The physical assessment examines the head, scalp, hair, face, eyelids, eyes, ears, mouth, neck, skin, nails, upper extremities, lower extremities, thoracic cavity, and abdomen. For each area, normal findings and actual findings are described and analyzed. The assessment found abnormalities in the skin, with black and blue areas on the lower back, and the abdomen, which was distended with tenderness on palpation. Otherwise, the physical exam was normal with no alterations noted.

1. III. PHYSICALASSESSMENT
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

2. 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

3. 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

4. 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

5. 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

6. 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 )