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Body Part/Area a.

HEIGHT AND WEIGHT

Technique
1. Using Growth chart 2. Using weighing scale

Patients Results
Height: 5 ft. Or 152.4 cm Weight: 127 lbs or 58 kg Lifestyle: sedentary BMI = 25 -> Normal Proportionate, varies with lifestyle

Normal Findings
Proportionate, varies with the lifestyle

Abnormal Findings
Excessively thin or obese

b. GENERAL INFORMATION

1. Prior to performing procedure, introduce self, and verify the clients identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. 2. Perform hand hygiene and observe appropriate infection control procedures. 3. Provide for client privacy. 4. Observe the body build, height and weight in relation to the clients age, lifestyle, and health. 5. Observe clients posture and gait, standing, sitting

Proportionate, varies with lifestyle

Proportionate, varies with lifestyle

Excessively thin or obese

Relaxed, slightly bent and slouched posture, coordinated movement

Relaxed, erect posture; coordinated movement

Tense, slouched, bent posture; uncoordinated movement, tremors

and walking. 6. Observe clients overall hygiene and grooming. 7. Note body and breath odour in relation to activity level. 8. Observe for signs of distress in posture or facial expression. 9. Note obvious signs of health or illness. 10. Assess the clients attitude. 11. Note the clients affect/mood; assess the appropriateness of clients responses. 12. Listen for quantity of speech, quality and organization. 13. Listen for relevance and organization of thoughts. 14. Document findings in the client record using handwritten or electronic forms and checklists supplemented by narrative notes when appropriate.

Clean, neat No body odour, no breath odour Bending over because of pain (due to surgery)

Clean, neat No body odour, or minor body odour relative to work or exercise; no breath odour No distress noted

Dirty, unkempt Foul body odour, ammonia odour, acetone breath odour; foul breath Bending over because of abdominal pain, wincing, frowning or labored breathing Pallor, weakness, lesions Negative, hostile, withdrawn Inappropriate to situation Rapid or slow pace; overly loud or soft; uses generalizations; lacks association Illogical sequence; flight of ideas; confusion; vague

Healthy appearance, no signs of illness Cooperative, able to follow instructions well Appropriate to situation; good mood

Healthy appearance Cooperative, able to follow instructions Appropriate to situation

Understandable in wording yet slightly slow in speech, speaks slightly soft Logical sequence; makes sense; has sense of reality

Understandable, moderate pace; clear tone and inflection; exhibits thought association Logical sequence; makes sense; has sense of reality

c. SKIN

1. Prior to performing procedure, introduce self, and verify the clients identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. 2. Perform hand hygiene and observe appropriate infection control procedures. 3. Provide for client privacy. 4. Inquire if the client has any history of the following: pain or itching; presence and spread of lesions, bruises, abrasions, pigmented spots; previous experience with skin problems, bruises, etc. 5. Inspect the skin color.

Usually experiences itching and pain at the back, no bruises in any part of the body

Light complexion

Varies from light to deep brown; from ruddy pink to light pink Generally uniform except in areas exposed to the sun No edema Freckles, some birthmarks, some flat and raised nevi; no abrasions or other lesions

Pallor, cyanosis, jaundice, erythema Areas of either hyper pigmentation or hypo pigmentation See the scale for describing edema Various interruptions in skin integrity; irregular, multicoloured or raised nevi

6. Inspect uniformity of skin colour. 7. Assess edema, if present. 8. Inspect, palpate and describe skin lesions.

Skin color distribution is uniform except for the arms which are darker in color No edema Contains birthmarks that are found beneath the right arm and legs

9. Observe and palpate skin moisture. 10. Palpate skin temperature. Compare the two feet and two hands, using the backs of your fingers. 11. Note the skin turgor (fullness or elasticity) by lifting and pinching the skin on an extremity. 12. Document findings in the client record using forms or checklists. 1. Prior to performing procedure, introduce self, and verify the clients identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. 2. Perform hand hygiene and observe appropriate infection control procedures. 3. Provide for client privacy. 4. Inquire if the client has any history of the following: past problems with lumps, itching, scaling, or dandruff, dizziness, seizures, headache, any

