Physical Assessment of Ms. Baby Rose Bajar I. Appearance and Mental Status

Physical Assessment of Ms.
Baby Rose Bajar

I. APPEARANCE AND MENTAL STATUS
BODY PART ASSESSED ACTUAL FINDINGS NORMS AND STANDARDS INTERPRETATION/ ANALYSIS
T: 35.6° (Oral) T: 37° (Oral)

VITAL SIGNS P: 80 bpm P: 60-100 bpm Hypertension is associated with
R: 19 cpm R: 16- 20 cpm thickening and loss of elasticity in
BP: 140/100 mmHg BP: 120/80 mmHg the arterial walls
(Fundamentals of Nursing, 5th edition by Taylor p. (Fundamentals of Nursing, 9th
525) Edition, by Potter & Perry p. 505)
HEIGHT 149 cm. Proportionate to Weight Abnormal

(Fundamentals of Nursing, 7th Edition, by Kozier (Her \weight is not proportion to
p. 531) her height)
WEIGHT 39 kg. Proportionate to Height Abnormal

(Fundamentals of Nursing, 7th Edition, by Kozier (Her height is not proportion to
p. 531) her weight)
Proportionate; varies with lifestyle

BODY BUILT She is underweight BMI = 18.5 to 24.5 Abnormal
BMI = 17.57 kg/m2 (Fundamentals of Nursing, 7th Edition, by Kozier She is underweight
p. 531)
POSTURE, GAIT, STANDING, SITTING Relaxed, bent posture, coordinated Erect Posture, Relaxed, Coordinated Movement Abnormal
AND WALKING movements (Fundamentals of Nursing, 7th Edition, by Kozier Bent posture
p. 531)
OVERALL HYGIENE AND GROOMING she is neat and tidy Neat and Clean Normal
(Fundamentals of Nursing, 7th Edition, by Kozier
p. 531)
BODY AND BREATH ODOR No presence of breath odor and foul smell on No Body and Breath Odor Normal
her body. (Fundamentals of Nursing, 7th Edition, by Kozier
p. 531)
SIGNS OF DISTRESS No distress noted No distress noted Normal

p. 531)
SIGNS OF HEALTH OR ILLNESS Healthy appearance Healthy Appearance Normal

(Fundamentals of Nursing, 7th Edition, by Kozier She looks pale
p. 531)
ATTITUDE She’s cooperative Cooperative Normal

p. 531)
MOOD Appropriate to situation Normal

She answers appropriately (Fundamentals of Nursing, 7th Edition, by Kozier
p. 531)
Has a very understandable speech and has a Understandable, moderate in pace and exhibits
QUANTITY AND QUALITY OF SPEECH moderate pace. thought association Normal
p. 531)
RELEVANCE AND ORGANIZATION OF She answer has a sense of reality. Doesn’t Logical in sequence, makes sense and has
THOUGHTS have any difficulty in expressing herself sense of reality Normal
through speech (Fundamentals of Nursing, 7th Edition, by Kozier
p. 531)
II. SKIN
Varies from deep to light brown; Generally

SKIN COLOR; The skin color of the client is deep brown. Uniform except in areas exposed to sun Normal
UNIFORMITY OF COLOR Uniform except in areas exposed to sun (Fundamentals of Nursing, 7th Edition, by
Kozier p. 538)
EDEMA No Edema Normal

(Fundamentals of Nursing, 7th Edition, by
No edema presence Kozier p. 538)
Freckles, some birthmarks, some flat and Some scars results to loss of
LESIONS She has a scar on her right leg. raised nevi, no abrasions or other lesions tissue function
Kozier p. 538) (Fundamentals of Nursing, 9th
Edition, by Potter & Perry p. 1190)
SKIN MOISTURE Her skin is moisturized Moist in skin folds and axillae Normal
Kozier p. 539)
SKIN TEMPERATURE Uniform skin temperature with normal range Uniform; within normal range Normal
Kozier p. 539)
Skin spring back to previous state less than 3 When pinched, skin springs back to previous
SKIN TURGOR seconds. state Normal
p. 539)
III. NAILS
Her nail is about 160º and has a convex Convex Curvature; angle of nail plate about
FINGERNAILS PLATE SHAPE curvature. 160 degrees
Normal
Kozier p. 543)
Highly Vascular and pink in light skinned

