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PA Result Vluna

PA Result Vluna

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Published by jcarysuitos

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Published by: jcarysuitos on Nov 12, 2009
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05/20/2012

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Confidential Page 1 11/11/2009
ARELLANO UNIVERSITYCOLLEGE OF NURSING
Physical Assessment
NAME OF CLIENT: ABCD EFGAGE: 4 Y/OGENDER: FEMALEArea of assessment
Assessment FindingsNorms and StandardsAnalysisSkin
Skin color: pale whiteVaries form light to deepbrownDeviation from normal
Uniformity of skin color:uniformGenerally uniform except inareas exposed to the sunNormal
Skin moisture: dryMoisture in skin folds and theaxillaeNormal
Skin temperature: warmWithin normal rangeDeviation from Normal
Skin turgor: goes backslowly to usual formSkin goes back to previousstateDeviation from normal
Hair 
Growth: evenlydistributedEvenly distributed hairNormal
Thickness or thinness:thick hair Thick hairNormal
Texture or oiliness: silkySilky, resilient hairNormal
presence of infection or infestation: withoutdandruff No infection or infestationNormal
Nails
Fingernail plate shape,curvature and angle:convex, 160ºConvex, 160ºNormal
Texture: smoothSmooth textureNormal
Bed color: pale pinkHighly vascular and pinkNormal
Tissue surroundingIntact epidermisDeviation from normal
 
Confidential Page 2 11/11/2009
nails: fairly intact
Blanch test: goes backslowly to its originalcolor in less than 7secondsPrompt return of pink or usualcolor Deviation from normal
Skull and Face
Size, shape andsymmetry: round,symmetricRounded; smooth skullcontour Normal
With some presence of nodules or masses anddepressionsAbsence of nodules or massesDeviation from normal
Facial features: slightlyasymmetricSymmetric or slightlyasymmetricNormal
Without presence of edema or hollownessNo edema or hollownessNormal
Symmetry of facialmovements: symmetricSymmetric facial movementNormal
Eye
Distribution andalignment of eyebrows:equally alignedHair evenly distributed;eyebrows symmetricallyalignedNormal
Distribution and directionof curl of the eyelashes:equally distributedEqually distributed; curledslightly outwardNormal
Bulbar conjunctiva:transparent; smoothTransparent; sclera appearswhiteNormal
Palpebral conjunctiva:pale pinkShiny, smooth and pink or redNormal
Lacrimal gland: nopresence of edema or tendernessNo edema or tendernessNormal
Lacrimal sac andnasolacrimal duct: notendernessNo edema or tearingNormal
 
Confidential Page 3 11/11/2009
Cornea: transparentTransparent, shiny andsmoothNormal
Anterior chamber:transparentTransparentNormal
Pupil: black, equal insize, roundBlack in color, equal in size,3-7 mm in diameter, round,smoothNormal
Ears and hearing
Color, symmetry of sizeand position of auricle:same as facial skin;symmetrical; alignedwith outer cantus of theeyesame as facial skin;symmetrical; aligned withouter cantus of the eyeNormal
Auricle’s texture ,elasticity and areas of tenderness: notenderness, smoothSmooth, firm, not tender;pinna recoils after it is foldedNormal
Client’s response tonormal voice tones: withaudible responseAudibleNormal
Nose and Sinuses
Shape, size, color or flaring of external nose:symmetric and straight;uniform in color symmetric and straight;uniform in color Normal
No tenderness, massesand displacements of bone and cartilageNot tender; no lesionsNormal
Pathway of bothcavities: air passesthrough freelyAir moves freely as the clientbreath through the naresNormal
Nasal septum betweennasal chambers: in theNasal septum intact and inmidlineNormal

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