ASSESSMENT FINDINGS

Integumentary

Skin
When skin is pinched it goes to
previous state immediately (2
seconds).With fair complexion.With
dry skin
Hair
Evenly distributed hair.With short,
black and shiny hair.With presence
of pediculosis Capitis.
Nails
Smooth and has intact epidermisWith
short and clean fingernails and
toenails. Convex and with good
capillary refill time of 2 seconds.
Skull
Rounded, normocephalic and
symmetrical, smooth and has
uniform consistency.Absence of
nodules or masses.
Face
Symmetrical facial movement,
palpebral fissures equal in size,
symmetric nasolabial folds.
Eyes and Vision

Eyebrows
Hair evenly distributed with skin
intact.Eyebrows are symmetrically
aligned and have equal movement.
Eyelashes Equally distributed and curled slightly
outward.
Eyelids
Skin intact with no discharges and no
discoloration.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,
Nasolacrimal
duct
No edema or tenderness over the
lacrimal gland and no tearing.
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.
Corneal
sensitivity
Blinks when the cornea is touched
through a cotton wisp from the back
of the client.
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.
Visual Fields
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.
Visual Acuity
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.
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.
External Ear
Canal Without impacted cerumen.
Hearing Acuity
Test Voice sound audible.
Watch Tick
Test
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.
Nasal Cavity
Mucosa is pink, no lesions and nasal
septum intact and in middle with no
tenderness.
Mouth and
Oropharynx
Symmetrical, pale lips, brown gums
and able to purse lips.
Teeth With dental caries and decayed
lower molars
Tongue and
floor of the
Central position, pink but with whitish
coating which is normal, with veins
mouth prominent in the floor of the mouth.
Tongue
movement
Moves when asked to move without
difficulty and without tenderness
upon palpation.
Uvula Positioned midline of soft palate.
Gag Reflex
Present which is elicited through the
use of a tongue depressor.
Neck
Positioned at the midline without
tenderness and flexes easily. No
masses palpated.
Head movement
Coordinated, smooth movement with
no discomfort, head laterally flexes,
head laterally rotates and
hyperextends.
Muscle strength With equal strength
Lymph Nodes Non-palpable, non tender
Thyroid Gland
Not visible on inspection, glands
ascend but not visible in female
during swallowing and visible in
males.
Thorax and lungs

Posterior thorax Chest symmetrical
Spinal
alignment
Spine vertically aligned, spinal
column is straight, left and right
shoulders and hips are at the same
height.
Breath Sounds
With normal breath sounds without
dyspnea.
Anterior Thorax Quiet, rhythmic and effortless
respiration
Abdomen
Unblemished skin, uniform in color,
symmetric contour, undistended.
Abdominal
movements
Symmetrical movements cause by
respirations.
Auscultation of
bowel sounds
With audible sounds of 23 bowel
sounds/minute.
Upper Extremities
Without scars and lesions on both
extremities.
Lower Extremities
With minimal scars on lower
extremities
Muscles
Equal in size both sides of the body,
smooth coordinated movements,
100% of normal full movement
against gravity and full resistance.
Bones and Joints
No deformities or swelling, joints
move smoothly.
Mental Status

Language
Can express oneself by speech or
sign.
Orientation Oriented to a person, place, date or
time.
Attention span
Able to concentrate as evidence by
answering the questions
appropriately.
Level of
Consciousness
A total of 15 points indicative of
complete orientation and alertness.
E4V5M6
Motor Function

Gross Motor and
Balance
Walking gait
Has upright posture and steady gait
with opposing arm swing unaided
and maintaining balance.
Standing on one
foot with eyes
closed
Maintained stance for at least five (5)
seconds.
Heel toe walking
Maintains a heel toe walking along a
straight line
Toe or heel walking
Able to walk several steps in
toes/heels.
Fine motor test for
Upper Extremities
Finger to nose test
Repeatedly and rhythmically touches
the nose.
Alternating
supination and
pronation of hands
on knees
Can alternately supinate and pronate
hands at rapid pace.
Finger to nose and
to the nurses finger
Perform with coordinating and
rapidity.
Fingers to fingers Perform with accuracy and rapidity.
Fingers to thumb
Rapidly touches each finger to thumb
with 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.