clients; dark skinned clients may have brown or
FINGERNAILS AND TOE NAILS nail bed is highly vascular and light pink in black pigmentation in longitudinal streaks
BEDCOLOR color. (Fundamentals of Nursing, 7th Edition, by Normal
Kozier p. 543)
Smooth in texture
FINGERNAILS AND Her fingernails and toe nails are smooth in (Fundamentals of Nursing, 7th Edition, by Normal
TOE NAILS TEXTURE texture Kozier p. 543)
TISSUES SURROUNDING NAILS Her fingernails and toe nails are smooth in Intact Epidermis Normal
texture (Fundamentals of Nursing, 7th Edition, by Kozier
p. 543)
BLANCH TEST OF CAPILLARY REFILL It takes 3 seconds to return to the normal state Prompt return of pink or usual color
(Fundamentals of Nursing, 7th Edition, by Kozier Normal
p. 543)
IV. SKULL AND FACE
Rounded ( normocephalic and symmetrical,

Her skull is normocephalic and it is in proportion with frontal, parietal, and occipital
SKULL and symmetric. prominences); smooth skull contour Normal
p. 544)
Smooth, uniform consistency, absence of

NODULES, MASSES, DEPRESSIONS no tenderness and masses nodules and masses Normal
p. 544)
Symmetric, palpebral equal in size, symmetric

FACIAL FEATURES facial movements are symmetrical nasolabial folds Normal
p. 545)
FACIAL MOVEMENT Symmetric Facial Movements Normal

facial movements are symmetrical
p. 545)
V. SCALP
COLOR AND APPEARANCE scalp is white in color. Clean free from masses, White, Free from infestations, no presence of Normal
lumps, scars, lies, nits, dandruff and lesions dandruff
AREAS OF TENDERNESS No tenderness Normal

No tenderness
VI. HAIR
EVENNESS OF GROWTH Her hair was evenly distributed over the scalp. Evenly Distributed Hair Normal
p. 541)
THICKNESS OR THINNESS Relatively thick. Thick Hair Normal

p. 541)
TEXTURE AND OILINESS OVER SCALP Her hair is dry Silky ; Resilient Hair Abnormal
(Fundamentals of Nursing, 7th Edition, by Kozier Her hair is dry
p. 541)
VII. EYE STRUCTURES AND VISUAL ACUITY
Eyebrow is aligned and hair evenly distributed. Hair evenly distributed; skin intact;
Also, it moves equally. symmetrically aligned; equal movement
EYEBROWS (Fundamentals of Nursing, 7th Edition, by Normal
Kozier p. 548)
EYELASHES eyelashes are evenly distributed and slightly Equally distributed; curled slightly outward Normal
curled outward (Fundamentals of Nursing, 7th Edition, by
Kozier p. 548)
Skin intact; no discharge; no discoloration; Lids

EYELIDS close symmetrically; Approximately 15 to 20
The skin is intact; no discharge. Lids close blinks per minute; bilateral blinking; When
symmetrically bilateral blinking. When the lids open, no visible sclera above cornea and upper Normal
open, no visible sclera above corneas and and lower borders are slightly covered.
upper and lower borders of cornea are slightly (Fundamentals of Nursing, 7th Edition, by
covered. Kozier p. 548)
BULBAR CONJUNCTIVA There is no presence of lesion and his Transparent, capillaries evident, sclera appears
conjunctiva is transparent white Normal
p. 548)
PALPEBRAL CONJUNCTIVA Shiny, smooth and light pink in color

conjunctiva is shiny, smooth and pink red in (Fundamentals of Nursing, 7th Edition, by Kozier Normal
color p. 548)
SCLERA sclera is white in color and some capillaries White and Clear Normal
are visible (Fundamentals of Nursing, 7th Edition, by Kozier
p. 548)
Transparent, shiny and smooth, details of the iris

CORNEA cornea is shiny and transparent, looks smooth are visible Normal
p. 550)
Black in color, equal in size, round and smooth

