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

    Uploaded by

    Charis Paroginog
    - The document describes the findings of a physical assessment of an individual's skin, hair, nails, head, eyes, ears, nose, mouth, neck, chest, heart, abdomen, and extremities. - The assessment found the individual to have normal color, texture, turgor, temperature, edema, rashes, hair characteristics, nails, head features, eyes, ears, nose, mouth, neck, chest, heart, abdomen, extremities, temperature and mobility. - A few abnormal findings included dry lips and a bruise near the left eye.

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

    Uploaded by

    Charis Paroginog
    42 views7 pages
    - The document describes the findings of a physical assessment of an individual's skin, hair, nails, head, eyes, ears, nose, mouth, neck, chest, heart, abdomen, and extremities. - The assessment found the individual to have normal color, texture, turgor, temperature, edema, rashes, hair characteristics, nails, head features, eyes, ears, nose, mouth, neck, chest, heart, abdomen, extremities, temperature and mobility. - A few abnormal findings included dry lips and a bruise near the left eye.

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    petit nacario love makoy

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    Craig chorva

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    - The document describes the findings of a physical assessment of an individual's skin, hair, nails, head, eyes, ears, nose, mouth, neck, chest, heart, abdomen, and extremities. - The assessment found the individual to have normal color, texture, turgor, temperature, edema, rashes, hair characteristics, nails, head features, eyes, ears, nose, mouth, neck, chest, heart, abdomen, extremities, temperature and mobility. - A few abnormal findings included dry lips and a bruise near the left eye.

    Copyright:

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

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

    Uploaded by

    Charis Paroginog
    - The document describes the findings of a physical assessment of an individual's skin, hair, nails, head, eyes, ears, nose, mouth, neck, chest, heart, abdomen, and extremities. - The assessment found the individual to have normal color, texture, turgor, temperature, edema, rashes, hair characteristics, nails, head features, eyes, ears, nose, mouth, neck, chest, heart, abdomen, extremities, temperature and mobility. - A few abnormal findings included dry lips and a bruise near the left eye.

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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 36.4(using digital thermometer)

    Temperature

    palpation

    presence of edema presence lesion of

    palpation

    no edema

    no edema

    Normal

    skin palpation

    some birth marks, no lesion, with Normal some flat and flat mole raised moles some birth marks, Some birthmarks Normal some flat and at right hand (Medication) raised moles Rashes on upper chest and inguinal area

    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 smooth and silky without lice Smooth and silky without lice Normal Normal

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

    palpation inspection

    Inspection Inspection palpation Inspection

    Pinkish

    Pinkish

    Normal

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

    Thickness Capillary refill

    Performed Prompt return of Returns blanched test (less pink or usual color immediately than 3 sec.)

    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

    Symmetric slightly

    or Symmetric naso- Normal labial folds

    structures)

    asymmetric facial features, palpebral fissures equal in size, symmetric nasolabial folds Inspection Can lift head slightly and turn them from side to side Can lift head Normal slightly and turn them from side to side

    Head movement

    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 Abnormal no discharge, with (injury) bruise on the left orbital area Bulbar Normal conjunctiva is clear with tiny capillaries visible, Palpebral conjunctiva is pink, no discharge, sclera

    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

    is white

    and No edema, no No edema, no Normal tenderness and no tenderness and tearing no tearing Round, black, Round, black, Normal equal in size equal in size Illuminated pupils Illuminated pupils Normal constrict constrict

    Pupils: color, shape Inspection and equality Response to light Inspection

    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 Abnormal contour uniform (dehydration) pink color, soft, moist, Dry Lip

    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 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 No foul odor Normal

    Texture, elasticity Palpation and areas of tenderness

    Mobile, firm, no tenderness, pinna recoils after it is folded Able to clearly

    Mobile, firm, no Normal tenderness, pinna recoils after it is folded hear Normal

    Auditory function

    Inspection

    hear Able to clearly

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

    Chest shape Chest circumference

    Inspection Inspection

    Rounded

    Normal Normal

    Less than head 45 cm circumference 30-50cpm midline 30cpm Midline

    Respiratory pattern Position of sternum

    Inspection Inspection

    Normal Normal

    Breath sound

    Auscultation

    Vesicular, broncho-vesicular and bronchial

    Clear sounds

    breath Normal

    HEART: Cardiac rhythm rate and auscultation 80-120 bpm 120 bpm Normal

    Apical pulse

    auscultation

    Left 5th ICS, lateral Left 5th ICS, Normal to midclavicular lateral to line midclavicular line S1 and S2 are S1 and S2 are heard, no heart heard, no heart murmur sound murmur sound

    Peripheral pulse

    palpation

    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 High pitched gurgling noises occur approximately every 3-4 seconds. Abnormal (diarrhea, increase peristalsis)

    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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