COLEGIO DE STA. LOURDES OF LEYTE FOUNDATION, INC.

TABONTABON, LEYTE
Brgy. 1 Quezon, Tabontabon, Leyte

Name: RHEYLANE KIM M. BENZON Course/Yr.&Sec: BSN 1-E Group 2 Date:07/24/2022

Instructor: MRS. HASSEN ZABALA Subject: RLE 101 Score:
CLIENT’S FINDINGS ON THE
ASSESSMENT OF THE HEAD TO TOE
Name of Patient: RUCHELLE BALANO Age: 19 YEARS OLD Birthdate: FEBRUARY 26, 20SS03

ASSESSMENT CLIENT’S FINDINGS

ASSESSMENT OF HEAD
 SKULL ▪ The patient has no masses and no involuntary muscle
movement.
▪ The patient’s cranial nerves V and VII are intact.
▪ The patient’s head movements were coordinated,
smooth, and with no discomfort. The head laterally
flexes, laterally rotates and was able to hyperextend.

 FACE ▪ The head is symmetrical, with a round face shape, and

face positions in the center. The color or skin tone of
her face is the same as her overall body.
▪ The patient was able to perform different expressions
such as smile, frown, and pout. She can move facial
muscles as will.

 SKIN ▪ The client’s skin returned to its previous state

immediately when I pinched.
▪ The client's skin color is tan.
▪ Skin type is normal and temperature.

 HAIR ▪ The patient’s hairs were also strongly intact with her
head. The nurse has not seen some hair lice.
▪ However, there were also small number of dandruffs
in the patient’s scalp.

 NAILS ▪ The client’s cuticles around the nails are generally

smooth, undamaged, and free of irritation, the nails
are translucent and convex.
▪ The nail bed of my client is color pink with translucent
white tips.

ASSESSING THE EYES

 EYEBROWS ▪ The client’s eyebrow was symmetrical and parallel to
 one another.
▪ Client’s eyebrow is color black.

 EYELASHES ▪ The patient’s eyelashes are symmetrical, evenly

distributed, and black in color.

 EYES ▪ The patients near vision are normal. She was able to
read the given newsprint at a distance of 14 inches.
There were no signs of hyperopia or presbyopia
present.
▪ The patient was able to identify correctly the different
colors given to her.
▪ The patient’s peripheral vision is normal in both eyes.
She was able determine when an object comes to sight
in all 4 visual fields.
▪ The patient’s extraocular muscle is normal. She was
able to move it into the six cardinal gaze positions.
Her both eyes move in concert such as when the left
eye moves left, the right eye moves left to a similar
degree.
▪ The patient’s corneal light reflex is centered on both
pupils. In both of her eyes, the pupils constrict when
the penlight went through it.
▪ In the external structure of the eye, the patient’s eye
color is black and it is normally aligned
▪ The patient’s lacrimal gland has no tenderness and no
regurgitation from the nasolacrimal duct.
▪ The patient’s bulbar and palpebral conjunctiva were
both pinkish to red in color. It was moist and no
foreign objects were seen.
▪ The patient’s sclera is white in color but there were
yellowish discoloration and as per patient she
verbalized it was maybe because of her insomnia. As
for lesions, there were no signs of it in her sclera
▪ The patient was able to blink when the cornea is
touched by a cotton wisp
▪ The patient’s iris is symmetrical along with her pupil
▪ In both of her eyes, the pupils constrict when the
penlight went through it.