Slightly dry Uniform; within normal range

Moisture in skinfolds, and the axillae Uniform; within normal range

The skin springs back slower to the previous state due to aging process

When pinched, skin springs back to previous state; may be slower in elders

Excessive moisture; excessive dryness Generalized hyperthermia; heneralized hypothermia; localized hyperthermia or hypothermia Skins stays pinched or tented or moves back slowly

d. HEAD

Has experienced dandruff and itchiness, headaches and dizziness

injury or lumps or bumps, symptoms, etc. 5. Inspect the skull for size, shape and symmetry.

Rounded; smooth skull contour

Rounded; smooth skull contour

6. Palpate the skull for nodules or masses and depressions. Use a gentle rotating motion with the fingertips. Begin at the front and palpate down the midline, then palpate each side of the head. 7. Inspect the facial features.

Smooth; uniform, absence of nodules or masses

Smooth, uniform consistency; absence of nodules or masses.

Lack of symmetry; increased skull size with more prominent nose and forehead; longer mandible Sebaceous cysts; local deformities from trauma; masses, nodules

Symmetric facial features; thinning of eyebrows

Symmetric or slightly asymmetric facial features; palpebral fissure equal in size; symmetric nasolabial folds

8. Inspect the eyes for edema and hollowness. 9. Note symmetry of facial movements. 10. Document findings in the client record using forms or checklists supplemented by narrative notes when appropriate.

Normal Symmetric facial movements Symmetric facial movements

Increased facial hair; thinning of eyebrows; asymmetric features; exophthalmos; myxedema facies; moon face Periorbital edema; sunken eyes Asymmetric facial movements

e. EYES AND VISION

1. Prior to performing procedure, introduce self, and verify the clients identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. 2. Perform hand hygiene and observe appropriate infection control procedures. 3. Provide for client privacy. 4. Inquire if the client has any history of the following: family history of diabetes, hypertension, blood dyscrasia, or eye disease, injury, or surgery, etc. 5. Inspect the eyebrows for hair distribution and alignment and skin quality and movement (ask client to raise and lower the eyebrows) 6. Inspect the eyelashes for evenness of distribution and direction of curl. 7. Inspect the eyelids for surface characteristics position in relation to the cornea, ability to blink, and frequency of blinking.

Her family has diabetic history, she has hypertension at present and rheumatoid arthritis and has underwent spinal (L5S1)surgery Hair is unevenly distributed (more hair at the back part of the head), loss of hair and flakiness of skin Unequal alignment and movement of eyebrows Equally distributed, slightly turned inward Skin intact; no discharge and discoloration Lids close symmetrically sluggish blinking Hair evenly distributed; skin intact Eyebrows symmetrically aligned; equal movement Equally distributed; curled slightly outward Skin intact; no discharge; no discoloration Lids close symmetrically Approximately 15-20 involuntary blinks per minute; bilateral blinking Loss of hair; scaling and flakiness of skin Unequal alignment and movement of eyebrows Turned inward Redness, swelling, flaking, crusting, plaques, discharge, nodules, lesions Lids close asymmetrically,

8. Inspect the bulbar conjunctiva for color, texture, and the presence of lesions. Retract the eyelids with your thumb and index finger, exerting pressure over the upper and lower bony orbits. 9. Inspect the palpebral conjunctiva by everting the lids. 10. Evert the upper lids if a problem is suspected. 11. Inspect the palpate the lacrimal gland. 12. Inspect and palpate the lacrimal sac and nasolacrimal duct. 13. Inspect the cornea for clarity and texture. 14. Perform the corneal sensitivity (reflex) test to determine the function of the 5th cranial nerve. 15. Inspect the anterior chamber for transparency and depth. 16. Inspect the pupils for colour, shape, and

transparent

Transparent; capillaries sometimes evident; sclera appears white

incompletely, painfully Rapid or absent blinking Jaundiced sclera, excessively pale sclera, lesions or nodules

