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    Skin:: Area Assessed Techniques Used Normal Findings Actual Findings Analysis

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    Charis Paroginog
    The skin assessment found the patient to have normal findings except for some flat and raised moles, and rashes on the upper chest and inguinal area. The head, eyes, nose, mouth, ears, neck, thorax, heart, and extremities were also found to be normal except for slightly asymmetric facial features. Breath sounds were clear.

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    Skin:: Area Assessed Techniques Used Normal Findings Actual Findings Analysis

    Uploaded by

    Charis Paroginog
    49 views7 pages
    The skin assessment found the patient to have normal findings except for some flat and raised moles, and rashes on the upper chest and inguinal area. The head, eyes, nose, mouth, ears, neck, thorax, heart, and extremities were also found to be normal except for slightly asymmetric facial features. Breath sounds were clear.

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    adam mayuga bakla! pretty sexy . macho palito

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    Area Assessed

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    The skin assessment found the patient to have normal findings except for some flat and raised moles, and rashes on the upper chest and inguinal area. The head, eyes, nose, mouth, ears, neck, thorax, heart, and extremities were also found to be normal except for slightly asymmetric facial features. Breath sounds were clear.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    49 views7 pages

    Skin:: Area Assessed Techniques Used Normal Findings Actual Findings Analysis

    Uploaded by

    Charis Paroginog
    The skin assessment found the patient to have normal findings except for some flat and raised moles, and rashes on the upper chest and inguinal area. The head, eyes, nose, mouth, ears, neck, thorax, heart, and extremities were also found to be normal except for slightly asymmetric facial features. Breath sounds were clear.

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    AREA ASSESSED SKIN: Color

    TECHNIQUES USED

    NORMAL FINDINGS

    ACTUAL FINDINGS

    ANALYSIS

    inspection

    light to brown

    deep Light to brown

    deep Normal

    Texture

    palpation

    smooth, presence Smooth, of hair presence of hair

    normal

    Skin turgor

    palpation

    skin springs back Skin springs back normal immediately when immediately pinched when pincheduniform within Uniform within Normal normal range normal range no edema no edema Normal

    Temperature

    palpation

    presence of edema presence lesion of

    palpation

    skin palpation

    some birth marks, no lesion, with Normal some flat and flat mole raised moles some birth marks, Rashes on upper Abormal some flat and chest and raised moles inguinal area balat sa kanang kamay/pasa left leg

    presence rashes

    of

    skin inspection

    HAIR: Color distribution inspection inspection brown or black evenly distributed Black Normal

    evenly distributed Normal

    hair thickness and inspection thinness

    either very little or Great number of Normal great deal of body body and scalp and scalp hair hair thick or thin hair

    texture and oiliness presence of lice NAIL: Color Shape and texture

    palpation inspection

    smooth and silky without lice

    Smooth and silky without lice

    Normal Normal

    Inspection Inspection palpation Inspection Performed blanched test

    Pinkish

    Pinkish

    Normal

    and Smooth, convex in Smooth, convex Normal curvature, long in curvature, long Extremely thin Extremely thin Normal Normal

    Thickness Capillary refill

    Prompt return of Returns pink or usual color immediately

    HEAD: Size, shape symmetry and Inspection Rounded (normocephalic)sy mmetric, with frontal, parietal and occipital prominences and 35-45 cm Rounded Normal (normocephalic) symmetric with frontal, parietal and occipital prominences 45 cm Normal

    Head circumference

    Inspection palpation

    Presence of mass or Inspection nodules

    Smooth, uniform in consistency, absence of nodules and mass.

    Smooth, uniform Normal in consistency, absence of nodules and mass.

