Professional Documents
Culture Documents
Head
Head: The head of the client is rounded; normocephalic and symmetrical. Skull: There are no nodules or masses and depressions when palpated. Face: The face of the client appeared smooth and has uniform consistency and with no presence of nodules or masses.
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Ears: The Auricles are symmetrical and has the same color with his facial skin. The auricles are aligned with the outer canthus of eye. When palpating for the texture, the auricles are mobile, firm and not tender. The pinna recoils when folded. During the assessment of Watch tick test, the client was able to hear ticking in both ears.
Extremities
The extremities are symmetrical in size and length. Muscles: The muscles are not palpable with the absence of tremors. They are normally firm and showed smooth, coordinated movements.
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Bones: There were no presence of bone deformities, tenderness and swelling. Joints: There were no swelling, tenderness and joints move smoothly.
Nails
Skull
Hair evenly distributed with skin intact.Eyebrows are symmetrically aligned and have equal movement. Equally distributed and curled slightly outward.
Eyelashes
Eyelids
Skin intact with no discharges and no discoloration.Lids close symmetrically and blinks involuntary. Transparent with capillaries slightly visible
Bulbar conjunctiva
Palpebral Conjunctiva
Sclera
Appears white.
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Cornea Clarity and texture Transparent, smooth and shiny upon inspection by the use of a penlight which is held in an oblique angle of the eye and moving the light slowly across the eye.Has brown eyes . Blinks when the cornea is touched through a cotton wisp from the back of the client.
Corneal sensitivity
Pupils
Black, equal in size with consensual and direct reaction, pupils equally rounded and reactive to light and accommodation, pupils constrict when looking at near objects, dilates at far objects, converge when object is moved toward the nose at four inches distance and by using penlight. When looking straight ahead, the client can see objects at the periphery which is done by having the client sit directly facing the student nurse at a distance of 2-3 feet. The right eye is covered with a card and asked to look directly at the student nurses nose. Hold penlight in the periphery and ask the client when the moving object is spotted. Able to identify letter/read in the newsprints at a distance of fourteen inches. She was able to read the newsprint at a distance of 8 inches.
Visual Fields
Visual Acuity
Ear and Hearing Auricles Color of the auricles is same as facial skin, symmetrical, auricle is aligned with the outer canthus of the eye, mobile, firm, non-tender, and pinna recoils after it is being folded. Without impacted cerumen.
Able to hear ticking on right ear at a distance of one inch and was able to hear the ticking on the left ear at the same distance
Nose and sinuses External Nose Symmetric and straight, no flaring, uniform in color, air moves freely as the clients breathes through the nares. Mucosa is pink, no lesions and nasal septum intact and in middle with no tenderness. Symmetrical, pale lips, brown gums and able to
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Nasal Cavity
Mouth and
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Oropharynx Teeth
Central position, pink but with whitish coating which is normal, with veins prominent in the floor of the mouth.
Tongue movement
Moves when asked to move without difficulty and without tenderness upon palpation.
Positioned midline of soft palate. Present which is elicited through the use of a tongue depressor. Positioned at the midline without tenderness and flexes easily. No masses palpated. Coordinated, smooth movement with no discomfort, head laterally flexes, head laterally rotates and hyperextends. With equal strength Non-palpable, non tender Not visible on inspection, glands ascend but not visible in female during swallowing and visible in males.
Thorax and lungs Posterior thorax Spinal alignment Chest symmetrical Spine vertically aligned, spinal column is straight, left and right shoulders and hips are at the same height. With normal breath sounds without dyspnea. Quiet, rhythmic and effortless respiration
Unblemished skin, uniform in color, symmetric contour, undistended. Symmetrical movements cause by respirations. With audible sounds of 23 bowel sounds/minute.
Without scars and lesions on both extremities. With minimal scars on lower extremities Equal in size both sides of the body, smooth coordinated movements, 100% of normal full movement against gravity and full resistance.
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Bones and Joints Mental Status Language Orientation Attention span Level of Consciousness Motor Function Gross Motor and Balance Walking gait
Can express oneself by speech or sign. Oriented to a person, place, date or time. Able to concentrate as evidence by answering the questions appropriately. A total of 15 points indicative of complete orientation and alertness. E4V5M6
Has upright posture and steady gait with opposing arm swing unaided and maintaining balance. Maintained stance for at least five (5) seconds.
Standing on one foot with eyes closed Heel toe walking Toe or heel walking Fine motor test for Upper Extremities Finger to nose test Alternating supination and pronation of hands on knees Finger to nose and to the nurses finger Fingers to fingers Fingers to thumb Fine motor test for the Lower Extremities Pain sensation
Maintains a heel toe walking along a straight line Able to walk several steps in toes/heels.
Repeatedly and rhythmically touches the nose. Can alternately supinate and pronate hands at rapid pace.
Perform with accuracy and rapidity. Rapidly touches each finger to thumb with each hand.
Able to discriminate between sharp and dull sensation when touched with needle and cotton.
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