Anda di halaman 1dari 9

Body Parts Norms and Actual findings Analysis

a. Height 4’6” or 4’7” in Normal
b. Weight 44 kg Normal
c. BMI Normal BMI 20-25 22.5 BMI Normal
d. Vital Signs
-Temperature 37 degrees C / 98.6 36.2 degrees celcius Normal
degrees F
-Pulse Rate Rate:50-90 BPM Rate: 83 Normal
Rhythm: regular or Rhythm: regular
irregular Volume: weak
Volume: strong or
-Respiratory Rate 15-20 CPM 25 CPM abnormal
-Blood Pressure 120/80 mmHg 170/80 mmHg Normal
General Survey
a. body built Endomorph/ Ectomorphic built Ectomorphi
Ectomorph/ c
b. height Proportionate to age, Proportionate to normal
weight health, body age,
built and varies with
c. weight Proportionate to age, Under weight abnormal
weight health, and
body built
d. posture Relaxed, and erect Relaxed, and Abnormal
posture posture w/ bending
e. body Coordinated Body Not Coordinated abnormal
movement movements Body movements
f. overall hygiene Clean and neat, no Poor hygiene. abnormal
and grooming body odor or minor
body odor due to
work or exercise, no
breath odor
g. clothing type Neat and Clean dirty abnormal
h. mood/ affect Cooperative, Not Cooperative and Abnormal
appropriate to not appropriate to
situation situation
i. quantity and Response Not Response not abnormal
quality of speech appropriate to the appropriate to the
situation/ clear loud situation/ clear loud
enough to be heard enough to be heard
j. organization of Response Not Response abnormal
thoughts appropriate to the appropriate to the
question and question and
situation situation
a. Skin
-appearance Uniform in The skin appears thin and Normal
color, no translucent because of loss
presence of of dermis and
edema or subcutaneous fat due to
lesions aging.

-skin moisture Slightly moist The skin is dry and flaky Normal
and temperature because sebaceous and
sweat glands are less
active. Dry skin is more
prominent over the
-skin turgor Not loose Due to the normal loss of Normal
peripheral skin turgor in
elders, assess for
hydration by checking skin
turgor over the sternum or
clavicle. The skin takes
longer to return to its
natural shape after being
tented between the
thumb and finger.
b. Nails
- curvature and Convex and Convex and 160 degrees Normal
angle 160 degree angle
- toenail bed Pinkish Pinkish to light red Normal
-texture Smooth Smooth and thick texture Normal
-tissues Epidermis Epidermis intact and no Normal
Intact surrounding tissues on the
-capillary refill Color easily Color easily goes back in Normal
goes back, no about 3 second and there
tenderness are no signs of tenderness

