Date of Assessment Vital Signs

General Appearance

July 24, 2012 @ 9:00 am T: 36.1 C PR: 68 bpm RR: 18 cpm BP: 100/80 mmHg FHT: 150 bpm Patient is conscious, coherent, cooperative clean , oriented, understandable; Received with ongoing IVF of # 4 D5LRS 1L x 30 gtss/min at 910 cc level patent and infusing well @ left metacarpal vein. Weight= 67kg Fundal Height= 29 cm

Measurements

AREA ASSESSED SKIN Color Temperature Texture Turgor

TECHNIQUE USED

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

Inspection Palpation Palpation Palpation

Accdg. to race Warm to touch Smooth Springs back to previous state (1-2 seconds) Moist Convex 160 degrees Smooth Pinkish with translucent tip Short

Fair complexion Warm to touch Smooth Springs back to previous state (1-2 seconds) Moist Convex 160 degrees Smooth Pinkish with translucent tip Short

Normal Normal Normal Normal

Moisture NAILS Curvature Angle Texture Color of nail bed

Palpation Inspection Inspection Palpation Inspection

Normal Normal Normal Normal Normal

Size

Inspection

Normal

Capillary refill time HAIR Color

Palpation

Should return within 2-3 seconds Varies from races, usually black among Filipinos Evenly distributed Smooth

Returns within 2- Normal 3 seconds

Inspection

Varies from races, usually black among Filipinos Evenly distributed Smooth Symmetrical Normocephalic and symmetric, smooth skull contour No nodules and lesions Symmetrical Smooth

Normal

Distribution Texture

Inspection Palpation

Normal Normal

HEAD Scalp Symmetry Skull size, shape and symmetry

Inspection Inspection

Symmetrical Normocephalic and symmetric, smooth skull contour No nodules and lesions Symmetrical Smooth

Normal Normal

Nodules and masses FACE Symmetry Texture Facial Movements Color EYES Position

Inspection & Palpation Inspection Palpation Inspection

Normal

Normal Normal

Symmetric Symmetric Normal Facial Movement Facial Movement Same as body color Symmetric position Pinkish Hair evenly distributed, skin intact, symmetric alignment Skin intact, no discharges and lesions Same as body color Symmetric position Pinkish Hair evenly distributed, skin intact, symmetric alignment Skin intact, no discharges and lesions Normal

Inspection

Inspection

Normal

Conjunctiva Eyebrows

Inspection Inspection

Normal Normal

Upper eyelids

Inspection

Normal

Pupils

Inspection (PERRLA)

Color black, pupils constrict when light passes through Skin intact, no discharges and lesions White

Color black, Normal pupils constrict when light passes through Skin intact, no discharges and lesions White Normal

Lower eyelids

Inspection

Sclera EARS Auricle

Inspection

Normal

Inspection

Symmetric position Symmetrical The same with both sides Mobile, firm and not tender; pinna recoils after it is folded No discharges

Symmetric position Symmetrical The same with both sides Firm and no tenderness

Normal

Symmetry Size

Inspection Inspection

Normal Normal

Texture, elasticity and areas of tenderness Canal Discharges

Palpation

Normal

Inspection

No Discharges

Normal

Distribution Nasal septum

Inspection Inspection

Symmetrical Evenly distributed Symmetric and straight, no discharge or flaring, uniform in color No tenderness and lesions

Symmetrical Evenly distributed Symmetric and straight, no discharge or flaring, uniform in color Not tender and no lesions

Normal Normal

NOSE Shape, size or Inspection color and flaring or discharge from the nares

Normal

Tenderness, masses or displacements of bones and cartilage

Palpation

Normal

Cilia , Hair MOUTH Lips Teeth & Gums

Inspection

Evenly distributed Accdg. race Pink gums, tightly fit against each tooth 32 adult teeth Shiny white enamel

Evenly distributed Pinkish Pinkish, tightly fit against each tooth Upper teeth= 16 Lower teeth= 16 with no cavities Pinkish, moist Pinkish, symmetrical, moist and no lesions Soft palate is light pink and hard palate is lighter pink

Normal

Inspection Inspection

Normal Normal

Normal

Mucosa Tongue

Inspection Inspection

Pinkish, moist Pinkish, symmetrical, moist and no lesions Soft palate= Light pink Hard Palate= Lighter pink

Normal

Hard and soft palate for color, shape and the presence of bony prominences Salivary duct opening for any swelling or redness

Inspection Normal

Inspection Same as color of buccal mucosa and floor of mouth Same as color of buccal mucosa and floor of mouth Normal

NECK Position Movement

Inspection Inspection

Head-centered Neck moves freely

Head-centered Neck moves freely

Normal Normal

Neck muscles for size, swelling or masses Range of motion

Inspection & Palpation

Muscles equal in Muscles equal in Normal size ; no swelling size ; no swelling or masses or masses Full range without discomfort Not Palpable Full range without discomfort Not Palpable Normal

Inspection

Lymph nodes

Palpation

Normal

TRACHEA Symmetry Position THORAX Respiratory movement Inspection Even movement Occurs in respiration Almost round in adults, expands bilaterally Even movement Occurs in respiration Almost round in adults, expands bilaterally Normal Inspection Inspection, Palpation Symmetrical Located midline of the neck Symmetrical Located midline of the neck Normal Normal

Contour

Inspection

Normal

(POSTERIOR THORAX) Shape & Symmetry

Inspection

1:2 Anteroposterior to Transverse Same as body color No nodules/lesions Symmetrical

1:2 Anteroposterior to Transverse Same as body color No nodules/lesions Symmetrical

Normal

Color

Inspection

Normal

Texture

Palpation

Normal

Symmetry of chest expansion (ANTERIOR THORAX) Breathing Pattern

Palpation

Normal

Inspection

Quiet, rhythmic and effortless Symmetrical Elliptical Same as body color Uniform with the rest of the body

Quiet, rhythmic and effortless Symmetrical Elliptical Same as body color Lighter in color, presence of linea

Normal

Symmetry Shape Color ABDOMEN Color

Inspection Inspection Inspection

Normal Normal Normal

Inspection

Hormonal changes

nigra

associated with pregnancy Striae result from stretching tissues due to pregnancy

Lesions

Inspection

No lesions

White stretch marks around the abdomen

Symmetry of contour Bowel sounds UPPER EXTREMITIES Symmetry Color

Inspection

Symmetrical

Round abdomen

Due to pregnancy

Auscultation

5-20 gurgling sounds in 5 mins

Inspection Inspection

Symmetrical Uniform with skin color Smooth

Symmetrical Uniform with skin color Stretch marks in the

Normal Normal

Texture LOWER EXTREMITIES Skin color

Palpation

Normal

Inspection

Uniform with skin color Equal size Symmetrical

Uniform with skin color Equal size Symmetrical

Normal

Size (legs) Symmetry

Inspection Inspection

Normal Normal