Revised Cholelithiasis BSN 4A Group 3 2

Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY

Cabanatuan City, Nueva Ecija, Philippines
ISO 9001:2015 CERTIFIED
Contact No. (044) 463-0226

Transforming Communities through Science and Email: nursing@neust.edu.ph
Technology www.neust.edu.ph
COLLEGE OF NURSING
PHYSICAL ASSESSMENT
HEAD TO TOE PHYSICAL ASSESSMENT
Body Parts Normal Findings Actual Findings Result

Skull - Symmetrical - Symmetrical Normal
- Smooth - Smooth
- Firm - No tenderness
upon
palpation
Scalp - Symmetrical - Symmetrical Normal
- White with no - Hite with
pinkish tone no pinkish
- Free from tone
flakes and - Free from
redness flakes and
- Free from lesions redness
- Free from
lesions
Hair - Hair color - Hair color Normal
varies from varies from
black to white black to white
- Fine texture - Fine texture
Face - No facial - Pale Normal
asymmetry
- Can move facial
muscles at will
Eyes - Palpebral and - No swelling Normal
bulbar and conjunctiva
conjunctiva pinkish
pinkish - No colored
- No colored spots or halo on
spots or halo on vision
vision
Ears - Non-tender - No Normal
auricle deformities
- No deformities and discharges
and discharges - No masses upon
noted palpation
- No masses upon
palpation
Contact No. (044) 463-0226

COLLEGE OF NURSING
Nose and - No symmetric - No symmetric Normal
Paranasal
Sinuses
Contact No. (044) 463-0226

COLLEGE OF NURSING
- Color the same - Color the same
as the as the
surrounding skin surrounding skin
- Maxillary and - Maxillary and
frontal frontal
sinuses non- sinuses non-
tender tender
- Mucosa dry, with - Mucosa dry,
septum in the with septum
midline in
the midline
Mouth - lips color: - slightly reddish Normal
reddish, no lips, smooth,
lesions, symmetrical
symmetrical and no lesions
and smooth - teeth are
- tongue is on the whitish with no
midline, moist, decay
and color pink;
can stick out
the tongue
- teeth are white,
smooth surfaces,
and edges with
shiny enamel; no
tooth decay
Neck - lymph nodes - no swelling Normal
are round and observed
movable, no - no masses
swelling - Full ROM
- no masses - symmetrical
- full ROM neck muscles
- symmetrical - trachea is
neck muscles located on the
- trachea is midline
located on the - thyroid is palpable
midline and soft
- thyroid is palpable
and soft
Chest - No abnormal - Normal heart Abnormal
heart sounds sound and
- Regular respiratory Cyst on an ovary can impact the
respiratory rate rate natural release of hormones in
Contact No. (044) 463-0226

COLLEGE OF NURSING
- Symmetric - Symmetric the body, this hormone
- No visible with no visible fluctuations will cause the breast
deformities deformities tissue to feel swore and tender.
- Guarding,
tenderness in
the breast
Contact No. (044) 463-0226

COLLEGE OF NURSING
- Breast is - Breast is
symmetric and symmetric
no pain and no pain
Thorax - Pulsation of - Pulsation is Normal
the apical visible and no
impulse visible abnormal
- -No lift or heaves heart sounds
- -No abnormal
heart sounds
Abdomen - Symmetric - Flat Abnormal
- No striae noted - Striae noted
- Good bowel - Flank not full Pain and tenderness in the right
sounds - All quadrants lower quadrant of the abdomen
- No pain moving symmetry may be related to the
- Non-tender with breathing appendicitis, which branches
- Hypoactive bowel off to the RLQ from the large
sound intestine. Inflammation in the
- Guarding, appendix is a common cause of
tenderness at RLQ right lower abdominal pain.
- Dull abdominal
pain
Upper - No cyanosis, - No cyanosis, Normal
Extremities redness and redness and
swelling swelling
- No deformities - No deformities,
- No swelling swelling,
- Full range masses and
of motion lumps noted
- No masses and - Full range
lumps notes of motion
Lower - Symmetrical - Symmetrical Abnormal- ovaries and legs
Extremities - No masses and - No masses share some nerves, pain in the
lumps noted and lumps lower back and thighs could also
- No ulcerations, noted arise from pressure put on the
varicosities - Tenderness pelvic nerves by an ovarian cyst.
and tenderness and pain in
- Normal lower back
peripheral pulses and thighs
- Full range of - Motion
motion reserved
Skin - Uniform in color - Normal color of Normal
- Light the skin
colored - palm is light
Contact No. (044) 463-0226

COLLEGE OF NURSING
palms colored
- Nail bed pink - Bed of the nail is
- Skin is intact pink
- Intact skin
Contact No. (044) 463-0226

COLLEGE OF NURSING
- Smooth, warm weather can be a symptom of
and dry to underlying medical conditions.
touch
Genital Area - No bulging anus - No bulging anus, Normal
- Free of lesions, warts,
lesions, warts and abnormal
and discharge
malodorous
discharge
Contact No. (044) 463-0226

COLLEGE OF NURSING
Contact No. (044) 463-0226


Revised Cholelithiasis BSN 4A Group 3 2

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Revised Cholelithiasis BSN 4A Group 3 2

Uploaded by

Copyright:

Available Formats

Republic of the Philippines

NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY

Contact No. (044) 463-0226

HEAD TO TOE PHYSICAL ASSESSMENT

Body Parts Normal Findings Actual Findings Result

Contact No. (044) 463-0226

Contact No. (044) 463-0226

Contact No. (044) 463-0226

Contact No. (044) 463-0226

Contact No. (044) 463-0226

Contact No. (044) 463-0226

Contact No. (044) 463-0226

Contact No. (044) 463-0226

You might also like