PHYSICAL ASSESSMENT A. General Survey The patient is 4 years old of age male. He has evenly distributed thin hair.

He has symmetrical face structure. He can move freely, His nails are concave; He has intact memory and is oriented with regards to where he is, his condition, and who he is with.

B. Head to toe assessment Body Parts Normal/Standard V. PHYSICAL ASSESSMENT a. hair Inspection and palpation: Evenly distributed hair, thick, silky, resilient hair; no infection or manifestations; coarse or texture fine. (fundamentals of Nursing Kozier, pp541) b. cranium Inspection and palpation: Rounded (normocephalic and symmetrical; smooth skull contour, uniform, consistent. (fundamentals of Nursing Kozier, pp.544) Face Inspection: Oval round or square, symmetrical and distribution of hair, (-) edema on eyes; (-) hollowness. (fundamentals of Nursing Kozier, pp.545) Facial movement Inspection: Symmetrical facial movement. (fundamentals of Nursing Kozier, pp.545) 2. EYES and VISION a. external eye structure a.1 eyebrows Inspection: Hair evenly distributed; skin intact; eyebrows symmetrically aligned; equal movements. (fundamentals of Nursing Kozier, pp.548)

Actual Findings

Analysis

Patients hair is evenly Normal distributed, thin with black hair

Patients head is round Normal and symmetrical With wound frontal area on the Due to wound gunshot

Patient has symmetrical Normal face structure.

He has symmetrical facial Normal movement

Upon inspection, Normal eyebrows are evenly distributed with white hairs, symmetrically aligned and has equal movement.

a.2 eyelids

Inspection: Skin intact; no discharge; no discoloration; lids close symmetrically; bilateral blinking when the lids open; no visible sclera above corneas. Upper and lower borders of cornea are slightly covered. (fundamentals of Nursing Kozier, pp.548)

Lids close symmetrically; Normal no discharge; upper and lower border of cornea is slightly covered.

a.3 eyelashes

a.4 conjunctiva

a.5 cornea

a.6 pupils

Inspection: Equally distributed curled slightly outward. (fundamentals of Nursing Kozier, pp.548) Inspection: Transparent; capillaries sometimes evident. (fundamentals of Nursing Kozier, pp.548) Inspection: Transparent; shiny; details of the iris are available (fundamentals of Nursing Kozier, pp.550) Inspection: Black in color, equal in size; normally 3-7 mm in diameter; round with smooth border. (fundamentals of Nursing Kozier, pp.550)

Eyelashes are equally Normal distributed curled slightly outward. Transparent ; capillaries sometimes evident Normal

Patient has transparent Normal cornea.

Black in color with equal Normal size, constricted

b. visual acuity b.1 near vision

Inspection: Able to read newsprint held at a distance of 14 inches. (fundamentals of Nursing Kozier, pp.552) b.2 color vision Able to perceive purple colors and discriminate pastel colors. (fundamentals of Nursing Kozier, pp.552) c. extra-ocular Inspection: motor function Both eyes are coordinated; move in unison with parallel alignment. (fundamentals of Nursing Kozier, pp.552) 3. EARS and

Patient can read at the Normal level of his age

Able to perceive and Normal discriminate color.

Both of patients eyes Normal were observed to move with coordination.

HEARING a. External Ear No drainage; color match Canal with the face; no redness; nodules; swelling or lesions. b. hearing Inspection: Normal voice tones audible; when watch thick test performed; able to head ticking in both ears (fundamentals of Nursing, Kozier, pp 558) 4. NOSE a. structure Inspection: Symmetric and straight; no discharge or flaring; uniform color, no tenderness, no lesions. (fundamentals of Nursing, Kozier, pp 560) b. obstruction Inspection: Air moves freely as client breathes through the nurse; no visible obstruction. (Fundamentals of Nursing, Kozier, pp. 560) c. sense of smell Able to identify common odors. (fundamentals of Nursing, Kozier, pp 559) 5. MOUTH a. lips

Symmetrically aligned.

Normal

Able to hear loud and Normal modulated sounds.

Symmetrical and straight Normal with no obvious deformity.

Air moves freely as the Normal client breathes

The patient is able to Normal identify common odors.