PUPILS pupils are round and have a smooth border. border Normal
The color is dark brown (Fundamentals of Nursing, 7th Edition, by Kozier
p. 550)
NEAR VISION Able to read newsprint Normal

She is able to read the newspaper held at a (Fundamentals of Nursing, 7th Edition, by Kozier
distance of 36cm p. 552)
DISTANCE VISION 20/20 in vision 20/20 vision on snellen ‘schart Normal

p. 552)
DIRECT REACTION Illuminated pupil constricts Normal

pupils constrict in reacting to light p. 550)
CONSENSUAL REACTION Non- illuminated pupil constricts Normal

p. 550)
Her pupils constrict when looking at near pen
light while it dilates when looking at a distant Pupils constrict when looking at near objects,
ACCOMMODATION pen light dilate when looking at far objects Normal
p. 550
LACRIMAL GLAND No edema and tenderness No edema and tenderness over lacrimal gland Normal
p. 550)
LACRIMAL SAC No edema and tearing Normal

No edema and tearing
p. 550)
Both eyes coordinated, move in unison, with

EXTRAOCULAR MUSCLES There is coordinated in the movement and parallel alignment Normal
parallel alignment (Fundamentals of Nursing, 7th Edition, by Kozier
p. 552)
She can see the pen light in her periphery When looking straight ahead, client can see
PERIPHERAL VISUAL FIELDS objects in the periphery Normal
p. 551)
VIII. EARS AND HEARING
auricle is aligned with outer canthus of her eyes. Color same as facial skin, symmetrical, aligned
AURICLES The color is same as facial skin with outer cathus of eye about 10 degrees from
(COLOR, SYMMETRY, POSITION) vertical Normal
Kozier p. 556)
AURICLES her auricle is firm and it recoils after it has been Mobile, firm and not tender; pinna recoils after it
(TEXTURE, ELASTICITY, AREAS OF folded. The pinna recoils when folded is folded Normal
TENDERNESS) (Fundamentals of Nursing, 7th Edition, by
Kozier p. 556)
Distal third contains hair follicles and glands, Dry

Distal third contains hair follicles and glands, cerumen, grayish tan color; sticky, wet cerumen
Presence of dry cerumen, in various shades of brown
EXTERNAL EAR CANAL (Fundamentals of Nursing, 7th Edition, by Kozier Normal
p. 556)
RESPONSE TO VOICE TONES Normal voice tone audible Normal

Normal voice tone audible (Fundamentals of Nursing, 7th Edition, by Kozier
p. 558)
WATCH TICK TEST She can hear the ticking of my watch Able to hear ticking in both ears Normal
p. 558)
Sound is heard in both ears or is localized at the

WEBER’S TEST She is negative in the Weber’s test center of the head (Weber Negative) Normal
p. 558)
Air conducted hearing is greater than bone

RINNE’S TEST She is positive in the Rinne’s test conducted (Rinne Positive) Normal
p. 558)
IX. NOSE AND SINUSES
SHAPE, SIZE, COLOR AND FLARING There is no deviation in his nose. Symmetrical Symmetric and straight, Uniform in Color and No Normal
and straight. Uniform in color Flaring
p. 560)
REDNESS, SWELLING, GROWTHS AND Her nasal cavity is moist, no lesions or Mucosa is pink, clear, watery discharge, no Normal
DISCHARGE discharge. Mucosa is pink lesions
p. 561)
Her nasal septum is intact and in midline Nasal Septum intact and in midline
NASAL SEPTUM (Fundamentals of Nursing, 7th Edition, by Kozier Normal
p. 561)
Air moves freely through his nose Air moves freely as the client breathes through
NASAL CAVITIES the nares Normal
p. 560)
TENDERNESS, MASSES Not tender, no lesions Not tender, no lesions Normal

p. 560)
FACIAL SINUSES Not Tender Normal

(Frontal, Sphenoid, Ethmoid, Maxillary) Not Tender (Fundamentals of Nursing, 7th Edition, by Kozier
p. 561)
X. MOUTH AND OROPHARYX
Her lip is dry. She was able to purse his Uniform pink color, soft, moist, smooth in texture,
LIPS lips. symmetry of contour, ability to purse lips Normal
p. 563)
N/A Uniform pink color, moist, smooth, soft, glistening