Slightly pale in color

Shiny, smooth, and pink or red Everting the upper eyelid Palpating the lacrimal gland

No edema, not tender No edema or tearing

No edema or tenderness over lacrimal gland No edema or tearing

Transparent, shiny and smooth Client blinks when the cornea is touched Transparent

Transparent, shiny and smooth; details of iris are visible Client blinks when the cornea is touched, indicating that the trigeminal nerve is intact Transparent No shadows of light on iris Depth of about 3 mm Black in color, equal in size; normally 3-7mm in

Extremely pale, extremely red, nodules or other lesions Holding the margin of the everted upper eyelid Palpating the lacrimal sac nasolacrimal duct Swelling or tenderness over lacrimal gland Increased tearing, regurgitation of fluid on palpation of lacrimal sac Opaque, surface not smooth Arcus senilis in clients One or both eyelids fail to respond Cloudy Crescent-shaped shadows in far side of iris Shallow chamber Cloudiness, mydiriasis, miosis, anisocoria,

Lighter black in color Has a smooth border

symmetry of size. 17. Assess each pupils direct and consensual reaction to light to determine the function of the 3rd and 4th cranial nerves. 18. Assess each pupils reaction to accommodation.

Symmetrical Illuminated pupil constricts Non-illuminated pupil constricts

diameter; round, smooth border, iris flat and round Illuminated pupil constricts Non-illuminated pupil constricts

bulging of iris Neither pupil constricts Unequal responses Absent responses

Pupils constrict when looking at near object; pupils dilate when looking at far object Visual field smaller than normal

19. Assess the peripheral visual fields to determine the function of the retina and neuronal visual pathways to the brain and second cranial nerve. 20. Assess six ocular movements to determine eye alignment and coordination. 21. Assess for location of light reflex by shining penlight on pupil in corneal surface. 22. Have client fixate on a near or far object.

Pupils constrict when looking at near object; pupils dilate when looking at far object; pupils converge when near object is moved toward nose When looking straight ahead, client can see objects in the periphery

One or both pupils fail to constrict, dilate or converge

Visual field smaller than normal

Both eyes are coordinated, moves in parallel position

Both eyes are coordinated, move in unison, with parallel alignment Light falls symmetrically on both pupils

Eye movements not coordinated or parallel; one or both eyes fail to follow a pen light in specific directions Light falls off center on one eye (misalignment) If misalignment is present, when dominant eye is covered, the uncovered eye will move to focus on object Difficulty in reading newsprint unless due to

when dominant eye is covered, the uncovered eye will move to focus on object difficulty in reading newsprint due to aging;

Uncovered eyes does not move

23. Assess near vision providing adequate lighting

Able to read newsprint

and asking client to read from a magazine or newspaper held at a distance of 36 cm (14 in). 24. Assess the distance vision by asking the client to wear corrective lenses, unless they are used for reading only. 25. If the client is unable to see even the top line of Snellen type chart, perform functional vision tests. 26. Document findings in the client record using forms or checklists supplemented by narrative notes when appropriate.

occurred blurry vision

aging

not a 20/20 vision

20/20 vision on Snellen type chart

Denominator of 40 or more on Snellen type chart with corrective lenses Functional vision only

f. EARS AND HEARING

1. Prior to performing procedure, introduce self, and verify the clients identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. 2. Perform hand hygiene and observe appropriate infection control procedures. 3. Provide for client privacy. 4. Inquire if the client has

any history of the following: family history of hearing problems, or loss; presence of ear problems or pains; medication history, hearing difficulty, etc. 5. Position the client comfortably, seated if possible. 6. Inspect the auricles for color, symmetry of size and position, note the level at which the superior aspect of the auricle attaches to the head in relation to the eye. 7. Palpate the auricles for texture, elasticity, and areas of tenderness. 8. using an otoscope, inspect the external ear canal for cerumen, skin lesions, pus and blood. 9. Inspect the tympanic membrane for color and gloss. 10. Assess the clients response to normal voice tones. 11. Document findings in the client record using the forms or check lists supplemented by narrative notes when appropriate.

