Assessment Findings
Assessment Findings
Assessment Findings
Integumentary
When skin is pinched it goes to previous
state immediately (2 seconds).
Skin
With fair complexion.
With dry skin
Evenly distributed hair.
Hair With short, black and shiny hair.
With presence of pediculosis Capitis.
Smooth and has intact epidermis
With short and clean fingernails and
Nails toenails.
Convex and with good capillary refill time of
2 seconds.
Rounded, normocephalic and symmetrical,
Skull smooth and has uniform
consistency.Absence of nodules or masses.
Symmetrical facial movement, palpebral
Face fissures equal in size, symmetric nasolabial
folds.
Eyes and Vision
Hair evenly distributed with skin intact.
Eyebrows Eyebrows are symmetrically aligned and
have equal movement.
Equally distributed and curled slightly
Eyelashes
outward.
Skin intact with no discharges and no
discoloration.
Eyelids
Lids close symmetrically and blinks
involuntary.
Bulbar conjunctiva Transparent with capillaries slightly visible
Palpebral Conjunctiva Shiny, smooth, pink
Sclera Appears white.
Lacrimal gland, Lacrimal sac, No edema or tenderness over the lacrimal
gland and no tearing.
Assessment Findings
Nasolacrimal duct
Cornea
Transparent, smooth and shiny upon
inspection by the use of a penlight which is
Clarity and texture 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
Corneal sensitivity
cotton wisp from the back of the client.
Black, equal in size with consensual and
direct reaction, pupils equally rounded and
reactive to light and accommodation, pupils
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
nurse at a distance of 2-3 feet.
Visual Fields
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.
Visual Acuity
Patient was able to read the newsprint at a
distance of 8 inches.
Ear and Hearing
Color of the auricles is same as facial skin,
symmetrical, auricle is aligned with the outer
Auricles
canthus of the eye, mobile, firm, non-tender,
and pinna recoils after it is being folded.
External Ear Canal Without impacted cerumen.
Assessment Findings
maintaining balance.
Maintained stance for at least five (5)
Standing on one foot with eyes closed
seconds.
Maintains a heel toe walking along a straight
Heel toe walking
line
Toe or heel walking Able to walk several steps in toes/heels.
Fine motor test for Upper Extremities
Repeatedly and rhythmically touches the
Finger to nose test
nose.
Alternating supination and pronation of Can alternately supinate and pronate hands
hands on knees at rapid pace.
Finger to nose and to the nurses finger Perform with coordinating and rapidity.
Fingers to fingers Perform with accuracy and rapidity.
Rapidly touches each finger to thumb with
Fingers to thumb
each hand.
Fine motor test for the Lower Extremities
Pain sensation Able to discriminate between sharp and dull
sensation when touched with needle and
cotton.
Systol
Weig
Respira ic Weig
Heart ht in
Age Group tory Blood ht in
Rate poun
Rate Press kilos
ds
ure
120 - 50 - 4.5 -
Newborn 30 - 50 2-3
160 70 7
Infant (1-12 80 - 70 - 4- 9-
20 - 30
months) 140 100 10 22
Toddler (1-3 80 - 80 - 10 - 22 -
20 - 30
yrs.) 130 110 14 31
Preschooler (3-5 80 - 80 - 14 - 31 -
20 - 30
yrs.) 120 110 18 40
School Age (6- 70 - 80 - 20 - 41 -
20 - 30
12 yrs.) 110 120 42 92
Adolescent (13+ 55 - 110 -
12 - 20 >50 >110
yrs.) 105 120