BUCCAL MUCOSA and elastic texture N/A
p. 563)
TEETH Has dental carries. Has four decayed tooth (2 Healthy teeth are white, smooth,shiny, and Tooth decay was produced by
upper molars and 2 lower molars). properly aligned interaction of food with bacteria
(Fundamentals of Nursing, 9th Edition, by Potter & (Fundamentals of Nursing, 9th
Perry p. 823) Edition, by Potter & Perry p. 823)
N/A Pink gums, moist, firm texture to gums, no

GUMS retraction of gums N/A
p. 564)
No visible deformity and presence of veins. Central position, pinkish in color, moist, slightly
TONGUE rough, no lesions, raised papillae Normal
p. 564)
a. Base of tongue, mouth floor and Smooth tongue base with prominent veins Smooth tongue base with prominent veins Normal
frenulum (Fundamentals of Nursing, 7th Edition, by Kozier
p. 564)
b. Movement Moves freely and no tenderness Moves freely and no tenderness Normal
p. 564)
c. Nodules, lumps or excoriated areas Smooth with no palpable nodules Smooth with no palpable nodules Normal
p. 564)
Light pink, smooth, soft palate

SOFT AND HARD PALATE N/A Lighter pink, hard palate, irregular texture N/A
p. 565)
N/A Positioned in midline of soft palate

UVULA (Fundamentals of Nursing, 7th Edition, by Kozier N/A
p. 565)
N/A Pink in color and has smooth posterior wall

OROPHARYNX (Fundamentals of Nursing, 7th Edition, by Kozier N/A
p. 565)
Pink in color and smooth in texture, no discharge

TONSILS and of normal size N/A
N/A
p. 565)
XI. NECK
LYMPH NODES Not palpable Not palpable Normal

p. 568)
No deformities. It is in the midline Central placement in midline of neck and

TRACHEA spaces are equal in both sides. Normal
p. 568)
Not visible in inspection, glands ascend during

Not visible on inspection swallowing but not visible,Lobes may not be
THYROID GLAND Thyroid gland is moving upward when she palpated. If palpated, lobes are small, smooth,
swallows centrally located, and painless Normal
p. 569)
XII. THORAX AND LUNGS
The client thorax ratio is 1:2 Anteroposterior to transverse diameter in ratio of

POSTERIOR THORAX Her chest is symmetric 1:2; chest is symmetric Normal
(SHAPE AND SYMMETRY) (Fundamentals of Nursing, 7th Edition, by Kozier
p. 576)
There are no deformities in the spine of the Spine is vertically aligned; Spinal column is
client. Spine vertically aligned straight, right and left shoulders and hips are at
A. SPINAL ALIGNMENT same height Normal
p. 576)
B. SKIN ( TEMPERATURE, Uniformity in temperature Skin is intact; uniform temperature; No

TENDERNESS AND MASSES) No tenderness and masses upon palpation tenderness and masses Normal
p. 576)
C. RESPIRATORY EXCURSION Full symmetric excursion thumbs normally Full and symmetric chest expansion Normal
separate 3 to 5 cm (Fundamentals of Nursing, 7th Edition, by Kozier
p. 576)
Bilateral symmetry of vocal fremitus. Fremitus Bilateral symmetry of vocal fremitus; Fremitus is
D. VOCAL FREMITUS is heard at the space of the lungs. Fremitus heard most clearly at the apex of the lungs Normal
vibrate equally on both lungs and most clearly Fundamentals of Nursing, 7th Edition, by Kozier p.
at the apex of the lungs. 577)
E. PERCUSSION OF POSTERIOR The breathing pattern of the client is quiet, Resonate, except over scapula; Lowest point of
THORAX rhythmic, and effortless. resonance is at the diaphragm Normal
p. 577)
F. AUSCULTATION OF PERCUSSION Vesicular and bronchovesicular breath sounds

