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weight in relation to the client s age and lifestyle Posture, gait, standing, sitting and walking Overall hygiene Body and breath odor NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION OR ANALYSIS
Proportionate, varies with lifestyle Relaxed, erect posture; coordinated movement Clean and neat No body odor or minor body odor relative to work and exercise; no breath odor. No distress noted
Signs of distress in posture or facial expression Obvious signs of health or illness Attitude Affect or mood: appropriateness of the response Quantity and quality of speech
Healthy appearance Cooperative, able to follow instruction Appropriate to situation
Relevance and organization of thoughts Measurement: Proportionality of height to weight
Understandable, moderate pace; clear tone and inflection; exhibits thought association Logical sequence, moderate pace; clear inflection: exhibits thought association BMI: weight (kg)/ height in meter/2 18.5-25 kg/m
Vital Signs: Temperature Pulse rate Respiratory rate Blood Pressure
36-37 C (98.6 F) 60-100beats/min. 15-20breaths/min 120/80 mmHg
-Edema -Lesions -Skin moisture -Temperature -Skin turgor Nails -finger nails plate shape. no abrasions or other lesions Moisture and skin folds and axillae (varies with environment temperature.Integumentary: Skin -color and uniformity of skin color Varies from light to deep brown. humidity. some flat and raised nevi. some birthmarks. angle of nail plate about 160 Highly vascular and pink in light-skinned clients. from ruddy pink to light pink. body temperature and activity) Uniform within normal range When pinched skin springs back to previous state. dark-skinned clients may have brown or black pigmentation in longitudinal streaks Smooth texture -fingernails and toenails texture -tissues surrounding nails Intact epidermis . maybe slower in elders. it s curvature and angle -fingernails and toenails color Convex curvature. from yellow overtones to olive No edema Freckles.
thick hair Silky. parietal and occipital prominences). resilient hair Slightly asymmetric facial features. symmetric nasolabial folds Symmetrical facial movements Eyes: Visual Acuity -near vision -distant vision Able to read newsprint 20/20 vision on snellen . symmetry of facial movements Evenly distributed. with frontal. thickness or thinness -texture and oiliness Face -facial features. shape or symmetry Prompt return of pink or usual color (generally less than 4 seconds) Rounded (normocephalic and symmetric. palpebral fissures equal in size. absence of nodules or masses -nodules.-Blanch test of capillary refill Head: Skull -size. smooth skull contour Smooth. masses and depressions Scalp -color and appearance The color is lighter than the skin No tenderness -areas of tenderness Hair -evenness of growth. uniform consistency.
ability to blink and frequency of blinking Skin intact. smooth.type chart Eyebrows -distribution of hair and symmetry of eyebrows Hair evenly distributed. skin intact Eyebrows are symmetrically aligned. bilateral blinking When lids open. texture and presence of lesions Sclera -color and clarity Transparent. Lacrimal gland. equal movement No edema or tenderness over lacrimal gland No edema or tearing Eyelids -surface characteristics. texture and presence of lesions -palpebral conjunctiva (lining of the eyelids) for color. position in relation to the cornea. and pink or red Sclera appears white ( darker or yellowish and . no visible sclera above corneas. lacrimal sacs and nasolacrimal duct Shiny. no discoloration Lids close symmetrically Approximately 15-20 involuntary blinks per minute. capillaries sometimes evident. no discharge. and upper and lower borders of cornea are slightly covered Conjunctiva -bulbar conjunctiva (lying over the cornea) for color.
round. symmetry and . normally 3-7mm in diameter. equal in size. details of the iris are visible Iris -shape and color Pupils -color. shape and symmetry of size Flat and round Black in color. iris in flat and round Illuminated pupil constrict (direct response) nonilluminated pupil constrict(consensual response) Pupils constricts when looking at near object. client can see objects periphery Both eyes coordinated. shiny and smooth. smooth border.with small brown macules or darkskinned clients) Cornea -clarity and texture Transparent. move in unison with parallel alignment Ears: Auricles -color. pupil dilate when looking at far object. pupil converge when near object is moved toward nose -light reaction and accommodation Extraocular Muscles -alignment and coordination Visual fields -peripheral fields When looking straight ahead.
