Area Assessed

Technique

Normal Findings

Actual Findings

Evaluation

swelling on the site was noted. Initial vital signs: T=38.1 C, PR=105bpm, RR=20cpm, BP=120/90mmHg.

Skin Color

Inspection

Soles and palms Moisture Temperature Texture Turgor Skin appendages a. Nails

Inspection Inspection/ Palpation Palpation Palpation Palpation

Light brown, tanned skin (vary according to race) Lighter colored palms, soles Skin normally dry Normally warm Smooth and soft Skin snaps back immediately

Light brown skin

Normal

Lighter colored palms, soles Skin normally dry Warm to Touch Smooth and soft Skin snaps back immediately

Normal Normal (+) Fever Normal Normal

Inspection

Transparent, smooth and convex

Transparent, smooth and convex

Normal

b.Nail beds

Inspection

Pinkish

Pale

Due to decreased blood flow Normal Normal

c.Nail base d.Capillary refill

Inspection Inspection/ Palpation

Firm White color of nail bed under pressure should return to pink within 2-3 seconds Distribution Evenly

Firm Returns within 2-3 seconds

e. Hair distribution f.Hair Color g.Hair Texture

Inspection

Evenly distributed

Normal

Inspection Inspection/ Palpation Inspection

Black Smooth

Black Smooth

Normal Normal

Eyes -Eyes

Parallel to each other

Parallel to each Other

Normal

-Visual Acuity

Inspection (penlight)

PERRLA- Pupils equally round react to light and accommodation Symmetrical in size, extension, hair texture and movement

PERRLA- Pupils equally round react to light and accommodation Symmetrical in size, extension, hair texture and movement

Normal

-Eyebrows

Inspection

Normal

-Eyelashes

Inspection

Distributed evenly and curved outward

Distributed evenly and curved outward

Normal

-Eyelids

Inspection

Same color as the skin Blinks involuntarily and bilaterally up to 20 times per minute

Same color as the skin Blinks involuntarily and bilaterally up to 18 times per minute Transparent with light pink color Color is white Transparent, shiny Black, constrict briskly Clearly visible Free of lesions, discharge of inflammation

Normal

-Conjunctiva

Inspection

Transparent with light pink color Color is white Transparent, shiny Black, constrict briskly Clearly visible Free of lesions, discharge of inflammation

Normal

-Sclera -Cornea -Pupils

Inspection Inspection Inspection

Normal Normal Normal

-Iris Ears -Ear canal opening

Inspection

Normal Normal

Inspection

Canal walls pink -Hearing Acuity Inspection Client normally hears words when whispered Smooth, symmetric with same color as the face Oval, symmetric and without discharge

Canal walls pink Client normally hears words when whispered Smooth, symmetric with same color as the face Oval, symmetric and without discharge

Normal

Normal Normal

Nose -Shape, size and skin color Nares

Inspection

Inspection

Normal

Mouth and Pharynx -Lips Inspection Pink, moist symmetric Glistening pink soft moist Slightly pink color, moist and tightly fit against each tooth Moist, slightly rough on dorsal surface medium or dull red Firmly set, shiny Light pink, dry, symmetric Glistening pink soft Moist Slightly pink color, moist and tightly fit against each tooth Moist, slightly rough on dorsal surface medium or dull red Firmly set, shiny With tooth decay Hard palate- domeshaped Soft Palate- light pink Lack of fluid intake Normal

-Buccal mucosa

Inspection

-Gums

Inspection

Normal

-Tongue

Inspection

Normal

-Teeth Inspection Firmly set, shiny -Hard and soft palate

Normal

Inspection

Hard palate- domeshaped Soft Palate- light pink

Normal

Neck -Symmetry of neck muscles, alignment of trachea Inspection Neck is slightly hyper extended, without masses or asymmetry Neck is slightly hyper extended, without masses or asymmetry Normal

Neck ROM Inspection Thyroid gland Thorax and Lungs Abdomen -Bowel sounds

Neck moves freely, without discomfort Rises freely with swallowing

Neck moves freely, without discomfort Rises freely with swallowing Clear breath sounds Clicks or gurling sounds occur irregularly and range from 20 per minute

Normal

Normal Normal Normal

Palpation Auscultation Clear breath sounds Auscultation Clicks or gurling sounds occur irregularly and range from 5-35 per minute

Extremities -Symmetry Inspection Symmetrical Symmetrical Normal

-Skin color

Inspection

Same with the color of other parts of the body

Same with the color of other parts of the body

Normal

-Hair distribution -Skin -Temperature

Inspection

Evenly distributed

Evenly distributed

Normal

Inspection Inspection

No lesions Warm to touch

No lesions Warm to touch

Normal Normal

-ROM

Inspection

Moves freely

Able to move but with assistance without discomfort

Due to body weakness

Neurology system -Level of consciousness Inspection Fully conscious, respond to questions quickly, perceptive of events Makes eye contact with examiner, hyperactive expresses feelings Fully conscious, respond to questions quickly, perceptive of events Makes eye contact with examiner, hyperactive expresses feelings Normal

Behavior and appearance

Inspection

Normal

with response to the situation

with response to the situation