THORAX Vesicular and bronchovesicular breath sounds (Fundamentals of Nursing, 7th Edition, by Kozier Normal
p. 577)
ANTERIOR THORAX Quiet, rhythmic and effortless respiration Quiet, rhythmic and effortless respiration Normal
(BREATHING PATTERNS) (Fundamentals of Nursing, 7th Edition, by Kozier
p. 578)
A. SKIN (TEMPERATURE, Uniform in temperature, no tenderness and Uniform temperature; No tenderness and masses
TENDERNESS, MASSES) masses (Fundamentals of Nursing, 7th Edition, by Kozier Normal
p. 578)
B. RESPIRATORY EXCURSION Full and symmetric chest excursion Full and symmetric chest excursion Normal
p. 578)
Fremitus is normally decreased over heart and Fremitus is normally decreased over heart and
C. VOCAL FREMITUS breast tissue breast tissue Normal
p. 579)
Resonate down to the 6th rib at the level of the Resonate down to the 6th rib at the level of the
diaphragm but are flat over areas of muscle diaphragm but are flat over areas of muscle and
D. PERCUSSION OF ANTERIOR and bone, dull over heart and liver, tympanic bone, dull over heart and liver, tympanic on Normal
THORAX on stomach stomach
p. 579)
E. AUSCULTATION OF TRACHEA Bronchial and Tubular breath sounds Bronchial and Tubular breath sounds Normal
p. 579)
F. AUSCULTATION OF ANTERIOR Bronchovesicular and vesicular breath sounds Bronchovesicular and vesicular breath sounds
THORAX (Fundamentals of Nursing, 7th Edition, by Kozier Normal
p. 579)
XIII. HEART AND CENTRAL VESSELS
AORTIC AND PULMONIC AREAS No pulsations No pulsations Normal

Kozier p. 583)
TRICUSPID AREA No pulsations: No lift and heaves No pulsations: No lift and heaves Normal
p. 583)
Pulsations visible in 50% of adults and Pulsations visible in 50% of adults and palpable
palpable in most PMI in fifth LICS or medial to in most PMI in fifth LICS or medial to MCL; No lift
APICAL AREA MCL; No lift or leave or leave Normal
p. 583)
S1: Usually heard at all sites

S1: Usually heard at all sites Usually louder at apical area
Usually louder at apical area S2: Usually heard at all sites Usually louder at
S2: Usually heard at all sites Usually louder at base of the heart
AUSCULTATION OF AORTIC, base of the heart Systole: silent interval, slightly shorter duration
PULMONIC, TRICUSPID and APICAL Systole: silent interval, slightly shorter than diastole at normal heart rate Normal
AREA duration than diastole at normal heart rate Diastole: silent interval, slightly longer duration
Diastole: silent interval, slightly longer than systole at normal heart rate
duration than systole at normal heart rate S3 in children and young adults
S3 in children and young adults S4 in many adults
S4 in many adults (Fundamentals of Nursing, 7th Edition, by Kozier
p. 583)
PALPATION OF CAROTID ARTERIES Symmetric pulse volume, Full pulsation, Symmetric pulse volume, Full pulsation, thrusting Normal
thrusting quality, elastic arterial wall quality, elastic arterial wall
p. 584)
AUSCULTATION OF CAROTID No sound heard on auscultation Normal

ARTERIES No sound heard on auscultation (Fundamentals of Nursing, 7th Edition, by Kozier
p. 584)
Veins not visible (indicating right side of heart is

JUGULAR VEINS Veins not visible functioning normally) Normal
p. 584)
XIV. BREAST AND AXILLAE