growths and discharge -nasal septum between the chambers -patency of both nasal cavities Symmetric and straight. size or color and flaring or discharge from nares -presence of redness. pus and blood Dry cerumen. pus and blood Hearing Acuity -response to normal voice tones -watch tick test Normal voice tones audible Able to hear ticking in both ears Sound is hear on both ears or is localized at the center of the head (Weber negative) Air conducted is greater than bone conduction (positive Rinne) -Weber s test -Rinne s test Nose: -shape. symmetrical. no discharge and flaring.position Color same as facial skin. distal third contains hair follicles and glands no skin lesions. swelling. firm. skin lesions. uniform in color Mucosa pink clear watery discharge Nasal septum intact and in midline Air moves freely as the client breaths through . elasticity and areas of tenderness External Ear Canal -cerumen. auricle aligned with outer canthus of eye. about 10 from vertical Mobile. and not tender. pinna recoil after it is folded -texture.
soft moist. moisture. symmetry of contour ability to purse lips Bucal Mucosa -color. 32 adult teeth Pink gums (bluish or brown patches in darkskinned clients) No retraction of gums Tongue -color and texture of mouth floor and frenulum -position. no . thin whitish coating Smooth. soft. masses displacements of bone and cartilage No tenderness and lesions Sinuses -sinuses and note for tenderness Mouth: Lips -symmetry of contour. lateral margins.the nares -tenderness. white. moist. movement and base of the tongue Pink color. number and condition and presence of dentures Gums -color and condition Smooth. smooth texture. color and texture. color and texture No tenderness Uniform color. slightly rough. texture and presence of lesions Uniform pink color (freckle brown pigmentation in darkskinned clients) Moist glistening. shiny tooth enamel. no lesions raised papillae Moves freely. smooth and elastic texture Teeth -color.
tenderness Smooth tongue base with prominent veins -nodules. lumps or excoriated areas Palates and Uvula -color. more irregular texture Positioned in midline of the palate -position of the uvula and mobility while examining the palates Oropharynx and tonsils -color and texture Pink and soft posterior wall Pink and smooth No discharge Of normal size or not visible Presence of gag reflex -size of the tonsils. soft palate Lighter pink hard palate. spaces are equal on both sides Thyroid gland -symmetry and visible masses Not visible in inspect gland ascends during swallowing but it is not visible Lobes may not be palpated -smoothness and areas of enlargement. shape and presence of bony prominences Smooth with no palpable nodules Light pink. texture. color and discharge Neck and Lymph nodes: Lymph nodes -locate and identify. smooth. masses . note for tenderness Trachea -placement No tenderness Central placement in midline neck.
no tenderness. tenderness and masses -respiratory excursion -vocal fremitus -posterior thorax . except over scapula Lowest point of resonance is at the diaphragm Excursion is 3-5cm Bilaterally in women and in men 5-6cm Diaphragm is usually higher on the right side Vestibular and bronchovesicular breath sounds -spinal alignment -temperature. and rise freely with swallowing Thorax: Posterior Thorax -size. shaper. no masses Full and symmetric chest expansion Bilateral symmetry of vocal fremitus Fremitus is heard most clearly at the apex of the lungs Percussion note resonate. right and left shoulders and hips are at the same height Skin intact uniform temperature Chest wall intact.or nodules If palpated lobes are small. centrally located. and diameter Anteroposterior to transverse diameter in ratio 1:2 Chest symmetry Spine vertically aligned Spinal column is straight. smooth. painless. symmetry.
