Ermita, Jasmin BSN2-C August 9,2019

Physical Assessment
I. Biographical Data
Name: Clavez, Baby girl
Age: Neonate
Gender: Female
Birth date: July 24, 2019
Address: Cabatuan, Iloilo
Occupation: N/A
Religion: N/A
II. Skin, Hair and Nails
 Skin is slightly yellow, warm, dry and elastic. No lesions are noted.
 Hair is black and the length is up to the skull. Normal distribution of the hair on scalp and
perineum. There is a presence of thin hairs distributed evenly in the whole body.
 Nails appear to be smooth and no clubbing is noted.

III. Head and neck

 Head symmetrically round, hard and smooth without lesions or bumps. Face round,
smooth and symmetrical.
 Neck symmetric with centered head position and no bulging masses.

IV. Eyes and Ears

 Eyelids in normal position with no abnormal widening or ptosis. No redness, discharge,
crusting noted on lid margins.
 Ears are equal in size bilaterally. Skin smooth, no lumps, lesions or nodules. There is no
discharge noted.

V. Mouth, Throat, Nose, and Sinuses

 Lips is pink, smooth and moist without lesions.
 Nose is smooth and symmetrical. Nasal septum is symmetrically place on the middle.
 No purulent drainage or discharge noted in the sinuses.

VI. Respiratory System

 Respirations 50/minute, relaxed and uneven. No retraction or bulging of interspaces.

VII. Cardiovascular System

 Apical pulse is 150 bpm and there is no arrhythmia observed.

VIII. Breasts and Axilla

 Bilateral breast, moderate in size and symmetric. Breast skin pale with light brown
areola. No dimpling, retractions, lesions, or inflammation observed.
 Axilla is free from rashes and inflammation.
Ermita, Jasmin BSN2-C August 9,2019

IX. Abdomen
 Abdomen is symmetrical in shape. There is no scars, pigmentation, lesions or masses
noted.