Demographic Data Name: Dana L.

Ferrer Age: 5 months Gender: Female Birthday: July 21, 2011 Address: Villa Apolania, Naic Cavite Physical Examination A. Vital Signs T = 37.1 C PR = 130 bpm RR = 51 cpm BP = N/A B. Anthropometric Data Weight = 6.2 kg Head Circumference: 42 cm Chest Circumference: 42 cm Abdominal Circumference: 40 cm B. Focused Assessment Date of exam: January 28, 2012

Body Part Examined Skin

Actual Finding Fair complexion: skin is smooth and moist: presence of needle puncture on right hand and left foot.

Normal Finding Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive. Generally uniform except in areas exposed to the sun; areas of lighter pigmentation (palms, lips, nail beds) No edema; freckles, some birthmarks, some flat nevi; no abrasions or other lesions Moisture in the skin

Clinical Significance According to Kozier and Erbs Fundamentals of Nursing, these findings ; Skin color is pink; no edema; no lesions; have flat and raised nevi; no lesions; skin is uniform in color; the skin, when pinched, return to previous state; uniform temperature of the skin is normal.

fold and the maxillae (varies with environmental temperature and humidity , body temperature and activity); uniform; within normal range; when pinched, skin springs back to previous state; may be slower in elders Eyes color of the eyes is brown; symmetrical blinking reflex; eyebrows are equally distributed; cornea is bright and shiny ;pupils are equal and reactive to light: eyelids has no discharge and are intact Pinna top on horizontal line with the outer canthus of the eye; pinna is soft and recoils when pinched; color same with facial color ; no lesion upon inspection; Slate gray or blue eye color; no tears. Fixation at times with ability to follow. Objects to midline. Blink reflex. Distinct eyebrows. Cornea bright and shiny. Pupils equal and reactive to light. Normal

Ears

Pinna top on Normal horizontal line with outer canthus of eye. Loud noise elicits Startle Reflex Flexible pinna with cartilage present. Skin tags on or around ears.

Nose

Nostrils are patent bilaterally ; no nasal

Obligate nose breathers; sneezes to

Normal

discharge ; nasal mucosa is pinkish in color ; no lesions upon inspection Mouth

clear nostrils; nostrils patent bilaterally bridge appears absent; thin white nasal mucus discharge Lips are smooth ; no Mucosa lesions upon moist,Shortly after inspection ; uvula is in birth may visualize the midline; gums are sucking calluses on smooth ; central portions of lips; Palate high arched; minimal or absent salivation; well developed fat pads bilateral cheeks. The palate of a newborn should be intact. Epsteins pearls on ridges of gums. bilateral chest movement ;chest color was brown symmetric ;nipples are symmetric and in proper position ; heart rate is 155 bpm ; bronchoviscicular breath sounds auscultated

Normal

Chest

The breasts of Normal newborn babies secrete a thin, watery fluid popularly termed witchs milk. Evident xiphoid process; equal anteroposterior and lateral diameter; bilateral synchronous chest movement RR are normally rapid (30 to 60 breaths per minute) but not distressed.

Abdomen

Round in contour ; bowel sounds present

Dome shape abdomen ,abdominal

Normal

upon auscultation ; no abdominal distention

Genitals

Extremities Arms

fair and smooth complexion ; clitoris is at the middle ; Labia majora are larger than the labia minora and the labia majora cover the labia minora ; watery and small, white amount of discharge present ; urinary meatus located on the upper portion of the vagina and it is on the middle arm is at 180 of flexion ; joints had a full range of motion ; muscle tone is intact. ; 10 fingernails are present ; skin is light brown and symmetric to body other body parts

respirations, soft to palpation, well formed umbilical cord, three vessels in cord, cord dry ay base, liver palpable between 2 to 3 cms below right colar margin, bilaterally equal femoral pulses, bowel sounds auscultated within the first two hours og birth, voiding within 24 hours of birth, meconium between 24 to 48 hours of birth edematous labia and Normal clitoris, labia majora are larger and surrounding labia majora, verix between labia

Legs

legs is light brown and it is symmetrical on the whole body ; . legs is longer than the

Maintain posture of Normal flexion, equal bilateral movement and tone, full range of motion all joints, ten fingers and ten toes, legs appear bowed, feet appear flat, palmar creases present, sole creases present, grasp reflex present. Maintain posture of Normal flexion, equal bilateral movement and tone, full range of motion

Anus

arms ; femur is full all joints, ten fingers flexed ; 10 toenails in and ten toes, legs both feet appear bowed, feet appear flat, palmar creases present, sole creases present, grasp reflex present. Anal opening is patent Anal opening patent

Normal