Assessment Procedure
Methods Used
Actual Findings
Normal Status
Interpretati on
INTEGUMENTARY SYSTEM SKIN
I: Color, uniformity Inspection -Slightly moist -Light brown -Fair and even complexion -No lesions -No Scar formation -No pressure sores -skin is intact -No reddened areas which may manifest pressure ulcers Slightly moist Evenly colored skin tones without unusual or prominent discoloration. Normal
Lesions
Inspection
Integrity
Palpation
Smooth without lesions. Healed scars, freckles, moles or birthmarks are common findings. Skin is intact, and there are no reddened areas.
Normal
Normal
P: moisture
Palpation
Skin surfaces vary from moist to dry depending on the area assessed.
Normal
Temperature
Palpation
Patient has a warm skin to touch.
Skin is normally a warm temperature.
Normal
Turgor
Palpation
Good skin turgor
Skin pinches easily and immediately returns to its original position.
Nornal
I: Evenness of growth, thickness, color, texture
-Inspection -Palpation
-Color black evenly distributed -Thick, soft and smooth
HAIR Evenly distributed, thick and smooth hair.
Normal
Body hair
Inspection
Even in growth and distribution.
Varying amounts of terminal hair cover the scalp, axillary, body, and pubic areas according to normal gender distribution.
Normal
I: Plate shape
-Inspection -Palpation
No clubbing of toenails
NAIL Round or square nail shape according to the cuticle. There is normally 160-degree angle between the nail base and the skin.
Normal
Texture
Palpation
-Hard and thick nails -Slightly rough
Nails are hard and basically immobile. Dark-skinned clients may have thicker nails.
Normal
Bed color
-Inspection -Palpation
Pink nail beds.
Pink tones should be seen. Some longitudinal ridging is normal.
Normal
Surrounding tissue
Palpation
-Intact skin was felt -No lesions
Soft tissue and without any lesions.
Normal
P: Blanch test
Palpation
2-3 seconds with quick return of pink cast on the nails when pressure was released.
Pink tones returns immediately to blanched nail beds when pressure is released.
Normal
HEAD Skull and Face
I: Size and shape, symmetry :Facial features Inspection -Inspection -Palpation -Normocephalic -Symmetric and oval in shape -Erected and was found along the midline. -Symmetric facial features -Can establish eye contact -Even distribution of hair -Aligned, fine and able to move upward and downward. Eyelashes of the patient is well distributed Head size and shape vary, especially in accord with ethnicity. Shapes of skull vary. Head is symmetric, round, erect and in midline. Facial features are symmetric with movement. Client establishes good eye contact when conversing with others. Aligned, evenly distributed hair, fine and able to move eyebrows. Normal
Normal
EYES AND VISION
I: Eyebrows for distribution and alignment, quality and movement. Inspection Normal
: Eyelashes for evenness of distribution and direction of curl. : Eyelids for surface characteristics
Inspection
Eyelashes are evenly distributed and curved outward along the lid margins.
Normal
Inspection
-Similar to the color of patients skin -No swelling, lesions, and discharges -Clear, moist, and
Eyelids depend on the color of skin tone, absence of swelling, lesions and discharges.
Normal
: Bulbar
-Inspection
Bulbar conjunctiva is clear,
Normal
conjunctiva for color, texture, and lesion.
-Palpation
smooth -There were no lesions observed
moist, and smooth. Underlying structures are clearly visible. Sclera is white and absence of lesions.
Direct and consensual reaction to light
Inspection
-Constricted when stimulus (light) is induced -Equally reactive Constriction of the pupils and convergence of the eyes when focusing on a near object. -Has same color as the skin -Symmetric and align with the outer canthus of the eye
The normal direct and consensual pupillary response is constriction.
Normal
Accommodation
Inspection
The normal pupillary response is constriction of the pupils and convergence of the eyes when focusing on a near object.