Skin is uniform in color; skin is smooth and
Skin uniform in color intact; diffuse symmetric horizontal or vertical
SKIN OF THE BREASTS Skin is smooth and intact vascular pattern in light skinned people; striae Normal
and moles (Fundamentals of Nursing, 7th Edition,
by Kozier p. 589)
Rounded in shape, unequal in size, generally Rounded in shape, slightly unequal in size and
BREASTS INSPECTION symmetric generally symmetric Normal`
p. 589)
Round or oval and bilaterally the same; color Round or oval and bilaterally the same; color
varies widely, dark brown in color; Irregular varies widely, from light pink to dark brown;
AREOLA placement of sebaceous glands on the surface Irregular placement of sebaceous glands on the Normal
of the areola surface of the areola
p. 590)
Round, everted and equal in size, soft and Round, everted and equal in size, soft and
NIPPLES smooth, both nipples point at the same smooth, both nipples point at the same direction, Normal
direction, no discharge no discharge
p. 590)
AXILLARY, SUBCLAVICULAR AND No tenderness, masses and nodules No tenderness, masses and nodules
SUPRACLAVICULAR LYMPH NODES (Fundamentals of Nursing, 7th Edition, by Kozier Normal
p. 590)
No tenderness, masses, nodules, or nipple No tenderness, masses, nodules, or nipple

BREAST PALPATION discharge discharge Normal
p. 590)
NIPPLES PALPATION No tenderness, masses, nodules or nipple

No tenderness, masses, nodules or nipple discharge Normal
discharge (Fundamentals of Nursing, 7th Edition, by Kozier
p. 590)
XV. ABDOMEN
Unblemished skin; uniform color; Silver-white Unblemished skin; uniform color; Silver-white
ABDOMEN’S SKIN INTEGRITY striae or surgical scars striae or surgical scars Normal
p. 594)
ABDOMINAL CONTOUR Round abdomen Round abdomen is normal in shape if the Normal
abdomen is symmetrical (Fundamentals of
Nursing, 9th Edition, by Potter & Perry p. 587)
INSPECTION OF ENLARGED LIVER OR No evidence of enlargements of liver or spleen No evidence of enlargements of liver or spleen
SPLEEN (Fundamentals of Nursing, 7th Edition, by Kozier Normal
p. 594)
Symmetric contour Symmetric contour

SYMMETRY OF CONTOUR (Fundamentals of Nursing, 7th Edition, by Kozier Normal
p. 594)
Symmetric movements caused by respiration;

Symmetric movements caused by respiration; Visible peristalsis in very lean people; Aortic
ABDOMINAL MOVEMENTS Visible peristalsis in very lean people; Aortic pulsations in thin persons at epigastric Normal
pulsations in thin persons at epigastric (Fundamentals of Nursing, 7th Edition, by Kozier
p. 595)
VASCULAR PATTERNS No visible vascular pattern No visible vascular pattern Normal

p. 595)
Audible bowel sounds; Absence of arterial bruits;

ABDOMINAL SOUNDS Audible bowel sounds; Absence of arterial Absence of friction rubs Normal
bruits; Absence of friction rubs (Fundamentals of Nursing, 7th Edition, by Kozier
p. 595)
Tymphany over the stomach and gas filled Tymphany over the stomach and gas filled
PERCUSSION OF ABDOMEN bowels; dullness, especially over the liver and bowels; dullness, especially over the liver and
spleen or a full bladder spleen or a full bladder Normal
p. 596)
No tenderness; relaxed with smooth, consistent

ABDOMINAL PALPATION No tenderness; relaxed with smooth, tension Normal
consistent tension (Fundamentals of Nursing, 7th Edition, by Kozier
p. 596)
XVI. MUSCULOSKELETAL SYSTEM

Equal size on both sides of body Equal size on both sides of body
MUSCLE SIZE (Fundamentals of Nursing, 7th Edition, by Kozier Normal
p. 600)
MUSCLES AND TENDONS No contractures No contractures Normal

p. 600)
MUSCLES FOR FASCICULATIONS AND No Fasciculations and tremors No Fasciculations and tremors Normal
TREMORS (Fundamentals of Nursing, 7th Edition, by Kozier
p. 600)
MUSCLE TONICITY Normally firm Normally firm Normal

p. 600)
Equal strength on each body side Equal strength on each body side
MUSCLE STRENGTH (Fundamentals of Nursing, 7th Edition, by Kozier Normal
p. 600)
SKELETON No deformities No deformities Normal

p. 601)
PALPATION OF BONES No tenderness or swelling Normal

No tenderness or swelling (Fundamentals of Nursing, 7th Edition, by Kozier
p. 601)
JOINTS No swellings No swellings Normal

p. 601)
Joints move smoothly, no swelling, no

PALPATION OF JOINTS Joints move smoothly, no swelling, no tenderness, crepitation or nodules Normal
tenderness, crepitation or nodules (Fundamentals of Nursing, 7th Edition, by Kozier
p. 601)
Varies to some degree in accdordance with Varies to some degree in accdordance with
JOINTS RANGE OF MOTION person’s genetic make up and degree of person’s genetic make up and degree of physical
physical activity activity Normal
p. 601)

