General Survey 1. Observe body built height & weight in relation to clients age, lifestyle & health. 2.

Observe clients posture & gait, standing, sitting and walking. 3. Observe the clients overall hygiene & grooming. 4. Note body & breathe odor in relation to activity level. 5. Observe sign of distress in posture or facial expression. 6. Assess clients attitude.

TECHNIQUE Inspection

Actual Findings Thin Thin looking

Normal Findings Proportionate. Varies with Lifestyle.

Analysis Weight loss is due to loss of appetite.

Inspection

Supine position

Relaxed erect posture and coordinated movement. Clean & neat.

Evidenced by normal breathing and making herself comfortable. Evidenced of providing proper hygiene Evidenced of providing proper hygiene

Inspection

Clean & neat clothes No body odor or minor body odor relative to work or exercise, no breath odor. eupnea

Inspection

No body odor or minor body odor relative to work or exercise, no breath odor. No distress noted.

Inspection

Evidenced of normal in breathing. Evidence of mild Anxiety.

Inspection

Cooperative

Cooperative.

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SKIN PARTS Integument normal Skin Inspection - Skin pigmentation varies from the light to deep brown, ruddy pink to light pink or yellow overtones to olive. Generally uniform except in areas exposed to sun; areas of lighter pigmentation (palms, lips nail beds) in dark skin people. Palpation No edema, abrasions, lesion. Temperature is uniform and w/in normal range. Skin should have good skin turgor. -brown complexion varies with the color of the body - No edema, abrasions, lesion. Temperature is uniform and w/in normal range. Skin should have good skin turgor. METHOD NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

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( Fundamentals of Nursing by 7th Edition, Kozier, Erb Blais, Wilkinson, pp.538-540) Nails Inspection Convex curvature; angle of nail plate about 160o, with smooth texture. Color is highly vascular& pink in light skinned clients; dark skinned clients may have brown or black pigmentation in longitudinal streaks, with intact epidermis on tissue surroundings, blanch test- prompt return of pink or usual color (gen. <3 sec) ( Fundamentals of Nursing by 7th Edition, Kozier, Erb Blais, Wilkinson, pp.542-543) Convex curvature; angle of nail plate about 160o, with smooth texture. Color is highly vascular& pink in light skinned clients; dark skinned clients may have brown or black pigmentation in longitudinal streaks, with intact epidermis on tissue surroundings, blanch testprompt return of pink or usual color (gen. <3 sec) .normal

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HEAD PARTS Hair METHOD Inspection NORMAL FINDINGS Evenly distributed hair over the scalp with thickness, variable amount of body hair. No infection or infestation. ( Fundamentals of Nursing by 7th Edition, Kozier, Erb Blais, Wilkinson, pp.541) Scalp Inspection Palpation Clean, free from masses, lice, scars, nits, dandruff, and lesions. There are no area of tenderness and lumps when palpated. ( Fundamentals of Nursing No signs of dandruff, lesions lice or scars -no tenderness normal ACTUAL FINDINGS Evenly distributed hair over the scalp with thickness, variable amount of body hair. No infection or infestation. INTERPRETATION normal

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by 7th Edition, Kozier, Erb Blais, Wilkinson, pp.544545) Skull Inspection Palpation Rounded (normocephalic) & symmetrical, with frontal, parietal, occipital, prominences) smooth, uniform, absence of modules or masses. -Rounded and proportional gross body structure and smooth skull contour -no mass, nodules, and tenderness -temporal pulse is palpable -frontal and maxillary sinuses are non-tender. Face Inspection Symmetric or slightly asymmetric facial features, palpebral fissures equal in size; symmetric nasolabial folds. Symmetric facial movement. ( Fundamentals of Nursing
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Round in shape and symmetric Normal Findings ( Fundamentals of Nursing by 7th Edition, Kozier, Erb Blais, Wilkinson, pp.544-545) normal

-Facial skin color is brown. -symmetrical facial expression with wrinkles. -no voluntary movements

by 7th Edition, Kozier, Erb Blais, Wilkinson, pp.545)