Inspection: Uniform, Uniform; pink in color; contour soft; moist; smooth texture; symmetric contour; able to purse lips Inspection: Central position; pink; moist; slightly rough thick whitish coating smooth lateral margins; no lesions Pink gums (bluish or brown patches in darkskinned clients), moist firm texture to gums, no retractions of gums (pulling away from the teeth). (Fundamentals of Nursing, Kozier, pp. 602) 32 adult teeth, smooth, white, shiny tooth enamel. (Fundamentals of Nursing,

symmetric Normal

b. tongue

The tongue is on central Normal position, with no lesions and moves freely Pink gums, moist firm Normal texture to gums, no retractions of gums (pulling away from the teeth).

c. gums

d. teeth

smooth, white, tooth enamel.

shiny Normal

e. breath odor

Kozier, pp. 602) No breath odor. no breath odor noted (Fundamentals of Nursing, Kozier, pp. 572)

Normal

6. NECK a. musculo- Muscles equal in size; skeletal head centered; movement structures coordinated with no discomfort Inspection: Equal strength against resistance of hands (fundamentals of Nursing, Kozier, pp 558) b. lymph nodes Inspection: Not palpable (fundamentals of Nursing, Kozier, pp 558) c. thyroid gland Inspection and palpation: Not visible on inspection; glands ascends during swallowing; lobes may not be palpated. (fundamentals of Nursing, Kozier, pp 568) 7. UPPER EXTREMITIES a. musculoskeletal structures, skin nails

Patients neck can rotate Normal sideways, up and down

Not palpable

Normal

The thyroid glands was Normal not visible on inspection; and the lobes are not palpated

Inspection and palpation: Equal size on both sides of the body; normally firm; no contractures (shortening); with equal number of fingers. Inspection: Color varies with lifestyle and genes; skin color uniform (-)edema (-abrasions, lesions temperature not excessively warm or cold Inspection: Convex curvature; 160 angle; smooth texture; highly vascular and pinkish; 1-2 sec capillary refill. (fundamentals of Nursing, Kozier, pp 600)

Equal size on both sides Normal of the body: color varies.

Brown Normal

Convex curvature; 160 angle; smooth texture; Normal highly vascular and pinkish; 1-2 sec capillary refill.

b. musculo Equal strength on each skeletal strength body side 8. ANTERIOR

CHEST a. breast

axillae

b. thorax

Palpation and Inspection: Breast even with the chest wall; if obese, may be similar in shape to female breast. Skin uniform in color (some in appearance as skin of abdomen or back) Skin smooth and intact Palpation: No tenderness, masses on nodules (fundamental of Nursing, Kozier, pp589) Inspection and Palpation: Chest symmetrical; quiet and effortless respiration; full symmetric excursions; skin intact; no tenderness (fundamentals of Nursing, Kozier, pp 578)

Skin uniform in color (some in appearance as skin of abdomen or back) Skin smooth and intact

Normal

No tenderness or masses.

Normal

Skin intact tenderness; symmetrical

and

no Normal chest

9. BACK a. musculoskeletal structures and posterior thorax 10. ABDOMEN a. 4 quadrants

Inspection and palpation: Chest symmetric Chest symmetric; spinal column is straight, right, and left shoulders and hips are at the same height; skin intact Inspection: Unblemished skin; uniform in color, flat round or scaphoid (concave); symmetric contour; no visible vascular pattern Auscultation: Audible bowel sounds; absence of arterial bruits; absence of friction rub. Palpation: No tenderness; relaxed abdomen with smooth, consistent tension (Fundamentals of Nursing, Kozier, pp 596/ 597) Inspection and palpation: Equal size on both sides of body; normally firm; no contractures(shortening) (Fundamental of Nursing Kozier, pp.600)

Normal

Unblemished skin; Normal uniform in color, flat round or scaphoid (concave); symmetric contour; no visible vascular pattern Auscultation: Audible bowel sounds; absence of arterial bruits; absence of friction rub.

11. LOWER EXTREMITIES a. musculo skeletal structures, skin, nails

12. GENITALS and PELVIS(male)

N/A

a. external No inflammation, swelling N/A genitals or discharge (Fundamental of Nursing, Kozier, pp654) 13. RECTUM a. lesions No presence of lesions N/A Level of consciousness: GCS: