Name: BP: RR: PR Temp:

AREA/BODY PART 1. MEASUREMENT a. Height b. Weight c. BMI

NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS

Proportionate, varies with lifestyle Proportionate, varies with lifestyle Normal 19.8-26.0

2. GENERAL SURVEY a. Describe the clients body built, height and weight in relation to clients age, lifestyle and behavior b. Describe the clients posture and gait, standing, sitting and walking c. Describe the clients overall hygiene and grooming d. Describe body and breath odor e. Identify signs of Proportionate varies with her age and lifestyle (Kozier, p.572)

Relaxed and erect posture, coordinated movements (Kozier, p.572) Clean and neat appearance and well-groomed (Kozier, p.572) No body and breath odor (Kozier, p.572) No signs of distress noted

distress, in posture or facial expression f. Describe obvious signs of health and illness

(Kozier, p.572)

Healthy appearance (Kozier, p.572) Coherent, conscious (Kozier, p.572) Appropriate to the situation (Kozier, p.572)

g. Describe clients attitude h. Describe clients affect or mood; assess the appropriateness of the clients response i. Describe quantity and quality of speech

Understandable and moderate pace, exhibits thoughts and association (Kozier, p.572) Logical sequence; make sense of reality (Kozier, p.572)

j.

Listen for relevance and organization of thoughts

3. INTEGUMENTARY A. Skin a. Inspect for color; uniformity of color

Generally uniform except in areas exposed to the sun; areas lighter pigmentation (palms, lips, nail beds) in dark skinned people. (Kozier, p.579) No presence of edema (Kozier, p.579)

b. Inspect for presence of edema

c. Inspect for lesions according to location, distribution, color, configuration, size, shape, type, structure d. Palpate skin moisture e. Palpate skin temperature f. Palpate for skin turgor

No lesion or abrasion; Flat and raised nevi (Kozier, p.579)

Moisture skin folds and axillae (Kozier, p.579) Uniform; with normal range (Kozier, p.579) When pinched, skin brings back to previous state (Kozier, p.580)

B. Nails a. Inspect fingernail plate shape to determine its curvature and angle b. Inspect fingernail and toenail bed color Convex curvature; angle of nail plate is about 160 degrees (Kozier, p.583) Highly vascular and pink in light-skinned clients; dark skinned clients may have brown or black pigmentation in longitudinal streaks (Kozier, p.584) Smooth texture (Kozier, p.583)

c. Palpate fingernail and toenail texture

d. Inspect tissues surrounding nails

Intact epidermis (Kozier, p.584)

e. Perform blanch test capillary refill

Prompt return in pink or usual color (Kozier, p.584)

4. HEAD TO TOE EXAMINATION

A. HEAD 1. Skull a. Inspect skull for size, shape or symmetry b. Palpate for nodules, masses and depressions Round; smooth, skull contour (Kozier, p.585) Smooth, uniform consistency; absence of nodules or masses (Kozier, p.585)

2. Scalp a. Inspect for color and appearance b. Palpate for areas of tenderness Evenly distributed hair; no dandruff (Kozier, p.582) No tenderness, nodules, masses and edema (Kozier, p.582)

3. Face a. Inspect the facial features, symmetry of facial movements B. EYES Symmetric or slightly asymmetrical facial features; Symmetrical facial movements (Kozier, p.585)

1. Eyebrows a. Inspect for hair distribution, alighnment, skin and quality and movement Hair evenly distributed; skin intact, eyebrows symmetrically aligned; equal movement (Kozier, p.588)

2. Eyelashes a. Inspect for evenness of distribution and direction of curl Equally distributed; curled slightly outward (Kozier, p. 588)

3.

Lacrimal gland, lacrimal sac and Nasolacrimal duct a. Inspect and palpate No edema nor tenderness over lacrimal gland; No tearing (Kozier, p.589)

4.

Eyelids a. Inspect for the surface characteristics, position in relation to the cornea, ability to blink; and frequency of blinking Skin intact; no discharge; no discoloration; lids close symmetrically; approximately 15-20 involuntary blinks per minute; bilateral blinking; when lids are open no visible sclera above cornea, and upper and lower borders of cornea are slightly covered (Kozier, p.588)

5. Conjunctiva

a. Inspect the bulbar for color, texture, and presence of lesion

Transparent capillaries sometimes evident; sclera appears white(yellow in darkskinned clients) (Kozier, p.588) Pinkish or red in color; with presence of small capillaries; moist; no foreign bodies (Kozier, p.588)

b. Inspect the palpebral for color, texture, lesions, foreign bodies

6. Sclera a. Inspect the color and clarity White; No yellowish discoloration; presence of capillaries (Kozier, p.588)

7. Pupils a. Inspect color, shape and symmetry of size Black; Equal in size; Normally 3-7mm in diameter; Round; Smooth border (Kozier, p.590) Illuminated and nonilluminated pupils constrict

b. Assess each pupil for direct and consensual reaction to light c. Assess each pupil for light reaction and accomodation

Pupils constrict when looking at near object; pupils dilate when looking at far objects; pupils converge when near objects is move towards the nose (Kozier, p.590)

8.

Visual Fields a. Assess peripheral fields When looking straight ahead. The client can see object in periphery (Kozier, p.591)

C. EARS 1. Auricles a. Inspect for color, symmetry and position Color same as facial skin; symmetrical; auricle aligned with outer canthus of the eye, about 10 degree from vertical (Kozier, p.596) Mobile; elastic; firm and not tender; Pinna recoils back after it is folded (Kozier, p.596)

b. Palpate for texture, elasticity and areas of tenderness

2. External ear canal a. Inspect ear canal for cerumen, skin lesion, pus and blood Distal thirds contains hair follicle and glands; (cerumengrayish tan in color) (Kozier, p.596)

3.

Hearing acuity test a. Assess clients response to normal voice tone Normal voice tones audible (Kozier, p.597)

b. Perform watch tick test c. Perform Webers test

Able to hear a ticking in both ears (Kozier, p.597) Sound are heard in both ears or is localized at the center of the head; Weber(-) (Kozier, p.597) Air conducted hearing is greater than bone conducted hearing; Rinne(+) (Kozier, p.598)

d. Conduct Rinnes test

D. NOSE a. Inspect for any deviations in shape, size or color and flaring or discharge frowm nerves b. Inspect the nasal cavities for the presence of redness, swelling, growths and discharge using penlight c. Inspect the nasal septum between nasal chambers d. Test patency of both nasal cavities Symmetric; no discharge; no flaring; uniform color (Kozier, p.600)

Mucosa pink; clear; watery; no discharge; no lesions (Kozier, p.600)

Nasal septum intact and in midline (Kozier, p.600) Air moves freely as the client breathes through the nares (Kozier, p.600)

E. SINUSES a. Locate/Palpate/Identif y the sinuses and note for tenderness No tenderness (Kozier, p.600)

F. MOUTH 1. Lips a. Inspect for symmetry of contour, color and texture Uniform pink color; moist; soft; glistening; elastic texture (Kozier, p.602)

2. Buccal Mucosa a. Inspect for color, moisture, texture and presence of lesions Uniform pink color; moist; soft; glistening; elastic texture; no lesions (Kozier, p.602)

3. Teeth a. Inspect color, number and condition and presence of dentures 32 adult teeth; smooth; white; shiny tooth enamel (Kozier, p.602)

4. Gums a. Inspect for the color and condition Pink gums; moist; firm texture to gums (Kozier, p.602)

5. Tongue/Floor of the mouth a. Inspect for color and texture of the mouth floor and frenulum b. Inspect and palpate the position, color and texture, movement and base of the tongue c. Palpate for any nodules, lumps or excoriated areas 6. Palates and uvula a. Inspect and palpate for color, shape, texture and the presence of bony prominences b. Inspect for position of the uvula and mobility while examining the palates 7. Oropharynx a. Inspect and palpate for color and texture b. Inspect the size of the tonsils, color and discharge Pink and smooth posterior wall (Kozier, p.604) Pink and smooth; no discharge; normal size (Kozier, p.604) Pink palate; hard palate; smooth and soft; more irregular texture (Kozier, p.604) Positioned midline of soft palate (Kozier, p.604) Pink color; moist; slightly rough; presence of whitish coating; can move freely; no tenderness (Kozier, p.603) Central position; pinkish in color; slightly rough; moves freely (Kozier, p.603) No palpable nodules, lumps or excoriated areas (Kozier, p.604)