EYES PARTS Eyebrows METHOD Inspection NORMAL FINDINGS Hair evenly distributed; skin intact. Eyebrows symmetrically aligned; equal movement ACTUAL FINDINGS -thin and evenly distributed hair, gray in color. -symmetrically aligned. -skin intact -no flakiness or scaling -can raise his eyebrows without difficulty. Eyelashes & Inspection Equally distributed, Curled slightly outward. Ski n intact. -Both eyelids are evenly distributed, curled slightly ( Fundamentals of Nursing by 7th Edition, Kozier, Erb Blais, Wilkinson, pp.547) Normal findings. INTERPRETATION Normal Findings

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Eyelids

No discharge, no discoloration. Lids close symmetrically. Approximately 15-20 involuntary blinks/min; bilateral blinking. When lids open, no visible sclera above cornea and upper & lower borders of cornea are slightly covered. No edema, tearing Palpation or tenderness over lacrimal glands. -

outward & close symmetrical. -with bilateral blink response. -no inversion of eyelids Skin intact -no discharge -no discoloration ( Fundamentals of 17 involuntary blinks per/min Nursing by 7th Edition, Kozier, Erb Blais, Wilkinson, pp.547)

Conjunctiva (Bulbar & Palpebral)

Inspection

Transparent; capillaries sometimes evident; sclera appears white (yellowish in dark skinned clients). ( Fundamentals of Nursing by 7th Edition, Kozier, Erb
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-no lesions or nodules -clear bulbar conjunctiva -pale conjuctuva in palpebral

The palpebral conjunctiva appears pale due to anemia Anemia is a condition in which the body does not have enough healthy

Blais, Wilkinson, pp.547553) Sclera Inspection Shiny smooth and salmon pink or red in color. -white in color

red blood cells. Red blood cells provide oxygen to body tissues.

Sclera appears white. ( Fundamentals of Nursing by 7th Edition, Kozier, Erb Blais, Wilkinson, pp.547553) Cornea Inspection Transparent, shiny & smooth. Details of the iris are visible. -Transparent, shiny and smooth. -Iris details are visible. ( Fundamentals of Nursing by 7th Edition, Kozier, Erb Blais, Wilkinson, pp.547-553)
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Normal Findings

Iris

Inspection

Flat round. No shadow of light on iris

-Evenly to the size of the eye, round black in color and symmetrical.

Normal findings. ( Fundamentals of Nursing by 7th Edition, Kozier, Erb Blais, Wilkinson, pp.547-553)

Pupils

Inspection

Black in color, equal in size; normally3-7 mm in diameter. Round, smooth boarder, illuminated pupil constricts (consensual response). Pupil constricts when looking at near object; a pupil dilates when looking in a far object. Pupils moved toward nose

Black in color, equal in size; normally3-7 mm in diameter. Round, smooth boarder, illuminated pupil constricts (consensual response). Pupil constricts when looking at near object; a pupil dilates when looking in a far object. Pupils moved toward nose

normal

converge when near object is converge when near object is

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( Fundamentals of Nursing by 7th Edition, Kozier, Erb Blais, Wilkinson, pp.547553) EARS PARTS Auricle METHOD Inspection NORMAL FINDINGS Color same as facial skin. Symmetrical. Auricle aligned with outer canthus of the eye 10 from vertical ACTUAL FINDINGS -Color matches the skin. -Symmetrically proportionally aligned to the face. INTERPRETATION Normal Findings (fundamentals of Nursing 7th Edition, Kozier, Erb Blais, Wilkinson, pp.560561) Auricle texture and elasticity Inspection Palpation Mobile, firm, and not tender; pinna recoiled after it is folded. - Mobile, firm, and not tender; pinna recoiled after it is folded. The skin of the patient ear appears dry and less resilient because of the loss of connective tissue.

