III. PHYSICAL ASSESSMENT

ORGAN

METHOD

(IPAPEA)

Normal Findings

ACTUAL FINDINGS

ANALYSIS

INTERPRETATI

ON

Head Inspection • Generally round, with prominences in the

frontal and occipital area. (Normocephalic).

• No tenderness noted upon palpation

No masses and lesions Normal There is no changes in patient

Scalp Inspection and palpation

Pale to pink in color, no lesions or any mass, no

anyinfestations

Sizes varies somewhat, shape: Symmetrical and round,

consistency hard and smooth, texture fine to coarse, pliant, presence parasites: none

Normal There is no alteration in

patients scalp

Hair Inspection and

palpation

Black in color,

Thin, straight course, shiny and resillient

Color:varies amount and

distribution: vary, texture fine to course, pliant, presence parasites: none

Normal There is no

alteration in clients scalp

Face Inspection and palpation

• Shape maybe oval

or rounded. • Face is

symmetrical. • No involuntary muscle movements.

• Can move facial muscles at will.

Symmetry: symmetrical Facial features: features vary

Symmetrical, centered heal position

Normal There is no alteration in

clients face

Eyelid and

lashes

Inspection and

Palpation

• Color dependent

on race. • Evenly

distributed. • Turned outward

Lid margins moist with pink:

lashes short, evenly spaced and curled

Outward: lower margins at bottom edge or Iris: upper margins of lids occur

approximately, 2mm of iris

Normal There is no

alteration in patients in clients

eyelid and lashes

Eyes Inspection

Palpation

• Evenly placed and

in line with each other. • None protruding.

• Equal palpebral fissure.

Iris and pupil

Shaped: round Equa;ity: equal color (iris)

uniform ulcer Lens: clear Lacrimal apparitus response to

pressure applied at nasal side of lower orbital rim: No tenderness

or discharge noted when pressure is applied

There is no

alteration in clients eyes

Ears Inspect • The ear lobes are bean shaped, parallel, and

symmetrical. • The upper connection of the ear lobe

is parallel with the outer canthus of the eye.

• No lesions noted on inspection. • The auricles are

has a firm cartilage on palpation.

• The pinna recoils when folded. • There is no pain or

tenderness on the palpation of the auricles

External ears: size and shape Ears equal size and similar

appearance position: alignment of pinnan with corner of eye and 10 angle

Normal There is no alteration in clients

ears

and mastoid process.

• The ear canal has normally some cerumen

of inspection. • No discharges or lesions noted at the ear

canal.

Mouth Inspection and

Palpation

With visible margin,

Symmetrical in appearance and

movement, Pinkish in color and No edema

Pale and dry lips

No lesions

abnormal There is no

alteration in clients mouth its normal

Neck Inspection

Palpate

• The neck is straight.

• No visible mass or lumps. • Symmetrical

• No jugular venous distension (suggestive of

cardiac congestion).

Smooth, controlled movement range of motion (ROM)

Midline positon symmetrical land marks idenfiable

normal There is no alteration in clients

neck its normal

Skin Inspect

Palpation

Pair complexion

Lighter colored palms soles nail bed. Black/ blue area over lower lumbar

area, rashes Texture , smooth soft,

warm, dry, poor skin turgor: no edema

Pair complexion

Lighter colored palms soles nail bed. Black/ blue area over lower lumbar area, rashes

Texture , smooth soft, warm, dry, poor skin turgor: no edema

abnormal There is no

alteration

Nails Inspection Pink nail bed

symmetry

Pink nail bed normal There is no

alteration or changes in clients

nail because the nail bed is pinkish

in color

Upper

extremities

Lower

extremities

Inspection

Palpation

Inspection

Palpation

Symmetry are even

No dryness suspected Symmetry are even

No dryness suspected

Symmetry are even

No dryness suspected Symmetry are even

No dryness suspected

Normal

Normal

There is no

alteration or changes in clients upper extremities

There is no alteration or

changes in clients

lower extremities

Thoracic

cavity

Inspection

Palpation

Pulsation of the apical impulse maybe visible.

(this can give us some indication of the cardiac size).

• There should be no lift or heaves.

• No, palpable pulsation over the aortic, pulmonic,

and mitral valves. • Apical pulsation can be

felt on palpation. There should be no noted abnormal heaves, and

Pulsation of the apical impulse maybe visible. (this can give us

some indication of the cardiac size). • There should be no lift or

heaves.

• No, palpable pulsation over the aortic, pulmonic, and mitral valves.

• Apical pulsation can be felt on palpation.

There should be no noted abnormal heaves, and thrills felt over the apex.

Normal There is no

alteration

thrills felt over the apex.

No abnormal heart sounds is heard (e.g. Murmurs,

S3 & S4). • Cardiac rate ranges from 60 – 100 bpm

No abnormal heart sounds is

heard (e.g. Murmurs, S3 & S4). • CR: 90 bpm

Abdomen Inspection

Auscultation

Percussion

Palpate

• Skin color is uniform, no lesions.

• Some clients may have striae or scar.

• No venous engorgement. • Contour may be

flat, rounded or scapoid • Thin clients may

have visible peristalsis. • Aortic pulsation maybe visible on thin

clients. Divide the abdomen in

four quadrants. • Listen over all auscultation sites, starting

at the right lower quadrants, following the

cross pattern of the imaginary lines in creating the abdominal

quadrants. This direction ensures that we follow the

direction of bowel movement. • Peristaltic sounds are

quite irregular. Thus it is

No masses or any lesions, but distended

During auscultation no

abnormality

There is an abdominal tenderness

Abnormal There is alteration or changes in

clients abdomen

recommended that the

examiner listen for at least 5 minutes, especially

at the periumbilical area, before concluding that no bowel sounds are present.

• The normal bowel sounds are high-pitched,

gurgling noises that occur approximately every 5 – 15 seconds. It is

suggested that the number of bowel sound may be as

low as 3 to as high as 20 per minute, or roughly, one bowel sound for each

breath sound.

(Reference: nurses handbook of Health Assessment; Lippincott Williams &Wilkins )