ASSESSING THE EAR AND HEARING
▪ The external structure of the ear was normal. It was
symmetrical and the upper helix of the ear is aligned
with the edge of the eyebrow.
▪ There was no tenderness in both of the client’s ear
and its color was the same with her entire body.
▪ There were no foreign objects inside of her ears just
some hairs and small amount of cerumen with brown
color

ASSESSING THE NOSE AND SINUSES
ASSESSING THE MOUTH AND
OROPHARYNX
▪ The patient’s tympanic membrane was normal. It was
translucent, in neutral position, and gray in color
▪ In performing gross hearing test, the patient was able
to repeat the word the nurse whispered in both of her
ears.
▪ In Weber test, the air conduction is greater than the
bone conduction in her frontal bone, which is normal.
▪ Even though the patient’s Weber test is negative and
normal, the nurse still proceeded in performing the
Rinne test for assurance and verification. In the
patient’s Rinne test, the air conduction was still
greater than the bone conduction which is normal.
▪ In performing the Romberg test, the client was able to
maintain her balance with her eyes opened. However,
when the client’s eyes were closed, she no longer
maintains her balance.
▪ The external structure of the patient’s nose is
symmetrical and positioned in the center of the face.
The color of the patient’s nose is the same as the color
of her entire face and body.
▪ In the patency test of the nasal passages, the air moves
freely as the client breathes through the nares.
▪ In the patient’s internal structure of the nose, the
mucosa is pink, there were no lesions and nasal
septum were intact and in middle, and with no
tenderness.
▪ As for the patient’s sinuses using a penlight, there
were no tenderness and there was a glow of red light
in both of her maxillary and frontal sinuses.
▪ The patient’s mouth is symmetrical, with pale lips, and
she was able to purse and move her lips.
▪ The patient’s oral mucosa such as the gingiva and
cheeks were pinkish in color
▪ There were no lesions inside each cheek. The gums
were pinkish in color and no bleeding nor lesions
▪ The teeth were slightly yellowish. Overall, her teeth in
the upper section were 10 and 12 in the lower section.
▪ The patient’s tongue is pinkish and rough with white
taste buds on the surface. There were no lesions nor
varicosities on the ventral surface. She was also able
to move her tongue freely and with strength
▪ The patient’s uvula is positioned in the center and
pinkish in color. There were no swelling nor lesion
spotted. The patient’s uvula moved upward and
downward when she was asked to say “ah”.
▪ The patient’s gag reflex is present which is elicited
through the use of a tongue depressor.
ASSESSING THE NECK
 POSTERIOR APPROACH
 ANTERIOR APPROACH
ASSESSING THE SENSORY
NEUROLOGICAL SYSTEM
 LANGUAGE
 ORIENTATION
 ATTENTION SPAN
 LEVEL OF CONSCIOUSNESS
CRANIAL NERVES
CN I (OLFACTORY)
CN II (OPTIC)
CN III (OCULOMOTOR), CN IV
(TROCHLEAR) & CN VI (ABDUCENT)
CN V (TRIGEMINAL)
▪ In the patient’s external structure of the neck, it was
symmetrical, with no visible mass or lumps. The
thyroid gland was not visible which is normal. During
swallowing, the patient’s gland did not ascend and it
is normal for females.
▪ There was no tenderness on the patient’s different
posterior nodes.
▪ There was no tenderness on the patient’s anterior
nodes.
▪ The client has told her name, where she is at the
moment, and what day and time it is.
▪ The client was able to answer all of the questions I
asked her about people, places, dates and times.
▪ The fact that the client answered the questions
correctly showed that she was able to focus.
▪ The client’s level of consciousness was given 15 points
because she answered all of my questions correctly.
▪ The client’s nostrils are normal and she has the ability
to identify the smell of common substances.
▪ The patients near vision are normal. She was able to
read the given newsprint at a distance of 14 inches.
There were no signs of hyperopia or presbyopia
present.
▪ The patient’s extraocular muscle is normal. She was
able to move it into the six cardinal gaze positions.
Both eyes move in concert such as when the left eye
moves left, the right eye moves left to a similar degree.
▪ The patient’s corneal light reflex is centered on both
pupils. In both of her eyes, the pupils constrict when
the penlight went through them.
▪ The client’s jaw can move from side to side and it’s
normal.
▪ The client can identify what part of her body I touched
while closing her eyes.
▪ Her cranial reflexes are normal.
CN VII (INTERMEDIATE)
CN VIII (VESTIBULOCHOCHLEAR)
CN IX (GLOSSOPHARYNGEAL) AND
CN X (VAGUS)
CN XI (ACCESSORY)
CN XII (HYPOGLOSSAL)
DISCRIMINATORY SENSATION TEST
REFLEXES
 BICEPS REFLEX
 TRICEPS REFLEX
 BRACHIORADIALIS REFLEX
 PATELLAR REFLEX
 ACHILLES REFLEX
ASSESSING THE
MUSCULOSKELETAL SYSTEM
▪ Clients can make faces, such as smile, frown, or
whistle.
▪ The client’s taste test is normal she can identify the
food whether it’s sweet, salty, and sour.
▪ In the Weber test, the air conduction is greater than
the bone conduction in her frontal bone, which is
normal.
▪ The way the client talk, swallows, and coughs are
normal.
▪ The patient’s uvula is positioned in the center and
pinkish in color. There was no swelling or lesion
spotted. The patient’s uvula moved upward and
downward when she was asked to say “ah”.
▪ The patient’s gag reflex is present which is elicited
through the use of a tongue depressor.
▪ The client’s shoulder can be against the resistance
and also in moving her head side to side.
▪ The client can recite the “d, l, n, t”
▪ The client can move her tongue side to side.
▪ The client can identify what object I put in her hand
while closing her eyes.
▪ The client can identify what I draw in her palm while
closing her eyes.
▪ The client can identify what part of her body I
touched.
▪ I give the client a scale of +2 because she responses
normally.
▪ I give the client a scale of +2 because she responses
normally.
▪ I give the client a scale of +2 because she responses
normally.
▪ I give the client a scale of +2 because she responses
normally.
▪ I give the client a scale of +2 because she responses
normally.
  WALKING GAIT ▪ The client stands up straight walks steadily, and
swings each arm in the opposite direction without help
while keeping their balance.
 STANDING ON ONE FOOT ▪ The client couldn’t stand, still for five seconds because
WITH EYES CLOSED she fell in three seconds.