Has a family history on hearing problems and hearing loss

The color is the same as the facial skin Symmetrical

Color same as facial skin Symmetrical Auricle aligned with outer canthus of eye about 10 degree from vertical Mobile, firm, and not tender; pinna recoils after it is folded Dital third contains hair follicles and glands Dry cerumen, grayish-tan color; or sticky Pearly gray color, semitransparent Normal voice tones audible

Bluish color of earlobes; pallor, excessive redness

Mobile, firm, not tender Pinna recoils after it is folded slowly

Normal voice tones are slightly audible

Lesions, flaky, scaly skin; tenderness when moved or pressed Redness and discharge Scaling Excessive cerumen obstructing canal Pink to red, some opacity Yellow-amber Dull surface Normal voice tones not audible

g. NOSE AND SINUSES

1. Prior to performing procedure, introduce self, and verify the clients identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. 2. Perform hand hygiene and observe appropriate infection control procedures. 3. Provide for client privacy. 4. Inquire if the client has any history of the following: history of allergies, difficulty breathing through the nose, sinus infections, injuries to nose or face, nosebleeds, medications taken; changes in sense of smell 5. Position the client comfortably, seated if possible. 6. Inspect the external nose for any deviations in shape, size, or color and flaring or discharge from the nares 7. Lightly palpate the external nose to determine any areas of tenderness, masses, and

Has undergone allergic reactions, sinus infections and nose bleeds

Symmetric and straight

Symmetric and straight

No lesions, not tender

Not tender; no lesions

Asymmetric Discharge from nares Localized areas of redness or presence of skin lesions Tenderness on palpation; presence of lesions

displacements of bone and cartilage. 8. Determine patency of both nasal cavities. 9. Inspect the nasal cavities using a flashlight or a nasal speculum. 10. Observe the presence of redness, swelling, growths and discharge. 11. Inspect the nasal septum between the nasal chambers. 12. Palpate the maxillary and frontal sinuses for tenderness. 13. Document findings in the client record using forms or checklists. 1. Prior to performing procedure, introduce self, and verify the clients identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. 2. Perform hand hygiene and observe appropriate infection control procedures. 3. Provide for client privacy. 4. Inquire if the client has

Air moves freely as she breathes through the nares

Air moves freely as the client breathes through the nares

Air movement is restricted in one or both nares

Clear discharge No lesions Nasal septum intact and in midline Not tender

Mucosa pink Clear, watery discharge No lesions Nasal septum intact and in midline Not tender

Mucosa red, edematous Abnormal discharge Presence of lesions Septum deviated to the right or to the left Tenderness in one or more sinuses

h. MOUTH

any history of the following: routine pattern of dental care, last visit to dentist, length of time ulcers or other lesions have been present, dentures, etc. 5. Position the client comfortably, seated if possible. 6. Inspect the outer lips for symmetry of contour, color and texture.

Usually visits dental care once a week, last visit to dentist was last Saturday

Has uniform pink color Soft, moist and smooth texture Ability to purse lips

Uniform pink color Soft, moist, smooth texture Symmetry of contour Ability to purse lips

7. Inspect and palpate the inner lips and buccal mucosa for color, moisture, texture and presence of lesions. 8. Inspect the teeth and gums while examining the inner lips and buccal mucosa.

Has uniform pink in color Moist, smooth, soft

Uniform pink color Moist, smooth, soft, glistening, and elastic texture 32 adult teeth Smooth, white shiny tooth enamel Pink gums Moist, firm texture gums No retraction of gums Smooth, intact dentures Central position Pink color Smooth, lateral margins; no

Missing teeth and usually uses pustiso everyday Pink in color and has firm gums

Pallor, cyanosis Blisters, generalized or localized swelling; fissures, crusts, or scales, excessrive moisture, nutritional defieciency Inability to purse lips Pallor, leukoplakia, red bleeding Excessive dryness Mucosal cysts, irritations , abrasions Missing teeth;ill-fitting dentures Brown or black discoloration of enamel Excessively red gums Spongy texture; bleeding, tenderness Ill-fitting dentures, irritated and excoriated area Deviated from center Smooth red tongue Dry, furry tongue