G. NECK 1. Neck Muscles a. Inspect for abnormal swellings or masses. 2. Lymph Nodes a. Locate /Palpate/Identify lymph nodes for tenderness 3. Trachea a. Inspect and palpate for placement

Muscle equal in size; head centered;swelling or masses (Kozier,p. 607) Not palpable (Kozier, 607)

Central placement in midline of the neck; spaces are equal in both sides (Kozier, p. 608) Not visible upon inspection (Kozier, p. 608) Lobes may not be palpated. If palpated, lobes are small, smooth centrally located, painless and rise freely with swallowing (Kozier, p. 609)

4. Thyroid Gland a. Inspect symmetry and visible masses b. Palpate for smoothness and areas of enlargement, masses or nodules

H. THORAX 1. Posterior Thorax a. Inspect the shape, symmetry and compare the diameter of anteroposterior thorax to transverse diameter b. Inspect the spinal alignment c. Palpate for temperature, tenderness and masses d. Assess respiratory excursion Anteroposterior to transverse diameter in ratio of 1:2; chest symmetric (Kozier, p.614)

Spine vertically aligned (Kozier, p.614) Uniform temperature; no tenderness; no masses (Kozier, p.614)

Full and symmetric chest expansion; thumbs separate3-5 cm (1 to 2 inches) (Kozier, p.615) Bilateral symmetry of vocal fremitus; fremitus is heard most clearly in the apex of the lungs (Kozier, p.615)

e. Palpate vocal fremitus

f.

Percuss the posterior thorax

Percussion notes resonate, except over scapula; lowest point of resonance is at the diaphragm (Kozier, p.615) Bronchial, vesicular and

g. Auscultate the

posterior thorax

bronchovesicular breath sounds (Kozier, p.615)

2. Anterior Thorax a. Inspect breathing patterns b. Palpate for temperature, tenderness and masses c. Assess respiratory excursion

Quiet, rhythmic and effortless respiration (Kozier, p. 617) Uniform temperature; no tenderness; no masses (Kozier, p. 617) Full and symmetric chest expansion; thumbs separate3-5 cm (1 to 2 inches) (Kozier, p.618) Same as posterior vocal fremitus; fremitus is normally decreased over heart and breast tissue (Kozier, p.618) Percussion notes resonance down to the 6th rib at the level of the diaphragm but are flat over the areas of heavy muscles and bones, dull on areas over the heart and liver and tympanic over the underlying stomach. (Kozier, p.618) Bronchial (tubular) breath sounds (Kozier, p.618)

d. Palpate vocal fremitus

e. Percuss anterior thorax

f.

Auscultate the trachea

g. Auscultate the anterior thorax

Bronchovesicular and vesicular breath sounds. (Kozier, p.618)

I. CARDIOVASCULAR 1. Simultaneously inspect and palpate the precordium for the presence of abnormal pulsations, lifts, heaves a. Aortic and pulmonic areas No pulsations (Kozier, p.621) No pulsations (Kozier, p.622) Pulsations visible in 50% of adults and palpable in most point of maximal impulse (PMI) in 5th LICS at/ or medial to midclavicular line ( MCL) (Kozier, p.622) S1 (usually heard at all sites, usually louder at apical area) S2 (usually heard at all sites, usually louder at the base of the heart) (Kozier, p.622) Symmetry pulse volumes; full pulsations, thrusting quality (Kozier, p.622) No sounds heard on auscultation

b. Tricuspid areas c. Apical area

d. Auscultate the aortic, pulmonic, tricuspid and apical valves

2. CAROTID ARTERIES a. Palpate carotid artery with extreme caution b. Auscultate the carotid arteries

(Kozier, p.622) 3. JUGULAR VEINS a. Inspect jugular vein distension

Veins not visible (Kozier, p.622)