Normal
EARS AND HEARING
I: Auricles for color, symmetry and position -Inspection -Palpation The ears are evenly colored. It is equal in size bilaterally. The auricle aligns with the corner of each eye and within a 10-degree angle of the vertical position. Normal
: External canal for cerumen
Inspection
-Normal amount of white to yellowish cerumen -Dry cerumen -The auricles were smooth -Elastic -Not tender -Symmetric -Color is the same as the face -No redness or discharge present -No redness, swelling, or discharges -Nasal septum was free of ulcers and perforations The client reports no tenderness or feeling of displacement of his nose.
A small amount of odorless cerumen is the only discharge normally present.
Normal
: Auricles for texture, elasticity and areas of tenderness I: Nose deviation in shape, size, color, flaring, discharge
Palpation
The skin is smooth with no lesions, lumps, or nodules. Normally the auricle is not tender. Color is the same as the rest of the face; the nasal structure is smooth and symmetric;
Normal
NOSE AND SINUSES
-Inspection -Palpation Normal
: Nasal mucosa for redness, swelling, growth or discharge
Inspection
The nasal mucosa is dark pink, moist, and free of exudates. The nasal septum is intact and free of ulcers or perforations.
Normal
: Tenderness, masses, displacements
Palpation
No tenderness.
Normal
: Maxillary and frontal sinuses for tenderness I: Lips for symmetry of contour, color, texture, moisture, lesion
Palpation
Non-tender and no crepitus noted
Frontal and maxillary sinuses are non-tender to palpation, and no crepitus is evident. Lips are smooth and moist without lesions or swelling. Pink lips are normal in lightskinned clients as are bluish or freckled lips in some darkskinned clients.
Normal
MOUTH/OROPHARYNX
-Inspection -Symmetric, -Slightly dry and pinkish lips -No lesions were present. Normal
: Teeth for alignment, loss, dental fillings and caries.
Inspection
-28 pearly whitish teeth with smooth Surfaces and edges. -Central incisor (right) covered with plastic jacket.
32 pearly whitish teeth with smooth surfaces and edges. Upper molars should rest directly on the lower molars and the front upper incisors should slightly override the lower incisors. No repaired or decayed areas; no missing teeth or appliances.
Normal
: Gums for bleeding, color, retraction, lesions, swelling
Inspection
Pinkish gums and without the presence of bleeding, lesions, swelling, or gum retraction
Gums are pink, moist, and firm with tight margins to the tooth. No lesions or masses.
Normal
: Tongue for position, color& texture
Inspection
-Pinkish to pale in color with white coloration or strips found, moist, and symmetric -Presence of papillae No swelling and redness -Soft palate is pinkish to pale and smooth -Hard palate is firm and has the presence of transverse rugae -Both have slight visible veins. Normal in size 1+ to 2+
Tongue should be pink, moist, a moderate size with papillae present, and symmetric in position.
Normal
: Salivary gland ducts for swelling, redness : Palates for color, shape, texture, presence of bony prominences
Inspection
Absence of swelling and redness in the client. The hard palate is pale or whitish with firm, transverse rugae. Torus palatinus is a normal variation seen more often in females, Eskimos, Native Americans, and Asians.
Normal
-Inspection
Normal
: Tonsils for color, discharge, and size
-Inspection
Normal tonsillar size is evaluated as 1+ to 2+.
Normal
BREAST AND AXILLAE
I: Breast for size, symmetry, contour or shape, discoloration, retraction, hypervascularity, swelling, edema : Areola for size, shape, symmetry, color, surface characteristics, masses, lesions
-Inspection -Palpation
-Symmetrical breast
The breast & axillae are fleshcolored, smooth and intact, striae, mole and nevi may be present. Rounded in shape, slightly unequal in size, generally symmetric.
Normal
-Inspection -Palpation
-Brown in color, smooth and intact -Round on shape and slightly unequal but symmetric as observed and as verbalized by the patient. -No nipple discharges
Areola and Nipples Areola-round or oval and bilaterally the same, color varies widely, from light pink to dark brown.
Normal
: Nipples for size, shape, position, color, discharge, lesion P: Lymph nodes, breast, areola & nipples for tenderness, masses, nodules,
-Inspection -Palpation
Nipple is round, everted, and equal in size, similar in color, soft and smooth, both nipples point in same direction.
