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Nursing Assessment in Tabular Form

Assessment Findings

Integumentary

When skin is pinched it goes to previous state immediately (2 seconds).

 Skin With fair complexion.
With dry skin

Evenly distributed hair.

 Hair With short, black and shiny hair.
With presence of pediculosis Capitis.

Smooth and has intact epidermis

 Nails With short and clean fingernails and toenails.
Convex and with good capillary refill time of 2 seconds.

Rounded, normocephalic and symmetrical, smooth and has uniform

Skull
consistency.Absence of nodules or masses.

Symmetrical facial movement, palpebral fissures equal in size,

Face
symmetric nasolabial folds.

Eyes and Vision

Hair evenly distributed with skin intact.

 Eyebrows
Eyebrows are symmetrically aligned and have equal movement.

 Eyelashes Equally distributed and curled slightly outward.

Skin intact with no discharges and no discoloration.

 Eyelids
Lids close symmetrically and blinks involuntary.

 Bulbar
Transparent with capillaries slightly visible
conjunctiva

 Palpebral
Shiny, smooth, pink
Conjunctiva

 Sclera Appears white.

 Lacrimal gland,
Lacrimal sac,
No edema or tenderness over the lacrimal gland and no tearing.
Nasolacrimal
duct

Cornea
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Assessment Findings

Transparent, smooth and shiny upon inspection by the use of a penlight

 Clarity and which is held in an oblique angle of the eye and moving the light slowly
texture across the eye.
Has [brown] eyes.

 Corneal Blinks when the cornea is touched through a cotton wisp from the back
sensitivity of the client.

Black, equal in size with consensual and direct reaction, pupils equally
rounded and reactive to light and accommodation, pupils constrict
Pupils when looking at near objects, dilates at far objects, converge when
object is moved toward the nose at four inches distance and by using
penlight.

When looking straight ahead, the client can see objects at the periphery
which is done by having the client sit directly facing the nurse at a
distance of 2-3 feet.
Visual Fields
The right eye is covered with a card and asked to look directly at the
student nurse’s nose. Hold penlight in the periphery and ask the client
when the moving object is spotted.

Able to identify letter/read in the newsprints at a distance of fourteen

Visual Acuity inches.
Patient was able to read the newsprint at a distance of 8 inches.

Ear and Hearing

Color of the auricles is same as facial skin, symmetrical, auricle is

 Auricles aligned with the outer canthus of the eye, mobile, firm, non-tender,
and pinna recoils after it is being folded.

 External Ear
Without impacted cerumen.
Canal

 Hearing Acuity
Voice sound audible.
Test

Able to hear ticking on right ear at a distance of one inch and was able
 Watch Tick Test
to hear the ticking on the left ear at the same distance

Nose and sinuses

Symmetric and straight, no flaring, uniform in color, air moves freely as

 External Nose
the clients breathes through the nares.

Mucosa is pink, no lesions and nasal septum intact and in middle with
 Nasal Cavity
no tenderness.
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Assessment Findings

Mouth and Oropharynx Symmetrical, pale lips, brown gums and able to purse lips.

 Teeth With dental caries and decayed lower molars

 Tongue and
Central position, pink but with whitish coating which is normal, with
floor of the
veins prominent in the floor of the mouth.
mouth

 Tongue Moves when asked to move without difficulty and without tenderness
movement upon palpation.

Uvula Positioned midline of soft palate.

Gag Reflex Present which is elicited through the use of a tongue depressor.

Positioned at the midline without tenderness and flexes easily. No

Neck
masses palpated.

Coordinated, smooth movement with no discomfort, head laterally

Head movement
flexes, head laterally rotates and hyperextends.

Muscle strength With equal strength

Lymph Nodes Non-palpable, non-tender

Not visible on inspection, glands ascend but not visible in female during
 Thyroid Gland
swallowing and visible in males.

Thorax and lungs

Posterior thorax Chest symmetrical

Spine vertically aligned, spinal column is straight, left and right

 Spinal alignment
shoulders and hips are at the same height.

Breath Sounds Within normal breath sounds without dyspnea.

 Anterior Thorax Quiet, rhythmic and effortless respiration

Abdomen Unblemished skin, uniform in color, symmetric contour, not distended.

Abdominal movements Symmetrical movements cause by respirations.

 Auscultation of
With audible sounds of 23 bowel sounds/minute.
bowel sounds

Upper Extremities Without scars and lesions on both extremities.

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Assessment Findings

Lower Extremities With minimal scars on lower extremities

Equal in size both sides of the body, smooth coordinated movements,

Muscles
100% of normal full movement against gravity and full resistance.

Bones and Joints No deformities or swelling, joints move smoothly.

Mental Status

Language Can express oneself by speech or sign.

Orientation Oriented to a person, place, date or time.

Able to concentrate as evidence by answering the questions

Attention span
appropriately.

Level of Consciousness A total of 15 points indicative of complete orientation and alertness.

Motor Function

Gross Motor and

Balance

Has upright posture and steady gait with opposing arm swing unaided
 Walking gait
and maintaining balance.

Standing on one foot

Maintained stance for at least five (5) seconds.
with eyes closed

Heel toe walking Maintains a heel toe walking along a straight line

Toe or heel walking Able to walk several steps in toes/heels.

Fine motor test for

Upper Extremities

Finger to nose test Repeatedly and rhythmically touches the nose.

Alternating supination
and pronation of hands Can alternately supinate and pronate hands at rapid pace.
on knees

Finger to nose and to

Perform with coordinating and rapidity.
the nurse’s finger

Fingers to fingers Perform with accuracy and rapidity.

Fingers to thumb Rapidly touches each finger to thumb with each hand.
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Assessment Findings

Fine motor test for the

Lower Extremities

Able to discriminate between sharp and dull sensation when touched

Pain sensation
with needle and cotton.