Professional Documents
Culture Documents
Initial vital signs: Temp: 36.8 degrees C Pulse: 77 bpm RR: 20 cpm BP: 120/80 mmHg Area Assessed GENERAL: Body build, height and weight Posture and gait Inspection Proportionate varies with lifestyle Clean, neat Normal build for woman with proportionate parts Standing shows no abnormal deviation on the spinal prominence Absence of odor in axillae but slight halitosis noted. Normal Technique Normal Findings Actual Findings Evaluation
Inspection
Normal
Inspection
Signs of distress
Inspection
No distress noted
Inspection
Inspection Inspection
Activities of daily living was seen properly done Ambulatory Normal and can do self-care Positive Normal Mood depress Normal due to hospitalization.
Due to decrease immune system the patient was in constant face masked thereby neglecting her oral care and erosion of dental enamel associated to GERD. Normal
Inspection
Moderate pace Normal in talking and shows appropriate answer to simple questions Able to identify Normal herself, time, place, and such.
Inspection
Moisture
Inspection/ Palpation
Temperature
Palpation
Texture
Palpation
Turgor
Palpation
Light brown, Tanned skin tanned skin (vary with dark according to race) brown parts especially in the armpits Lighter colored Bruising was palms, soles found in the arms. Extending from the palms to the brachial artery part. Skin normally dry Dry skin in the exposing part but some moisture on the skin folds like axillae. Normally warm 36.8 degrees Celsius and warm upon palpation Smooth and soft Skin was soft and no swelling was noted Skin snaps back Skin returns immediately after a quick pinch. No edema was also noted
Normal
Due to inappropriate IV medication introduction leading to the scarring of the veins. Normal
Normal
Normal
Normal
NAILS: a. Nails Inspection Transparent, smooth and convex Pinkish Small, round nail in convex shape Slightly pale Normal
Nail beds
Inspection
Nail base
Inspection
Firm
Capillary refill
Inspection/ Palpation
Firm with160 degrees nail base. White color of nail Capillary refill bed under in 3-4 seconds pressure should after pressure return to pink within 2-3 seconds Evenly distributed The scalp was white with hair covering the entire scalp. Hair was thick and shiny Free form masses, lumps, nits, dandruff and lesion. With no area of tenderness upon palpation.
b. Hair Distribution
Inspection
Normal
Color Texture
Black Smooth
Normal Normal
EYES: Eyes Inspection Parallel to each other Parallel, symmetrical and not protruding and clear in inspection Pupil is same shape as the round size of the iris and Normal
Visual Acuity
Inspection (penlight)
Normal
Eyebrows
Inspection
Eyelashes
Inspection
Eyelids
Inspection
Conjunctiva
Inspection
both of them constrict with light at the same time. Symmetrical in Black in color size, extension, and hair texture and symmetrical movement and can able to raise both in the same time. Distributed evenly Small in and curved amount but is outward distributed evenly and curved outward. Same color as Same color as the skin the exposing skin areas. Blinks involuntarily and Fixed and bilaterally up to involuntary 20 times per blinked and is minute irritated to foreign objects. Do not cover the pupil and the The upper sclera, lids eyelids cover a normally close small portion symmetrically of the sclera but patients said it was inborn. Transparent with Slightly pink in light pink color outer area with bland part of yellowish area.
Normal
Normal
Normal
Normal
Normal
Sclera
Inspection
Color is white
Cornea
Inspection
Transparent, shiny
Due to callous like thickening of the conjunctiva making it more prone to irritations. Normal
Normal
Pupils
Inspection
Iris
Inspection
Clearly visible
Black and rounded with the normal ability to constrict to light. Transparent, Proportionate in the size of the eyes and moist
Normal
Normal
EARS: Ear canal opening Inspection Free of lesions, discharge of inflammation Bean like helix in shaped no discharge and parallel to one another. No inflammation and canal wall are slightly tanned pink. 3 out of 3 whispers were heard by the client in the shoulder distance. Normal
Inspection
Normal
Hearing Acuity
Inspection
Normal
NOSE: Shape, size and skin color Inspection Smooth, symmetric with same color as the face Symmetric and Normal straight with no obvious enlargement.
Nares
Inspection
Normal
Inspection
Inspection
Gums
Inspection
Slightly pink color, moist and tightly fit against each tooth
Tongue
Inspection
Teeth
Inspection
Due to decrease blood supply in buccal area associated to SLE. Slightly dark in Due to acid color same as reflux faltering the color of her from GERD. lips but in a more bland type. Tooth is Somehow loosed in some areas. Noticeable Due to prolong fissures and masked dryness. wearing because of decrease immune system thereby neglecting her oral care. Pale yellowish, Due to noticeable irreversible loss decrease in of tooth size but no structure due to dental carries chemical noted. dissolution by acids
NECK: Symmetry of neck muscles, alignment of trachea Inspection Neck is slightly hyper extended, without masses or asymmetry Symmetrical with head at the center and no masses were observed in the trachea part. Was able to move in 4 directions Normal
Neck ROM
Inspection
Normal
Thyroid gland
Palpation
upon instruction. No mass, Normal nodules, lesion were noted upon palpation.
ABDOMEN: Skin Color Inspection Skin same color with the rest of the body Normal
Inspection
4 quadrants
Auscultation
Concave and rises due to breathing with same color as the other part of skin. Audible bowel sounds
Normal
Normal
Percussion
Tympany over the Tympany over stomach; dullness the stomach; over the liver dullness over the liver
Normal
EXTREMITIES: Symmetry Inspection Symmetrical No positional deviation was seen and are symmetrical Same color as the exposing skin area Warm in the trunk part of the extremities with slight decrease in temp on the finger parts No masses, Normal
Skin color
Inspection
Same with the color of other parts of the body Warm to touch
Normal
Skin Temperature
Palpation
Normal
Presence of
Inspection /
No lesions
Normal
lesion ROM
lesion, rashes, etc. was noted The patient shows full ROM of every extremity of her body with ease and no pain.
Normal