 TANDEM WALK ▪ The client can walk straight while doing tandem walk.

 HEEL AND TOE WALK ▪ The client can walk straight line while doing heel and
toe walk.

 DEEP KNEE BEND ▪ The client can do deep knee bend.

 HOPPING ▪ The client can hop both side of feet while hopping in
straight line.

 ROMBERG TEST ▪ The client can stand straight while open her eyes and
closed eyes.

ASSESSING COORDINATION ▪ The client could quickly switch from supine and
pronate and stop when I told her to.
▪ The client rhythmic toe topping is normal in both feet
▪ The client can heel run both side of her feet
▪ The client was able to touch her nose over and over,
even with her eyes closed
▪ The client did fine on this test because she was able to
do it right and put her fingers in the right place
▪ The client was also able to do this test correctly and
touch her fingers in both her hands and her feet.
▪ The client was able to perform this test appropriately.
MEASUREMENTS
 ACROMION TO TIP OF THE  38 CM.
MIDDLE FINGERS
 ANTERIOR SUPERIOR ILIAC  48 CM
CREST TO MEDIAL
MALLEOLUS
 CIRCUMFERENCE OF  18 CMs
FOREARM
 CIRCUMFERENCE OF UPPER  22 CM
ARM
 CIRCUMFERENCE OF THIGHS  24 CM
 CIRCUMFERENCE OF CALVES  20 CM
ASSESSING CLIENT’S ROM ▪ The client can actively move her muscle motion
against the full resistance and it’s normal. I give my
client a scale of 5.