thrills and bruit -temperature. no tenderness. tenderness and masses -respiratory excursion -vocal fremitus -anterior thorax -trachea No pulsation No pulsation.Anterior Thorax -breathing pattern Quiet rhythmic and effortless respiration Skin intact uniform temperature Chest wall intact. lift and heaves Pulsation visible in 50% -apical area (locate . thumbs normally separate 35cm Fremitus is normally decreased over heart and breast tissue Percussion notes resonate down to the sixth rib at the level of the diaphragm but are flat over areas of heavy muscle and bone. dull on areas over the heart and the liver and tympanic over the underlying stomach Bronchial and tubular breath sounds Bronchovesicular and vesicular breath sounds Cardiovascular: -precordium for the presence of abnormal pulsations. lifts and heaves -aortic and pulmonic areas -tricuspid areas No heaves. no masses Full symmetric excursion.
slightly longer duration than systole at normal heart rates S3: children and young adults S4: in many older adults Symmetric pulse volumes Full pulsations. diffuse symmetric horizontal or vertical vascular pattern in light-skinned people . slightly shorter duration than diastole at normal heart rate Diastole: silent in interval. skin smooth and intact. symmetry. tricuspid and apical valves Carotid arteries Jugular Veins Breast and axillae -size.point of maximal impulse) of adults and palpable in most PMI in fifth LICS at or medial to MCL. turns head and changes from sitting to supine position Elastic arterial wall No sound heard on auscultation Veins not visible Rounded shape. swelling or Skin uniform in color. thrusting quality Quality remains same when client breathes. pulmonic. Diameter is 1-2cm No lift and heaves S1: usually heard at all sites and usually louder at apical area S2: usually heard at all sites and usually louder at base of the heart Systole: silent interval. dimpling. localized hyper vascular areas. retraction. generally symmetric -aortic. slightly unequal in size. contour while in sitting position -skin of breast for localized discolorations or hyper pigmentation.
masses. masses. discharge and lesions -axillary. light pink-dark brown irregular placement of sebaceous glands on the surface of the areola Round.edema striae (stretch marks). both nipples point in same direction No discharge. surface characteristics or any mass or lesions -nipples for size. position. color. rounded(covex) or scaphoid(concave) -abdominal contour (profile line from rib margin to the pubic bone) -enlarged liver or spleen No evidence of enlargement of liver or . except from breast-feeding females Inversion in one or both nipples that is present from puberty No tenderness. everted. masses or nodules -areola for size. silverwhite striae or surgical scars Flat. symmetry. color. mole and nevi Round or oval and bilaterally the same. soft and smooth. nodule or nipple discharge -nipples for tenderness and discharge Abdomen: -skin integrity Unblemished skin uniform color. nodule or nipple discharge No tenderness. similar in color. shape. shape. subclavicular and supraclavicular lymph nodes -breast for masses and tenderness No tenderness. and equal in size.
especially over the liver and spleen or a full bladder 6-12cm in the midclavicular line. relaxed abdomen with smooth. consistent tension Tenderness maybe present near xiphoid process. 4-8 at the midsternal line No tenderness. peristalsis or aortic pulsations spleen Symmetric movement caused by respiration Visible peristalsis in very lean people Aortic pulsation in thin persons at epigastric area No visible vascular pattern Audible bowel sounds Absence of arterial bruit Absence of friction rub Tympany over the stomach and gas-filled bowels.-symmetry of contour -abdominal movement associated with respiration. dullness. over cecum and over sigmoid colon Not palpable -vascular patterns -bowel sounds. vascular sound and peritoneal friction rubs -areas of the four quadrants -size of the liver -above symphysis to determine urinary retention Musculoskeletal System: Muscles -muscle size Equal on both sides of the body .
lower extremities (popliteal) . smoothness of movement. smoothness of movement.lower extremities (ankles) No contractures No tremors and fasciculation Normally firm Equal strength on each sides No deformities No edema or tenderness No swelling No tenderness.-muscle and tendons contractures -fasciculation and tremors -muscles tonicity -strength neck. swelling. crepitating and presence of nodules Range of Motion -upper extremities (shoulder and scapula) -upper extremities(elbows) -upper extremities (hands) -lower extremities ( acetabulum /inguinal area) . swelling. crepitation or nodules Joints move smoothly Varies to some degree in accordance with person s genetic makeup and degree of physical activity . upper extremities and lower extremities Bones -skeleton for normal structure and deformities -edema or tenderness Joints -swelling -tenderness.