Physical Assessment

• Skin


  Uniform in color, unblemished, no foul odor, good skin turgor, normal temperature
• Hair


  Thick, silky, evenly distributed, variable amount of body hair, no signs of infection or infestation
• Nails


  Light brown, convex curve, smooth, intact with epidermis, good capillary refill time
• Skin assessment


  1. Inspect every inch of patient's skin

  2. Remove gown

  3. Remove socks

  4. Look under dressing (unless contraindicated or have order not to)
• Integumentary assessments are often done simultaneously with other body systems
• Supplies needed for integumentary assessment

  • Wound measurement tape/supplies
  • Dressing supplies as needed
• Skin inspection


  • Color
  • Moisture
  • Wounds
  • Pressure areas
  • Edema
• Color changes


  • Hyperpigmentation (Addison's disease)
  • Hypopigmentation (Vitiligo)
  • Erythema (Inflammation)
  • Cyanosis (Oxygenation issues)
  • Pallor (Perfusion issues)
  • Jaundice (Liver failure)
• Edema


  • Pitting edema scale (1+ to 4+)
  • Dependent (Lowest aspect of body part)
  • Generalized (Throughout body, usually non-pitting)
• Nail abnormalities


  • Clubbing (Hypoxia/Hypoxemia)
  • Scoop-like nails (Anemia)
  • Pale nail beds (Perfusion issues)
• Turgor


  • Tight (Swelling, edema, venous insufficiency)
  • Tenting (Dehydration)
• Head


  Rounded, normocephalic, symmetrical
• Skull


  No nodules, masses or depressions
• Face


  Smooth, uniform consistency, no nodules or masses
• Eyebrows


  Evenly distributed, symmetrically aligned, equal movement
• Eyelashes


  Equally distributed, curled slightly outward
• Eyelids


  No discharges, discoloration, close symmetrically
• Eye assessment


  • Bulbar conjunctiva (Transparent with few capillaries)
  • Sclera (White)
  • Palpebral conjunctiva (Shiny, smooth, pink)
  • Lacrimal gland (No edema or tearing)
  • Cornea (Transparent, smooth, shiny)
  • Pupils (Black, equal, PERRLA, constrict on near object, dilate on far object, converge on nose)
  • Peripheral visual field (Can see objects in periphery)
  • Extraocular muscles (Coordinated, parallel movement)
• Ears


  Auricles symmetrical, same color as facial skin, mobile, firm, not tender, able to hear ticking
• Nose


  Symmetric, straight, uniform color, no discharge or flaring, no tenderness or lesions
• Lips


  Uniformly pink, moist, symmetric, smooth
• Teeth and gums


  No discoloration, no gum retraction, gums pink
• Buccal mucosa


  Uniformly pink, moist, soft, glistening, elastic
• Tongue


  Centrally positioned, pink, moist, slightly rough, thin whitish coating
• Palate


  Soft palate light pink and smooth, hard palate more irregular texture
• Uvula


  Positioned in midline of soft palate
• Neck


  Muscles equal in size, coordinated smooth movement, no discomfort, lymph nodes not palpable, trachea midline, thyroid not visible
• Appearance of the eye

  • Clear, without scalings or secretions, lacrimal duct openings (puncta) are evident at the nasal ends of the upper and lower lids
• Palpebral Fissures


  The longitudinal opening between the eyelids
• Palpebral Fissures


  • Appear equal when the eyes are open
• Lower palpebral conjunctiva


  • Salmon pink, shiny, moist and transparent
• Sclera


  • White and clear
• Iris


  • Proportional to the size of the eye, round, black/brown, and symmetrical
• Pupils


  • From pinpoint to almost the size of the iris, round, symmetrical, constrict with increasing light and accommodation
• Checking pupillary reaction to light

  Use a penlight, shield the side of the eye opposite the direction of the penlight, note the degree of constriction of the pupils
• Checking pupillary accommodation


  Instruct the client to look straight into a photo shield placed at different distances, note the reaction of the pupils
• Eye Movement


  • Able to move eyes in full range of motion or able to move in all direction
• Measuring Visual Acuity


  Let client read the Snellen's chart at 20 feet, record the smallest line of print they can identify correctly
• Visual Acuity


  20/20 - distance from the chart / distance at which a normal eye can read
• Field of Vision


  • Able to see 60 degrees superiorly, 90 degrees temporally, and 70 degrees inferiorly