Daniel Aquino Age: 7 years old Position in the family: son (4th eldest) Occupation: student Category Temperature

Pulse rate Respiratory rate 1st day of assessment 37.3C 97 bpm 22 cpm 2nd day of assessment 37.3C 95 bpm 21 cpm 3rd day assessment 37.5C 98 bpm 23 cpm

Assessment Method used General Appearance Body built Inspection Observe client over Hygiene and grooming Body odor Obvious signs of health illness Skin Color Inspection Inspection Inspection

Findings

Normal findings

Interpretation

Average

Average built

Normal

Untidy looking No body odor No sign of illness

Clean and neat No body odor Absence of illness: healthy

Not normal Normal Normal

Inspection

Light brown

Lesions and wounds Moisture Turgor

Inspection

Presence of Abrasions Moist When pinch, the skin brings back to its previous state

Palpation and Inspection Palpation

Varies from light brown to dark brown No abrasion, wounds or lesions Moist When pinch, the skin brings back to previous state

Normal

Not Normal

Normal Normal

Hair Palpation and inspection Inspection and Evenly distributed Stiff and thick Evenly distributed Smooth and Normal Not normal

Distribution Texture

palpation Color Infestation Inspection Palpation and inspection

hair Black Presence of pediculosis

varies with thickness of hair It varies from black to brown Absence of pediculosis capitis and pubis

Normal Not normal

Scalp Inspection None None Normal

seborrhea and scars Skull

Shape and Inspection symmetry Contour, masses, Palpation depression, and tenderness Face Inspection

Rounded and symmetrical Smooth, no tenderness, free from masses or depression

Rounded and symmetrical Smooth, no tenderness, free from masses or depression

Normal Normal

Facial feature

Texture Mobility and turgor

Inspection and palpation Palpation

Rounded and symmetrical with movements Smooth Skin turns back to its previous state after being pinch

Rounded and Normal symmetrical with movements Smooth Normal Skin turns back to its previous state after being pinch Normal

Nails Inspection Inspection Palpation and inspection Convex curvature Highly vascular Immediately returns to its original color (23 seconds) Smooth and slightly rounded, no splintering or brittle edges. Convex curvature High vascular to pinkish Immediately returns to its original color (23 seconds) Smooth and slightly rounded, no splintering or brittle edges. Normal Normal Normal

Curvature and angle Nail bed color Capillary refill (Blanch test)

Shape and configuration

Palpation and inspection

Normal

Eyes Inspection Inspection Evenly distributed Symmetrical with no drooping, tumors or infection of the lids. Pinkish and moist Evenly distributed Symmetrical with no drooping, tumors or infection of the lids. Pink and moist, no lesions, exudates or foreign bodies. White with some small superficial vessels and without exudates, lesions, or foreign bodies. Moist and shiny with no discharge, cloudiness or irregularities. Normal Normal

Eyebrows Eyelids

Conjunctiva

Inspection

Normal

Sclera

Inspection

White

Normal

Cornea

Inspection

Moist and shiny

Normal

Ears Inspection and percussion Inspection and palpation Sounds is heard in both ears Without lesion and abrasion, smooth Sounds is heard in both ears Without lesion and abrasion, smooth Normal Normal

Hearing Texture

Nose Inspection Inspection Inspection Symmetric Uniform in color No discharge, no nasal flaring Symmetric Uniform in color No discharges, no nasal flaring Normal Normal Not Normal

Shape and size Color Flaring and discharge

Mouth Inspection Inspection Inspection and palpation Inspection Inspection Inspection Asymmetry of contour Dark Soft, moist in texture Moves freely Complete set teeth No halitosis Asymmetry of contour Pinkish to darker Soft, moist in texture Moves freely 32 sets complete set No halitosis Normal Normal Normal Normal Normal Normal

Contour Color Texture Tongue Teeth Breath Neck Muscles

Inspection and palpation

Movements

Inspection

Symmetrical with the head in a central position, without palpable masses or spasm. Move the head through a full range in motion without complaint of discomfort.

Symmetrical with the head in a central position, without palpable masses or spasm. Move the head through a full range in motion without complaint of discomfort.

Normal

Normal

Thorax Inspection Inspection and palpation Auscultation symmetric Spine vertically align Clear breath sounds symmetric Spine vertically align No adventitious sound heard, normal breath sound heard bilaterally on both lungs Normal Normal Normal

Shape Spinal alignment Breath sound

Abdomen Inspection Unblemished skin and uniform in color Flat Unblemished skin and uniform in color Flat to rounded Normal

Skin integrity

Contour and symmetry

Inspection

Normal

Musculoskeletal system Inspection Inspection Equal Size Equal strength on both sides Equal Size Equal strength on both sides Normal Normal

Size Strength Bones

Structure Joints

Inspection

Inspection and palpation Lower extremities Inspection

No fracture or deformity No swelling or pain

No fracture or deformity No swelling or pain

Normal Normal

Leg size, shape, presence of lesion

Symmetrical in shape and size, no presence of lesion

Symmetrical in size and shape, no presence of lesion

Normal