Weight:12 kg Vital signs Temperature Pulse Respiration 37.

6 C 92 bpm 33 cpm

PHYSICAL ASSESSMENT Area of Assessment/ Body Part Body build, Height, Weight Posture, Gait, Standing, Sitting, Walking Overall Hygiene and Grooming Body and Breath Odor Signs of Distress Obvious signs of Health or Illness Attitude Affect/Mood Quantity/Quality of Speech Reverence and Organization of Thought Normal Findings (ref. Fundamentals of Nursing by Kozier and Erb p.572) Proportionate, varies with lifestyle Relaxed, erect posture, coordinated movement Clean and neat No body odor or minor body relative to work or exercise; no breath odor No distress noted Healthy appearance Cooperative, able to follow instructions Appropriate to situation Understandable, moderate pace; clear tone and infection; exhibits thought association Logical sequence. Makes sense, has sense of reality Actual findings Analysis

The weight is not appropriate with her age. Relaxed, straight posture, corresponding movement Clean and neat No body odor or insignificant body relation to work or exercise; no breath odor distress noted Not healthy appearance Cooperative, able to follow instructions Appropriate to situation Comprehensible, moderate pace; clear tone and infection; exhibits thought association Logical sequence. Makes sense, has sense of reality

Abnormal Normal Normal Normal

Normal Normal Normal Normal Normal

Normal

Area of Assessment

Normal Findings

Actual findings

Analysis

Integumentary Skin

Nails

Light brown. Generally uniform except in areas exposed to the sun; areas of lighter pigmentation (palms, lips, nail beds) in dark skinned people. No edema. Uniform temperature; within normal range. (ref. Fundamentals of Nursing by Kozier and Erb p.579-580) Convex curvature; angle of nailplate about 160. Smooth texture, highly vascular and pink, intact epidermis, prompt return of pink or usual color. (ref. Fundamentals of Nursing by Kozier and Erb p.583-584) Rounded, normocephalic and symmetric. (ref. Fundamentals of Nursing by Kozier and Erb p.585) Lighter than skin tone. No tenderness or lesions. No signs of dryness Hair is evenly distributed. Thick hair (ref. Fundamentals of Nursing by Kozier and Erb p.582) Symmetric or slightly asymmetric facial features. Symmetric facial movements. (ref. Fundamentals of Nursing by Kozier and Erb p.585) Able to read news print. (ref. Fundamentals of

Light brown skin, her skin color is light brown. Generally uniform except in areas exposed to the sun. No edema. Uniform temperature; within normal range.

Normal

Convex curvature, the angle is about 160. Smooth texture, pinkish in color, intact epidermis. Nails return to pink immediately when pressed.

Normal

Head Skull

Scalp Hair

Symmetrical to frontal, parietal and occipital parts, has smooth skull and is proportion to the body. White scalp, no lesions, no manifestation and infestation. He has short, thick and evenly distributed hair

Normal

Normal Normal

Face

Symmetric facial features and facial movements.

Normal

Eyes Visual acuity

Able to read news print even without glasses.

Normal

Nursing by Kozier and Erb p.592) Eyebrows Evenly distributed. Skin is intact. (ref. Fundamentals of Nursing by Kozier and Erb p.588) Lacrimal gland, No edema or tearing. lacrimal sac and (ref. Fundamentals of nasolacrimal duct Nursing by Kozier and Erb p.589) Eyelashes Evenly distributed. Curled slightly outward. (ref. Fundamentals of Nursing by Kozier and Erb p.588) Eyelids Skin intact, no discharged, no discoloration. Lids close symmetrically. 15-20 blinks per minute. Bilateral blinking. When lids open, no visible sclera above corneas. (ref. Fundamentals of Nursing by Kozier and Erb p.588) Conjunctiva Bulbar: transparent. Bulbar and Capillaries sometimes Palpebral evident. (ref. Fundamentals of Nursing by Kozier and Erb p.588) Palpebral: pink or red. Shiny and smooth. (ref. Fundamentals of Nursing by Kozier and Erb p.588) Sclera Appears white. (ref. Fundamentals of Nursing by Kozier and Erb p.588) Cornea Transparent, shiny and smooth. Details of iris are visible. Client blinks when the cornea is touched. (ref. Fundamentals of

Hair evenly distributed; skin intact; eyebrows symmetrically aligned; equal movement. No edema or tenderness over lacrimal gland, No edema or tearing. Equally distributed; curled slightly outward.

