AREA ASSESSED METHODS NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS

GENERAL
ASSESSMENT

SKIN

GEERAL SKIN INSPECTION  Evenly colored  Evenly Normal

COLORATION skin tones colored skin
without tones without
unusual or unusual or
prominent prominent
discoloration discoloration

Skin integrity and INSPECTION  skin is intact,  (+) rashes on d/t irritation
texture and and there are both feet
PALPATION to fabric
no reddened
bleach and
areas
the rapid
 skin is smooth
growth of
and even
number of
skin cells
associated
with
hyperthyrodis
m

 (+)heat rash  heat rash

on patient’s d/t
posterior excessive
thorax sweating
which dries
up skin

THICKNESS PALPATION  skin is normally  (+) calluses at d/t strenous

thin but digitals household
calluses (rough, activities such
thick sections as laundry
of epidermis)
are common on
areas of the
 body that are
exposed to
constant
pressure

MOISTURE PALPATION  skin surface  isolated dry  heat rash

vary from moist areas at d/t
to dry patients arms excessive
depending on , feet and sweating
the area back, heat which dries
assessed rash up skin

TEMPERATURE PALPATION  skin is normally  skin is warm d/t increase

a warm to touch at body
temperature face and palm metabolic
process
related to
thyroid
production

DETECT EDEMA PALPATION  skin rebounds  skin rebounds NORMAL

and does not and does not
remain remain
indented when indented
pressure is when
released pressure is
released

SCALP AND HAIR

GENERAL COLOR INSPECTION/  natural hair  hair is ebony d/t poor

AND CONDITION color, as in color, thin, hygiene and
OF SCALP AND PALPATION hormonal
opposed to and dry
HAIR chemically effects such as
colored hair thyroid
 scalp is clean hormones
and dry. which alter
 hair is smooth the production
and firm, of hair cells
somewhat
elastic

NAILS
GROOMING AND INSPECTION  Nails are clean  Nails are Normal
CLEANLINESS, and and manicured clean and
COLOR PALPATION  Pink tones manicured
should be seen  Pink tones
 Nails are hard should be
and basically seen
immobile  Nails are hard
 Pink tone and basically
returns immobile
immediately to  Pink tone
blanched nail returns
beds when immediately
pressure is to blanched
released nail beds
(Capillary Refill when
Test) pressure is
released
(Capillary
Refill Test)

HEAD AND FACE

HEAD INSPECTION  head size and  head slightly d/t thyroid

shape vary, tilts to the growth
especially in right
accord with
ethnicity
 symmetric,
round, erect
and in midline
 No lesions

MOVEMENT INSPECTION  head should be  The patient d/t thyroid

held still and had difficulty growth
upright in rotating
and flexing
head

HEAD PALPATION  head is  head is Normal

normally hard normally hard
and smooth, and smooth,
without lesions without
 lesions

FACE INSPECTION  face is  face is Normal

symmetric with symmetric
a round, oval, with a round,
elongated, or oval,
square elongated, or
appearance square
 no abnormal appearance
movement  no abnormal
movement

NECK

NECK INSPECTION  neck is  neck has d/t thyroid

symmetric, globular mass growth
with head growth at the
centered and left part neck
without bulging
masses

MOVEMENT OF INSPECTION  The thyroid  neck d/t thyroid

THE NECK cartilage and movement is growth
STRUCTURE cricoid cartilage minimal
move upward
symmetrically
as the client
swallows

THYROID GLAND PALPATION/  landmark are  Obviously d/t thyroid

positioned enlarged overstimulatio
AUSCULTATIO n, bruits
midline  Bruits were
N indicate
 no bruits are heard when
auscultated auscultated presence of
blood vessels

EYES

Eye Appearance INSPECTION  Eyes appear D/t

symmetrical Slight bulging of ophthalmic
and normal eyes pressure

Eyelid Appearance INSPECTION Eyelids appear smooth  Eyelids Dry and tired
and hydrated appear dry eyelids noted
 and tired, due to fatigue
darker in and
color sleeplessness

VISION ASSESSMENT  Normal  Patient steted D/t

peripheral her vision is ophthalmic
vision blurry pressure

EARS

EARS (General) PALPATION  Skin is Smooth,  Skin is Normal

and with no lesions, Smooth, with
ASSESSMENT lumps, or no lesions,
nodules lumps or
 Vibrations are nodules
heard equally  Vibrations are
well both ears heard equally
well both ears

LIP AND MOUTH

LIPS INSPECTION/  Lips are  Dry lips d/t

PALPATION smooth and physiological
moist distress
without brought to by
lesions or post-partum
swelling events,
excessive
heat, and
abnormal
metabolism
brought to by
hyperthyroidis
m

Black gums
were
observed,
 Gums appear consistent
Visual  Pink or coral- black or with smoking
Gum Color inspection colored gums darkened history

NOSE
NOSE INSPECTION  Color is the  Color is the Normal
same as the same as the
rest of the face rest of the
 Able to sniff face
through each  Able to sniff
nostril through each
 No Nasal nostril
Flaring  No Nasal
Flaring

THORAX INSPECTION  Symmetrical  Symmetrical Normal

chest chest
expansion, no expansion, no
deformities deformities
 Full range of  Full range of
motion , no motion , no
pain in pain in
movement movement

ABDOMEN INSPECTION/  Unblemished Sagging

PALPATION skin abdomen and
 Symmetric stretch marks
 No visible are common
vascular postpartum
patterns
changes due
 Abdomen is
to stretching
nontender
 Abdomen of the
and soft
 No guarding appears abdominal
saggy with wall and skin
noticeable during
stretch marks pregnancy
MUSCULOSKELET INSPECTION  Posture is
AL erect and
comfortable Postpartum
for age difficulty
 Snapping and walking
clicking may
suggests
be felt and
 Difficulty potential
heard in
walking post- issues like
normal client
 Equal size on birth muscle
both size of observed weakness or
the body residual
 Smooth effects from
coordinated childbirth
movement trauma,

NEUROLOGIC INSPECTION  Display no  Display no Normal

difficulty on difficulty on
speaking and speaking
able to follow and able to
verbal or follow verbal
written or written
instructions. instructions.
 Intact  Intact
immediate immediate
recall, recent recall, recent
memory and memory and
remote remote
memory memory
 Able to  Able to
concentrate concentrate
and maintain and
attention span maintain
good attention
calculation span good
skills calculation
skills