GENERAL SURVEY AND INTEGUMENTARY

I. GENERAL APPEARANCE AND MENTAL STATUS

NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS AND
INTERPRETATION
Sign of distress in No distress noted
posture or facial
Body Built, Height, Proportionate, varies with
and Weight in lifestyle
relation to the
client’s age,
lifestyle and
health
Client’s Posture Relaxed, erect posture and
and gait, standing, coordinated movement
sitting and
walking
Overall hygiene Clean, neat
and grooming
Body and breath No body/breath odor or
odor minor body odor relative to
work or exercise
Signs of health Healthy Appearance
and illness
Client’s Attitude Cooperative
Client’s
affect/mood; Appropriate to situation
assess the
appropriateness
of the client’s
responses
Quantity, Quality, Understandable, moderate
and organization pace, and exhibits thought
of speech association
II. ASSESSMENT PROCEDURES
SKIN
Uniformity of Skin Generally uniform except in
color areas exposed to sun; areas
of lighter pigmentation in
dark skinned
Skin lesions Freckles, some birthmarks,
some flat and raised nevi, no
abrasion or other lesion
Skin moisture Moisture in skin folds and the
axillae, affected by different
factors
Skin temperature Uniform; within normal
range
Presence of No edema
edema
Skin turgor When pinched, skin springs
back to previous state
HAIR
Evenness of Evenly distributed hair
growth over the
scalp
Hair thickness and Thick Hair
thinness
Hair texture and Silky, resilient hair
oiliness
Presence of No infestation or infection
infections or
infestations
Amount of body Variable
hair
NAIL
Fingernail plate Convex curvature; angle
shape between nail and nail bed
usually 160 degrees
Fingernail and Highly vascular and pink in
toenail bed color light skinned; dark skinned
may be brown or black
Tissues Intact epidermis
surrounding nails
Fingernail and Smooth texture
toenail texture
Blanch test of Prompt return or pink or
capillary refill usual color, less than four
seconds
HEAD TO NECK ASSESMENT
ASSESSMENT PROCEDURES
I. HEAD AND FACE
NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS AND
INTERPRETATION
Inspect the head Head size and shape vary,
especially in accord with
ethnicity. Usually the head
is symmetric, round, erect,
and in midline and
appropriately related to
body size (normocephalic).
No lesions are visible.
Palpate the head The head is normally hard
and smooth, without
lesions.
Palpate the The temporal artery is
temporal artery elastic and not tender
Palpate the Normally there is no
temporomandibular swelling, tenderness, or
joint (TMJ) crepitation with movement.
Mouth opens and closes
fully (3 to 6 cm between
upper and lower teeth).
Lower jaw moves laterally
1 to 2 cm in each direction.
II. NECK
Inspect the neck Neck is symmetric, with
head centered and without
bulging masses.
Inspect movement The thyroid cartilage,
of the neck cricoid cartilage move
structures upward symmetrically as
the client swallows.
Inspect the cervical C7 (vertebrae prominens)
vertebrae is usually visible and
palpable.
Inspect range of Normally neck movement
motion should be smooth and
controlled with 45-degree
flexion, 55-degree
extension, 40-degree
lateral abduction, and
70degree rotation.
Palpate the trachea Trachea is midline.
Palpate the thyroid Landmarks are positioned
gland midline
Auscultate the No bruits are auscultated.
thyroid gland
Palpate the lymph There is no swelling or
nodes enlargement and no
tenderness.
III. EYES
Test distant visual Normal distant visual
acuity acuity is 20/20 with or
without corrective lenses.
This means that the client
can distinguish what the
person with normal vision
can distinguish from 20feet
away.
Test near visual Normal near visual acuity is
acuity 14/14 (with or without
corrective lenses). This
means that the client can
read what the normal eye
can read from a distance of
14 inches.
Test visual fields for With normal peripheral
gross peripheral vision, the client should see
vision the examiner’s finger at the
same time the examiner
sees it. Normal visual field
degrees are approximately
as follows:

