Lafuente, Maryca Shaina M.

BSN 2 2

I.

General Survey

Normal Findings

Vital signs
Temperature

36.5-37C

Cardiac Rate

70-150bpm

Respiratory rate

20-35cpm

Anthropometric Signs
Weight

G: Weight: 36 - 135 lbs

B: Weight: 36.5 - 130 lbs

Height

G: Height: 42 - 64 in
B: Height: 42.2 - 63.5 in

General Appearance

-Demonstrates an
upright, straight and wellbalanced posture
-clean
-attentive
-well-rested

II.

Skin

Temperature:

warm

Color:

uniformed skin tone

Texture:

soft and smooth

Dryness:

moist with good turgor

and without edema

Presence of lesion:

skin should be lesion free

Findings

Normal skin variations:

III.

Port white stains

Hemangiomas
Caf-au-lait spots
(are normal in
small numbers)

head

General appearance

Appears symmetrical
Normocephalic

Head Control

Full range of motion

up, down and sideways
Face is normally
proportionate and
symmetric
Movements equal
bilaterally

Hair

Smooth texture: has no

lice and no bald spots
Hair is normally lustrous,
silky, strong and elastic
IV.
Alignment

Eyelid
Sclera and Conjunctiva

Iris and Pupils

eyes
Symmetrical; clear and
properly aligned
No swelling, discharge or
lesions of eyelids
Clear sclera and
conjunctiva and free of
discharge. Lesions,
redness or lacerations
Pupils are equal, round,

Eyebrows and Eyelashes

and reactive to light and

accommodation
Eyebrows are symmetric
in shape and movement,
should not meet midline
Evenly distributed
eyelashes and curled
outward

Visual Acuity
Extra ocular Muscle test

20/20

Cover test

Eyes remain focused

Light reflects symmetrical
in the center of both
pupils

Internal Eye Inspection

Ref reflex is present

V.

ears

Alignment

Should appear pink and

moist
Pinna should cross the
eye occiputline and
within 10-degree angle of
a perpendicular line
No excessive cerumen,
discharge, lesions,
excoriations or foreign
body in external canal

Internal Ear

Tympanic membrance is
pearly gray to light pink
Answers whispered
questions

Test Hearing Acuity

VI.
Appearance

Nose
No flaring of the nostrils

Nose is midline in face

Septum is straight
Turbinates are pink and
free of edema
Mucous membrane

Should appear pink and

moist

Patency

Both nostrils should be

patent

Sinuses

No palpated tenderness
VII.

Mouth

Lips

Symmetrical and pinkish

in color

Gum line

No redness, tenderness
and edema

Tongue

No lesions; smooth and

moist
VIII.

Neck

Lymph nodes

Not enlarged and no

tenderness

Flexion

No pain upon flexion

VIX. Thorax and Lungs

Shape of Thorax

Thoracic diameter
reached the adult 1:2 or
5:7 ratio (anteroposterior
to transverse)

Lungs
Percussion of Lungs

Hyperresonance is the
normal tone elicited in
young children

Auscultate

No adventitious sounds

should be heard
Breath sounds seem
louder and harsher in
young children
X.

Chest

Appearance

Should appear
symmetrical side to side

Breast

No edema, erythema,
wrinkling or retraction of
the skin
Flat and symmetric in
prepubertal children
Obese children may
appear to have breast
tissue
XI.

Heart

Inspect and palpate precordium

Apical pulse is at the

right of MCL

Auscultate heart sounds

No murmurs can be
heard
Heart sounds are louder,
higher pitched, and of
shorter duration, no
transmission to other
areas; loudest in
pulmonic area
No other associated
signs o heart disease

XII.
Contour

Abdomen
Appears slightly
prominent when standing
but flat when supine

Bowel sounds

Occur every 10 to 30 s
Sound like clicks, gurgles
or growls

Palpation

No tenderness

Umbilicus

Umbilicus is pink, no
discharge, odor redness
or herniation

Auscultation

Normal bowel sounds

occur every 30to 30s,
sounds like clicks,
gurgles or growth.

Palpate for masses and tenderness

Soft to palpation and

without masses or
tenderness

XIII.

Genitalia

Male
Appearance

No lesions
No discharge of redness

Testes

Both testes should be

present in the scrotum
and descended

Penis

Appears small for obese

Scrotum

Free of lesions
Equal in size, smooth
and mobile

Inguinal area

No inguinal hernias are

present

Female
Appearance

Normal contours
Labia majora and minora

are pink and moist

Flattened majora, thin
minora, small clitoris, thin
hymen
Discharge

No discharge or meatus
No redness or edema
XIV.

Anus

Visible anal opening,

moist and hairless
Perianal skin is smooth
and free of lesions

XV.

Rectum

Male: Prostate gland is

nonpalpable
Female: small midline
mass (cervix)

XVI.

Muscoloskeletal

Feet and legs are

symmetric in size, shape,
movement and
positioning.

Back
Spinal Alignment

Symmetrical

Extremities
Upper and Lower

Symmetric, warm, mobile

and adequate capillary
refill

Fingernails

Pink, smooth, and

convex

Movement

Should move
symmetrically

Gait
Joints

Usually knock-kneed
(genu valgum)
Full range of motion and
no swelling, redness or

tenderness
Muscles

Muscle size and strength

should be adequate for
the particular age and
should be equal
bilaterally
XVII. Neurologic

Cerebral Function

Should be alert and

active
Responds appropriately
and relate well to the
parent and nurse

Cranial Nerve function

Normal finding are the

same as for adults

Deep tendon and superficial reflexes

Normal findings are the

same as for adults
Absent Babinski reflex
and Triceps reflex

Test balance and coordination

Able to perform most

balance and coordination
tests

Sensory function

Sensitivity to touch and

discrimination is present

Motor function

Appropriate development
of gross and fine motor
skills