AREA TECHNIQUES NORMAL ACTUAL

ANALYSIS
ASSESSED USED FINDINGS FINDINGS
SKIN
Color Inspection Brown (varies) Flushing Due to
Dehydration
Texture Palpation Smooth and dry Due to
soft Dehydration
Turgor Palpation Skin snaps back Skin slowly Due to
immediately snaps back at 3 Dehydration
when pinched seconds
Hair Distribution Inspection Evenly Evenly Normal
distributed distributed
Temperature Palpation with 36.5-37.5 38.1 Increased
the use of axillary Axillary pyrogens in
Thermometer the body
Moisture Inspection skin folds are dry Due to
normally moist dehydration
NAILS
Color of nail bed Inspection Pink and Clean Pink and Clean Normal
Texture Palpation Smooth Smooth Normal
Shape Inspection Convex Convex curvature Normal
curvature
Nail Base Inspection Firm Firm Normal
Capillary Refill Blanch Test 2-3 seconds 3 seconds Normal
time
HAIR
Color Inspection Black (varies) Black Normal
Distribution Inspection Evenly Evenly Normal
distributed distributed
Moisture Inspection Neither Neither Normal
excessively dry excessively dry
nor oily nor oily
Texture Inspection Silky, resilient Silky, resilient Normal

HEAD
Scalp Symmetry Inspection Symmetrical Symmetrical Normal
Skull Size Inspection Normocephalic Normocephalic Normal
Shape Inspection and Round Round Normal
Palpation
Nodules/ Masses Palpation Absence of Absence of Normal
nodules and nodules and
masses masses
FACE
Symmetry Inspection Symmetrical Symmetrical Normal
Facial Inspection Symmetrical Symmetrical Normal
Movement
Skin color Inspection Brown (varies) Flushing Due to
Dehydration
EYES
Eyebrows Inspection Symmetrically Symmetrically Normal
aligned, equal aligned, equal
movement movement
Eyelashes Inspection Slightly curved Slightly curved Normal
upward upward

Eyelids Inspection Smooth, tan, do Smooth, tan, do Normal

not cover pupil not cover pupil as
as sclera, close sclera, close
symmetrically symmetrically
Eyeballs Inspection Sunken
Ability to blink Inspection Blinks Blinks Normal
voluntarily and voluntarily and
bilaterally bilaterally
Ocular Inspection Eye moves Eye moves freely Normal
movement freely
Position Inspection Drawn from Drawn from Normal
lateral angle lateral angle
Size Inspection Medium Medium Normal
Conjunctiva
Color Inspection Transparent with Transparent with Normal
light color light color
Texture Inspection Shiny and Shiny and Normal
smooth smooth
Presence of Inspection No lesions No lesions Normal
lesions
Lacrimal
Apparatus
Cornea
Clarity Inspection Clear Clear Normal

Texture Inspection Shiny, smooth, Shiny, smooth, Normal

transparent transparent

Pupils
Color Inspection Black Black Normal
Reaction to light Inspection Pupils Equally Pupils Equally Normal
Round and Round and React
React to Light to Light
Accommodation Accommodation
(PERRLA) (PERRLA)
Visual Fields Inspection When looking When looking Normal
straight ahead, straight ahead,
client can see client can see
objects in objects in
periphery periphery
Ocular Inspection Eyes move Eyes moves Normal
freely freely
NOSE
Symmetry, Inspection Symmetrical, Symmetrical, Normal
shape, size and smooth and tan smooth and tan
color
Mucosa color Inspection Reddish to Reddish to Normal
Pinkish Pinkish
Nasal Septum
Nares
Inspection Oval, Oval, Normal
symmetrical symmetrical
Nasal discharge Inspection No discharge No discharge Normal
Sinuses Inspection Not tender Not tender Normal
MOUTH

Lips
Color Inspection Pinkish to Pale pink Due to
slightly brown Dehydration
Symmetry Inspection Symmetrical Symmetrical Normal
Texture Palpation Soft, moist, Chapped/Cracked
smooth
Moisture Palpation Soft and moist Dry Due to
Dehydration
Gums
Color Inspection Pinkish Pinkish Normal
Moisture Palpation Moist Moist Normal
Buccal Mucosa
Color
Inspection Glistening pink Pale pink Due to
dehydration
Texture Palpation Soft Soft Normal
Moisture Palpation Moist Dry Due to
Dehydration
Tongue
Color Inspection Pinkish Pinkish Normal
Symmetry Inspection Symmetrical Symmetrical Normal
Mobility Inspection Moves freely Moves freely Normal

Uvula
Location Inspection At the midline At the midionline Normal
Symmetry Inspection Symmetrical Symmetrical Normal
Tonsils
Color Inspection Pinkish Pinkish Normal
Discharges Inspection No discharges No discharges Normal
Teeth
Color Inspection Ivory/yellowish Yellowish Normal
NECK
Position Inspection Head- Centered Head- Centered Normal
Movement Inspection Moves freely Moves freely Normal
Range of Motion Inspection Full range Full range Normal
Consistency Inspection No Enlargement No Enlargement Normal

HEART
Heart sounds Auscultation Clear, without Clear, without Normal
murmurs murmurs
THORAX AND
LUNGS
Posterior
Thorax
Symmetry Inspection Symmetrical Symmetrical Normal
Lung Field Auscultation Resonant Resonant Normal
Respiratory rate Inspection Normally 12-20 21 cpm Slightly
cpm above
normal but
still
considered
to be normal
Anterior
Thorax Inspection Breathing is Breathing is Normal
Breathing Auscultation automatic and automatic and
pattern effortless, effortless, regular
regular and even and even.
and produces no
noise.
Lung/ breath Auscultation Broncho- Broncho- Normal
sounds vesicular Vesicular
ABDOMEN
Contour Inspection Flat Flat Normal
Texture Palpation Smooth Smooth Normal

Frequency and Auscultation Audible; soft Audible; soft Normal

character gurgling sound gurgling sound
occur irregularly occur irregularly
and rages from and rages from 5-
 5-35 minutes 35 minutes
UPPER
EXTREMITY
Skin color Inspection Brown Flushing Due to
Dehydration
Size (arms) Inspection Equal Equal Normal
Symmetry Inspection Symmetrical Symmetrical Normal
Hair distribution Inspection Evenly Evenly Normal
distributed distributed
LOWER
EXTREMITY
Skin color Inspection Tan Flushing Due to
Dehydration
Size (legs) Inspection Equal Equal Normal
Symmetry Inspection Symmetrical Symmetrical Normal
Hair distribution Inspection Evenly Evenly Normal
distributed distributed
NEUROLOGIC
Level of
consciousness Interview Can follow Can follow Normal
instructions and instructions and
commands commands
Behavior and Interview Makes eye Makes eye Normal
appearance contact with the contact with the
examiner examiner
Mood Interview Expresses Expresses Normal
feelings which feelings which
correspond to correspond to
situation situation
Mannerisms
and actions
Language
Voice inflection Interview Clear and strong Clear and strong Normal
Tone Interview Fluent and Fluent and Normal
articulated articulated
Manner and Interview Can give Can give Normal
speech appropriate appropriate
answers to answers to
questions questions
Mental Status
Orientation Interview Oriented with Oriented with Normal
time time
Time
Recall recent and Interview Recall events Recall events Normal
remote memory readily, readily,
immediate recall immediate recall
 of remote of remote
information information
Judgments and Interview Can make Can make logical Normal
thoughts logical decisions decisions.