Body part I. General Observation a. Posture and Gait b.

Clients attitude

Norms

Actual findings

Interpretation and analysis

erect posture cooperative

N/A ASLEEP BU A!OUSABLE "#EN A$ING %I AL SIGNS AN& GI%ING 'E&ICA IONS

II. 'easure(ents and %ital Si)ns a. #ei)*t b. "ei)*t c. %ital Si)ns e(perature Pulse !ate !espirator+ !ate Blood Pressure bot* s*ould be proportion to t*e clients a)e N/A

,-../,0.1 2 C -3/433 bp( 41/.3 cp( 53/4.3/-3/53

,-.,2 C 63 bp( 45 bp( 53/-3

1. Head to Toe Examination A. Integumentary a. Skin 7 color %aries 8ro( li)*t to deep bro9n : 8ro( rudd+ pin; to li)*t pin; : 8ro( +ello9 overtones to olive: )enerall+ uni8or( e<cept in areas e<posed to t*e sun : areas o8 li)*ter pi)(entation in dar; s;inned people No ede(a 7 lesions =rec;les> so(e birt*(ar;s> so(e 8lat and raises nevi: no abrasions or ot*er lesions it! lesions Abnor(al. It is due to t*e persistent scratc*in) o8 t*e patient. Jaundice Abnor(al. It is due to t*e buildup o8 bilirubin in t*e blood

ede(a

No ede(a Nor(al

7 7

(oisture 'oisture in s;in 8olds and a<illae te(perature Uni8or( 9it*in nor(al ran)e

#ry Abnor(al. Uni8or( 9it*in nor(al ran)e o8 ,-., C "*en pinc*ed> s;in sprin)s bac; to previous state (a+ be slo9er in elders Nor(al

tur)or "*en pinc*ed> s;in sprin)s bac; to previous state (a+ be slo9er in elders

Nor(al

". Hair 7 evenness o8 )ro9t* over t*e scalp Evenl+ distributed *air 7 *air t*ic;ness or t*inness *ic; *air 7 *air te<ture and oiliness Sil;+> resilient *air 7 in8ections or in8estations No in8ections or in8estations 7 *air a(ount o8 bod+ variable c. Nails 7 8in)ernail plate s*ape Conve< curvature: an)le o8 nail plate about 4-3 de)rees 7 8in)ernail and toenail te<ture 7 8in)ernail and toenail bed color S(oot* te<ture ?????Conve< in s*ape> an)le is 4-3 de)rees Nor(al #as s(oot* te<ture Nor(al Nor(al No in8estations suc* as lice. Nor(al %ariable "aldness "aldness $$$$$!air loss %alopecia&

Abnor(al. #air loss (a+ be related to a)in). Abnor(al. 'a+be related to a)in) process. Abnor(al. 'a+be related to a)in) process. Nor(al

#i)*l+ vascular and pin; in li)*t s;inned clients: dar; s;inned clients (a+ *ave bro9n or blac; pi)(entation in lon)itudinal strea;s 7 tissues surroundin) t*e nails 7 capillar+ re8ill Intact epider(is Pro(pt return o8 pin; or usual color B. Head A. skull and face 7 si@e> s*ape and s+((etr+ !ounded 7 nodules or (asses and depressions S(oot*> uni8or( consistenc+: absence o8 nodules and (asses 7 8acial 8eatures and (ove(ents S+((etric or sli)*tl+ as+((etric 8acial 8eatures: palpebral 8issures eAual in si@e: s+((etric nasolabial 8olds and *as s+((etric 8acial (ove(ents ". Eyes 7 ede(a

Bro9nis*

Nor(al intact Nor(al returns to nor(al less t*an . seconds

Nor(al Nor(ocep*alic Nor(al No (asses> nodules noted Nor(al

n/a

Nor(al No ede(a Nor(al No ede(a #air evenl+ distributed: s;in intact: e+ebro9s s+((etricall+ ali)ned :eAual (ove(ent Evenl+ distributed> intact> s+((etrical.

E+ebro9s /#air distribution> ali)n(ent> s;in Aualit+ and (ove(ent e+elas*es

Nor(al

/evenness o8 distribution and direction o8 curl e+elids /sur8ace c*aracteristics> position in relation to corned> abilit+ and 8reAuenc+ o8 blin;in) EAuall+ distributed> curled sli)*tl+ out9ard

Curled sli)*tl+ out9ard Abnor(al. 'erior"ital dark circles S;in intact: no disc*ar)e: no discoloration. Appro<i(atel+ 41 B .3 involuntar+ blin;s per (inute: bilateral blin;in) Icteric sclera ransparent: capillaries so(eti(es evident. Sclera appears 9*ite

sclera and iris color

Abnor(al. It is due to t*e buildup o8 bilirubin in t*e blood.

c. Ears auricles /color> s+((etr+ o8 si@e> position> te<ture> elasticit+ and areas o8 tenderness

Color sa(e as 8acial s;in s+((etrical> auricle ali)ned 9it* outer cant*us o8 e+e .'otile> 8ir( and not tender. Pinna recoils a8ter it is 8olded

'resence of (aundice Ears ali)ned 9it* t*e outer cant*us o8 t*e e+e about 43 de)rees 8ro( vertical. Pinna recoils.

