PHYSICAL ASSESSMENT Date of Admission: June 15,2011 Date and Time of Assessment: June 29, 2011 General Appearance:

Looks weak and restless VITAL SIGNS:

BP- 110 70 PR-99 RR-26 T-36.50 C

AREA ASSESSED SKIN:

Color Texture Skin turgor Temperature Presence of edema Presence of skin lesion HAIR: Distribution Thickness or thinness Amount of body hair Texture and oiliness Presence of lice NAIL: Color Shape and texture

TECHNIQUE USED Inspection Palpation Palpation Palpation Palpation Palpation, inspection Inspection inspection Inspection Palpation Inspection Inspection Inspection and palpation Inspection Performed blanched test Palpation and inspection

NORMAL FINDINGS
Light to deep brown smooth, presence of hair Skin springs back when pinched Uniform; within normal No edema Freckles, some birthmarks Evenly distributed thick Variable Smooth and silky Without lice Pinkish Convex; angle of nail palate not exceed 160 Extremely thin Prompt return of pink or usual color Normocephalic and symmetrical

ACTUAL FINDINGS
Light to deep brown Rough, presence of hair Skin slows back when pinched Uniform; within normal No edema Freckles dome birthmarks Evenly distributed Thick Variable Rough and dry Without lice Pinkish Club

ANALYSIS

Normal Abnormal Abnormal Normal Normal Normal

Normal Normal Normal Abnormal Normal Normal Abnormal

Thickness Capillary refill HEAD: Size, shape and symmetry

Thick Prompt return of pink or usual color Normocephalic and symmetrical

Abnormal Normal

Normal

Presence of mass and nodules

Palpation

Facial features and movement

Inspection

Smooth, uniform in consistency, absence of nodules and mass Slightly asymmetric facial feature, symmetric facial movements Hair evenly distributed, symmetrical aligned; equal movement Equally distributed; curled slightly outward Intact skin, no discharge, no discoloration, eyelids closed symmetrically Bulbar conjunctiva is clear, with tiny capillaries visible, palpebral conjunctiva is pink, no discharge, no sclera is white No edema, no tenderness and no tearing Illuminated pupils constrict and when looking at near objects

Smooth, uniform in consistency, absence of nodules and mass Slightly asymmetric facial feature, symmetric facial movements Hair evenly distributed, symmetrical aligned; equal movement Equally distributed; curled slightly outward

Normal

Normal

EYES: Eyebrows

Inspection

Normal

Eyelashes

Inspection

Normal

Eyelids

Inspection

Normal

Conjunctiva and sclera

Inspection

Lacrimal gland

Inspection

Bulbar conjunctiva is clear, with tiny capillaries visible, palpebral conjunctiva is pink, no discharge, no sclera is white No edema, no tenderness and no tearing Illuminated pupils constrict and when looking at near objects farsightedness Air moves freely as the client breathes through the nares Clear, watery discharge, pink mucosa No tenderness

Normal

Normal

Pupil size PERRLA

Inspection

Normal

Visual activity NOSE: Patency of both nasal cavities

Inspection Air moves freely as the client breathes through the nares Clear, watery discharge, pink mucosa No tenderness

Normal

Occurrence of redness, swelling and discharge Facial sinuses

inspection

Normal

Palpation

Normal

MOUTH: Lips: Symmetry, color, tenderness

Inspection

Teeth and gums

Inspection

Position, color and texture of the tongue

Inspection

Symmetry of contour uniform pink color, soft moist, smooth texture Pink, moist and firm gums; 32 adult teeth, smooth, white, shiny tooth enamel Central position; slightly rough; pink color; no lesions, moves freely Color is the same as the color of the face, symmetrical auricles align in the outer cantus of the eyes Same with the body temperature within normal range (36.5C-37.5C) Able to hear clearly Short and mobile Not palpable

Reddish brown in color, dry lips

Crust, scales, that may result to nutritional deficiency or fluid deficit Dental decay

Present of tooth decay

Central position; slightly rough; pink color, no lesions, moves freely Color is the same as the color of the face, symmetrical auricles align in the outer cantus of the eyes Same with the body temperature within normal range (36.5C-37.5C) Able to hear clearly Short and mobile Not palpable

Normal

EARS: Auricles: Color, symmetry of size and position

Inspection

Normal

Temperature

Palpation

Normal

Auditory function NECK: Appearance and movement Lymph nodes THORAX: Chest shape Breath sound

Normal

Inspection Palpation

Normal Normal

Auscultation

Alignment of the spine

Inspection

Rounded Vesicular, bronchovesicular and bronchial sound Vertically aligned; (R) (L) shoulders and hips are at the same height

Rounded Vesicular, bronchovesicular and bronchial sound Vertically aligned; (R) (L) shoulders and hips are at the same height

Normal Normal

Normal

HEART: Cardiac rate and rhythm

Auscultation

UPPER AND LOWER EXTREMETIES Strength and tone

Temperature

Palpation

Can flex and extend arms and legs Same with body temp within normal range

Can flex and extend arms and legs Same with body temp within normal range

Normal

Normal