Physical Assessment (Head-to-Neck-)

Name:

Parts to be Assess: Normal Actual Results Remarks

Behavior
1.Measure height
2. Measure weight

General Survey
3. Describe body built, height and Proportionate, varies
weight in relation to the client’s age with the lifestyle
lifestyle and health.
4.Describe the client’s posture, Relaxed, erect posture,
gait, standing, sitting and walking coordinated movement
5. Describe the client’s overall Clean and neat
hygiene and grooming
6. Describe body and breath odor No body odor or minor
body odor relative to
work or exercise, no
breath odor
7.Identify signs of distress, in No distress noted
posture or facial expression
8. Identify obvious sign of health Healthy appearance
illness
9. Describe client’s attitude Cooperative
10.Describe the client’s Appropriate to situation
affect/mood; assess the
appropriateness of the client’s
response
11. Describe the quantity and Understandable,
quality of speech moderate pace, exhibits
thought association
12. Listen for relevance and Logical sequence;
organization of thoughts makes sense; has
sense of reality

Integumentary
Skin:
13. Inspect for color; uniformity of Varies from light deep
color brown; from ruddy pink
to light pink; from
yellow overtones to
olive. Generally uniform
except to sun; areas of
lighter pigmentation in
dark skin people
14.Inspect for presence of edema No edema
15. Inspect for lesions according to Freckles, some
loc., distribution, color, birthmarks, some flat
configuration, size, shape, type or and raised nevi; no
structure abrasions or other
lessions
16. Palpate skin moisture Moisture in skin folds
and the axillae
17.l Palpate skin temperature Uniform; within normal
 range
18.Palpate skin turgor When pinched, skin
springs back to
previous state
Nail:
19. Inspect fingernail plate shape Convex curvature:
to determine its curvature and angle angle of nail plate about
160 degrees
20. Inspect fingernail and toenail Highly vascular and
bed color pink in light-skinned
clients; dark skinned
clients may have brown
or black pigmentation
21.Palpate fingernail and toenail Smooth texture
texture
22.Inspect tissues surrounding Intact epidermis
nails
23. Perform blanch test or capillary Prompt return of pink or
refill usual color (generally
less than 4 seconds)

Head
Skull:
24. Inspect the skull;; for size, Round( normocephalic
shape or symmetry and symmetrical w/
frontal, parietal and
occipital prominences)
smooth skull contour
25. Palpate for nodules, masses Smooth, uniform
and depression consistency, absence of
nodules or masses
Scalp:
26. Inspect for color and No depression
appearance
27.Palpate areas of tenderness No tenderness
Hair:
28.Inspect for evenness or growth, Evenly distributed hair,
thickness or thinness thick hair
29. Palpate for texture and oiliness Silky, resilient hair
over the scalp
Note the presence of infections or No infection or
infestations by parting the hair in infestations
several areas, checking behind the
areas along the hairline at the neck
Face:
30. Inspect facial symmetry, Symmetric or slightly
features and facial movements asymmetric facial
features; palpebral
fissures equal in size;
asymmetric nasolabial
fold

Eyes
Eyebrows:
31. Inspect for hair distribution, Hair evenly distributes;
alignment, skin and quality and skin intact; eyebrows
movement symmetrically aligned;
equal movement
Eyelashes:
32. Inspect for hair distribution and Equally distributed;
direction of curl curled slightly outward
Eyelids:
33.Inspect for the surface Skin intact, no
characteristics, position in relation discharge; no
to the cornea, ability to blink and discoloration; lids close
frequency of blinking symmetrically,
Approximately 15-20
involuntary blinks per
minute; bilateral
blinking. When lids are
open no visible sclera
above corneas and
upper and lower
borders of cornea
slightly covered
Conjunctiva:
34. Inspect for bulbar con junctiva Transparent; capillaries
for color, texture and presence of sometimes evident;
lessions sclera appears white(
yellowish in dark
skinned)
35.Inspect for palpebral Shiny, smooth and pink
conjunctiva for color, texture, and red
presence of lessions
Sclera:
36. Inspect the color and clarity white
Cornea:
37. Inspect for clarity and texture Transparent, smooth,
shiny details of iris are
visible