Head to neck examination

A. Head
a. skull Rounded (normocephalic, Rounded and Normal
symmetrical with frontal, normocephalic,
parietal and occipital smooth skull contour,
prominences), smooth skull smooth uniform
contour, smooth uniform consistency, no
consistency, absence of masses nodules, has
masses or nodules, no no tenderness in the
tenderness upon palpation, symmetric, palpebral
symmetric or slightly fissures are equal in
asymmetric, palpebral size, and symmetric
fissures are equal in size, nasolibial folds
symmetric nasolibial folds
b. scalp Lighter in color than the Lighter color than Normal
complexion, can be moist or majority of skin, no
oil, no scars noted, free from tenderness, nodules or
lice, nits and dandruff, masses, no lesions,
smooth, absence of nodules little moist and no
and masses, no tenderness dandruff
upon palpation, no lesions
c. hair Can be black, brown or White and thin but Normal
burgundy depending on the equally distributed,
race, Evenly distributed and silky and no
covers the whole scalp ( no microorganism
evidence of Alopecia),thick or infestation
thin hair, silky, resilient, no
infection or infestation,
neither brittle nor dry
d. face Symmetric, or slightly Symmetric and equal Normal
symmetric facial features, in size and there is
palpebral fissures equal in symmetry on facial
size, symmetrical facial movement
e. eyes Symmetric not puffy Symmetric Normal
f. Symmetrical and in line with Symmetrical in line Normal
eyebrow each other, hair evenly with each other color
s distributed, can be black, is the same as that of
brown or blonde depending on the hair and is evenly
race distributed
g. eye Color depend on race, equally Color the same of the Normal
lashes distributed, turned outward hair, slightly short but
turned outward
h. eye Upper eyelids cover the small Cover the cornea and Normal
lids portion on the iris, cornea, is intact with the eye,
and sclera when eyes are no lesions and is
open, meet skin intact, no smooth
discharge, no discolorization,
lids closed asymmetrically,
approximately 15-2,
involuntary blinks, bilateral,
blinking, when lids open, no
visible sclera above corneas
and upper and lower borders
of cornea are slightly covered.
i. bulbar Transparent, capillaries Transparent, normal
conjuncti sometimes evident, sclera capillaries sometimes
va appears white (yellowish in evident, sclera
white skin clients) appears white
(yellowish in white skin
j. Shiny, smooth and red and Shiny, smooth and red normal
palpebra pink in color and pink in color
k. sclera No yellowish discolorization, Dirty white and there Normal
capillaries sometimes evident, is minute presence of
sclera appears white veins or capillaries.
l. cornea There is a positive corneal Appears white, Normal
reflex, transparent, shiny and smooth, and positive
smooth, details of iris are corneal reflex.
m. iris The anterior chamber is Colored brown and is Normal
transparent, no noted visible circular and smooth
materials, smooth, Brown in
color and rounded
n. pupils Black in color, equal in size, Black and slightly Ab-
normally 3-7 mm in dm; cloudy in color and normal
equally round, smooth and pupils are sized 2mm
border iris flat and round, and are equally
illuminated pupil constricts rounded and react
and non-illuminated pupil accordingly to light
dilates, pupils constricts when and accomodation.
looking at near objects, pupil
dilates when looking at far
objects is moved toward nose
o. Coordinated movement or Coordinated Normal
moveme unison; with parallel movement.
nt alignment
p. No presence of edema, No presence of edema Normal
lacrimal lesions, tenderness or pain tenderness and
gland/ lesions.
sac and
mal duct
q. extra Extra ocular muscles are Extraocular Normal
ocular symmetrical in movement movements are
muscles symmetrical in
r. visual Able to see on the periphery Able to see on the normal
fields periphery
s. Ears
-Auricles Slightly pinkish in color The color is the same Normal
, symmetrical and the position as that of the skin,
is aligned with the outer elastic and smooth, no
cantus of the eye. Smooth, no tenderness and no
nodules, no blood lesions.
-External Presence of cerumen, skin There is little presence Normal
ear canal lesions, no pus and blood of cerumen and no
lesions, pus, or blood.
-Voice Easily heard Poor sensorineural Normal
tone’s heard due to aging
test and
watch tick
t. Nose
-External No discharge or flaring, No discharge, no Normal
and uniform color, no tender or flaring, the same color
internal lesions, air moves freely as of the face and
nares the client moves through the majority of the skin.
nares Air moves freely
-nasal Mucosa pink, clear watery Pinks mucosa, no Normal
cavities discharge, no lesions discharge, no lesions.
-Septum Nasal septum intact and in Nasal septum is intact Normal
the middle, no tenderness and is in the middle,
no tenderness.
u. Mouth
-Lips Uniform pink color, smooth, Light pink in color, no Normal
moist, soft, symmetry in lip break, or lesions
contour. Ability to purse lips smooth, and little dry
-Gums Pink gums(bluish or dark Pink gums and is Normal
patches on darkened skinned moist, firm and no
clients) moist, firm texture to retractions and
gums, no retraction of gums lesions.
(pulling away from teeth)
- Teeth 32, adult teeth, smooth, presence of dentures Lack of
whiter, shiny, tooth enamel teeth
-Tongue Central position, pink in color, Central position, light Normal
(some brown pigmentation on pink in color with white
tongue border); moist; slightly cover on top, rough
rough, thin whitish coating, and moist with veins
smooth tongue base with on base of the tongue.
prominent veins, smooth with
no palpable nodules
-Frenulum Pink in color, central position, Light pink, central Normal
no lesions position and no
- Buccal Pink in color and no lesions Pink in color and no Normal
mucosa lesions.
-Palates Light pink, smooth palate, Light pink, smooth Normal
lighter pink, hard palate, more palate at near the
irregular texture uvula.
-Uvula Position in midline soft palate In the middle and is Normal
attached to the soft
- Pink smooth posterior wall Pink and smooth and Normal
Orophary moist.
-Tonsils Pink smooth, of normal size Pink, smooth and of Normal
normal size
v. Neck
- Lymph No tenderness No tenderness Normal
- Trachea Central placements in midline Placed at the center Normal
of neck, spaces are equal in and is symmetrical on
both sides both sides
-Thyroid Not visible on inspection Glands ascend through Normal
Body Parts Norms and Actual Analysis
Standards findings
Posterior Thorax
Inspect the size, Symmetric, 1:2 Symmetric, Normal
shape, symmetry, 1:2
and compare the
gland of gland ascends during swallowing and there
swallowing but not visible are no depressions
thorax toLobes may not be palpated, if and swelling.
transverse palpate, lobes are small,
diameter smooth, centrally located,
painless and
Inspect the spinal rise freely with
Symmetrically Symmetricall Normal
alignment swallowing absence
aligned of brut y aligned
Palpate for the No tenderness and No Normal
temperature, masses, normal tenderness
tenderness and temperature and masses
masses and normal
Asses respiratory Both thumbs Both thumbs Normal Physical
excursion moved apart and moved apart Assessment II
the distance equal and the
Palpate vocal Vibrations clearly Vibrations Abnormal
fremitus heard not clearly
Percuss the Resonance Resonance, Normal
posterior thorax flat and dull
Auscultate the Vesicular at lungs Vesicular at Normal
posterior thorax base and lungs base
pheriphery, and and
bronchovesicular pheriphery,
sounds between and
the scapulae and bronchovesic
lateral to the ular sounds
sternum at the 1st between the
and 2nd intercostals scapulae and
spaces lateral to the
sternum at
the 1st and