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External ear canal

Inspection

Distal third contains hair follicles and glands. Dry cerumen. Dry cerumen, grayish-tan color; sticky, when cerumen in various shades of brown. (fundamentals of Nursing 7th Edition, Kozier, Erb Blais, Wilkinson, pp.560-561) NOSE

Distal third contains hair follicles and glands. Dry cerumen. Dry cerumen, grayish-tan color; sticky, when cerumen in various shades of brown.

normal

PARTS External Nose

METHOD Inspection

NORMAL FINDINGS Symmetric and straight No discharge in flaring Uniform in color.

ACTUAL FINDINGS -Symmetrical straight septum. -Both nares are patent. -No discharge or flaring, uniform color -with nasal cannula; 2-3 LPM

INTERPRETATION normal

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Facial Sinuses

Palpation

No tenderness

No tenderness noted.

Normal findings. (fundamentals of Nursing 7th Edition, Kozier, Erb Blais, Wilkinson, pp.560561)

Septum

Inspection

Air moves freely as the client breathes through the nares. Nasal septum intact & in midline

Air moves freely as the client breathes through the nares. Nasal septum intact & in midline

Normal findings (fundamentals of Nursing 7th Edition, Kozier, Erb Blais, Wilkinson, pp.560561)

MOUTH PARTS Lips Uniform pink color, soft, a. Outer Lips Inspection Uniform pink color, soft, moist, smooth texture.
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METHOD

NORMAL FINDINGS

ACTUAL FINDINGS

INTERPRETATION normal

moist, smooth texture. Symmetry of contour.

Symmetry of contour. Ability to purse lips. Uniform pink in color; soft, moist, glistening and elastic in b. Inner Lips Inspection texture. (fundamentals of Nursing 7th Edition, Kozier, Erb Blais, Wilkinson, pp.563-565) Gums Inspection Pink gums (bluish or dark patches in dark-skinned clients). Moist firm texture to gums; no retraction of gums (pulling away from teeth) (fundamentals of Nursing 7th Edition, Kozier, Erb Blais, Wilkinson, pp.563-565) Teeth Inspection 32 adult teeth; smooth,
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Ability to purse lips. Uniform pink in color; soft, moist, glistening and elastic in texture.

Pink gums (bluish or dark patches in dark-skinned clients). Moist firm texture to gums; no retraction of gums (pulling away from teeth)

normal

normal

white, shiny tooth enamel. Smooth intact. (fundamentals of Nursing 7th Edition, Kozier, Erb Blais, Wilkinson, pp.563-565) Tongue Inspection Palpation Central position. Pink color the tongue boarders in darkskinned clients), moist, slightly rough; thin whitish coating. Smooth; lateral margins; no lesions. Moves freely, no tenderness Smooth tongue base with prominent veins. (fundamentals of Nursing 7th Edition, Kozier, Erb Blais,
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32 adult teeth; smooth, white, shiny tooth enamel. Smooth intact. Central position. Pink color the tongue boarders in darkskinned clients), moist, slightly rough; thin whitish coating. Smooth; lateral margins; no lesions. Moves freely, no tenderness Smooth tongue base with prominent veins. normal

(some brown pigmentation in (some brown pigmentation in

Wilkinson, pp.563-565) Uvula Inspection Light pink, smooth, soft palate, lighter pink. Hard palate, more irregular in texture and positioned in midline of soft palate. (fundamentals of Nursing 7th Edition, Kozier, Erb Blais, Wilkinson, pp.563-565) Tonsils Inspection Tonsils of normal size. Pink and smooth posterior wall. No discharge. (fundamentals of Nursing 7th Edition, Kozier, Erb Blais, Wilkinson, pp.563565) NECK PARTS Neck METHOD Inspection NORMAL FINDINGS Proportional to size of the
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- Light pink, smooth, soft palate, lighter pink. Hard palate, more irregular in texture and positioned in midline of soft palate.

normal

Tonsils of normal size. Pink and smooth posterior wall. No discharge.

normal

ACTUAL FINDINGS -symmetric on both sides

INTERPRETATION .normal

head, symmetrical and straight. Freely movable without difficulty. Head flexed 45 & head laterally rotates 70. Palpation No palpable lumps or tenderness The trachea is in the Central placement in midline of neck, spaces are equal on both sides. (fundamentals of Nursing 7th Edition, Kozier, Erb Blais, Wilkinson, pp.569)

and head center. -skin intact and color is the same with the face. - muscles -head movement is coordinated with -no palpable lumps & tenderness.

