Area Technique Normal Abnormal Actual Remarks

Assess Use findings findings findings

General Conscious, The patient The

Appearanc coherent is patient's
e conscious conscious
and and
responsive coherent
to stimuli. state
The suggests
patient's intact
level of cognitive
consciousn function.No
ess rmal
appears findings in
normal, as consciousn
evidenced ess and
by their coherence
ability to are
maintain reassuring
wakefulnes indicators
s and of the
awareness. patient's
The patient overall
is coherent mental
in speech status.The
and se
communica observatio
tion, ns
demonstrat contribute
ing clear to a
and logical positive
expression assessmen
t of the
patient's
general
appearanc
e and
mental
well-being

Head,eyes,
ears,nose ,
throat

Chest,lung
s

Heart
Abdomen Flat,soft , The The
non tender abdomen abdomen
is observed presents
to be flat in with normal
appearanc contour
e, without and
any texture,
noticeable suggesting
protrusions absence of
or underlying
distension. abnormaliti
Upon es such as
palpation, fluid
the accumulati
abdomen on or
feels soft to masses.So
the touch, ftness of
indicating the
normal abdomen
muscular indicates
tone and normal
lack of muscle
rigidity.The tone and
patient relaxation,
does not without
exhibit any evidence of
signs of involuntary
discomfort guarding or
or pain rigidity.Abs
upon ence of
palpation, tenderness
with no upon
areas of palpation is
tenderness a
noted reassuring
sign of
normal
visceral
and
peritoneal
sensation.

Extremities CRT <2: A Edema Edema: Edema:

capillary Swelling is The
refill time observed presence
(CRT) of in one or of edema
less than 2 both in the
seconds extremities, extremities
characteriz suggests
ed by an potential
increased underlying
volume of issues
interstitial such as
fluid in the venous
tissues. insufficienc
The y, heart
swelling failure,
may be kidney
pitting or disease, or
non-pitting lymphatic
and can obstruction
affect the . Further
hands, assessmen
arms, legs, t is needed
or feet.CRT to
<2s: determine
Capillary the cause
refill time is and
assessed appropriate
by applying manageme
pressure to nt of the
a fingertip edema.CR
or toe and T <2s:
observing Normal
the time it capillary
takes for refill time
the color to indicates
return. A adequate
CRT of blood flow
less than 2 to the
seconds is extremities,
considered suggesting
normal, intact
indicating peripheral
adequate circulation.
peripheral This finding
circulation is
CRT <2s: reassuring
Capillary and
refill time is suggests
assessed no
by applying immediate
pressure to vascular
a fingertip compromis
or toe and e in the
observing extremities.
the time it
 takes for
the color to
return. A
CRT of
less than 2
seconds is
considered
normal,
indicating
adequate
peripheral
circulation.

Skin Pallor, Pallor: The Pallor:

jaundice,cy skin Pallor may
anosis appears suggest
unusually anemia,
pale, circulatory
indicating issues, or
reduced shock.
blood flow Further
or assessmen
decreased t and
hemoglobi investigatio
n n are
levels.Jaun needed to
dice: determine
Yellow the
discoloratio underlying
n of the cause and
skin and appropriate
sclerae manageme
(whites of nt.Jaundice
the eyes), : Jaundice
resulting often
from indicates
elevated liver
levels of dysfunction
bilirubin in or
the excessive
bloodstrea breakdown
m.Cyanosi of red
s: Bluish blood cells.
discoloratio It requires
n of the thorough
skin or evaluation
mucous of liver
membrane function
s, and
indicating potential
 inadequate causes
oxygenatio such as
n of the liver
blood. disease,
hemolysis,
or bile duct
obstruction
.Cyanosis:
Cyanosis is
a sign of
hypoxia
and can
result from
respiratory
or
cardiovasc
ular
problems.
Prompt
assessmen
t and
interventio
n are
necessary
to address
the
underlying
cause and
improve
oxygenatio
n

BP: 110/70 CR:99

TEMPERATURE: 36.5 RR: 25