Manzanillo, Sheena Lhane B.

BSNS1C
Check in Activity: Observation Skills
REGIONS FINDINGS
There are no visible physical flaws. The BMI is
1. OVERALL APPEARANCE within limits. The weight is 51 kilograms and
height are 5’3.
2. LEVEL OF CONSCIOUSNESS The patient is aware, alert and responds quickly.
The features of the face are symmetrical. No
3. FACIAL FEATURES AND EXPRESSIONS drooping. No unintentional movements. Ease an
equal action.
The patient is cooperative and have appropriate
4. DEMEANOR AND AFFECT
behavior.
The posture is upright. The spine is straight and
5. POSTURE
the shoulders are in proportion.
6. GAIT The gait is balanced and smooth.
7. MOTOR ACTIVITY The patient movement is coordinate/sync.
The patient can speak clearly with the use of
8. SPEECH
simple words.
The skin is normal color, warm in temperature and
smooth in texture. Her skin turgor is elastic, and it
9. SKIN COLOR AND LESION
returns to its resting position quickly. No lesions
can be found.
The patient appears to be well dressed; she had no
10. DRESS AND PERSONAL HYGIENE
bad odor. The nails are clean and short.
The skull and body are in symmetrical. There are
no lumps in the head, and the scalp does not have
11. SKULL
unusual texture. During palpation, there is no
tenderness.
 The face is symmetrical. No unintentional
12. FACE movements. During palpation, there is no
tenderness.
The eyes are the same size. There are no swelling
eyelids. The sclera is white and the conjunctiva is
13. EYE STRUCTURES
pinkish. The pupil is 3mm in diameter, round, and
adapts to light. The lacrimal glands are moist.
At 20 feet, the patient can clearly see and read
14. VISUAL ACUITY
Snellen chart.
The ears are all the same size. No redness or
15. EARS swelling as well as any drainage issues. Respond to
whisper test correctly.