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    Harlene Joyce Rey
    The document presents a tabular format for conducting a physical assessment of a patient, with assessment areas listed down the left column and findings recorded in the right column. The assessment areas include integumentary system, head, eyes, ears, nose, mouth, neck, chest, and spine. An example assessment is provided for a 53-year-old male patient, with normal findings recorded for each assessment area examined.

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    Name: - Age: - Gender

    Uploaded by

    Harlene Joyce Rey
    21 views5 pages
    The document presents a tabular format for conducting a physical assessment of a patient, with assessment areas listed down the left column and findings recorded in the right column. The assessment areas include integumentary system, head, eyes, ears, nose, mouth, neck, chest, and spine. An example assessment is provided for a 53-year-old male patient, with normal findings recorded for each assessment area examined.

    Original Description:

    Community Health Nursing

    Original Title

    Physical Assessment

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    The document presents a tabular format for conducting a physical assessment of a patient, with assessment areas listed down the left column and findings recorded in the right column. The assessment areas include integumentary system, head, eyes, ears, nose, mouth, neck, chest, and spine. An example assessment is provided for a 53-year-old male patient, with normal findings recorded for each assessment area examined.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    21 views5 pages

    Name: - Age: - Gender

    Uploaded by

    Harlene Joyce Rey
    The document presents a tabular format for conducting a physical assessment of a patient, with assessment areas listed down the left column and findings recorded in the right column. The assessment areas include integumentary system, head, eyes, ears, nose, mouth, neck, chest, and spine. An example assessment is provided for a 53-year-old male patient, with normal findings recorded for each assessment area examined.

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    © All Rights Reserved
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    of 5

    PHYSICAL ASSESSMENT (TABULAR FORM)

    Name: __________________________________ Age: __________________


    Gender: _________________________________
    Assessment Findings
    Integumentary
     Skin
     Hair
     Nails
    Skull
    Face
    Eyes and Vision
     Eyebrows
     Eyelashes
     Eyelids
     Bulbar conjunctiva
     Palpebral Conjunctiva
     Sclera
     Lacrimal gland, Lacrimal sac,
    Nasolacrimal duct
     Corneal Clarity and texture
     Corneal sensitivity
     Pupils
     Visual Fields
     Visual Acuity
    Ear and Hearing
     Auricles
     External Ear Canal
     Hearing Acuity Test
     Watch Tick Test
    Nose and sinuses
     External Nose
     Nasal Cavity
    Mouth and Oropharynx
     Mouth and Oropharynx
     Teeth
     Tongue and floor of the mouth
     Tongue movement
     Uvula
     Gag Reflex
    Head and Neck
     Neck
     Head movement
     Muscle strength
     Lymph Nodes
     Thyroid Gland
    Thorax and lungs
     Posterior thorax
    Spinal alignment
    Example
    PHYSICAL ASSESSMENT (TABULAR FORM)

    Name: Juan dela Cruz Age: 53 years old


    Gender: Male
    Assessment Findings
    Integumentary
    When skin is pinched it goes to previous state
    immediately (2 seconds).
     Skin
    With fair complexion.
    With dry skin
    Evenly distributed hair.
     Hair With short, black and shiny hair.
    With presence of pediculosisCapitis.
    Smooth and has intact epidermis
    With short and clean fingernails and toenails.
     Nails
    Convex and with good capillary refill time of
    2 seconds.
    Rounded, normocephalic and symmetrical,
    Skull smooth and has uniform consistency.Absence
    of nodules or masses.
    Symmetrical facial movement, palpebral
    Face fissures equal in size, symmetric nasolabial
    folds.
    Eyes and Vision
    Hair evenly distributed with skin intact.
     Eyebrows Eyebrows are symmetrically aligned and have
    equal movement.
    Equally distributed and curled slightly
     Eyelashes
    outward.
    Skin intact with no discharges and no
    discoloration.
     Eyelids
    Lids close symmetrically and blinks
    involuntary.
     Bulbar conjunctiva Transparent with capillaries slightly visible
     Palpebral Conjunctiva Shiny, smooth, pink
     Sclera Appears white.
     Lacrimal gland, Lacrimal sac, No edema or tenderness over the lacrimal
    Nasolacrimal duct gland and no tearing.
    Transparent, smooth and shiny upon
    inspection by the use of a penlight which is
     Corneal Clarity and texture held in an oblique angle of the eye and moving
    the light slowly across the eye.
    Has [brown] eyes.
    Blinks when the cornea is touched through a
     Corneal sensitivity
    cotton wisp from the back of the client.
    Black, equal in size with consensual and direct
    reaction, pupils equally rounded and reactive
    to light and accommodation, pupils constrict
     Pupils when looking at near objects, dilates at far
    objects, converge when object is moved
    toward the nose at four inches distance and by
    using penlight.
    When looking straight ahead, the client can
    see objects at the periphery which is done by
    having the client sit directly facing the nurse at
    a distance of 2-3 feet.
    Source: https://nurseslabs.com/nursing-assessment-cheat-sheet/
    *Note: Please see Kozier and Erb’s Fundamentals of Nursing by Berman, 8th Edition, Volume
    1, pages 565-665.

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