A.

Physical Assessment
Body Parts Technique Used Normal Findings Actual Findings Analysis
Head Inspection Norm cephalic Norm cephalic
smooth skull, smooth skull,
contour, proportion contour, proportion Normal
to the size of the to the size of the
neck and body. neck and body. No
infestations of lice
dandruff.

Absence of nodules Absence of nodules

Palpation or masses. or masses. No
lesions, masses and
nodules. Normal
Scalp Inspection No lice and nits. No lice and nits.
No dandruff. No dandruff. Normal
Hair Inspection Evenly Distributed The hair is evenly
hair, color varies distributed, color
mostly in black, varies mostly in Normal
smooth in texture & black, smooth in
shiny. texture & shiny.
Face Inspection Symmetric facial Facial movement
movement, and nasolabial is Normal
symmetric symmetric.
nasolabial folds.
Eyes Inspection 20/20 visions, Client has 20/20
round cornea in visions, round
black color & white cornea in black
sclera. Reacts to color & white Normal
light & sclera. Reacts to
accommodation. light &
accommodation.
Eyebrows Inspection Hair evenly With even hair
distributed w/skin distributed
intact, symmetrically Normal
symmetrically aligned w/equal
aligned w/equal movement.
movement
Eyelids Inspection Skin intact, no Skin color same
discharge, no with facial skin
discoloration. Lids tone, skin intact,
able to close w/no discharge and Normal
symmetrically. no discoloration,
symmetrical
movement of lids.
Ears Inspection Same color as facial Ears with same
skin, symmetrical color as facial skin
auricle with outer tone, symmetrical
cantus of eyes auricle with 10 Normal
about 40 degrees degrees outer
from vertical. cantus from
vertical.
 Mobile, firm and
not tender. Mobile, firm. Free
Palpation from lesions.
Normal
Nose Inspection Midline With midline Normal
symmetrical to symmetrical to
face. No lesions, no face. No lesions, no
nasal discharges or nasal discharges or
flaring, uniform in flaring, uniform in
color. Air moves color. Air moves
freely. freely.
Mouth Inspection Proportional and Proportional and
symmetrical with symmetrical with Normal
face face
Lips Inspection Pink in color, Pink in color,
smooth, no lesions. smooth, no lesions. Normal
Teeth Inspection Complete without Complete without
dentures. dentures. Normal
Tongue Inspection Tongue floor is in Tongue floor is in
central position, central position,
pink in color, moist. pink in color, moist. Normal
No lesions or No lesions or
swelling swelling
Neck Inspection Proportion to size No discomfort on
of body and head, moving, proportion
coordinated, to size of body and
smooth head, coordinated Normal
movements, no and smooth
discomfort. movement.
With palpable
No lumps and Adam’s apple, no
Palpation tenderness. Adam’s lumps and
apple is palpable tenderness. Normal
Chest Inspection Symmetrical during Symmetrical Lung
lung expansion and expansion and Normal
recoil. recoil. RR= 17 bpm

No abnormal
Auscultation breath sounds. No abnormal Normal
breath sounds.
Heart Auscultation Normal rate, Normal rate,
rhythm, no murmur rhythm, no murmur Normal
Skin Inspection Fair complexion, Yellow in The skin is yellow
absence of scars complexion, fair that indicates that
and lesion. Good presence of lesions the client needs to
skin turgor. on the abdominal take iron
area. But has good supplement to
skin turgor. supply the loss of
the blood during
the CS procedure.
Abdomen Inspection No abdominal No abdominal
enlargement noted, enlargement noted,
 symmetrical symmetrical
without without Normal
discoloration. discoloration.

No abnormal bowel No abnormal bowel

sounds heard. sounds heard. Normal
Auscultation
No lesions, masses with lesions,
or tenderness. masses or
Palpation tenderness. Lesions due to the
CS procedure that
has been done to
the patient risk for
infection because
of open wound.

Upper Extremities Inspection Symmetrical to the Symmetrical to the

body, no lesions. body, no lesions. Normal

No Tenderness, no No tenderness and

Palpation palpable mass palpable mass
noted. Palpable noted. Palpable Normal
brachial and radial peripheral pulse. PR=72 bpm
pulse.
Able to move freely
Range of motion Able to move freely without discomfort;
Inspection on without discomfort; able to adduct,
Adduction,Abduction, able to adduct, abduct, flex, and
Flexion and Extension abduct, flex, and extend Normal
extend
Palms Inspection Pink in color, hand Pink in color, hand
warm to touch. No warm to touch. No Normal
lesions noted. lesions noted.
Fingernails Inspection Nails are clean. Pink Nails are clean. Pink
nail beds. nail beds. Normal

Palpation
Capillary Refill of 2-
Capillary Refill of 2- 3 seconds. Normal
3 seconds.
Lower Extremities Inspection Symmetrical to the Symmetrical to the
body, no lesions. body, no lesions Normal
Muscles appear noted. Muscles
equal with good appear equal with
muscle tone. good muscle tone.

No tenderness, No tenderness,
Palpation masses masses Normal

Range of motion Able to move freely Able to move freely

Inspection on without discomfort; without discomfort;
 Adduction,Abduction, able to adduct, able to adduct,
Flexion and Extension abduct, flex, and abduct, flex, and Normal
extend extend
Toenails Inspection Pink nail beds with Pink nails bed,
capillary refill of 2-3 capillary refill of 2-3 Normal
seconds. seconds.