 TEMPOROMANDIBULAR ▪ The client can able to move her jaw from side to side
and can flex, extend, protrude, and retract the jaw.
  NECK ▪ The client’s neck can flex, extend, hyperextend, bend
her neck literally, and can rotate her neck from side to
side.
 THORACIC AND LUMBAR ▪ The client can able to bend the waist, can stand
SPINE upright, hyperextend (bend backward), bend laterally,
and can rotate the waist from side to side.

 SHOULDER ▪ The client’s shoulder can move the arm forward &
backward, can abduct & adduct and can rotate
internally & externally.

 UPPER ARM AND ELBOW ▪ The client can bend, extend, supine and pronate her
elbow.

 WRIST ▪ The client’s wrist can flex, extend, hyperextend, and

can move from side to side.

 HANDS AND FINGERS ▪ The client’s finger can abduct & adduct, flex, extend,
hyperextend, and palmar adduction.

 HIPS ▪ The client’s hips can able to extend the leg straight,
flex the knee, abduct, adduct, and move rotationally
the hip from internal to external.

 KNEE ▪ The client’s knee can able to flex and extend.

 ANKLES AND FEET ▪ The client can able to do dorsiflexion and plantar
flexion, internal, external abduction, and adduction.

ASSESING THE CHEST AND LUNGS

 INSPECTION  The chest looks normal from the outside.
 No discoloration has been seen.
 There are no signs of trouble in breathing.
 Patient is breathing normally.

 PALPATION  It is in the middle.

 There is symmetry in the way the chest grows.
 When the chest wall is touched, neither tenderness nor
masses are felt.

 PERCUSSION  Resonance is normal when you tap on any part of the

lung.

 AUSCULTATION  All of the lobes can hear clear lung sounds. No sounds
like stridor, Ronchi, or wheezing have been heard.

 CHEST EXCURSSION  The space between the two thumbs or the chest
expansion is 2 to 5cm.

ASSESSING THE BREAST AND

AXILLAE
  INSPECTION OF THE BREAST  The patient has a small symmetrical breast.
 The nipples are pinkish and no signs of discharge.
 No swelling or redness can be seen.
 No presence of breast lump.

 INSPECTION OF THE  The skin color in the axillary is fair and there are
AXILLARY small hairs present.

 PALPATIONOF THE BREAST  There is no tenderness or swelling on the breast.

 No flattering, no dimpling was observed.
 No discharge notices on the nipple during palpation.
 The nipple is elastic in a normal way.

 PALPATION OF THE AXILLARY  No tenderness, nodules or masse were observed.

 PALPATION OF THE LYMPH  No tenderness, nodules, or masses were observed.

NODES
ASSESSING THE HEART AND
VASCULAR SYSTEM
 INSPECTION  No scar can be seen. No problem with the chest. Skin
is the same in color. Skin hair is spread out evenly.
There is no swelling in the jugular vein (JVD). There
is no edema present. Fingers and toes are still able to
move and feel.

 PALPATION  Skin is warm and dry. Pulses can be felt in all

peripheral arteries and carotid arteries, and there are
the same on both sides. When the carotid arteries are
felt, they have a pulse force of 2+. Precordium has
two equal parts. In the fifth intercostal space between
the fifth rib and the fifth clavicle, you can find and feel
the apical pulse.

 AUSCULTATION  Blood flow is quiet in the carotid artery. There were

no sounds from the carotid artery.
 The S1 and S2 sounds of the heartbeat in a steady
rhythm.

ASSESSING THE ADBOMEN

 INSPECTION  The abdomen is soft, even, and not sensitive. No
visible masses. There isn’t any stretching and bulging.
There are no wounds or scars that can be seen. There
are no stretch marks seen. There are no spots on the
wall of the abdomen. Skin color is fair. The hair is
spread out evenly. No strange movement was seen.
The belly button is in the right place. No change in
color in the belly button.

 PALPATION  There were no masses or tenderness seen. The liver

can be felt. You can’t feel the spleen.

 AUSCULTATION  There were no poop sounds. No sounds were heard in

any artery. No strange sounds were heard in any of
the four corners.