PHYSICAL ASSESSMENT B.

Arteries and veins (rate and rhythm of

pulse, strength, type and equality of
I. GENERAL SURVEY arterial pulses)
A. General appearance and
behavior VII. BREASTS (symmetry, contour, color,
1. Gender and race lesions, mass, pain, discharges)
2. Signs of distress (Anxiety, pain,
difficulty of breathing)
3. Body type (trim, muscular, obese,
or excessively trim) VIII. ABDOMEN
4. Posture (erect, bent, stoop or A. Inspection
slumped) B. Auscultation
5. Gait C. Percussion
6. Body movement (purposeful, D. Palpation
presence of tremors, immobility)
7. Age IX. GENITALIA (Female / Male)
8. Hygiene and grooming (distribution of hair growth, color of
(appearance of hair, skin, and fingernails)
perineum, presence of discharges,
9. Dress (culture, lifestyle,
socioeconomic level and personal inflammation, edema, ulceration, lesions)
preference affects the type of
clothes worn) X. RECTUM and ANUS (presence of
10. Body odor lesions, ulcers, inflammation, rashes,
11. Affect and mood (feelings) discoloration)
12. Speech (normal tone, rapid, or
slow)qq XII. MUSCULOSKELETAL SYSTEM
B. Taking Height and Weight A. General inspection (gait and
C. Taking Vital Signs posture)
B. Range of joint motion (equality of
II. INTEGUMENT movement, presence of pain,
A. Skin (color, moisture, temp., texture, nodules)
turgor, vascularity, edema, lesions) C. Muscle tone and strength
B. Hair and scalp (distribution, texture, (rigidity, weakness)
scaliness, lesions, dryness, presence of
lice) XIII. NEUROLOGICAL SYSTEM
C. Nails (color, thickness, shape, condition A. Mental and emotional status
of the nail folds) (level of consciousness, behavior
& appearance, language)
III. HEAD and NECK B. Intellectual function (memory,
A. Head knowledge, abstract thinking,
B. Eyes (visual acuity, extraocular association, judgment)
movements, visual fields, external eye C. Cranial nerve function
structure) D. Sensory function (vision, hearing,
C. Ears (auricles, ear canals, eardrums, smell, touch, taste)
hearing acuity) E. Motor function (coordination,
D. Nose and sinuses (color of mucosa, balance)
lesions, discharge, swelling, symmetry) F. Reflexes
E. Mouth and pharynx (color, edema,
bleeding, lesions, smell, swelling or GORDON’S 11 FUNCTIONAL HEALTH
infection) PATTERNS
F. Neck (neck muscles, lymph nodes, size,
shape, tenderness and mobility) PATTERN OF HEALTH PERCEPTION &
IV. THORAX and LUNGS (Posterior, HEALTH MANAGEMENT
Lateral, Anterior) ● How does the person describe her/ his
V. HEART (rate, rhythm, presence of chest current health?
pain) ● What does the person do to improve or
VI. VASCULAR SYSTEM maintain her/ his health?
● What does the person know about links
A. Blood pressure
between lifestyle choices and health?
● How big a problem is financing health
care for this person? ROLE - RELATIONSHIP PATTERN
● Can this person report the names of ● How does this person describe her/ his
current medications s/he is taking and various roles in life?
their purpose? ● Has, or does this person now have
● If this person has allergies, what does positive role models for these roles?
s/he do to prevent problems? ● Which relationships are most important
● What does this person know about to this person at present?
medical problems in the family? ● Is this person currently going through
● Have there been any important illnesses any big changes in role or relationship?
or injuries in this person's life? What are they?

NUTRITIONAL - METABOLIC PATTERN SEXUALITY - REPRODUCTIVE

● Is the person well nourished? PATTERN
● How do the person's food choices ● Is this person satisfied with her/ his
compare with recommended food situation related to sexuality?
intake? ● How have the person's plans and
● Does the person have any disease that experience matched regarding having
affects nutritional- metabolic function? children?
● Does this person have any disease/
PATTERN OF ELIMINATION dysfunction of the reproductive
● Are the person's excretory functions system?
within the normal range?
● Does the person have any disease of PATTERN OF COPING & STRESS
the digestive system, urinary system or TOLERANCE
skin? ● How does this person usually cope
with problems?
PATTERN OF ACTIVITY & EXERCISE ● Do these actions help or make things
● How does the person describe her/ his worse?
weekly pattern of activity and leisure, ● Has this person had any treatment for
exercise and recreation? emotional distress?
● Does the person have any diseases
that affect her/his cardio-respiratory PATTERN OF VALUES & BELIEFS
system or musculoskeletal system? ● What principles did this person learn as
a child that is still important to her/
COGNITIVE - PERCEPTUAL PATTERN him?
● Does the person have any sensory ● Does this person identify with any
deficits? Are they corrected? cultural, ethnic, religious, regional, or
● Can this person express her/ himself other groups?
clearly and logically? ● What support systems does this
● How educated is this person? person currently have?
● Does the person have any disease that
affects mental or sensory functions?
● If this person has pain, describe it and
its causes.

PATTERN OF SLEEP & REST

● Describe this person's sleep-wake
cycle.
● Does this person appear physically
rested and relaxed?

PATTERN OF SELF PERCEPTION &

SELF CONCEPT
● Is there anything unusual about this
person's appearance?
● Does this person seem comfortable
with her/ his appearance?
● Describe this person's feeling state.