J. BREAST a. Inspect breast for size, symmetry, contour or shape while the client is in sitting postion Male: Breast even within the chest wall; if obese maybe similar in shape to female breasts Female: Round; slightly unequal in size; generally symmetric (Kozier, p.628) Skin uniform in color(same appearance as skin of abdomen or back); skin smooth and intact; diffuse symmetrical horizontal or verticular vascular pattern in light-skinned people (Kozier, p.628) Round or oval; smooth, no lesions, color varies from pink to dark brown (Kozier p.628)

b. Inspect the skin of the breast for localized discolorations or hyper pigmentation, retraction, dimpling, localized hypervascular areas, swelling or edema c. Inspect the areola for size, shape, symmetry, color, surface characteristics, and any mass or lesions d. Inspect the nipples for size, shape, position, color, discharge and lesions

Round or oval, everted and equal in size; similar in color; soft and smooth; no discharges and lesions

(Kozier, p.628) e. Palpate the axillary, subclavicular and supraclavicular lymph nodes f. Palpate the breast for masses and tenderness Not palpable and no tenderness (Kozier, p.629) No masses and no area of tenderness (Kozier, p.629) No tenderness, no discharges (Kozier, p.630) Unblemished skin; uniform color (Kozier, p.633)

g. Palpate nipples for tenderness K. ABDOMEN a. Inspect the abdomen for skin integrity

b. Inspect the abdominal contour c. Inspect for an enlarge liver or spleen d. Assess the symmetry of contour while standing at the foot of the bed e. Inspect the abdominal movements associated with respirations, peristalsis or aortic pulsations

Flat, rounded (convex) or scaphoid (concave) (Kozier, p.633) No evidence of enlargement of liver and spleen (Kozier, p.633) Symmetric contour (Kozier, p.633)

Symmetric movements caused)by respiration; visible peristalsis in every lean people in thin person and epigastric area (Kozier, p.633)

f.

Observe vascular patterns

No vascular pattern (Kozier, p.634) Audible bowel sounds (5-20 bowel sounds per minute) (Kozier, p.634)

g. Auscultate the abdomen for bowel sounds, vascular sounds and peritoneal friction rubs h. Percuss several areas in each of the four quadrants

Tympanic over the stomach and gas-filled bowels; dullness especially over the liver and spleen, or a full bladder (Kozier, p.635) No tenderness; relaxed abdomen with smooth consistent tension (Kozier, p.636) May not be palpable; borders feels smooth (Kozier, p.637) Not palpable (Kozier, p.638)

i.

Perform light palpation followed by deep palpation of all four quadrants Palpate the liver for enlargement and tenderness

j.

k. Palpate the bladder

L. MUSCULOSKELETAL SYSTEM 1. Muscles a. Inspect the muscles for size. Compare the muscle on one side of the body (arm, thigh, Equal size on both side of the body (Kozier p.640)

calf) to the same muscle on the other side b. Inspect the muscle and tendons for contractures (shortening) c. Inspect the muscle for fasciculations and tremors. Inspect any tremors of the hands and arms out in front of the body d. Palpate muscle tonicity e. Test for strength (neck) f. Test for strength (upper extremities) No contractures (Kozier p.640)

No fasciculations (Kozier p.640)

Firm (Kozier p.640) Equal strength on each side of the body (Kozier p.640) Equal strength on each side of the body (Kozier p.640) Equal strength on each side of the body (Kozier p.640)

g. Test for strength (lower extremities) 2. BONES a. Inspect the skeleton for normal structure and deformities b. Palpate the bones for any edema or tenderness

No deformities (Kozier p.641) No tenderness or swelling (Kozier, p.641

3. Joints a. Inspect joints for swelling b. Palpate each joint for tenderness , smoothness of movement, swelling, crepitation, and presence of nodule No swelling (Kozier p.641) No tenderness; no presence of nodules; no swelling; smooth coordinated movements (Kozier p.641)

M. ASSESS JOINT RANGE OF MOTION a. Upper extremities (shoulder and scapula) b. Upper extremities (elbows) c. Upper extremities (hands) d. Lower extremities (acetabulum or inguinal area) e. Lower extremities (popliteal) f. Lower extremities (ankles) Smooth coordinated movements Smooth coordinated movements Smooth coordinated movements Smooth coordinated movements Smooth coordinated movements Smooth coordinated movements