Normal
-Inspection -Palpation
-The nipple of the No pain, lumps, dimplings and patient was round, rashes everted and points on the same direction going upward. -No masses or nodule palpated -No skin dimpling
Normal
THORAX AND LUNGS
Posterior Thorax I: Shape & symmetry from posterior-lateral views; spinal alignment for deformities Inspection -Elliptical, shoulders are at same height -Presence of spinal deformity Elliptical in shape, shoulders be at the same time height AP diameter- 1:2-5:7; shoulders at same height bilaterally 45 degrees ribs articulate w/ the sternum Anterior Thorax I: Breathing pattern, coastal and costovertebral angle I: Skin integrity, contour & symmetry, hernia, distention (girth), movements associated w/ -Inspection -Auscultation -Wheezes noted upon auscultation -Symmetrical chest expansion ABDOMEN -Round in shape. His Abdomen must be symmetrical liver and spleen are in shape and no palpable masses palpable or tenderness. The contour -Hypoactive bowel should be smooth and free of sounds, non-tender, lesions tumors or any injuries no organomegaly Abnormal Normal
Palpation
Normal
-Inspection -Palpation
Abnormal
respiration, peristalsis & aortic pulsations. Muscles I: Size, contractures, tremors -Inspection -Palpation
noted -(+) Muscle Spasm MUSCULOSKELETAL SYSTEM
- Shortened leg at right
P: Tonicity, flaccidity, spasticity, smoothness of movement, strength Bones
Inspection
-Head is midline and perpendicularly aligned with the shoulders and pelvis
Body weight and height should be appropriate for age and gender. Structural defects should be absent In standing position, the torso and head are upright. The head is midline and perpendicular in the horizontal line of the shoulders and pelvis. Extremities are proportional in the overall body size and shape and limbs are also symmetrical with each other.
Abnormal
Normal
P: Edema, tenderness Joints I: Swelling
Inspection
-No edema -No tenderness on joints -The patient is ectomorph in body built -clearly observed with body weakness and easy fatigueability
Normal
Palpation
Abnormal
NEUROLOGICAL SYSTEM
Neurologic Inspection -The facial affect and Affect/mood: mood of the patient were all appropriate Appropriate of the clients to her current responses appropriate to situation situation. -oriented to time, place and person Mentally alert (oriented to time, -Able to open her place, and person) memory, eyes spontaneously, ability to follow command, follow commands response to stimulus. promptly and able to converse with us with full awareness of his condition Normal
GENITALIA
* For females: -Inspection -Palpation -Evenly distributed pubic hair -Labia majora and minora are -Distributed like an inverse triangle; -No nits or lice; -Urethral opening is slit like in Normal
proportional; -Normal appearance of urethral opening; -No foul odor
appearance and in the midline; -Free or discharge, swelling or redness and about the size of the pea; -Clear and free of foul odor discharge -This area should be smooth and free of lesions, swelling, inflammations and tenderness. Normal
RECTUM AND ANUS
I: anus and -Inspection surrounding tissue -Palpation for color, integrity, lesions P: anal spinchter tonicity, nodules, masses and tenderness Palpation -smooth and free of lesions, swelling, inflammations and tenderness -presence of rugae
- There should be no evidence of feces or mucus on the perinial skin. The anal mucosa is deeply -No leakage of feces present from the anus pigmented, coarse moist and hairless. - The anal opening should be - no tissue pro closed. - There should not be any leakage of feces or mucus from the anus with the straining and there should not be any tissue protrusion.
Normal
I.
Diagnostic Procedure Type Invasive Normal Finding M 127183 g/L F 110158 g/L Abnormal Finding 108 Interpretation Abnormal Nursing Responsibility Monitor and record Vital signs. Elevate head of bed especially at night. Instruct to avoid strenuous activity. Restrict sodium, fluid and fat intake as
Procedure Hemoglobin Mass
Hematocrit Invasive 0.37-0.54 0.34 Abnormal
Differential Count (Lymphocytes)
Invasive
0.20-0.40
0.16
Abnormal
indicated. Promote bed rest. Monitor and record vital signs. Promote comfort measures for relief from pain. Monitor and record vital signs. Promote bed rest Increase intake of protein.