THORAX & LUNGS PARTS Thorax METHOD Inspection NORMAL FINDINGS Diameter in ratio of 1:2
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ACTUAL FINDINGS Chest wall intact: no

INTERPRETATION Normal

& Lungs

Chet symmetric and spine vertically aligned. Skin intact; uniform in temperature. Chest wall Palpation intact: no tenderness. Full & symmetric chest expansion. Bilateral symmetry of vocal Percussion Auscultation fremitus is heard most clearly at the lungs. Low pitched voice of males is more readily palpated, those higher pitched voice of females. Percussion notes resonate, except over the scapula. Lowest point of resonance is at the diaphragm. Vesicular & bronchovesicular breathe sounds.

tenderness. Full & symmetric chest expansion. Bilateral symmetry of vocal fremitus is heard most clearly at the lungs. females. Percussion notes resonate, except over the scapula. Lowest point of resonance is at the diaphragm. Vesicular & bronchovesicular breathe sounds.

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(Understanding Pathophysioloigy, Heuther & MC cance, pp 753-759) Cardiovascular Auscultation Aortic, pulmonic, tricuspid, apical and epigastric pulsation are not palpable. PMI is located at the 5th intercostals space medial to the left midclavicular line. No murmurs noted. (Medical Surgical Vol.2. Black, hawks p.1603) Aortic, pulmonic, tricuspid, apical and epigastric pulsation are not palpable. PMI is located at the 5th intercostals space medial to the left midclavicular line. No murmurs noted. normal

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ABDOMEN PARTS Abdomen METHOD Inspection NORMAL FINDINGS Abdomen should be symmetry; the surface motion should be smooth and wave-like. The skin color should be close to the Auscultation color of the individual. There should no lesions or scars. Bowel sounds should be no tenderness, organ Palpation enlargement and ascites. (Fundamentals of Nursing 7th Edition, Kozier, Erb Blais, Wilkinson, pp.594-595) ACTUAL FINDINGS -flat in contour -no skin elasticity -symmetrical n size and shape -no lesion or scars -no venous engorgement -normoactive bowel sounds, 5-35 mins. INTERPREATTION normal

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MUSCULOSKELETAL SYSTEM PARTS Upper Extremities METHOD Inspection Inspection NORMAL FINDINGS The muscle should be firm equal on both sides of the body, bilaterally non-tender; and without fascinations, lumps or bulges. Clean fingers equal in number and no abnormalities. Symmetrical, well aligned and Palpation proportion relative to the body trunk. Muscle equal muscle strength equal to the upper arms, forearms, wrist and fingers. Equal in range of motion. (Fundamentals of Nursing 7th Edition, Kozier, Erb Blais, Wilkinson, pp.600-601) -Skin is smooth and warm. -No tenderness and muscle spasm. - -Peripheral pulses are palpable and rapid & bounding in rhythm. ACTUAL FINDINGS -Upper extremities, uniform in color. -Symmetrical in size and length. -No deformities. INTERPRETATION normal

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Lower Extremities

Inspection

Symmetrical, equal in number and clean. Equal number of digits. Skin smooth, slightly moist, same color and no lesions or masses. No visible

-patient has a left leg amputation -visible scar

Patient has undergone left leg amputation to prevent further spread of cancer.

Palpation

varicose veins. Equal in range of motions. No contractures. No swelling of joints & moves smoothly.

(Fundamentals of Nursing 7th Edition, Kozier, Erb Blais, Wilkinson, pp.600-601)

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