Abnor(al. It is due to t*e buildup o8 bilirubin in t*e blood

e<ternal ear canal ceru(en> s;in lesions pus and blood

&istal t*ird contains *air 8ollicles and )lands> dr+ ceru(en> )ra+is* tan color> or stic;+ 9et ceru(en in various s*ades o8 bro9n

Contains *air 8ollicles and )lands. dr+ ceru(en> )ra+is* tan color> or stic;+ 9et ceru(en in various s*ades o8 bro9n Nor(al voice tones audible

Nor(al

Nor(al

*earin) acuit+ /response to nor(al voice tones

Nor(al voice tones audible

#. Nose

Abnor(al. 7 s*ape> si@e> color and 8larin) or disc*ar)e 8ro( t*e nares> tenderness> (asses> displace(ent o8 bone and cartila)e

NG
S+((etric and strai)*t no disc*ar)e or tearin) uni8or( color> not tender no lesions 'resence of Jaundice. S+((etric and strai)*t No lesions. "it*out tenderness or lesion Air (oves 8reel+ as client breat*es

Nor(al

7patenc+ o8 bot* nasal cavities Air (oves 8reel+ as t*e client breat*es t*rou)* t*e nares f. )out! and *rop!arynx

Abnor(al lip and buccal (ucosa /s+((etr+ o8 contour o8 color> te<ture> (oisture> abilit+ to pursue lips Uni8or( pin; color> so8t> (oist> s(oot*> te<ture> s+((etr+ o8 contour > can pursue lips 'ale and #ry

Nor(al teet* /color> nu(ber> condition > presence o8 denture )u(s /color and condition Gu(s pin; and no lesions. ,. adult teet*> s(oot*> 9*ite> s*in+ toot* cara(el Co(plete set o8 teet*

NO!'AL > related to a)in) Gu(s sli)*tl+ dar;er in color and no lesions.

c. Neck and +ymp! nodes No (asses

Nor(al

l+(p* nodes enlar)e(ent > tenderness

no (asses and s9ellin) No tenderness and not palpate

s9ellin) noted. No tenderness and not palpable

d. T!orax 1.posterior 7s*ape >s+((etr+> spinal ali)n(ent 7presence o8 bul)es> tenderness or abnor(al (ove(ents ,. anterior 7breat*in) pattern d.#eart e. A"domen 7s;in inte)rit+ Cuiet and r*+t*(ic> e88ortless respirations C*est s+((etric> spine verticall+ ali)ned C*est 9all intact no tenderness and no (asses Cuiet and r*+t*(ic> e88ortless respirations 9it* t*e nor(al rate o8 .3 bp(. 'resence of Jaundice .it! lesions and dryness of skin

Nor(al

n/a

Nor(al

Nor(al

Abnor(al

N*T S/0E
Unble(is*ed s;in> uni8or( color > silver 9*ite striae or sur)ical scars Abnor(al

7contour and s+((etr+

=lat> rounded or s+((etric contour No lesions> No &isc*ar)e> No S(e)(a

Nor(al

7tenderness or (uscle )uardin) f. -enitalia Penile s;in intact> appears sli)*tl+ 9rin;led and varies in color as 9idel+ as ot*er bod+ s;in> =ores;in easil+

Nor(al

1. 'enis

#as eAual (uscle

retractable 8ro( t*e )lans penis II. )usculoskeletal system

si@e on bot* sides Nor(al

n/a
#as 8ir( (uscles Nor(al

n/a
A . muscle si1e EAual si@e on bot* sides o8 t*e bod+ B. 2ontractures of muscles and tendons 2. )uscle tonicity #. )uscle Strengt! Nor(all+ 8ir( EAual stren)t* on eac* bod+ sides No contractures #as no de8or(ities No tenderness or s9ellin) present No s9ellin)> tenderness or nodules noted. Nor(al Nor(al

Nor(al Nor(al

E. Structure of t!e Skeleton 3. Edema or tenderness on t!e "ones and muscles -. Joint S.elling4 tenderness4 smoot!ness of mo5ement4 crepitation4 presence of nodules

Nor(al No de8or(ities No tenderness or s9ellin) No s9ellin)> tenderness> crepitation or nodules> (ove s(oot*l+