9. Inspect the dentures. 10. Inspect the surface of the tongue for position, color, and texture.

Ill-fitting dentures The tongue is center, pink in color Has dry, furry tongue

11. Inspect the tongue movement. 12. Inspect the base of the tongue, the mouth floor, and the frenulum. 13. palpate the tongue and floor of the mouth for any nodules, lumps or excoriated areas, 14. Inspect the salivary duct openings for any swelling or redness. 15. Inspect the hard and soft palate for color, shape, texture, and the presence of bony prominences. 16. Inspect the uvula for position and mobility while examining the palates. 17. Inspect the oropharnyx for color and texture. 18. Inspect the tonsils for color, discharge and size. 19. Elicit the gag reflex, by pressing the posterior tongue with a tongue depressor. 20. Document findings in the client record using forms or checklists.

Moves freely, no tenderness No swellings or findings of ulceration Smooth in texture, no palpable nodules No inflammation or signs of inflammations Light pink, smooth, soft palate

lesions Raised papillae (taste buds) Moves freely, no tenderness Smooth tongue base with prominent veins Smooth, with no palpable nodules Same as color of bucaal mucosa and floor of mouth Light pink, smooth, soft palate Lighter pink hard palate, more irregular texture Positioned in midline of soft palate Pink and smooth posterior wall Pink and smooth No discharge Of normal size or not visible Present

Nodes, ulcerations, tenderness Restricted mobility Swelling, ulceration Swelling nodules

Inflammation (redness and swelling) Discoloration Palates the same color Exostoses growing from hard palate Deviation to one side from tumor or trauma; immobility Reddened or edematous; presence of lesions, plaques or drainage Inflamed Presence of discharge Swollen Absent

Pink and smooth posterior wall Pink and smooth No discharge Present

i. NECK

1. Prior to performing procedure, introduce self, and verify the clients identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. 2. Perform hand hygiene and observe appropriate infection control procedures. 3. Provide for client privacy. 4. Inquire if the client has any history of the following: problems with neck lumps, neck pain or stiffness; when and how any lumps occurred, etc. 5. Inspect the neck muscles for abnormal swellings or masses. 6. Observe the head movement.

Muscles are equal in size, head is in center position Coordinated, slightly with discomfort Head hyperextends 60 degree Head laterally flexes 40 degree Head laterally rotates 70 degree

Muscles equal in size; head centered Coordinated, smooth movements with no discomfort Head hyperextends 60 degree Head laterally flexes 40 degree Head laterally rotates 70 degree Equal strength

Unilateral neck swelling, head titled to one side Muscle tremor, spasm or stiffness Limited range of motion; painful movements; involuntary movements Head hyperextends less than 60 degree Head laterally flexes less than 40 degree Head laterally rotates less than 70 degree Unequal strength

7. Assess the muscle

Slightly unequal

strength. 8. Palpate the entire neck for entire lymph nodes. 9. Palpate the trachea for lateral deviation. 10. Inspect the thyroid gland.

Not palpable

Equal strength Not palpable Central placement in midline of neck; spaces are equal on both sides Not visible on inspection Gland ascends during swallowing but is not visible Lobes may not be palpated If palpated, lobes are small, smooth, centrally located, painless and rise freely when swallowing Absence of bruit

11. Palpate the thyroid gland for smoothness.

Unequal strength Enlarged palpable, possibly tender Deviation to one side, indicates possible neck tumor Visible diffuseness or local enlargement Gland is not fully movable with swallowing Solitary nodules

12. If enlargement of the gland is suspected, auscultate over the thyroid area for a bruit. 13. Document findings in the client record using the supplemented checklist of forms.

Absence of bruit

Presence of bruit

Submitted by: SANTOS, NINA FRANCEZ A. 3N1-Group 1 Health Care Laboratory