RR- 20 12-20 beats/min. Normal PR- 80 60-100 beats/min. Normal BP- 120/70 90/60- 130/90 mmHg Normal
Height = 5’1 ft.
Weight = 57 Kg.
Body Parts Technique Normal Actual Significance
used findings findings Head Inspection Normocephalic Normocephalic Normal Palpation No abnormal No abnormal Normal mass mass Hair and scalp Inspection Evenly Even Normal distributed, distribution of Thick hair, hair , no no infection infection and and infestation infestation Eyes Inspection Symmetric to Sunken eyeball Not Normal. the face, Due to both eyes dehydration coordinated with parallel alignment. External eye Structure
Eyebrows Inspection Hair evenly Evenly Normal
distributed, distributed with Skin intact skin intact Eyelashes Inspection Equally Equally Normal distributed, distributed, Curled slightly Curled slightly outward outward Eyelids Inspection Skin intact, Skin intact, no Normal No discharge, discharge, no No discoloration, discoloration, lids are Lids close symmetrical. symmetrically Lacrimal Inspection No edema or No edema and Normal gland tearing. tearing Pupils (color , Inspection Black in color, Black in color, Normal shape and equal in size equal in size symmetry of normally 3-7 4mm in size) mm in diameter diameter, round smooth border , iris flat and round.
Ears Inspection Symmetrically Positioned Normal
aligned to the symmetrically to face, firm and the face, not tender with No notable ear no discharged discharge, clean noted. and dry,. Nose Inspection Symmetric and Symmetric and Normal straight, no straight , no nasal discharges or discharges noted, flaring no flaring noted Mouth
Lips Inspection Uniform pink Uniform dark color Not Normal
in color, soft dry due to and moist and chemical smooth content of cigarette such as nicotine. Tongue Inspection Tongue at Dry and free of Normal midline lesion without lesion Teeth Inspection Complete, Incomplete, Not normal. white, shiny missing teeth, ill Aging is a tooth enamel, fitting dentures factor affecting free of debris loss of teeth and also insufficient calcium and fluoride. Neck Inspection Coordinated , Coordinated Normal smooth movement with no movement with discomfort no discomfort Palpation No masses, No masses, Normal tenderness tenderness Upper Extremities
Skin Inspection Pinkish in Pallor Not normal.
color It is a manifestation of in adequate circulating blood or hemoglobin. Palpation Slightly moist Poor skin turgor Not normal due to dehydration Palpation Normothermia Not warm, not cold Normal to touch, T=36 Arms Inspection Normally firm, Normally firm, no Normal no contracture, contracture, no no swelling, swelling, equal size equal size on on both sides of both sides of body body Palpation Pulse Rate: 60- Pulse rate: 80 Normal 100 Nails Inspection Smooth, highly Pink, smooth Normal vascular and texture, convex intact curvature epidermis Palpation Capillary Refill Capillary refill: 2 Normal of 1-2 seconds seconds Chest and Inspection Symmetric Symmetric chest Normal Lungs chest expansion, quiet, expansion, rhythmic and quiet, rhythmic effortless and effortless respiration respiration
Palpation No retraction, No retraction, no Normal
no tenderness, tenderness, no no masses masses Auscultation Quiet, Adventitious Not normal due rhythmic breath sounds to presence of secretion Heart Auscultation Normal heart Cardiac rate of 80 Normal rate 60- 100bpm Abdominal Inspection Unblemished Lesions noted on Not normal skin, uniform the surgical site because of post in color procedure done
Auscultation Average Audible bowel Normal
normal bowel sound of 8 per sounds 5-25 minute per minute Lower extremities
Skin Inspection No lesion, can No edema, no Normal
move freely deformities and can move freely Palpation Capillary refill: Capillary refill: 2 Normal 1-2 seconds seconds