Normal

Normal

Normal

Skin intact, no discharge, no discoloration. Lids close symmetrically. Has 16 involuntary blinks per minute; bilateral blinking. When lids open, no visible sclera above corneas, and upper and lower borders of cornea are slightly covered. Bulbar: Transparent, capillaries are evident, sclera appears white. Palpebral: Shiny, appears smooth and pinkish.

Normal

Normal

Appears white.

Normal

Appears transparent, shiny and smooth. Details of iris are visible.

Normal

Iris

Pupils

Extraocular muscles

Visual fields

Nursing by Kozier and Erb p.589) Flat and round. (ref. Fundamentals of Nursing by Kozier and Erb p.589) Illuminated pupil constricts. Non-illuminated pupil constricts. Pupils constrict when looking at near objects. Pupils dilate when looking at far objects. Pupils converge when near objects are moved towards the nose. (ref. Fundamentals of Nursing by Kozier and Erb p.590) Both eyes are coordinated. Moves in unison with parallel alignment. (ref. Fundamentals of Nursing by Kozier and Erb p.592) When looking straight ahead client can see objects in periphery. (ref. Fundamentals of Nursing by Kozier and Erb p.591) Color same as facial skin. Symmetrical, auricle align with the outer canthus of the eye about 10 from vertical. Mobile firm and not tender. Pinna recoils after it is folded. (ref. Fundamentals of Nursing by Kozier and Erb p.596) Dry cerumen or sticky wet cerumen. (ref. Fundamentals of Nursing by Kozier and Erb p.596)

Iris is round and flat.

Normal

Black, round, equal in size, smooth borders. Pupil constricts when looking at near objects; pupils dilate when looking at far object; pupils converge when near object is moved toward nose.

Normal

Both eyes coordinated, move in unison, with parallel alignment.

Normal

He has the ability to read newsprint. When looking straight ahead client can see objects in periphery.

Normal

Ears Auricles

Color same as the facial skin. Symmetrical. Auricle is aligned in the outer canthus of the eye about 10 degrees from vertical. Firm and mobile. When folded, it returns to original feature. Dry cerumen is present; grayish tan color; no lesions; no pus and no blood.

Normal

External ear canal

Normal

Nose External Internal

Sinuses

Symmetric and straight. No discharged or flaring. Uniform color. Not tender. No lesions. Air moves freely as the client breathes through the nares. (ref. Fundamentals of Nursing by Kozier and Erb p.600) Not tender. (ref. Fundamentals of Nursing by Kozier and Erb p.600) Uniform pink color. Soft moist. Smooth texture. Ability to purse lips. (ref. Fundamentals of Nursing by Kozier and Erb p.602) Uniform pink color. Soft moist, smooth soft, glistening and elastic texture. (ref. Fundamentals of Nursing by Kozier and Erb p.602) 26 teeth. Smooth white shiny tooth enamel. (ref. Fundamentals of Nursing by Kozier and Erb p.602) Moist and firm texture to gums. (ref. Fundamentals of Nursing by Kozier and Erb p.602) Pink color, smooth lateral margins, no lesions, raised papillae. Moves freely: no tenderness. Smooth tounge base with prominent veins. (ref. Fundamentals of

Uniform color same as the face; symmetric and straight; no discharge; no lesions; not tender. Air passes smoothly on both nares; Mucosa is pink; No lesions; no tenderness Nasal septum is intact and in midline. No tenderness.

