AREA ASSESSED SKIN: Color

TECHNIQUES USED

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

inspection

light to brown

deep Light to brown

deep Normal

Texture

palpation

smooth, presence Smooth, of hair presence of hair

normal

Skin turgor

palpation

skin springs back Skin springs back normal immediately when immediately pinched when pincheduniform within Uniform within Normal normal range normal range no edema no edema Normal

Temperature

palpation

presence of edema presence lesion of

palpation

skin palpation

some birth marks, no lesion, with Normal some flat and flat mole raised moles some birth marks, Rashes on upper Abormal some flat and chest and raised moles inguinal area balat sa kanang kamay/pasa left leg

presence rashes

of

skin inspection

HAIR: Color distribution inspection inspection brown or black evenly distributed Black Normal

evenly distributed Normal

hair thickness and inspection thinness

either very little or Great number of Normal great deal of body body and scalp and scalp hair hair thick or thin hair

texture and oiliness presence of lice NAIL: Color Shape and texture

palpation inspection

smooth and silky without lice

Smooth and silky without lice

Normal Normal

Inspection Inspection palpation Inspection Performed blanched test

Pinkish

Pinkish

Normal

and Smooth, convex in Smooth, convex Normal curvature, long in curvature, long Extremely thin Extremely thin Normal Normal

Thickness Capillary refill

Prompt return of Returns pink or usual color immediately

HEAD: Size, shape symmetry and Inspection Rounded (normocephalic)sy mmetric, with frontal, parietal and occipital prominences and 35-45 cm Rounded Normal (normocephalic) symmetric with frontal, parietal and occipital prominences 45 cm Normal

Head circumference

Inspection palpation

Presence of mass or Inspection nodules

Smooth, uniform in consistency, absence of nodules and mass.

Smooth, uniform Normal in consistency, absence of nodules and mass.

Facial Inspection features(symmetry of structures)

Symmetric or Symmetric naso- Normal slightly labial folds asymmetric facial features, palpebral fissures equal in size, symmetric naso-

labial folds Head movement inspection Can lift head slightly and turn them from side to side Can lift head Normal slightly and turn them from side to side

EYES: Eyebrows: distribution alignment hair Inspection and Hair evenly distributed, skin intact, eyebrows symmetrically aligned Hair evenly Normal distributed, skin intact, eyebrows symmetrically aligned

Eyelashes: evenness inspection of distribution and direction of curl

Equally Equally Normal distributed, curled distributed, slightly outward. curled slightly outward. Skin intact, discharge, discoloration no Skin intact, no Normal no discharge, no discoloration Bulbar Normal conjunctiva is clear with tiny capillaries visible, Palpebral conjunctiva is pink, no discharge, sclera is white

Eyelids: surface Inspection characteristics

Conjuctiva and sclera

Inspection

Bulbar Conjunctiva is clear with tiny capillaries visible, Palpebral conjunctiva is pink, no discharge, sclera is white

Lacrimal gland, Inspection nasolacrimal duct palpation

and No edema, no No edema, no Normal tenderness and no tenderness and tearing no tearing Round, black, Round, black, Normal

Pupils: color, shape Inspection

and equality Response to light Inspection

equal in size

equal in size

Illuminated pupils Illuminated pupils Normal constrict constrict

NOSE: Symmetry, shape and Inspection color Symmetrical, Symmetrical and normal straight and uniform in color uniform in color Pink mucosa, no discharge and swelling free of lesion No tenderness Pink mucosa, no Normal discharge and swelling free of lesion No tenderness Normal

Occurrence of Inspection redness, swelling and discharge

Facial sinus MOUTH: Lips: Symmetry, tenderness

Palpation

color, Inspection palpation

and Symmetry of contour uniform pink color, soft, moist, smooth texture

Symmetry of Normal contour uniform pink color, soft, moist, smooth texture

Gums: Color and moisture Inspection Pink, moist and Pink, and moist firm Normal

Position and color

Inspection

Central position, Central position, Normal pink in color, pink in color, slightly round slightly round

Smell

Inspection

No foul odor

No foul odor

Normal

EARS: Auricles: Color, symmetry of size and position Inspection Color is same as the color of the face, symmetrical auricles align in the outer canthus of the eyes Color is same as Normal the color of the face, symmetrical auricles align in the outer canthus of the eyes

Texture, elasticity Palpation and areas of tenderness

Mobile, firm, no tenderness, pinna recoils after it is folded Same with body temperature within normal range (36.5C37.5C) Able to clearly

Mobile, firm, no Normal tenderness, pinna recoils after it is folded Same with body Normal temperature within normal range (36.5 C)

Temperature

Palpation

Auditory function

Inspection

hear Able to clearly

hear Normal

NECK: Appearance movement THORAX: Color Inspection Light to brown Rounded Less than deep Brown Normal and inspection Short and mobile Short and mobile Normal

Chest shape Chest circumference

Inspection Inspection

Rounded head 49 cm

Normal Normal

circumference Respiratory pattern Position of sternum Breath sound Inspection Inspection Auscultation 30-50cpm midline Vesicular, broncho-vesicular and bronchial 30cpm Midline Clear sounds Normal Normal breath Normal

HEART: Cardiac rhythm rate and auscultation 60-100 bpm 128 bpm Normal

Apical pulse

auscultation

Left 5th ICS, lateral Left 5th ICS, Normal to midclavicular lateral to line midclavicular line Symmetrical, other distal pulses maybe hard to feel high pitched gurgling noises that occur approximately every 5 to 15 seconds. Symmetrical, Normal other distal pulses maybe hard to feel

Peripheral pulse

palpation

Abdomen

auscultation

UPPER & LOWER EXTREMITIES: size Strength and tone inspection inspection Equal in size Equal in size Normal

Can flex and Can flex and Normal extend arms and extend arms and legs legs mobile Mobile Normal

Mobility

Inspection

Temperature

palpation

Same with body Same with body Normal temp within temp within normal range normal range