Renea Joy M.

Arruejo
BSN II-D

A. VITAL SIGNS

Normal Range Findings Interpretation

BLOOD PRESSURE 120/80 mmHg 140/110 mmHg Beyond normal
HEART RATE 60-100 bpm 89 bpm Normal
RESPIRATION 20-30 cpm 23 cpm Normal
TEMPERATURE 36.4-37.5°c 37.5°c Normal

B. CEPHALOCAUDAL ASSESMENT

NORMAL RANGE ACTUAL FINDINGS REMARKS

A. HEAD
(SKULL)
a.) size, shape or rounded, symmetrical, rounded No definite abnormality
symmetry smooth skull contour (normocephalic), noted
symmetrical, smooth
skull contour
smooth uniform
b.) nodules, masses, consistency, absence smooth uniform No definite abnormality
depressions of nodules or masses consistency, no absence noted
of nodules or masses

symmetric or slightly symmetric or slightly

c.) facial features asymmetric facial asymmetric facial No definite abnormality
features, palpebral features, palpebral noted
fissures equal in size, fissures equal in size,
symmetric nasolabial symmetric nasolabial
folds folds

B. INTEGUMENTARY
(SKIN) uniform in color, uiform in color, No definite abnormality
unblemished and no unblemished and no noted
presence of any foul presence of any foul
odor, good skin turgor odor, good skin turgor
and skin’s temperature and skin’s temperature
is within normal limit. is within normal limit
(HAIR) thick, silky hair, evenly thick, silky hair, evenly No definite abnormality
distributed, has distributed, has variable noted
variable amount of amount of hair, no signs
hair, no signs of of infection and
infection and infestation observed.
infestation observed.
(NAILS) has a light brown nails has a light brown nails No definite abnormality
 and has the shape of and has the shape of noted
convex curve. It is convex curve. It is
smooth and is intact smooth and is intact
with the epidermis with the epidermis
C. EYES AND VISION
(EYEBROWS) hair is evenly hair is evenly No definite abnormality
distributed, distributed, noted
symmetrically aligned, symmetrically aligned,
showed equal showed equal
movement movement
(EYELASHES) equally distributed and equally distributed and No definite abnormality
curled slightly outward curled slightly outward noted

(EYELIDS) no presence of no presence of No definite abnormality

discharges, no discharges, no noted
discoloration, and lids discoloration, and lids
close symmetrically close symmetrically
with involuntary blinks with involuntary blinks
approximately 15-20 approximately 15-20
times per minute. times per minute
EYES conjunctiva and cornea conjunctiva and cornea No definite abnormality
are transparent, are transparent, noted
capillaries sometimes capillaries sometimes
evident, and sclera evident, and sclera
appears white and appears white and
clear, iris are visible, clear, iris are visible,
brown, flat and round brown, flat and round
C. EARS AND HEARING
(EARS) auricles are auricles are No definite abnormality
symmetrical, has same symmetrical, has same noted
color with facial skin, color with facial skin,
aligned with outer aligned with outer
canthus of eye, mobile, canthus of eye, mobile,
firm, not tender. Pinna firm, not tender. Pinna
recoil when folded. recoil when folded.
D. NOSE AND SINUS
(NOSE) Appeared symmetric, Appeared symmetric, No definite abnormality
straight, uniform in straight, uniform in noted
color, no presence of color, no presence of
discharge or flaring, no discharge or flaring, no
tenderness and lesions tenderness and lesions
when palpated. when palpated.
(MOUTH) Lips, tongue, buccal Lips, tongue, buccal No definite abnormality
mucosa, are uniformly mucosa, are uniformly noted
in pink; moist, in pink; moist,
symmetric, smooth symmetric, smooth
texture. No texture. No
discoloration of discoloration of
enamels, no retraction enamels, no retraction
of gums, pinkish in of gums, pinkish in color
 color of gums. of gums.
(NECK) Neck muscles are Neck muscles are equal No definite abnormality
equal in size, lymph in size, lymph nodes are noted
nodes are not not palpatable.
palpatable.
E. THORAX, LUNGS,
ABDOMEN
(LUNGS/CHEST) Chest wall intact with Chest wall intact with No definite abnormality
no tenderness and no tenderness and noted
masses, full and masses, full and
symmetric expansion symmetric expansion
and thumbs separate and thumbs separate 2-
2-3 cm deep 3 cm deep inspiration
inspiration when when assessing
assessing respiratory respiratory excursion.
excursion.
(HEART) No visible pulsations No visible pulsations on No definite abnormality
on the aortic and the aortic and pulmonic noted
pulmonic areas, no areas, no presence of
presence of heaves or heaves or lifts.
lifts.
(ABDOMEN) Unblemished skin, Unblemished skin, No definite abnormality
uniform in color, uniform in color, noted
symmetric contour, symmetric contour,
jugular veins are not jugular veins are not
visible. visible.
E. EXTREMITIES
(MUSCLES) Not palpable with Not palpable with No definite abnormality
absence of tremors, absence of tremors, noted
normally firm and normally firm and
showed smooth, showed smooth,
coordinated coordinated
movements. movements
(BONES) No presence of bone No presence of bone No definite abnormality
deformities, deformities, tenderness, noted
tenderness, and and swelling.
swelling.
(JOINTS) No swelling, No swelling, tenderness, No definite abnormality
tenderness, joints joints move smoothly. noted
move smoothly.