Head to Toe Assessment

INTEGUMENTARY: He has slightly poor skin turgor. His skin in arms and feet are dry, slightly cracked and scaly. They are soft and cool to touch. He has no lesions and free from redness and discharges. No mass is noted. HEENT: Head is symmetrical and free from lesions. Hair is equally distributed. Headache is claimed. She has anicteric sclerae and pink palpebral conjunctiva. Eyebro s are symmetrical to the eyes. Ears are symmetrical, upper and outer pinnacle is aligned to outer and inner canthus. !artilage is firm. "ree from lesions and discharges. Nose is symmetrical ith t o nostrils and has patent air ay. "ree from lesions, redness discharges and mass. #outh is symmetrical to the face. He has dry and cracked lips. His tongue is pinkish in color, able to move from side to side. Taste buds are still functioning. CARDIO-RESPIRATORY: He has a respiratory rate of $% cycles per minute and shallo breathing. He does not complain difficulty of breathing. His cardiac rate is &'$ beats per minute and his blood pressure is &$'()' mmHg. He has no further problem on cardiac and respiratory system. GASTROINTESTINAL: He claimed of left lo er abdominal pain. GENITO-URINARY: He has inadequate urine output and negative for dysuria. MUSCULOSKELETAL: He has difficulty in mobili*ation and slo body movement because of incision on left lo er abdomen and he could not fle+ his lo er e+tremities. NEUROLOGIC: ,ue to his present illness, He has mood s ings and often has irritated emotional response. He is a ake and coherent. He is responsive but al ays lying on back. EXTREMITIES: His upper e+tremities is ell mobili*ed but his lo er e+tremities is slightly able to move but ith assistance due to incision on left lo er abdomen. -t is free from redness and masses. ABDOMEN: She has a flat, non . tender abdomen. He has active bo el sounds upon auscultation. GENERAL: /enerali*ed body eakness claimed or noted. He complains of pain upon slight activity. There is also observation of facial grimace upon every change of position.