IX. Able to move --

GLOSSOPHARYNGE the tongue
AL side to side.

Apply tastes on (Ref:

posterior tongue for Fundamentals
identification. Ask the of Nursing 8th
client to move tongue Edition by
side to side. Kozier and
Erb, page
603)

X. VAGUS No signs of --
hoarseness
Assess clients
hoarseness.

XI. ACCESSORY Equal --

strength
Ask the client to shrug
shoulders against (Ref:
resistance from your Fundamentals
hands and turn head of Nursing 8th
to side against Edition by
resistance from your Kozier and
hand Erb, page
607)

XII. HYPOGLOSSAL Tongue is at --

the central
Ask client to protrude position. Able
tongue at midline, and to move the
then move side to tongue side to
side. side.

(Ref:
Fundamentals
of Nursing 8th
Edition by
Kozier and
Erb, page
603)