• Inferior: 70 degrees
• Superior: 50 degrees
• Temporal: 90 degrees
• Nasal: 60 degrees
Perform corneal The reflection of light on
light reflex the corneas should be in
the exact same spot on each
eye, which indicates
parallel alignment.
Perform cover test The uncovered eye should
remain fixed straight
ahead. The covered eye
should remain fixed
straight ahead after being
uncovered.
Perform positions Eye movement should be
test smooth and symmetric
throughout all six
directions.
Inspect the eyelids The upper lid margin
and the eyelashes should be between the
 upper margin of the iris
and the upper margin of
the pupil. The lower lid
margin rests on the lower
border of the iris. No white
sclera is seen above or
below the iris. Palpebral
fissures may be horizontal.
Assess ability of The upper and lower lids
eyelids to close close easily and meet
completely when closed.
Note the position of The lower eyelid is upright
the eyelids in with no inward or outward
comparison with turning. Eyelashes are
the eyeballs evenly distributed and
curve outward along the lid
margins.
Observe eyelids for Skin on both eyelids is
redness, swelling, without redness, swelling,
discharge or lesions or lesions.
Observe eyelids for Eyeballs are symmetrically
position and aligned in sockets without
alignment of the protruding or sinking.
eyeball in the eye
socket
Inspect the bulbar Bulbar conjunctiva is clear,
conjunctiva and moist, and smooth.
sclera Underlying structures are
clearly visible. Sclera is
white.
Inspect the The lower and upper
palpebral palpebral conjunctivae are
conjunctiva clear and free of swelling or
lesions.
Evert the upper Palpebral conjunctiva is
eyelid free of swelling, foreign
bodies, or trauma.
Inspect the lacrimal No swelling or redness
apparatus should appear over areas of
the lacrimal gland. The
puncta is visible without
swelling or redness and is
turned slightly toward the
eye.
Palpate the lacrimal No drainage should be
apparatus noted from the puncta
when palpating the
nasolacrimal duct.
Inspect the cornea The cornea is transparent,
and lens with no opacities. The
oblique view shows a
smooth and overall moist
surface; the lens is free of
opacities.
Inspect the iris and The iris is typically round,
pupil flat, and evenly colored.
The pupil, round with a
regular border, is centered
in the iris. Pupils are
normally equal in size (3 to
5 mm). An inequality in
pupil size of less than 0.5
mm occurs in 20% of
clients. This condition,
called anisocoria, is normal.
Test pupillary The normal direct pupillary
reaction to light response is constriction.
(pupillary light
reflex)
Assess consensual The normal consensual
response pupillary response is
constriction.
Test The normal pupillary
accommodation of response is constriction of
pupils the pupils and convergence
of the eyes when focusing
on a near object
(accommodation and
convergence).
IV. EARS
Inspect the auricle, Ears are equal in size
tragus and lobule bilaterally (normally 4–10
cm). The auricle aligns with
the corner of each eye and
within a 10-degree angle of
the vertical position.
Earlobes may be free,
attached, or soldered
(tightly attached to
adjacent skin with no
apparent lobe). The skin is
smooth, with no lesions,
lumps, or nodules. Color is
consistent with facial color.
Darwin’s tubercle, which is
a clinically insignificant
projection, may be seen on
the auricle. No discharge
 should be present.
Palpate the auricle Normally the auricle,
and mastoid tragus, and mastoid
process process are not tender.
Perform whisper Able to correctly repeat the
test two-syllable word as
whispered.
Perform weber’s Vibrations are heard
test equally well in both ears.
No lateralization of sound
to either ear.
Perform the Rinne’s Air conduction sound is
test normally heard longer than
bone conduction sound (AC
> BC).
Perform the Client maintains position
Romberg test for 20 seconds without
swaying or with minimal
swaying.
V. MOUTH AND
THROAT
Inspect the lips Lips are smooth and moist
without lesion.
Inspect the teeth Thirty-two pearly whitish
and gums teeth with smooth surfaces
and edges. Upper molars
should rest directly on the
lower molars and the front
upper incisors should
slightly override the lower
incisors. Some clients
normally have only 28
teeth if the four wisdom
teeth do not erupt.
Inspect the buccal The buccal mucosa should
mucosa appear pink in light-
skinned clients; tissue
pigmentation typically
increases in dark skinned
clients.
Inspect and palpate Tongue should be pink,
the tongue moist, a moderate size with
papillae (little
protuberances) present. A
common variation is a
fissured, topographic map–
like tongue, which is not
unusual in older clients. No
lesions are present.
Assess the ventral The tongue’s ventral
surface of the surface is smooth, shiny,
tongue pink, or slightly pale, with
visible veins and no lesions.
Inspect for The frenulum is midline;
Wharton’s ducts Wharton’s ducts are visible,
with salivary flow or
moistness in the area. The
client has no swelling,
redness, or pain.
Observe the sides of No lesions, ulcers, or
the tongue nodules are apparent.
Check the strength The tongue offers strong
of the tongue. resistance

Inspect the hard The hard palate is pale or

(anterior) and soft whitish with firm,
(posterior) palates transverse rugae (wrinkle-
and uvula like folds). Palatine tissues
are intact; the soft palate
should be pinkish, movable,
spongy, and smooth
Note odor while the No unusual or foul odor is
mouth is wide open noted
Assess the uvula The uvula is a fleshy, solid
structure that hangs freely
in the midline. No redness
of or exudate from uvula or
soft palate. Midline
elevation of uvula and
symmetric elevation of the
soft palate. A bifid uvula,
common in Native
Americans, looks like it is
split in two or partially
severed
Inspect the tonsils Tonsils may be present or
absent. They are normally
pink and symmetric and
may be enlarged to 1+ in
healthy clients. No exudate,
swelling, or lesions should
be present.
Inspect the Throat is normally pink,
posterior without exudate or lesions
pharyngeal wall
VI. NOSE
Inspect and palpate Color is the same as the
the external nose rest of the face; the nasal
 structure is smooth and
symmetric; the client
reports no tenderness.
Check patency of Client is able to sniff
airflow through through each nostril while
nostrils other is occluded.
Inspect the internal The nasal mucosa is dark
nose pink, moist, and free of
exudate. The nasal septum
is intact and free of ulcers
or perforations. Turbinates
are dark pink (redder than
oral mucosa), moist, and
free of lesions.
VII. SINUSES
Palpate the sinuses Frontal and maxillary
sinuses are nontender to
palpation, and no crepitus
is evident.
Percuss the sinuses The sinuses are not tender
on percussion