BODY PARTS /
SYSTEM AND ACTUAL FINDINGS NORMAL INTERPRETATION
METHOD OF FINDINGS
ASSESSMENT USED
Skin
Inspection Brown complexion Varies from light The patient’s skin
to deep brown; color is normal.
from ruddy pink to
light pink
Uniform in color Generally uniform Patient skin was
in color except in uniform in color.
areas of lighter
pigmentation like
the palm, lips and
nail beds; areas
exposed to the sun
Palpation (+) pitting edema, No edema The client has edema
has a grade of +2 which is not normal
due to fluid
retention.
Edema is a decrease
in skin mobility
caused by an
accumulation of fluid
in the intercellular
spaces. Edema
makes the skin look
puffy, pitched and
tight. It may be
noticeable in the skin
of the hands, feet,
ankles and sacral
area. (An
Introduction to
Health and Physical
Assessment in
Nursing by D’Amico
and Barbarito, p.
204)
Skin temperature Normal range; The client has normal
is within normal Uniform. skin temperature.
range; Uniform
Hair
Inspection Evenly distributed The client has normal
Evenly distributed hair distribution.
The client has normal
Thick hair thickness of hair.
Thick hair
Palpation
Silky, resilient hair. The client has normal
Silky, resilient hair texture and oiliness.
The client has normal
Variable
amount of body hair.
Variable
Nails
Smooth texture
Smooth texture
The client’s nails are
in normal conditions.
Pink nail beds
Pink nail beds
Capillary refill of 2
sec. Capillary refill of 2
sec.
Eyes
Shinny, smooth, The client’s
Shinny, smooth, conjunctiva is normal
and pink
and has no nodules
conjunctiva and pink
or lesions.
conjunctiva
No edema or The client’s lacrimal
tenderness over No edema or gland is in normal
tenderness over condition.
lacrimal gland
lacrimal gland
The client’s lacrimal
No edema or gland is in normal
tearing on lacrimal No edema or condition.
gland tearing on lacrimal
gland
This reflex indicates
Blinks when cornea that the trigeminal
is touch Blinks when cornea nerve is intact.
is touch
The pupil is black The client’s pupil is in
in color; equal in normal condition.
size; and is 5mm The pupil is black
in diameter in color; equal in
size; and normally
3mm to 7mm in
diameter.
Illuminated pupil
The client’s pupil has
constricts normal reaction to
Non-illuminated Illuminated pupil
light.
pupil constricts constricts
Non-illuminated
pupil constricts
Pupils constrict
The client’s pupils
when looking at have normal reaction
near objects; Pupils constrict
to accommodation.
pupils dilate when when looking at
looking far at near object
object; pupils (penlight); pupils
converge when dilate when looking
near object is far at object
moved toward the (wall); pupils
nose. converge when
near object is
moved toward the
When looking nose. The client’s
straight ahead, peripheral visual field
client can see When looking is in normal function.
objects in the straight ahead,
periphery. client can see
objects in the
periphery. The client performs
Both eyes
six ocular
coordinated, move
movements which
in unison, with Both eyes determine the eye
parallel alignment coordinated, move alignment and
in unison, with coordination.
parallel alignment
Color same as The client’s auricle
facial skin has normal color and
Symmetrical Color same as is symmetrical.
facial skin
Symmetrical
Mobile, firm, and The client’s auricle
not tender; pinna has normal texture,
recoils after it is Mobile, firm, and elasticity and areas
folded not tender; pinna of tenderness.
Ears
recoils after it is
folded
Normal voice tones The client responds
audible to normal voice
Normal voice tones tones.
audible
Symmetric and The client’s nose is
straight symmetrical and
straight.
Symmetric and
straight
Not tender; no
The client has
lesions neither tenderness
Not tender; no nor lesion on his
lesions; (-) polyps external nose.
Nose and
Sinuses Mucosa is pink
Clear, watery The client external
nose has a pinkish
discharges
Mucosa is pink mucosa with clear
No lesions watery discharges
Clear watery
discharges and no lesions which
is normal.
No lesions
Facial sinuses are The client’s sinuses
not tender have no tenderness
which is normal.
Facial sinuses are
not tender