Iris:
38.Inspect for shape and color Color vai, oval and flat
Pupil:
39. Inspect for color, shape and Black in color; equal in
symmetry of size size, round, smooth
borders
Visual Acuity:
40. Test near vision Able to read newspaper
41. Test distant vision 20/20 vision on snellen
chart
Pupils:
42. Test each pupil for light Illuminated pupil
reaction and accommodation constrict, constrict
when looking at near
object, dilate at far
Lacrimal Gland, Lacrimal Sac
and Nasolacrimal Duct:
43. Inspect and palpate the No edema or tearing
lacrimal gland
Extraocular Muscle
44. Test each eye for alignment Both eyes coordinated,
and coordination move in unison, with
parallel alignment
Visual Fields:
45. Test peripheral fields When looking straight
ahead, client can see
objects in periphery

Ears
Auricles:
46. Inspect for color symmetry and
position
47. Palpate for texture, elasticity
and areas for tenderness
External Ear Canal:
48. Inspect for cerumen, skin
lesions, pus and blood
Hearing Acuity Test:
49. Assess client’s response to
normal voice tones
50. Perform tick test
51. Perform Weber’s test
52. Perform Rinne’s test
Color same as the
facial skin; symmetrical;
auricle aligned w/ outer
canthus of the eye,
about 10 deg from
vertical
Mobile, firm and not
tender; pinna recoil
after it is folded
Presence of cerumen
Normal voice tones
audible
Able to hear ticking in
both ears
Sound is heard in both
ears or is localized at
the center of the head
Air conducted hearing
is greater than bone
conducted hearing

Nose
53. Inspect for any deviations in Symmetric and straight,
shape, size or color and flaring or no discharge or flaring,
discharge from nares uniform color
54. Inspect the nasal cavities for Mucosa pink; clear,
the presence of redness, swelling, water discharge, no
growths and discharge lessions
55. Inspect nasal septum bet. Nasal septum intact
nasal chambers and in midline
56. Test patency of both nasal As the client breath
cavities towards the nose air
moves freely
57. Palpate for any displacement, No tenderness and
masses, displacements of bone displacement
cartilage
Sinuses:
58. Locate/palpate/ identify the No tenderness
sinuses; note for tenderness

Mouth
Lips:
 59. Inspect for symmetry of
contour, color and texture
Buccal Mucosa:
60. Inspect for color, moisture,
texture and presence of lesions
Uniform pink color, soft,
moist smooth texture,
symmetry of contour,
ability to purse lips
Uniform pink color,
smooth, soft glistening
and elastic texture

Teeth:
61.Inspect for color, number and 32 adult teeth, smooth,
condition and presence of dentures white, shiny tooth
enamel
Gums:
62. Inspect for color and condition Pink gums, moist, firm
texture; no retraction of
gums
Tongue/Floor of the Mouth:
63. Inspect for color, texture of the Smooth tongue base
mouth floor and frenulum with prominent veins
64.Inspect and palpate position, Central position, pink
color and texture, movement and color, moist, slightly
base of the tongue rough; thin whitish
coating, smooth lateral
margins: no lesion
raised papillae
It moves freely; no
tenderness
65. Palpate for any nodules, lumps Smooth with no
or excoriated areas palpable nodules
Palates and Uvula:
66. Inspect and palpate for color, Light pink, smooth, soft
shape, texture and the presence of palate: light pink hard
bony prominences palate; more regular
texture
67.Inspect for position of uvula Positioned in the
and mobility while examining the midline of the soft
palate palate

Oropharynx and Tonsils:

68. Inspect and palpatefor color Pink and smooth
and texture posterior wall
69. Inspect the size of the tonsil, Pink, smooth, no
color and discharge discharge: of normal
size

Neck and Lymph Nodes

Lymph Nodes:
70. Locate /palpate / identify No tenderness
lymph nodes and note for
tenderness
Trachea:
71. Inspect and palpate for Central placement in
placement the midline of the neck
Thyroid Gland:
72. Inspect symmetry and visible Not visible in inspection
masses
73. palpate for smoothness and Lobes may not
areas of enlargement masses or palpated, If palpated
nodules lobes are small ,
smooth centrally
located, painless and
rise freely with
swallowing

Vital Signs:
1. Body Temperature =
2. Pulse Rate =
3. Respiratory Rate =
4. Blood Pressure =