Name : Sheena Saludang

Age :

24 yrs. old

Weight: 52.2 kg.

Height: 5ft 3 in
BMI: 20.4

Vital Signs

BP: 110/80
T: 36.5 C
PR: 87 bpm
RR: 20 cpm

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS

Body built
Height & weight

Inspection

Proportionate (Ectomorph,
Mesomorph, Endomorph)

Mesomorph

Normal

Posture & gait

Inspection
Inspection

Stands comfortably erect, normal

posture, walks normally
Well-groomed, clean

Normal

Overall hygiene &

grooming
Physical deformities &
signs of health or illness

Stands comfortably erect, normal

posture, walks normally
Well-groomed, clean

Inspection

No physical deformities, no signs of

illness

No physical deformities, no signs of

illness

Normal

Level of consciousness

Inspection
Inspection

Language &
communication

Inspection

responds to questions correctly and

clearly
Appropriate to the situation; happy,
normal, relaxed
Understandable; do not exhibits
relevance and organization of
thoughts

Normal

Emotional status

Responsive; responds to questions

correctly and clearly
Appropriate to the situation; happy,
normal, relaxed
Understandable; exhibits relevance and
organization of thoughts

Color varies from light to dark brown,

uniform in color, unblemished skin, no
signs of edema
No lesions or abrasions. Freckles,
birthmarks & moles are normal
Moist where the skin folds and in
axillae
Skin springs back when pinched; < 3
seconds is normal

Color varies of light brown, uniform

in color, unblemished skin, no signs
of edema
No lesions or abrasions. Freckles,
birthmarks & moles are normal
Moist where the skin folds and in
axillae
Skin springs back when pinched in 1
second

Normal

No clubbing or spooned; convex

curvature, about 160 degrees
Pinkish in color, highly vascular,
smooth texture

Normal

BODY PARTS
ASSESSED
GENERAL SURVEY:

Normal

Normal
Normal

SKIN:
Skin color, uniformity,
presence of edema

Inspection

Skin lesions

Inspection

Skin moisture &

temperature
Skin turgor

Palpation
Inspection

Normal
Normal
Normal

NAILS:
Fingernail plate shape

Inspection

Fingernail color & texture

Inspection &
Palpation

Tissues surrounding the

nails
Capillary refill

Inspection

HEAD:

Inspection &
Palpation

No clubbing or spooned; convex

curvature, about 160 degrees
Pinkish in color, highly
vascular, smooth
texture
Intact epidermis
Prompt return of usual color when
blanch test is performed

Normal

Intact epidermis

Normal

Prompt return of usual color when

blanch test is performed

Normal