Normal

Normal

Mouth Lips

Smooth; uniform pink in color; no lesion or swellings; moist; soft and has the ability to purse lips. Elastic, appears smooth, soft, light pink, moist, no lesions.

Normal

Buccal mucosa

Normal

Teeth

Smooth, white and shiny tooth enamel. There is no black discoloration of tooth enamel. Pink gums; Moist; No retraction of gums.

Normal

Gums

Normal

Tounge/ floor of the mouth

Central position. Pink; smooth; no lesions; raised papillae. Moves freely; no tenderness; no nodules. Same color as buccal mucosa and floor of the mouth.

Normal

Palates and uvula

Oropharyx and tonsils

Neck

Lymph nodes

Trachea

Thyroid gland

Nursing by Kozier and Erb p.603-604) Light pink, smooth, soft, palate, lighter pink hard palate more irregular texture. (ref. Fundamentals of Nursing by Kozier and Erb p.604) Pink and smooth posterior wall. posterior wall. (ref. Fundamentals of Nursing by Kozier and Erb p.604) Pink and smooth. No discharged. (ref. Fundamentals of Nursing by Kozier and Erb p.604) Not palpable. (ref. Fundamentals of Nursing by Kozier and Erb p.607-608) Central placement in midline of neck. (ref. Fundamentals of Nursing by Kozier and Erb p.608) Not visible in inspection. Lobes not palpable. (ref. Fundamentals of Nursing by Kozier and Erb p.608-609) Anteroposterior to transverse diameter in ratio of 1:2. Chest is symmetric; spine vertically aligned. Skin intact. Uniform temperature. Bilateral symmetry or fremitus. Full and symmetric chest expansion. (ref. Fundamentals of Nursing by Kozier and Erb

Light pink; smooth and soft palate; Irregular in texture; Lighter pink in hard palates. Freely to move in midline of soft palate. No redness. Oropharynx is pink and appears smooth. Tonsils have no discharges, smooth; Elicit gag reflex. Pink and smooth. No discharged.

Normal

Normal

Normal

Lymph nodes are not palpable. No enlargements. It is midline of the neck; Spaces on both sides of the neck are equal. Not visible on inspection. Lobes not palpable.

Normal

Normal

Normal

Thorax Posterior thorax

Chest symmetric. Spine vertically aligned. Chest wall intact; no tenderness; no masses. Full and symmetric chest expansion when the client takes a deep breath, thumbs move apart an equal distance and at the same time. Bilateral Symmetry of

Normal

p.614-616)

vocal fremitus. Fremitus is heard most clearly at the apex of the lungs. Quiet, rhythmic, and effortless respirations. Full symmetric excursion. Normal

Anterior thorax Trachea Thorax

Jugular veins

Axillae

Abdomen

Musculoskeletal system

Bones

Joints

Quiet and rhythmic and effortless respirations. Full symmetric excursion. Bilateral fremitus. (ref. Fundamentals of Nursing by Kozier and Erb p.617) Veins not visible. (ref. Fundamentals of Nursing by Kozier and Erb p.623) No tenderness, nodules and masses. (ref. Fundamentals of Nursing by Kozier and Erb p.629) Uniform color, flat, rounded. No tenderness. Relaxed abdomen. (ref. Fundamentals of Nursing by Kozier and Erb p.633-636) Equal size on both sides of the body. Smooth coordinated movement. (ref. Fundamentals of Nursing by Kozier and Erb p.640) No deformities, tenderness or swelling. (ref. Fundamentals of Nursing by Kozier and Erb p.641) No swelling, no tenderness joints move smoothly. No limited range of motion. (ref. Fundamentals of Nursing by Kozier and Erb p.641)

Veins not visible.

Normal

No tenderness, nodules and masses.

Normal

Uniform color, flat, rounded. No tenderness. Relaxed abdomen.

Normal

Equal size on both sides of the body. Smooth coordinated movement.

Normal

No deformities, tenderness or swelling.

Normal

No swelling, no tenderness joints move smoothly. No limited range of motion.

Normal