Assessment Findings

Integumentary
When skin is pinched it goes to previous
state immediately (2 seconds).
Skin
With fair complexion.
With dry skin
Evenly distributed hair.
Hair With short, black and shiny hair.
With presence of pediculosis Capitis.
Smooth and has intact epidermis
With short and clean fingernails and
Nails toenails.
Convex and with good capillary refill time of
2 seconds.
Rounded, normocephalic and symmetrical,
Skull smooth and has uniform
consistency.Absence of nodules or masses.
Symmetrical facial movement, palpebral
Face fissures equal in size, symmetric nasolabial
folds.
Eyes and Vision
Hair evenly distributed with skin intact.
Eyebrows Eyebrows are symmetrically aligned and
have equal movement.
Equally distributed and curled slightly
Eyelashes
outward.
Skin intact with no discharges and no
discoloration.
Eyelids
Lids close symmetrically and blinks
involuntary.
Bulbar conjunctiva Transparent with capillaries slightly visible
Palpebral Conjunctiva Shiny, smooth, pink
Sclera Appears white.
Lacrimal gland, Lacrimal sac, No edema or tenderness over the lacrimal
gland and no tearing.
 Assessment Findings

Nasolacrimal duct
Cornea
Transparent, smooth and shiny upon
inspection by the use of a penlight which is
Clarity and texture held in an oblique angle of the eye and
moving the light slowly across the eye.
Has [brown] eyes.
Blinks when the cornea is touched through a
Corneal sensitivity
cotton wisp from the back of the client.
Black, equal in size with consensual and
direct reaction, pupils equally rounded and
reactive to light and accommodation, pupils
Pupils constrict when looking at near objects,
dilates at far objects, converge when object
is moved toward the nose at four inches
distance and by using penlight.
When looking straight ahead, the client can
see objects at the periphery which is done
by having the client sit directly facing the
nurse at a distance of 2-3 feet.
Visual Fields
The right eye is covered with a card and
asked to look directly at the student nurses
nose. Hold penlight in the periphery and ask
the client when the moving object is spotted.
Able to identify letter/read in the newsprints
at a distance of fourteen inches.
Visual Acuity
Patient was able to read the newsprint at a
distance of 8 inches.
Ear and Hearing
Color of the auricles is same as facial skin,
symmetrical, auricle is aligned with the outer
Auricles
canthus of the eye, mobile, firm, non-tender,
and pinna recoils after it is being folded.
External Ear Canal Without impacted cerumen.
 Assessment Findings

Hearing Acuity Test Voice sound audible.

Able to hear ticking on right ear at a distance
Watch Tick Test of one inch and was able to hear the ticking
on the left ear at the same distance
Nose and sinuses
Symmetric and straight, no flaring, uniform in
External Nose color, air moves freely as the clients
breathes through the nares.
Mucosa is pink, no lesions and nasal
Nasal Cavity septum intact and in middle with no
tenderness.
Symmetrical, pale lips, brown gums and able
Mouth and Oropharynx
to purse lips.
Teeth With dental caries and decayed lower molars
Central position, pink but with whitish
Tongue and floor of the mouth coating which is normal, with veins
prominent in the floor of the mouth.
Moves when asked to move without difficulty
Tongue movement
and without tenderness upon palpation.
Uvula Positioned midline of soft palate.
Present which is elicited through the use of a
Gag Reflex
tongue depressor.
Positioned at the midline without tenderness
Neck
and flexes easily. No masses palpated.
Coordinated, smooth movement with no
Head movement discomfort, head laterally flexes, head
laterally rotates and hyperextends.
Muscle strength With equal strength
Lymph Nodes Non-palpable, non tender
Not visible on inspection, glands ascend but
Thyroid Gland not visible in female during swallowing and
visible in males.
Thorax and lungs
 Assessment Findings

Posterior thorax Chest symmetrical

Spine vertically aligned, spinal column is
Spinal alignment straight, left and right shoulders and hips are
at the same height.
With normal breath sounds without
Breath Sounds
dyspnea.
Anterior Thorax Quiet, rhythmic and effortless respiration
Unblemished skin, uniform in color,
Abdomen
symmetric contour, not distended.
Symmetrical movements cause by
Abdominal movements
respirations.
With audible sounds of 23 bowel
Auscultation of bowel sounds
sounds/minute.
Without scars and lesions on both
Upper Extremities
extremities.
Lower Extremities With minimal scars on lower extremities
Equal in size both sides of the body, smooth
coordinated movements, 100% of normal full
Muscles
movement against gravity and full
resistance.
No deformities or swelling, joints move
Bones and Joints
smoothly.
Mental Status
Language Can express oneself by speech or sign.
Orientation Oriented to a person, place, date or time.
Able to concentrate as evidence by
Attention span
answering the questions appropriately.
A total of 15 points indicative of complete
Level of Consciousness
orientation and alertness.
Motor Function
Gross Motor and Balance
Walking gait Has upright posture and steady gait with
opposing arm swing unaided and
 Assessment Findings

maintaining balance.
Maintained stance for at least five (5)
Standing on one foot with eyes closed
seconds.
Maintains a heel toe walking along a straight
Heel toe walking
line
Toe or heel walking Able to walk several steps in toes/heels.
Fine motor test for Upper Extremities
Repeatedly and rhythmically touches the
Finger to nose test
nose.
Alternating supination and pronation of Can alternately supinate and pronate hands
hands on knees at rapid pace.
Finger to nose and to the nurses finger Perform with coordinating and rapidity.
Fingers to fingers Perform with accuracy and rapidity.
Rapidly touches each finger to thumb with
Fingers to thumb
each hand.
Fine motor test for the Lower Extremities
Pain sensation Able to discriminate between sharp and dull
sensation when touched with needle and
cotton.

Pediatric Vital Sign Normal Ranges

Systol
Weig
Respira ic Weig
Heart ht in
Age Group tory Blood ht in
Rate poun
Rate Press kilos
ds
ure
 120 - 50 - 4.5 -
Newborn 30 - 50 2-3
160 70 7
Infant (1-12 80 - 70 - 4- 9-
20 - 30
months) 140 100 10 22
Toddler (1-3 80 - 80 - 10 - 22 -
20 - 30
yrs.) 130 110 14 31
Preschooler (3-5 80 - 80 - 14 - 31 -
20 - 30
yrs.) 120 110 18 40
School Age (6- 70 - 80 - 20 - 41 -
20 - 30
12 yrs.) 110 120 42 92
Adolescent (13+ 55 - 110 -
12 - 20 >50 >110
yrs.) 105 120