Physical Assessment of Ms. Baby Rose Bajar I. Appearance and Mental Status

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Physical Assessment of Ms. Baby Rose Bajar I. Appearance and Mental Status

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Physical Assessment of Ms.

Baby Rose Bajar

T: 35.6° (Oral) T: 37° (Oral)

HEIGHT 149 cm. Proportionate to Weight Abnormal

WEIGHT 39 kg. Proportionate to Height Abnormal

Proportionate; varies with lifestyle

SIGNS OF DISTRESS No distress noted No distress noted Normal

SIGNS OF HEALTH OR ILLNESS Healthy appearance Healthy Appearance Normal

ATTITUDE She’s cooperative Cooperative Normal

MOOD Appropriate to situation Normal

Varies from deep to light brown; Generally

EDEMA No Edema Normal

Highly Vascular and pink in light skinned

IV. SKULL AND FACE

Rounded ( normocephalic and symmetrical,

Smooth, uniform consistency, absence of

Symmetric, palpebral equal in size, symmetric

FACIAL MOVEMENT Symmetric Facial Movements Normal

AREAS OF TENDERNESS No tenderness Normal

THICKNESS OR THINNESS Relatively thick. Thick Hair Normal

VII. EYE STRUCTURES AND VISUAL ACUITY

Skin intact; no discharge; no discoloration; Lids

PALPEBRAL CONJUNCTIVA Shiny, smooth and light pink in color

Transparent, shiny and smooth, details of the iris

Black in color, equal in size, round and smooth

NEAR VISION Able to read newsprint Normal

DISTANCE VISION 20/20 in vision 20/20 vision on snellen ‘schart Normal

DIRECT REACTION Illuminated pupil constricts Normal

CONSENSUAL REACTION Non- illuminated pupil constricts Normal

LACRIMAL SAC No edema and tearing Normal

Both eyes coordinated, move in unison, with

Distal third contains hair follicles and glands, Dry

RESPONSE TO VOICE TONES Normal voice tone audible Normal

Sound is heard in both ears or is localized at the

Air conducted hearing is greater than bone

IX. NOSE AND SINUSES

TENDERNESS, MASSES Not tender, no lesions Not tender, no lesions Normal

FACIAL SINUSES Not Tender Normal

X. MOUTH AND OROPHARYX

N/A Uniform pink color, moist, smooth, soft, glistening

N/A Pink gums, moist, firm texture to gums, no

Light pink, smooth, soft palate

N/A Positioned in midline of soft palate

N/A Pink in color and has smooth posterior wall

Pink in color and smooth in texture, no discharge

LYMPH NODES Not palpable Not palpable Normal

No deformities. It is in the midline Central placement in midline of neck and

Not visible in inspection, glands ascend during

XII. THORAX AND LUNGS

The client thorax ratio is 1:2 Anteroposterior to transverse diameter in ratio of

B. SKIN ( TEMPERATURE, Uniformity in temperature Skin is intact; uniform temperature; No

F. AUSCULTATION OF PERCUSSION Vesicular and bronchovesicular breath sounds

XIII. HEART AND CENTRAL VESSELS

AORTIC AND PULMONIC AREAS No pulsations No pulsations Normal

S1: Usually heard at all sites

AUSCULTATION OF CAROTID No sound heard on auscultation Normal

Veins not visible (indicating right side of heart is

XIV. BREAST AND AXILLAE

No tenderness, masses, nodules, or nipple No tenderness, masses, nodules, or nipple

NIPPLES PALPATION No tenderness, masses, nodules or nipple

Symmetric contour Symmetric contour

Symmetric movements caused by respiration;

VASCULAR PATTERNS No visible vascular pattern No visible vascular pattern Normal