    Facial Inspection features(symmetry of structures)

    Symmetric or Symmetric naso- Normal slightly labial folds asymmetric facial features, palpebral fissures equal in size, symmetric naso-

    labial folds Head movement inspection Can lift head slightly and turn them from side to side Can lift head Normal slightly and turn them from side to side

    EYES: Eyebrows: distribution alignment hair Inspection and Hair evenly distributed, skin intact, eyebrows symmetrically aligned Hair evenly Normal distributed, skin intact, eyebrows symmetrically aligned

    Eyelashes: evenness inspection of distribution and direction of curl

    Equally Equally Normal distributed, curled distributed, slightly outward. curled slightly outward. Skin intact, discharge, discoloration no Skin intact, no Normal no discharge, no discoloration Bulbar Normal conjunctiva is clear with tiny capillaries visible, Palpebral conjunctiva is pink, no discharge, sclera is white

    Eyelids: surface Inspection characteristics

    Conjuctiva and sclera

    Inspection

    Bulbar Conjunctiva is clear with tiny capillaries visible, Palpebral conjunctiva is pink, no discharge, sclera is white

    Lacrimal gland, Inspection nasolacrimal duct palpation

    and No edema, no No edema, no Normal tenderness and no tenderness and tearing no tearing Round, black, Round, black, Normal

    Pupils: color, shape Inspection

    and equality Response to light Inspection

    equal in size

    equal in size

    Illuminated pupils Illuminated pupils Normal constrict constrict

    NOSE: Symmetry, shape and Inspection color Symmetrical, Symmetrical and normal straight and uniform in color uniform in color Pink mucosa, no discharge and swelling free of lesion No tenderness Pink mucosa, no Normal discharge and swelling free of lesion No tenderness Normal

    Occurrence of Inspection redness, swelling and discharge

    Facial sinus MOUTH: Lips: Symmetry, tenderness

    Palpation

    color, Inspection palpation

    and Symmetry of contour uniform pink color, soft, moist, smooth texture

    Symmetry of Normal contour uniform pink color, soft, moist, smooth texture

    Gums: Color and moisture Inspection Pink, moist and Pink, and moist firm Normal

    Position and color

    Inspection

    Central position, Central position, Normal pink in color, pink in color, slightly round slightly round

    Smell

    Inspection

    No foul odor

    No foul odor

    Normal

    EARS: Auricles: Color, symmetry of size and position Inspection Color is same as the color of the face, symmetrical auricles align in the outer canthus of the eyes Color is same as Normal the color of the face, symmetrical auricles align in the outer canthus of the eyes

    Texture, elasticity Palpation and areas of tenderness

    Mobile, firm, no tenderness, pinna recoils after it is folded Same with body temperature within normal range (36.5C37.5C) Able to clearly

    Mobile, firm, no Normal tenderness, pinna recoils after it is folded Same with body Normal temperature within normal range (36.5 C)

    Temperature

    Palpation

    Auditory function

    Inspection

    hear Able to clearly

    hear Normal

    NECK: Appearance movement THORAX: Color Inspection Light to brown Rounded Less than deep Brown Normal and inspection Short and mobile Short and mobile Normal

    Chest shape Chest circumference

    Inspection Inspection

    Rounded head 49 cm

    Normal Normal

    circumference Respiratory pattern Position of sternum Breath sound Inspection Inspection Auscultation 30-50cpm midline Vesicular, broncho-vesicular and bronchial 30cpm Midline Clear sounds Normal Normal breath Normal

    HEART: Cardiac rhythm rate and auscultation 60-100 bpm 128 bpm Normal

    Apical pulse

    auscultation

    Left 5th ICS, lateral Left 5th ICS, Normal to midclavicular lateral to line midclavicular line Symmetrical, other distal pulses maybe hard to feel high pitched gurgling noises that occur approximately every 5 to 15 seconds. Symmetrical, Normal other distal pulses maybe hard to feel

    Peripheral pulse

    palpation

    Abdomen

    auscultation

    UPPER & LOWER EXTREMITIES: size Strength and tone inspection inspection Equal in size Equal in size Normal

    Can flex and Can flex and Normal extend arms and extend arms and legs legs mobile Mobile Normal

    Mobility

    Inspection

    Temperature

    palpation

    Same with body Same with body Normal temp within temp within normal range normal range

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